By: John E. Bennett, MD, MACP
Note: You do not need to antibiotic resistance mechanisms buy macrolid 150 mg with visa preauthorize treatment for mental health and substance use disorder services rendered outside of the United States antibiotics for uti cephalexin buy line macrolid. Note: You do not need to antibiotics vs virus cheap 150mg macrolid overnight delivery preauthorize treatment when Medicare covers your services antibiotic during pregnancy macrolid 150mg otc. Where to file claims Claims should be submitted to: OptumHealth Behavioral Solutions P. Prescription Drug Benefits Important things to keep in mind about these benefits: · We cover prescribed medications and supplies as described in the chart beginning on page 83. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice. You may fill the prescription at a network pharmacy, a non-network pharmacy, or by mail. Formularies are developed by an independent panel of doctors and pharmacists who ensure medications are clinically appropriate and cost effective. If your physician believes a brand name drug is necessary, or if there is no generic available, ask your physician to prescribe a formulary brand name drug from this list. Your out-of-pocket costs will be higher for non-formulary drugs that are not on the list. If you purchase more than two fills of a maintenance medication at a network pharmacy without prior Plan authorization you will need to file a paper claim to receive reimbursement at 55% of the Plan allowance. Network retail pharmacy limitations are waived when you have Medicare Part D as your primary payor and they cover the drug. You may obtain up to a 30-day fill and unlimited refills for each prescription purchased at a non-network retail pharmacy. Our benefit includes the Advanced Control Specialty Formulary that includes a step therapy program and uses evidence-based protocols that require the use of a preferred drug(s) before non-preferred specialty drugs are covered. The Advanced Control Specialty Formulary is designed as a specialty drug formulary that includes generics and clinically effective brands as determined through clinical evidence. The therapy classes chosen for Advanced Control Specialty Formulary have multiple specialty drugs available that are considered therapeutically equivalent (similar safety and efficacy), thus providing the opportunity to utilize the lowest cost drug(s). In addition, categories, therapies and tiering changes could be updated every quarter and added to the formulary. When specialty medication is purchased with a third party copayment assistance coupon, rebate, or card, the Plan will not apply the amount of the discount towards your out-of-pocket maximum. If you receive a brand name drug when a federally-approved generic drug is available, and your physician has not specified "Dispense as Written" for the brand name drug, you have to pay the difference in cost between the brand name drug and the generic. Under federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness. If you purchase prescriptions at a non-network pharmacy, foreign/overseas pharmacy, or elect to purchase additional 30-day refills at a network pharmacy, complete the short-term prescription claim form. After the primary carrier has processed the claim and made a payment, we will pay as secondary up to our Plan limit. Note: We will waive the one 30-day fill and one refill limitation at retail for patients confined to a nursing home, patients who are in the process of having their medication regulated, or when state law prohibits the medication from being dispensed in a quantity greater than 30 days. Note: If the cost of a prescription is less than the mail order copayment amount, you will pay the cost of the prescription. Note: Some specialty medications may qualify for third party copayment assistance programs which could lower your out-ofpocket costs for those medications. Wellness and Other Special Features for information on the Enhanced CaremarkDirect Retail Program where you may obtain non-covered medications at a discounted rate. The following drugs and supplements are covered without costshare, even if over-the-counter, when prescribed by a health care professional and filled at a network pharmacy. Your Costs for Covered Services, for valuable information about how cost-sharing What is an accidental dental injury? An accidental dental injury to a sound natural tooth is an injury caused by an external force or element such as a blow or fall that requires immediate attention. A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, prosthetic or porcelain restoration, or treated by endodontics, or tooth implant is not considered a sound, natural tooth. We provide benefits for services, supplies, or appliances (such as space maintainers) for dental care necessary to repair injury to sound natural teeth (as defined above) required as a result of, and directly related to, an accidental injury. Wellness and Other Special Features Special feature 24-hour help line for mental health and substance use disorder 24-hour Health Information Line Description You may call 877-468-1016, 24 hours a day, 7 days a week, to access in-person