Tryggve Nev?us, MD, PhD

• Associate Professor, Department of Women? and Children?
• Health, Uppsala University
• Consultant in Pediatric Nephrology,
• Uppsala University Children? Hospital, Uppsala, Sweden

If we decide that they should not receive the denied service gastritis diet èãðè discount prevacid 15mg overnight delivery, that letter will tell them how to file another appeal through us or ask for a State Fair Hearing gastritis diet ulcer cheap 30 mg prevacid fast delivery. For administrative and claims related complaints xeloda gastritis buy prevacid 30 mg line, the Provider Relations Department will provide a written or phone response to the provider within 10 days from the date of receipt of the complaint gastritis diet butter trusted 15 mg prevacid. The Executive Medical Director or designee will meet with the provider to discuss his/her complaint and will render a response within five days chronic gastritis months prevacid 15 mg visa. Complaints related to quality of care issues are forwarded to the Executive Medical Director and the Director of Quality Assurance gastritis remedios 15 mg prevacid free shipping. Both the Executive Medical Director and the Director of Quality Assurance will review the case and meet with the provider to discuss his/her complaint. The Chief Executive Officer will meet with the provider to discuss his/her complaint and will render a written response to the provider within 5 days. A provider must file their formal grievance/appeal with Jai Medical Systems within 90 business days of the action or adverse decision. The provider is contacted 3 to 5 days after receipt of the formal grievance/appeal form to discuss a mutually convenient date/time for the hearing. The Executive Medical Director must attend the hearing (or be on call) to provide input regarding medical issues. During the grievance/appeal hearing, a summary of the complaint issue and all supporting documentation is presented by the Executive Medical Director to the Committee members. The complainant also presents the complaint issue and all supporting documentation from his/her perspective to the members of the Committee. The Committee has the opportunity to ask questions and review all supporting documentation. After the hearing, the Committee members assemble to assess the facts and make a fair decision. The Committee will provide a written response (sent via certified mail) to the complainant within ten days from the date of the grievance/appeal hearing. The Chief Executive Officer, or designee, will provide a response in writing to the complainant within five business days of receipt of the request for a second hearing, including the reasons for his decision. Jai Medical Systems will not take any punitive action against a provider for utilizing our provider complaint process. For more detailed information regarding the claims appeal process, please see page 30. The HealthChoice Help Line and the Complaint Resolution and Provider Hotline Units, are responsible for the tracking of both provider and member complaints and grievances called into the hotlines, or sent to the Department in writing. The Help Line has the capability to address callers in languages other than English either through bilingual staff or through the use of a language line service. The Help Line uses an automated system for logging and tracking member inquiries and grievances. Provider Hotline staff respond to general inquiries and resolves complaints from providers concerning member access and quality of care as well as educating providers about the HealthChoice program. We will not take any punitive action against you for accessing the Provider Hotline. Utilizes the local health department Administrative Care Coordinator Unit and Ombudsman Program to provide localized assistance. Coordinates the State appeal process relating to a denied covered benefit or service for the member. The ombudsman educates member about the services provided by Jai Medical Systems and their rights and responsibilities in receiving services from us. The Ombudsman program is operated locally in each county of the State, under the direction of the Department. In most jurisdictions, local health departments carry out the local ombudsman function. Local ombudsman programs include staff with suitable experience and training to address complex issues that may require medical knowledge. The local ombudsman does not have the authority to compel us to provide disputed services or benefits. The Department conducts a periodic review of the Ombudsman Program activities as part of the quarterly and annual complaint review process. If it cannot be resolved in 10 business days, the member will be sent a notice that gives them a choice to request a fair hearing or wait until the Complaint Resolution Unit has finished its review. When the Complaint Resolution Unit is finished, working on the appeal, the member will be notified of their findings. If the Department disagrees with our determination, it may order us to provide the benefit or service immediately. The member may exercise their right to an appeal by calling 1-888-767-0013 or by completing the Request for a Fair Hearing form attached to their appeal letter and sending it to: Susan J. In appeals concerning the medical necessity of a denied benefit or service, a hearing that meets Department established criteria, as determined by the Department, for an expedited hearing, shall be scheduled by the Office of Administrative Hearings, and a decision shall be rendered within 3 days of the hearing. In cases other than those that are urgent concerning the medical necessity of a denied benefit or service, the hearing shall be scheduled within 30 days of receipt by the Office of Administrative Hearings of the notice of appeal and a decision shall be rendered within 30 days of the hearing. We will provide all relevant records to the Department and provide witnesses for the Department, as required. Following the hearing, the Office of Administrative Hearings issues a final decision. The final decision of the Office of Administrative Hearings is appealable to the Board of Review pursuant to Health-General Article, 2-201 to 2-207, Annotated Code of Maryland. The decision of the Board of Review is appealable to the Circuit Court, and is governed by the procedures specified in State Government Article, 10-201 et seq. The criteria below will be used to be determine if a member is eligible for corrective manage care: a. The Member is prescribed six or more controlled substances in a 30 calendar day period, and either, b. The Member fills the controlled substance prescriptions at three or more pharmacies in a 30 calendar day period, or c. The Member is prescribed controlled substances from three or more providers in a 30 calendar day period. Jai Medical Systems will send a letter to the member alerting them that they are being enrolled into corrective managed care. The Maryland Healthy Kids Program requires yearly preventive care visits between ages 2 years through 20 years. This Referral is not valid for any inpatient services or any procedures requiring pre-certification or prior authorization. This Referral Form cannot be used to convey participating provider status to non-participating providers. Medically necessary, emergency services may be provided by any provider regardless of referral. Signature: (Individual Completing this Form) Authorization #: (If Required) Referral certification is not a guarantee of payment. White: Carrier; Yellow: Primary or Requesting Provider; Pink: Consultant/Facility Provider; Goldenrod: Patient See Carrier/Plan Manual for Specific Instructions. If a member requires dialysis, please notify the Utilization Management Department as soon as possible. A full history and physical examination should be undertaken and the patient should be asked questions regarding: Diet (types of foods, frequency of meals, snacking, eating out, access to healthy foods, portion sizes, cultural traditions, etc. United States Department of Agriculture Center for Nutrition Policy and Promotion. We regret any inconvenience to you and look forward to working with you to address your concerns. Clear, full, and complete factual explanation of the reasons for the denial, reduction, or termination in understandable language. Conclusive statements such as "services included under another procedure" and "not medically necessary" are not legally sufficient. Statement that the enrollee may represent self or use legal counsel, a relative, a friend, or other spokesperson. An explanation that it is assumed an enrollee received the letter 5 days after it is dated unless he/she shows evidence otherwise. A statement providing the availability of the letter in other languages and alternate formats. Attachment M: Provider Quick Reference Guide Provider Quick Reference Guide Thank you for being a participating provider with Jai Medical Systems Managed Care Organization. For the most up-to-date information about Jai Medical Systems, please visit our website at Our website provides detailed information regarding our Clinical Guidelines, Utilization Management Program, Formulary, Quality Assurance Program, Disease Management Programs, Member Rights and Responsibilities, Prior Authorization Requirements, and Online Provider Directory. By calling this number, you may reach our Provider Relations Department, Case Management Department, as well as receive information regarding Claims and Appeals. Please use either the Jai Medical Systems Referral Form or the Maryland Uniform Consultation Referral Form. To request Jai Medical Systems referral forms, please contact our Provider Relations Department. Please only refer members in-network to participating providers listed in the Jai Medical Systems Provider Directory, which is available online. If you are having difficulty locating a particular provider, please contact our Provider Relations Department for assistance. If the claim is submitted electronically, please fax the referral to 1-866-381-7200 prior to submitting the claim. Pre-Certification & Prior Authorization Provider Quick Reference Guide Please visit our website, For questions regarding prior authorization of a service and/or procedure, please contact the Utilization Management Department at 410-433-5600. Claims & Appeals Electronic Claims: To submit electronic claims, please register at Please attach a copy of the authorization or referral form to each claim, if applicable. For information regarding paper and electronic claims submissions, as well as the claims appellate process, please visit our website at Pharmacy Please prescribe covered medications listed on the Jai Medical Systems Formulary, unless medically necessary circumstances dictate non-formulary prescriptions. Please refer to the Formulary for instructions on how to submit a prior authorization request for these medications. If you have questions about our pharmacy benefits, please contact ProCare at 1-800-213-5640. Laboratory Jai Medical Systems is contracted with LabCorp for all laboratory services. LabCorp maintains drawing stations throughout Maryland and provider drop boxes are available from LabCorp, upon request. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit Government Employees and Their Families at Overseas Embassies Reviewers this Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. We thank the following individuals for their review of this report: Ellen Wright Clayton, Center for Biomedical Ethics and Society Marion Ehrich, Virginia Polytechnic Institute & State University Michael E. Gordon, National Institute of Mental Health Suzet McKinney, Illinois Medical District Aubrey K. Miller, National Institute of Environmental Health Sciences Xin Qi, Case Western Reserve University David A. Whitney, University of Pittsburgh Ross Zafonte, Harvard University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. Responsibility for the final content rests entirely with the authoring committee and the National Academies. Government Employees and Their Families at Overseas Embassies Preface An individual assigned to the U. Embassy in Cuba was awakened one night at home in Havana in 2016 by severe pain and a sensation of intense pressure in the face, a loud piercing sound in one ear with directional features, and acute disequilibrium and nausea. A handful of other cases involving colleagues with similar features began that year, and others in the next. In addition, the mechanisms and origins were mysterious, and for these and other reasons, there was a delay in recognizing an important cluster of unexplained illnesses, and an early failure to investigate them in a concerted, coordinated, rigorous, and interdisciplinary manner. In some ways, the problem presented here is an age-old one; that is, how to detect and recognize important anomalies or signals, in a complicated, "noisy" background. The most common clinical presentation was neurologic; a known infectious cause was discovered for only a minority of them; and no obvious relationships among cases were uncovered (Nikkari et al. But the landscape that countries face today in which the cases in question arise, is an even more complicated one. Not only must governments consider a wide variety of evolving natural causes in a rapidly changing world, but also an increasing threat of disease of deliberate human origin, both accidental and purposeful. Among the reasons and ramifications, the clinical features were unusual; the circumstances have led to rampant speculation about the cause(s); and numerous studies, along with the charged political setting, have had consequences for international relations. The committee faced a variety of challenges in responding to these requests (see Section 2). In particular, much of the detail and many of the investigations performed by others were not available to it, either because they are classified for reasons of national security or restricted for other reasons. Despite these challenges, the committee arrived at a number of observations and recommendations, after carefully reviewing the information that was available. First, the committee found a constellation of acute clinical signs and symptoms with directional and location-specific features that was distinctive; to its knowledge, this constellation of clinical features is unlike any disorder in the neurological or general medical literature.

Skin and soft tissue infections in diabetic patients may develop in candidates and are often polymicrobial gastritis polyps order prevacid 30 mg. In chronic infections or ulcers gastritis diet èãðè buy cheap prevacid 15 mg on line, an atypical organism (eg gastritis symptoms heartburn discount prevacid 30mg amex, Mycobacterium) or an underlying osteomyelitis should be considered and excluded gastritis diet fruit cheap 15mg prevacid fast delivery. In the ideal situation gastritis diet natural prevacid 30 mg with visa, an ulcer should not be actively infected and healing should be complete or nearing completion prior to transplantation gastritis yahoo answers buy prevacid 30 mg line. Knowledge of colonization with specific organisms can help in management and selection of antimicrobials for peri- and post-operative infections. Many healthcare facilities have implemented screening practices to detect and manage colonization with drug resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant enterobacteriaceae, etc. In such cases, consideration can be given to modification of perioperative and post-transplant prophylaxis to cover the organisms found during screening. Transplant candidates may have a history of fungal, parasitic or bacterial colonization. Colonization without evidence of infection is not a contraindication for transplant. However, there is greater risk of progression to infection and strategies to mitigate progression such as antimicrobial prophylaxis should be considered at the time of transplant. One study reported on 73 polycystic kidney disease patients, 30 of whom underwent pretransplant nephrectomy while 43 did not. Microbiologic eradication should be documented in situations where cultures can be obtained. Any active infection at the time of transplant surgery can increase the risk of sepsis and wound infection. In addition, the infection can also become more difficult to resolve due to post-transplant immunosuppression. Ideally, the patient should complete the full course of therapy for an active infection prior to transplantation. Although not ideal, transplantation can be considered prior to completion of the course of therapy as long as clinical improvement has occurred, cultures have become negative and the patient will continue on the antimicrobials post-transplant. Common infections in dialysis patients include central venous catheter-related, soft tissue and bloodstream infections. These infections are usually caused by Staphylococcus aureus or coagulase-negative Staphylococci although Gram-negative organisms and fungi can also be isolated. Infection source, such as catheters, should be removed especially in the case of bloodstream infections from Staphylococcus aureus, Candida spp. Culture negativity, a decrease in peritoneal dialysis fluid leukocyte count as well as clinical improvement should be documented before transplantation. In some cases, infection of the peritoneal dialysis catheter can recur or become chronic. In such cases, infection is not possible to completely cure and transplantation with simultaneous removal of the catheter is the best S56 Transplantation April 2020 Volume 104 Number 4S Recommendations for initial and follow-up screening of viral and non-viral pathogens in kidney transplant candidates. Ideally, the candidate should be stabilized on an anti-retroviral regimen that minimizes risks of drug-drug interactions post-transplant. There is a small risk of reactivation (< 5%) post-transplant and monitoring S60 Transplantation April 2020 Volume 104 Number 4S Transplant candidates are at risk for primary herpesvirus infection or reactivation of latent herpesviruses. Screening is therefore important in order to risk stratify and make decisions for post-transplant prevention. Since varicella vaccine is live-attenuated, the candidate should defer transplant for at least 4 weeks after immunization. Immunization should not occur pre-transplantation if patient is immunosuppressed for another indication (eg, treatment of underling kidney disease with steroids). Similarly, live virus immunization should not occur pre-transplantation if patient is immunosuppressed for another indication (eg, treatment of underling kidney disease with steroids). Although the above recommendations describe established viruses in the population, the clinician should be cognizant of emerging viral infections such as new respiratory viruses (eg, new coronaviruses), arboviruses (eg, Zika, Chikungunya virus) and hemorrhagic fever viruses (eg, Ebola), their incubation periods and disease manifestations. Transplant candidates with symptomatic disease from these viruses should await resolution. Therefore, serology should be routinely performed in patients awaiting transplantation and the patient treated if a confirmatory test for syphilis is positive. Testing for endemic infections and tropical diseases should only be done in transplant candidates at risk. The worldwide distribution of endemic zones for various infections is readily available on the World Health Organization website ( Strongyloides infection may be asymptomatic and lead to hyperinfection post-transplant. Therefore, screening for strongyloides is recommended in those who have lived in or travelled to strongyloides endemic areas. For patients living in endemic areas, testing should be performed if clinical symptoms suggest disease. Chagas disease is endemic in Latin America and is caused by the protozoan parasite, Trypanosoma cruzi. This infection is transmitted by an insect vector and can establish clinical latency for decades. After kidney transplantation, reactivation generally occurs in the first year as asymptomatic parasitemia or fever with skin, heart or brain involvement. In