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Meg Wolfe, MD

• Associate Professor of Surgery
• Department of Surgery
• University of California, San Francisco-Fresno
• Fresno, California

If the latter is present pump for erectile dysfunction purchase 100mg aurogra amex, the potential risk of cognitive impairment is increased erectile dysfunction hormonal causes buy 100 mg aurogra mastercard, which could be magnified in a hypoxic or high-stress environment erectile dysfunction juice drink order generic aurogra, affecting safety erectile dysfunction pills list purchase aurogra online pills. While your physician understands how to keep your blood sugar stable while on the ground, he/she may not understand the additional challenges of the demanding aviation environment and may not consider them when determining clinical limitations. Be sure to discuss with your physician the fact that you operate in an environment that can be both hypoxic and place high demands on your ability to think clearly and rapidly. It is in your best interest to inform them to ensure that you receive the appropriate evaluations and care. Low blood sugar can be present at levels below 70 mg/dL and high blood sugar 267 Guide for Aviation Medical Examiners can cause cognitive impairment at levels just above 250 mg/dl. Accordingly, values between 100 and 200 are highly recommended, but the blood sugar is mandated at 70-250. Additionally, the acceptable range for the blood sugar is narrow because workload demands may render blood sugar testing and insulin injection difficult or even impossible. In addition, the more time spent in a low blood sugar or hypoglycemic condition, the more likely that one is unaware of it. The best way to ensure good control in flight is to require blood sugar maintenance in a tight range in the days and hours prior to the flight. Turbulence can make it impossible for pilots to perform finger sticks, even with an autopilot and/or second pilot. Check your device?s user guide for instructions as well as computer and software requirements as these may differ between manufacturers. You should have a backup correction pen and basal insulin available if using an insulin pump. In this case, go to a back-up plan for the remainder of the flight and measure your finger stick blood sugar every 30 minutes. If you are unable to correct your blood sugar, treat this as any in flight emergency and land as soon as practicable. This risk is present each time there is a change in pressure altitude, however, airmen can mitigate the risk by limiting the amount of insulin available for injection and by clearing bubbles at the top of ascent. These pumps are relatively resistant to the effects of pressure changes and provide obvious advantages to pilots who operate aircraft in the flight levels. The ability to suspend insulin delivery for a low reading is a good safety feature. In addition, as previously noted, a pump in which the insulin reservoir is not in direct line for delivery is preferred. Talk with your board-certified endocrinologist about whether or not adjustments should be made on days when you are flying. If neither the primary nor the backup system is functional, you must terminate flight activity. Individuals certificated under this policy will be required to provide medical documentation regarding their history of treatment, accidents, and current medical status. First and second class applicants will be evaluated on a caseby-case basis by the Federal Air Surgeon?s Office. The applicant must have had no recurrent (two or more) episodes of hypoglycemia in the past 5 years and none in the preceding 1 year which resulted in loss of consciousness, seizure, impaired cognitive function or requiring intervention by another party, or occurring without warning (hypoglycemia unawareness). The applicant will be required to provide copies of all medical records as well as accident and incident records pertinent to their history of diabetes. A report of a complete medical examination preferably by a physician who specializes in the treatment of diabetes will be required. Two measurements of glycosylated hemoglobin (total A1 or A1c concentration and the laboratory reference range), separated by at least 90 days. Specific reference to the presence or absence of cerebrovascular, cardiovascular, or peripheral vascular disease or neuropathy. Confirmation by an eye specialist of the absence of clinically significant eye disease. Verification that the applicant has been educated