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L. Gancka, MD

Associate Professor, University of Pittsburgh School of Medicine

In pulmonary disease, surgery is indicated only when a mass is impinging on a great vessel. Allergic bronchopulmonary aspergillosis is treated with corticosteroids and adjunctive antifungal 1 Infectious Diseases Society of America. Allergic sinus aspergillosis also is treated with corticosteroids, been found to be useful. These latter measures may be expensive and phylaxis against invasive aspergillosis for patients 13 years and older who have undergone hematopoietic stem cell transplantation and have graft-versus-host disease, and in patients with hematologic malignancies with prolonged neutropenia. Patients at risk of invasive infection should avoid environmental exposure (eg, gardening) following discharge from the hospital. Congenital infection with manifestation as severe sepsis syndrome has been reported. Thrombocytopenia is common; disseminated intravascular coagulation can be a complication of severe babesiosis. If untreated, illness can last for several weeks or months; even asymptomatic people can have persistent low-level parasitemia, sometimes for longer than 1 year. Babesia parasites also can be transmitted by blood transfusion and through congenital/perinatal routes. An increase in the deer population in some geographic areas, including some suburban areas, during the past few decades is thought to be a major factor in the spread of I scapularis and the increase in numbers of reported cases of babesiosis. The reported vectorborne cases of B microti infection have been acquired in the Northeast (particularly, but not in the upper Midwest (Wisconsin and Minnesota). Occasional human cases of babesiosis transfusion-associated cases can occur year round. The incubation period typically ranges from approximately 1 week to 5 weeks following a tick bite and from approximately 1 to 9 weeks after a contaminated blood transfusion but occasionally is longer (eg, latent infection might become symptomatic after splenectomy). B microti and other Babesia Plasmodium falciparum; examination of blood smears by a reference laboratory should be is performed at the Centers for Disease Control and Prevention and at some other laboratories. If indicated, the possibility of concurrent B burgdorferi or Anaplasma infection should be considered. The emetic syndrome develops after a short incubation period, similar to staphylococcal foodborne illness. It is characterized by nausea, vomiting, and abdominal cramps, and diarrhea can follow in up to a third of patients. The organism is a common cause of seek care for mild illness and physicians or clinical laboratories do not routinely test for B cereus. The most commonly used and informative subtyping method for B cereus is multilocus sequence typing. In patients with risk factors for invasive disease, isolation of B cereus from wounds, Bacillus species as "contaminants" may delay recognition and treatment of serious B cereus infections. Prompt removal of any potentially infected foreign bodies, such as central lines or implants, is essential. For intraocular infections, an ophthalmologist should be consulted regarding use of intravitreal vancomycin therapy in addition to systemic therapy. B cereus usually is resistant to beta-lactam antibiotics and clindamycin but is susceptible to vanconolones, may be considered depending on susceptibility results. Information on recommended safe food handling practices, including time and temperature requirements during cooking, storage, and reheating, can be found at Symptoms of vulvovaginal irritation, pruritus, dysuria, or abdominal pain are not been associated with adverse outcomes, including chorioamnionitis, premature rupture utable to group A streptococci, Escherichia coli, herpes simplex virus, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or enteric bacteria, including Shigella species. Treatment considerations should include patient preference for oral versus intravaginal treatment, possible adverse effects, and the presence of coinfections. For patients with frequent recurrences, limited data support the use of metof metronidazole (10-14 days with vaginal gel or oral tablets) or tinidazole (for a week) before starting the course of metronidazole gel to increase the likelihood of remaining and their routine use is not recommended at this time. Oral therapies are preferred in pregnancy to treat possible upper genital been shown to reduce the incidence of preterm delivery in females with or without additional risk factors (such as prior history of a preterm birth); some studies demonstrate an increase in adverse events among treated females. Intravaginal clindamycin given during the latter half of pregnancy has been associated with adverse outcomes in the newborn. Members of the Bacteroides fragilis Prevotella melaninogenica (formerly Bacteroides melaninogenicus) and Prevotella oralis (formerly Bacteroides oralis) groups are more common in the oral cavity. Because infections usually are polymicrobial, aerobic cultures also should tube or a sealed syringe is recommended for collection of clinical specimens.