support for a wide range of concerns, including depression, eating disorders, coping with grief and loss, alcohol or drug dependency, physical abuse and managing stress. This nurse line seeks to influence consumer behavior by providing tools, education, counseling and support to help members make decisions with respect to their health and use of healthcare services. Consumers may contact a CareAllies registered nurse at any time of the day or night, for: · Answers to questions about medical conditions, diagnostic tests or treatments prescribed by their physicians, or other health or wellness topics · Assistance to determine the appropriate level of healthcare services (emergency room, doctor visit, self care, etc. You can access numerous articles on food, nutrition, exercise and fitness specifically geared for children of all ages. Diabetes care management program Transform Diabetes Care Disease management program - Gaps in Care this program helps deliver better overall care and lower costs for members with diabetes. Members and their physicians are informed by mail of potential gaps and are instructed on how to improve adherence to existing therapies. Some examples of conditions that are managed through the program are: diabetes, hypertension, and cardiac disorders. Enhanced CaremarkDirect Retail is a value-added program that provides you with safe, convenient access to competitively priced, non-covered prescriptions, and certain over-thecounter drugs. Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services. Your Health Assessment profile provides information to put you on a path to good physical and mental health. Copayment waivers will be applied to claims for services rendered after completion of the Health Assessment; or - A wearable activity tracking device. Copayment waivers will be applied to claims for services rendered after completion of the Health Assessment; or - A wearable activity tracking device (limit 2 devices per enrollment). Note: You must be 18 years or older to be eligible to complete the Health Assessment. Individuals age 13 and older can access other services offered by CareAllies/Cigna. CignaPlus Savings is a discount dental program that provides members access to discounted fees with participating dental providers. Healthy Pregnancies, Healthy Babies Program this is a voluntary program for all expectant mothers. You will receive educational information and support throughout your entire pregnancy and after. You will speak to a pregnancy specialist and receive unlimited coaching calls to provide you with caring support to optimize your chances of having a healthy, full-term pregnancy. Healthy Pregnancies, Healthy Babies will work together with you and your doctor to develop a plan of care. Call 877-220-6252 to enroll in the Healthy Pregnancies, Healthy Babies program as soon as you know you are pregnant. You will receive discounts on weight management and nutrition services, fitness clubs, vision and hearing care, and healthy lifestyle products. Our Personal Health Record allows you to create and maintain a complete, comprehensive, and confidential medical record containing information on allergies, immunizations, medical providers, medications, past medical procedures, and more. You must call 877-468-1016, 24 hours a day, 7 days a week, to access the services of Solutions for Caregivers. You may also access educational resources and discounted products and services anytime online at Better treatment outcomes occur when you have a clear individualized treatment plan within your community. Virtual visits can be used for adults or children with minor acute, non-emergency medical conditions such as flu, sinus problems, allergies, abrasions or minor wounds. Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals. Make sure that you review the benefits that are available under the benefit option in which you are enrolled. Please read the Important things you should keep in mind about these benefits at the beginning of each subsection. The covered services include office visits/exams, immunizations and screenings and are fully described in Section 5.
Antimicrobial Activity of Crude Extracts from Plant Parts and Corresponding Calli of Bixa orellana L holistic antibiotics for sinus infection order macrolid toronto. Hagiwara A antibiotics for sinus infection and drinking cheap 150mg macrolid amex, Imai N antibiotics acne pills cheap macrolid 150 mg with visa, Ichihara T xeroform antimicrobial cheap macrolid online amex, Sano M, Tamano S, Aoki H, Yasuhara K, Koda T, Nakamura M, Shirai T. A thirteen-week oral toxicity study of annatto extract (norbixin), a natural food color extracted from the seed coat of annatto (Bixa orellana L. Hypersensitivity reactions to food colours with special reference to the natural colour annatto extract (butter colour). Extraction of an hyperglycaemic principle from the annatto (Bixa orellana), a medicinal plant in the West Indies. A preliminary study of the effects of some West Indian medicinal plants on blood sugar levels in the dog. Screening for antimicrobial activity of ten medicinal plants used in Colombia folkloric medicine: a possible alternative in the