in diabetes and its control and understands the actions that should be taken if complications, especially hypoglycemia, should arise. The examining physician must also verify that the applicant has the ability and willingness to properly monitor and manage his or her diabetes. In order to serve as a pilot in command, you must have a valid medical certificate for the type of operation performed. This evaluation must include a general physical examination, review of the interval medical history, and the results of a test for glycosylated hemoglobin concentration. The results of these quarterly evaluations must be accumulated and submitted annually unless there has been a change. On an annual basis, the reports from the examining physician must include confirmation by an eye specialist of the absence of significant eye disease. Monitoring and Actions Required During Flight Operations To ensure safe flight, the insulin using diabetic airman must carry during flight a recording glucometer; adequate supplies to obtain blood samples; and an amount of rapidly absorbable glucose, in 10 gm portions, appropriate to the planned duration of the flight. One-half hour prior to flight, the airman must measure the blood glucose concentration. If it is less than 100 mg/dl the individual must ingest an appropriate (not less than 10 gm) glucose snack and measure the glucose concentration one-half hour later. If the concentration is within 100 -300 mg/dl, flight operations may be undertaken. If less than 100, the process must be repeated; if over 300, the flight must be canceled. One hour into the flight, at each successive hour of flight, and within one half hour prior to landing, the airman must measure their blood glucose concentration. If the 272 Guide for Aviation Medical Examiners concentration is less than 100 mg/dl, a 20 gm glucose snack shall be ingested. If the concentration is greater than 300 mg/dl, the airman must land at the nearest suitable airport and may not resume flight until the glucose concentration can be maintained in the 100 -300 mg/dl range. In respect to determining blood glucose concentrations during flight, the airman must use judgment in deciding whether measuring concentrations or operational demands of the environment (e. In cases where it is decided that operational demands take priority, the airman must ingest a10 gm glucose snack and measure his or her blood glucose level 1 hour later. If measurement is not practical at that time, the airman must ingest a 20 gm glucose snack and land at the nearest suitable airport so that a determination of the blood glucose concentration may be made. Quarterly hemoglobin A1c (A1c?s must be done > 30 days after meds change and < 90 days of recertification. Those individuals who have a negative work-up may be issued the appropriate class of medical certificate. If areas of ischemia are noted, a coronary angiogram may be indicated for definitive diagnosis. Food and Drug Administration and is used in accordance with an acceptable drug therapy protocol. An assessment of cognitive function (preferably by Cogscreen or other test battery acceptable to the Federal Air Surgeon) must be submitted. Additional cognitive function tests may be required as indicated by results of the cognitive tests. At the time of initial application, viral load must not exceed 1,000 copies per milliliter of plasma, and cognitive testing must show no significant deficit(s) that would preclude the safe performance of airman duties. If granted Authorization for Special Issuance, follow-up requirements will be specified in the Authorization letter. Persons on an antiretroviral medication will be considered only if the medication is approved by the U. In order to be considered for a medical certificate the following data must be provided: 1. Follow-up neurologicalpsychological evaluations are required annually for first and second-class pilots and every other year for third-class. To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to this secure site. This report should include the information outlined below, along with any separate additional testing. Readable samples of all electronic pacemaker surveillance records post surgery or over the past 6 months, or whichever is longer. It must include a sample strip with pacemaker in free running mode and unless contraindicated, a sample strip with the pacemaker in magnetic mode. A current Holter monitor evaluation for at least 24-consecutive hours, to include select representative tracings.

