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The current instrument is installed on a laboratory optical table and has never left that room; future studies may involve design of a portable instrument that can be carried to weight loss pills target buy slimex with amex other locations for real-world testing and evaluation weight loss balloon purchase 15 mg slimex. We have concurrently conducted fundamental studies to weight loss pills best rated purchase slimex with amex advance the scientific basis of infrared imaging for crime scene visualization weight loss qsymia purchase 10 mg slimex fast delivery. These efforts have included a study of coating effects on the infrared reflectance spectra of fabrics, evaluation of blood discrimination on textile fabrics, determination of achievable detection limits for blood on fabrics, examination of the effects on spectra of blood induced by fabric orientation and coating uniformity, estimation of the age of blood stains up to 9 months old by infrared spectroscopy, and fundamental studies on optical properties of surfaces and a novel investigation extending the Kubelka-Munk model of diffuse reflectance to three dimensions. While providing a firm scientific background for future studies, this research has opened up novel applications of diffuse reflectance imaging in the mid-infrared region of the spectrum which may have valuable future forensic applications to biological materials on surfaces. Detection limits for blood on fabrics presently near a dilution factor of 200 11 3. News releases and publicity 27 Appendix Note: Please contact the authors for the following materials. Part 2: Simulation driven design A-18 this document is a research report submitted to the U. Diffuse reflectance infrared spectroscopy for the forensic discrimination of blood on textiles A-79 G. A study of electric field standing waves on reflection micro-spectroscopy of polystyrene particles A-137 this document is a research report submitted to the U. Detection, collection, and analysis of blood and/or semen evidence recovered from a crime scene can be critical in a forensic investigation. Latent stains, those invisible to the naked eye, can result from attempts to alter or clean a surface by an individual. Patent stains, those visible to the naked eye, can still be difficult to detect at the crime scene, especially if a lack of contrast exists between the stain and the background surface. Crime scene investigators often use a high intensity light source to identify stains for further visual inspection. If nothing is observed, but there is reason to believe blood might be present, luminol or another enhancement chemical (such as amido black, fluorescein, or leuco-crystal violet) is often used. However, such presumptive tests suffer from both false positive and false negative results. For example, because fluorescence of luminol is catalyzed by iron in blood hemoglobin, false positive reactions can occur with any materials containing iron, as well as with other common household materials. False negatives, usually the result of a strong reducing agent being present that interferes with the oxidation-reduction reaction, can lead to potentially probative blood samples being missed at the scene. Finally, health concerns exist for crime scene investigators with the use of any of the chemical reagents required for stain enhancement and/or presumptive testing. Confirmatory tests, conducted in the laboratory and to prove presence or absence of blood, include microcrystalline tests such as the Takayama or Teichman tests. That blood is of human origin can be shown with immunological tests such as the precipin test. Methods to replace the currently used enhancement reagents and presumptive tests for blood and other biological material have been sought continuously. These absorbance features are largely clearly seen against the background of common surfaces and textiles. This project has produced proof-of-concept development of a prototype camera requiring minimal operator technical knowledge that is capable of rapid and selective identification of blood stains in ambient lighting without the use of enhancement reagents. Imaging is achieved by chopping the source and digitally processing each pixel by a lock-in amplifier approach to produce an output that shows visual contrast between stain/no-stain regions. We show this method is useful for visualizing thin coatings on fabrics that are invisible to the eye. We also take advantage of a “like-detects-like” chemical filtering approach to chemical selectivity for the purpose of chemical identification using a broadband thermal detector. The response of the detector was optimized by a combinatorial simulation-driven design process to select chemical filters that maximize the discrimination between blood and unstained surfaces. There are many factors involved in optimizing discrimination by using optical filtering aids, including, but not limited to, the detector response, optical throughput of the system, optical properties of the samples, and optical properties of the materials for sensitizing films/filters. There are nearly infinite possible setups for the system, which means it is neither cost nor time-efficient to physically test each one. In lieu of this, we developed approaches to simulate the camera output, per pixel, given specific conditions. Beginning with measured spectra of calibration samples or standards, a figure of merit (in our case, the discrimination between stained and non-stained regions) was employed to predict performance