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David B. Joseph, MD, FACS, FAAP
- Professor of Surgery,
- University of Alabama at Birmingham
- Chief of Pediatric Urology,
- University of Alabama at Birmingham,
- Children? Hospital, Birmingham, Alabama
As needed diabetes definition deutsch cheap glucotrol xl 10 mg mastercard, you should also educate the driver regarding drug interactions with other prescription and nonprescription drugs and alcohol diabetes mellitus gestational generic 10 mg glucotrol xl with visa. Any illness or injury in the last 5 years A driver must report any condition for which he/she is currently under treatment diabetes diet pop purchase genuine glucotrol xl on line. The driver is also asked to report any illness/injury he/she has sustained within the last 5 years diabetes hyper signs 10 mg glucotrol xl fast delivery, whether or not currently under treatment signs juvenile diabetes babies buy glucotrol xl on line. Seizures diabetes mellitus cardinal signs purchase glucotrol xl pills in toronto, epilepsy Ask questions to ascertain whether the driver has a diagnosis of epilepsy (two or more unprovoked seizures), or whether the driver has had one seizure. Gather information regarding type of seizure, duration, frequency of seizure activity, and date of last seizure. Eye disorders or impaired vision (except corrective lenses) Ask about changes in vision, diagnosis of eye disorder, and diagnoses commonly associated with secondary eye changes that interfere with driving. Complaints of glare or near-crashes are driver responses that may be the first warning signs of an eye disorder that interferes with safe driving. Ear disorders, loss of hearing or balance Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. Loss of balance while performing nondriving tasks can lead to serious injury of the driver. Obtain heart surgery information, including such pertinent operative reports as copies of the original cardiac catheterization report, Page 29 of 260 stress tests, worksheets, and original tracings, as needed, to adequately assess medical fitness for duty. High blood pressure Ask about the history, diagnosis, and treatment of hypertension. In addition, talk with the driver about his/her response to prescribed medications. The likelihood increases, however, when there is target organ damage, particularly cerebral vascular disease. As a medical examiner, though, you are concerned with the blood pressure response to treatment, and whether the driver is free of any effects or side effects that could impair job performance. Muscular disease Ask the driver about history, diagnosis, and treatment of musculoskeletal conditions, such as rheumatic, arthritic, orthopedic, and neuromuscular diseases. Does the diagnosis indicate that the driver is at risk for sudden, incapacitating episodes of muscle weakness, ataxia, paresthesia, hypotonia, or pain However, most commercial drivers are not short of breath while driving their vehicles. Feel free to ask other questions to help you gather sufficient information to make your qualification/disqualification decision. Lung disease, emphysema, asthma, chronic bronchitis Ask about emergency room visits, hospitalizations, supplemental use of oxygen, use of inhalers and other medications, risk of exposure to allergens, etc. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving. Page 30 of 260 Kidney disease, dialysis Ask about the degree and stability of renal impairment, ability to maintain treatment schedules, and the presence and status of any co-existing diseases. Digestive problems Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. Diabetes or elevated blood glucose controlled by diet, pills, or insulin Ask about treatment, whether by diet, oral medications, Byetta, or insulin. Loss of or altered consciousness Loss of consciousness while driving endangers the driver and the public. Your discussion with the driver should include cause, duration, initial treatment, and any evidence of recurrence or prior episodes of loss of or altered consciousness. Fainting, dizziness Note whether the driver checked Yes due to fainting or dizziness. Ask about episode characteristics, including frequency, factors leading to and surrounding an episode, and any associated neurologic symptoms. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Ask the driver about sleep disorders. Also ask about such symptoms as daytime sleepiness, loud snoring, or pauses in breathing while asleep. Page 31 of 260 Stroke or paralysis Note any residual paresthesia, sensory deficit, or weakness as a result of stroke and consider both time and risk for seizure. Missing or impaired hand, arm, foot, leg, finger, toe Determine whether the missing limb affects driver power grasping, prehension, or ability to perform normal tasks, such as braking, clutching, accelerating, etc. Spinal injury or disease Refer to the guidance found in Regulations You must review and discuss with the driver any "Yes" answers. How does the pain affect the ability of the driver to perform driving and nondriving tasks You should refer the driver who shows signs of a current alcoholic illness to a specialist. Narcotic or habit-forming drug use Explore the use of the medication, whether or not it is prescribed, and the medications effect on driver reaction time, ability to focus, and concentration. Include a copy of any supplementary medical reports obtained to complete the health history. Specialist Vision Certificationthe vision testing and certification may be completed by an ophthalmologist or optometrist. When the vision test is done by an ophthalmologist or optometrist, that provider must fill in the date, name, telephone number, license number, and State of issue, and