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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Radiation Changes to Bone

There are two main reasons that bones receive radiotherapy: 1) an intentional delivery to bones to treat painful metastatic bone lesions or 2) their unavoidable inclusion into a radiation field which intends to treat an adjacent soft tissue neoplasm. In either case, the effects on the bone are varied and depend upon:

 * 1) Dosage.
 * 2) Quality of the x-ray beam.
 * 3) Age of the patient.
 * 4) Method of fractionation (fractionating treatment enables the physician to give the patient the necessary treatment dose while separating its delivery by a time interval in order to reduce toxic side effects to normal tissue).
 * 5) Length of time of therapy.
 * 6) Specific bone or bones involved.
 * 7) Existence of trauma or infection at the site.

The main effects on the bone include: disruption of normal growth and maturation, scoliosis, osteonecrosis, and neoplasm formation.

Growth Arrest and Disturbances
Growth arrest, in general, is believed to be caused by a combination of cellular injury to chondrocytes  and damage to the physeal blood vessels. The epiphysis is the most sensitive area to radiation and it has been shown that delivery of a total of 20 Gy to immature bone can cause growth disturbance. Radiotherapy can also increase the risk for epiphyseal plate trauma such as slipped capital femoral epiphysis.

Radiation delivered to the metaphysis can cause bowing, fraying and sclerosis and look similar to rickets.

The diaphysis is thought to be relatively more radioresistant and periosteal bone formation may be less affected than enchondral bone formation. Nevertheless, when an entire bone is exposed to radiation, it will demonstrate narrowing of the shaft and an overall reduction in size and diameter.

Fig. 1 Hypoplastic pelvis and lumbar scoliosis in a patient who received radiotherapy as a child.

Scoliosis
As with bone growth abnormalities in other areas of the body, the reason for radiation induced scoliosis are multifold. In general, scoliosis induced by radiotherapy is thought to be mild and non progressive. It affects the growing spine more severely than mature spine. Children who are treated before the age of 2 show the largest degree of abnormality. Uneven growth arrest, leading to curvature, was initially thought to be due to "fall off" at the edge of the x-ray beam and some investigators believed that irradiating the entire vertebral body equally would prevent scoliosis from developing. This has not shown to be true, although asymmetric radiation is associated with more severe and more frequent deformities. Changes can occur with doses of 10 Gy and higher and generally occur 9 to 12 months after treatment.

Osteonecrosis
In a mature skeleton, "growth damage"  manifests as osteonecrosis. Radiation necrosis is dose-dependent, with "radiation osteitis" seen at around 30 Gy and osteoradionecrosis associated with doses of 50 Gy or higher. Radiation osteitis is a term used to describe potentially reversible changes such as temporary cessation of growth, periostitis, bone sclerosis and increased fragility, ischemic necrosis and infection. Radiographs will show bone which is mottled demonstrating both osteopenia and sclerosis and areas of coarse trabeculation. Some investigators and clinicians believe that radiation osteitis is the set-up for osteoradionecrosis and that a patient does not progress to necrosis unless infection is present.

Others favor a "cell death" theory. Recent evidence suggests that radiation induces osteoblasts to enter G2 cell cycle arrest and sensitizes them to agents which mediate their apoptosis. Radiation induced vascular injury is also a likely culprit to the development of radiation osteitis and osteonecrosis. Its role, however, is debated.

Changes are seen at different time intervals depending on which bone is irradiated. There are several bones which have characteristic complications which are listed below.

Mandible
Frequently the changes are seen within a year of treatment. It is a more superficial bone, and therefore it inadvertently receives a larger dose during treatment of head and neck neoplasms. One of the major concerns with osteoradionecrosis of the mandible is that can be very difficult to differentiate it from tumor recurrence. Pain, ulceration, and bleeding can be present, but do little to determine the diagnosis as these symptoms are common to both entities.

Pelvis
Avascular necrosis of the femoral head can, of course, be seen. In 2% of patients, fractures of the femoral head occur. Protrusio acetabuli is also a reported complication. Femoral neck fractures have been seen as early as 5 months after therapy and with as little as 16 Gy of radiation given. The fractures generally heal with normal callous formation. The SI joints may also be effected showing bilateral, symmetric sclerosis.

Shoulder
Frequently in the treatment of breast carcinoma, the shoulder receives radiation. This can induce osteopenia and/or a coarse and disorganized pattern of trabeculation which looks like Paget's disease. Rib, clavicular and scapular fractures are seen. In some cases, there can be avascular necrosis of the humeral head.