for large numbers of combinations of chemical films as filters. We have also demonstrated that this method can be used to discriminate between a blood stain and four common interferents to other blood detection methods: bleach, rust, cherry soda, and coffee. These results indicate that this system could be useful for crime scene investigations by focusing non-destructive attention on areas more likely to be suitable for further confirmatory analysis. Knowledge and understanding of the nature of diffuse reflectance on surfaces coated with chemical stains may have further implications for the interpretation and uses of the infrared reflectance of many types of coated materials. Ultimately, the fundamental relationships observed could lead to the design of an improved system for the measurement of surface coatings of forensic relevance. Specific research conducted includes a study of coating effects on the infrared reflectance spectra of fabrics, evaluation of blood discrimination on textile fabrics, determination of achievable detection limits for blood on fabrics, examination of the effects on spectra of blood induced by fabric orientation and coating uniformity, estimation of the age of blood stains 3-9 months old by infrared spectroscopy, and a theoretical investigation of the fundamental Kubelka-Munk model of diffuse reflectance and an extension of that model to three dimensions. The sections of the main body of the technical report document the accomplishments, methodology, and results of our project. The appendix to this technical report contains papers that have been accepted or submitted for publication and other manuscripts that are in revision prior to submission for publication. However, these items may not be arranged in an orderly manner; more often, a crime scene is chaotic. The initial task of a forensic investigator is to recognize items that might have evidentiary value and to collect samples for further study. Latent stains, those invisible to the naked eye, may result if only trace amounts of blood are present, or if an attempt has been made to modify or clean a surface. Even patent stains, those visible to the naked eye, can still be difficult to detect if a lack of contrast exists between the stain and the background surface. If nothing is observed, but there is reason to believe blood might be present, a presumptive test such as luminol or another enhancement chemical (such as amido black, fluorescein, leuco 1-5 crystal violet, phenolphthalein, leucomalachite green, and benzidine) is often used. A major issue is that the crime scene can be contaminated thoroughly by such treatment. An approach to visualization of blood at crime scenes that is rapid, non-invasive, and not adversely affected by potential interferents would be ideal. Literature citations and review Crime scene investigators often employ high intensity light sources to highlight stains for further visual inspection. However, this step can be insufficient for detection if only trace amounts of blood are present, if the bloodstained area has been cleaned, and/or if a strong contrast does not exist between the blood and a dark surface. If nothing is observed, but there is reason to believe blood might be present, chemical enhancement reagents. A presumptive test is a test, which is used to screen for the presence of a substance, typically performed when there is doubt as to whether an object at a crime scene should be processed and collected. Plasma consists of soluble proteins, the two most prevalent being albumin (70%) and immunoglobulin G (10%). The heme moiety is usually the part of the hemoglobin that interacts with a chemical enhancement reagent for detection of blood. For example, the phenolphthalein and leucomalachite green tests are based on an oxidation-reduction reaction with heme, causing conversion of the colorless reagents to colored by-products after oxidation. The luminol test is based on the peroxidase activity of the heme moiety, with a positive result indicated by chemiluminescence over the first minute or two after exposure of blood to luminol. The chemiluminescence, including splatter patterns, can then be photographed for documentation. In many cases, luminol is used for dual purposes, both to visualize patterns 1-4,6-10 and as a presumptive test for blood. Although crime scene investigators at the South this document is a research report submitted to the U. Specificity can also be an issue if the chemical employed also reacts with other protein-based biological fluids. While many of the false positive reactions can be identified during the presumptive testing procedure, problems can arise if the examiner does not exactly follow the prescribed procedure within the allotted time frame and/or has not conducted extensive testing on known standards so as to have a full understanding of a positive reaction process due to blood. Furthermore, false negatives can occur with these tests, causing blood samples to be left at the scene. This is usually the result of a strong reducing agent being present that interferes with the oxidation-reduction reaction, preventing or delaying color formation. Due to the possibility of false positives and false negatives with presumptive testing, confirmatory testing is ultimately required in the laboratory to prove the presence or absence of a substance. Confirmatory methods for blood include microcrystalline tests such as the Takayama or Teichman tests in which chemical reagents are added to blood causing the formation of 1,2,8 distinctive hemoglobin derivative crystals.