the case of seropositivity, most experts recommend to monitor for reactivation posttransplant using polymerase chain reaction rather than treatment of the asymptomatic phase. The clinical utility for detection of endemic fungal infection in an otherwise asymptomatic transplant candidate is low as the serologybased tests lack sensitivity. However, data suggest that some vaccines are more immunogenic when given pretransplant rather than post-transplant. In addition, live-attenuated vaccines should only be given prior to transplantation. Therefore, assessment of vaccination status is an integral part of the pre-transplant evaluation. Vaccines should be updated as per local guidelines for diphtheria, polio, tetanus, pertussis, and Hemophilus influenzae. Transplant recipients have an increased risk for developing invasive pneumococcal disease. As such, kidney transplant candidates should receive the conjugated pneumococcal vaccine followed by the polysaccharide pneumococcal vaccine at least 8 weeks later. Meningococcal conjugate vaccine should be given to children as per local guidelines. In adults, meningococcal conjugate vaccine should be given to those with risk factors including functional or anatomic asplenia, travelers to meningococcus endemic areas (eg, sub-Saharan Africa, travelers for Hajj) or those likely to require complement inhibitors perioperatively or post-transplant. In candidates who may receive eculizumab or other complement inhibitors, two doses of quadrivalent meningococcal vaccine (for serogroups A, C, Y, W-135) as well as meningococcal serogroup B vaccine should be administered. Human papillomavirus vaccine is also inactivated and can be given using the 3-dose schedule to males and females over age 9 years. A recombinant subunit inactivated vaccine is available to prevent herpes zoster and can be used in transplant candidates 50 years of age. Please refer to Table 12 for a summary of routine vaccinations for kidney transplant candidates. For inactivated vaccines, no specific wait period is required pre-transplantation and candidates can remain active if on a deceased donor waitlist; however, at least two weeks is required for establishment of vaccine immunity. Nevertheless, due to lack of data, there are no recommendations for reimmunization if transplantation occurs within days after vaccination. Vaccine series that are not completed pre-transplant can be generally resumed S62 Transplantation April 2020 Volume 104 Number 4S If the herpes zoster live vaccine has already been administered, the transplant candidate can be reimmunized with the inactivated vaccine a minimum of one year after the live vaccine. Limited data show that vaccine titers persist post-transplant although the duration of persistence is unclear. In general, the inactivated herpes zoster vaccine is preferred over the live zoster vaccine since its efficacy in the general population is higher than that of live vaccine and candidates can remain active on the waitlist. For transplant candidates at increased risk of developing yellow fever, vaccination must be given at least 4 weeks before transplantation. Transplant candidates should also receive specific travel vaccines if travel to endemic areas is anticipated. Based on exposure risk, transplant candidates can safely receive any travel vaccines including both inactivated and live vaccines. Further details on vaccination in transplant candidates can be found in this recent review from the American Society of Transplantation Infectious Diseases Community of Practice. We address screening for geographically restricted infections (eg, strongyloides, Chagas disease, malaria) which are not addressed in most other guidelines. With newer high-dose influenza vaccines and adjuvanted influenza vaccines, comparative trials can be performed with immunogenicity or efficacy as an endpoint. Women older than 65 should talk to their doctors about whether or not they need to have regular cervical screening. Recommended waiting times between cancer remission and kidney transplantation91 Breast Colorectal Bladder Kidney Uterine Cervical Lung Testicular Melanoma Prostate Thyroid Hodgkin Lymphoma Non-Hodgkin Lymphoma Post-transplant lymphoproliferative disease Early Advanced Dukes A/B Duke C Duke D Invasive Incidentaloma (< 3 cm) Early Large and invasive Localized Invasive Localized Invasive Localized Localized Invasive Localized Invasive Gleason 6 Gleason 7 Gleason 8-10 Papillary/Follicular/ Medullary Stage 1 Stage 2 Stage 3 Stage 4 Anaplastic Localized Regional Distant Localized Regional Distant Nodal Extranodal and cerebral At least 2 years At least 5 years At least 2 years 2-5 years At least 5 years At least 2 years No waiting time At least 2 years At least 5 years At least 2 years At least 5 years At least 2 years At least 5 years 2-5 years At least 2 years 2-5 years At least 5 years Contraindicated No waiting time At least 2 years At least 5 years the patient, a hematologist/oncologist and the transplant program (Not Graded). Evidence from observational studies and registry data reported a 2-fold increase in overall cancer incidence among patients on dialysis, with kidney-related (such as urogenital cancers), endocrine-related malignancy such as thyroid cancer, and solid organ cancers such as colorectal cancer seen in excess compared to the general population. Trials have reported significant reductions in cancer mortality, of at least 20% for solid organ cancers such as colorectal cancer, in the screened versus unscreened arms. While the longterm overall risk of cancer recurrence after transplantation may be low (between 5-10%), cancer prognoses after recurrence are poor. Recipients with prior cancer also have an increased risk of developing de novo malignancy after transplantation. The highest risk of recurrences occurs among symptomatic renal cell carcinomas, sarcomas, melanocytic skin cancers, invasive bladder cancers and multiple myeloma. Other solid organ tumors such as breast, prostate and colorectal cancers confer a lesser risk, with a recommended minimum waiting period before transplantation of 2 years. More recently, data from Norway found no association between waiting time and all-cause mortality after kidney transplantation for those with prior cancer. However, an increased risk of cancer-related death was observed among recipients with a prior history of kidney, prostate, breast, lung or plasma cell cancers compared to those without a cancer history. Between the years 1963 and 1999, the overall cancer recurrence rate in 210 kidney transplant recipients with a prior cancer history was only 5%, with a much higher rate of death among those whose prior cancers were diagnosed after commencement of dialysis compared to those diagnosed before dialysis. For those who did not die from cancer, less than 20% survived more than 10 years after cancer diagnosis. Cancer of the digestive, respiratory and urinary tract systems were the three most common causes of cancer death regardless of cancer types (first cancer, recurrence and second primary). However, there were no significant differences in the risk of cancer-specific and all-cause mortality between patients who developed their first cancer after transplantation and those with cancer recurrence and those with second primary cancers. To better define and stratify the risk of disease recurrence in a potential transplant candidate, genomic profiling may represent a novel application that distinguishes between breast cancers that are likely to result in early recurrence versus those that are unlikely to recur. These assays can calculate a Breast Cancer Recurrence Score that correlates with the risk of cancer recurrence 10 years after transplantation, thus representing a potentially effective prognostic tool to guide treatment and future management. For potential transplant recipients with a prior history of cancer, clinical guidelines generally recommend a waiting time of between two and five years prior to transplantation, largely due to the fear of recurrent disease. These recommendations are based on previous studies which showed a reduction in cancer recurrence with time. However, often the risk of death from cardiovascular causes or infection outweighs the projected risk of cancer recurrence. Future work is needed to model the tradeoff for early transplantation versus remaining on dialysis for these patients. As such, the recommendations are based on evidence from the general population who undergo preoperative pulmonary assessment for nontransplant surgery. Pulmonary function tests are not needed in most transplant candidates without significant pulmonary disease or symptoms given the lack of benefit seen with the use of these tests in the preoperative setting in the general population. However, preoperative pulmonary function tests may offer benefit in patients with impaired functional capacity, known pulmonary disease, or unexplained dyspnea. Given the evidence in the general population and transplant recipients, transplant candidates must be advised to stop smoking. The benefit of kidney transplantation in patients with severe pulmonary disease will be offset by poor outcomes related to their lung pathology. Prospective cohort studies should be done assessing survival and quality of life in patients with pulmonary functional impairment who undergo transplant compared to those remaining on dialysis. Exclude such patients from kidney transplantation if significant cardiac amyloid is confirmed (Not Graded). Additionally, patients with cardiac disease have a higher risk of death and cardiac events in the peri-transplant and post-transplant periods. Kidney transplantation is generally classified as intermediate risk surgery, however many patients have comorbidities that increase the risk for cardiac events. For these reasons, assessment for cardiac disease is important in the evaluation of candidates. There are a number of guidelines and consensus statements in the literature regarding cardiac assessment for patients prior to both general and kidney transplant surgery.