Sternum
Pectus excavatum can develop. Other complications include osteopenia, disorganized trabecular pattern, and necrosis involving one or more sternal segments.

Radiation-induced neoplasms
Radiation-induced tumors in patients who receive radiotherapy before 2 years of age are usually benign. The most commonly reported tumor in this group of patients is osteochondroma, and are thought to be induced with doses ranging from 16-64 Gy.

In patients who received radiotherapy during adulthood, induced tumors are more likely to be malignant. Osteosarcoma and fibrosarcoma are generally considered to be the most common radiation-induced tumors in this population. Chondrosarcoma and malignant fibrous histiocytoma are also seen. Specific criteria aid in diagnosing a radiation-induced sarcoma and are as follows:

 * 1) The sarcoma arises in an irradiated field.
 * 2) There is a 4 year latent period
 * 3) The sarcoma is histologically different from the original tumor and radiation was delivered in the absence of a diagnosis of the sarcoma.

Radiation-induced sarcomas have been shown to develop anywhere from 4 to 42 years after therapy. The average latent period is 11 years. The radiation doses associated with tumor development vary, but usually at least 30 Gy is needed. As mentioned previously, tumor can sometimes be confused with osteonecrosis, as they can demonstrate similar symptoms. In those cases, serial radiologic exams or biopsy may be needed.

Fig. 3 Osteosarcoma of the rib in a patient who had received radiation therapy for lung carcinoma 9 years earlier.


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/ACL Reconstruction

In order to have an ACL reconstruction, you first need to have an ACL tear. Symptoms of an ACL tear include: pivot shift episodes, pain, and feeling a 'pop.'  On physical exam, the physician usually finds an effusion, a positive anterior drawer sign, a positive Lachman's test, and/or a positive pivot shift test. MR has a greater than 90% sensitivity and specificity for detecting a ruptured ACL (3). Tears are best demonstrated on T2 MRI sequences. The characteristics of ACL disruption are as follows:

 * incomplete ruptures: increased T2 signal, thickening, normal course;
 * ruptured ACL: absence of intact fibers, high signal on T2;
 * chronic tears: ACL atrophy, laxity, normal or intermediate signal intensity, thickening.

Joint space findings can also provide clues as to an ACL tear. These include effusion, posterior cruciate ligament (PCL) angulation, anterior subluxation, bone bruise, Segond fracture, uncovered lateral meniscus, deep femoral notch, MCL tear, and meniscal tear (2-3).

Types of Reconstruction
Today, reconstruction is usually done without an open knee surgery. It is performed with arthroscopic assistance and running a graft through reamed tunnels in the tibia and femur. The graft is generally anchored at both ends. Graft materials are more often harvested from the patient, but cadaver grafts are still used in select patients. Prior to graft placement, the existing torn ACL must be arthroscopically debrided out of the knee thoroughly.

One common method of reconstruction uses a central third patellar-tendon autograft. The middle one third of the ipsilateral patellar tendon is harvested with bone plugs from the patella and tibial tuberosity. The graft is inserted through femoral and tibial tunnels. It is often secured by two metal or absorbable interference screws. An animation of how this procedure is performed can be found here. Follow the links for examples of how this reconstruction appears in AP and lateral plain x-rays (15).

Another method of reconstruction, favored at the University of Washington currently, uses a double loop graft of semitendinous and gracilis tendons. In this procedure, portions of the hamstring tendons are dissected from their muscular insertion. Their bony insertion remains intact. The graft is then pulled through the tunnels and looped back over an Endobutton in the femur, thus becoming a double loop. The lower portion is secured with a screw in the tibia. The EndoButton is a metal flat washer (what we see on x-ray) attached to a loop of polyester tape through which the graft is run. An animation of how this procedure is performed can be found here, except that an EndoButton is used instead of a screw to secure the loop in the femur.

Causes of Failure and Complications of ACL Reconstruction
Causes of graft failure can be divided into three categories: technical, biologic, and external (5). Technical causes include nonanatomic tunnel placement, hardware failure, bone plug fracture, inadequate notchplasty, improper tensioning, graft fixation, and insufficient graft material. Plain x-rays can be used to evaluate fracture of the bony portions of the grafts, metallic screw integrity and position, union of the bony portions of the graft, tunnel placement, and size of screw tunnels. MR can also be used to evaluate tunnel positioning, graft integrity, the other soft tissues of the knee. The femoral tunnel should be at the intersection of Blumensaat's line (intercondylar roof line) and a line extended from the posterior femoral cortex. Tibial tunnel placement should be posterior and parallel to the tibial intersection of Blumensaat's line. One of the more common problems with the tunnels is placement that is too anterior (15). Tunnels may enlarge over time but this does not seem to affect outcome (1). Screw placement does not necessarily correlate with the tunnel lines. Osseous incorporation of the patellar tendon grafts occurs by one year in most cases (1, 11). On MR, an intact unimpinged graft should have homogenous low signal. It should be posterior to and not in contact with the intercondylar roof (14). Grafts impinging on the roof or sidewall will have irregular increased signal (6). Due to metal artifact on T2 images, T1 may be more useful for assessing technical failure (2).

