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The amount of control granted to the crew will almost certainly vary depending on the phase of the mission. Closer proximity to Earth will allow ground crew to provide more direct support in all aspects of the mission. So, autonomy afforded to the crew will increase for the crew and decrease for ground support as the spacecraft travels away from Earth with the crew having the most autonomy when physically farthest from Earth. Later in the mission as the spacecraft returns toward Earth, the balance of autonomy will follow the same path, flowing from the crew back toward ground support. Both crew and ground support will need to learn to cede autonomy as the other assumes it. Control in the form of autonomy is not the only aspect of designing the job that will affect eudaimonic well-being on exploration missions. Astronauts have often reported about the importance of meaningful work (Britt, Jennings, Goguen, and Sytine, n. Having sufficient meaningful work to conduct is more than just an important component of a successful exploration mission; it will be a critical one. Thagard, "[T]he single most important psychological factor on a long-duration flight is to be meaningfully busy. And, if you are, a lot of the other things sort of take care of themselves" (Herring 1997, p. Vehicle maintenance, for example, might be deemed meaningful by one crewmember while another views such work as necessary but not personally meaningful. The type of work that is considered meaningful could very well differ during the mission. During an outbound phase of a mission, crew is more likely to be focused on training tasks. In contrast, on the return phase, training might be less meaningful while analyses of samples would be more meaningful. Among other contributing factors, monotony and boredom are closely tied to design of the environment and meaningful work, which were discussed in the two immediately preceding sections. A lack of variety in social interaction, leisure activities, and the physical 44 environment can contribute to perceptions of monotony and lead to boredom, interpersonal conflict, loss of energy and concentration, and a decrease in physical activity and social interaction (Basner et al. This combination of monotony with high-risk consequences for errors is especially stressful (Thackray 1981). Even in the face of monotony, however, performance remains high enough for mission success, provided that the motivation is high (Kanas and Fedderson 1971). Chronic boredom, well documented in environments with limited sensory stimulation, could lead to more serious mood disturbances (Vessel and Russo, 2015). As missions become longer, the focus on the amount of work that humans can safely perform changes from how much to how little (Weiner, 1977). Daily hassles that are associated with the physical environment that is unique to space include: a growing accumulation of garbage, limited facilities for sanitation, the need for constant vigilance, and a relative lack of privacy. These seemingly small hassles can aggregate into larger psychological issues (Nicoletti & Garrido n. An inherent dislike of psychological testing is one impediment to measuring psychological constructs in general. Further increasing the difficulty in measuring the relationship between hassles and well-being or mood is the transient nature of hassles. A disconnect between occurrence of hassles and measurement means that the impact of hassles can be missed. Glad I could vent to the journal and not via email because that could be catastrophic to my career" (Stuster, current research). Cultural factors Culture is a broad term that can encompass national culture at a macro level as well as organizational culture or even intra-organizational subcultures, such as a distinction between civilian scientists and military pilots, at a more micro level. Factors associated with national and other types of culture are covered in greater detail in the evidence book on the Risk of Performance and Behavioral Health Decrements Due to Inadequate Cooperation, Coordination, Communication, and Psychosocial Adaptation within a Team.

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Prism therapy: Prisms are used to correct the head position and shifting the image into the null point area. Nystagmus surgery: the surgery improves the visual acuity and broadens the null zone. Flutter-like oscillations of eyes and ocular dysmetria signify inability to fixate on an object accurately while shifting the gaze. Opsoclonus is marked by wild and chaotic movements of the eyes associated with myoclonic movements of face and extremities. Treatment Attempts should be made to improve the vision by correction of refractive error of the patient. Prism therapy and large recession of both medial rectus muscles are recommended to transfer the null point (where nystagmus is least) from the eccentric position to straight-ahead position. The margins of upper and lower lids meet at the medial and the lateral angle called the canthi. There is a semilunar fold of conjunctiva called the plica semilunaris at the medial canthus. The two eyelids are separated medially by a triangular space, the lacrimal lake or lacus lacrimalis. A fleshy raised body, the lacrimal caruncle, is located in