sign the examination form. Additionally, ensure that any attached specialist report includes all required examination and provider information listed on the Medical Examination Report form. The forced whisper test was administered first, and hearing measured by the test failed to meet the minimum five feet requirement in both ears. This three-month certificate is a one-time issuance for the recertification period and is not intended to mean once in the drivers lifetime. The medical examiner may use his/her clinical expertise and results of the individual driver examination to determine the length of time between recertification examinations. Figure 10 Medical Examination Report Form: Blood Pressure/Pulse Rate Recommendation Tablethe following table corresponds to the first two columns of the recommendation table in the Medical Examination Report form. Column one has the blood pressure readings, and column two has the category classification. The next table corresponds to columns three and four of the recommendation table in the Medical Examination Report form. Use the Expiration Date and Recertification columns to assist you in determining driver certification decisions. Expiration Date Recertification 1 year 1 year if less than or equal to 140/90 1 year from date of examination if less than One-time certificate for 3 months or equal to 140/90 6 months from date of examination if less 6 months if less than or equal to 140/90 than or equal to 140/90 Table 3 Blood Pressure/Pulse Rate Recommendation Table Columns 3 and 4 A driver with Stage 3 hypertension (greater than or equal to 180/110) is at an unacceptable risk for an acute hypertensive event and should be disqualified. By signing the Medical Examination Report form, you are taking responsibility for and attesting to the validity of all documented test results. Additional Tests and/or Evaluation from a Specialist Abnormal dip stick readings may indicate a need for further testing. As a medical examiner, you should evaluate the test results and other physical findings to determine the next step. If the urinalysis, combined with other medical findings, indicates the potential for renal dysfunction, you should obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Attach any additional medical reports obtained to the Medical Examination Report form. You should consider height and weight factors as part of the overall driver medical fitness for duty. For each body system, mark "Yes" if abnormalities are detected, or "No" if the body system is normal. You must document abnormal findings on the Medical Examination Report form, even if not disqualifying. Page 39 of 260 Start your comments using the number to indicate the body system. General Appearance Observe and note on the Medical Examination Report form any abnormalities with posture, limps, or tremors. Note driver demeanor and whether responses to questions indicate potential adverse impact on safe driving. If yes, what are the clinical and safety implications when integrated with all other findings Eyes At a minimum, you must check for pupillary equality, reaction to light and accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, and exophthalmos. Is an eye abnormality an indicator that additional evaluation, perhaps by a specialist, is needed to assess the nature and severity of the underlying condition At a minimum, you must check for scarring of the tympanic membrane, occlusion of the external canal, and perforated eardrums. Does your examination of the ear find abnormalities that might account for hearing loss or a disturbance in balance Should the driver consult with a primary care provider or hearing specialist for possible treatment that might improve hearing test results Mouth and Throat Does the condition or treatment require long-term follow-up and monitoring to ensure that the disease is stabilized, and the treatment is effective and well tolerated Heart You must examine the heart for murmurs, extra sounds, enlargement, and a pacemaker or implantable cardioverter defibrillator. Does your examination find any abnormalities that indicate the driver may have a current cardiovascular disease accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure Can the condition be corrected surgically or managed well by pharmacological treatments Does the condition or treatment require long-term follow-up and monitoring to ensure that the disease is stabilized and treatment is effective and well-tolerated The commercial driver must be able to perform all job related tasks, including lifting, to be certified. Lungs and Chest, Not Including Breast Examination You must examine the lungs and chest for abnormal chest wall expansion, respiratory rate, and breath sounds including wheezes or alveolar rales. Be sure to examine the extremities to check for clubbing of the fingers and other signs of pulmonary disease. The driver may need to have additional pulmonary function tests and/or have a specialist evaluation to adequately assess respiratory function. Abdomen and Viscera You must check for enlarged liver and spleen, masses, bruits, hernia, and significant abdominal wall muscle weakness. You should not make a certification decision until the etiology is confirmed, and treatment has been shown to be adequate/effective and safe. Vascular System You must check for abnormal pulse and amplitude, carotid or arterial bruits, and varicose veins. The diagnosis of arterial disease should prompt you to evaluate for the presence of other cardiovascular diseases. An abnormal urinalysis indicates further testing to rule out underlying medical problems. Check for fixed deficits of the extremities caused by loss, impairment, or deformity of an arm, hand, finger, leg, foot, or toe.