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Recently weight loss kids buy discount slimex 15mg line, it was found that synaesthesia (perception of one sensory modality as another weight loss pills phenergan cheap slimex 15mg online, for example hearing colors or seeing music) is associ ated with disruptions of the insular cortex weight loss on zoloft generic 10mg slimex amex. Emotionally weight loss pills 832 cheap slimex 15mg on line, the insular cortex is involved in processes for anger, fear, disgust, happiness, and sadness. The insular cortex is involved in the association of disgust to both olfactory inputs and/or visual images of mutilation and contamination or putrification. Imagination of these inputs is sufficient for similar brain activation and insular cortex activity. Finally, emotional salience, that is, attending to and making decisions about, the subjective importance of stimuli, is associated with the insular cortex (along with the cingulate gyrus and connected orbitofrontal cortex). The occipital cortex is traditionally identified as integral for visual processing. Neurons of V1 project to other visual unimodal and heteromodal cortex (V2, V3, etc. The region of V4 is specialized to appreciate color, although cells here also respond to color/form combinations. Lesions to V4 result in inability to see color and are unable to “think” in color. The area described as area V3 appears to be sensitive to process ing the object of shapes in motion (Kolb and Whishaw 2009). Lesions to area V5 can result in the inability to see objects when they are moved, while still retaining the ability to see the objects when they are stationary. The dorsal pathway is primarily involved in identifying where objects are in space and the relative distances from one another and the person as well as guiding body movements by vision, which runs from the occipital cortex to the parietal cortex. The ventral pathway processes the object forms and the associated semantic network for recognizing objects in space. The parietal cortex is demarcated by the cortex posterior to the central sulcus and anterior to the parietoccipital sulcus and ventral (superior) of the sylvian (lateral) fissure. It also includes the cortex and underlying white matter from the interhemispheric fissure to the cingulate gyrus. Functionally, the parietal cortex may be divided into two broad functions: soma tosensory processing and sensory integration for motor control. The anterior parietal area reflects primary and unimodal somatosensory cortex, and processes information about tactile, muscle, joint, vibration, vestibular, and two-point discrimination information. The posterior parietal cortex is involved in the integration of sensory inputs (somatosensory, visual, auditory, etc. In addition, arithmetic functions, particularly those involved in more complex arith metic requiring “borrowing” or other mathematical operations requiring a spatial aspect, have been associated with posterior parietal regions, particularly the inferior parietal lobule. Lesions of the postcentral gyrus that disrupt the connections between primary and unimodal association cortex areas result in astereognosia (inability to recog nize objects by feel/palpitating them but not seeing them). Damage also frequently results in agraphesthesia, which is the inability to identify letters or numbers writ ten on the palm of the hand or finger tips. Other associated agnosias include atopognosia (inability to localize touch) and abarognosia (the inability to discrimi nate weights). The temporal lobe includes primary sensory and association cortex for auditory stimuli as well as association cortex for visual information. Cells in the left (language-dominant) hemisphere within Heschel’s gyrus are disproportionately sensitive to sound frequencies associated with human speech, while cells in the right (nonlanguage-dominant) hemisphere are sensitive to the pitch, timbre and melodies of music. The activation of this region is specific to faces, and is active despite variability in the presentation of faces (having glasses, a beard, a hat, etc. The right hemisphere is more sensitive to facial perception than the left hemisphere. The neurons making up the cortex of the inferior temporal lobe activate to com plex visual features, and cells having similar but not identical selectivity for activa tion to particular complex visual stimuli are organized together in columns. The columnar organization of neurons responding to similar, but not identical, complex visual features allows these areas to activate despite slight variations in the visual properties of the stimuli. In so doing, this organization allows for learning visual categorization based on similarity of a complex series of features. A processing pathway projecting posterior and dor sally to the parietal cortices thought to be involved in semantic knowledge of words and word reading, and related to aspects of directing movements that are related to auditory sensory