the lacus lacrimalis on the medial side of the plica. On the top of the papilla is the lacrimal punctum which leads the tears to the lacrimal canaliculus. Layers of the Eyelid Each eyelid from outer to inner aspect has following layers. A horizontal fold is present in the skin of the upper lid which becomes prominent on the upward gaze, the superior palpebral sulcus or lid crease. The anterior border of the lid margin is round, while the posterior is sharp and lies closely in contact with the eyeball. The skin is loosely attached to the underlying structures; this loose attachment permits easy accumulation of edematous fluid or blood. Layer of striated muscle is composed of fibers of palpebral part of the orbicularis oculi. The orbital part is arranged in a concentric manner around the orbital margin covering the tarsus. The preseptal portion overlies the orbital septum and the pretarsal portion of orbital part of orbicularis oculi muscle lies anterior to the tarsus. An incision at the gray line (a line between the anterior and posterior margins of the lid) splits the lid through the plane into an anterior and a posterior portion. It has two parts, a thick central part, the tarsal plate and a thin peripheral part, the orbital septum or septum orbitale. They also join the unstriped muscle of Mьller at the upper border of the tarsal plate. The lateral palpebral ligament attaches the lateral ends of the tarsi to the Whitnall tubercle, while the medial ends of the tarsi are attached by the medial palpebral ligament to the lacrimal crest. It is thicker on the lateral side than on the medial and in the upper lid than in the Diseases of the Lids 387. In the upper lid the septum is in contact with the orbital fat which separates it from the levator palpebrae superioris. They are believed to help in the retraction of eyeball and elevation of the upper lid. Glands of the Eyelid the glands of Zeis are situated at the lid margin in close association with the cilia. The glands secrete oily secretion which lubricates the eye and prevents evaporation of tears from the cornea. They form two main arcades: the superior peripheral arcade lying between the upper part of the tarsus and the orbicularis, and the inferior peripheral arcade, nearly 3 mm above the lid margin. The superior arcade is reinforced by the branches from the superficial temporal, lacrimal and supraorbital arteries, while the inferior by the transverse facial and facial arteries. Each lid is drained by the pretarsal and the posttarsal plexus into the subcutaneous and ophthalmic veins, respectively. Lymphatics from most of the upper lid and lateral half of the lower lid drain into the preauricular lymph nodes and the medial portions of both the lids drain into the submandibular lymph nodes.

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Fanconisyndromeshould beconsideredinachildpresentingwith: · · · · · Polydypsiaandpolyuria Saltdepletionanddehydration Hyperchloraemicmetabolicacidosis Rickets Failuretothrive/poorgrowth. Investigationbyultrasoundscanwillidentifyobstruc tion of the urinary tract, the small kidneys of chronic renalfailure,orlarge,brightkidneyswithlossofcortical medullarydifferentiationtypicalofanacuteprocess. The hypovolaemia needs to be urgently corrected with fluid replacement and circulatory supportifacutetubularnecrosisistobeavoided. Renal failure Ifthereiscirculatoryoverload,restrictionoffluidintake andchallengewithadiureticmayincreaseurineoutput sufficiently to allow gradual correction of sodium and water balance. Emergency management of metabolic acidosis, hyperkalaemia and hyperphosphataemia is shown in Table18. Ifthecauseofrenalfailureisnotobvious, a renal biopsy should be performed to identify rapidly progressive glomerulonephritis, as this may need immediate treatment with immunosuppression. Dialysis Dialysis in acute renal failure is indicated when thereis: · · · · · · Failureofconservativemanagement Hyperkalaemia Severehypoorhypernatraemia Pulmonaryoedemaorhypertension Severeacidosis Multisystemfailure. Postrenal failure Thisrequiresassessmentofthesiteofobstructionand relief by nephrostomy or bladder catheterisation. If there is cardiacdecompensationorhypercatabolism,continu ousarteriovenousorvenovenoushaemofiltrationpro vides gentle, continuous dialysis and fluid removal. Acute renal failure in childhood generally carries a goodprognosisforrenalrecoveryunlesscomplicating a lifethreatening condition. Plateletsareconsumed in this process and microangiopathic haemolytic anemia results from damage to red blood cells as they circulate through the microcirculation, which is occluded. Clinical features Chronicrenalfailurepresentswith: · · · · · · · · Anorexiaandlethargy Polydipsiaandpolyuria Failuretothrive/growthfailure Bonydeformitiesfromrenalosteodystrophy(renal rickets) Hypertension Acuteonchronicrenalfailure(precipitatedby infectionordehydration) Incidentalfindingofproteinuria Unexplainednormochromic,normocyticanaemia. Manychildrenwithchronicrenalfailurehavehadtheir renaldiseasedetectedbeforebirthbyantenatalultra sound or have previously identified renal disease. Management Theaimsofmanagementaretopreventthesymptoms and metabolic abnormalities of chronic renal failure, to allow normal growth and development and to preserve residual renal function. Summary Acute renal