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In 2017, one in every six work-related deaths was attributed to workplace violence for a total of 807-more than from equipment or fires and explosions. New legislation, the Workplace Violence Prevention for Health Care and Social Service Workers Act (H. Homicides and Suicides Homicides account for the majority of workplace violence deaths: 458 in 2017, compared with 500 in 2016 and 417 in 2015. Eighty-three of these homicides were among women workers, a proportion that has increased since last year despite a slight overall decline in total workplace homicides. In 2017, workplace homicide was the second-leading cause of job death for women workers, accounting for 22% of their work-related fatalities (roadway incidents was first). Domestic violence in the workplace has become a worsening problem; women were three times more likely to be killed by a relative or domestic partner at work than men. White workers experienced 48% of workplace homicides and Hispanic or Latino workers experienced 15% of homicides. Homicides among black workers and Asian workers were disproportionate related to overall employment: Black workers experienced 25% of workplace homicides, while representing only 12% of total employment, and Asian workers experienced 10% of homicides, while representing 6% of total employment. Overall, homicides were responsible for 31% of all work-related deaths among Asian workers (44 out of 144 deaths), 21% among black workers (113 out of 530 deaths), 8% among Latino workers (68 out of 903 deaths) and 6% among white workers (220 out of 3,449 deaths). Workplace homicides largely occur in transportation, law enforcement and retail, with motor vehicle operators (49 deaths), law enforcement personnel (46 deaths) and supervisors of sales workers (46 deaths) the leading occupations. The leading source of death from workplace homicide was assault by an assailant or suspect (235 deaths). Firearms were the primary source involved in workplace homicides, responsible for 355 workplace deaths. The last major increase in workplace suicides was just as the recession hit in 2008, when workplace suicides increased by 33%. Hopelessness, uncertainty and toxic work environments that include increased work pressures, workplace bullying and lack of control most likely have contributed to this growing problem. According to the study results, workplace suicides were highest for men, workers ages 65 to 74 years, those in protective service occupations and those in farming, fishing and forestry. Nonfatal, Serious Injuries the majority of nonfatal injuries from violence occur in health care, social assistance and educational services. The Bureau of Labor Statistics reported that in private industry, nearly 29,000 workplace violence incidents led to injuries involving days away from work in 2017. These attacks are serious, under-reported and often leave workers physically and emotionally scarred for life. All of these numbers and rates only reflect injuries that led to days away from work, not all violence-related injuries reported or all that occur. Health care workers are twice as likely to suffer a workplace violence injury as other occupations, and workers in psychiatric settings are at especially great risk, with a workplace violence injury rate of 181. In 2017, transit and intercity bus drivers and school or special client bus drivers experienced serious violence injuries at rates of 17. Since 2008, the rate of workplace violence injuries has increased 127% in private-sector educational services, 233% in state government and 118% in local government. Health Care and Social Assistance Workers in the health care and social service industries are particularly affected. The nature of their frontline work-direct contact with patients and clients-makes these workers at great risk for job-related violence. There were 27 homicides among workers in health care and social assistance in 2017, compared with 29 in 2016 and 15 in 2015. In 2017, the health care and social assistance sector accounted for 68% of lost-time injuries from workplace violence (excluding violence form animal and insects). Workers in nursing and residential care facilities experienced the greatest number of injuries from violence, followed by those in hospitals, social assistance and educational services. Nursing, psychiatric and home health aides, registered nurses and personal care aides were the occupations at greatest risk of 57 Tiesman, H. In 2017, the private-sector rate of workplace violence in health care and social assistance was 14. Since 2007, the rate of violence in nursing and residential care facilities has increased 54%, in home health services 184%, and in social assistance 28%, although this difference has fluctuated over time and last year was much higher at 118%. Home-based services such as home health, client management and social services have been playing a larger role in physical and mental care. In 2017, state government health care and social service workers were nearly nine times more likely to be assaulted than private-sector health care workers (128. In state government, psychiatric aides experienced injuries caused by violence at a rate of 693. Survey results released in 2012 by the Merit Systems Protection Board reported that one in eight federal government employees witnessed workplace violence. This violence against health care and social service workers is foreseeable and preventable. With the expected job growth in the health care and social assistance sectors, workplace violence events will continue to rise without safeguards in place. Workplace controls are more necessary than ever to address this systemic and serious issue, and reduce the prevalence and severity of violence in the workplace. Merit Systems Protection Board, "Employee Perceptions of Federal Workplace Violence: A Report to the President and the Congress of the United States," 2012, available at To date, the Trump administration has continued these programs, but there has been a decline in the number of workplace violence inspections conducted and citations issued. The report found that workplace violence is a serious and growing concern for 15 million health care workers, and is preventable through violence prevention programs. In 2015, an administrative law judge upheld the citations, but the employer appealed the case to the full review commission, where it was pending since July 2015. Government Accountability Office, "Additional Efforts Needed to Help Protect Health Care Workers from Workplace Violence," March 2016, available at Federal Regulatory Action In response to the growing threat from workplace violence, there have been increased efforts to secure workplace violence protections through mandatory regulations. However, the Trump administration has failed to move forward on the development of the workplace violence standard. In July 2017, in its first regulatory agenda, the administration moved the standard to "long-term" status, with future action on the standard undetermined. A small business review originally slated to begin in January 2019 has yet to occur, and the administration has declined to provide any information on when a proposed or final standard will be issued. The bill ensures that front-line workers have input in the plan, helping employers identify commonsense measures like alarm devices, lighting, security, and surveillance and monitoring systems to reduce the risk of violent assaults and injuries. State Regulations and Legislation A number of states have taken action to adopt laws, standards and policies on workplace violence, which vary widely. In December 2016, the California Department of Industrial Relations filed its final workplace violence standard with the California secretary of state, with an effective date of April 1, 2017. It was developed through consensus rulemaking, and it is a good model for a comprehensive regulatory approach to combat workplace violence. In response to a 2014 petition from a teacher, the California Occupational Safety and Health Standards Board tasked an advisory committee to examine workplace violence prevention in all California workplaces, which currently is going through the state process to develop a workplace violence standard for all of general industry. New York passed a comprehensive workplace violence standard in 2006, but it only covers the public sector. Connecticut, Illinois, Maryland, New Jersey and Washington have adopted some form of legislation specifically focused on health care settings. The measure requires public and private health care employers to establish a safety committee consisting of management and employees, and it requires the committee to establish a safety program that consists of: 1) a written policy; 2) an annual comprehensive risk assessment and recommendations for injury prevention; 3) a process for reporting, responding to and tracking incidents of workplace injuries; and 4) regular safety and health training. Chemical Exposure Limits and Standards Occupational exposure to toxic substances poses a significant and unreasonable risk to millions of workers and is a major cause of acute and chronic disease in the United States. Occupational diseases caused by chemical exposures are responsible for more than 50,000 deaths and 190,000 illnesses each year, including cancers and other lung, kidney, skin, heart, stomach, brain, nerve "Workplace Violence Prevention in Health Care," General safety orders, New Section: 3342," effective April 1, 2017, available at The costs of fatal and nonfatal occupational illnesses from chemical exposures create an enormous burden on the U. They make chemicals or are otherwise exposed early in the chemical life cycle, often at the highest exposures, for long durations, when little to no hazard information is known; are a conduit for bringing chemicals home to their families via clothing, equipment, skin and hair; and dispose of chemicals and sort through chemical-containing waste.