Such programs may include the following: A school-wide component centered on training definition de gastritis prevacid 15mg mastercard, awareness chronic gastritis with h pylori purchase 15 mg prevacid otc, monitoring gastritis diet ðàäèî cheap prevacid 15mg with amex, and assessment of bullying; A classroom component focused on reinforcing school-wide rules and building social and emotional skills and empathy; and An intervention component for students who are frequent targets or perpetrators of bullying gastritis diet quick buy cheap prevacid 15mg line. Programs directed at only one of these levels gastritis symptoms how long do they last prevacid 15 mg sale, or interventions designed only for bullying targets and bullying offenders chronic gastritis x ray generic 30mg prevacid, are less likely to be effective (Farrington & Ttofi, 2010; Vreeman and Carroll, 2007). When bullying prevention activities are scaffolded onto a larger comprehensive framework for prevention and positive youth development, the prevention efforts are strengthened, while also addressing some of the underlying, contributing social, emotional and environmental factors that can lead to bullying (DuPage County, 2011). Additionally, programs are more likely to be effective when supported by strong administrative leadership and the ongoing commitment to the program on the part of the adults in the school system. A focus on creating a school-wide environment or climate that builds connection and caring among students, among staff and between students and staff, and discourages bullying and aggression. Surveys of students, staff and parents to assess the nature, extent and perceptions of bullying behavior and attitudes towards bullying. Classroom activities to discuss issues related to bullying and to teach or devise strategies for responding to and reporting bullying. Use of teacher or staff groups to increase staff knowledge and motivation to ending bullying. The duration (number of days) and intensity (number of hours) of a program are significantly related to the reduction of bullying and victimization. School Climate and Culture Students face the challenges of a dramatically accelerated pace of life, economic pressures on parents and a pervasive culture of advertising and digital media, some of which appears to support anti-social norms, and violent problem solving. School climate is often linked with the term "school culture," which describes the way schools "do things," informed by shared history, customary practices, formal and informal traditions, celebrations, teamwork and a psychological sense of community (The School Climate Challenge, 2008). The terms school culture and school climate describe the environments that affect the behavior of teachers and students. School culture is the shared beliefs and attitudes that characterize the district-wide organization and establish boundaries for its constituent units. School climate characterizes the organization at the school building and classroom levels. It refers to the "feel" of a school and can vary from school to school within the same district. School climate and school culture are two distinct but highly interactive aspects of a school system. Research reports on school climate suggest that positive interpersonal relationships and optimal learning opportunities for students in all demographic environments can increase achievement levels and reduce maladaptive behavior (Marshall, 2004). Research findings on school climate in high-risk urban environments indicate that a positive, supportive and culturally conscious school climate can significantly shape the degree of academic success experienced by urban students (Haynes and Comer, 1993). In addition to there being a substantive connection between school culture and student achievement, there is a strong connection among school culture and staff member satisfaction, parent engagement and community support. School climate is a key factor in whether students or adults will bully one another (DuPage County Schools, 2011). Are students and adults helpful and interested in who you are and how to help you get where you want to go There is growing evidence that schools in which rules are effectively enforced. The amount of connectedness experienced by the average student appears to consistently contribute to predicting his or her likelihood of aggression and victimization (Wilson, 2004). For middle school and high school students, safe, caring and responsive school climates tend to foster a greater attachment to school and provide the optimal foundation for social, emotional and academic learning. Most elementary students feel connected to their schools; however, school connectedness generally begins to decline in middle schools. When it comes to high schools, as many as 40-60% of all youth - urban, suburban and rural - report being disconnected from their schools (Monahan, 2010). Districts are encouraged to consider implementing strategies that support the most vulnerable students and reinforce the importance of respecting individual differences, including for race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity and expression, or a mental, physical or sensory disability, or for any other distinguishing characteristic. Some examples of these strategies include the following: o Instituting a Gay-Straight Alliance in the school; o Training staff to be supportive of student differences; or o Celebrating important cultural events of students from diverse cultural backgrounds. Research findings indicate that the student-teacher relationships in kindergarten are related to later academic and behavioral outcomes for students. If a teacher is negative and disagreeable in kindergarten, it is more likely that the students will have behavioral and academic problems in later grades (National School Climate Center, 2011). The following tend to occur in schools that have positive institutional environments (adapted from the National School Climate Center, 2011): o Staff, students, and families feel a positive connection to the school and participate in many different aspects of school life. While smaller schools are positively correlated to school connectedness, school size is not the only way to improve the learning environment. Assessing Bullying A best practice for effective bullying prevention and intervention involves regular, thorough assessments of the bullying behavior and climate of a school. Different types of bullying occur with varied frequency and magnitude among different populations in assorted school settings at various points in time. Therefore, a data-driven approach for reducing bullying and improving school climate, rather than a "one-size-fits-all" approach, is critically important for the development of an effective bullying prevention strategy. The importance of engaging in data collection efforts is underscored by the evidence of a disparity in the number of incidents that are reported to school staff and those that go unreported. Provided below are a few tips for assessing bullying: It is essential to be able to identify where, when and how students experience bullying at school (DuPage County Schools, 2011). The assessments should consider multiple factors and individuals within the school system using direct measures, such as surveys and interviews, and indirect measures, such as disciplinary and attendance records (Marshall, 2004). Anonymous student questionnaires and focus groups can be employed to assess the nature and extent of bullying and perceptions of and attitudes towards bullying (DuPage County Schools, 2011). Once these areas are identified, it is imperative for district or school officials take immediate action (DuPage County Schools, 2011). Schools are most likely to prevent bullying and other problem student behavior and promote student well-being and success through comprehensive, coordinated and systematically planned programs, services and activities that are cooperatively developed in consultation with school staff and administrators, students, volunteers, law enforcement, parents and other community members, as required under N. Engage interested partners from a variety of sources, including educators, counselors, medical and mental health professionals, child development and family centers, social service agencies, law enforcement officials, neighborhood associations, faith-based organizations, volunteer groups and businesses. Include the voices of students from especially vulnerable populations, including racial, ethnic or religious minorities; gay, lesbian, bisexual, transgender or questioning individuals; individuals with mental, physical or sensory disabilities; and other groups representing distinguishing characteristics. Inform parents and students of resources that are available to help learn about bullying and bullying prevention efforts. Use assessment results to identify bullying concerns, determine priorities for a bullying prevention plan, target responses to bullying incidents and assess progress. Become an advocate for appropriate anti-bullying policies in the schools and other community institutions. A student advisory committee could be formed to focus on bullying prevention and provide valuable suggestions and feedback to school staff. Observances of the Week of Respect and School Violence Awareness Week could be used to focus on prevention messages that will be sustained throughout the school year. Some key areas of focus for bullying training include the following: Understanding the nature of bullying and its effects; Recognizing, reporting and responding to bullying; Identifying and addressing the special needs of vulnerable populations; Utilizing classroom activities to discuss bullying and related issues; Integrating bullying prevention into the curriculum; Coordinating with others in the school to prevent bullying; and Sustaining bullying prevention programs. Increase Adult Supervision in Areas Where Bullying has Occurred Once student questionnaires or other information gathering techniques reveal where most incidents of bullying occur, seek creative ways to increase an adult presence in those areas. Separate follow-up meetings should be held with both victims and alleged offenders. Parents of affected students must be contacted by the principal, and should be involved to the extent possible. Focus Class Time on Bullying Prevention Bullying prevention should include a classroom component. For example, 20-30 minutes a week could be set aside to discuss bullying and peer relations with students. This facilitates teachers keeping their fingers on the pulse of student concerns, allows for discussions about bullying and its effects, and provides opportunities to reinforce rules and expectations and