failure · Prerenal: commonest cause in children, from hypovolaemiaandcirculatoryfailure · Renal:mostoftenhaemolyticuraemicsyndrome ormultisystemfailure · Postrenal:fromurinaryobstruction · Management:treatunderlyingcause,metabolic abnormalities,dialysisifnecessary. Prevention of renal osteodystrophy Phosphate retention and hypocalcaemia due to decreased activation of vitamin D leads to secondary hyperparathyroidism, which results in osteitis fibrosa andosteomalacia. Congenitalandfamilialcausesaremore common in childhood than are acquired diseases (Table18. Control of salt and water balance and acidosis Manychildrenwithchronicrenalfailurecausedbycon genital structural malformations and renal dysplasia have an obligatory loss of salt and water. Hormonal abnormalities Many hormonal abnormalities occur in chronic renal failure. Most importantly, there is growth hormone resistancewithhighgrowthhormonelevelsbutpoor growth. Recombinant human growth hormone has beenshowntobeeffectiveinimprovinggrowthforup to5yearsoftreatment,butwhetheritimprovesfinal heightremainsunknown. Manychildrenwithchronic renal failure have delayed puberty and a subnormal pubertalgrowthspurt. Ideally, a child is transplanted before dialysis is required, but if this is not possible, a period of dialysismaybenecessary. Summary Chronic renal failure · Causes:congenital(structuralmalformationsand hereditarynephropathies)mostcommon · Presentation: abnormal antenatal ultrasound, anorexia and lethargy, polydipsia and polyuria, failure to thrive/growth failure, renal rickets, hypertension,proteinuria,anaemia · Management: diet and nasogastric or gastros tomy feeding, phosphate restriction and acti vatedvitaminDtopreventrenalosteodystrophy, salt supplements and free access to water to controlsaltandwaterbalance,bicarbonatesup plements to prevent acidosis, erythropoietin to prevent anaemia, growth hormone and dialysis andtransplantation. Dialysis and transplantation Itisnowpossibleforallchildrentoenterrenalreplace ment therapy programmes when endstage renal failure is reached. Websites (Accessed May 2011) Emedicine: Details about a range of paediatric nephrology conditions. Inguinoscrotal disorders Embryology the testis is formed from the urogenital ridge on the posterior abdominal wall close to the developing (a) Testis (retroperitoneal) (on posterior abdominal wall) Abdominal descent Inguinoscrotal descent (third trimester) Peritoneum Internal inguinal ring Gubernaculum Scrotum Phallus Processus vaginalis kidney. During gestation, the testis migrates down towards the inguinal canal, guided by mesenchymal tissue known as the guber naculum, probably under the influence of anti Mьllerianhormone(Fig. Inguinoscrotal descent of the testis requires the releaseoftestosteronefromthefetaltestis. Atongueof peritoneum, the processus vaginalis, precedes the migratingtestisthroughtheinguinalcanal.

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Investigations Asthma can usually be diagnosed from the history and examination and no investigations are needed. Sometimes, specific investigations are required to confirmthediagnosis,orexploretheseverityandphe notype in more detail. Skinprick testing for common allergensisoftenconsideredbothasanaidtothediag nosisofatopyandtoidentifyallergenswhichmaybe acting as triggers. If there is: · Sputum · Finger clubbing · Growth failure ­ If present, other causes should be sought Monitor: · Peak flow diary · Severity and frequency of symptoms · Exercise tolerance · Interference with life, time off school · Is sleep disturbed? Inhaled corticosteroids(oftencalledpreventers)arethe most effective inhaled prophylactic therapy. They decrease airway inflammation, resulting in decreased symptoms,asthmaexacerbationsandbronchialhyper activity. They have no clinically signifi cantsideeffectswhengiveninconventionallicensed doses. Slow-release oral theophylline is an alternative; however, it has a high incidence of side effects (vomiting, insomnia, headaches, poor concen tration),soitisnotcommonlyusedinchildren. All are given by inhalation, except prednisolone, leukotriene modulators, theophylline preparations, which are by mouth, and omalizumab, which is by injection. Other therapies Oral prednisolone, usually given on alternate days to minimisetheadverseeffectonheight,isrequiredonly inseverepersistentasthmawhereothertreatmenthas failed. Itisusedforthetreatmentofsevereatopicasthma,and should only be administered by a specialist in child hoodasthma. Mostantibioticsareofnovalueintheabsenceofa bacterial infection, although recent data suggest that macrolide antibiotics. Itis important to set the aims with the child as they aremorelikelytocomplywiththeirtherapyiftheyare involved in their management. An evidencebased and regularly updated British Guideline on Asthma Management gives guidance on asthma treatment in childrenandadults. They are used as required for increased symptoms, and in high doses for acute asthmaattacks. Theyare not used in acute asthma, and should not be used withoutaninhaledcorticosteroid. Allergen avoidance and other non-pharmacological measures Although asthma in many children is precipitated or worsenedbyspecificallergens,completeavoidanceof theallergenisdifficulttoachieve. This is determined by the frequency and severity of symptoms and the response to