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Note: See Appendix C in this handbook for the Diagnosis Code List for Additional Ultrasounds for Pregnant Women. Abbreviated ultrasounds (procedure code 76815) are reimbursed for fetal position, fetal heart beat, placenta location or qualitative amniotic fluid volume when clinically indicated. Follow-up ultrasounds (procedure code 76816) are reimbursed when findings including fetal measurements for assessment of fetal size, and interval growth or re-evaluation of one or more anatomic abnormalities are documented in the report. Transvaginal Ultrasounds Ultrasound screening of the cervix should not begin before 16 to 20 weeks of gestation because the upper portion of the cervix is not easily distinguished from the lower uterine segment in early pregnancy. The report must include evidence of medical necessity, a plan of care and the results of the ultrasound study. If the diagnosis code is not included in the above list, the ultrasound must be billed with a modifier 22. A report submitted with the claim must include documentation of medical necessity, a plan of care, and the results of the ultrasound study. December 2012 2-69 Practitioner Services Coverage and Limitations Handbook Obstetrical Care Services, continued Fetal Velocimetry Reimbursement to the physician is limited for procedure code 76820 (doppler velocimetry, umbilical artery) to two per pregnancy for the growth-restricted fetus or diabetic pregnant woman. Reimbursement to the physician is limited for procedure code 76821 (doppler velocimetry, middle cerebral artery) to two per pregnancy to evaluate fetal anemia. Color flow mapping must be documented in the report for reimbursement of the separate procedure code 93325. If more than two biophysical profiles are required, the additional biophysical profiles must be billed with a modifier 22. A report must be submitted with the claim that documents the medical necessity for the biophysical profile and the result of each component. These components include fetal breathing, fetal movements, fetal muscle tone, fetal heart rate, and amniotic fluid volume. These components include fetal breathing, fetal movements, fetal muscle tone, fetal heart rate, amniotic fluid volume, and a non-stress test. Biophysical testing should not be performed earlier than the gestational age at which extra-uterine survival or active intervention for fetal compromise is possible. Note: See the Florida Medicaid Birth Center and Licensed Midwife Handbook for more information. December 2012 2-72 Practitioner Services Coverage and Limitations Handbook Obstetrical Care Services, continued Delivery Services Include Postpartum Services Delivery procedure codes 59410, 59515, 59614, and 59622 include immediate postpartum services within the delivery hospitalization. High-Risk Deliveries For the physician to receive enhanced reimbursement for a high-risk delivery, the recipient must have a diagnosis listed on the Diagnosis Code List for Delivery of High-Risk Pregnant Women. Inpatient Deliveries All inpatient labor and delivery services require an authorization number for reimbursement purposes. Deliveries of Less Than 20 Weeks Gestation Deliveries of less than 20 full weeks of gestation are reimbursed using procedure codes 59820 or 59821, not a delivery procedure code. Non-Practitioner Delivery If a recipient does not deliver with the assistance of a practitioner, the delivery is not reimbursable. Delivery of More Than One Infant Delivery of two or more infants from one pregnancy, by the same delivery method, can be reimbursed as only one delivery. When there is a vaginal delivery followed by a cesarean section, the provider must bill both the procedure code for the vaginal delivery and the procedure code for the cesarean section with a modifier 22 on the same claim form. Postpartum Visit Frequency Two postpartum visits within 90 days following delivery may be reimbursed per pregnancy when medically necessary. The physician must record the reason for the abortion in the medical records for the recipient. Enrollment in this program will enable the ophthalmologist to bill for services related to the provision, fitting, dispensing and adjusting of corrective lenses. Note: Contact the Medicaid fiscal agent for information on adding a specific provider contract (category of service) by calling Provider Enrollment at 1-800289-7799 or by visiting their Web site at Medicaid may reimburse special ophthalmological services, in addition to a general ophthalmological visit or an evaluation and management visit, if a special evaluation of part of the visual system is made or if special treatment is given. Note: See the Florida Medicaid Optometric Services and the Visual Services Coverage and Limitations Handbooks for additional information. Blepharoplasty Blepharoplasty is surgical repair of drooping eyelids by removing excess skin, muscle and fat. Select Public Information for Providers, Provider Support and then select Provider Handbooks. Note: See the Florida Medicaid Optometric Services Coverage and Limitations Handbook for additional information. December 2012 2-77 Practitioner Services Coverage and Limitations Handbook Ophthalmological Services, continued Lacrimal Punctum Plugs Medicaid reimburses for medically-necessary lacrimal punctum plugs. Reimbursement Limitations Temporary lacrimal punctum plugs are limited to 12 per year (maximum of four plugs every four months), for procedure code 68761, for treatment of dry eye syndrome when a more permanent conservative treatment will cause discomfort to the recipient. Procedure code 68761, (closure of lacrimal punctum by plug, each), includes reimbursement for plugs; therefore, the plug may not be billed separately. Service Exclusions A routine eye exam in the absence of a reported vision problem, an illness, disease, or injury is not reimbursable. Covered Procedures Medicaid enrolled dentists who are also enrolled with a specialty in oral surgery may be reimbursed for specific radiology and evaluation and management procedure codes. Note: See the Florida Medicaid Dental Services Coverage and Limitations Handbook for additional information. Reimbursement of Medicaid-covered organ or tissue transplants is limited to those services that are determined to be reasonable, medically necessary, and be standard medical procedures. Bone Marrow, Cord Blood, and Stem Cell Transplants Medicaid considers cord blood and stem cell transplants as synonymous with bone marrow transplants. Age 21 and Over For recipients age 21 years and older, Medicaid covers cornea, heart, intestine, liver, lung, multivisceral, pancreas, and bone marrow transplants that are medically necessary and determined appropriate by the Medicaid medical consultant; and the Bone Marrow Advisory Panel or the Organ Transplant Advisory Council. Re-transplantation of the same organ occurring within the initial transplant hospitalization is reimbursed at 25 percent of the global transplant fee for the facility and physician costs. Re-transplantation of the same organ that occurs after discharge from the initial transplant episode through the first 365 days will be reimbursed 75 percent of the global transplant fee for the facility and physician costs. The transplant facility must notify the Medicaid transplant coordinator within three days of the organ transplantation surgery. Recipients must be eligible for Medicaid at the time transplantation services are rendered for providers to receive global reimbursement. Global reimbursement for lung transplant is the same for single or bilateral lung transplantation. All other unrelated care is reimbursed to physicians on a fee-for-service basis according to the Medicaid