Biologic causes for failure include: failed ligamentization (for those grafts which were not originally ligaments), infection, arthrofibrosis, and infrapatellar contracture syndrome. Arthrofibrosis is a loss of extension of more than 10 degrees or flexion of greater than or equal to 15 degrees. It could be caused by a cyclops lesion. This is a fibrous nodule anterolateral to the tibial tunnel that impinges on the intercondylar notch when the knee is extended. It causes an abrupt endpoint of extension with a popping sensation. The cyclops lesion could result from drilling debris, ACL stump remnants, broken graft fibers, or repeated impingement of the graft on the notch (4). Adequate notchplasty (anterolateral debidement of the tibial tunnel) is required to reduce the rate of cyclops formation, which can occur in as many as 5-10% of patients (12). A cyclops lesion is seen on MR as a low-signal intensity nodule outlined by fluid.

External causes for failure include: traumatic rupture, secondary instability of the knee, and improper rehabilitation (5). Graft rupture, similar to native ACL rupture, is best demonstrated on MRI as has been described (4). Caution is advised when using secondary signs of ACL rupture since some of these are normal in a post-operative state, such as an effusion (1).

Osteoarthritis (OA) is a common complication of ACL reconstruction and can be imaged by plain x-rays. Changes usually can be seen by 7 years post-operative (8-9, 12). A recent study showed that patellofemoral OA is more common than tibiofemoral OA (47% vs. 14-18%) an average of 7 years post-operative (7). In this study, the patellofemoral OA corresponded in severity to degree of shortening of the patellar tendon. The OA is more advanced in those patients for which the ACL injury was chronic (> 12 weeks) prior to surgery and when meniscectomy was required (8-9, 12).

Subsequent surgery is not an infrequent complication of ACL reconstruction. Meniscectomy can later be needed in a small percentage of patients (9, 12). Screw removal can also be required in as many as 10% of patients (9). This might be necessary due to patient pain or that the screws may back out as the bone heals and affect cosmesis. Debridement procedures could be required for adhesions, arthrofibrosis, or cyclops lesions.

Other knee injuries can complicate an ACL repair. These include associated tendon injuries, meniscal injuries requiring surgery, patellar tendonitis, patellar tendon rupture, and patellar fracture. The latter three would be seen with the patellar tendon grafts. Patellar fracture can be detected with plain x-rays. Derangement of the soft tissues structures can be seen on MRI.

Outcome
Short term success of ACL reconstruction is generally very good. Data is limited on long term success of many of the procedures employed today. An additional traumatic injury seems to be the most common cause of reoperation now that many of the technical problems of the surgery have been perfected. For patellar tendon grafts, approximately 4-10% have traumatic rupture in 5–7 years (9, 12).

In the case of patellar tendon grafts, the central third of the patellar tendon reconstitutes after 12–18 months, as has been demonstrated by MRI (12). The patellar tendon can remain increased in thickness. Absorbable interference screws are generally resorbed by 1 year (1) and can be seen on MRI.

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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Jumpers Knee

Also known as patellar tendinitis. Relatively common cause of pain in the inferior patellar region in athletes. Begins as inflammation in the patellar tendon where it attaches to the patella and may progress by tearing or degenerating the tendon. Overuse injury from repetitive overloading of the extensor mechansism of the knee. Microtears exceed the body's healing mechanism unless the activity is stopped. Occurs in many athletes, but is most common in sports such as soccer, volleyball, or basketball which require explosive movements. Early stages may be treated conservatively. Uncommonly may require surgery to remove myxoid degeneration in the tendon. This is reserved for patients with debilitating pain for 6–12 months despite conservative measures.

Radiologic Findings
Thickening of the proximal patellar tendon with high signal in/around the proximal patellar tendon on T2W images.


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Lateral Meniscus Pathology

Anatomy
The knee has two menisci, the medial and the lateral menisci. They are C-shaped, fibrocartilaginous structures that are thick peripherally and thin centrally. They function to increase the articular surface of the tibia, to deepen the flat tibial plateaus, in order to accommodate the relatively round femoral condyles. The menisci function as shock absorbers and as passive stabilizers for the knee. They are firmly attached to the tibia at their anterior and posterior portions.

