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N. Lee, M.S., Ph.D.

Professor, State University of New York Upstate Medical University

The concentric contractions of the ipsilateral internal oblique and the contralateral external oblique are balanced by the eccentric contractions of the contralateral internal oblique, ipsilateral external oblique, abdominals, and erector spinae to rotate the trunk. The anterior deltoid, pectoralis major, subscapularis, and wrist extensors contract concentrically to rotate the shoulder and upper arm through the transverse plane as the posterior deltoid, infraspinatus, teres minor, trapezius, rhomboids, and serratus anterior contract eccentrically. Concentric and eccentric contractions of the obliques, back extensors, and erector spinae cause the trunk to rotate into the shot. The acceleration phase of the upper arm is performed through concentric contractions of the infraspinatus, teres minor, posterior deltoid, and trapezius. During the follow-through, the subscapularis, pectoralis major, biceps, and wrist flexors contract eccentrically to decelerate the upper arm. Both arms are used, increasing the power of the stroke, and fewer body segments are involved, which helps learning players coordinate the movement. These benefits help players hit balls in the strike zone and balls that bounce higher that must be hit above shoulder level. Although the two-handed backhand uses many of the same muscle groups as the one-handed backhand, the two-handed backhand requires greater trunk rotation versus the one-handed backhand. Therefore, the muscles of the torso and midsection should be well trained, especially the internal and external obliques. This is especially important in open-stance backhands, which are becoming more prevalent at all levels of the game. In addition, the legs should be trained to provide a stable base of support, to properly transfer the forces from the ground to the racket, and to provide endurance for long matches. One area unique to the two-handed backhand is the use of the nondominant arm and wrist. The flexors and extensors of the nondominant forearm and wrist and the muscles involved in ulnar and radial deviation must be trained appropriately. Concentric contractions of the ipsilateral internal oblique and contralateral external oblique are aided by eccentric contractions Trapezius Erector spinae Posterior deltoid Serratus anterior External oblique Internal oblique Gluteus medius Gluteus maximus Quadriceps Gastrocnemius Soleus Pectoralis major Rectus abdominis a b Figure 1. The shoulder and upper arm on the dominant side rotate through the transverse plane through concentric contractions of the anterior deltoid, pectoralis major, subscapularis, and wrist extensors and eccentric contractions of the posterior deltoid, infraspinatus, teres minor, trapezius, rhomboids, and serratus anterior. On the nondominant side, concentric contractions of the middle and posterior deltoid, latissimus dorsi, infraspinatus, teres minor, and wrist extensors create the rotation of the shoulder and upper arm, assisted by eccentric contractions of the anterior deltoid, pectoralis major, and subscapularis. Concentric and eccentric contractions of the obliques, back extensors, and erector spinae rotate the trunk. The upper arm on the dominant side moves to the ball through concentric contractions of the infraspinatus, teres minor, posterior deltoid, and trapezius. On the nondominant side, concentric contractions of the anterior deltoid, subscapularis, biceps, serratus anterior, and pectoralis major bring the arm to the ball. During the follow-through, the dominant arm decelerates through eccentric contractions of the subscapularis, pectoralis major, and wrist flexors. The nondominant arm decelerates through eccentric contractions of the infraspinatus, teres minor, posterior deltoid, rhomboids, serratus anterior, trapezius, triceps, and wrist extensors. Each player starts half the points with a serve, for which he has time to prepare. The serve has become a true weapon in the game because it can dictate much of what happens in the ensuing point. Since the swing pattern of the overhead is quite similar to that of the serve, we are including it in this section as well. From a strategy and tactics perspective, the main keys to a successful serve are pace, spin, and placement. Of course, physical preparation to develop strength, power, flexibility, and coordination determines the quality of these three components. You also can make the serve a true weapon by preparing your body for the rigors of serving at a high level for an entire match. Typically, the player chooses which serve to use based on personal preference and style. In the foot-up serve, the rear foot typically starts in the same position as for the foot-back serve. However, during the toss and backswing, the back foot slides up to join the front foot. This allows for more forward weight Posterior deltoid Trapezius Infraspinatus Teres minor Rhomboid major Internal oblique Gluteus medius Gluteus maximus Gastrocnemius Soleus External oblique Quadriceps Posterior deltoid Infraspinatus Rhomboid minor Rhomboid major Trapezius Teres minor External oblique Gluteus medius Gluteus maximus Internal oblique Erector spinae a Posterior deltoid Quadriceps Gastrocnemius Soleus Gluteus maximus External oblique Gluteus medius Quadriceps Gastrocnemius Soleus b c E4826/Roetert/Fig. The foot-back position allows for a slightly more balanced position and possibly more upward (vertical) force production.