treatment of non-nosocomial infections. Note: Although the first species indicated above is most commonly used by Dominicans, the Spanish name palo de brasil can refer to more than one botanical tree species, most of which have similar orangish-reddish heartwood. These species, along with their distinguishing characteristics, are as follows: Caesalpinia violacea (Miller) Standley [Synonyms: Brasilettia violacea (Miller) Britton & Rose, Caesalpinia cubensis Greenman, Peltophorum brasiliense (L. To prepare a cold infusion, a small piece of wood (palo) is immersed in lukewarm or room temperature water until the water turns red which indicates that the infusion is ready. This remedy is kept in a closed container in the refrigerator to prevent spoilage. Traditional Uses: this tree is renowned for its depurative (blood purifying) properties. The wood is nearly without odor, has a slightly sweet taste and imparts red color to water if used to make a cold infusion or tea; it also turns saliva red if chewed. Wood is orangish to dark red in the center and valued for its hard, durable lumber. Leaves occur in an alternate pattern along branches and are twice-divided with 4-10 pinnae and 12-16 leaflets; leaflets are elliptical or oval in shape (2-3 cm). Flowers are arranged in small, branching clusters; petals are greenish-white and covered with glandular dots. Fruits are long, narrow, leguminous seed pods (7-8 cm long) that are pointed at the end and contain dark seeds (Liogier 1985). Distribution: Endemic to the island of Hispaniola, this tree can be found in dry forest areas (Liogier 1985). Antitumor activity and antioxidant status of Caesalpinia bonducella against Ehrlich ascites carcinoma in Swiss albino mice. Cassane- and norcassane-type diterpenes from Caesalpinia crista of Indonesia and their antimalarial activity against the growth of Plasmodium falciparum. Antibacterial activity of crude extracts from Mexican medicinal plants and purified coumarins and xanthones. Note: the common name Bruja may also be used for another species, Kalanchoe gastonis-bonnieri; see entry for Mala madre. One distinguishing feature for differentiating between these two species is that the leaves of Bruja are slightly shorter than those of Mala madre. Traditional Preparation: For external application, the leaves are heated, crushed and applied topically to the affected area. Traditional Uses: the leaves of this plant are best known as a remedy for treating earache (mal de oido or dolor de los oidos), but they are also used for treating several other illnesses. For earache, a fresh leaf is used with all appendages removed (the kidney-like flowers and fruits are said to be harmful to the body), plunged into boiling water or heated over a flame briefly to steam or wilt (marear) the leaf, (care is taken 183 to avoid boiling/heating it for too long so that it will not lose its therapeutic qualities) and then the liquid inside the leaf is squeezed onto a cloth or small cotton-tipped swab that is placed inside the ear and kept there for a short period of time. Eventually the ear will release some water indicating that the ear has been sufficiently treated. For stomach ache, abdominal pain and gastroduodenal ulcers (including bleeding ulcers), the fresh leaves (with flowers and fruits removed) are eaten like a salad in the morning and at night. For headache or sinusitis, the fresh leaves are bruised and applied topically to the forehead. Some say that this plant is called "bruja" because it grows so prodigiously, even if only a single leaf is planted, as long as it finds enough soil. Its other name, "tope-tope" is attributed to the sound that its balloon-like fruits and flowers make when they squeezed until they explode, resulting in a small popping sound. As this is a succulent plant, its leaves do not air-dry like those of other plants, making storage difficult. Because they decompose easily once cut, the leaves are challenging to maintain which affects their availability at stores. However, some individuals who use this plant as a remedy grow it at home because it is a hardy houseplant. Leaves are thick and fleshy, grow in opposite pairs and can be either simple or deeply lobed (6-13 cm long), oblong to lance-shaped with scalloped, reddish edges. Flowers are slightly balloonshaped, hanging down in large branching clusters with petals ranging in color from reddish green to red to salmon. Distribution: this plant is native to Madagascar, grows in the Caribbean and is cultivated and naturalized throughout the neotropics, often growing in disturbed areas (Acevedo-Rodrнguez 1996). Animal Toxicity Studies: Kalanchoe pinnata orally administered to mice for 30 days did not show signs of toxicity to the liver, heart or kidney. Biologically active compounds in this plant include: acetic acid, alpha-amyrin, beta-amyrin, betasitosterol, bryophyllin, caffeic acid, citric acid, ferulic acid, friedelin, fumaric acid, isocitric acid, kaempferol, lactic acid, malic acid, mucilage, n-hentriacontane, oxalic acid, p-coumaric acid, p-hydroxy- 184 benzoic acid, p-hydroxycinnamic acid, patuletin, quercetin, succinic acid, syringic acid and taraxerol (Duke & Breckstrom-Sternberg 