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Deputy Director, University of California, Riverside School of Medicine

Accelerated age-related cortical thinning in healthy carriers of apolipoprotein E epsilon 4. Multimodality neuroimaging in mild cognitive impairment: a cross-sectional comparison study. However, the relationship between recurrent ipsilateral hemorrhage and choroidal collateral anastomosis subtypes (anterior choroidal artery anastomosis, lateral posterior choroidal artery anastomosis, and medial posterior choroidal artery anastomosis) is unclear. This study aimed to assess this potential association in adult patients with Moyamoya disease. Two readers assessed the angiographic images to identify choroidal collateral anastomosis subtypes, and Cox proportional hazard regression models were used to estimate the risk of recurrent hemorrhage associated with each subtype. Patients with recurrent hemorrhage had a higher prevalence of choroidal collateral (94. Lateral posterior choroidal artery anastomosis was associated with recurrent hemorrhage before (hazard ratio ј 6. This work was supported by the Natural Science Foundation of China (81720108022, B. We also excluded patients who met any of the following 3 conditions: 1) age older than 65 years12; 2) the presence of factors influencing the evaluation of recurrent hemorrhage such as bleeding diathesis, uncontrolled diabetes mellitus (fasting blood glucose level of. The occurrence of recurrent hemorrhage was recorded if there was an acute neurologic symptom during follow-up with a corresponding new intracranial hemorrhage on brain imaging. Demographic and clinical characteristics for all patients were collected from the medical records. Schematic illustrations and representative examples of each subtype are shown in Fig 1. The initial angiographic images were reviewed in consensus by 2 neuroradiologists, both with. Definitions and Analysis of Angiographic Variables Follow-Up After the initial hemorrhagic event was investigated and conservative treatment was initiated, all patients underwent follow-up in the outpatient clinic every 3­6 months so that cases of hemorrhage recurrence could be identified. The interval between the initial event and hemorrhage recurrence was also recorded. The imaging parameters for this examination were as follows: 6 frames/s, injection pressure =300 psi/kg, and contrast medium administered at a rate of 3 mL/s. Schematic illustrations and angiographic findings from representative cases of each subtype of choroidal collateral anastomosis. A and B, Anterior-posterior and lateral right carotid artery angiograms show a dilated anterior choroidal artery extending beyond the lateral ventricle to the cortex (arrows). C and D, Anterior-posterior and lateral right vertebral artery angiograms show a medial posterior choroidal artery extending beyond the level of the pericallosal artery (arrows) to the corpus callosum. E and F, Anterior-posterior and lateral left vertebral artery angiograms show a lateral posterior choroidal artery extending beyond the body of the lateral ventricle to the cortex (arrows). An inPatients without Patients with tracranial aneurysm was identified Recurrent Hemorrhage Recurrent Hemorrhage in those 4 patients presenting with Characteristic (n ј 20) (n ј 19) P Value subarachnoid hemorrhage, includWomen (No. No other significant differences hemorrhages in patients with recurrent events was signifiwere noted in baseline angiographic characteristics between cantly higher than in those without recurrent events (21. Intracranial Hemorrhage In 39 hemispheres, the initial hemorrhagic sites were in the subependymal area of the lateral ventricle in 21 hemispheres (53. Comparisons of imaging features in hemispheres with and without recurrent hemorrhage are shown in Fig 3. These differences in results between studies may be partially due to the different exclusion criteria used in different studies. Topographic analysis showing the distribution of initial and recurrent hemorrhagic sites. B, Another topographic analysis shows the distribution of recurrent hemorrhagic sites (black dots). The recurrent hemorrhagic intracranial aneurysm rupture are not shown in this analysis. A 50-year-old man experienced a recurrent hemorrhage in the ipsilateral hemisphere.

