The revisions eliminated the restrictive lien provisions previously imposed by some States and excluded parental liability for disabled adults. The Social Security Act Amendments of 1962 increased incentives to the States to provide for a wide range of social services without cost to recipients or applicants for public assistance, to those previously receiving assistance payments and to those likely to become applicants for or recipients of financial assistance. These amendments authorized open-ended matching formula grants to single State agencies with 75 percent Federal reimbursement for most services. A further restriction (later lifted) required that 90% of costs go to "actual" recipients. Braddock estimates that total social service obligations to mentally retarded children and adults progressed from nearly $2 million in 1963 to nearly $114 million in 1973. The enactment required States to accept these goals for the recipients: self-sufficiency, self-care, reduction of inappropriate institutional care and services to individuals who are appropriately placed in institutions. Fee schedules for services scaled to income are required if the State uses Federal funds to serve persons whose income exceeds 80 percent of the State median income. A wide range of possible services is specified within these limits, with the States setting priorities by target group and by type of service. The extent to which mentally retarded clients will benefit depends largely on the effectiveness of advocacy in the State planning process. The Federal concern is limited to receiving an acceptable State plan as a condition for Federal financial participation; the State plan no longer is required to detail the actual services to be offered. The State services are determined by an intra-State planning process culminating with a plan approved by the Governor. This leaves the extent of participation by the retarded undocumented in 19 States. However, otherwise eligible persons in public institutions, other than "medical institutions," remained ineligible for both federally aided public and medical assistance. The eligibility depended, however, on their receiving "active treatment" of a "health or rehabilitative" nature. Statutes required conformity with the life safety code; and regulations required compliance of the institutions with further specific qualitative standards of service in order to qualify. The social insurance provisions of the Social Security Act of course, covered mentally retarded persons generically insofar as they entered the labor force in covered occupations. It is impossible to estimate the number of retarded workers who qualified for retirement payments without disability because of the tendency of a high proportion of the mildly retarded to "disappear" into the general working population and in effect cease to be identifiably retarded. Nor is it possible to retrieve the number or amounts paid in the case of retarded minor dependents of deceased workers. In 1957 an important amendment to the Social Security Act authorized benefit payments to "adult disabled children. Depending on what classification system is used, it is estimated that 70 percent (250,000) of the recipients of these "adult disabled child" benefits have had a primary diagnosis of mental retardation, and have received benefits increasing from $22 million in 1958 to $288 million in 1975. The Social Security Act in all its ramifying and evolving provisions has thus contributed by far the greatest volume of Federal dollars to mentally retarded children and adults, accounting overall for two-thirds to four-fifths of all such funds in any year since 1955 (Braddock, pp. These programs, although nowhere specifying mental retardation categorically, have been the most stable source of support to mentally retarded individuals. The Public Health Service is the Federal agency charged by law to "promote and assure the highest level of health attainable for every individual and family in America" and to develop cooperative relations in health projects with other nations. Nashville, Tennessee, to develop a doctoral program in psychology emphasizing mental retardation. The N I M H portion supported the behavioral component of the survey of mental retardation research sponsored by N A R C and conducted by Masland, Sarason and Gladwin. In the major reorganization of 1966 and 1967, N I M H was separated from the other institutes and became a part of the Health Services and Mental Health Administration, and was later incorporated into the Alcohol, Drug Abuse and Mental Health Administration, with mental retardation activity reduced to a small volume of research grants. In 1950 the National Institute of Neurological Diseases and Blindness had been created. He gave direction to the collaborative perinatal research project in 1959, involving a massive followup of some 56,000 pregnant women and their children over a seven or eight year span.