This unbundling of detoxification and treatment services in the services has promoted the separation of all future diabetes dtour diet plan order cheap glucotrol xl on line. This chapter discusses the criteria for placing Settings in the patients in the appropriate treatment settings and offering the required Delivery of Services intensity of services diabetes symptoms and types buy 10 mg glucotrol xl visa. Patients should be treated in those settings that least interfere with their civil rights and freedom to participate in society diabetes symptoms urine test discount 10 mg glucotrol xl otc. While this includes the right to refuse any care at all diabetes diet zone purchase genuine glucotrol xl, it also includes the right to obtain care in a setting of their choice (as long as considerations of dangerousness and mental competency are satisfied) diabetes in bichon frise dogs order glucotrol xl 10 mg overnight delivery. It implies a patients right to seek a higher or different level of care than that which the clinician has planned diabetes type 2 zwanger purchase glucotrol xl canada. In such cases, State law and/or case law may hold providers responsible if they do not commit the patient to care, but in other cases programs may be open to lawsuits for forcibly holding a patient. Readiness to Change ment (level of care) are so important, the American Society of Addiction Medicine 5. Staffing should include certified lish participation in treatment activities and interpreters for the deaf and other language patient role induction. That is, this phase Settings, Levels of Care, and Patient Placement 13 interpreters if the program is serving patients under a defined set of policies and procedures in need of those services. Ambulatory tant for medical and nursing personnel to be detoxification is considered appropriate only readily available to evaluate and confirm that when a positive and helpful social support detoxification in the less supervised setting is network is available to the patient. This will permit the rapid transfer of Freestanding Urgent Care the patient to a setting where complete care Center or Emergency can be provided. Appropriate triage and successful legal restrictions that forbid holding persons linkage to ongoing detoxification services is against their will under certain conditions essential. Acute intoxication, it cations are more likely to require treatment must be remembered, creates special issues in an inpatient setting. Because of their volatility biomedical issues, is recommended wherever and often risky behavior, patients who are possible. Nonetheless, like that are uniquely designed to address the substance abuse treatment facilities, the range needs of patients in biomedical crisis. For of available services varies from one mental patients with substance use disorders, care in health facility to another. Concern for safety is Residential settings vary greatly in the level of of primary importance, and the final decision care that they provide. Those with intensive regarding placement always rests with the medical supervision involving physicians, nurse treating physician. Appropriately licensed and credentialed staff should be available to administer medications in accordance with physician orders. Medical evaluation and consultation should be available 24 hours a day, in accordance Level of care with treatment/transfer practice guidelines. Most alcohol treatment programs detoxification that is delivered by medical and have found that more than 90 percent of nursing professionals. Medically supervised patients with withdrawal symptoms can be evaluation and withdrawal management in a treated as outpatients (Abbott et al. Nevertheless, they are an important set of In part because of the need to keep costs to a guidelines that are of great help to clinicians. Biomedical Issues Detoxification presents a unique opportunity to intervene during a Strategies for period of crisis and move a client to make changes in the direction of health and recovery. Hence, a primary goal of the detoxification staff Engaging and should be to build the therapeutic alliance and motivate the patient to Retaining Patients enter treatment. This process should begin even as the patient is being in Detoxification medically stabilized (Onken et al. This chapter addresses the psychosocial and biomedical issues that may affect detoxification and ensuing treatment. They often are a first step toward recovery and the first door through which patients pass to treatment. The detoxification staff needs to be sis or expose other clients or staff to contagious equipped to identify and address potential diseases. Detoxification is notthe following sections include some general an exact science, but any significant deviation guidelines and important considerations to from the expected course of withdrawal should follow when providing detoxification services.