1998). Clinical Data: Kalanchoe pinnata Activity/Effect Antileishmanial Preparation Leaf extract, given orally; 30 g fresh leaves/day for 14 days Design & Model Clinical case report: one human patient (36 yrs) with active skin leishmaniasis lesions Results Treatment halted growth & showed a slight decrease in lesion; no observed adverse reactions or toxicity Reference Torres-Santos et al. Isolation and chemical analysis of a fatty acid fraction of Kalanchoe pinnata with a potent lymphocyte suppressive activity. The anti-leishmanial effect of Kalanchoe is mediated by nitric oxide intermediates. The antileishmanial activity assessment of unusual flavonoids from Kalanchoe pinnata. Toxicological analysis and effectiveness of oral Kalanchoe pinnata on a human case of cutaneous leishmaniasis. Traditional Preparation: the seeds are pulverized and prepared as a decoction to make hot chocolate and taken orally. Traditional Uses: In the Dominican Republic, the leaves are used for kidney and urinary tract disorders due to their diuretic effects (Liogier 2000). Flowers are borne in clusters on short stalks with white, greenish or pale violet petals and no fragrance. Fruits are fleshy, variable in size and shape (10-20 cm long) and generally resemble a small, narrow football with longitudinal grooves or creases; skin turns bright yellow-orange to reddish when ripe. No negative side effects or health risks are known in association with the appropriate therapeutic use of this plant, except for the possibility of allergic reaction or the provocation of migraine headaches due to amine content. Large doses of the seeds can result in constipation due to their high tannin content. The acute lethal dosage of caffeine for humans is 5-10 g, and powdered seeds of cacao contain 5 mg caffeine and 250 mg theobromine per cup (Germosйn-Robineau 2005). Animal Toxicity Studies: Several studies on the potential toxicity of this plant have been conducted. Isolated xanthines, some of the key constituents of cacao (such as caffeine, theobromine and theophylline), have in rare cases led to fatal intoxication when ingested (Germosйn-Robineau 2005). Contraindications: In individuals with a history of allergy or hypersensitivity to cacao seeds, caution is advised due to demonstrated potential for skin reactions, headache and migraine. May also be contraindicated in patients with heart disorders due to the cardiac stimulant effects of the seed constituents theobromine and caffeine (Brinker 1998). Drug Interactions: Phenelzine (monoamine oxidase inhibitor): concomitant use may lead to high blood pressure, although this association is speculative (Brinker 1998). These drugs include: oral contraceptives, cimetidine, furafylline, verapamil, disulfiram, fluconoazole, mexiletine, phenylpropanolamine, numerous quinolone antibiotics. The seeds, seed extracts and/or isolated compounds of this plant have demonstrated the following biological activities in preclinical studies: antibacterial, antioxidant, antiulcer, endocrine and nervous system effects, erythropoiesis stimulation and immunomodulatory (see "Laboratory and Preclinical Data" table below). The mechanism of the antiulcer effects of this plant is linked to its ability to modulate leukocyte function in addition to radical scavenging activity (Osakabe et al.
Purchase macrolid 150mg free shipping. Protecting Patients: Innovating to Combat Antibiotic Resistance.
Effect of pneumonia case management on mortality in neonates antibiotic resistance database purchase macrolid without prescription, infants antibiotics immune system purchase macrolid 150mg on line, and preschool children: a meta-analysis of communitybased trials antibiotic list order macrolid from india. Review how to virus definition biology order macrolid discount perform and interpret basic anthropometric measurements in children. When growth problems are found, the health care provider should attempt to identify and treat the underlying cause of the problem. Further studies are needed to clarify the reasons for the inconsistencies seen between these populations. Accurate measurements of weight, length/height, and head circumference are essential parts of the health evaluation of growing children. However, a recent meta-analysis of 14 separate studies concluded that treatment with antiretroviral regimens during pregnancy is not associated with an overall increased risk of premature delivery. Asymptomatic infected children have growth patterns that are similar to those of mildly or moderately symptomatic children. However, children with severe illness tend to have significantly poorer growth, and high viral loads have been clearly associated with decreased growth. Those children who do not develop symptoms and who survive past 5 years of age are slow progressors. Studies in Thailand, Rwanda, and the United States suggest that growth failure can signal rapid disease progression. In resource-limited environments, where obtaining laboratory data is sometimes not possible, growth monitoring may be the best available tool for assessing risk of disease progression. A child is said to be failing to thrive when he or she loses weight or fails to