impart or devise tools for students to address bullying problems. Anti-bullying themes and messages should be incorporated throughout the school curriculum. Bullying prevention should be woven into the educational program and the entire school environment. Research reports indicate that educators might not recognize students identified by their peers as students who bully. In 2005, the Colorado Trust launched a project titled the Bullying Prevention Initiative. The results of this study indicate that a reduction in bullying occurred in schools where teachers and students were willing to intervene, treat each other fairly and demonstrate that they care about one another. In order to effectively intervene, all school staff should know the signs of bullying so that they can appropriately intervene even when there is only a suspicion that bullying may be occurring, which is important for sending the message that bullying is not acceptable behavior. Some key factors for effective bullying intervention follow: Respond in the moment to manage the situation and ensure safety. Stay alert to possible continued bullying incidents by using active supervision strategies. Best Practices in Responding to Children Who Bully Conduct a screening and functional assessment as a means of gathering information to uncover variables associated with patterns of behavior and determine the function or purposes of the behavior. The purpose of behavioral information gathering is to improve the effectiveness, relevance and efficiency of behavior support plans and interventions. Both theories indicate that it is essential to be mindful of the function or purpose the behavior serves for a student, and that logical consequences, rather than punishments. Logical consequences should offer students a clear and logical choice of behavior and results, and the students must perceive that they have a choice and must 25 accept the relationship of their choice to the response. Consequences are structured and arranged by the adult, but must be experienced by the students as logical in nature (Dreikurs, 1972). The student must clearly see the relationship between his or her act and the result of his or her own behavior rather than that of others. A logical consequence gives the student the choice of deciding for him or herself whether or not the student wants to repeat a given act. Short- and long-term interventions should focus on addressing social-emotional, behavioral, academic, environmental and other issues related to the underlying reasons for the bullying pattern. Instructional interventions may occur one-on-one with the student or in small groups using instructional formats that could include: Role plays, Discussion; Practice; and Problem-solving situations. While consequences and remedial actions typically are different, they can overlap and have complementary purposes: modifying bullying behavior. School staff should use violations of the school rules as opportunities to help students improve their social and emotional skills, accept personal responsibility for their learning environments, and understand consequences for poor choices and behaviors. Remedial measures provide the student with an opportunity to reflect on behavior, learn pro-social skills and make amends to those affected by the bullying behavior. However, punitive measures are not necessarily logical outcomes or commonsense responses to behavior; typically are not effective in correcting behavior and can be counterproductive; should be used only when appropriate and absolutely necessary; and almost always should be used in conjunction with remediation measures (DuPage County Schools, 2011). Logical consequences (described above), on the other hand, are complementary to remedial strategies, in that they are designed to correct the behavior of concern, while the student also experiences the negative effects of his or her behavior. Additionally, in all cases the district should attempt to actively involve parents in the remediation of the behaviors(s) of concern. Examples of responses that apply to each category are as follows: Individual Responses can include consistent and appropriate positive behavioral interventions such as peer mentoring, short-term counseling or life skills groups intended to remediate the problem behaviors. The following factors should be considered when determining remedial measures: Personal o Life skill deficiencies; o Social relationships; o Strengths; o Talents; o Interests; o Hobbies; o Extra-curricular activities; o Classroom participation; o Academic performance; and o Relationship to students and the school district. Environmental o School culture; o School climate; o Student-staff relationships and staff behavior toward the student; o General staff management of classrooms or other educational environments; o Staff ability to prevent and manage difficult or inflammatory situations; o Social-emotional and behavioral supports; o Social relationships; o Community activities; o Neighborhood situations; and o Family situation. School Considerations o School culture, climate and general staff management of the learning environment; o Social, emotional and behavioral supports; o Student-staff relationships and staff behavior toward the student; o Family, community and neighborhood situation; and o Alignment with policy and procedures. Parents, Family and Community o Develop a family agreement; o Refer the family for family counseling; and o Offer parent education workshops related to bullying and social-emotional learning. Environmental (Classroom, School Building) o Conduct school and community surveys or implement other strategies for determining the conditions contributing to the bullying; o Revise school policy and procedures; o Communicate behavioral expectations to students, parents and staff; o Modify student schedules or transportation routes; o Increase supervision in "hot spots". Examples of Consequences the use of negative consequences should occur in conjunction with remediation and not be relied upon as the sole intervention approach. Negative consequences should be immediate, short-term, varied, graded and developmentally appropriate, such as the following: Admonishment; Temporary removal from class; Deprivation of privileges; Classroom or administrative detention; Referral to disciplinarian; In school suspension; Out of school suspension (short-term or long-term); Report to law enforcement or take other legal action; Expulsion; and For adult offenders, bans from providing services, participating in school-district sponsored programs or being in school buildings or on school grounds and other disciplinary measures permitted under local bargaining unit agreements, board of education policies and State law. The Role of Peers in Bully-Victim Interactions Immediate anti-bullying interventions address the bullies and victims, but long-term interventions should engage the entire student body and should specifically engage groups of students who witness acts of bullying. It is essential to change the behavior of the bystanders who witness bullying but do nothing to stop it. Although anti-bullying attitudes are common, few students actually express anti-bullying attitudes or try to intervene in bullying. On the contrary, many students act in ways that encourage or support the bullying, taking on the participant roles of assistants or reinforcers of the bully. Other students, so-called outsiders, withdraw and pretend not to notice these events.

Two recently published studies showed that pre-radiation intensive chemotherapy benefited patients most when they had a gross total resection [50 gastritis diet ÷òî 15 mg prevacid overnight delivery,51] gastritis relieved by eating prevacid 15 mg overnight delivery. However gastritis diet cookbook generic prevacid 15mg otc, subtotal resection is performed if tumor is found to invade the brainstem gastritis symptoms heart attack buy 30mg prevacid with visa. Post-operative cerebellar mutism is thought to result from excessive dissection at the junction of the cerebellar peduncles and the brainstem [55] gastritis diet 50 prevacid 15 mg cheap. Other common temporary post-operative complications are ataxia gastritis diet vegetarian order 30 mg prevacid, hemiparesis and sixth cranial nerve palsy [56]. Clinical symptoms usually involved hydrocephalus: headaches, lethargy, nausea and vomiting in the morning, macrocephaly. The current treatment protocol starts with initial surgical treatment that maximally reduces tumor burden and relieves obstructive hydrocephalus. While such lesions are frequently anaplastic, in such cases a neurosurgical approach to biopsy and resection may be warranted. Acute post-radiation effects occur in the first week and consist of temporary drowsiness, nausea and headaches. Results from a prospective randomized multi-institutional trial in North America to validate the efficacy of reduced craniospinal radiation dose combined with cisplatinbased chemotherapy regimens are pending [56]. Another method being investigated for maximizing target radiation dose and reducing toxicity to adjacent normal brain includes the use of stereotactically guided conformal radiation therapy for performing the posterior fossa boost. Chemotherapy regimens have been developed to augment and possibly delay radiation therapy, and are continuing to be refined for patients in both risk groups. The long-term sequelae of radiation therapy are deemed unacceptable in infants and very young children, therefore trials of high dose marrow-ablative chemotherapy with autologous stem cell rescue are being performed in order to delay or eliminate the need for radiation therapy [65]. Current investigations attempt to determine the optimal timing and dosage of adjuvant therapies to maximize efficacy and minimize toxicity. As more markers are identified and validated in clinical trials as outcome factors, molecular profiling of tumors from individuals could potentially be used to tailor patient-specific therapies. They arise from ependymal or subependymal cell layers adjacent to the ventricular system or central spinal canal [73,74]. Presenting symptoms frequently relate to obstructive hydrocephalus due to a fourth ventricular ependymoma. Filum or cauda equina lesions are usually of the myxopapillary variant and probably arise from ectopic embryonic foci of ependymal cells [73]. It has also been reported to decrease the incidence of leptomeningeal metastasis compared to subtotal resections [77]. Tumors recur predominantly at the primary tumor site, suggesting that they arise from residual ependymoma cells [77,79,81,86,87]. This further supports the need to completely extirpate the primary ependymoma when feasible, although one third of tumors are infiltrating