Abuse may lead to moderate or low physical dependence or high psychological dependence warning signs diabetes dogs buy glucotrol xl amex. Schedule V drugs have the lowest potential for abuse and include narcotic compounds or mixtures managing diabetes and high blood pressure purchase glucotrol xl in united states online. Therefore diabetes mellitus definition signs and symptoms buy glucotrol xl 10mg low cost, a substance can have little risk for addiction and abuse but still have side effects that interfere with driving ability diabetes food list order glucotrol xl master card. Page 212 of 260 Appendix A: Medical Examination Report Form To print a sample Medical Examination Report form diabetes type 2 nutrition generic glucotrol xl 10 mg on-line, visit diabetes in dogs how much insulin purchase glucotrol xl with amex. Driver Information A complete physical examination is required for new certification and recertification. Verify that the date of the examination is accurate because this is used to calculate the expiration date. Any individual can request and be given a Federal Motor Carrier Safety Administration physical examination. Health Historythe health history is an essential part of the driver physical examination. Discuss the safety implications of effects and/or side effects of prescription and over-the-counter medications, supplements, and herbs. By signing the form, the driver certifies that the information and history are complete and true. Document the significant findings of the health history in the comments section below the signature of the driver. Medical Examination Report Form Page 2the results of the four required tests: vision, hearing, blood pressure/pulse, and urinalysis are recorded on the second page of the Medical Examination Report form. Abnormal test results may disqualify a driver or indicate that additional evaluation and/or testing are needed. Drug and alcohol testing are not required for the driver physical examination unless findings indicate they are needed to determine medical fitness for duty. Visionthe medical examiner or a licensed ophthalmologist or optometrist can examine and certify vision test results. Color vision must be sufficient to recognize and distinguish traffic signals and devices showing the standard red, amber, and green colors. When corrective lenses are used to meet vision qualification requirements, the corrective lenses must be used while driving. A driver with monocular vision, who is otherwise medically qualified, may apply for a Federal vision exemption. You may certify the driver who meets vision qualification requirements, with or without the use of corrective lenses, for up to 2 years. Hearing To qualify, the driver must meet the hearing requirement of either the forced whisper test or the audiometric test in one ear. The driver who wears a hearing aid to meet the hearing qualification requirement must wear a hearing aid while driving. Blood Pressure/Pulse Record pulse rate and rhythm on the Medical Examination Report Form. The driver with stage 1 or stage 2 hypertension may be certified in accordance with the cardiovascular recommendations, which take into consideration known hypertension history. The dipstick urinalysis must measure specific Page 214 of 260 gravity and test for protein, blood, and glucose in the urine. Attach copies of additional test results and interpretation reports to the Medical Examination Report form. Medical Examination Report Form Page 3 Record the physical examination and certification status on the third page of the Medical Examination Report form. Physical Examinationthe physical examination should be as thorough as described in the Medical Examination Report form, at a minimum. Note any abnormal finding, including the safety implication, even if not disqualifying. Inform the driver of any abnormal findings and as needed advise the driver to obtain follow-up evaluation. Physical examination may indicate the need for additional evaluation and/or tests. Document the certification decision, including the rationale for any decision that does not concur with the recommendations. Certification and Documentation Certification Status Document the certification decision in the space provided for certification status. The driver who must wear corrective lenses, a hearing aid, or have a Skill Performance Evaluation certificate may be certified for up to 2 years when there are no other conditions that require periodic monitoring. Federal exemptions and some Federal Motor Carrier Safety Administration guidelines specify annual medical examinations. Certification and recertification occur only when the medical examiner determines that the driver is medically fit for duty in accordance with Federal qualification requirements for commercial drivers. The expiration date should be consistent with the Medical Examination Report form certification status and cannot exceed 2 years from the date of the examination. The certificate can be the original or a photocopy, and can be reduced in size (usually wallet-sized). The examiner may provide a copy to a prospective or current employing motor carrier who requests it. If the driver was certified as physically qualified, then the medical examiner should also retain the medical certificate as well for at least 3 years from the date the certificate was issued. Provisions of the vision