However, cleaner fuels can be more expensive and can increase national reliance on foreign fuel sources. Reduction in emissions from stationary sources can also be accomplished through increased attention to plant maintenance. Plants that release significant quantities of pollutants into the environment frequently do so as the result of improperly maintained equipment. Adequately scheduled maintenance must be performed to reduce both the exhaust and amount of fugitive emissions released from vats, valves, and transmission lines. Periodic maintenance also reduces the likelihood of spill-related accidents by discovering faulty equipment before problems occur (Godish, 1997). A final way to reduce emissions from stationary sources is through the use of advanced, addon control technology. Control devices can destroy or recover gaseous compounds or particulate matter for proper disposal or re-use. The pollution control operations used to destroy or capture gases include combustion, adsorption, absorption, and condensation. Control devices that implement these processes include thermal incinerators, catalytic incinerators, flares, boilers, process heaters, carbon absorbers, spray towers, and surface condensers. The most important process parameters for selecting air pollution control equipment are the exhaust gas characteristics obtained from emissions tests and process or site characteristics obtained from a field survey. Many factors (such as particle size and chemical characteristics) determine the appropriate particulate control device for a process. Devices most commonly used to control particulate matter include electrostatic precipitators, fabric filters, venturi scrubbers, cyclone collectors, and settling chambers. The following section provides a more detailed discussion of each type of control technology used for both particulate and gaseous emissions (Godish, 1997). Examples of particulate matter include smoke, dust, or some forms of fine mist and is entrained in effluent gas streams or suspended in ambient air. Toxic substances, such as sulfates, sulfites, nitrates, heavy metals, and polycyclic organic matter are predominantly carried by particles in this size range. Typically, particles must be captured from an effluent gas stream; therefore, characteristics of the particles and the gas stream will determine the appropriate control device. Characteristics that must be considered include the particle size and resistivity, exhaust flow rate, temperature, moisture content, and various chemical properties of the exhaust stream such as explosiveness, acidity, alkalinity, and flammability. Exposing a highly explosive, volatile substance to a control device that relies primarily on electrical charge would be a dangerous and inappropriate use of technology. In many cases, a combination of multiple devices yields the best collection efficiency. For example, a settling chamber can be used to remove large particles from the exhaust stream before it enters an electrostatic precipitator where smaller particles are removed. The Venturi scrubber uses wet impingement to trap gas-laden particles in a liquid form. Venturi Scrubber 9-11 Control of Stationary Sources (Particulate Matter) Venturi Scrubbers. Venturi scrubbers use a liquid stream to remove solid particles, as shown in Figure 9-1. A venturi scrubber accelerates the waste gas stream to atomize the scrubbing liquid and to improve gas-liquid contact. In a venturi scrubber, a "throat" section is built into the duct that forces the gas stream to accelerate as the duct narrows and then expands. Depending on the scrubber design, the scrubbing liquid is sprayed into the gas stream before the gas encounters the venturi throat, or in the throat, or upwards against the gas flow in the throat.
Diseases
This tendency is most apparent on the broadest levels of "generic" services, such as income maintenance, social services, education and health services. The net effect has been to multiply the resources, but to make it more difficult to evaluate their impact on the specific problem. Consolidation of agencies, programs and budgets has managerial advantages and in the long run may result in economy and efficiency. The advocates of particular interests, such as mental retardation, however, are concerned that increasing anonymity within broad-gauged legislation will blunt the sharp edge of attack on the problem, and that the ebb and flow of politically and socially popular causes will undermine the sustained resolution of the problem. The target elements in mental retardation may be divided broadly into two groups: a) those dealing with broad basic strategic elements such as basic research, applied research and development, preventive strategies, planning and coordination, information and data analysis, manpower and personnel training, and facilities improvement and construction; and b) those relating to individual services and supports including income maintenance, residence, personal and social services, health, developmental and educational services, work training and employment, legal and protective services, and social integration. Presidential goals set for the committee are: (1) to reduce the occurrence of mental retardation by one-half before the end of the century, (2) to return to the community one-third of the retarded persons residing in institutions, and (3) to assure retarded individuals full status as citizens under the law. In carrying out its mandate, the Committee acts as a focal point for the circulation of information, the coordination of activity and the stimulation of effort. It evolved from a Departmental Committee on Mental Retardation originally established in 1955, but with broadened scope of responsibility and with a special charge to serve as a central clearinghouse for information and resources available to all handicapped populations. In 1973 it became a part of the Office of Human Development which focuses on groups of Americans with special needs. The Bureau funds research and demonstration activities for (1) children with physical and mental handicaps, and (2) institutionalized children who are being returned to community and home settings-important constituents in the achievement of the Presidential goals for mentally retarded persons. These functions need to be fully coordinated with all other efforts to provide alternatives to institutional residence and supporting service for those who are mentally retarded. A number of experimental and demonstration projects, some in collaboration with the Bureau of Education for the Handicapped, are exploring the most effective approaches and techniques of integrating handicapped and non-handicapped children in these pre-school developmental programs. Again, a crucial issue is in the coordination of these programs with others in early intervention and developmental stimulation of children at risk of mental retardation. Vocational Rehabilitation programs have been in operation since 1923 but made available to mentally retarded persons since 1943. However, the number of mentally retarded who have been "rehabilitated" increased very slowly, comprising only 3% of the total in 1960, but accelerating to 11. Statutory authority of 1973 emphasizes "serving first those with the most severe handicaps," especially "those who have been under-served in the past. Though a large proportion of mildly retarded people make their way unaided into the employment market, for many who are marginally employable, personal-social factors limit their vocational adaptability and make them vulnerable to labor market fluctuations. Of a total $609 million appropriated in 1974, $82 million was obligated for mentally retarded individuals. At 90% of costs for not more than 3 years, these allow expansion to new clientele but focus on those on Public Assistance. This allows for upgrading existing rehabilitation facilities on a 90% matching basis. These are 90% grants for special projects to improve the services provided in approved vocational rehabilitation facilities. Phase-out grants over a period of 4 years 3 months start at 75% and reduce to 30% in the final year, in order to facilitate the start-up of new facilities. Technical Assistance to Rehabilitation Facilities provides teams of experts to meet special problems encountered in the development and operation of facilities. Most frequently requested are consultations in administration, program, production, contract procurement and fiscal management. Twenty percent, or $40,000, of this budget in 1974 was directed to mental retardation facilities. Twelve of these concentrate on medical rehabilitation, three in general vocational rehabilitation, one in deafness, and three specialize in rehabilitation of the mentally retarded. Of the total 1974 appropriation of $14 million for this program, a bit less than $1. Gains have been made in the transition between special education and vocational training and placement, but links with other community services need strengthening, especially provision of resources to support the movement of retarded individuals from institutions to community; advancement of research-based technical knowledge and skill in developing and utilizing productive capabilities of more severely retarded clients.
Current and Future Needs /Future Directions Many studies are addressing the issues of possible new treatments and preventive strategies for food allergy, but we only report here the major trends expected to have a socioeconomical impact in the near future. The aim is both to reduce the risk of major reactions and to avoid nutritional restrictions in patients suffering from food allergy. Studies are on-going to evaluate the effectiveness and the safety of oral desensitization under blinded conditions. If the efficacy of tolerance induction is confirmed in prospective studies, this will represent a breakthrough in the management of such patients24. Dietary Prevention: Traditionally predicated on the avoidance of food allergens, epidemiological data highlighting the involvement of the intestinal micro-flora in the development of allergic disease have been used to design strategies to interfere with the pathogenesis of food allergy using "success factors", rather than the exclusion of "risk factors". Studies on this approach, defined as "proactive" in contrast to the traditional "prohibitionistic" approach, have explored the effect of pro-biotics and/or pre-biotic supplementation on the development of allergy. To date, the initially encouraging results with pro-biotics supplements25 have not been confirmed by further studies26, but the topic is still a matter of active debate, particularly because the infant food industry is extremely interested in this field27. Socio-economic: Food allergy is a modifiable risk and its only form of management is dietary. Unsupportive or uninformed measures arising from the family or school environments (emphasizing the importance of patient/parental education). Ultimately, the empowerment of patients through education, the guidance of an allergist and dietitian, and support from and quality-of-life-enhancing strategies to be implemented through all levels of care, in the absence or failure of other approaches. These evidencebased guidelines are of the utmost importance to identify patients suffering from food allergy and to reduce unnecessary dietary treatments. Full evaluation of the possibilities offered by novel diagnostic microarray-based technologies. Education of clinicians in affluent parts of the world in the recognition of possible food allergy symptoms. This latter need is particularly important in countries experiencing rapid economic development, where a rise in food allergy prevalence is expected due to the linear relationship between gross national product and allergy. The development of sensitive prediction indices is also needed to find out which children will outgrow their food allergy, and when. Quality of life data, once an unpopular outcome of studies, can now be quantified using estimators or questionnaires adapted for children participating in trials. The clinical relevance of sensitization to pollen-related fruits and vegetables in unselected pollen-sensitized adults. Unmet Needs Despite over-perception of food allergy in developed countries, the extension and manifestations of the disease at the global level remain poorly explored. The recognition of the importance of the problem is poor, even in the developed world, as the behavior of the medical community in emergency rooms attests: the majority of patients presenting with food anaphylaxis are not adequately treated at this level. Food hypersensitivity in two groups of children and young adults with atopic dermatitis evaluated a decade apart. Second symposium on the definition and management of anaphylaxis: summary report-Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. First aid management in children who were prescribed an epinephrine autoinjector device (EpiPen). Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993-1994 to 2004-2005. The impact of food hypersensitivity reported in 9-year-old children by their parents on health-related quality of life. The difficult nutritional balancing act of reconciling the special needs of the child with food allergy, taking into account the age and stage of development (calorie-, vitamin- and mineral-wise) requires individual dietetic advice. Patients with food allergy are in need of a virtuous therapeutic relationship between nutritional compliance, allergy risk minimization and the paramount need for vigilance: success of their elimination diets, the cornerstone of food allergy management, depends on these basic conditions. Contamination of dry powder inhalers for asthma with milk proteins containing lactose. Economic burden of atopic manifestations in patients with atopic dermatitis analysis of administrative claims. Probiotics and prevention of atopic disease: 4-year follow-up of a randomised placebo-controlled trial.
Availability of Health Care services Availability refers to the existence of services and the presence of sufficient personnel to provide those services. Rural areas have fewer physicians and clinicians, nurse practitioners, and specialists; especially obstetricians, pediatricians, psychiatrists, and social-service professionals. Access to Health Care services Accessibility refers to whether a person has the means to obtain and afford needed services, or is impaired by certain barriers to accessing health care. It has been noted that, "rural residents were more likely to report that cost had kept them from seeing a doctor than were urban residents. The proportion of adults who reported deferring care because of cost increased with the level of rurality. Consider the case of a rancher with a high income, who lives in a medically underserved frontier area, and who suddenly suffers a heart attack. A Landscape View of Life and Health Care in Rural Settings 27 He may not have access to the most basic emergency care because of his geographic distance from the hospital, even though he has comprehensive medical insurance. In addition to economic and physical barriers to health care, there are cultural and educational barriers that result when rural individuals lack a particular skill or element of education. Perhaps a small clinic is seeking a grant to access funding to implement a health program. Or there may be a community perspective that opposes the use of federal or state welfare programs. Rural-based clinicians must recognize the stigma attached to the use of some types of services, and then adapt delivery approaches to try and assure anonymity and confidentiality within a rural context where people tend to be acquainted or related. With the wide diversity among rural residents, acceptability of available services, like community nursing services, can be hampered by any of several factors, as described in Box 2. In turn, ethics conflicts in rural settings generally are associated with these characteristics. Due to the geographical and social structure of rural communities, rural health care providers commonly interact with members of the community in more than one relationship-i. Generally, rural providers live and work in the same place, and everyone knows one another. Rural health care professionals frequently interact outside the office with community members. These multiple relationships can enhance and complicate the patient-clinician relationship. This regular contact allows rural clinicians to have a knowledge of their patients that is unlikely in more urban settings. The patient-provider relationship is formed and cultivated in both the examining room and in the general store. This can be very beneficial for treatment; however, ethics issues can also arise in maintaining professional boundaries with patients. Almost every rural ethics issue encountered is influenced and shaped by provider familiarity and overlapping roles. Patient-provider relationships and overlapping roles are discussed in more detail in Chapters 5 and 6, respectively. Community values Can Differ From Professional Practices Authors have noted that rural residents from various cultures hold different views of pain, the etiologic explanations for sickness, tolerance of illness, and the use of folk healers. When the pervasive community values about illness differ from the traditional practice and ethos of clinicians, it is more likely that ethics conflicts will arise. Ethics conflicts may occur if providers show insufficient respect for cultural and community values. Recognizing community values and openly communicating with patients about how those values and beliefs differ from traditional health care clinical and ethics practices are key to the provider in addressing potential conflicts. Clinicians should also consider approaches to patient care that apply community values to their professional standards of practice. For example, a community value may be that an individual nearing death is allowed to remain in his or her home, with family, friends and neighbors supporting the family during this life transition. Embarrassment may be evidenced in certain ethnic or cultural groups, who may minimize symptoms of illness, not acknowledge self-care practices, or not seek care when it is needed.