Provider Fee Schedule. December 2012 2-83 Practitioner Services Coverage and Limitations Handbook Organ and Bone Marrow Transplant Services, continued Out-of-State Facility Requirements, continued For reimbursement from the Florida Medicaid program for an out-of-state transplant, the facility and professional providers must be enrolled as Florida Medicaid providers. Post-transplant Care Post-transplant medical care coverage begins when the recipient is discharged from the inpatient hospital following the transplant procedure. December 2012 2-84 Practitioner Services Coverage and Limitations Handbook Organ and Bone Marrow Transplant Services, continued Anti-Rejection Medications Anti-rejection medications and other reimbursable medications prescribed specifically for use in preventing organ rejection are reimbursable under the Medicaid Pharmacy Services program, even if the transplant was not reimbursed by Medicaid. Medicaid does not reimburse for organ transplant procedures involving living donor organs except for kidney and pediatric liver transplants. Medicaid does not reimburse separately for the living donor expenses related to kidney or pediatric liver transplants. Hospice Services Medicaid recipients are not permitted to receive transplant services while enrolled in hospice care. Medicaid does not reimburse for the cost of the ventricular assist device separately. December 2012 2-85 Practitioner Services Coverage and Limitations Handbook Orthopedic Services Description Orthopedic services provide for prevention or correction of deformities or disorders of the musculoskeletal system. Initial Casting and Strapping Subsequent Casting and Strapping the supplies, application and removal of the first cast or strapping are included in the reimbursement for the initial service. Otolaryngology Services Description these services provide for diagnosis and treatment of diseases related to otology, otorhinolaryngology, and laryngology. December 2012 2-86 Practitioner Services Coverage and Limitations Handbook Otolaryngology Services, continued Included Tests Otoscopy, rhinoscopy, and tuning fork tests are not reimbursed separately from an evaluation and management visit.

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In the European Union, twelve food items are required by law to appear on food labels: cereals containing gluten, crustaceans, egg, fish, peanut, soy, milk (including lactose), nuts, mustard, sesame seeds, celery, and sulphites >10 mg/kg. For children at risk of anaphylaxis the probability of recurrences caused by foods is one every two years, with a mortality of 0. On both sides of the Atlantic, the regulatory problem is now the opposite concern - whether too many foods containing trace amounts of these allergenic foods are being "over-labeled" and whether this may restrict potentially safe food choices for allergic consumers. The legislation does not require the indication of potential contaminants, but many manufacturers are now indicating "may contain" as a warning of potential contamination during food preparation. Tolerance Induction: the possibility of active induction of tolerance in food allergic patients through desensitization protocols has been studied in the past few years. 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 patients26. 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 prebiotic supplementation on the development of allergy. To date, the initially encouraging results with pro-biotics supplements27 have not been confirmed by further studies29, but the topic is still a matter of active debate, particularly because the infant food industry is extremely interested in this field29. Parents with food-allergic children are more likely to stop working, reduce their work hours, or incur other financial hardships and to limit overseas vacations. In Europe it incurs costs through product recalls running into millions of Euros, together with hidden costs associated with the need for comprehensive allergen management systems of around 30 million for food manufacturing operations alone25. 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. 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 development of sensitive prediction indices are 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. Socio-economic: Food allergy is a modifiable risk and its only form of management is dietary. Ignoring cross-reacting allergens in other foods (corrected with medical education). Unsupportive or uninformed measures arising from the family or school environments (emphasizing the importance of patient/parental education). All these therapeutic, diagnostic and socio-economic 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 level34. In this era of managed care, it is also important that different medical (sub) specialties be deployed in a patient-centered, rationale-based manner35, but the final say in terms of diagnosis for all suspected IgE-mediated food allergies should rest with the certified allergist. 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 balanced 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. Child and parental reports of bullying in a consecutive sample of children with food allergy. The psychosocial impact of food allergy and food hypersensitivity in children, adolescents and their families: a review. The clinical relevance of sensitization to pollen-related fruits and vegetables in unselected pollen-sensitized adults. 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. Probiotic supplementation in the first 6 months of life in at risk Asian infants-effects on eczema and atopic sensitization at the age of 1 year. Early dietary intervention with a mixture of prebiotic oligosaccharides reduces the incidence of allergic manifestations and infections during the first two years of life. 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. World allergy organization guidelines for the assessment and management of anaphylaxis. 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. Kaplan Definition the term urticaria is derived from the Latin name for stinging nettle (Urtica urens). The disease is characterized by the development of wheals (hives), angioedema (deeper swellings of skin and mucus membranes) or both which can occur anywhere on the body. The typical duration of a single lesion can vary from a few hours to a maximum of 24 hours. However, deeper swelling, called angioedema, can also occur and can last up to 72 hours. Urticaria needs to be differentiated from other medical condition where wheals, angioedema, or both can occur as a symptom. Three major categories exist: a) spontaneous occurrence of wheals, associated with acute and chronic urticaria; b) wheals and angioedema elicited by specific stimuli, and in particular physical urticarias; and c) other urticarial disorders such as exercise-induced urticaria. Except for acute urticaria, diagnostic and therapeutic procedures can be complex and referral to a specialist is often required. Eliciting Factors and Underlying Mechanisms of Urticaria Urticaria is a heterogeneous disease. Many different subtypes are distinguishable which have different underlying mechanisms1. Additionally, two or more different subtypes of urticaria can coexist in any given patient. Urticaria is a common problem and the probability of a single person having an episode during their lifetime is more than 20%. This disease leads to a significant decrease in quality of life, to absenteeism, and to decreased productivity. Given the average life expectancy in Germany, a lifetime prevalence of 12% was ascertained. However, it is likely that not all subjects seek medical care, thus a 20% overall lifetime prevalence is more realistic.