Passively transferred maternal treponemal antibodies can be present in infants until age 15 months. A reactive treponemal test after age 18 months is diagnostic of congenital syphilis. If the nontreponemal test is non-reactive at that time, no further evaluation or treatment is necessary. Management of failed treatment of acquired syphilis in older children and adolescents is identical to that in adults. Maternal syphilis and vertical perinatal transmission of human immunodeficiency virus type-1 infection. Discordant results from reverse sequence syphilis screening-five laboratories, United States, 2006-2010. Efficacy of risk-reduction counseling to prevent human immunodefiency virus and sexually transmitted diseases: a randomized controlled trial. A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. Acquired: Early Stage (Primary, Secondary, Early Latent): · Benzathine penicillin 50,000 units/kg body weight (maximum 2. Comments/Special Issues For treatment of congenital syphilis, repeat the entire course of treatment if >1 day of treatment is missed. Examinations and serologic testing for children with congenital syphilis should occur every 2­3 months until the test becomes non-reactive or there is a fourfold decrease in titer. Children with increasing titers or persistently positive titers (even if low levels) at ages 6­12 months should be evaluated and considered for retreatment. Children and adolescents with acquired syphilis should have clinical and serologic response monitored at 3, 6, 9, 12, and 24 months after therapy. If pyrimethamine is unavailable clinicians may substitute trimethoprim-sulfamethoxazole, dosed according to age and weight, in place of the combination of sulfadiazine, pyrimethamine, and leucovorin. If pyrimethamine is unavailable clinicians may substitute trimethoprim-sulfamethoxazole dosed according to age and weight. The estimated incidence of congenital toxoplasmosis in the United States is one case per 1,000 to 12,000 live-born infants. However, cats excrete oocysts in their feces only transiently after initial infection, and most studies have failed to show a correlation between cat ownership and Toxoplasma infection in humans. Indeed, Toxoplasma infection in humans in the United States has declined despite increased cat ownership. Clinical Manifestations In studies of non-immunocompromised infants with congenital toxoplasmosis, most infants (70%­90%) are asymptomatic at birth. Symptoms in newborns take either of two presentations: generalized disease or predominantly neurologic disease. When symptoms occur, they are frequently nonspecific and can include malaise, fever, sore throat, myalgia, lymphadenopathy (cervical), and a mononucleosis-like syndrome featuring a maculopapular rash and hepatosplenomegaly. As a result, a neurologic examination is indicated for children in whom Toxoplasma chorioretinitis is diagnosed. Ocular toxoplasmosis appears as white retinal lesions with little associated hemorrhage; visual loss can occur initially. Brain biopsy is reserved by some experts for patients who do not respond to specific therapy. All meat (lamb, beef, and pork) should be cooked to an internal temperature of 145°F for 3 minutes. Thus, the recommendation for adults and adolescents specifies discontinuing prophylaxis after an increase to >200 cells/mm3. Treatment Recommendations Treating Disease Pregnant women with suspected or confirmed primary toxoplasmosis and newborns with possible or documented congenital toxoplasmosis should be managed in consultation with an appropriate infectious disease specialist. If pyrimethamine is unavailable, clinicians may substitute age-appropriate-dosed trimethoprim-sulfamethoxazole in place of the combination of sulfadiazine, pyrimethamine, and leucovorin. Longer courses of treatment may be required for extensive disease or poor response after 6 weeks. Azithromycin instead of clindamycin also has been used with pyrimethamine and leucovorin in sulfa-allergic adults, but this regimen has not been studied in children.

Clarke had also mentioned domestic terrorist cells in connection with the possibility of reopening Pennsylvania Avenue. This approach was consistent with how this same issue was addressed almost exactly a year earlier, despite the fact that by 2001 the threat level was higher than it had ever been previously. The presentation did indicate, however, that if a hijacker was intending to commit suicide in a spectacular explosion, the terrorist would be likely to prefer a domestic hijacking. Of the eight such circulars issued between July 2 and September 11, 2001, five highlighted possible threats overseas. For example, an international terrorism squad supervisor in the Washington Field Office told us he was not aware of an increased threat in the summer of 2001, and his squad did not take any special actions to respond to it. The special agent in charge of the Miami Field Office told us he did not learn of the high level of threat until after September 11. Dale Watson, who did not attend any of the briefings, told us that Pickard complained after one of the briefings that Ashcroft did not want to be briefed on the threats because "nothing ever happened. Retrospective analysis of available information would have answered that question, but that analysis was not done until after 9/11. They had not yet discovered that Khallad, traveling under an alias, had actually flown to Bangkok with Mihdhar. Still, as Director Tenet conceded in his testimony before the Joint Inquiry, the Kuala Lumpur meeting took on additional significance once Khallad was identified as having attended the meeting. Such messages are routinely not shared in order to protect intelligence sources and methods. Because of the circumstances of the interview site, the agent would have been absent for a significant period of time. He did not focus on the purpose of showing the photographs; he was only concerned with whether the source recognized the individuals. During the millennium crisis,Attorney General Reno authorized electronic surveillance of three U. The watchlist request included Mihdhar, Nawaf al Hazmi, Salah Saeed Mohammed Bin Yousaf (they did not yet realize this was an alias for Tawfiq bin Attash, a. Jane told investigators that she viewed this matter as just another lead and so assigned no particular urgency to the matter. There was no broad prohibition against sharing information gathered through intelligence channels with criminal agents. Moreover, once information was properly shared, the criminal agent could use it for further investigation. While the agent expressed his frustration with the situation to "Jane," he made no effort to press the matter further by discussing his concerns with either his supervisor or the chief division counsel in New York. Whatever the merits of the March 1995 Gorelick memorandum and the subsequent July 1995 Attorney General procedures on information sharing, they did not apply to the information the analyst decided she could not share with the criminal agent. The Gorelick memorandum applied to two particular criminal cases, neither of which was involved in the summer 2001 information-sharing discussions. There was an exemption for the Southern District of New York from Part B of the 1995 procedures, so they did not apply. The 1995 procedures governed only the sharing of information with criminal prosecutors. Neither Attorney General acted to resolve the conflicting views within the Justice Department. Simply put, there was no legal reason why the information the analyst possessed could not have been shared with the criminal agent. Thus,"Jane" had permission to share the information with the criminal agent prior to their August 29 emails. Hazmi also had a car registered and had been listed in the San Diego telephone book. A search on the car registration would have unearthed a license check by the South Hackensack Police Department that would have led to information placing Hazmi in the area and placing Mihdhar at a local hotel for a week in early July 2001.