If nystagmus has been present for a number of years and has not recently worsened best erectile dysfunction pills treatment purchase aurogra 100 mg without prescription, it is usually necessary to consider only the impact that the nystagmus has upon visual acuity impotence due to alcohol purchase aurogra 100mg without prescription. The Examiner should be aware of how nystagmus may be aggravated by the forces of acceleration commonly encountered in aviation and by poor illumination impotence of organic origin discount 100mg aurogra with visa. The applicant should be advised of any abnormality that is detected erectile dysfunction kegel order aurogra pills in toronto, then deferred for further evaluation. Aerospace Medical Dispositions the following is a table that lists the most common conditions of aeromedical significance, and course of action that should be taken by the examiner as defined by the protocol and disposition in the table. Applicants with seasonal allergies requiring any other antihistamine (oral and/or nasal) may be certified by the examiner with the stipulation that they do not exercise the privileges of airman certificate until they have stopped the medication and wait after the last dose until: At least five maximal dosing intervals have passed. For example, if the medication half-life is 6-8 hours, wait 40 hours (5x8) after the last dose to fly. Airmen who are exhibiting symptoms, regardless of the treatment used, must not fly. Applicants for firstor secondclass must provide this information annually; applicants for third-class must provide the information with each required exam. Acceptable Medications [ ] One or more of the following Inhaled long-acting beta agonist Inhaled short-acting beta agonist (e. Examiner must caution airman not to fly until course of oral steroids is completed and airman is symptom free. If the applicant has frequent exacerbations or any degree of exertional dyspnea, certification should be deferred. On the other hand, an individual who has sustained a repeat pneumothorax normally is not eligible for certification until surgical interventions are carried out to correct the underlying problem. A person who has such a history is usually able to resume airmen duties 3 months after the surgery. A brief description of any comment-worthy personal characteristics as well as height, weight, representative blood pressure readings in both arms, funduscopic examination, condition of peripheral arteries, carotid artery auscultation, heart size, heart rate, heart rhythm, description of murmurs (location, intensity, timing, and opinion as to significance), and other findings of consequence must be provided. The Examiner should keep in mind some of the special cardiopulmonary demands of flight, such as changes in heart rates at takeoff and landing. High G-forces of aerobatics or agricultural flying may stress both systems considerably. Degenerative changes are often insidious and may produce subtle performance decrements that may require special investigative techniques. Check the hematopoietic and vascular system by observing for pallor, edema, varicosities, stasis ulcers, and venous distention. The pulses should be examined to determine their character, to note if they are diminished or absent, and to observe for synchronicity. The medical standards do not specify pulse rates that, per se, are disqualifying for medical certification. These tests are used, however, to determine the status and 72 Guide for Aviation Medical Examiners responsiveness of the cardiovascular system. Bradycardia of less than 50 beats per minute, any episode of tachycardia during the course of the examination, and any other irregularities of pulse other than an occasional ectopic beat or sinus arrhythmia must be noted and reported. If there is bradycardia, tachycardia, or arrhythmia further evaluation may be warranted and deferral may be indicated. Temporary stresses or fever may, at times, result in abnormal results from these tests. Determine heart size, diaphragmatic elevation/excursion, abnormal densities in the pulmonary fields, and mediastinal shift. Check for resonance, asthmatic wheezing, ronchi, rales, cavernous breathing of emphysema, pulmonary or pericardial friction rubs, quality of the heart sounds, murmurs, heart rate, and rhythm. It should be noted whether it is functional or organic and if a special examination is needed. It is recommended that the Examiner conduct the auscultation of the heart with the applicant both in a sitting and in a recumbent position. Aside from murmur, irregular rhythm, and enlargement, the Examiner should be careful to observe for specific signs that are pathognomonic for specific disease entities or for serious generalized heart disease. Examples of such evidence are: (1) the opening snap at the apex or fourth left intercostal space signifying mitral stenosis; (2) gallop rhythm indicating serious impairment of cardiac function; and (3) the middiastolic rumble of mitral stenosis. Standardization of examination methods and reporting is essential to provide sufficient basis for making determinations and the prompt processing of applications. Particular reference should be given to cardiovascular abnormalities cerebral, visceral, and/or peripheral. A statement must be included as to whether medications are currently or have been recently used, and if so, the type, purpose, dosage, duration of use, and other pertinent details must be provided. In addition, any history of hypertension must be