information. It is complex heteromodal/multimodal association cor tex and has a role in associating visual and auditory information for categorization (associating sounds with certain objects). This region is also involved in the percep tion of different facial features and body movements with nonverbal communica tion cues and social behaviors. The projections of the auditory, visual and other somatosensory information is projected towards the parahippocampal gyrus where information is “funneled” to the perirhinal cortex and then entorhinal cortex along to the hippocampal formation and/or amygdala. Efferent projections from the hippocampus form the perforant pathway which form part of the Papez circuit involving the limbic cortex. The mesial temporal lobe structures (perirhinal and entorhinal cortices and hippocampus) are involved in declarative memory, particu larly episodic (time and person specific) memory (see Chap. Affective/emotional aspects to memory and movement control/frontal lobe path way. The temporal lobe has projections to the frontal lobe, both the dorsolateral and the orbitofrontal lobe based on fibers from the inferior longitudinal fasciculus and the uncinate fasciculus that is primarily involved in affective/emotional processing, short term memory, and aspects of movement control. The emotional processing is associ ated with connections of the amygdala and orbitofrontal connections, inclusive of olfactory processing and affective/emotional processing. One function of the amygdala is to “tag” affective/emotional features to visual and/or auditory informa tion, which increases the encoding (learning) of material and provides a neuroana tomic pathway for state dependent learning. An example of state dependent learning is that being in a similar affective state can enhance retrieval (memory). The recognition of body movements as having emotional/social communication implications has been associ ated with the “theory of mind”, and is thought to be involved in the “theory of mind” (see Chap. Briefly, theory of mind refers to the ability of a person to theorize about other individuals’ feelings, thoughts, and the intentions of their behaviors. After summarizing the five different neuroanatomic projection pathways in the temporal lobe, there are nine neuropsychological symptoms frequently associated with temporal lobe lesions, which include impaired: 1. Perception of visual features (visual object agnosias, prosapagnosia, alexia, and appreciation of social facial/body part cues). Patients with right temporal resections fail to exhibit the left visual feld bias in viewing faces that is normal. Patients may exhibit an increased focus on minutiae, particularly details of personal problems, have religious pre occupation, paranoia, and increased aggressiveness associated with the so-called temporal lobe or Geshwind personality. However, these features are rarely all present, and there are no consistent data supporting the temporal lobe personal ity. Nonetheless, personality change has been associated with temporal lobe damage, more often with right temporal lobe injury. The neuroanatomic organization of the brain into net works can be appreciated at a cellular level, discussed above in terms of the exten sive connections of each neuron with other neurons (one neuron may synapse to 1,000 or more other neurons via axons and dendrites) as well as the hierarchical 120 M. Fibers (bundles of axons) may project from one closely associated region to another (neighboring gyri) with arcuate fibers (also called U-fibers) or to regions quite distant from each other via fasciculi. The multiple processing networks involved in many behaviors/cognitions are illustrated by two examples. Recall that semantic memory (conceptual knowledge) refers to one’s memory for facts and knowledge and is not specific to time or place (autobiographical), and is cultural in nature. The two theories accounting for semantic memory reflect a distrib uted network model and a distributed network-plus-hub model. The later model includes a distributed network of modality specific cortex processing areas. The distributed network plus-hub model is garnering increasing support, but there remains debate as to the location and importance of these nondomain-specific hub area(s). While the debate continues, neuropsychological processes clearly involve a distributed network of areas, many with “hub” areas which are highly efficient at integrating stimuli for the neuropsychological functions reviewed in this book. The second example is the complex parallel distributed network needed for speech, which is presented in detail in Chap. In addition, motor and premotor areas are involved in reading and writing, respectively, along with the corticobulbar tracts and cranial nerves. Chapter 7 reviews the analogous areas in the nondominant hemisphere involved in language prosody functions. Clearly, there is 3 Neuroanatomy Primer: Structure and Function of the Human Nervous System 121 Fig.