treatment. The aim is to gain control of symptoms and to then step down treatment over the next few months. Allergen immunotherapy is effective for treating atopic asthma, but its use is limitedbytheriskofsystemicallergicreactionsassoci atedwiththetreatment(seeCh. Although exercise improves general fitness, there is no evidence that physicaltrainingimprovesasthmaitself. Acute asthma Assessment Witheachacuteattack,thedurationofsymptoms,the treatment already given and the course of previous attacksshouldbenoted. With appropriate treatment, asthma should notrestrictexercise,andtherearemanyeliteathletes withasthma. Needs a good inspiratory flow, therefore less good in severeasthmaandduringanasthmaattack. Onlyusedinacute asthma where oxygen is needed in addition to inhaled drugs; occasionally used at home as part ofanacutemanagementplaninthosewithrapid onsetsevereasthma(brittleasthma). Many children fail to gain the benefit of their treat mentbecausetheycannotusetheinhalercorrectly. Inyoungchildren,parentsneedtobe skilled in assisting their child to use the inhaler cor rectly. Assessingandreassessinginhalertechniqueis vital to good management and should be a routine partofanyreview. Criteria for admission to hospital Childrenrequirehospitaladmissionif,afterhighdose inhaledbronchodilatortherapy,they: · However, the severity of an acute asthma attack may be underestimated by clinical examination alone. Therefore: · havenotrespondedadequatelyclinically;thereis persistingbreathlessness,tachypnoea · areexhausted · stillhaveamarkedreductionintheirpredicted(or usual)peakflowrate · haveareducedoxygensaturation(<92%inair).

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Classically, a pterygium has four parts: (i) a blunt apex, head, (ii) a few infiltrates in front of the apex, cap, (iii) a limbal part, neck, and (iv) a bulbar portion extending between the limbus and the canthus, body. When pterygium stops growing, infiltration and vascularization disappear, and it becomes pale and thin. They are commonly found in elderly persons suffering from trachoma or chronic conjunctivitis. Foreign body sensation is the main symptom and occasionally a corneal abrasion may develop. Removal of concretions with a sharp needle after topical anesthesia eliminates the symptoms. Pinguecula Pinguecula is a degeneration of the bulbar conjunctiva characterized by the presence of a yellowish triangular spot near the limbus, the apex of the triangle being towards the canthus. The condition is found in elderly people, especially in those living in dusty and windy climate. However, it is really a hyaline infiltration and elastotic degeneration of the submucosa of the conjunctiva with little or no vascularization. It is characterized by a triangular encroachment of the conjunctiva onto the cornea usually on the nasal side. An autoconjunctival graft or amniotic membrane transplantation (See video) often prevents the recurrence of pterygium. Probe Pterygium Usually seen in adults Unknown Palpebral aperture Horizontal Progressive or stationary Adherent to limbus Cannot be passed underneath Pseudopterygium Usually seen in children Postinflammatory Palpebral aperture cum fornix Oblique Almost always stationary Free Can be passed Pseudopterygium A pterygium-like condition. It can be differentiated from a true pterygium by the passage of a probe between it and the bulbar conjunctiva. An early age of onset, obliquity of the axis and stationary course are other differentiating features (Table 11. Conjunctival cysts may occur due to dilatation of lymph spaces, lymphangiectasis, of the bulbar conjunctiva. Dermolipoma Dermolipoma is a yellowish-white, fibro-fatty congenital tumor commonly found at the outer canthus. Congenital Epibulbar Dermoid Congenital epibulbar dermoid of the conjunctiva is a white or yellow oval mass at the limbus Diseases of the Conjunctiva 139. Papilloma Papilloma is a benign polypoid tumor of the conjunctiva occurring in the fornix or at the canthus. Benign Tumors Nevus Nevus or congenital mole is frequent on the bulbar conjunctiva. Fibroma Fibroma is a rare firm or hard polypoid growth often seen in the lower fornix needing surgical removal. Granuloma Granuloma of the conjunctiva may develop either on the palpebral or on the bulbar conjunctiva. Epithelioma can involve an extensive conjunctival area and may rarely cause perforation of the globe. Basal Cell Carcinoma Basal cell carcinoma is a common tumor which usually involves the plica semilunaris and medial part of the lower lid. Malignant Melanoma Malignant melanoma may arise from a pre-existing nevus or de novo in the normal conjunctiva. The radii of curvature of the anterior and posterior surfaces of the central part of the cornea are 7. The transparency of the cornea is due to its peculiar lamellar arrangement of collagen fibers, selective permeability of the epithelium and the endothelium, avascularity and deturgescence. The corneal deturgescence is maintained by an active sodium-potassium pump situated in the endothelium. Epithelium is a continuation of the epithelium of bulbar conjunctiva and consists of five layers of cells. The deepest layer has a palisade-like arrangement, the middle layers comprise polygonal cells and the superficial layer is formed by a flat squamous epithelium without keratinization.