adjacent brain and cannot be completely removed [47]. Radiation therapy is the adjuvant therapy of choice It is generally recommended that even after a gross total tumor resection, patients with localized disease undergo local tumor bed irradiation with fractionated external beam therapy to 6000 cGy. With the advent of stereotactic conformal radiotherapy, treatment can be tightly targeted to the tumor bed while sparing adjacent normal brain or brainstem in order to minimize radiation-associated toxicity. Current treatment regimens rely mainly on radical surgical resection followed by radiation therapy. Current and future advances in diagnosis and management the evolution and advancement of imaging technologies have been instrumental in the diagnosis and follow-up of brain tumor patients. Improved scanner performance has enabled development of new, faster acquisition pulse sequences, thereby providing higher resolution and better contrast images in less time (reviewed in [92]). New methods for producing 3-dimensional reconstructions aid in stereotactic conformal radiotherapy dosing of brain tumors, and new radiosurgery instrumentation makes targeting, dosing and Figure 4. Intra-operative image of posterior fossa ependymoma showing a lesion filling the upper cervical spinal canal posteriorly and entering the fourth ventricle. Such lesions should be approached with the goal in mind of achieving a gross total resection. The anatomic relationship of a tumor and associated epileptogenic foci to surrounding functional neurological and vascular structures can be mapped for pre-operative planning, and imported into a surgical navigation system for intra-operative guidance (Figure 6). Techniques now under development will potentially allow optical imaging of brainstem nuclei and nerve tracts, thereby enabling safer surgery in surgically difficult regions such as the brainstem. Neuroendoscopy technology has greatly improved the management of patients with obstructive hydrocephalus via the advent of safe and effective endoscopic third ventriculostomies, Figure 6. New roboticassisted neuroendoscopy systems will allow safer and more precise ventricular navigation via minimal cranial access [96]. Convection-enhanced delivery of macromolecules to the brain parenchyma safely circumvents the blood-brain barrier, and is a technical advance being tested in clinical trials. Studies with animal models show the efficacy and safety of delivering large amounts of macromolecules over large volumes of brain via bulk diffusion and hold much promise for the delivery of therapeutic molecules [97,98]. This technique, coupled with the appropriate anti-tumor molecules, could potentially enable treatment of infiltrative, intrinsic lesions via neurosurgical delivery of local chemotherapy [99]. Molecular studies are identifying new molecular markers for use in improving tumor diagnosis and possibly generating individual tumor-specific expression profiles predicting response to therapies or clinical outcomes. Potential novel therapeutic approaches with immunotoxin, anti-angiogenesis, pro-apoptosis, differentiation-promoting, radiosensitizer molecules can also be generated by such biological studies, all of which may improve the survival and quality of life of future pediatric brain tumor patients. Continued refinement in imaging and surgical technology, coupled with better biological understanding of these tumors will yield improved therapies in the future. Continued collaboration between multi-institutional groups will be essential to validate future therapeutic approaches in clinical trials. Kuo is supported by a fellowship from the American Brain Tumor Association and the Neurosurgery Research and Education Foundation of the American Association of Neurological Surgeons. Rutka is a Career Scientist of the Canadian Institutes of Health Research, and supported by the National Cancer Institute of Canada, the Pediatric Brain Tumor Foundation of the United States, Katies Kids for the Cure Foundation and the Ontario Cancer Research Network. A geographical analysis of cases from the Pediatric Cooperative Clinical Trials groups. Tamiya T, Kinoshita K, Ono Y, Matsumoto K, Furuta T, Ohmoto T: Proton magnetic resonance spectroscopy reflects cellular proliferative activity in astrocytomas. Rutka, Division of Neurosurgery, Suite 1502, the Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8, Tel. Review Molecular pathogenesis of childhood brain tumors Torsten Pietsch1, Michael D. Rutka2 1 Department of Neuropathology, University of Bonn Medical Center, Bonn, Germany; 2Division of Neurosurgery, Hospital for Sick Children, Toronto, Canada Key words: atypical teratoid/rhabdoid tumor, choroid plexus tumors, ependymoma, medulloblastoma, molecular genetics, pilocytic astrocytoma Summary In the last decade, the molecular biology revolution has advanced considerably. These advances have enhanced our understanding of the genetic underpinnings of human brain tumors in general, and pediatric brain tumors in particular. We now know that many pediatric brain tumors arise from disturbances in developmentally regulated signaling pathways. New techniques in genetic engineering have allowed for the creation of sophisticated mouse models of brain tumors that recapitulate the human disease. In the next decade, the use of several new molecular techniques to establish brain tumor diagnoses will likely become standard tools in the diagnostics and treatment stratification of children with central nervous system tumors. Introduction Our understanding of the pathogenesis of childhood brain tumors has advanced considerably over the past 20 years. While this advancement can be ascribed in part to knowledge that has been acquired for other tumors or cancers in which various oncogenes and tumor suppressor genes are known contributors, it can also be stated with some confidence that certain childhood brain tumors have specific or unique genetic alterations that have been uncovered through detailed analysis of the molecular genetics of these neoplasms. In the last years crucial genetic steps contributing to the molecular pathogenesis of this entity have been identified. In a recent study, virus genomic sequences have been detected in medulloblastomas as well as large T-protein, an oncogenic virus product [2]. Genetic aberrations are believed to contribute to the pathogenesis of medulloblastomas. Although this aberration is relatively rare, it was found to represent a predictor for bad clinical outcome [26,27]. Loss of chromosome 17p is the most frequent finding in medulloblastomas present in up to 50% of the cases, in many tumors related to the occurrence of an isochromosome 17q [8]. Interestingly, chromosome 17 alterations are mostly present in medulloblastoma of the classic (non-nodular) type but are absent in most nodular/desmoplastic type medulloblastomas. The variants of medulloblastomas seem to differ in their clinicopathological and genetic features, their cell of origin, and also in molecular Figure 1. The most common classic variant is characterized by frequent alterations of chromosome 17 while the desmoplastic subtype shows frequent activation of the hedgehog pathway. While the latter variant is believed to be derived from external granule cell precursors the cellular origin of classic type, which is mostly located in the midline, is still under discussion but may be the ventricular matrix. Medulloblastoma with extensive nodularity represents a variant of the desmoplastic type medulloblastomas in young children and is associated with good prognosis. Signaling leads to translocation of Gli proteins into the nucleus where they induce the transcription of specific target genes [41]. These patients are predisposed to develop basal cell carcinomas and desmoplastic medulloblastomas. Since patched is a signaling component with inhibiting activity, its inactivation leads to an overactivation of the pathway. Hedgehog-patched signaling is known to control the proliferation of specific progenitor cells of the cerebellum, the so-called external granule cells [52]. Thus, aberrant activation of this pathway, which is needed for normal cerebellar development, seems to be crucially involved in the tumorigenesis of medulloblastomas derived from these progenitor cells [53]. The identification of specific inhibitors of hedgehog-patched signaling may influence the proliferation of tumor cells [56,57]. In a transgenic mouse in which activated b-catenin is expressed in neural progenitors, a tremendous proliferation of neuronal cells could be observed [58]. These genetic events lead to a nuclear accumulation of b-catenin and increased expression of specific target genes in medulloblastomas. Pediatric diffuse astrocytomas Although pediatric fibrillary astrocytomas are histologically similar to adult fibrillary astrocytomas, they show a distinct biological behavior and probably a different molecular pathogenesis. Common losses in pediatric astrocytomas included losses on chromosomes 16p, 17p, 19p, 22 and 19q. Survival is significantly shorter in pediatric astrocytomas showing amplification of chromosome 1q [74]. Distinct cytogenetic changes are seen in pediatric anaplastic 206 astrocytoma (+5q,)6q,)9q,)12q and)22q) as opposed to pediatric glioblastoma multiforme (+1q, +3q, +16p,)8q, and)17p) [74]. Microsatellite instability is not seen in adult astrocytomas but has been demonstrated in 27% (12/45) of pediatric malignant astrocytomas and 4/ 17 pediatric gangliogliomas [75]. Colon tumors with microsatellite instability have a better prognosis than those that do not, which is interesting in light of the better prognosis in pediatric astrocytomas [76]. Loss of expression of p16 was seen in 11/18 (61%) of pediatric glioblastomas [84]. Pediatric pilocytic astrocytomas show few changes and those are usually gains of a single chromosome. Trisomy of chromosomes 7 and 8 are the most common aberrations seen in pediatric pilocytic astrocytomas [91]. Adult pilocytic astrocytomas have much more complex karyotypes with multiple areas of gains and losses [90]. This pathological subtype carries a worse prognosis than classic pilocytic astrocytomas, and is frequently found in patients under 3 years of age. These findings were replicated in a subsequent paper where the same polymorphism was seen in 8% of controls but 12. While the functional significance of the mutation is not apparent, the authors used laser microdissection to show that the mutation was limited to the glial component of the neoplasm and was not present in the dysplastic neurons [110]. Gangliogliomas Ependymomas Gangliogliomas are benign neoplasms with both neuronal and glial components. A single patient with Turcot syndrome and ganglioglioma has also been reported [101].