gain weight at a normal rate for a child of that age. Growth deceleration can occur as early as the first few months of life, though some children have normal growth for many years. When people have low bone density for their age, they are said to have osteopenia. Children who fail to form bone normally are at high risk of developing early osteoporosis and suffering from fractures during adulthood. The virus also elevates levels of Puberty several cytokines (interleukin 1, interleukin 6, and tumor Delay of sexual maturation is common among children necrosis factor) that contribute to increased activity with chronic diseases. Vitamin D delays both in the age of onset of puberty and in their deficiency also contributes to abnormal bone metabolism progression through the pubertal stages (Table 1 and and has been reported more frequently in patients with Table 2). Female pubertal (Tanner) staging later in life because of their early Normal development of osteopenia and Age Pubic Hair Other Significant Stage Range (yrs) Breast Growth Growth Changes osteoporosis. The appearance of bones on plain X rays can provide qualitative evidence for the existence of osteopenia or osteoporosis. Children Stage Range (yrs) Testis Growth Growth with increased immune I 015 Preadolescent testes Preadolescent system dysfunction (<2. Head circumference should also be monitored in children who are younger than 2 years. Adult distribution (medial aspect of thighs and linea alba) Measuring Weight When weighing young children, consider these basic guidelines to ensure accuracy: · Use the same scale at each visit. Another option is tared weighing, where the caregiver is weighed, the scale is tared (or "zeroed"), and then the undressed child is held by the caregiver, capturing the weight of the child only. When measuring length and height, consider these basic guidelines to ensure accuracy: · Measure the length of children aged 0-2 years when they are lying down with a length board, with back flat, knees straight, and ankles in neutral position. Measuring Head Circumference When measuring head circumference, consider these basic guidelines to ensure accuracy: · Head circumference should be routinely checked for the first 24 months of life by using a nonstretchable tape (usually plastic coated or metallic) and recorded to the nearest 0. Once measurements have been plotted, the resulting growth curve makes it easy to determine whether the child is experiencing growth failure. Though his weight is recovering quickly, his height will lag behind, and he is likely to remained stunted, with a lower than average adult height. Plotting Measurements on Growth Charts Once weight and height (or length) are measured, they should be plotted and interpreted using a standard growth chart. These growth charts depict age on the horizontal axis and weight, height, or head circumference on the vertical axis. Weight should be checked each visit and height checked every 3 months throughout childhood. Head circumference should be plotted at least every 3 months until 24 months of age and more frequently during the first 6 months of life. The weight-for-height ratio is a growth indicator that relates weight to length (for children <2 years) or height (for children 2 years). Health care providers should therefore aim to identify poor growth early before stunting occurs. A variety of different criteria exist to aid in the timely diagnosis of clinically significant poor growth. Three criteria that are commonly used to indicate a growth abnormality are · Weight loss of 10% or more of body weight · Deceleration in weight gain resulting in a downward crossing of two or more of the percentile lines for age. The nutrition chapter discusses other clinical signs of malnutrition in more detail. Persistent weight loss not explained by poor or inadequate feeding or other infections and not adequately responding in 2 weeks to standard therapy. To ensure adequate intake, give children with poor growth counseling regarding adequate intake of high-energy and nutrient-rich foods. Longitudinal changes of bone mineral density and metabolism in antiretroviral treated human immunodeficiency virus-infected children. Natural history of somatic growth in infants born to women infected by human immunodeficiency virus. Maternal antiretroviral drugs during pregnancy and infant low birth weight and preterm birth. Treatment with highly active antiretroviral therapy in human immunodeficiency virus type 1-infected children is associated with a sustained effect on growth. Management of Severe Malnutrition: Manual for Physicians and Other Senior Health Care Workers. Adult immune systems respond when exposed to a disease-causing antigen because of previous exposure to the antigen, either through vaccination or through acquisition of the infection. An unimmunized child who has never been exposed to the disease-causing antigen is reacting for the first time. Patients who have been severely immunosuppressed but have had immune reconstitution with highly active antiretroviral therapy can also usually respond to immunizations. The possibility of transient increases in viral load is not a contraindication