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In spite of this increase, even in the developed world, the care of patients with allergic diseases is fragmented and far from ideal. In light of the observations that adherence to treatment in Chronic Diseases is less then 50% and the cost of non adherence highly impacts the burden of chronic diseases worldwide, adherence needs to be a priority patientrelated outcome and an important step in patient education. Allergy not only causes long-term immune dysfunction, but also has underlying inflammation, which forms the underlying factor for other non-communicable diseases. Another important factor that comes into play are the gene-environment interactions. Because of the huge extent of allergy prevalence, allergy should be regarded as a major public health problem and within the framework of non-communicable diseases. The World Allergy Organization is greatly concerned about the increasing global burden of allergic diseases and is committed to increased collaboration and communication at a global level, engaging governments and policy makers to channel resources and efforts to recognize allergic disease as a public health issue. Surgery should only be considered in those patients who are properly managed but in whom a number of medical treatment programs fail. It is associated with airway hyperresponsiveness and airflow obstruction that is often reversible either spontaneously or with treatment. The burden of severe asthma is substantial with high perperson annual costs which can be largely attributed to medications, hospital admissions, and work loss. Food allergy significantly affects the quality of life of sufferers (mainly children). Stakeholders must be prepared to meet the needs of patients by enhancing the diagnostic process, the traceability of responsible foods, and the availability of substitute foods, assisting hospitalized patients, and preventing mortality. Atopic eczema is the most common chronic inflammatory skin disease with a varied clinical spectrum. As diagnostic and therapeutic decision strategies are not clinicians, patients, governments and industry to deal with the challenge of food allergy. Oral desensitization represents a promising approach to reduce the burden of disease caused by food allergy. These include: generalized systemic reaction; systemic allergic reaction; constitutional reaction; and serious hypersensitivity reaction. The socio-economic impact of urticaria is great, since it is a disease which primarily occurs in people of working age. Mild systemic reactions may be limited only to the skin and consist of flushing, urticaria, and angioedema. The association between sensitization to grass pollens and symptoms of hay fever occurring during the grass pollen season provides strong evidence for a causal role of grass pollen in the disease. Human genetics has a role to play in understanding susceptibility for disease onset, phenotypes and subphenotypes, severity, response to treatments and natural history. Exposure to outdoor/indoor pollutants is associated with new onset of asthma, asthma exacerbations, rhinitis, rhinoconjunctivitis, acute respiratory infections, increase of anti-asthmatic drug use, and hospital admissions for respiratory symptoms. Disparities in asthma morbidity and mortality, with an inverse relationship to social and economic status, are increasingly documented around the world. The identification of a temporal association between symptoms and allergen exposure constitutes the basis for further testing. Skin tests should include relevant allergens and the use of standardized allergen extracts. In vitro testing is especially useful when skin test results do not correlate with the history or cannot be performed. In vitro tests can be applied to "probability of disease" prediction in food allergy. There is a need for increased accessibility to allergy diagnosis and therapies and improved diagnostic methodologies that can substitute in vivo provocation tests for drug and food allergy. 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. Several studies of comprehensive environmental interventions in asthmatic children reported benefits. For adult asthma there is little evidence to support the use of simple, single interventions. More research about the mechanisms involved in the development of tolerance should be encouraged. Inadequate or lack of tolerance in allergic individuals appears to link with immune regulatory network deficiencies. 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 care professionals, and patient organizations commit to an educational plan to implement best practices for prevention and treatment of allergic diseases. Sensitization rates to one or more common allergens among school children are currently approaching 40%-50%. Primary prevention is difficult because the reasons for increased sensitization rates are unknown. 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. Conversely, the under-appreciation under-treatment or the lack of potentially life-altering immunotherapy. 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. 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. Availability Of Allergy, Asthma And Clinical Immunology Services (Allergists) And Appropriate Medications IdentifiedNeed: There is an increasing need for more allergy specialists and for the existence of local and regional allergy diagnostic and treatment centers in order to facilitate timely referrals for patients with complex allergic diseases. Accessibility to affordable and costeffective therapy and to novel therapies is needed. For example, adrenaline auto-injectors for patients at risk of anaphylaxis; new and more effective medications to treat severe asthma; and access to allergen immunotherapy are lacking in some parts of the world. Recommendation: Every country should undertake epidemiological studies to establish the true burden of allergic diseases; asthma; and primary and secondary immunodeficiency diseases.