exemption include an annual medical examination and an eye examination by an ophthalmologist or an optometrist. At the annual recertification examination, the driver should present the current vision exemption and a copy of the specialist eye examination report. The motor carrier is responsible for ensuring that the driver has the required documentation before driving a commercial vehicle. At the conclusion of that study, 2,656 drivers received a one time letter confirming participation in the study and granting a continued exemption from the monocular vision requirement, as long as the driver is otherwise medically fit for duty and can meet the vision qualification requirements with the one eye. The driver who was grandfathered must have an annual medical examination and an eye examination by an ophthalmologist or optometrist. At the annual medical examination, the driver should present to the medical examiner the letter identifying the driver as a participant in the vision study program and a copy of the specialist eye examination report. The Federal Diabetes Exemption Program is responsible for determining if the driver meets program requirements and for issuing the diabetes exemption. The driver must provide a quarterly evaluation checklist from his/her endocrinologist throughout the 2-year period or risk losing the exemption. Please direct questions concerning Driver Exemption Programs to medicalexemptions@dot. Although hypoglycemia can occur in non-insulin-treated diabetes mellitus, it is most often associated with insulin-treated diabetes mellitus. Mild hypoglycemia causes rapid heart rate, sweating, weakness, and hunger, while severe hypoglycemia causes headache and dizziness. The examination is based on information provided by the driver (minimum 5-year history), objective data (physical examination), and additional testing requested by the medical examiner. Key Points for Examination When the Driver Has Diabetes Mellitus and Uses Insulin this physical examination starts the Federal Diabetes Exemption Program application process. The driver must provide a 5 year medical history for your review before you determine certification status. You should ask about and document diabetes mellitus symptoms, blood glucose monitoring, insulin treatment, and history of hypoglycemic episodes. State-issued Medical Waivers and Exemptions It is important that as a medical examiner you distinguish between intrastate waivers/exemptions and Federal diabetes exemptions for insulin-treated diabetes mellitus. Follow-upthe driver should have at least biennial physical examinations or more frequently when indicated. All proposed changes to the medical standards are subject to public notice-and-comment rulemaking. Yes if: Annual Ultrasound to identify Asymptomatic; Ultrasound for change in change in size. Aneurysms of other Assess for risk of rupture No vessels and for associated cardiovascular diseases. Subvalvular Aortic Mild = favorable Yes if: Annual Stenosis Has potential for No valvular abnormality Evaluation by cardiologist progression. Yes if: Annual At least 3 months after Evaluation by cardiologist successful surgical knowledgeable in adult resection when cleared congenital heart disease by cardiologist required, including knowledgeable in echocardiogram. At least 3 months post Evaluation by cardiologist surgical intervention; knowledgeable in adult Cleared by cardiologist congenital heart disease knowledgeable in adult is recommended. Evaluation by cardiologist knowledgeable in congenital heart disease including echocardiogram. Symptoms of dyspnea, palpitations or a paradoxical embolus; Pulmonary hypertension; Right-to-left shunt; or Pulmonary to systemic flow ratio > 1. Yes if: Annual At least 3 months after Evaluation by cardiologist surgery or at least 4 knowledgeable in adult weeks after device congenital heart disease closure; asymptomatic every 2 years. Evaluation by cardiologist knowledgeable in adult congenital heart disease required including echocardiogram. Yes if: Annual At least 3 months after Evaluation by cardiologist surgical intervention if knowledgeable in adult none of the above congenital heart disease. Small shunt and Evaluation by cardiologist Prognosis depends on hemodynamically knowledgeable in adult size of atrial septal defect. No if: Symptoms of dyspnea, palpitations or a paradoxical embolus; Echo-Doppler examination demonstrating pulmonary artery pressure greater than 50% systemic; Echo Doppler examination demonstrating a right-to left shunt; A pulmonary to systemic flow ratio greater than 1. Yes if: Annual At least 3 months after Evaluation by cardiologist surgical intervention; knowledgeable in adult Hemodynamics are congenital heart disease, favorable; including Holter Monitor. Rest angina or change in (If test positive or Condition usually implies angina inconclusive, imaging at least one coronary pattern within 3 months of stress test may be artery has examination; indicated). Yes if: Annual At least 3 months after Should have evaluation surgery or 1 month after by cardiologist device closure; knowledgeable in adult None of above congenital heart disease. Coarctation of the Aorta Unfavorable prognosis Yes, if Annual after intervention with persistent risk of perfect repair (see text p. Yes if: Annual 3 months after surgical Recommend evaluation valvotomy or 1 month by cardiologist