fully developed to also include all medications used, dosages, and comments on side effects. A statement of the ages and health status of parents and siblings is required; if deceased, cause and age at death should be included. Also, any indication of whether any near blood relative has had a ?heart attack, hypertension, diabetes, or known disorder of lipid metabolism must be provided. Smoking, drinking, and recreational habits of the applicant are pertinent as well as whether a program of physical fitness is being maintained. Comments on the level of physical activities, functional limitations, occupational, and avocational pursuits are essential. Detailed reports of surgical procedures as well as cerebral and coronary arteriography and other major diagnostic studies are of prime importance. The presence of an aneurysm or obstruction of a major vessel of the body is disqualifying for medical certification of any class. The presence of permanent cardiac pacemakers and artificial heart valves is also disqualifying for certification. The maximum systolic during exam is 155mmHg and the maximum diastolic is 95mmHg during the exam. If during the exam the airman?s blood pressure is higher than 155/95, do I have to defer? If the airman?s blood pressure is elevated in clinic, you have any the following options:? If this can be done within the 14 day exam transmission period, you could then follow the Hypertension Disposition Table. Can I hold an exam longer than 14 days to allow the airman time provide the necessary information? Yes, the majority of common blood pressure medications can be approved for flight. The airman had medication(s) adjusted and now meets the standards, but it took longer than 14 days and the exam was deferred. The treating physician note should describe the clinical rationale as to why the unacceptable medication was previously chosen and why it is ok for the airmen to be on a different medication now. A current status report from the treating cardiologist [ ] Yes verifies the airman:? Has not developed any new conditions, arrhythmias, or complications that would affect cardiac function;? Hypertrophy or dilatation of the heart as evidenced by clinical examination and supported by diagnostic studies. Cardiac enlargement or other evidence of cardiovascular abnormality, If the applicant wishes further consideration, a consultation is required, preferably from the applicant?s treating physician. A 1month observation period must elapse after the procedure before consideration for certification. If the Examiner is in doubt, it is usually better to defer issuance rather than to deny certification for such a history. Evidence of extensive multi-vessel disease, impaired cardiac functioning, precarious coronary circulation, etc. Based upon this information, it may be possible to advise an applicant of the likelihood of favorable consideration. Check the hematopoietic and vascular system by observing for pallor, edema, varicosities, stasis ulcers, venous distention, nail beds for capillary pulsation, and color. Aerospace Medical Disposition 87 Guide for Aviation Medical Examiners the following is a table that lists the most common conditions of aeromedical significance, and course of action that should be taken by the examiner as defined by the protocol and disposition in the table. Observation: the Examiner should note any unusual shape or contour, skin color, moisture, temperature, and presence of scars.

If your hair loss is genetic erectile dysfunction doctors fort lauderdale buy 100 mg aurogra fast delivery, you have a wider range of physicians to choose from erectile dysfunction causes yahoo buy aurogra 100mg on line. From the 1960s through the 1980s almost all hair restoration surgical procedures and prescriptions for hair restoration medication were done by board certified dermatologists and cosmetic surgeons impotence lexapro buy discount aurogra 100 mg on-line. Dermatologists typically performed hair transplants muse erectile dysfunction medication reviews discount aurogra 100mg, scalp reductions, and prescribed medications, while cosmetic surgeons typically performed more elaborate scalp flap and scalp lift procedures. In the past, the physician selection process was fairly straightforward, and was a matter of learning about the experience and artistic abilities of the surgeon, or pharmaceutical expertise if medication was the hair restoration method desired. An initial consultation included an examination and an opportunity to see past patient photos, and ideally to meet with and examine real live past patients. In the 1990s, a combination of two factors brought all kinds of medical doctors into the hair restoration field. The first factor was the refinement of the micrografting technique to the point where almost any physician could perform the procedure. Micrografting is considered by physicians to be a relatively simple surgical procedure that can be performed in the office. The procedure generally results 181 Chapter Seventeen in a very good to excellent outcome. Even more important, in comparison to all other forms of hair restoration surgery, micrografting has a lower risk of poor cosmetic results, as well as a low risk of medical complications. With a solid general medical training background and some specific training in micrografting techniques, micrografting made it possible for almost any medical doctor to become a hair restoration surgeon. Also in the 1990s there was a national emphasis on cutting the cost