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Palmer gave reports relative to the school, its history, its finances, and its program. The financial report surprised everyone, especially that the school was operating in the black. When the books were closed after the end of the sixth school term [including the Bible school at Melbourne], they could report a gain of Ј331 (Ibid. First she read from a manuscript titled "The Avondale School Farm" (reproduced in the July 31, 1899, Union Conference Record), based on a vision given to her some months before, and having a very practical bearing on the development of the school: I have words of counsel for our brethren regarding the disposition and use of the lands near our school and church. Many particulars regarding the work at Cooranbong have not been opened before me until recently, and not until now have I felt at liberty to speak of them. At the beginning of the Sabbath I fell asleep, and some things were clearly presented before me. All the land near the buildings is to be considered the school farm, where the youth can be educated under well-qualified superintendents. They are to plant it with ornamental trees and fruit trees, and to cultivate garden produce. The school farm is to be regarded as a lesson book in nature, from which the teachers may draw their object lessons. The light given to me is that all that section of land from the school orchard to the Maitland road, and extending on both sides of the road from the meetinghouse to the school, should become a farm and a park, beautified with fragrant flowers and ornamental trees. There should be fruit orchards and every kind of produce cultivated that is adapted to this soil, that this place may become an object lesson to those living close by and afar off. Every power at our command is to be brought into this training work, that students may go forth equipped for the duties of practical life. When she finished reading, she laid her manuscript down and continued to speak to the audience on the objectives of the school: God designs that this place shall be a center, an object lesson. Our school is not to pattern after any school that has been established in America, or after any school that has been established in this country. Here they are to be educated and trained, and sent to the islands of the sea and other countries. It was now a strong training center and soon would be a home base for mission field activities. It was becoming a positive influence in the community; it demonstrated what, with intelligent and diligent efforts, could be accomplished in that backward region. Shortly after Ellen White had returned to America, Australia suffered a prolonged and distressing drought. For the past two years the school has had marked evidences of the protection and prospering hand of our heavenly Father. While the drought was so severe all around that practically nothing was raised, the school estate of fifteen hundred acres was blessed with frequent rains and abundant crops, so that sufficient was raised to supply the school and leave a surplus for sale. Speaking of this a few days later, he declared: It is really remarkable; there is just as marked a difference between that school estate and the surrounding country as we have reason to believe existed between the Egyptians and the children of Israel in the time of the plagues. The form of set type was taken by a handcart to a nearby printer, where it was run on the press. Four years later, land was bought on Best Street and a building erected to house the emerging Echo Publishing Company and to provide a meeting hall on the second floor. Commercial work was taken in to supply work to justify the sophisticated equipment needed to produce denominational publications. After printing in a commendable manner a pamphlet for the governor of Victoria, the Echo Publishing Company was officially appointed "Publishers to His Excellency Lord Brassey, K. From one person employed in 1885, the work grew, until in 1899 there were eighty-three employees. This gave it the third position among Adventist publishers, following the Review and Herald which employed 275, and the Pacific Press, with 150 workers (Australasian Union Conference Record, July 19, 1899). With an establishment standing first among the publishing houses operated outside of North America, the Echo Publishing Company was indeed "of age. Evangelism, which had moved rather slowly at first in Australia and New Zealand, was vitalized by the extended evangelistic camp meetings introduced in 1893 and 1894. Year by year methods were refined, and in the late 1890s evangelism was forging ahead, yielding rich harvests.