after balloon knowledgeable in adult valvuloplasty; congenital heart disease. None of above disqualifying criteria; Cleared by cardiologist knowledgeable in adult congenital heart disease. Other causes of right Double chambered right Yes if: Annual ventricular outflow ventricle. Hemodynamic data and Recommend evaluation obstruction in persons Infundibular pulmonary criteria similar to by cardiologist with congenital heart stenosis. Mild; Asymtomatic; Evaluation by cardiologist No intracardiac lesions; knowledgeable in adult No shunt; congenital heart disease. Yes if: Annual Asymptomatic and Evaluation by cardiologist excellent result obtained knowledgeable in adult from surgery (see text). After arterial switch No (Data currently not repair, prognosis appears sufficient to support favorable. Yes if: At least 3 months after Annual surgery; Evaluation by cardiologist None of above knowledgeable in adult disqualifying criteria; congenital heart disease. Prosthetic valve must meet requirements for that valve; Cleared by cardiologist knowledgeable in adult congenital heart disease. Stage 3 High risk for acute No (>180/110 mm Hg hypertension-related Immediately disqualifying; event. Secondary prevention Patient demonstrated to No have high risk for death and sudden incapacitation. Yes if: Annual At least 4 weeks post Annual evaluation by a percutaneous balloon cardiologist. Syncope survival prognosis but there is risk for syncope Yes if: Annual that may be due to 3 months* after Documented pacemaker cardioinhibitory (slowing pacemaker implantation; checks; heart rate) or Documented correct Absence of symptom vasodepressor (drop in function by pacemaker recurrence blood pressure) center; Absence of components, or both. Pacemaker will affect only cardioinhibitory component, but will lessen effect of vasodepressor component. Intermittent Claudication Most common presenting Yes if: Annual manifestation of occlusive At least 3 months arterial disease. Yes if: Annual At least 3 months after surgery; Relief of symptoms and signs; No other disqualifying cardiovascular disease. Atrial fibrillation as cause Risk for stroke decreased Yes if: Annual of or a risk for stroke by anticoagulation. Atrial fibrillation following Good prognosis and In atrial fibrillation at time Annual thoracic surgery duration usually limited. Isthmus ablation Annual performed and at least 1 month after procedure; Arrhythmia successfully treated; Cleared by electrophysiologist. Multifocal Atrial Often associated with Yes if: Annual Tachycardia comorbidities, such as lung disease, that may Asymptomatic; impair prognosis.
In helicopters diabetes oral signs purchase glucotrol xl 10 mg with visa, they use infrared cameras and other equipment that can detect cannabis by measuring the heat and reflective signature of the vegetation below diabetes test one touch cheap glucotrol xl 10 mg with visa. Cannabis has higher reflectivity at certain wavelengths than other rural crops blood glucose 68 fasting buy generic glucotrol xl on line, such as corn diabetes type 1 nclex questions cheap glucotrol xl 10mg on line. Law enforcement agencies have found that the use of this technology has become necessary in their detection efforts because many growers hide cannabis among other plants blood sugar after meal cheap glucotrol xl line, making detection with the naked eye difficult even from the air diabetes mellitus of any type cheap glucotrol xl 10 mg overnight delivery. It has been said that if the cannabis plant is planted by a pine or cedar tree the heat from the tree will overlap the cannabis plant heat making it harder to detect from helicopters. Cultivating Cannabis indoors traditionally has to do with growing the plants in a soil like medium and adding fertilizer when the plants are given water. Cultivating marijuana indoors is more complicated and expensive than growing outdoors, but it allows the cultivator 216 complete control over the growing environment. Cannabis grown outdoors can be just as potent as its indoor counterpart if tended to properly. Cultivating plants indoors can also be done through the use of hydroponics; however, this method is somewhat less common. In order to grow plants indoors, a growing medium (eg soil or growing substrate), water, nutrients, light and air need to be supplied to the plant. The optimum photo/dark-periods is specific depending on each plant (some prefer long days and short nights an others preferring the opposite, or something in between) Most plants will grow under most light spectra, yet always prefer a full spectrum light. However, certain plants (as cannabis) can be grown successfully under both types of light. High pressure sodium lamps trigger a greater flowering response in the plant and are thus used for the second (or reproductive) phase of the growth, or they are used by those people [21] who only wish to purchase 1 single lamp. If high pressure sodium lamps are used for the vegetative phase, plants will usually grow slightly more quickly, but will also have longer internodes, and may be taller. However, luminous efficiency is not applicable to plant growth since it is based on what wavelengths humans see best. A plant is, for example very sensitive to far red, while humans can barely see that wavelength. According to the inverse square law, the intensity of light radiating from a point source (in this