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Decipher 81542 L37785 L36256 A56984 L37911 L35000 Biopsy Prostate (A56921) (A57526) (A57564) (A56199) Cancer (A56958) L35160 (A57527) Classifier Assay for Men with Very Low and Low Risk Disease 36 weight loss pictures cheap 10 mg slimex with mastercard. EndoPredict 81522 L37264 L35160 A56997 L37663 Breast Cancer (A56963) (A57526) (A57567) Gene L36256 (A57527) Expression Test 39 weight loss 50 pounds order slimex mastercard. Envisia weight loss no exercise discount slimex 10 mg free shipping, 81479 L37857 L37887 L37905 L37919 Veracyte weight loss pills review order slimex 10mg free shipping, (A56898) (A57419) (A56985) A57568) Idiopathic L37891 (A57420) Pulmonary Fibrosis Diagnostic Test 41. Fragile X 81243 A53638 A55242 L36021 L36807 81244 A55241 (A54264) (A55163) 81470 81471 47. GeneSight 81479 L35633 L36323 L35443 L36799 Assay for (A56927) (A57525) (A56936) (A57569) Refractory L36325 (A57547) Depression 49. Inivata, 81479 L37870 L37897 L37903 L37921 InVisionFirst, (A56924) (A57664) (A56982) (A56333) Liquid Biopsy L37899 (A57665) for Patients with Lung Cancer 62. MammaPrint 81521 L35025 L36256 L36021 L36807 L33586 (A53104) (A54447) (A54194) (A55175) (A57756) L35160 (A54445) 69. Mitochondrial 81479 A53669 A55290 L36021 L36807 Nuclear Gene A55291 (A54288) (A55190) Tests 75. Multiplex 87631 L37713 L37301 L37348 L37764 Nucleic Acid 0098U (A56851) (A57338) (A56974) (A57579) Amplified Tests 0099U L37315 for Respiratory 0100U (A57340) Viral Panels 0115U 87632 87633 78. Percepta 81479 L36854 L36886 L36908 L37195 Bronchial (A56849) (A57502) (A56972) (A57584) Genomic L36891 (A57504) Classifier 90. Pigmented 0089U L38153 L36256 A57915 A57983 Lesion Assay (A57868) (A57526) L35160 (A57527) 91. Plasma-Based 81479 L38043 A57917 L38168 Genomic (A57867) (A57936) Profiling in Solid Tumors 93. Prolaris™ 81541 L35869 L36348 L36002 L36787 Prostate Cancer (A56918) (A57509) (A57303) (A57585) Genomic Assay L37043 L36350 (A56911) (A57511) 96. ProMark Risk 81479 L36665 L36704 L36675 L37011 Score (A56957) (A57515) (A57034) (A57587) L36706 (A57609) 97. ResponseDx 81504 L35025 L36256 L36021 L36807 L35000 L33777 Tissue of (A53108) (A54496) (A54198) (A55204) (A56199) (A57743) Origin L35160 (A54494) 101. ThermoFisher 0022U L35025 L36256 L36021 L36807 L35396 Oncomine Dx (A55822) (A55881) (A56973) (A55846) (A52986) Target Test For L35160 Non-Small Cell (A55888) Lung Cancer 109. The recent discovery and elucidation of the endocannabinoid receptor system, coupled with improvements in technology and new research tools, has facilitated analytical, pharmacological, and other preclinical research. The conundrum in many states is that liberal cannabis distribution to patients with various medical conditions occurs in a setting where little scientific evidence exists to guide this process in a rational, ethical manner to protect patient health and safety. The purpose of this review is to examine the circumstances that led to this situation and explore the scientific issues involved in moving toward a resolution. It also sets out recommendations to assist physicians in coping with these issues and proposes policy recommendations for consideration that, if adopted, could reduce the potential for more problems in the future. Results: Review findings indicate that in order to think clearly about “medical marijuana,” one must distinguish first between 1) the therapeutic potentials of specific chemicals found in marijuana that are delivered in controlled doses by nontoxic delivery systems, and 2) smoked marijuana. Marijuana is high on that list because it is widely abused and a major cause of drug dependence in the United States and around the world. This process provides important protections for patients, making medications available only when they: 1) are standardized by identity, purity, potency and quality; 2) are accompanied by adequate directions for use in the approved medical indication; and 3) have risk/benefit profiles that have been defined in wellcontrolled clinical trials. Key Words: cannabis, cannabinoid medication, medical marijuana Executive Summary Research into the therapeutic potential of cannabis and cannabinoids has lagged behind that of other modern medications. Clinical research is also increasing, although only a small number of controlled studies meeting modern scientific standards have been published. The Institute of Medicine has also rejected this approach and has called for further research into the development of nonsmoked, reliable delivery systems for cannabisderived and cannabinoid medications. Rigorous research is needed better to understand the significance of different cannabinoid formulations and ratios, methods of administration, and doseresponse relationships. Cannabis has a range of effects, some of which may be disturbing to patients with serious medical conditions, adversely impact their cognitive skills, or impair their lung function. Such effects should be better understood, particularly in the context of chronic medical use. It lacks quality control and standardization; can be contaminated with pesticides and microbes; and