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Earlier, in her letter to Olsen, she declared: "Few thought that Elder Daniells could be the one for the place of president; but with W. Our membership increased encouragingly, and it became necessary to establish a training school for Christian workers, also church schools for the children of our believers. Then followed the erection of a sanitarium for the treatment of the sick, and the establishment of a factory for the manufacture of health foods. As president, I was held more or less responsible for progress in all these endeavors. I was also closely associated in committee and administrative work with her son, W. His counsel was very helpful to me; it was based on a longer experience than my own, and also upon his intimate knowledge of the many messages of counsel that had been given through his mother during past years, in meeting conditions similar to those we were facing. On Sunday, January 3, it closed, but the program continued for another full week in "An Institute for Instruction in Christian Work" and devotional meetings. Gates taught the cooking, and Miss May Walling gave practical instruction in the care of the sick. The people attending felt they had gained a good deal of practical instruction and were highly satisfied. The overall plan was that she would make Melbourne her headquarters for six months, and write on the life of Christ. From there she would visit the principal churches and even spend two months in New Zealand in connection with their conference session. On Sunday morning, January 3, Stephen Belden drove Ellen White in his carriage five miles north to a suburb known as Preston. She was pleased with the country atmosphere and with the area generally, but the cottage they went to see was not large enough for the group that had to work together. She noted in her diary: We found a nice brick house with nine rooms which, with a little squeezing, would accommodate Elder Starr and his wife and our workers. Wednesday they were there again, this time to make arrangements to rent the unfurnished house for six months. The next two [30] days were spent in buying furniture, dishes, and other household necessities. Sunday morning she was up early packing and getting ready to move into their new home. By noon they were in their new quarters, and quite content with the prospects: a large lot; pure, invigorating air; a yard full of flowers "of fine rich quality": and good soil. They secured a good healthy cow to provide their milk supply, and a stable was built to accommodate the horse and cow (Letter 90, 1892). Because their plans called for only a six-month stay, they bought secondhand furniture, improvising somewhat with packing boxes. Some of the old carpeting used in packing the goods shipped from America served as floor covering. The women helpers took the yard work under their care, and the garden responded well. Wrote Ellen White: the girls went to work in the garden, pulling weeds, making flower beds, sowing seeds for vegetables. It was very dry, so we bought a hose, and Marian [Davis] was chief in the flower garden. I never saw them blossom as they do here; the geraniums, Lady Washingtons, in immense bunches of the richest colors to delight the eye. But for Ellen White, who began to feel ill during the conference session, there was an acceleration in her suffering. From week to week she seemed to be in more and more pain and was becoming more helpless. On January 23, near the onset of her illness, she stated in a letter to Lucinda Hall: I am now writing on the life of Christ, and I have had great comfort and blessing in my writing. This is how she herself depicted it: When the work, newly started in Australia, was in need of help, our brethren in America desired me to visit this field. They urged that as one whom the Lord was especially teaching I could help the work here as others could not.

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Even though the rent seemed high, they would go forward in the name of the Lord and do something. In the evening Starr addressed an audience of about the same size on the inspiration of the Scriptures. An interest was created, and meetings continued for some time in the skating rink on Sabbath and Sunday and some evenings. Now in the winter months in New Zealand, when travel would be somewhat curtailed, she determined to push the work forward as her strength and her program would allow. Letters she should have answered remained unanswered, in some cases, for months, as she tried to make room for work on her book. A diary entry for May 19 reads: "Before breakfast, wrote seven pages on the life of Christ. White was enduring the damp and windy weather of Wellington very well, and having found at the Tract Society Depository a quiet and comfortable place to reside, is engaged in writing on some of the unfinished chapters of her forthcoming "Life of Christ. The appointment of the next annual conference early in the season may enable her, if she can endure the dampness of the climate, to remain and attend this meeting, before the next annual conference and first camp meeting in Australia-July 1, 1893. From time to time through the winter-June, July, and August- she mentions, in her letters and her diary, writing on the life of Christ. Thursday, June 15, 1893: I do not flatter myself that very much progress can be made on the life of Christ. Monday, June 19: I am trying to write on the life of Christ, but I am obliged to change my position quite often to relieve the spine and the right hip. Sister Tuxford and I had our season of worship alone-only two to claim the promise. We have secured a wheelchair, that I can be wheeled in the open air when I cannot ride in carriage. Letters are constantly coming for an answer, and should I write to the many that I desire, I should not find any time to write on the life of Christ. An Agonizing Letter to Edson Letters from James Edson White brought little comfort to his mother. While she was in New Zealand, he was in Chicago in the printing business, and quite involved in debt, which was not unusual for him. Her response opened: Dear Son Edson, Why should you express yourself as you have done? If you were a man unacquainted with truth, I could address you in a different way, approach you by presenting the truth in all its beauty and attractive loveliness, but this would not move you. Many had collected on the beach to observe your movements, and this seemed to make you more determined and venturesome. The waves were rolling up nearer and still nearer and then would roll back with a sullen roar. Gestures and warnings were given by the anxious ones looking on, but in answer to all their warnings you were more presumptuous. A strong rope was brought and fastened securely around the body of a strong young man who ventured to risk his own life to save you. I have had opportunity to watch the movements of the waves as I have often visited Island Bay, four miles from Wellington. It represents the power of Satan and a set, independent, stubborn will of your own which has reached even against God. You have taken the molding of your character out of the hands of your mother, out of the hands of God, and are placing defective, rotten timbers in the building. You would almost fail to recognize yourself should your present picture of character be presented by the side of the former one when you tried to walk in the fear of God. Your religious history need not have been vacillating, but firm and true; but you would be independent and take your own course. I am now determined to press upon your notice and make you hear: "This is the undertow. I know your only hope is to cling to God and to (1893) the Winter in New Zealand 113 your mother and brother.