In the lateral meniscus, additional meniscofemoral ligaments can variably be found, extending from the posterior horn of the lateral meniscus to the medial femoral condyle. If, on sagittal images, the ligament is anterior to the PCL, then it is the ligament of Humphrey; if it is posterior to the PCL, it is the ligament of Wrisberg.

The lateral meniscus is attached to the joint capsule less intimately than the medial meniscus. This increased mobility results in less injury to the lateral meniscus. The anterior and posterior horns of the lateral meniscus are equal in size.

Clinical
Symptoms of lateral meniscal tear include intermittent pain due to synovitis, locking, catching and clicking. Although a lateral meniscal tear can be related to trauma, significant trauma is not necessary. A sudden twist can cause a tear. On exam, lateral joint line tenderness, effusion or limited range of motion can be found. Provocative maneuvers can often reproduce the click or the pain of the tear.

Imaging
MR is the imaging study of choice to evaluate the menisci. The normal meniscus is devoid of signal on all imaging sequences. Proton density or T1 weighted coronal and sagittal images are the most accurate for evaluation of the menisci.

The lateral meniscus tears less commonly than the medial meniscus. A discoid lateral meniscus, which is thought to be a congenital variant, occurs much more commonly on the lateral meniscus. A discoid meniscus can be symptomatic, in and of itself, causing joint locking and joint line tenderness. The abnormal biomechanics of the discoid meniscus also makes it prone to tearing. It is diagnosed on sagittal images, when 3 or more consecutive segments including the body are identified. On coronal images, it is diagnosed when the horizontal measurement between the free margin and the periphery of the body is more than 1.4 cm.

A tear is diagnosed when there is increased signal within the meniscus that extends to the articular surface. If there is increased signal within the meniscus that almost extends to the articular surface, but not quite, this is intrasubstance degeneration.

3 types of tears include:

1. Horizontal/oblique tear—most common type

2. Vertical longitudinal tear—this tear can also become a bucket handle tear if the medial fragment displaces. The fragment can displace into the intercondylar notch or flip anteriorly.

3. Radial tear—this tear extends from the periphery to the free edge of the meniscus.

Parameniscal cysts are occasionally found and are highly associated with meniscal tears. They are more common in the lateral meniscus.


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Medial Collateral Ligament Injury

Anatomy
The medial collateral ligament is typically divided into the superficial and deep bands. The superficial portion of the ligament typically arises from the medial femoral condyle and passes distally to insert approx. 5 cm below the joint line and posterior to the pes anserinus on the medial aspect of the proximal tibia. Superficial fibers are separated from the deep fibers by a bursa.

The deep ligament is firmly attached to the capsule and the midportion of the medial meniscus and attaches to the femur and tibia adjacent to the joint. The medial collateral ligament is a stabilizer that resists external rotation and anterior forces and is more often injured than its lateral counterpart.

Click here for anatomy link for Medial Collateral Ligament anatomy from Wheeless' Textbook of Orthopaedics.

Pathophysiology
This injury usually occurs when a blow to the outer side of the knee causes stretching or tearing of the medial collateral ligament. It can also be caused by twisting the knee. Specifically, the ligament is injured due to a valgus stress with the knee in flexion.

Grading Injury
TYPES OF MEDIAL COLLATERAL LIGAMENT INJURY(GRADE I-III):

Three appearances of the MCL with T2 Weighted Images.

I. A sprain, shows high T2 signal in the soft tissues medial to the MCL.

II. A severe sprain or partial tear, shows high signal in the soft tissues medial to the MCL, but also has high signal or partial disruption of the MCL itself. As well, there can be thinning of the MCl itself.

III. A complete tear, shows complete disruption of the MCL.

Associated Injuries
Associated injuries of the capsule specifically meniscocapsular separation, and can be diagnosed by noting fluid between the MCL and the medial meniscus. Additionally, injuries of the anterior cruciate ligament are also commonly seen with these injuries.

Commonly seen injury is so named the UNHAPPY TRIAD:

 * 1) ANTERIOR CRUCIATE LIGAMENT TEAR
 * 2) MEDIAL COLLATERAL LIGAMENT INJURY
 * 3) MEDIAL MENISCUS TEAR

Treatment
Treatment of a medial collateral ligament injury rarely requires surgical intervention. Grade I sprains of the MCL usually resolve within a few weeks. Resting from activity, icing the injury and the use of anti-inflammatories will usually be all the treatment that is needed.