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This study aims at investigating the possibility of simplifying a cannulation procedure by using the deltoid tubercle as a reliable palpable landmark. The skin, muscle and all other structures were removed to completely expose the deltoid tubercle. Measurement, in millimeters, was taken from the tip of the deltoid tubercle to the medial aspect where the deltoid tubercle meets body of the clavicle. We observed a palpable deltoid tubercle in all but two cadavers; with 11 left and right deltoid tubercles measuring greater than 3mm. Regional nerve blocks of the lower limb have become part of routine surgical care. Regional nerve blocks are evolving and require detailed knowledge of anatomy to place anesthetic for optimal nerve affects. Knee surgery, especially replacements, is one of the most common joint surgeries performed. Ultrasound was conducted on cadaveric tissue and used to inject 30 ml of fluid into the lateral femoral triangle. Teaching by repeated testing - a further study of question types in a radiological anatomy paradigm. We have extended these previous findings into the realm of the undergraduate anatomy cadaver lab, the teaching of radiological anatomy, and how to translate 2D images from a screen into a 3D understanding of cadaver anatomy. We gave short "radiological anatomy" quizzes in 3 of the first 4 lab sessions of 6-8 session curricular units. The quizzes were followed by a 5-10 minute debriefing session over the images and student questions. The average "washout period" between last quiz and the end-of-unit exam was 13 calendar days. This study switched the topics that had been previously tested via multiple choice questions into free-response questions. Differences in improvement as a function of question type support our earlier conclusion that there may be differences in learning that emerge from using open ended rather than multiple choice questions in our quizzes. Additional evaluation of our data is required to determine if and how this in turn correlates with overall mastery of the subject matter. Arrhythmia is a serious heart condition that affects 14 million people in the United States, and is characterized by irregular frequency of atrial and ventricular beats. Although cardiac ablation has been effective for ameliorating arrhythmia in regions of the heart that are commonly affected, the method could be improved, especially for non-commonly affected regions of the heart, by providing a data-driven, statistical map of cardiac plexus innervation of the myocardium. We have started the production of a three-dimensional (3D) atlas based on the mapping of cardiac plexus nerve fibers through translucent myocardium. The nerves distinguish easily from cardiac muscle tissue and are in preparation for 3D photography. In future studies, we will create heat maps of spatially registered nerve models to visualize the areas of highest probability of fiber locations. The resulting atlas will depict the cardiac plexus nerve fiber locations throughout the heart myocardium, allowing for greater accuracy in ablation procedures. Qualitative data were collected from 84 students (32 class of 2013 and 52 class of 2014) using a questionnaire to assess strategies used in implementing the 5 progress tests and their perceived benefits. Additionally, students reflect on the adequacy of anatomical and physiological sciences in our integrated curriculum. Progress tests are perceived to supplement formative assessments in guiding future planning and learning, as well as identifying gaps in basic science curriculum and validating internal examinations. Total course (72 hours over 6 weeks) includes interactive team-based learning sessions (16 hours) and whole body dissection (56 hours). Concepts are focused on surgical landmarks and structural relationships with opportunity to practice basic surgical skills such as vein harvesting, use of specific retractors and suturing. Course competencies are evaluated by audience response system (10%), laboratory practical testing (40%), written examinations (30%), peer evaluation (10%), and faculty evaluation (10%). Interprofessional teaching team consists of anatomy faculty, certified surgical assistant instructors, 3rdyear medical student teaching assistants and surgery residents. Graduates of the Surgical First Assistant Program enter clinical training with understanding of the anatomy relevant for surgical approaches. The tissue was cut into small fragments and placed into collagen-coated plates with media. Once significant numbers of cells had migrated from the explants, they were transferred into T25 flasks and expanded until adequate numbers were obtained for analysis. This study demonstrates that attached gingiva is a suitable source for both epithelial and fibroblast/mesenchymal cells. Further analysis is in progress to determine if the fibroblastoid cells are mesenchymal stem cells or a more differentiated population of transit amplifying cells. The direct explant technique is an acceptable method for obtaining cells from small tissue samples obtained from teeth that are typically discarded. Both preparations of cadaveric tissue allowed for visualization of the Foreign Bodies. The traditionally embalmed cadaveric tissue contained more air and was less compliant. The use of Freedom art embalming yields more lifelike tissue leading to less air trapped in tissue and is better for ultrasound imaging. Training healthcare personal to identify Foreign Bodies in Freedom art tissue allows for better imaging and a more effective educational process. The celiac trunk classically produces the splenic, left gastric, and common hepatic arteries. The common hepatic then produces the gastroduodenal and right gastric arteries then continues as proper hepatic artery. The gastroduodenal artery produces the right gastro-omental and superior pancreaticoduodenal arteries. The superior mesenteric artery classically produces the middle and right colic arteries, and the ileocolic artery, as well as jejunal and ileal branches. This common trunk produced the common hepatic artery, splenic artery, and superior mesenteric artery. The splenic artery gave rise to the left gastric artery, a branch to the colon, the left gastro-omental, as well as an arterial loop that sent a branch to the pancreas. The common continued on next page page 74 hepatic artery gave rise to the proper hepatic artery, the right gastric artery, and the gastroduodenal artery. The right gastric artery also gave off an esophageal branch and a branch to the stomach. The Anatomy Mentor Program: evolution of student-directed learning and mentorship. The transition to first-year gross anatomy in a medical school curriculum can be challenging for some students. The rigor and speed of a new medical curriculum requires effective study skills and time management beyond that of previous studies. To design a mentor program that eases the transition for first-year medical (M1) students by establishing relationships with second-year medical (M2) students who have completed the anatomy coursework successfully. The Anatomy Mentor Program provides new students with various mentor-led opportunities for testing their knowledge of anatomy content and identification skills prior to the first exam. Each year 30 M2 student mentors were paired together to lead a small group (~8) of M1 students during the gross-anatomy block, particularly the first three weeks of the course. Mentors met with M1 students for an introductory session with study tips during which they exchanged contact information for future meetings. M2 students organized and facilitated cadaver lab review sessions during which mentors answered questions and actively quizzed the M1 students. Feedback from mentors and mentees has been used to enhance the Anatomy Mentor Program each year. The Anatomy Mentor Program has assisted M1 students in their transition to coursework in medical school by creating opportunities for M1 students to interact and learn from M2 students. In addition, M2 mentors gain experience in mentoring early on in their professional careers and have opportunities to actively review cadaver anatomy.