does not assure patients a reliable and reproducible dose. Increased cannabis potency heightens the risk of adverse events, especially among cannabisnaive patients, as well as the dangers of dependence and addiction. There are no effective risk management measures to prevent diversion and abuse, especially by adolescents. The practice of medicine must be evidencebased; all medical interventions should be justified by highquality data. There is no rationale for carving out large scale exceptions to this review process. Any rationale offered loses currency when one considers the potential harm associated with increasing the availability of a substance with a high abuse liability. Yet physicians, who are the gatekeepers of this process under state law, have inadequate information on which to base their judgment if they choose to discuss cannabis as a treatment option with their patients. Physicians should carefully consider their ethical and professional responsibilities before issuing a cannabis recommendation to a patient. A physician should not advise a patient to seek a treatment option about which the physician has inadequate information regarding composition, dose, side effects, or appropriate therapeutic targets and patient populations. Introduction During the past 40 years, popular interest in the therapeutic potential of cannabis has significantly increased, propagated by widespread media attention. Because cannabinoid research poses special challenges, data from such research have accumulated slowly and only recently have gained substantial attention within the scientific and medical communities. The conundrum in many states is: liberal cannabis distribution to patients with various medical conditions; little scientific evidence exists to guide this process in a rational, ethical manner which ensures patient health and safety. This report will examine the circumstances that led to this situation and explore the scientific issues involved in moving toward a resolution. It will also set out recommendations to assist physicians in coping with these issues and propose policy recommendations for consideration that are intended to reduce the potential for more problems in the future. Modern History of Cannabis in Medicine In the early part of the 19 century, the European medical community became th aware of the therapeutic potential of cannabisbased medications. William O’Shaughnessy, an Irish physician, conducted clinical and nonclinical work in India with cannabis preparations and upon his return to England, the results of his studies became widely known. Across Europe and North America interest increased in the therapeutic potential of these materials. Reports often blame the enactment of the federal Marihuana Tax Act of 1937, which imposed administrative limitations on the prescription of cannabis preparations, for the 3 contraction in the use of marijuana in medicine. The main reasons for this disappearance were the variable potency of cannabis extracts, the erratic and unpredictable individual responses, the introduction of synthetic and more stable pharmaceutical substitutes such as aspirin, chloral hydrate and barbiturates, and the recognition of important adverse effects such as anxiety and cognitive impairment (Fankhauser M, 2002). Accordingly, cannabis preparations gradually fell out of use by the medical profession. Synthetic analgesics and hypnotics have almost entirely displaced these preparations from their original field of application. Coincidentally, popular interest in smoked cannabis began to increase significantly. A number of individuals reported that smoking cannabis for recreational purposes seemed to alleviate some of their medical symptoms. There is a possibility that a re­study of the drug by modern means may show other advantages to be derived from its medicinal use. Walton was Professor and Head of the Department of Pharmacology and Therapeutics, Medical College of South Carolina, Charleston, S. Thus, the “lag” in the 6 technological capabilities of modern science probably contributed to the controversy of “medical marijuana. These monumental discoveries, parallel in their basic framework to the discovery of the brain’s endogenous morphinelike neural system (the endorphins), transformed the focus of research from marijuana to the brain itself. We now understand that an extensive system of nerves within the brain communicate with each other using the same basic chemistry found in marijuana. While we are only beginning to unravel the role the endocannabinoid system plays in overall brain function, Raphael Mechoulam has declared that “The cannabinoid receptors are found in higher concentrations than any other receptor in the brain and the endocannabinoid system acts essentially in just about every physiological system that people have looked into, so it appears to be a very central system” (Brown D, 20052006). Tonic activity within the endocannabinoid system is continuously modulating a huge variety of physiological and brain functions, including shortterm memory, learning, appetite, anxiety/fear, pain, and spontaneous motor activity.