When a grade II MCL sprain occurs, use of a hinged knee brace is common in early treatment. Athletes with a grade II injury can return to activity once they are not having pain over the MCL. When a grade III injury occurs, patients usually wear a hinged knee brace and protect weight-bearing with a gradual return to normal activities. Patients with more severe injuries usually require physical therapy and will not return to their full level of activity for 3 to 4 months.


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Raising Cattle/why get started

Motivation
The first question is: why do you want to raise cattle? What is your objective? Maybe you just love cows. Perhaps you're trying to fulfill a childhood fascination with cowboys and the Old West. Some more practical reasons could be to provide a source of healthy more natural food (either dairy or beef) for your family, or to start a small side business to provide additional income. There are many valid reasons, and you most likely have a combination of motivations.

Regardless of what your motivation is, it will be helpful in making future decisions and working through problems if you honestly know why you are trying to raise cattle.

Acreage

There are many horse facilities that have limited acreage and are well suited for cattle raising. However, there is no economic advantage to raising cattle on small acreage unless you have evolved your operation into one where you are selling embryos at a very nice premium. However, a small ranching property that is too large to economically mow (such as 40 acres) may benefit from having cattle graze on it. Many rural municipalities require that property owners control the weeds growing on their properties. Having a small cattle operation can help in this. Also some places having a minimum amount of cattle can qualify you for farming taxation which can be cheaper than leasing the property alone.

Because forage plays such a large part of the feeding regimen, cattle require two to three acres per animal on the small side in the southeast where temperatures allow for a spring and fall forage growing program. Going in any other geographical direction requires even larger land to cattle ratios and the feeding program becomes a financial drain that can be unmanageable.

title: Raising Cattle/why get started


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Segond fracture

Avulsion fracture of the lateral tibial plateau immediately distal to the articular surface. Originally described by Dr. Paul Segond in 1879 after a series of cadaveric experiements, the Segond fracture occurs in association with ACL tears (75-100%) and medial meniscal injury (66-75%), as well as injury to the posteriolateral knee structures.

Originally thought to be a result of avulsion of the medial third of the lateral collateral ligament, more recent research suggests that the insertion of the iliotibial tract (ITT) and the anterior oblique band (AOB), a ligamentous attachment of the fibular collateral ligament to the midportion of the lateral tibia, also play an important role.

A rare, mirror image of the Segond fracture has also been described. The so-called "reverse Segond" fracture is comprised of avulsion fracture of the tibial component of the medial collateral ligament in association with posterior cruciate ligamentous injury and medial meniscal tears.

Mechanism
Segond fracture is typically the result of abnormal varus stress and internal rotation. Reverse Segond fracture, as its name suggests, is caused by abnormal valgus stress and external rotation.

Clinical Significance
Because of the high rate of associated ligamentous and meniscal injury, the presence of a Segond or reverse Segond fracture requires these other pathologies must be specifically ruled out.

Radiologic Findings
Segond and reverse Segond fractures are characterized by a small avulsion fragment of characteristic size that is best seen on plain radiography in the AP plane. Nonetheless, the avulsion fragment may be very difficult to see, and the only direct imaging evidence of this pathology may be by MRI. MRI findings include improved visualization of the fracture fragment on T1W images and marrow edema of the underlying tibial plateau on fat saturated T2W and STIR images, as well as the associated findings of meniscoligamentous injury.


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Popliteus Muscle Injury

Anatomy and Function

 * Its origin is on the anterior portion of the popliteal groove on the lateral surface of the lateral femoral condyle (anterior & inferior to LCL origin) and another less strong origin is from the fibular head, called the popliteofibular ligament. An additional origin from the lateral meniscus can be seen in a small percent of patients.
 * The popliteus tendon courses under the lateral collateral ligament, descends into the popliteus hiatus, then passes under the arcuate ligament and becomes extraarticular before finally joining its muscle belly
 * Its insertion is fan like on the posterior surface of the tibia above the popliteal line
 * Its primary function is internal rotation of the tibia on the femur in the non weight-bearing state &, when weight-bearing, external rotation of the femur on the leg. It helps with posterior stability of the knee in preventing posterior translation of the tibia on the femur & prevents excessive external and varus rotation of the tibia during knee flexion. It is the main lateral stabilizer of the knee.