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Boyer K, Andriacchi T Stanford University 199 Directional Characteristics of Fingertip Force Production After Hemiparetic Stroke Towles J, Triandafilou K, Stoykov M, Kamper D Rehabilitation R&D Service, Edward Hines Jr. Wu J, McKay S, Angulo-Barroso R Georgia State University 221 Effect of Arm Restriction on Upper Body Response to a Slip Jayadas A, Boros R Texas Tech University 223 Postural Stiffness Model and Outdoor Falls in Older Adults: the Mobilize Boston Study Kang H, Quach L, Li W, Lipsitz L California State Polytechnic University Pomona 225 Affect of Intensive Environmental Noise of Human Postural Control Bateni H, Vaizasatya A, Blaschak M Northern Illinois University 227 Foot Placement and Seat Height Effects on Sit-To-Stand Joint Moments Gillette J, Stevermer C Iowa State University 229 the Effect of a Subject-Specific Dual-Task on Standing Balance Sukits A, Chambers A, Cham R, Nebes R University of Pittsburgh Posture and Balance 218 Age-Related Modifications in Forward Reach Movement Patterns Lin S, Liao C National Cheng Kung University 220 the Effect of Obesity on Balance Recovery Using an Ankle Strategy is Dependent on Perturbation Type Matrangola S, Madigan M Virginia Polytechnic Institute and State University 222 Sensitivity and Specificity of a Clinical Screening Tool for Fall Risk Bigelow K University of Dayton 224 Postural Stiffness Model and Dual Task in Older Adults: the Mobilize Boston Study Kang H, Lipsitz L California State Polytechnic University Pomona 226 What Aspects of Postural Transitions Affect Balance Control Upon Standing? Recent high-resolution video analyses of fish fin movements during locomotion show that fins undergo much greater deformations than previously suspected. His work has produced some of the major insights into the mechanical function of the locomotor and feeding apparatus of fish. Current projects in his lab pioneer the use of robotics to explore the mechanical design of fins, the mechanisms of hydrodynamic propulsion, and the potential for bioinspired robotic swimming devices. From Vibrating Insoles to Synthetic Gene Networks Jim Collins, PhD Professor, Department of Biomedical Engineering, Boston University In this talk, we describe how nonlinear dynamical approaches can be used to study, mimic and improve biological function at multiple scales, ranging from whole-body dynamics to gene networks. Specifically, we show that touch sensation and balance control in young and older adults, patients with stroke, and patients with diabetic neuropathy can be improved with the application of sub-sensory mechanical noise. We also describe how techniques from nonlinear dynamics and molecular biology can be used to model, design and construct engineered gene networks, leading to the development of the field of synthetic biology. We discuss the implications of synthetic gene networks for biotechnology, biomedicine and biocomputing. He is a pioneer in systems biology, and currently developing methods and applications for reverse engineering gene regulatory networks. The Role of Biomechanics in the Health, Degeneration, and Repair of the Synovial Joint Farshid Guilak, PhD Laszlo Ormandy Professor of Orthopaedic Surgery, Duke University Medical Center Osteoarthritis is a painful and debilitating disease of the joints that is characterized by progressive degeneration of the articular cartilage that lines the joint surfaces. Using a hierarchical approach to span different systems ranging from clinical studies and in vivo animal models to studies of tissue, cellular, and subcellular mechanics, we have identified specific mechanical signaling pathways that appear to play a role in cartilage physiology as well as pathology. These pathways may provide novel pharmacologic targets for the modification of inflammation or cartilage degeneration in osteoarthritis. Using novel textile processes that allow weaving of biomaterial fibers in three dimensions, we have created functionalized bioactive scaffolds that can recreate many of the complex biomechanical properties and anatomic features of articular cartilage. In combination with a multipotent population of stem cells isolated from subcutaneous fat, we have developed a tissue-engineering approach for resurfacing osteoarthritic joint surfaces. Taken together, these studies emphasize the critical role that biomechanics plays in the physiology as well as pathology of the joint, and demonstrate the importance of biomechanical factors in functional tissue engineering of cartilage and other joint tissues. While both increase directly with speed, maximum sprinting speed is reached when stride frequency can no longer be increased [1]. The force-velocity relation of skeletal muscle has thus been implicated as a critical limiting factor in speed achievement [2,3]. Other muscular properties such as forcelength and activation dynamics have been shown to influence the control of walking [4] and jumping [5]. At maximal speed, lower extremity muscles undergo substantial length and activation changes; these properties may also influence running speed. Thus, our purpose was to evaluate the effects of removing various muscle mechanical properties on the achievement of maximum sprinting speed. Since it is impossible to remove muscle mechanical properties in vivo, a computer simulation approach was used to systematically test the limiting effects of specific properties on sprint performance. The skeleton was comprised of seven rigid segments (trunk, 2 thighs, 2 legs, 2 feet). The seven-segment musculoskeletal model with nine muscles actuating each lower extremity; only the right muscle models are shown. Each excitation signal E(t) was parameterized by nine nodal values over the time for one step. Periodicity in the initial and final kinematic states was enforced with a penalty function, as was the constraint that the net horizontal ground reaction impulse must equal zero. The initial kinematic state was taken from motion capture data of eight human runners sprinting at maximum effort. To evaluate the effects of muscle mechanical properties, the optimization was repeated four times with different Hill model versions for all muscles. In the second, the force-velocity property was removed by altering its traditional double-hyperbola to a straight line with a slight slope to avoid numerical indeterminacy. In the final model, all muscular properties were removed by optimizing the active joint torques. Table 1 compares the speeds achieved in the optimizations when particular mechanical properties were removed from the muscle model algorithm. Removal of the force-length property increased the sprinting speed by only 2% above the speed of the initial optimization with all muscular properties. However, removing the force-velocity and the excitation-activation relationships increased speed by 16% and 8%, respectively. Moreover, the effect of muscular property removal was additive: when the optimization was performed with all muscular properties removed, the speed increased by 21%. In each simulation, at least 80% of the increase in speed was due to an increase in stride frequency (see Table 1). Of the tested muscular properties, removing forcevelocity had the largest effect on speed, supporting previous conjectures that the force-velocity property plays a major role in the limitation of human running speed [2,3]. However, even small speed differences can have a large effect on the outcome of a race such as the 100-m dash. Therefore, the excitation-activation (8% speed changes) and forcelength (2%) relations also could affect maximal running speed. The exact influence of variations between runners is unknown, but our simulations indicate that differences in force-velocity and excitation-activation will have the largest effect. Physiologically, it is notable that both of these properties are strongly influenced by muscle fiber type ratios, which play a determinative role in athletic potential for power and endurance. The removal of muscular properties also had an effect on the ability of the model to perform a periodic step. The smallest differences between the initial and final kinematic states were present when all muscular properties were included, while the largest differences were present with all muscular properties removed (see Table 1). It may be that muscle mechanical properties are needed for accurate spatio-temporal control of the limbs in preparation for stride events such as foot contact. However, the differences in angular positions and velocities between the optimizations were relatively small on an absolute scale (less than 1 deg and 10 deg s-1). However, the excitation-activation relationship, and to a lesser extent the force-length relationship, may also play important roles, and the speed-limiting effects of these muscular relationships appear to be additive. Future work will address the extent that individual variation in muscular properties between runners impacts maximal speed, and the importance of the mechanical properties of individual muscles in limiting maximum speed achievement. Simulated sprinting performances when various muscle mechanical properties were removed. The model was able to accurately reproduce in-situ experimental data when incorporated into a forward dynamics computer simulation and was used to examine the influence of force depression on dynamic cyclic movements. The results showed that in maximal power pedaling, force depression has the potential to substantially reduce the amount of muscle power produced. It is not clear to what extent stretch induced force enhancement effects mechanical output, nor is it known to what degree force depression and force enhancement may offset one another during dynamic cyclic movements. Therefore, the aims of this study were to 1) develop and validate a muscle model that includes stretch induced force enhancement, and 2) combine this model with our previous model of force depression to validate the cumulative effects during controlled stretch-shorten and shorten-stretch cycles. Briefly, the model consisted of two blocks mounted horizontally on a frictionless surface with a muscle governed by Hill-type intrinsic properties mounted between them. One block underwent prescribed linear motion in which position and velocity was controlled. Values for the optimal muscle fiber length (36 mm), tendon slack length (74 mm, including aponeurosis), maximum shorting velocity (3. Simulations were developed to match a subset of the protocol from the experimental study [2]. The experiment was designed to compare the isometric force following constant velocity stretches of fully active muscles with the isometric force of a muscle that was not stretched. Individual stretches were made for three lengths (3mm, 6mm and 9mm) at three different velocities (3mm/s, 9mm/s and 27mm/s) for a total of nine stretches.