of health care in the United States. Physicians were being financially squeezed by the cutbacks in health care, and they increasingly found their medical judgment questioned by insurance companies. Doctors and staff started spending less time with patients and more time filling out insurance forms. Thousands of doctors trained in specialties ranging from heart surgery to urinary tract medicine and even pediatrics and psychiatry left those fields and entered the field of elective cosmetic surgery, including hair transplantation. In the United States, any medical doctor can practice any type of medicine, regardless of the specific type of medical training they have had. Common sense, fear of malpractice lawsuits, and hospital qualification requirements prevent untrained doctors from performing major surgical procedures in hospital operating rooms. When a procedure is performed in the doctor?s office, only common sense and fear of medical malpractice lawsuits restrict what surgical procedures are performed. In the 1990s all areas of the elective cosmetic surgical business suddenly became much more marketing-driven than it ever had been in the past. The hair follicles that are relocated will continue growing new hairs in the new 182 Choosing a Physician locations for as long as they would have where they were originally located. Because micrografting is a very forgiving surgical procedure, and even a surgeon with minimal training and limited artistic abilities can achieve reasonably good results, it has become easier today than in the past to select an adequate physician to perform transplant surgery. On the other hand, with all of the advertising hype, partial truths, and occasional false claims, is harder than ever before to find the very best physician to perform your hair restoration surgery. The vast majority of physicians who have recently entered the field of hair restoration surgery are well-educated doctors who are capable of performing excellent micrograft transplant procedures. Many doctors have taken several days of intensive micrografting training and have worked for weeks side by side with other experienced hair restoration surgeons to learn the subtle aspects of the micrografting technique. But just as is the case in any occupation, there are always a few less capable people out there. Read books such as this one, review Internet websites, and learn about alternative treatments that may work for you. When you request information from a doctor?s office, or from a clinic, you will receive literature and probably videotapes to review. The clinics will send a lot of information and will probably phone you several times as well. After doing your research, if surgery or medication, or a combination of surgery and medication seem to be the best way to address your hair loss condition, then the next step would be visiting the doctor?s office for an initial consultation. Usually there is no charge for an initial consultation for hair loss restoration caused by genetics. If you feel your hair loss is not the results of genetics, and may instead be due to a disease condition, or from a medication you are taking, or from some other cause, and you have health insurance, then you should follow the procedures for scheduling an examination that your health insurance provider recommends. You may see a 183 Chapter Seventeen primary care physician first, and after that examination, you may be referred to a dermatologist or another specialist. Regardless of whether the doctor has been medically trained specifically to treat conditions affecting the skin and hair, or whether he or she have been trained in another medical specialty area, the examination will include an assessment of your scalp condition, overall physical health, and emotional condition. You will be asked about any allergies to medications, such as the antibiotics and anesthetics used during surgery. It is rare that a patient comes in for hair transplants and has a health condition that would prohibit or delay surgery, but determining that possibility is one purpose of the initial exam. The doctor wants to be certain you are a qualified patient, both physically and also emotionally. A hair transplant procedure can significantly enhance your appearance, but it is not guaranteed to solve psychological problems, or make you successful in business or in relationships. As part of the examination, your current hair loss pattern will be assessed and measured against standardized hair loss charts, such as the Hamilton/Norwood chart for men, or the Ludwig Scale for women. In addition to the pattern the character of your hair loss will also be evaluated. Are the remaining hairs on the top and front of your scalp very fine and short, or are they full-size and long growing? The character of your remaining hair, both on top and at the donor area, has a significant effect on the appearance of transplants. Genetic hair loss is progressive, meaning that the degree of loss tends to increase over time. Some people lose their hair slowly, and others more rapidly, but without medical treatment, hair loss will continue year after year. The doctor will want to know about hair loss conditions of your close relatives, especially older brothers and sisters, your parents, and grandparents. The most experienced and artistically capable hair restoration physicians plan their transplant procedures so that you will look natural decades into the future. This means a slightly conservative approach that includes