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As Marita Sturken puts it in her recent analysis of the Weather Channel: "In the increasingly technologized story of the weather gastritis diet ñåðèàëû 15mg prevacid fast delivery, the weather reporter remains a crucial human element gastritis symptoms and treatments discount prevacid 30 mg overnight delivery. The physical body of the on- site weather news reporter must by convention be subject in uncomfortable ways to the weather gastritis in pregnancy order 15 mg prevacid visa. Physical risk to Cooper implies a potential financial loss for the television network gastritis diet vegetables order 30 mg prevacid with visa, and the loss of an icon for audiences in the United States and beyond gastritis diet gastritis symptoms purchase prevacid 30mg without prescription. This became eminently clear in February 2011 gastritis diet èãðè buy cheap prevacid 15mg on-line, after attacks on Cooper and his crew by supporters of the soon-to-be-deposed Egyptian president Hosni Mubarak resulted in Cooper being relieved of his assignment in Cairo. These anecdotes make clear that the impression of "raw" documentary immediacy associated with the humanitarian live media event is in fact a highly artificial effect produced by placing the reporter in the middle of the storm, wherein television produces the real situation of disaster victims as a coded drama. The emphatically visible physical threat to Cooper and other correspondents during their on-location reports conveyed a shared sense of vulnerability, allowing an inclusive nationalist message to prevail: "We are all in this together. This sentimental call to participate directly in what Daniel Dayan and Elihu Katz call the "nationalistic mass ceremony" of the live media event glosses over the fact that exposure to environmental risk is thoroughly striated by race, class, and other categories of structural marginalization. Whereas catastrophe is a "subject-less," abstract discourse of instantaneous and punctual timing, Doane describes crisis as "an event of some duration which is startling and momentous precisely because it demands resolution within a limited period of time. Etymologically, crisis stems from the Greek krisis, or decision, and hence always seems to suggest the necessity of human agency. If televisual catastrophe promises reference, or a possibility of touching the real, then, Chun argues, the allure of new media is that of intervening in the real as an "empowered user" rather than passively "watching" events take place. She elaborates, "Crises- moments that demand real time response- make new media valuable and empowering by tying certain information to a decision, personal or political (in this sense, new media also personalizes crises). Trouble the Water positions Roberts as an "un-anchor" of sorts, whose credibility as a survivor of the storm authorizes her to narrate the true story of Katrina. The film thereby draws on televisual strategies of immediation to distinguish its own truth-value relative to the mainstream news. My analysis focuses on how Roberts cynically performs the role of eyewitness reporter as a means of enhancing the exchange value of her eyewitness footage, as well as her own credibility as a local media personality. If there is a central immediation on which Trouble the Water is founded, it has to do with the expurgation from the diegetic frame of the film of the mutually beneficial transaction between the Roberts and the filmmakers. In press releases and interviews, Scott and Kimberly report that they premeditatedly approached Lessin and Deal and their crew when they converged at a Red Cross shelter in Alexandria, Louisiana, two weeks after the storm. Kimberly is fully aware of the commodity value of her camcorder eyewitness footage, and her reluctance to turn this footage over to the local news suggests her wariness of compounding her existing economic disadvantage by being transformed into a stock supplier of generic information. Her enunciative presence in the film has been described by Janet Walker as an "autobiographical" form of "situated testimony"- a geographically grounded mode of bearing witness that "realizes the materiality of testimony in the power of place. Morse writes that television news derives its credibility in large part from the coded sincerity, stability, and trustworthiness of the news anchor. Traditionally male and white, network news anchors must emanate "patriarchal authority and middle-aged accessibility"; anchors of other genders, races, and sexuality either aspire to this conservative norm or are relegated to the morning and nightly news. In this opening montage, the filmmakers stitch together their own flow of silent vignettes from the documentary, set to cacophonous audio samples drawn from television and radio coverage of the storm and its immediate aftermath. Training the camera on the television in her living room, which is tuned to the Weather Channel, Kimberly pans away to focus on herself and her home, pets, and neighborhood. When the hurricane finally makes its landfall, Kimberly finds it less easy to distance herself from the threat of imminent death by assuming the avatar of the eyewitness reporter. She strains under the pressure of performing her eyewitness status, or what Doane describes as the televisual demand for "presence in space. Her commentary shifts from ironic critique to affirmations of spiritual faith as she realizes there is nowhere left to escape to . She is also cognizant of the need to provide visual proof of her endurance over time, in order to back up her claim and status as an authentic eyewitness. This stop sign appears in three different shots, as an index of the rising water (as well as the only point of view available to Kimberly from her place of refuge) but, perhaps more important, as a sign of rising urgency- a marker of time slipping away. For someone in her precarious position, the failure of a link to the discursive reality that is the media, the cutting off of the medium of the live humanitarian appeal, can be the real disaster. By locating the value of such a troubling document in its unmediatedness, Lessin and Deal well-meaningly enact what is perhaps the most dangerous mediation of all: far from challenging the testimonial codes of the humanitarian emergency, they intensify their insistence on referentiality, reinforcing a racialized discourse of catastrophe in which black bodies at risk represent the ultimate live spectacle. This sequence captures her improvising an impassioned rendition of her song, an autobiographical journey through the impossible odds she has faced and survived throughout her life (Kimberly sings that she started life as "a little girl caught up in the storm"), culminating in Katrina. This incident is never mentioned again because the subtle editing says what is needed: love conquers all. Kimberly needs to perform what Lauren Berlant calls "cruel optimism" in order to motivate herself to survive, even as she recognizes that her attachment to self- reliance is killing her slowly. They conclude on this basis that the Roberts have a right to return- a right to be recognized as citizens rather than as refugees- and that they deserve the advocacy platform of the film. While the film appears to celebrate a narrative of media empowerment, it invites the most vulnerable individuals to voluntarily and even heroically assume personal risk as a means of intervening in their own fate, which illustrates with startling clarity the precise opposite: the coercive, biopolitical logic that constitutes the racist division of society into "us" and "them. While these debates may not at first seem related to the problematic of documentary immediacy, I will show that their investment in the political poten92 / Chapter 2 tial of exceptional political states is thoroughly bound up with the concerns that I have laid out regarding emergency, human rights, and liveness. The Mediation of Biopolitical Emergence Over the past two decades, a number of cultural critics have turned to the vocabulary of "biopolitics" to assess the political options available to the subjects of humanitarian emergencies. The concept of biopolitics, initially elaborated by Foucault, refers to a transformation in the strategies and techniques of power, coincident with the series of epistemic shifts that we now refer to as modernity, characterized by the entrance of "life" into the field of politics. Foucault notes the myriad ways in which private, biological functions, most prominently those related to health and sexuality, were turned into objects of administration through a series of normalizing, regulatory processes that aimed to enhance life and stave off death. He contrasts the affirmative logic of biopower, which "makes live and lets die," with sovereign power, which "makes die and lets live," but notes that racism functions as the primary rationalizing technique of biopower, introducing a caesura into the social field at those crucial moments in which decisions must be made regarding who lives and who dies. In a much- cited essay, Giroux coins the term biopolitics of disposability to describe how the merger between a racist state and the mainstream media apparatus resulted in a form of racialized neglect that operated through excommunication. During Katrina, these institutions operated in collusion, he argues, to condemn the victims of disaster, especially the poor and people of color, to the discursive "black holes" of prisons, ghettos, and media invisibility. His elaboration of this argument is worth quoting at length: Something more systematic and deep-rooted [than incompetence or failed national leadership] was revealed in the wake of Katrina- namely that the state no longer provided a safety net for the poor, sick, elderly, and homeless. Instead, it had been transformed into a punishing institution intent on dismantling the welfare state and treating the homeless, unemployed, illiterate and disabled as dispensable populations to be managed, criminalized, and made to disappear into prisons, ghettos, and the black hole of despair. Excommunicated from the sphere of human concern, they have been rendered invisible, utterly disposable. Giroux positions the exposure of black suffering as an urgent corrective to the racist collusion of the state and mainstream media apparatus. He accordingly proposes that the Internet, camcorders, and cell phones should be used as documentary tools of the oppressed against the "sanitized" corporate media landscape, labeling such autoethnographic uses of media as an "oppositional biopolitics" oriented toward democracy and social empowerment. Bernstein has argued, furthermore, that the benefits of public exposure cannot be taken for granted in a media environment in which such exposure can further disadvantage those stripped of their human rights by eviscerating their privacy or, worse, aestheticizing its lack. As previously mentioned, Hardt and