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The most common passenger restrictions limit teenage drivers to weight loss pills without caffeine generic 10mg slimex overnight delivery zero or just one passenger weight loss recipes slimex 10 mg generic. Some restrictions apply to weight loss 80 20 rule buy cheapest slimex all passengers and some only to weight loss breakfast ideas slimex 10mg lowest price passengers younger than a specified age. Some restrictions apply only during the initial months of the intermediate license. Effectiveness: There is growing evidence that passenger restrictions are effective in reducing young driver crashes, though the restrictions sometimes are violated (Goodwin & Foss, 2004; Williams, 2007). California allows no passengers younger than 20 for teenagers who hold an intermediate license. For example, one study showed a 38% decrease in 16-year-old driver crashes in California in which a teen passenger was killed or injured (Williams, 2007). Results showed that 16 year-old-driver crashes were reduced in all three States, as were motor vehicle related injuries among 15 to 17-year-olds (Chaudhary, Williams, & Nissen, 2007). Subsequent to this restriction, 16-year-old crashes involving multiple passengers decreased by 8% (Foss, 2009). Use: Twenty-one States and the District of Columbia prohibit cell phone use for some young drivers. California, Connecticut, New Jersey, New York, Washington, and the District of Columbia prohibit handheld cell phone use by all drivers (see Chapter 4, Section 1. Effectiveness: One recent study examined the short-term effects of a teenage driver cell phone restriction (Foss, Goodwin, McCartt, & Hellinga, 2009). In North Carolina, teenage driver cell phone use was observed one month before and five months after a ban on cell phones took effect. The proportion of teens using cell phones while driving was unchanged following the law. Telephone interviews with parents and teens found that support for the restriction was high among both parents (95%) and teens (74%), but awareness for the restriction was only moderate. Hence, it appears that publicity and enforcement are key to obtaining compliance with teen driver cell phone restrictions (Foss et al. Seat belts are particularly important for teenage drivers because of their elevated crash risk. Nonetheless, teenage drivers and passengers have lower seat belt use rates than older drivers and passengers (Ferguson, 2003). Young drivers are covered by seat belt laws in all States (with the exception of New Hampshire, which only requires seat belts for people under age 18) (Williams, 2007). Six States have primary enforcement belt use laws for passengers under 18 or 19 but secondary enforcement for older passengers (Glassbrenner, 2004; see also Chapter 2, Sections 1. Evaluations of the restrictions in these two States found little, if any, effect on teen driver belt use (Freedman & Levi, 2008). Probationary licensing had no intermediate phase, so that beginning drivers received a full and unrestricted license after their learner’s permit. The probationary feature has been included in the intermediate phase of graduated licensing, typically by delaying full licensure until the intermediate licensee has demonstrated a good driving record. Effectiveness: the few evaluations of early stand-alone probationary license systems generally found no substantial benefits (McKnight & Peck, 2003; Simpson, 2003). In general, it appears that awareness of penalties for license violations among parents and teens is relatively low, enforcement is rare, and licensing delays are not always applied even when violations are enforced (Goodwin & Foss, 2004; Steenbergen et al. Driver education in high schools grew in popularity in the 1950s, using a standard curriculum of at least 30 hours classroom instruction and 6 hours on-the-road driving practice. By about 1970, approximately 14,000 high schools taught driver education to about 70% of all eligible teenagers. Many States and insurance companies encouraged driver education: States licensed graduates at an earlier age and insurance companies reduced auto insurance premiums for graduates. See Smith (1994), Mayhew (2007) or Williams, Preusser and Ledingham (2009) for a concise review of the history of driver education in the United States. The net effect of driver education may increase crashes because it puts more young drivers on the road. It has been suggested that crash outcomes are not appropriate or fair measures for driver