F102 Dimensions for Adults and Children the technical requirements are based on adult dimensions and anthropometrics. F103 Modifications and Waivers the Architectural Barriers Act authorizes the Administrator of the General Services Administration, the Secretary of the Department of Housing and Urban Development, the Secretary of the Department of Defense, and the United States Postal Service to modify or waive the accessibility standards for buildings and facilities covered by the Architectural Barriers Act on a case-by-case basis, upon application made by the head of the department, agency, or instrumentality of the United States concerned. The General Services Administration, the Department of Housing and Urban Development, the Department of Defense, and the United States Postal Service may grant a modification or waiver only upon a determination that it is clearly necessary. Section 502(b)(1) of the Rehabilitation Act of 1973 authorizes the Access Board to ensure that modifications and waivers are based on findings of fact and are not inconsistent with the Architectural Barriers Act. The provisions for modifications and waivers differ from the requirement issued under the Americans with Disabilities Act in that "equivalent facilitation" does not apply. There is a formal procedure for Federal agencies to request a waiver or modification of applicable standards under the Architectural Barriers Act. For example, if this document requires "1Ѕ inches," avoid specifying "1Ѕ inches plus or minus X inches. It will also more often produce an end result of strict and literal compliance with the stated requirements and eliminate enforcement difficulties and issues that might otherwise arise. Information on specific tolerances may be available from industry or trade organizations, code groups and building officials, and published references. Where the required number of elements or facilities to be provided is determined by calculations of ratios or percentages and remainders or fractions result, the next greater whole number of such elements or facilities shall be provided. Unless specifically stated otherwise, figures are provided for informational purposes only. The specific edition of the standards listed below are referenced in this document. The provisions for escalators require that at least two flat steps be provided at the entrance and exit of every escalator and that steps on escalators be demarcated by yellow lines 2 inches wide maximum along the back and sides of steps. Lifts are classified as: vertical platform lifts, inclined platform lifts, inclined stairway chairlifts, private residence vertical platform lifts, private residence inclined platform lifts, and private residence inclined stairway chairlifts. The enclosure walls not used for entry or exit are required to have a grab bar the full length of the wall on platform lifts. The maximum permitted height for operable parts is consistent with Section 308 of this document. The test methods in this standard address access for children and adults who may traverse the surfacing to aid children who are playing. When a surface is tested it must have an average work per foot value for straight propulsion and for turning less than the average work per foot values for straight propulsion and for turning, respectively, on a hard, smooth surface with a grade of 7% (1:14). The technical criteria for accessible means of egress allow the use of exit stairways and evacuation elevators when provided in conjunction with horizontal exits or areas of refuge. An exception addresses the height of the railings, guards, or handrails where a fishing pier or platform is required to include a guard, railing, or handrail higher than 34 inches (865 mm) above the ground or deck surface. Copies of the referenced standards may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, Massachusetts 02169-7471, A governmental agency that adopts or enforces regulations and guidelines for the design, construction, or alteration of buildings and facilities. A change to a building or facility that affects or could affect the usability of the building or facility or portion thereof. Normal maintenance, reroofing, painting or wallpapering, or changes to mechanical and electrical systems are not alterations unless they affect the usability of the building or facility. A seat that is built-in or mechanically fastened to an amusement ride intended to be occupied by one or more passengers. A building or facility, or portion thereof, used for the purpose of entertainment, worship, educational or civic gatherings, or similar purposes. An exterior or interior way of passage provided for pedestrian travel, including but not limited to , walks, hallways, courtyards, elevators, platform lifts, ramps, stairways, and landings. A telephone with a dedicated line such as a house phone, courtesy phone or phone that must be used to gain entry to a facility. A play component that is approached above or below grade and that is part of a composite play structure consisting of two or more play components attached or functionally linked to create an integrated unit providing more than one play activity. An entrance includes the approach walk, the vertical access leading to the entrance platform, the entrance platform itself, vestibule if provided, the entry door or gate, and the hardware of the entry door or gate.