Generally, for all humans, recognition tasks are easier because they require less cognitive energy. Older adults show roughly equivalent memory to young adults when assessed with a recognition task (Rhodes, Castel, & Jacoby, 2008). With recall measures, older adults show memory deficits in comparison to younger adults. While the effect is initially not that large, starting at age 40 adults begin to show declines in recall memory compared to younger adults (Schwartz, 2011). The Age Advantage: Fewer age differences are observed when memory cues are available, such as for recognition memory tasks, or when individuals can draw upon acquired knowledge or experience. For example, older adults often perform as well if not better than young adults on tests of word knowledge or vocabulary. With age often comes expertise, and research has pointed to areas where aging experts perform quite well. For example, older typists were found to compensate for agerelated declines in speed by looking farther ahead at printed text (Salthouse, 1984). Compared to younger players, older chess experts focus on a smaller set of possible moves, leading to greater cognitive efficiency (Charness, 1981). Accrued knowledge of everyday tasks, such as grocery prices, can help older adults to make better decisions than young adults (Tentori, Osheron, Hasher, & May, 2001). Research has shown that older adults are less able to selectively focus on information while ignoring distractors (Jefferies et al. Other studies have also found that older adults have greater difficulty shifting their attention between objects or locations (Tales, Muir, Bayer, & Snowden, 2002). Researchers have studied cognition in the context of several different everyday activities. Although older adults often have more years of driving experience, cognitive declines related to reaction time or attentional processes may pose limitations under certain circumstances (Park & Gutchess, 2000). In contrast, research on interpersonal problem solving 401 suggested that older adults use more effective strategies than younger adults to navigate through social and emotional problems (Blanchard-Fields, 2007). In the context of work, researchers rarely find that older individuals perform poorer on the job (Park & Gutchess, 2000). Similar to everyday problem solving, older workers may develop more efficient strategies and rely on expertise to compensate for cognitive decline. Problem Solving: Problem solving tasks that require processing non-meaningful information quickly (a kind of task that might be part of a laboratory experiment on mental processes) declines with age. Older adults resolve everyday problems by relying on input from others, such as family and friends. They are also less likely than younger adults to delay making decisions on important matters, such as medical care (Strough, Hicks, Swenson, Cheng & Barnes, 2003; Meegan & Berg, 2002). The processing speed theory, proposed by Salthouse (1996, 2004), suggests that as the nervous system slows with advanced age our ability to process information declines. This slowing of processing speed may explain age differences on many different cognitive tasks. For instance, as we age, working memory becomes less efficient (Craik & Bialystok, 2006). Yet, when given sufficient time older adults perform as competently as do young adults (Salthouse, 1996). Thus, when speed is not imperative to the task healthy older adults do not show cognitive declines. In contrast, inhibition theory argues that older adults have difficulty with inhibitory functioning, or the ability to focus on certain information while suppressing attention to less pertinent information tasks (Hasher & Zacks, 1988). In directed forgetting people are asked to forget or ignore some information, but not other information. For example, you might be asked to memorize a list of words but are then told that the researcher made a mistake and gave you the wrong list and asks you to "forget" this list. Cognitive losses exaggerated: While there are information processing losses in late adulthood, overall loss has been exaggerated (Garrett, 2015). One explanation is that the type of tasks that people are tested on tend to be meaningless.

Many of our peer countries have universal or near-universal home visiting systems. But we do know that the homeschooling regime permits children to be raised this way, and we know that few children resemble Tara. Homeschooling proponents make two primary arguments in defense of the current regime, one factual and one legal. The factual claim is that homeschooled children do as well as or better than public school children, including on standard educational measures like college admission tests. We have no way of identifying, based on existing information, the total group of homeschoolers, the percentage whose progress is assessed by some objective testing system, or the percentage who graduate from high school or college, and thus no way of knowing how homeschoolers do on average. The only methodologically sound social science indicates that even the atypically privileged and successful subset of homeschoolers who graduate high school, take college tests, and attend college have some significant problems as compared to nonhomeschoolers. Even if many homeschooled children did do all right on some standard educational measures, this would say nothing about significant subsets of homeschooled children we should be concerned about. These subsets include those whose parents are either uninterested in educating their children or incapable of doing so and those whose parents subject them to serious abuse and neglect. Many homeschooled children miss out on exposure to others with different experiences and values. A very large proportion of homeschooling parents are ideologically committed to isolating their children from the majority culture and indoctrinating them in views and values that are in serious conflict with that culture. Some believe that women should be subservient to men; others believe that race stamps some people as inferior to others. It is inconsistent with state and federal laws guaranteeing children protection against abuse and neglect. From early on, our law recognized that the state has a role to play in child-rearing and that parents have responsibilities and not just rights. The legal claim is also inconsistent with an idea that has been central since the beginning of compulsory education-that the state has a powerful interest in educating children