for immunization. This can be done either as part of a routine schedule or in an immunization campaign. The best sites for injection are dorsogluteal and the lateral aspect of the upper arm, but in many countries the location is standardized. Attention should be given to how high on the upper arm one should give the injection. This improves slowly and is followed by a local lesion that may ulcerate 6-8 weeks later. The reactions usually consist of localized redness and swelling, which can last a few weeks to several months. Poor injection technique, such as giving the injection too deep, can cause the formation of large abscesses. In addition to the development of subcutaneous abscesses, regional lymphadenitis may also develop. Parents should be instructed to return to the clinic if the child has a fever of more than 39. Hepatitis A Vaccine In the United States the hepatitis A vaccine is recommended for all children at 1 year and is given in a twodose series, with the second dose being given 6-12 months after the first dose. There are both pediatric and adult formulations of the vaccine, and they differ in the dose of the hepatitis A antigen used. As with other vaccines, however, patients with severe immunosuppression may have a suboptimal response. The hepatitis A vaccines are given intramuscularly, with the deltoid muscle being the preferred site of administration. The pediatric and adult forms vary based upon the amount antigen in the vaccine as well as the amount injected.
Arch Structure Arch structures are particularly suited to antibiotics for uti female discount 150mg macrolid fast delivery applications in which large antimicrobial essential oils list buy 150 mg macrolid otc, unobstructed areas are needed antibiotics for dogs for diarrhea cheap macrolid 150mg with mastercard, such as churches antibiotic curam 625mg buy discount macrolid line, recreational buildings, and aircraft hangars. Many arch forms are possible with the variety limited only by the imagination of the architect. Churches have used arches from the beginning of glulam manufacture in the United States. Dome Radial-rib domes consist of curved members extending from the base ring (tension ring) to a compression ring at the top of the dome along with other ring members at various elevations between the tension and compression rings. If they are curved to the same radius as the rib and have their centers at the center of the sphere, the dome will have a spherical surface. Connections between the ribs and the ring members are critical because of the high compressive loads in the ring members. During construction, care must be taken to stabilize the structure because the dome has a tendency to rotate about the central vertical axis. Their geometries are quite complex, and specialized computer programs are used in their design. Log Stringer A simple bridge type that has been used for centuries consists of one or more logs used to span the opening. The log stringer bridge has been used to access logging areas and is advantageous when adequate-sized logs are available and the bridge is needed for only a short time. Unless built with a durable species, the life span of log stringer bridges is usually limited to less than 10 years. The following sections provide a brief description of the design considerations for these factors. Structural the structural design of any building consists of combining the prescribed performance requirements with the anticipated loading. The probability that the building will ever collapse is minimized using material property information recommended by the material manufacturers along with code-recommended design loads. These requirements are directed at ensuring that the structure is functional, and the most notable one is that deformations are limited. It is important to limit deformations so that floors are not too "bouncy" or that doors do not bind under certain loadings. Building codes often include recommended limits on deformation, but the designer may be provided some latitude in selecting the limits. Glulam beam bridge over the Dangerous River, near Yukatat, Alaska, consists of three 43. Even though the span is usually limited to about 9 m (30 ft) because of the limited size of lumber available, this span length entails the majority of timber bridges in the United States. Several timbers can be used to span the opening, and a transverse lumber deck can be placed over them to form a stringer and deck bridge. Lumber can be placed (on-edge) side-by-side and used to span the entire opening, forming a longitudinal deck bridge. The lumber can be fastened together with nails or large spikes in partial-width panelized bridge systems or compressed together with high-strength tension rods to form a "stress-laminated" slab-type deck. Wood frame construction is well-suited to application of both cavity insulation and surface-applied insulation. The most common materials used for cavity insulation are glass fiber, mineral fiber, cellulose insulation, and spray-applied foams. For surface applications, a wide variety of sheathing insulations exist, such as rigid foam panels. Insulating sheathing placed on exterior walls may