Syndromes
Idaho doubled its State budget for mentally retarded citizens, from $3 million to $6 million in five years. In 1969 Nebraska adopted its new regional plan with a budget of $600,000 which provided services for 85 clients that first year. The Ohio division of Mental Retardation and Developmental Disabilities presently serves five times as many persons in community as in residential settings, a reversal from 1968. In that period the budget has increased 400%, with 70% of the total supporting institutions, down from 90% seven years ago. The South Carolina budget for the Department of Mental Retardation has grown from $9. The budget for Developmental Disabilities in South Dakota, not including institutional support, has grown from $60,000 in 1971 to over $1 million in 1975. Here are some of the findings from the Gettings survey and from other sources: Education All States, with exceptions of Ohio and Mississippi, now have mandatory special education laws, 34 of which have been passed or revised in the past two years. Ohio, in particular, has made impressive strides in extending services to moderately retarded children over the past eight years through a network of county mental retardation service boards. In terms of coverage, 37 States require educational services for all retarded children-regardless of degree of their handicap. In six States education is mandatory only for those classified as "educable" or "trainable" (Georgia and New York exclude only the profoundly retarded). The Council for Exceptional Children has reported that the mandatory laws of six States have exclusionary language with regard to certain categories of children with retardation. The Council for Exceptional Children, Digest of State and Federal Laws, 3rd Edition 1975. As to the upper age limit on eligibility, there is more uniformity, with 32 States setting age 21 as the upper limit. Three have none, three specify age 18, three at 20, four allow retention to 23 or 25, and six made no response. Not every State can report these rates of fiscal growth, nor are budgetary increases synonymous with quality improvement or the absence of problems and frustrations. The unmistakable fact is, however, that States have been showing real progress in the development and expansion of services to mentally retarded individuals over the past ten years. This growth has been greatly stimulated by Federal programs and matching Federal dollars. However, in terms of overall outlay, the costs of such direct service borne by the States and their subdivisions exceed by many times the contribution of Federal agencies. Program Trends in the States National policies and trends are not always reflected uniformly in what happens on the local scene. In recent years, national attention has focused on a number of goals for special education, rehabilitation, residential services, community services, and health and preventive services as they relate to mentally retarded people. In general there has been an assumption that these projections reflected the thinking of people in most parts of the country. What are the trends in the States in these major areas of service and concern for individuals with mental retardation Here again, because of the lack of adequate information processes, it is impossible to obtain and to summarize all the facts. There is some evidence of a trend in recent years to widen the age range at both lower and upper limits, with variations in what is permissive and what is mandatory in the various statutes. In general there is greater recognition of the value of early education below the traditional "school age" than of continuing education beyond traditional "school age. What is generally meant by "mainstreaming" is the placement of exceptional children in regular classes with special assistance geared to individual needs through the use of resource persons. However, 22 stated that very few school districts in their States were mainstreaming retarded children, 11 indicated mainstreaming to some extent and 9 reported considerable use. Several felt that it was being applied inappropriately, especially in reported cases of wholesale placement of children with substantial educational and adaptive handicaps in regular classrooms. Other evidence suggests that the principle is understood quite differently from place to place and that school administrators are generally conservative in initiating programs which require considerable recasting of established practices. On the other hand, the growth of specialized resource personnel in the public school as a whole has interested many administrators in exploring more extensive integration of children with academic limitations in normal classroom situations.