case a bulb) is inversely proportional to the square of the distance from the source. This is a serious hurdle for indoor marijuana growers, and many techniques are employed to use light as efficiently as possible. Plants or lights are moved as close together as possible so that they receive equal lighting and that all light coming from the lamps wind up on the plants (rather than partly besides it). Some marijuana cultivators cover the walls of their grow room with some type of reflective material, or alternatively, white paint to maximise efficiency. The plastic is installed with the white side facing in to the room to reflect light, and the black facing the wall, to reduce fungus and mold growth. Another common covering is flat white paint, with a high titanium dioxide content to maximize reflectivity. It is also important to promote vigorous air circulation within the grow room, which is usually accomplished by mounting an extraction fan and one or more oscillating fans. Plants grown with supplemental carbon dioxide will grow more quickly, have larger stomata, and can utilize more light. Certain plants (eg most strains of cannabis) emit a distinctive odor during their reproductive phase. This presents difficulties to those who are cultivating in places where it is illegal. The most common way of eliminating odor is by pulling odorous air through a 219 carbon filter. Many cultivators simply attach a large carbon filter to their air extraction system, thereby filtering any smell before the air is expelled from the grow-room. Another way of eliminating odor is by installing an ozone generator in the extraction ducting. The air is forced past the ozone generator by the extraction fan, and the odorous air is neutralized as it mixes with the ozone; however the cultivator must ensure that the air is thoroughly mixed before it is expelled outside, lest some odor escape. Care must be taken to prevent excessive ozone concentrations in the garden itself, or where it might be inhaled by the grower or his/her family. Ozone itself has a distinctive smell and is harmful to living things, although the molecule breaks down quickly (20 minutes to an hour) in atmospheric conditions. So called grow ops (growing operations, often located in grow houses) are seen by many marijuana enthusiasts as a much cheaper way in which to gain a steady, higher quality supply of cannabis. On a larger scale they have proven a viable commercial venture, with some law enforcement agencies finding grow-ops large enough to yield several kilograms of marijuana. More expansive grow ops, however, are generally more susceptible to detection than smaller operations. Since individual grow light power generally ranges from 250 watts to in excess of 1000 watts and remains lit for a long time each day, differences in utility bill costs are a significant security issue. Growers frequently use carbon scrubbers in conjunction with ventilation in order to control odors. This typically involves forcing air from the grow room through a device containing activated carbon, before being vented outdoors. However, ozone can build up to levels that may be hazardous both for the grower and the plant. As a last resort, strong air fresheners are used to control smells as well as keeping windows firmly shut. This is a risky method, as the smell of air fresheners may often arouse suspicion by police officers. Checking outside to see if any smells are emanating from indoors is often a necessary precaution, as many growers become acclimated to the smell, and fail to realize just how pervasive the odor may be. Many store plants in more isolated areas such as a basement or attic to prevent smell detection. Another less common solution is to simply grow a strain which possesses a weaker odor. Storing plants and lights away from windows and areas which may be seen by visitors is also a common practice, as is keeping the entire grow op in an attic or basement. Some growers, finding this impractical, may cover their windows with light resistant materials. This can solve the problem of escaping bright light but may arouse suspicion amongst neighbours and local residents. Shoddy fixtures and sockets, improperly grounded equipment, and faulty circuit breakers are some of the most prevalent causes. Due to the large amount of electricity needed for large-scale cultivation, old or damaged wiring is prone to melt and short. Some commercial growers resort to power theft in order to hide electricity usage and many do not take precautions to ensure that their connections are safe. Many growers adapt light cycles so that the lights are on when they are home and off when they are away. Growers using fluorescent bulbs with reasonable air circulation do not have this problem. Word of mouth can of course be as much a threat to growers as any of the above issues. Often, a few sentences of conversation overheard can result in a tip off and thus speedy detection. It is for this reason that many growers are reticent to talk about their cultivation. Generally, ripeness is defined as when the white pistils start to turn dark yellow, orange, light to mid red, etc. These trichomes can range from completely clear (generally deemed underdeveloped), to amberish-red. Ideally, professionals will use a decent power magnifying glass, a brix meter (to measure "sugar" content), and a microscope. The