Therefore, it is best to assume that any given system can harbor the organism, and that routine, continuous microbiological control practices should be implemented to minimize the risk of Legionella amplification and associated disease. Testing for Legionella is recommended in the event of an outbreak (to identify potential sources of the organism) and to evaluate the effectiveness of disinfection procedures. Testing is also recommended whenever process intrusions into the cooling water occur or other factors mitigate a loss of microbiological control for an extended period of time. There have been reports of vary rapid increases in Legionella concentrations in a short period of time under these circumstances. If testing is required, contact a laboratory experienced in performing Legionella analyses on environmental samples. Also, concurrent sampling should be performed on the bulk water and surface deposits for microscopic detection of higher life forms, along with total aerobic heterotrophic counts. Where evident, collect deposit samples from the basin walls, tower fill, and distribution decks. The following three scenarios are possible: · A low Legionella count with an undetectable or small population of amoebae/protozoa (higher life forms) and low biofilm counts (low sessile bacteria numbers) is a good indication of a clean, wellmaintained system with low risk to health. Since protozoa that promote Legionella amplification graze on bacteria in biofilms, the presence of significant biofilm can promote the development of higher, and thus potentially more dangerous, levels of Legionella. These may be required to control biofilm and planktonic organisms in systems that use makeup water from other than potable water sources, and those with process leaks or contamination. The choice of nonoxidizing biocides should be based on the results of toxicant evaluations. Intermittent Use of Halogens Continuous halogenation is always preferred for Legionella risk minimization; however, if this is not possible, intermittent use of halogen is necessary. The choice of nonoxidizing biocide should be based on the results of toxicant evaluations. Routine On-Line Disinfection Hyperhalogenation Hyperhalogenation as practiced is the maintenance of a minimum of 5 ppm free halogen residual for at least 6 hours. Microscopic examination for the presence of higher life forms requires a trained microscopist and specialized microscopy equipment. Routine Treatment Continuous Application of Halogens · For relatively clean systems or where clean potable water makeup is used, feed a source of halogen (chlorine or bromine) continuously and maintain a free residual. Periodic monitoring of the residual at sample points throughout the cooling water system is needed to insure adequate distribution. The effectiveness of either halogen decreases with increasing pH; bromine is relatively more effective at a higher pH (8. Third Edition 6 Periodic hyperhalogenation will discourage development of large populations of Legionella and their host organisms. Consequently, periodic hyperhalogenation may eliminate the need for conducting more complicated and higher risk off-line emergency disinfection procedures. Other Treatment Approaches: Because of the interest incontrolling Legionella, a number of products have been promoted as a control of Legionellosis in Cooling Systems. Some of them are electronic water treatment devices, material coatings and bio-static components. At the date of this publication, there is little application data to support these approaches. While these technologies may have some benefit, they should not distract your attention from the key issues of: · Eliminating stagnant water areas · Eliminating controllable sources of nutrient to the Cooling Water system. This procedure may require modification based on system volume, water availability and wastewater treatment capabilities. Close building air intake vents in the vicinity of the cooling tower (especially those downwind) until after the cleaning procedure is complete. Since the rate of halogen disinfection slows at higher pH values, acid may be added, and/or cycles reduced in order to achieve and maintain a pH of less than 8. If the unit discharges to a surface water under a permit, dehalogenation will be needed.

A cuffed tube provides a closed circuit, which is required for mechanical ventilation through a tracheostomy. Reserve use for patients who have an inadequate response or intolerance to alternative therapies (1. Patients with both asthma and allergic rhinitis should take only one dose daily in the evening (2. For oral granules: Must administer within 15 minutes after opening the packet (with or without mixing with food) (2. Systemic eosinophilia, sometimes presenting with clinical features of vasculitis consistent with Churg-Strauss syndrome, has been reported. These events have been sometimes associated with the reduction of oral corticosteroid therapy (5. Inform patients with phenylketonuria that the 4-mg and 5-mg chewable tablets contain phenylalanine (5. The types of events reported were highly variable, and included, but were not limited to , agitation, aggression, depression, sleep disturbances, suicidal thoughts and behavior (including suicide). The following doses are recommended: For adults and adolescents 15 years of age and older: one 10-mg tablet. Safety and effectiveness in pediatric patients less than 12 months of age with asthma have not been established. Patients who miss a dose should take the next dose at their regular time and should not take 2 doses at the same time. There have been no clinical trials in patients with asthma to evaluate the relative efficacy of morning versus evening dosing. The pharmacokinetics of montelukast are similar whether dosed in the morning or 3 evening. Efficacy has been demonstrated for asthma when montelukast was administered in the evening without regard to time of food ingestion. Safety and efficacy in patients younger than 6 years of age have not been established. Efficacy was demonstrated for seasonal allergic rhinitis when montelukast was administered in the morning or the evening without regard to time of food ingestion. The following doses for the treatment of symptoms of seasonal allergic rhinitis are recommended: For adults and adolescents 15 years of age and older: one 10-mg tablet. Safety and effectiveness in pediatric patients younger than 2 years of age with seasonal allergic rhinitis have not been established. The following doses for the treatment of symptoms of perennial allergic rhinitis are recommended: For adults and adolescents 15 years of age and older: one 10-mg tablet. For pediatric patients 2 to 5 years of age: one 4-mg chewable tablet or one packet of 4-mg oral granules. Safety and effectiveness in pediatric patients younger than 6 months of age with perennial allergic rhinitis have not been established. After opening the packet, the full dose (with or without mixing with baby formula, breast milk, or food) must be administered within 15 minutes. These postmarketing reports have been highly variable and included, but were not limited to , agitation, aggressive behavior or hostility, anxiousness, depression, disorientation, disturbance in attention, dream abnormalities, dysphemia (stuttering), hallucinations, insomnia, irritability, memory impairment, obsessivecompulsive symptoms, restlessness, somnambulism, suicidal thoughts and behavior (including suicide), tic, and tremor. Animal studies showed that montelukast distributes into the brain in rats [see Clinical Pharmacology (12. Therefore, continue to monitor and provide supportive care until symptoms resolve. Patients who have exacerbations of asthma after exercise should have available for rescue a short-acting inhaled -agonist. These events have been sometimes associated with the reduction of oral corticosteroid therapy. Physicians should be alert to eosinophilia, vasculitic rash, 5 worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients.