in ways that enable positive participation in the larger society. These laws recognize that children have powerful rights both to education and to protection against maltreatment and that nations have duties to protect those rights. The current homeschooling regime exists not because our society through its elected representatives has decided it should. It exists because homeschooling advocacy groups have become an overwhelming political force and because there is no effective opposing political force. The question is whether we can move beyond current power politics to achieve such reform. It argues that there is a basis both in our federal constitution and in our state constitutions for finding the current homeschooling regime unconstitutional and for imposing a duty on legislatures to regulate to ensure that all children receive an adequate education and adequate protection against maltreatment. It concludes with emphasizing the importance of taking action on behalf of the quintessential politically powerless group that children represent. History and Trends 29 Homeschooling as it exists in the United States today is a relatively recent phenomenon. It is true that prior to the existence of public and private schools, some parents educated their children at home. But the development of free public education and compulsory education laws in the mid-nineteenth century was broadly accepted as an advance for both children and society. Education was supposed to protect against abusive child labor and equalize opportunity, enabling poor children to move beyond the circumstances of their birth. It was supposed to expose children to a range of cultural values and enable them to become productive participants in society, in employment, and in other ways. Homeschooling as we know it today began in the mid-twentieth century as the result of political movements that were very different in nature. The other was a conservative Christian movement, which rejected many of the views and values reflected in public education and the larger society as inconsistent with religious beliefs. As time went on, the conservative Christian wing became the clear majority of all homeschoolers.

In Western medicine, from the time of the ancient Greeks through the Elizabethan era, the thinking was that four bodily humors (black bile, yellow bile, phlegm and blood) influenced mood, physical health and even personality. Shakespeare built some of his characters around the characteristics of the humors (such as anger or depression). It sounds faintly ridiculous, but the idea that good health came from a balance of the humors - in essence, that the physical and the mental were closely related - was not so far off the mark. Take, for instance, something that most people have experienced at some point in their lives: a "nervous" stomach. It turns out that having a "gut feeling" and "going with your gut" are not just metaphors. Researchers have begun to refer to the stomach as the "second brain" and the "little brain. It contains 100 million neurons and numerous types of neurotransmitters, including serotonin and dopamine. Researchers are still teasing out whether (and how) the gut-brain conversation causes emotion to affect the gastrointestinal system and vice versa, but a major area of focus is the microbiome - the vast community of bacteria that dwell primarily within the gut. So far, research suggests that these bacteria affect many things in the body, including mood. Gut bacteria may directly alter our behavior; they definitely affect levels of serotonin. Digestive issues such as irritable bowel syndrome and functional issues such as diarrhea, bloating and constipation are associated with stress and depression. Some researchers believe a causal connection may exist that is bidirectional - meaning it is not always the psychological that causes the gastrointestinal problems but perhaps vice versa. Interestingly, research has shown that approximately 75 percent of people who have autism have some kind of gastro abnormality such as digestive issues, food allergies or gluten sensitivity. Once again, these aphorisms and metaphors represent an instinctive understanding of another significant connection: that between emotion and the heart. Research indicates that inflammation in the body plays some kind of role in many chronic diseases, including asthma, autoimmune disorders, chronic obstructive pulmonary disease, obesity and type 2 diabetes. Some researchers believe that inflammation may also be a causative factor in mental illness. Letting go If physical and mental health are so tightly bound, what role do counselors play in balancing the two? For example, gratitude and forgiveness, and particularly letting go of anger, are essential to emotional wellness, and in some studies, Curtis says, they have been shown to have a physical effect. Those who thought of someone they had consciously forgiven despite being wronged by them in the past were able to jump higher than participants who received no such instruction, he says. Curtis, who also researches positive psychology, asks clients in his small part-time private practice to keep gratitude journals, which is something that he also does personally. In addition, he uses motivational interviewing techniques to help clients develop forgiveness. If the client is still resistant to the thought of issuing forgiveness, then the counselor can broach the idea of the client at least letting go of his or her anger, he adds. These individuals need to obtain a better balance between their emotional states and their thinking states. Over time, as the body is constantly put into this "fight or flight" mode, the immune system may treat chronic stress or anger almost like a disease, triggering inflammation. To help ameliorate the effects of toxic emotions, Neukrug recommends that counselors teach clients how to sit and engage in quiet contemplation. By taking time for self-reflection, clients can become better aware of how they are reacting to these thoughts, both emotionally and physically, and can then engage in stress reduction techniques such as progressive relaxation and mindfulness exercises. Neukrug also recommends what he calls "life-enhancing changes" such as exercising, eating healthfully, journaling, confronting and resolving personal conflicts, and getting enough sleep. He also is a big proponent of nurturing personal relationships, taking regular breaks from work and going away on vacations to lessen the effects of stress.