potential seed pods swell with resins usually reserved for seed production, thus improving the quality of the buds (called colitas, Spanish for "little tails"), which will swell to form full "colas" (Spanish for "tails"). The latter cannabinoids are non-psychoactive; they contribute to the bouquet of the marijuana and modulate the overall nature of the high anywhere from purely psychedelic to purely sedative. Contrary to sinsemilla (bud production focused cultivation), seeds are harvested when fully developed and often after the accompanying buds have begun to deteriorate. In contrast, hemp grown for fiber is harvested before flowering, and cannabis grown for cloning is not flowered at all. This process can take from a few days to two weeks, depending on the size and density of the buds and the relative humidity of the air. Some believe flowers are hung by their stalks, allowing the internal fluids of the plant to remain in the flowers. Others believe the cut stem is simply a handy non sticky place from which to hang the plant. When the stems in the middle of the largest buds can be snapped easily, the plant is dry enough to be cured. Usually, the dried product is packed (not compressed) into glass canning jars which are airtight. Initially the product is checked periodically (every few hours) to make sure it was properly dried and has not remoistened itself. After several days, when the product is dried to satisfaction, the jars are sealed off and opened just once a week. For the same reasons as when drying, curing jars are stored in a cool, dark, place. The freshly cut buds are submersed in water for a period of 7 straight days, changing the water daily. When water curing, the water will flush out harmful chemicals (such as the ones used to feed the plants) as well as proteins, sugars, pigments, chlorophyll and some resins. Many believe the finished product is not as attractive as using a standard dry and cure > Tincture. Many smokers prefer to dip cigarettes in the mixture, which allows them to smoke in public without detection. After a harvest, there are typically many green leaves particularly large shade leaves which themselves cannot be smoked, but have collected over time many fallen trichomes. The liquid is then passed through a succession of bags with decreasing screen sizes which capture the trichromes, which are then pressed into shape and let dry. The result is called bubble hash, due to the bubbling which occurs when it is heated for smoking. This bubbling is due to its purity, as adulterants tend to cause hash not to bubble. If these need to be treated with chemicals only pesticides and insecticides which are safe to use on food crops should be used. Popular and safe pesticides include: Pyrethrins: Organic and very effective, although sometimes hard to find and expensive due to high production cost. Indoor growers also have problems with pests, usually caused by the grower or a pet bringing them in from the outdoors. If caught too late, eradication of many destructive insect species indoors may be impossible until all infected plants are removed from the space and sterilization methods employed. These methods include: using a water or air based growth medium (known as hydroponics and aeroponics respectively). Research into the production of cannabis for the drug Marinol and other more profitable and marketable forms of cannabis based medicines has further pushed the envelope of cannabis cultivation in all forms of laboratory, both public and private. The internet in particular has brought together widely diverse genetics from around the world through trading and purchasing. In this technique, which is often grown in hydroponic media, only the colas of the plants are harvested. Containers are used to enforce the geometric distribution of flowers and plant material, as well as their exposure to lighting and atmosphere. Sea of green is popular with commercial cultivators, as it minimizes the amount of time a plant spends in vegetative stage, and allows very efficient light distribution, keeping the plants much closer to the lights than when grown to full size. However, the individual plants grown with this method typically give smaller yields than those grown with other methods. Medical growers may find this a helpful technique to maximize harvest if they are only allowed a certain number of plants. A screen such as chicken wire is hung over plants so that the tips of branches are kept at the same level. Once the flowering stage is initiated, the flower tips will reach through the wire and all be at relatively equal distances from the light source. This is beneficial because it produces more by getting light where the plant needs it. Vegetative State:the plant should remain in the vegetative state until 70 to 80 percent of the net is full As a branch reaches three to four inches above the wire it is pulled back under the wire and so trained to grow vertically until flowering. Due to the amount of plant required to fill the net, the vegetative period may require longer than normal to be ready for flowering. Knowing how a plant grows can help to visualize when to flower for maximum effect. In general, it consists of a non-soil medium which is exposed to a nutrient and water flow.
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References
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