This disorder increases the likelihood that a person who is primarily attracted to the mature physique will approach a child, on one or a few occa sions, on the basis of relative availability. The individual often shows other signs of this personality disorder, such as recurrent law-breaking. The disinhibiting effects of intoxication may also increase the likelihood that a person who is primarily attracted to the mature physique will sexually approach a child. There are occasional individuals who complain about ego-dystonic thoughts and worries about possible attraction to children. Clinical inter viewing usually reveals an absence of sexual thoughts about children during high states of sexual arousal (e. Comorbidity Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depres sive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic disorders. However, findings on comorbid disorders are largely among individuals con victed for sexual offenses involving children (almost all males) and may not be generalizable to other individuals with pedophilic disorder (e. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors. The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the puose of tactile genital stimulation (e. Specify: Body part(s) Nonliving object(s) Other Specify if: in a controiied environment: this specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in fetishistic behaviors are restricted. Specifiers Although individuals with fetishistic disorder may report intense and recurrent sexual arousal to inanimate objects or a specific body part, it is not unusual for non-mutually ex clusive combinations of fetishes to occur. Thus, an individual may have fetishistic disorder associated with an inanimate object (e. Diagnostic Features the paraphilic focus of fetishistic disorder involves the persistent and repetitive use of or de pendence on nonliving objects or a highly specific focus on a (typically nongenital) body part as primary elements associated with sexual arousal (Criterion A). A diagnosis of fetishistic dis order must include clinically significant personal distress or psychosocial role impairment (Criterion B). Common fetish objects include female undergarments, male or female footwear, rubber articles, leather clothing, or other wearing apparel. Highly eroticized body parts asso ciated with fetishistic disorder include feet, toes, and hair. It is not uncommon for sexualized fetishes to include both inanimate objects and body parts (e. Many individuals who self-identify as fetishist practitioners do not necessarily report clinical impairment in association with their fetish-associated behaviors. Such individuals could be considered as having a fetish but not fetishistic disorder. A diagnosis of fetishistic disorder requires concurrent fulfillment of both the behaviors in Criterion A and the clin ically significant distress or impairment in functioning noted in Criterion B. Associated Features Supporting Diagnosis Fetishistic disorder can be a multisensory experience, including holding, tasting, rubbing, inserting, or smelling the fetish object while masturbating, or preferring that a sexual part ner wear or utilize a fetish object during sexual encounters. Some individuals may acquire extensive collections of highly desired fetish objects. Deveiopment and Course Usually paraphilias have an onset during puberty, but fetishes can develop prior to ado lescence. Once established, fetishistic disorder tends to have a continuous course that fluc tuates in intensity and frequency of urges or behavior. Cuiture-Reiated Diagnostic issues Knowledge of and appropriate consideration for normative aspects of sexual behavior are important factors to explore to establish a clinical diagnosis of fetishistic disorder and to distinguish a clinical diagnosis from a socially acceptable sexual behavior. Gender-Reiated Diagnostic issues Fetishistic disorder has not been systematically reported to occur in females. In clinical samples, fetishistic disorder is nearly exclusively reported in males. Functionai Consequences of Fetishistic Disorder Typical impairments associated with fetishistic disorder include sexual dysfunction during romantic reciprocal relationships when the preferred fetish object or body part is unavailable during foreplay or coitus. Some individuals with fetishistic disorder may pre fer solitary sexual activity associated with their fetishistic preference(s) even while in volved in a meaningful reciprocal and affectionate relationship. Although fetishistic disorder is relatively uncommon among arrested sexual offenders with paraphilias, males with fetishistic disorder may steal and collect their particular fe tishistic objects of desire. Such individuals have been arrested and charged for nonsexual antisocial behaviors (e. As noted in the diagnostic criteria, fetishistic disorder is not diagnosed when fetish objects are limited to articles of clothing exclusively worn during cross-dressing (as in transvestic disorder), or when the object is genitally stimulating because it has been de signed for that purpose (e.