education, and are unrealistic to expect (Waller, 2003). A second analysis, which tracked the students’ driving records for a longer period of time, found a slight crash reduction for standard course graduates during their first months of driving only, and no difference between the long course and no course graduates (Smith, 1994). Research shows that driver education “discounts” increase, rather than reduce, crashes (Mayhew, 2007). For example, a study in British Columbia found that crash rates were 27% higher for driver education graduates, who reduced their learner’s permit holding period by three months, than for non-graduates (Wiggins, 2004). Presently, 33 States and the District of Columbia require some form of driver education before licensure. Most commonly this includes 30 hours of classroom instruction and 6 hours of behind-the-wheel practice, although requirements vary considerably across States. For example, some States require novices to obtain a certain number of hours practice on a driving simulator. No data are currently available on commercial driver education courses or students. Effectiveness: Driver education can lead to earlier licensure and does not reduce crash rates (Mayhew, 2007; Roberts et al, 2006; Vernick et al. Nonetheless, there has been a growing interest in improving and evaluating driver education. Time to implement: A driver education course requires at least a year to plan and implement. Other issues: • Parent involvement: There has been a growing interest in integrating parents into driver education. For example, Virginia passed legislation in 2009 requiring a minimum of 90 minutes of parent participation in the in-classroom portion of driver education. Parents appear to support being more involved in their teenager’s driver education course (Hartos & Huff, 2008). Unfortunately, research has not yet determined the most effective way to accomplish this goal. One recent study delivered the Checkpoints program in driver education classes (Zakrajsek et al. Relative to a comparison group, parents who participated in the Checkpoints program showed greater awareness of teen driving risks, and they were more likely to complete a parent-teen driving agreement. However, participation in the program was voluntary and, despite diligent recruitment efforts, parent attendance was low (Zakrajsek et al. These “second-tier” post-licensure courses teach safety-related information, building on the on-road experience that the students have acquired in their initial months of driving. They should not be confused with “advanced driving performance” courses that teach driving skills such as panic braking, skid control, and evasive lane-changing maneuvers. Previous post-licensure driver education courses were remedial, directed at drivers who had accumulated enough violations or crashes to warrant some attention. Initiatives in Australia and Europe may provide insight on potential approaches for post-license training for beginning drivers (Senserrick, 2007; Twisk & Stacey, 2007). Christie and colleagues have developed a model “best practice” curriculum for intermediate license drivers with at least 6 months of driving experience in Australia (Christie, Harrison, & Johnston, 2004). The 8-hour curriculum consists of eight modular sessions with a mentor or coach, including one-on-one driving and discussion, group observation and discussion of driving behavior, and telephone follow-up. A trial involving 14,000 intermediate drivers in New South Wales and Victoria, funded by a consortium of government bodies, insurers, industry groups, and automobile clubs, began in 2005. Michigan is the only State that has adopted a two-stage system of driver education (Mayhew, 2007). Costs: If a post-licensure driver education program proves to be effective, it likely will require substantial funds to implement. Parents could use guidance and assistance in teaching and managing their teenage drivers (Hedlund et al. For summaries of the research on parent involvement in teen driving, see Simons-Morton and Ouimet (2006) or Simons-Morton, Ouimet and Catalano (2008). The central feature of the Checkpoints program, developed by Simons-Morton and colleagues at the National Institute of Child Health and Human Development, is a written agreement that parents and teens sign. The program’s educational kit includes a video, guide, and brochure, and the Web site contains online learning material, parental tips and a coaching guide.

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