Posterolateral Region

 * The posterolateral region of the knee is often seen as a functional tendoligamentous unit, which is termed the arcuate ligament complex.
 * This complex encompasses the popliteus muscle and tendon along with the lateral collateral ligament; biceps femoris tendon; popliteal meniscal and popliteal fibular ligaments; oblique popliteal, arcuate, and fabellofibular ligaments; and lateral gastrocnemius muscle.
 * Injuries of the popliteus are infrequent and rarely isolated (less than 10%). They usually occur as part of a posterolateral corner complex injury, which is also frequently associated with injury of the anterior or posterior cruciate ligament.
 * It is important not to overlook popliteus and posterolateral injury in the presence of an anterior or posterior cruciate ligament injury, because the reconstructed cruciate ligament will likely fail without repair of the posterolateral injuries.
 * Unrepaired popliteus injuries can cause severe disability from both instability and articular cartilage degeneration.

Mechanism of Injury

 * Athletic trauma, motor-vehicle accidents,and falls are the most common causes of injury of the posterolateralcorner of the knee.
 * Rare isolated posterolateral injury can result when a force is directed in a posterolateral direction against the proximal anteromedial aspect of the tibia with the knee at or near full extension, which produces knee hyperextension and varus bending that disrupts the posterolateral structures.
 * Combined hyperextension and tibial external rotation forces can also produce posterolateral injury.
 * Usually these forces are so severe orcombined with other forces to injure other ligaments in the knee.
 * The varus and hyperextension instability that results is frequently overlooked at clinical examination or masked by more extensive injury symptomatology.

Radiographic Evaluation

 * Radiographs with posterolateral injury may show abnormal widening of the lateral joint space, an arcuate fracture of the fibular head, avulsion of the Gerdy tubercle off the tibia, or a Segond fracture (avulsion of the lateral aspect of the capsule from the tibial plateau).
 * Although a Segond fracture is usually considered indicative of a tear of the anterior cruciate ligament, it also occurs in association with isolated posterolateral injury.

MR Evaluation
At MR imaging, popliteus lesions have different appearances depending on the level and grade of damage. They may appear as an avulsion of the popliteus tendon from its femoral attachment, as an irregular contour of the tendon at the popliteal hiatus with surrounding high-signal-intensity edema, or as swelling and high-signal-intensity changes within the popliteus muscle. A complete popliteus tendon tear may be seen as an interruption and possibly as retraction of the muscle belly, which may appear as a "mass" surrounded by fluid. Only fat should be present behind the popliteus tendon. Therefore, the presence of fluid posterior to the tendon should suggest a capsular tear if the existence of a fluid-filled popliteal bursa is taken into account.

The majority of popliteus tears are extraarticular, involving the muscular or myotendinous portion, although they can be intraarticular at the level of the popliteal hiatus and at or near the femoral insertion. Such injuries can also be a mixture of intraarticular and extraarticular

The popliteal bursa is an extraarticular extension of the synovial membrane of the knee joint extending from the popliteal hiatus along the proximal part of the popliteus tendon. On T2-weighted images, a fluid-filled popliteal bursa appears as a well-defined area of high signal intensity surrounding the popliteus muscle and tendon. This bursa may be confused with a tear of the popliteus muscle and tendon or of the posterior capsule.

In 95.8% (23/24) of patients, the tears of the popliteus involved the muscular portion. Three patients had tears of both the muscular and tendinous portions or the tendon alone. The anterior and posterior cruciate ligaments were torn in 16.7% (4/24) and 29.2% (7/24) of patients, respectively. There were medial and lateral meniscal tears in 45.8% (11/24) and 25% (6/24) of patients, respectively. There were injuries of the medial and lateral collateral ligaments in 8.3% (2/24) and 4.2% (1/24) of patients, respectively. Bone bruises and/or fractures were seen in 33.3% (8/24) patients. In 8.3% (2/24) of patients, the popliteus injury was an isolated finding.

Avulsion injuries at the femoral insertion of the popliteus tendon have been reported. However, injuries of the muscle belly and myotendinous junction of the popliteus are far more common. Enlargement of the muscle and increased signal intensity on T2-weighted images can be demonstrated at MR imaging. MR imaging is also useful for differentiation of partial interstitial tear from complete muscle rupture, since the latter produces retraction and clumping.


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Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Pediatric Elbow

First, we will review some basic concepts necessary to evaluate traumatic injuries of the pediatric elbow. Then, we will cover the most common injuries that you are likely to encounter in this population and discuss the incidence, mechanism of injury, diagnosis and treatment for these injuries.

Ossification Centers of the Elbow
Knowledge of the order and ages of appearance of the ossification centers of the elbow is essential in differentiating fractures from normal ossification centers in the pediatric elbow. A simple mnemonic, CRITOE, can be used to remember the sequence of appearance.