Placement of the geomembrane or the geotextile which will be coated with bitumen after placement on the base of the excavation and extending up and over the side slopes at a sufficient distance to allow for complete encapsulation of the surface. Folding over the geosynthetic liner, overlapping and sealing the seams as required. Flowable fill, consisting of medium-graded sand, a small percentage of cement, and a large portion of high fly ash and water, is used to backfill the trench so that the geomembrane will not be damaged. The geomembranes from both sides are then extended over the subgrade surface for the required distance, ideally over the entire surface between the trench lines and seamed at the centerline of the roadway. The geomembranes are supplied in roll form with lengths varying from 650 to 1,000 feet and widths of approximately 15 to 35 feet or may be delivered in panels of a specific size. It is important to order widths that are appropriate for the design dimensions to minimize field cutting and seaming. A nonwoven geotextile cushion layer will be required above the liner to protect it during placement of fill over the liner. A roughened sheet geomembrane should be considered to avoid slippage of the geotextile and consequently the roadbed material over the surface of the geomembrane. For full encapsulation, if rocky soils are encountered at the base of the excavation, a geotextile cushion layer will also be required beneath the liner to protect it from puncture during installation as well as to provide enhanced long-term puncture resistance. As previously indicated, the liner can also be constructed in-place using impregnated geotextiles. A nonwoven geotextile is used with a variety of coatings, including asphalt, rubber-bitumen, emulsified asphalt, or polymeric formulations. The geotextile type and mass per unit area will be a function of the coating treatment, although use of lightweight nonwoven geotextiles, in the range of 6 to 12 oz/yd2, is common. Although sprayed-on membranes are seam-free, bubbles and pinholes may form during installation and can cause performance problems. As indicated above, a nonwoven geotextile will be required for rocky subgrade soils below a geomembrane barrier to enhance its puncture resistance during installation and in-service. For this application, 8 oz/yd2 needled punched nonwoven geotextiles are typically used as the protection layer. Two design methods are available: · · Determining the depth of vertical moisture barrier based on the climatic conditions (Picornell-Darder 1985), and Determining the water diffusion through membrane based on the diffusion coefficient of soil (Lord and Koerner 1986). Determine the depth to the base of the encapsulation layer or the vertical depth of the partial encapsulation geomembrane, typically 5 to 10 feet according to Steinberg (1998). For pavement design, by maintaining constant moisture over time, the resilient modulus can be assumed to remain constant over the life of the pavement. Geosynthetics ­ Overview of Construction Specifications and Quality Assurance Specification Development · · · 9. Method approach specifications state a specific installation pattern, procedure, and equipment. Method approach specifications should only be used if the specifying agency is confident in their understanding of partial encapsulation and its implementation methods. Performance approach specifications grant the contractor flexibility when selecting implementation methods which satisfy specified performance criteria and allocate most of the risk to the contractor. For either specification, the contractor has to submit the details of the geomembrane, such as manufacturer, product name, composition, strength properties. The owner has to check the material and work done by the contractor as mentioned in the specification. The specification should be complete such that the contractor can bid on the work without needing additional information. The specification should not require overly elaborate or expensive construction methods. The specification should contain all the detailed requirements necessary for the quality assurance, as appropriate to the technology and specification type. The specification should require the contractor to submit a detailed quality assurance plan for the installation of the liner. The specification should also contain information, such as minimum contractor qualifications, preconstruction meeting, etc. The geomembrane installer should be certified by the International Association of Geosynthetic Installers. Quality assurance methods for partial encapsulation projects include determination of the moisture variation of the encapsulated soil layer at different time periods from the construction phase to the end of the design life are necessary to evaluate the effectiveness of the partial encapsulation technique.