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The authors showed variations in specimen length or height (L) from 10 to 20 mm, diameter (D) from 13 to 73 mm, and D/L ratio from 1 to 4. Additionally, the compression ratio varied from 50 to 85% and compression speed from 5 to 200 mm/min. A decrease in D/L resulted in a decrease of hardness 1(H1), hardness 2 (H2), cohesiveness, and gumminess, and an increase in springiness and chewiness. Increasing the compression rate resulted in decreasing springiness, cohesiveness, gumminess, and chewiness. According to Peleg (1977), at the same deformation rate, a shorter specimen is actually deformed at a higher strain rate and, therefore, should exhibit higher stress than a longer specimen under the same strain. Employing these standard conditions will allow direct comparison of data from different laboratories/institutions and reduce confusion and mistakes that result from choosing inappropriate parameters. The test can be done to failure, where the sample is compressed until it totally breaks or shatters, or to a pre-fracture point where the deformation is measured. When force is applied to hard candy, the sample deforms very little but at a certain point it will shatter. A marshmallow, on the other hand, is quickly deformed when force is applied, but can easily recover. Meat samples fall in between these two extremes, as they possess moderate elasticity. A single compression test can also be used to measure the fracture force of a food product (hard candy, meat loaf, Jell-O), which can help formulate the product with various ingredients. The controlled rotation can be done with a viscometer after the sample ends have been glued to plastic disks. Volume changes are minimized and squeezing out of water and fat prior to the breakpoint (typically occurring in a compression test) are avoided. The test has revealed differences in meat protein functionality (Hamann, 1988) in the ability of salt soluble proteins to form heat-induced cohesive gels under different protein concentrations, different thermal processing conditions, and in the presence of non-meat additives. It was shown that shear stress relates to sensory hardness and shear strain to sensory cohesiveness. The authors reported that it was more difficult to modify sensory cohesiveness by addition of non-meat ingredients than it was to modify sensory hardness of meat gels. Furthermore, these two instrumental parameters (shear strain and stress) correlated strongly with each other (R = 0. Overall, the torsion test has the potential to obtain some fundamental data about gel structure without strongly deforming the structure. To illustrate what can be expected, the results 12 of a small scale trial of commercial whole muscle, turkey breast meat products showing good slice integrity. First, the cooked product was sliced into 3 mm thick pieces and Modulus ofFigure 16. A microscopic evaluation of the weak slices revealed poor connective tissue structure among muscle fibers in certain areas. Conversely, scanning rigidity monitoring is a non-destructive test that is used to continuously monitor a process such as meat protein gelation during heating. Measurement from a continuous scanning rigidity example are provided in Figure 16. The changes are related to protein unfolding, proteinprotein interactions, and interactions with other non-meat components. Overall, the test provides basic information on transition temperatures, protein interactions, etc. However, several studies have shown that the results do not correlate well with sensory texture or rupture strength. Nevertheless, the information is very valuable for optimizing processing conditions, ingredient substitution, and studying the effects of factors such as salt concentration and pH (Hamann, 1988). One of the first laboratory devices used was a glass microscope coverslip that was moved up and down a short distance at an extremely slow rate in a protein solution while it was heated. The resistance to movement was recorded and plotted against temperature (see figure by Yasui et al. The data revealed gelation temperatures, the effect of the myosin:actin ratio on gel structure formation, and the magnitude of the protein-protein interactions. Today, more sophisticated stress/strain rheometers are available where operation is controlled by high speed computers that provide precise movement and temperature control and facilitate calculations. The two most common types of measuring probes are the parallel plates configuration and the bob and cup. As an example, results obtained by a commercial rheometer that show the effect of phosphate addition to low salt (slippery) poultry meat batter are shown in. Green is = 0 days;a serratedblue there line also red line = 1 day; plate that can line = 4 days. A significant amount of meat flavour develops during cooking via complex reactions between natural compounds present in raw meat (Aliani and Farmer, 2005; Calkins and Hodgen, 2007). This is evidenced by the aroma that cooked meat, which is completely different than that of raw meat. Many of the compounds produced during cooking (a few hundreds) have relatively high odour thresholds and present little contribution to the overall aroma and flavour. Overall, flavour is a combination of taste and smell, which are perceived by the taste buds and olfactory receptors in the nose, respectively (Farmer, 1999). Flavour and taste perception mechanisms are complex and are still not fully understood. It is known, however, that they are affected by numerous factors such as the quantity and ratio of different flavour compounds, fat content, and temperature. Taste is perceived by sensors on the tongue that are capable of detecting four major tastes: salty, sweet, sour/acid, and bitter. Other sensations such as "umami" (a Japanese term meaning deliciousness), astringency, metallic, and pain ("hot" and "cold") are also known. A number of textbooks and reviews have been written on the subject of meat flavour (Calkins and Hodgen, 2007). The following discussion highlights some of the major findings in the area of chemical contribution to the taste and smell sensation as well as the effect of certain processing practices on meat flavour and aroma. The precursors may include amino acids, reducing and phosphorylated sugars, lipids, and thiamine. Most volatile compounds are present in concentrations below their taste threshold, which suggests that synergistic effects are important in taste perception. To identify the contribution of different volatile compounds, researchers use diluted aroma extracts that are obtained by gas chromatography and a subjective human odour assessment. In this way, the thresholds of many individual compounds have been established and evaluated. Discrepancies in the reported compounds of importance underline the complexity of sensory perception and the effect of different methods used for extraction, sample preparation, and assessment. The major compounds were glutamic acid, inosine monophosphate, and potassium ions. The glutamic acid and inosine monophosphate conferred "umami" and salty tastes, while the inosine also produced some sweetness. During cooking, a change in the concentration of reducing sugars, free amino acids, and nucleotides was observed. These changes affect the taste and aroma of the poultry meat, as many of the substances are precursors for chemical reactions that are responsible for odour formation during cooking, roasting or frying. They indicated that ribose appeared to be most important in increasing an aroma described as "roasted" and "chicken". They also mentioned that the change in odour was probably also caused by elevated concentrations of compounds such as 2-furanmethanethiol, 2-methyl-3 furanthiol, and 3-methylthiopropanol. In her 1999 review, Farmer produced a summary list of the most important compounds in cooked poultry meat and later Calkins and Hodgen (2007) produced a table concerning flavours in beef. Individually, these compounds can be responsible for one major aroma note such as meaty, mushroomy, fruity, sulphurous, or toasted, but together they combine to provide the typical aroma of a cooked chicken. The important compounds for cooked chicken aroma differ from those for cooked beef in that 2-methyl-3-furyl disulphide, methional, and phenylacetaldehyde are less important and certain lipid oxidation byproducts such as trans-2,4-decadienal and trans-undecenal are more important (Gasser and Grosch, 1990). Gasser and Grosch suggested that this difference may be related to the higher concentrations of linoleic acid in chicken than beef.