Ossification centers - Approximate age of appearance

Capitellum - 1 year

Radial head - 5 years

Internal epicondyle (Medial epicondyle) - 7 years

Trochlea - 10 years

Olecranon - 10 years

External epicondyle (Lateral epicondyle) - 11 years

Note: Females tend to have an earlier appearance of ossification centers by 1–2 years.

Fat Pad Sign
There are two fat pads within the elbow which are helpful clues in the evaluation of traumatic injuries of the elbow. Normally, on a lateral radiograph of the elbow, the anterior fat pad is seen as a small triangular lucency anterior to the distal humeral diaphysis. The posterior fat pad is ordinarily not visualized on a lateral radiograph because it is tucked away in the olecranon fossa. With fractures, the joint becomes distended with blood. The anterior fat pad becomes displaced superiorly and outward from the humerus giving the so called "sail sign." The posterior fat pad gets displaced out of the olecranon fossa and becomes visible on the lateral radiograph. However, the fat pad sign can be seen with any joint effusion, making clinical history essential in the evaluation. In the setting of trauma, effusions are indicative of fractures about the elbow.

Supracondylar Fracture
Supracondylar fractures make up 60% of all fractures about the elbow in the pediatric population. There are two types of supracondylar fractures based on the mechanism of injury. Of those, 96% are extension type fractures and 4% are flexion type fractures. We will discuss the extension type injury as it is, by far, the more common. These injuries are usually seen in skeletally immature patients in the first decade of life.

The extension type fracture is caused by a fall on the outstreched hand with the elbow hyperextended. The distal fragment of the humerus will angulate and displace posteriorly, depending on the severity of the trauma. There is a relatively high risk of nerve injury (approximately 10% of fractures) associated with this injury. When there is nerve injury, the radial nerve is most commonly involved followed by the median nerve, and then the ulnar nerve.

Radiological evaluation of these fractures can be difficult depending on the amount of displacement. The use of the fat pad sign is very helpful. Additionally, one should look for the anterior humeral line intersection with the capitellum. The anterior humeral line is drawn along the anterior humerus on a true lateral radiograph. Normally, this line intersects the middle third of the capitellum. In supracondylar fractures, the line often intersects the anterior third of the capitellum or beyond.

Treatment depends on the amount of angulation or displacement that is present. In most non-displaced fractures, patients are immobilized for approximately three weeks and reassessed. However, depending on the amount of angulation, the patient may require reduction and percutaneous fixation. In completely displaced fractures, closed reduction with percutaneous pinning is the most common treatment option.

Lateral Condyle Fracture
Lateral condyle fractures are the second most common fractures about the elbow in the pediatric population, encompassing approximately 15% of fractures.

Two mechanisms of injury have been proposed. First, the injury may result from a fall on the outstretched hand with the forearm supinated which transmits a force through the forearm extensor musculature to its attachment on the lateral condyle. These fractures may also occur with a force directed to the outstretched hand with the elbow flexed.

The fracture can be easily identified radiographically if the capitellum is well ossified and displaced. In more difficult cases, oblique radiographs may assist in the diagnosis.

Nondisplaced fractures may be treated by immobilization for approximately three weeks. However, frequent radiographs must be obtained to ensure that the fracture does not displace during the immobilization. To insure that the fracture does not displace, closed pinning of the fracture may be performed. Anatomic reduction is essential in these fractures because they are intra-articular and involve the growth plate. Therefore, displaced fractures are usually treated with open reduction and internal fixation.

Medial Epicondyle Fracture
Medial epicondyle fractures are the third most common fracture about the elbow in the pediatric population encompassing approximately 10% of fractures. These are typically seen in an older age group, most commonly adolescent males.

This injury results from a valgus force combined with contraction of the forearm flexor muscles. If the valgus force is great enough, elbow dislocation can result, in addition to avulsion of the medial epicondyle.

Radiographic diagnosis is not difficult in displaced fractures. In non-displaced fractures, the apophysis of the medial epicondyle may appear wider than normal. Comparison with the contralateral side will often be helpful in these situations. Additionally, some have recommended obtaining stress views to determine the stability of the elbow in these injuries.

Treatment of this fracture depends on the amount of displacement of the epicondyle. Nondisplaced or minimally displaced fractures (<5 mm) can be treated with immobilization of the elbow and 90 degrees of flexion for approximately one week. Treatment of displaced fractures is controversial. If there is instability in addition to the fracture, open reduction and internal fixation is the treatment of choice. If there is no instability, these fractures can be treated with closed reduction.