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There are significant concerns about how this increase will affect the transition and adult disability service systems. However, we also know that some individuals with autism do experience positive outcomes. It is unclear to what extent these findings apply to individuals in mid- or later-adulthood, from racial/ethnic minority groups, or with fewer socioeconomic resources. Pursuing postsecondary education can be important in fostering independence, self-determination, and employment success. For students with co-occurring intellectual disability, a college-like transition program with a focus on independent living skills may be appropriate. Yet, the effectiveness of these post-secondary education and employment programs is almost never evaluated. Many of the cohort studies that inform our knowledge and build job interviewing skills 21,22,23 and customized employment supports. Those interventions that show promising initial results ideally will be tested in large-scale randomized controlled trials, with the ultimate goal of incorporating them into intervention options to improve adult outcomes. Yet, the measurement in these datasets does not have the detailed, personalized information needed to provide targeted recommendations to disability service workers on college campuses, parents who want their sons and daughters to succeed in college or employment, or adults themselves who are searching for the most appropriate services and supports based on their unique situations. Discoveries in the employment realm have centered on understanding patterns over time. Yet, evidence to support the development of targeted programs and support is woefully lacking. Lakin and colleagues (2008)30 describe the national agenda to increase the number of community-based housing options for individuals with intellectual disabilities as a way of increasing community participation and self-determined choice making. The few studies that have examined employment beyond young adulthood do not find patterns of improvement over time; most adults who are unemployed or underemployed in early adulthood tend to stay that way, and independence in vocational positions declines over time for some. One notable exception is self-care skills, which consistently predict employment and are amenable to intervention. A one-dimensional look at outcomes such as vocation, health, illness, or quality of life at a specific point in time will not capture the rich diversity of life course trajectories. Without valid, sensitive outcome measures, it becomes exponentially more difficult to detect whether an intervention or service is effective and should be pursued. To reach the Aspirational Goal, careful research is needed to understand how to define "good" outcomes in a systematic yet personalized way, and then measurement tools are needed that reliably capture those outcomes. More work must be done to develop and test interventions that prevent, control, and/or moderate the effects of physical and mental health disabilities. Several studies have suggested that people on the autism spectrum are vulnerable to premature death due to a number of causes, including epilepsy, late diagnosis of medical conditions, and accidents. There has also been limited consideration of differences in how the manifestations, course, or treatment of psychiatric disorders might differ for these adults. Better measurement tools and methods are necessary to understand the scope of physical and mental health needs and design appropriate services and supports. Studies must include consideration of young, middle-aged, and older adults, including those diagnosed as children and those identified in later life. Exclusive reliance on self-report may also not be ideal, due to possible limitations in insight, communicative difficulties, or over-reporting of autism characteristics to achieve secondary gain. As such, there is a need for training grants and initiatives focused on training professionals who will be working with adults to detect, diagnose, and address mental and physical health-related needs in this population. Research focused on adults in the criminal justice system is also important to understand precipitating factors for criminality or adverse interactions with law enforcement; Helverschou et al. Supports should also take a lifespan developmental perspective, encouraging the development of new skills and abilities throughout adulthood. Despite this, the current research is insufficient to understand the types and extent of need, or to inform evidence-based programs to ensure safety among adults on the autism spectrum. More work is needed to understand and evaluate the effectiveness of long-term supports for those with high support needs (such as those with significant cognitive impairments). As many of these adults will be receiving some sort of formal adult disability service, more rapid headway can be made in this area if service providers systematically collect outcome data. Because housing and other adult services are limited in availability, it is even more critical for policy makers and providers to ensure that families are well-supported so that they can continue their caregiving role as long as possible. This is, perhaps, where the greatest progress toward the Aspirational Goal has been made. These questions form the necessary building blocks for effective and efficient interventions and services; nevertheless, these questions can be seen as lacking significance or innovation for those outside the autism field (who assume the answers are known).