The primary clinical goal is to habituate reactions of the limbic and autonomic nervous systems (Fig. Consequently, patients who achieve full habituation of their reactions do not experience annoyance, anxiety, or any other negative reactions of their brain and the body. Note that the patients still perceive their tinnitus and, in case of exclusive habituation of reactions, the proportion of the time when they are aware of tinnitus is still the same. Nevertheless, since these patients no longer are bothered by their tinnitus, even when perceived, tinnitus ceases to be an issue. In this case, tinnitus-related neuronal activity is blocked before it reaches the level of awareness, and patients are unaware of the presence of tinnitus. Note that even when a very high level of habituation of the reaction and perception is achieved, it is still not a cure for tinnitus, as patients can interaction with the auditory system, mechanisms of conditioned reflexes, and the physiologic mechanisms of the brain plasticity) was suggested (Jastreboff, 1990, 1995; Jastreboff et al, 1996a). Use of habituation to help tinnitus patients was first proposed by Hallam et al (1984), but their model was psychological rather than physiologic. Consequently, their approach to induce and sustain habituation was different, focused on reassurance, relaxation, and attention distraction (Jakes et al, 1986), and did not appear to produce significant, sustained improvement in tinnitus patients. Retraining counseling acts to decrease the level of stimulation from the cortical areas of the brain to the limbic and autonomic nervous systems and to decrease the general level of activity within these two systems. During counseling, a number of points are presented to the patient: (1) the perception of tinnitus results from a compensation occurring within the auditory system, (2) tinnitus is a problem because of the activation of emotional (limbic) and autonomic nervous systems, and (3) by using the plasticity of the nervous system, it is possible to retrain the brain to achieve habituation of tinnitus-induced reactions and tinnitus perception. Once the patient accepts these ideas as realistic and "making sense" to them, this puts tinnitus into the category of neutral stimuli, to which they may gradually habituate. The crucial point to recognize, for both the therapist and the patient, is that tinnitusinduced reactions are governed by the conditioned reflex principle. Consequently, the conscious realization of the benign nature of tinnitus is not sufficient to remove these reactions, and a significant amount of time is needed for their gradual extinction. Sound therapy provides significant help in the process of habituation by decreasing the strength of tinnitus-related neuronal activity within the auditory system and from the auditory system to the limbic and autonomic nervous systems. Therefore, the strength of tinnitusrelated activation within all loops presented in Figure 1 decreases, making habituation of tinnitus easier. Specifically, sound therapy acts by providing the auditory system with constant, lowlevel, neutral auditory signals to (1) decrease the contrast between tinnitus-related neuronal activity and background neuronal activity, (2) interfere with the detection of the tinnitus signal, and (3) decrease enhanced gain within the auditory pathways. As predicted by the model, tinnitus maskability may decrease a few decibels (Jastreboff et al, 1994), but the change is too small to have a practical significance for patients. Although some patients achieve a high level of tinnitus habituation, to be of clinical significance, habituation does not have to be complete, and patients can experience significant improvement even with partial habituation of reactions and perception. Since the habituation-related modifications of the nervous system occur above the source of tinnitus, the etiology of tinnitus is irrelevant, and any type of tinnitus, as well as somatosounds, can be treated by inducing habituation. Journal of the American Academy of Audiooogy/Volume 11, Number 3, March 2000 From the perspective of achieving habituation, the masking of tinnitus is counterproductive, since it prevents detection oftinnitus (signal to be habituated), thus preventing, by definition, habituation. Even partial masking is not recommended, as it will change the tinnitus signal, and habituation would occur to this modified signal. Once the external sound is removed and the tinnitus signal is restored to its initial characteristics, it will not be effectively habituated. The relationship of the effectiveness of habituation from the sound intensity is presented in Figure 4. All of our senses are acting upon the principle of gradient or the difference between a signal and its background. The same sound appears louder and evokes more detectable change in the neuronal activity when there are no other competing sounds. When the same sound is presented with some additional auditory background, it will appear to be softer, and the neuronal activity evoked by it will become more difficult to detect. However, by enhancing background neuronal activity, through exposing patients to low-level sounds, the relative strength of the tinnitus signal decreases, thereby making habituation easier. Enhancement of the background sound can be provided by enrichment of environmental sounds, which can be further amplified by hearing aids for patients with a significant hearing loss or by the use of special sound generators.