placing some transplant grafts between existing hairs that are likely to become thin in the future, as well as avoiding a low hairline appropriate for a thirty-year old, but one that would look unnatural when the patient is in their fifties or sixties or seventies. This aspect of hair restoration surgery is more art than science, and experience counts. Depending upon your age and current hair loss condition, the doctor may also recommend medical treatment to slow or stop your hair loss condition. A patient with a family history of extensive hair loss, who responds well to medication that stops the hair loss, is a better candidate than the same patient without the medication. Transplants will certainly enhance your appearance, and medication can help you keep more of the hair you have. All of these aspects of an initial consultation and examination are reasons why it is important to meet with the doctor who will actually be doing the surgery. You want to be examined by the doctor who will be doing the work, and to have him or her answer your questions directly, and to allow you to answer his or her questions directly. The initial consultation is a two-way meeting, and the doctor will also ask you questions to qualify you as a patient. Some doctors, and practically all clinics, have an ?assistant meet with you initially to determine your qualifications and to help answer some of your basic questions. These ?assistants may be medically trained personnel who also assist with the surgical procedures when not meeting prospective new patients; or they may just be salespeople. While these photos are impressive, keep in mind that they are typically the best results achieved. And it is difficult for someone who is not an expert to assess the effectiveness of transplant procedures from photos alone. If possible, see if you can schedule your consultation at a time when you can also meet with a past patient, so you can see the results in person for yourself. Look at his or her web site, if you feel uncomfortable asking the doctor about this directly. Some doctors prominently feature the qualification ?Board Certified in their advertisements. Some doctors subscribe to a monitoring service that randomly contacts past patients to assure that the doctor continues to keep his or her patients happy.

Examples include epinephrine injection erectile dysfunction kits order aurogra 100 mg without prescription, cardiac trauma erectile dysfunction treatment saudi arabia order aurogra 100 mg visa, complications of catheterization erectile dysfunction doctors austin texas aurogra 100 mg lowest price, Factor V Leiden erectile dysfunction in teens order 100 mg aurogra overnight delivery, etc. Recovery time before consideration and required tests will vary by the airman medical certificate applied for and the categories above. Copies of all medical records (inpatient and outpatient) pertaining to the event, including all labs, tests, or study results and reports. Required documentation for all pilots with any of the remaining conditions above: a. Additional required documentation for first and unlimited* second class airmen a. The applicant should indicate if a lower class medical certificate is acceptable (if they are found ineligible for the class sought) E. Additional required documentation for percutaneous coronary intervention: the applicant must provide the operative or post procedure report. Note: If cardiac catheterization and/or coronary angiography have been performed, all reports and actual films (if films are requested) must be submitted for review. Neuropsychological evaluations should be conducted by a qualified neuropsychologist with additional training in aviationspecific topics. To promote test security, itemized lists of tests comprising psychological/neuropsychological test batteries have been moved to a secure site. When an applicant with a history of diabetes is examined for the first time, the Examiner should explain the procedures involved and assist in obtaining prior records and current special testing. Applicants with a diagnosis of diabetes mellitus controlled by diet alone are considered eligible for all classes of medical certificates under the medical standards, provided they have no evidence of associated disqualifying cardiovascular, neurological, renal, or ophthalmological disease. Specialized examinations need not be performed unless indicated by history or clinical findings. For medications currently allowed, see chart of Acceptable Combinations of Diabetes Medications. When medication is started the following time periods must elapse prior to certification to assure stabilization, adequate control, and the absence of side effects or complications from the medication. The report must contain a statement regarding the medication used, dosage, the absence or presence of side effects and clinically significant hypoglycemic episodes, and an indication of satisfactory control of the diabetes. The applicant should be informed of the potential for hypoglycemic reactions and cautioned to remain under close medical surveillance by his or her treating physician. Hemoglobin A1C lab value and date (A1C lab value must be taken more than 30 days after medication change and within 90 days of re/certification) 5. Any evidence of progressive diabetes induced end organ disease Cardiac?. Yes No Treating Provider Signature Date Note: Acceptable Combinations of Diabetes Medications and copies of this form for future follow-ups can be found at There are