This prevents the new onset of asthma in patients with allergic rhinitis and prevents the onset of new sensitizations. Asthma and allergic rhinitis are common health problems that cause major illnesses and disability worldwide. The strategy to treat allergic diseases is based on: (i) patient education, (ii) environmental control and allergen avoidance, (iii) pharmacotherapy, and (iv) immunotherapy. They have to make the initial clinical diagnosis, begin treatment, and monitor the patient. Modern information technology is valuable, especially to educate younger subjects. Education and training programs should contain a written self management action plan. Primary prevention is difficult because the reasons for mechanisms involved in the progression of sensitization in increasing numbers of individuals resulting in allergic diseases are incompletely understood. Several studies of comprehensive environmental interventions in asthmatic children report benefits. Inadequate or lack of tolerance in allergic individuals appears to link with immune regulatory network National asthma and allergy plans. The Finnish Asthma Programme 1994-2004) have concluded that the burden of these community health problems can be reduced. The change for the better is achieved as governments, communities, physicians and other health to an educational plan to implement best practices for prevention and treatment of allergic diseases. The total global cost of care for people with asthma and allergic disorders is disproportionately high despite the relatively low cost per person mainly due to the high prevalence of these disorders. Education should focus on training physicians to promote and foster self-management skills in their patients. The main defining characteristics of allergists are their appreciation of the importance of external triggers in causing diverse diseases; their expertise in both the diagnosis and treatments of multiple system disorders, including the use of allergen avoidance and the selection of appropriate drug and/or immunological therapies; and their knowledge of allergen specific immunotherapy practices. It may lead to over-prescription of therapy and costly and unnecessary allergen avoidance measures, including exclusion diets that can lead to nutritional deficiency and secondary morbidity. The responses from the Member Societies along with the scientific reviews which are included in the White Book form the basis of the World Allergy Organization Declaration. Allergens And Environmental Pollutants IdentifiedNeed: Evidence-based information about the major indoor and outdoor allergens and pollutants responsible for causing or exacerbating allergic diseases and asthma is either lacking or, when available, is not always universally accessible. Recommendation: Local indoor and outdoor allergens and pollutants which cause and exacerbate allergic diseases should be identified and, where possible, mapped and quantified. Appropriate environmental and occupational preventative measures should be implemented where none exist or as necessary. Strategies proven to be effective in disease prevention should also be implemented. Epidemiological Studies Of Allergic Diseases IdentifiedNeed: In several parts of the world, there is a paucity of published epidemiological information about the overall prevalence of allergic diseases and, in particular, about specific diseases. For example, there is little or no information about severe asthma; anaphylaxis; food allergy; insect allergy; drug allergy; and complex cases of multi-organ allergic disease. Data concerning some of these disorders are available in a few countries, but only for certain age groups.
They spent a year in Oak Ridge and supplemented their classroom training with part-time research assignments at the Laboratory. After two semesters, students would load fuel into the movable assembly in the Bulk Shielding Reactor, plotting the power output curve as fuel was added and the flux increased. The school expanded during the 1950s, occupying a new building completed by the Laboratory in 1952 and specializing in advanced subjects not taught at universities. Under director Lewis Nelson, the school in 1957 joined six universities in offering a standard two-year curriculum. Five years later, the school closed when university science and engineering programs became equal to the task of providing this type of specialized instruction. Flying High When Union Carbide assumed management of the Laboratory, the Graphite Reactor was the only nuclear reactor on the Oak Ridge Reservation. In addition, it had high-speed computers, high-energy cyclotrons, and Van de Graaff particle accelerators. Equally important, the Laboratory had succeeded in assembling an aggressive research staff that worked with a sense of urgency rivaling that of the war years. Electronics experts from the Physics Division, for example, moved into an Instrumentation and Controls Division, and the Shielding group became a separate Neutron Physics Division (renamed the Engineering Physics Division, and later the Engineering Physics and Mathematics Division). Similar organizational changes took place in chemistry, reactor technology, and other Laboratory research pursuits. By 1953, Laboratory personnel numbered 3600, more than double the wartime peak; the staff was divided into 15 research and operating divisions. The prime force behind Laboratory expansion during the early 1950s ended in 1957, when Congress objected to continuing the costly nuclear aircraft project in the face of supersonic aircraft and ballistic missile development that made the nuclear aircraft concept obsolete. In response to this congressional decision, the Laboratory shelved its aircraft shielding and reactor prototype investigations. In 1961, President John Kennedy canceled the remainder of the nuclear aircraft pr. The scientific data gleaned from the aircraft project, however, soon proved useful when the Laboratory undertook the design of a molten-salt reactor for electric power production. William Manly, a veteran of the nuclear aircraft program, later pointed out that the knowledge gained in handling liquid metals and fused salts also proved useful in design of nuclear generators and reactors for use in space. The 21,000-ton ship, propelled by a