Negri appeal to Giroux because, unlike Agamben, they view media and communication as the milieu and catalyst of biopolitical resistance, as opposed to a medium of excommunication. By the same token, they argue, the new forms of knowledge, collaboration, and communication that result from immaterial production liberate the productive synergies of laboring bodies from the standardizing forces of the classical commodity cycle and from the traditional mediating categories of social life, such as race, class, and gender, thus potentially transforming the nature of subjectivity and the subjective conditions of relationality. It follows, Hardt and Negri propose, that the generalized existential predicament of dispossession that marks the hegemony of immaterial labor would also enable new modes of commonality with the poor and the dispossessed, who then logically stand for universality. Throughout their work, Hardt and Negri turn to figures of dispossessed existence such as the subaltern, the migrant, the refugee, and the poor- in short, figures that Agamben might reBare Liveness / 97 gard as emblematic of bare life, or who Giroux argues were marked as disposable during Katrina- as paradigmatic figures of the "multitude," namely, the revolutionary subjectless subjectivity that is both exploited and activated by the new communicative milieu. For instance, at the end of Empire, they advocate the institution of universal citizenship, a minimum income, and the reappropriation of communications media. This book rearticulates biopolitics as a struggle to actualize the common human potential for intellectual and affective communication, locating this potential, and not membership within any identitarian formation, as the necessary foundation for a truly democratic community. Bishnupriya Ghosh sums up this dilemma: she argues, paraphrasing Ranajit Guha, that sighting subaltern insurgency- that is, sighting the pressure exerted by the subaltern on "semiotic codes that maintain established political and moral hierarchies"- requires a "semiotic leap of faith" on the part of the theorist. The task, she writes, lies in decoding this semiotic confusion without totally compromising the subversive potential of the subaltern to transform the social. She warns that such recodification is inevitable especially when popular cultural forms, which often trade in and play with hegemonic semiotic codes, apprehend the subaltern. These competing accounts of biopolitics represent two sides of an ideology of immediacy, neither of which is attuned to the concrete testimonial codes that mediate the speech of the dispossessed Bare Liveness / 99 when it is articulated in the form of human rights claims. The consequences of such thinking come to light in a particularly compelling way when we consider Trouble the Water as a symptomatic instance of the desire to read the communicative acts of the dispossessed immediately, at their face value. Indeed, the indexical appeal of race as a mark of self-evidence has the same structure of immediacy as documentary realism: both signal "truth and nothing but the truth. The analysis of bare liveness that I have laid out in this chapter makes this distinction clear: it allows us to see how the humanitarian appeal to the dispossessed to affirm the political value of their lives- to make themselves live- can operate, during moments of crisis, as a racist technique of letting them die. The cool objectivity of this male voice, set off by the metallic hiss of the sparse audioscape, heightens the horror of the words it utters in the first person: "I am autism. With each threat, the wholesome landscapes of childhood seen in the brief vignettes- playground, baseball pen, backyard, beach, aquarium, school yard- assume the form of potential disease vectors, while the innocent gestures of the children as they strum their hands across a table or stare into space begin to resemble the symptoms of an epidemic that renders them mute and alien. The scenes are played over but as family portraits: a new cast of characters- siblings, parents, extended families, and friends- emerges from off-screen to envelop the children in a communal embrace. The video speeds up, and the frozen faces of the children break into smiles, as an uplifting guitar theme and the sounds of youthful laughter announce their release into sociality. Paralleling these reversals, a chorus of predominantly female voices takes over the vocal commentary on behalf of the parents, families, siblings, friends, doctors, and therapeutic staff of autistics from "all climates" and "all faiths" the world over. This "community of warriors," we are told, are united across their differences by their common quest for a cure for autism- to "knock down" the "wall" imprisoning their children by any means necessary, be it "technology," "prayers," "voodoo," or "genetic studies. Does speaking necessarily equate to agency, or are there circumstances in which it does not pay to speak When it comes to "speaking out," what kind of interiority is presupposed by a voice, and what kind of outside can be said to await the autistic speaking for themselves The problems of autistic voicing hone in on one of the most familiar and paradigmatic metaphors of humanitarian recognition and inclusion: giving a voice to the voiceless. The metaphor of "having a voice" that drives discourses of social justice turns on the importance of speech for participating in any political process. Many autistics develop language on a nonnormative timeline, and some have been known to lose their verbal faculties later in life. In addition, autistics frequently exhibit echolalia, or the repetition of certain words or phrases in socially inappropriate or irrelevant circumstances, often detached from their conventional meanings. From a humanitarian standpoint, the absence of articulate speech is regarded as a sign of underdevelopment. In stark contrast, many autistics regard their range of verbal capacities as a spectrum of neurological diversity that they wish to preserve, and they assert the value of atypical neurological development as a normal human variation. While proponents of neurodiversity do not deny the real challenges of everyday life for autistics and their caregivers, they also acknowledge the desirable aspects of living with autism that would be eliminated by a cure. The assumption that autistics are in need of "saving" or a "cure," they argue, is profoundly "neurotypical": it misrecognizes neurological difference as a disease in need of rectification or, worse, elimination- an idea that many autistics strongly oppose. This tactic has historically been used, according to Johannes Fabian, in traditional ethnographies that purport to objectively depict non-Western cultures. Just as the ethnographic native is said 106 / Chapter 3 to be "born with rhythm" by the anthropologist who did not see him grow up, learn, or practice (per Fabian), the autistic is seen and heard by humanitarian organizations like Autism Speaks as a primitive, lacking the capacity for mental reasoning that "proper" speech is thought to transmit. The ejection of autistics from the intersubjective dialogue between the voice of autism and the parents and families of autistics- that is, the various humanitarian agents speaking on behalf of autistics- positions autistic modes of communication and relationality in a private self-referential world outside time. This insight provides a point of departure for this chapter, in which I examine what happens when the documentary tropes of persuasive speech are used to "give a voice" to autistics. Whereas this trope is synonymous in the humanitarian context with having a voice, and thus with being human, I argue that from an autistic perspective it can be seen as a documentary immediation- one whose effects of unmediated presence and proximity are achieved by denying the coevalness of autistic modes of language, communication, and relationality. I begin with a survey of recent documentary films that depict autistic individuals as protagonists, filmmakers, and scriptwriters. I isolate and perform close readings of two of these films: Autism Is a World (dir. Gerardine Wurzburg, 2004), a television documentary produced for cnn, and "In My Lan"Having a Voice" / 107 guage" (dir. Mel Baggs, aka Amanda Baggs, 2007), a short self- made video posted on YouTube by Baggs. In addition to participating in and producing very different conversations around autism, these two films also illustrate contradictory stances regarding the first-person voice-over as an index of autistic subjectivity. Meanwhile, Baggs draws on experimental video techniques to position the first-person voice-over as a poor translation of hir "native language," one whose promise of interiority and personhood comes at the cost of being in a "constant conversation with every aspect of [hir] environment. I propose that Baggs and other autistic writers, like Tito Rajarshi Mukhopadhyay, Dawn Prince, and Temple Grandin, extend the work of scholars like Mladen Dolar and Roland Barthes in producing a critical counterdiscourse of the voice. Like Dolar and Barthes, autistic accounts of language and communication locate the voice in a space between the body and language that opens onto paralinguistic, embodied modes of meaning making and relationality. These autistic accounts of voicing stage a compelling critique of humanitarian notions of having and giving a voice. Rather than capitulating to the humanitarian call to "speak out" or "come to voice," they redefine voice as something that is not oriented exclusively toward the human, as it is understood in the logocentric tradition. They show, paradoxically, that the mode of voicing cultivated in contemporary therapeutic interventions around autism bears all of the characteristics commonly attributed to autistic communication. I argue that this autistic counterdiscourse of the voice demands a critical reassessment of the role of the speaking voice in documentary. This critique also points to the limitations of the way reflexivity is understood in documentary- a theme that chapter 4 takes up in greater detail. These voices, which I dub dominant, resistant, and autistic, also map onto the major representational tendencies in contemporary diagnostic debates around autism and productively illuminate the contradictions of producing a "discourse of unreason on reason. This analysis of who speaks for autism also sheds light on the different voices speaking for the child and for the disaster victim in the previous two chapters. Much of the image track is left intact, while the delivery of the commentary in a monotonous electronic voice casts Autism Speaks as a soulless and shamelessly profit- driven corporation. The plain red background of this video focuses attention on the voice, which sings an altered commentary, describing itself as "different, not weak," "smart," "sensitive," and "equal in humanity.

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