also have sufficient structural properties to provide required lateral bracing. Prefinished insulating paneling can be used as an inside finish on exterior walls or one or both sides of the interior partitions. Attic construction with conventional rafters and ceiling joists or roof trusses can be insulated between framing members with batt, blanket, or loose-fill insulation. In some warm climates, radiant barriers and reflective insulations can provide an additional reduction in cooling loads. Department of Energy (1991) provides information on climatic areas that are best suited for radiant barrier applications. This document also provides comparative information on Glulam Structural glued-laminated (glulam) timber greatly extends the span capabilities of the same types of bridges described in the previous paragraph. Using glulam panels to span the opening results in a longitudinal deck system, but this is usually limited to about 9-m (30-ft) spans. These panels are either interconnected or supported at one or more locations with transverse distributor beams. Glulam beams can be used to form a solid deck and are held together with high-stress tension rods to form a stress-laminated slab-type deck. Curved glulam members can be used to produce various aesthetic effects and long-span bridges. Water may therefore be expected to move between categories over time, blurring the distinctions between categories. Christian (1994) provides quantitative estimates of potential moisture loads from various sources. Moisture accumulation within a building or within parts of a building can affect human comfort and health, influence building durability, and necessitate maintenance and repair activities (or can require that these activities be undertaken more frequently). Examples include: (a) mold and mildew, (b) decay of wood-based materials, (c) corrosion of metals, (d) damage caused by expansion of materials from moisture (such as buckling of wood floors), and (e) decline in visual appearance (such as paint peeling, distortion of wood-based siding, or efflorescence on masonry surfaces). Some problems associated with moisture accumulation may not be readily apparent but are nonetheless real; an example is reduced performance of insulated assemblies (resulting in increased energy consumption). Mold, Mildew, Dust Mites, and Human Health Mold and mildew in buildings are offensive, and the spores can cause respiratory problems and allergic reactions in humans. Mold and mildew will grow on most surfaces if the relative humidity at the surface is above a critical value and the surface temperatures are conducive to growth. The longer the surface remains above this critical relative humidity level, the more likely mold will appear; the higher the humidity or temperature, the shorter the time needed for germination. The surface relative humidity is a complex function of material moisture content, material properties, local temperature, and humidity conditions. Mildew and mold can usually be avoided by limiting surface relative humidity conditions >80% to short periods. Only for nonporous surfaces that are regularly cleaned should this criterion be relaxed. Moisture accumulation at temperatures below 4 °C (40 °F) may not cause mold and mildew if the material is allowed to dry out below the critical moisture content before the temperature increases above 4 °C (40 °F). They thrive at high relative humidity levels (>70%) at room temperature, but will not survive at sustained relative humidity levels less than 50%. However, these relative humidity levels relate to local conditions in the typical places that mites tend to inhabit (for example, mattresses, carpets, soft furniture). The Alton Sylor Memorial Bridge is a glulam deck arch bridge crossing Joncy Gorge in Angelica, New York. The center three-hinged arch spans 52 m (171 ft) and is the longest clear span in the United States. Existing frame construction can be insulated pneumatically using suitable loose-fill insulating material. When loose-fill materials are used in wall retrofit applications, extra care must be taken during the installation to eliminate the existence of voids within the wall cavity. All cavities should be checked prior to installation for obstructions, such as fire stop headers and wiring, that would prevent the cavity from being completely filled. Accessible space can be insulated by manual placement of batt, blanket, or loose-fill material. In addition to being properly insulated, the exterior envelope of all buildings should be constructed to minimize air flow into or through the building envelope. Air flow can degrade the thermal performance of insulation and cause excessive moisture accumulation in the building envelope. Moisture Control Moisture sources for buildings can be broadly classified as follows: (1) surface runoff of precipitation from land areas, (2) ground water or wet soil, (3) precipitation or irrigation water that falls on the building, (4) indoor humidity, (5) outdoor humidity, (6) moisture from use of wet building materials or construction under wet conditions, and (7) errors, accidents, and maintenance problems associated with indoor plumbing.