no restrictions regarding flight outside of the United States air space. Airmen with a current 3rd class certificate will have the limitation removed with their next certificate. See the links below (or the following pages in this document) for details of what specific information must be included for each requirement/report for third-class certification. For details of what specific information must be included for each requirement/report (Items #1-7), see the following pages. Submit the following performed within the past 90 days: Item # 1 Initial Comprehensive report from your treating board-certified endocrinologist. It should be marked with times/dates of flights and any actions taken for glucose correction during flight activities. Thyroid palpation and skin exam (acanthosis nigricans, insulin injection or insertion sites, lipodystrophy); and 4. Readings from (at a minimum) the preceding 6 months for initial certification and thereafter 3 months. Have automatic alarms for notification for high or low glucose readings with at least two of the following: audio, visual, or tactile; 4. Have ?predictive arrow trends that provide warnings of potentially dangerous glucose levels (high or low) before they occur; 5. Visual field defects: type of test, method used (confrontation fields are acceptable). Evaluation from a board-certified cardiologist assessing cardiac risk factors; and 2. Maximal exercise treadmill stress testing (Bruce), beginning at age 40, and every 5 years thereafter and as clinically indicated. Customize low glucose to 70 mg/dL and high glucose to 250 mg/dL before printing report. Various flight safety considerations for this serious health condition could not be safely mitigated for commercial operations until recently. Testing ensures both good control and demonstrates the absence of end-organ damage. An applicant with a history of liver transplant must submit the following for consideration of a medical certificate. Applicants found qualified will be required to provide annual follow up evaluations per their authorization letter. A six (6) month post-transplant recovery period with documented stability for the last three (3) months;? Pre-transplant treatment notes that identify the diagnosis, indication for transplant, and any sequelae prior to transplant. An Examiner may re-issue a subsequent airman medical certificate under the provisions of the Authorization. The initial Authorization determination will be made on the basis of a report from the treating physician. For favorable consideration, the report must contain a statement regarding the medication used, dosage, the absence or presence of side effects and clinically significant hypoglycemic episodes, and an indication of satisfactory control of the metabolic syndrome. The results of an A1C hemoglobin determination within the past 30 days must be included. Note must also be made of the presence of cardiovascular, neurological, renal, and/or ophthalmological disease. The presence of one or more of these associated diseases will not be, per se, disqualifying but the disease(s) must be carefully evaluated to determine any added risk to aviation safety. Re-issuance of a medical certificate under the provisions of an Authorization will also be made on the basis of reports from the treating physician. The contents of the report must contain the same information required for initial issuance and specifically reference the presence or absence of satisfactory control, any change in the dosage or type of medication, and the presence or absence of complications or side effects from the medication. An applicant with metabolic syndrome should be counseled by his or her Examiner regarding the significance of the disease and its possible complications, including the possibility of developing diabetes mellitus. This certificate will permit the applicant to proceed with flight training until ready for a medical flight test. This affords the student an opportunity to demonstrate the ability to control the aircraft despite the handicap. When prostheses are used or additional control devices are installed in an aircraft to assist the amputee, those found qualified by special certification procedures will have their certificates limited to require that the device(s) (and, if necessary, even the specific aircraft) must always be used when exercising the privileges of the airman certificate. Head trauma, stroke, encephalitis, multiple sclerosis, other suspected acquired or developmental conditions, and medications used for treatment, may produce cognitive deficits that would make an airman unsafe to perform pilot duties. Recommendations should be strictly limited to the psychologist?s area of expertise. In that event, authorization for release of the data by the airman to the expert reviewer will need to be provided. If eligible for unrestricted medical certification, no additional testing would be required. However, pilots found eligible for Special Issuance will be required to undergo periodic re-evaluations. The letter authorizing special issuance will outline required testing, which may be limited to specific tests or expanded to include a comprehensive test battery. Specifically, sleep apneas are characterized by abnormal respiration during sleep. For example, an applicant with a history of bleeding ulcer may be required to have the physician submit followup reports every 6-months for 1 year following initial certification.

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