pressurized-water reactor, was a floating laboratory, demonstrating the feasibility of commercial ships propelled by nuclear energy. At the Laboratory, a Maritime Reactors group headed by Alfred Boch provided technical review of the ship reactor design, while other Laboratory units assisted with on-board health monitoring, environmental studies, and waste disposal. Savannah could remain at sea for 300,000 miles without refueli ng, proving the scientific and engineering feas ibility of such ships. Nuclear-powered ships, however, could not compete economically with oil-fired vessels; thus, the N. In the 1960s, the Laboratory became involved in nuclear power studies for the national space program, and in the 1980s it studied space reactors for the Strategic Defense Initiative. Postwar dreams of nuclear-powered trains, automobiles, aircraft, and tractors ended, but the sc ientific fi ndings that evolved from these endeavors would find applications in other areas in the years ahead. Chapter 4 Olympian Feats A symbol of peaceful competition first in the ancient world and then in the 20th century, the Olympics were revived after World W~ I, not only in quadrennial athletic performances but also in scientific competitions. In these competitions, the world-class research at Oak Ridge National Laboratory often took the laurels. Science during the 1950s became a full-blown instrument of foreign policy, both in Cold War weapons competition and in peaceful applications of nuclear science, especially nuclear fission reactors and fusion energy devices. Both these programs earned the Laboratory much prestige at the 1955 scientific olympics. Elsewhere, other nuclear mileposts were passed: a demonstration atomic reactor to propel submarines and an experimental breeder reactor began operating in Idaho, and the first university research reactor was unveiled at North Carolina State University. In a dramatic speech on the future of the atom to the United Nations in 1953, President Eisenhower pledged the United States "to find the way by which the miraculous inventiveness of man shall not be dedicated to his death, but consecrated to his life. The initiative, Alvin Weinberg declared, would make nuclear science the "touchstone of peace. Beyond its work on the homogeneous reactor, the Laboratory in the l950s-as a national center for chemistry and chemical technology-focused on developing fluid fuels for nuclear reactors. The "A homogeneous reactor held the promise of simplifying nuclear reactor designs. It also provided conceptual designs for a transportable Army package reactor, a maritime reactor, and a gas-cooled reactor.
It relied on the states and the people to obey whatever it decreed, but voluntary compliance proved to be virtually impossible. To support its operation and pay for carrying on the war, it had to rely on contributions from each state as set forth by the national legislature. If hard-pressed for cash, they would pay less, and there was nothing the central government could do about it. First, the unanimous agreement of all the states was required before the document could go into effect. Maryland withheld its consent until all the states ceded their western lands to the central government. That state had no claim to the western country and hoped to share in the largess of more fortunate states, such as Virginia. Not until 1781 did all the states agree to the condition and Maryland finally added its consent. The second problem involved amending the Articles once the government began operation. Again it required unanimous approval by the states, and that proved to be impossible. What the document created was a government subservient to thirteen other governments. It must be remembered that at the time, the delegates who produced the Articles of Confederation had no experience in establishing a workable central authority that would understand and recognize the sovereignty of each state. It would take a learning experience of almost half a dozen years for others to decide what had to be done to create a permanent Union that could pass and enforce laws to protect liberty and property for its citizens and show proper regard for the rights of the states. The delegates debated the Articles of Confederation for over a year, and not until November 15, 1777, was it formally adopted. Then, it took another three and a half years before all the states agreed and the government under the Articles was established. If they could maintain an army in the field over an extended period of time, it was very likely that they could obtain their objective. They rendezvoused with other British troops from South Carolina under General Henry Clinton to constitute a powerful force of 30,000 soldiers. Washington had less than half that number and realized he could never hold New York. Following an inevitable defeat, he moved his army under cover of a thick fog across the East River to Manhattan. Howe pursued him up the Hudson River valley, and Washington retreated to New Jersey. Washington crossed the Delaware River at Trenton and tried to keep his army together. But his soldiers shivered in the December cold and began to desert, since the situation looked hopeless. Their general pleaded with Congress to provide supplies and additional troops but had little success. On Christmas evening, with about 2,500 men, he crossed the ice-filled Delaware River about nine miles northwest of Trenton and attacked the Hessians who had taken the town and were sleeping off their Christmas celebration. Lord Cornwallis attempted to strike back, but Washington hit the British rear guard at Princeton and forced Cornwallis to retreat to protect his military supplies. Resolved as ever to put down the rebellion, the British came up with a three-pronged plan. They would bring down two separate armies from Canada, which would meet in Albany and then join a Independence and Nation Building 43 force sent northward by General Howe in New York, thereby cutting off New England. Lawrence via Lake Champlain and commanded by General John Burgoyne was surrounded by thousands of Americans from Massachusetts, New Hampshire, and New York led by General Horatio Gates. Recognizing the hopelessness of his situation, Burgoyne surrendered his army of 6,000 at Saratoga on October 17, 1777.