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Like Alcott, Sylvia has absorbed ``pride, intellect, and will' from her father, while inheriting from her mother ``passion, imagination, and the fateful melancholy of a woman defrauded of her dearest hope. As Alcott describes it, ``No one was so much to her as he; no one so fully entered her thoughts and feelings. As man and woman they talked, as father and daughter they loved; and the beautiful relation became their truest solace and support. In important respects, Moods critiques the romantic notions of the Transcendentalist movement, particularly its faith in nature as a benevolent and restorative influence. Sylvia is magnetically drawn to nature in its most tempestuous aspects, and her attraction repeatedly threatens to annihilate her. On a boating excursion, as her companions desperately seek shelter from a violent thunderstorm, Sylvia sits erect, impervious to the danger and eager to share in the elemental fury. In earlier chapters, she has been nearly consumed by a brushfire and almost drowned by a fast-rising ocean tide. Warwick is a ``violently virtuous' man who ``always takes the shortest way, no matter how rough it is. He advises, ``Let her alone, give her plenty of liberty, and I think time and experience will make a noble woman of her. As another character observes, ``Adam has only the pride of an intellect which tests all things and abides by its own insight. He clings to principles; persons are but animated facts or ideas; he seizes, searches, uses them, and when they have no more for him, drops them like the husk, whose kernel he has secured. An Alcott heroine is typically called upon to choose between a man who, like Warwick, speaks compellingly to her soul, and one who stands for some more practical principle. An essentially bland, forgettable character, Moor appeals to Sylvia precisely because he inspires no passion. He has also just spent five years caring for a dying sister, a service that appears to qualify him to help Sylvia conquer her mental ills. She reaches out to him in search of a Platonic friend, little imagining the difficulties of preventing such an attachment from edging toward marriage, with all its daunting implications of sex and permanence. Sylvia at first rebuffs him, but then, in the mistaken belief that Warwick has left never to return, she consents. Perhaps echoing the consociate spirit of Fruitlands, Warwick argues that unhappy marriages will remain ``the tragedies of our day. While away, the two achieve a literary rapprochement, co-authoring a book to which Moor contributes poems and Warwick supplies essays. On the return voyage, the boat in which the two men are traveling sinks, and Warwick heroically and conveniently drowns. In the 1882 version, however, inspired by the advice that ``in making the joy of others we often find our own,' Sylvia gives up morbid self-contemplation in order to serve others. As a woman long tormented and betrayed by her emotions, Sylvia Yule is more than happy to submerge the mercurial aspects of her temperament in contented marriage. They stand to lose not only their troublesome restlessness, but also the opportunity to develop their positive talents and energies. Alcott published Little Women in two parts, the first appearing in October 1868 and the conclusion making its debut the following spring. Although both parts obviously relate the experiences of the same characters, they are two different books in terms of their central thematic concerns. Part One is about the formation of character; it presents the March sisters as young girls struggling to develop their talents, to achieve emotional maturity, and to master their initially egocentric desires. Part Two is about young women who, having achieved a sense of self, must struggle against external forces ­ for example, mortality and phallocratic social conventions ­ that threaten to diminish or destroy those selves. However, as Mark Adamo has shown in his recent operatic adaptation of the novel, it is also about the dread of growing up. Eager to lead her siblings forward into almost every other kind of adventure, Jo not only resists her own coming of age, but also resents the comparative ease with which her sisters appear to be making the transition. While they lavished intellectual and moral stimuli upon their daughters, Bronson and Abba were not precisely clear as to what ought to become of all that knowledge and training when its recipients reached womanhood.

References:

  • https://pediatrics.aappublications.org/content/pediatrics/107/Supplement_1/832.full.pdf
  • https://scottkramermd.com/webdocuments/Vulvar-Irritation-Vulvitis.pdf
  • https://www.med.navy.mil/sites/nmcphc/Documents/policy-and-instruction/oem-prevention-and-treatment-of-heat-and-cold-stress-injuries.pdf
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