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If caught in a current, try to float downstream feetfirst on your back and steer out of the main current. Hydraulics and Dams Hydraulics are vertical whirlpools that happen as water flows over an object, such as a low-head dam or waterfall, causing a strong downward force that may trap a swimmer. A fixed-crest/low-head dam is a barrier built across a river, stream or creek to control the flow of water. Some of the most harmless looking low-head dams are often Avoid strainers at all costs. Anyone approaching a strainer should try to swim toward the object headfirst, grab any part of the strainer at the surface of the water and try to kick and climb up and over the top. Low-head dams with a thin line of whitewater across the surface can contain powerful hydraulic forces. No matter how small the hydraulic appears, the reverse flow of the water can trap and hold a person under water. Anyone caught in a hydraulic should resist fighting the current and try to swim to the bottom and get into the downstream current and then reach the surface. When the floodgates open, the water level can rise quickly below the dam, making a wall of water. If the dam is part of a hydroelectric power plant, the current made when the gates are open can pull anyone or anything above the dam into danger, including boats. Recirculating water currents caused by the movement of water over or through the dam can draw objects back toward the dam. Do not swim at unguarded ocean beaches or in areas not designated for swimming. In the open ocean during strong winds that travel in the same direction for long distances, waves can reach heights of well over 20 feet. Differences in bottom conditions and wave height create changes in how waves break. In some situations, the weight of the wave and power of the crashing water can hold a person under water-1 cubic foot of water weighs 62 pounds! Anyone caught in breaking waves near a rocky shore can suffer severe injuries or even die. Longshore currents can transport beach sediment, debris or swimmers rapidly away from the original point of entry. Anyone caught in a longshore current should try to swim toward shore while moving along with the current. Rip currents, sometimes referred to as rip tides, move water away from the shore or beach and out to sea beyond the breaking waves. A narrow strip of choppy, turbulent water that moves differently from the water on either side of it is a common rip current indicator. A band of water a few feet wide may rush back from the beach through a gap in the sandbar made by breaking waves. Rip currents typically break apart just past the line of breaking waves and are usually no more than 80 feet wide. Under gentle surf conditions, there may be more frequent, less intense rip currents. In periods of high-wave activity however, rip currents tend to form fewer but stronger currents. Rip currents account for more than 80 percent of rescues performed by surf beach lifeguards. Because rip currents can be very strong and carry a person away from shore, anyone near a beach needs to be careful. Even though most rip currents break apart near the shore, they can still take a person into deep water or a frightening distance from the shore. In rare cases, rip currents can sometimes push a person hundreds of feet beyond the surf zone. Rip currents can be a challenge to even the strongest and most experienced swimmers. A swimmer also can just let the rip current take them out to sea, then swim back after the current breaks apart. If you are too exhausted to swim to shore, signal a lifeguard by calling and waving for help. No matter what the case, the most important thing to remember if ever caught in a rip current is not to panic. Tides Tidal currents are a cycle of ocean water movements that first surge toward shore, called. When the moon is in its first or third phases, tidal currents are weak, called neap tides. Tidal currents near inlets, estuaries and bays can be very strong and should be avoided. In many cases, lake and pond water is murky, which makes it difficult to see below the surface. In such murky conditions, it may be hard to notice a distressed or submerged swimmer. It also may be difficult to determine the depth of the water or safety of the bottom surface, making these areas unsafe for diving. The bottom of lakes and ponds often contain hidden hazards, such as rocks, plants or weeds, sunken logs or broken glass that can cause serious injury and/or entrapment. Weeds, grass and kelp often grow thickly in open water and can entangle a swimmer. If you find yourself caught up in any aquatic plant life, avoid quick movements, which may only entangle you more. Anyone in this situation should try to stay horizontal at the surface and swim slowly and gently out of the plants, preferably along with a current. Call for emergency medical help if the victim- n Does n Has n Is not know what caused the sting. In the ocean, however, Portuguese man-of-war, jellyfish or other types of marine life can pose a threat to swimmers. A sting can be very painful and may cause illness or even death if the affected area is large. Swimmers may not see the tentacles of stinging jellyfish below the surface, and they may extend far from what is seen on the surface. A sting can even be caused by In some ocean areas, there are sea urchins with spines that can break off in the foot and cause a painful wound. Before going into any ocean, find out what local marine life may be dangerous, how to avoid it and how to care for any injuries. When entering the ocean, shuffle the feet to stir up marine life resting on the bottom to avoid stepping on anything that could cause harm. Because the consequences are severe, the risk should always be minimized whenever possible. The period in between tides when water is neither moving toward nor away from shore is called slack water. Feeding areas or areas where sewage, runoff or rivers flow into the sea are also dangerous. Hypothermia is a lifethreatening condition in which cold or cool temperatures cause the body to lose heat faster than it can produce it. Here is what happens when a person falls into cold water: n the n At n Do n Do temperature of the skin and of the blood in the arms and legs drops quickly. If the temperature drops more, death from heart failure is possible, but drowning may occur first. Alligators are very dangerous, especially to small children, and can be found in freshwater in some southern states, such as Florida, Louisiana, Georgia and Texas. Do not go into water known to be inhabited by alligators or snapping turtles and stay away from the shore. Swimmers usually will not see a leech but may come out of the water and find one on their skin. Anyone who spends time near the ice should first determine the ice conditions, and then take precautions to stay safe. Remember, the ice may not be the same thickness over the entire area of a lake or pond. It is generally safe, but it is not thick enough for snowmobiles, all-terrain vehicles or other vehicles. It may be difficult to exit the car if it falls through the ice and a life jacket worn under the clothes cannot be easily removed in an emergency.