This lifts up the proximal nail fold that becomes inflamed and irritated from the proximal stacked thin sharp nails, resulting in paronychia. Another clue for the diagnosis is the shortening of the distal nail bed due to the excessive pressure of the distal plate onto the bed and the lifting of the proximal part of the plate from the successive superposed nails. Fingernails may be affected, but in this case, it always follows an acute injury that the patient remembers. Even after an adequate surgical treatment, a permanent nail dystrophy may be observed in about 30% of teenager cases. Primary or idiopathic chilblains is more frequent in children, compared to the secondary form, associated with connective tissue disease and hematologic disorders. Capillary refill time was prolonged in 100% and modified Allen test was abnormal in 75. Beside finger swelling and proximal interphalangeal joint swelling, skin ulceration was observed in more than half of the cases (54. Predisposing factors among children are the presence of cryoproteins,47 excessive cold exposure, and anorexia nervosa. If needed, nifedipine, which produces vasodilation, has been demonstrated to be effective in reducing pain, facilitating healing, and preventing new lesions of pernio. When present, it is induced either by pressure during clinical examination or from footwear. The authors have observed an extremely painful exostosis, associated with an infection with septic shock in a child (Figure 16. Subungual exostosis is an osteocartilaginous tumor that affects the distal phalanx of the toes or fingers. It was for a long time considered as a reactive dermal metaplasia resulting from microtrauma. The hallux was the most common location of the exostoses (80%) followed by the second toe (6%), third toe (7%), fourth toe (5%), and the fifth toe (2%). Pain was the most common complaint (77%) followed by a swelling mass under the nail (31%), nail dystrophy (15%), or other complaints such as shoe wear rubbing or stiffness (3%). The bony proliferation usually elevates the nail plate, mostly at its distolateral part, sometimes mimicking a subungual wart. Radiographs demonstrate a pediculated exophytic lesion of the distal phalangeal bone. Prostaglandins are found in the nidus at levels of 100 to 1 000 times than that of normal tissue. The the Painful Nail 235 Downloaded by [Chulalongkorn University (Faculty of Engineering)] at nidus releases prostaglandins (via Cox-1 and Cox-2), which in turn induce vasodilation. The resultant increased capillary permeability in the surrounding tissues is believed to mediate tumor-related pain, classically described as night nagging pain relieved by salicylates. Plain films may be normal or may show a solid periosteal reaction with cortical thickening. The nidus is sometimes visible as an ovoid well-circumscribed lucent region, occasionally with a central sclerotic dot. It typically shows a focally lucent nidus within surrounding sclerotic reactive bone. It most commonly demonstrates a lytic lesion rather than the classic appearance of reactive sclerosis surrounding a central lucent nidus. At that location, osteoid osteoma causes swelling of the distal phalanx or even enlargement of the entire tip and clubbing. Because of persisting pain, treatment is usually surgical, but spontaneous remission could be achieved in some patients following long-term treatment with nonsteroidal anti-inflammatory drugs. Subungual Neurofibroma Exceptionally, a subungual neurofibroma may induce moderate tenderness and deform the distal phalanx, as reported in an adolescent female.
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