Proximal Radius Fracture
This is the most common fracture about the elbow in adults. However, proximal radius fractures encompass only about 8% of fractures in the pediatric population. These fractures also differ from those seen in adults because they usually involve the radial neck and physis rather than the radial head, as in adults.

These injuries can result from a fall on the outstretched hand with the elbow extended. In the skeletally immature, the force is transmitted through the head which is mostly cartilage, and directed to the physis and metaphysis. These fractures may also occur in association with posterior dislocation of the elbow.

Displaced fractures are usually easily diagnosed on radiographs. However, non-displaced fractures can be difficult to visualize radiographically. Oblique views of the radius may be helpful.

The treatment of this fracture depends on the amount of angulation. In minimally angulated fractures, patients can be treated with immobilization in 90 degrees of flexion for approximately one week. With greater angulation, the fracture is treated with closed or percutaneous reduction. Open reduction is reserved for situations where closed or percutaneous reduction fails.

Dislocation of the Elbow
Dislocation of the elbow is rare in children. The mechanism of injury is a posteriorly directed force.

Closed reduction of the dislocation should be performed as soon as possible. First, any lateral displacement is corrected. Then, the arm is supinated and distal traction is applied with the patient's elbow flexed. Following reduction, the elbow is immobilized for 2–3 weeks.

Radial Head Dislocation
Isolated dislocation of the radial head is extremely rare. In the pediatric population, it is most likely due to bending of the ulna. Most dislocations of the radial head are associated with a fracture of the ulna, the Monteggia fracture-dislocation injury.

Diagnosis can be made on lateral radiograph by examination of the radiocapitellar line and its intersection with the capitellum. The radiocapitellar line is created by bisecting the proximal radial shaft. This line normally intersects the capitellum in all radiographic projections. If it does not, the radial head is subluxed or dislocated. Radial head dislocations are treated with reduction.

Subluxation of the Radial Head
This is the most common traumatic injury of the elbow in children. It is also known as "pulled elbow" or "nursemaid's elbow." The average age of incidence is 2–4 years. As children get older, the annular ligament gets thicker and resists tearing, making this injury less likely.

The injury results from a pull on the extended pronated arm. The annular ligament tears at its attachment to the radius and the radial head moves distally. As the traction is relieved, the annular ligament gets caught between the radial head and the capitellum.

The diagnosis is a clinical one. Radiographs can be obtained to rule out other injuries.

Treatment entails reduction of the subluxation by forcefully supinating the forearm with the elbow flexed 60 to 90 degrees. The child should be observed following reduction as he/she should use the arm shortly after the subluxation is reduced.


text:
Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Scapholunate Instability

The wrist, with its enormous range of motion, is one of the most complex and frequently used joints within the human body. However, because of the prominent role it plays in normal daily activities, the wrist can oftentimes wind up being a source of significant disability and pain.

The proximal bones of the wrist (scaphoid, lunate, and triquetram) have no muscular attachment. As a result, their main purpose is to stabilize the wrist joint and provide a focal plane to help transmit the force generated by the flexors and extensors of the arm. To help them in this task, numerous strong ligaments bind the proximal bones together, allowing them to function more cohesively. Damage to any of these ligaments results in either acute symptoms or a less noticeable but possibly more dangerous malalignment of the carpal bones that, if left uncorrected, will accumulate abnormal wear and tear—eventually leading to severe and debilitating osteoarthritis.

Ligamentous injuries and subsequent carpal instability tend to occur in young and middle aged patients. This is because as people age, their bones become more fragile and thus trauma in the elderly tends to cause outright bone fractures instead of soft tissue damage. The most frequently encountered ligamentous injury of the wrist is scapholunate instability.

Three main ligaments bind the Lunate and Scaphoid bones together:
 * Volar radioscapholunate ligament
 * Scapholunate interosseous ligament
 * Dorsal scapholunate ligament

Scapholunate instability is defined as significant injury to two or more of these ligaments.

Cause
Scapholunate instability is usually caused by stress placed on a hyperextended wrist, especially in ulnar deviation (such as frequently happens when patients fall on an outstretched hand). When this occurs, the ligaments binding the scaphoid and lunate bones begin to tear, starting with the scapholunate interosseous ligament. When a ligamentous wrist injury occurs, patients will generally describe one or more of the following symptoms:

 * Pain
 * Weakness
 * "Giving way"
 * A "clunk, snap, or click" during use

One of the easiest ways to evaluate these patients is with a simple physical exam maneuver known as the Watson test.

Watson Test
A painful snap is obtained when pressing hard on the scaphoid tubercle volarly and moving the wrist from ulnar to radial deviation, the wrist being maintained in axial compression. If clinical suspicion is high, further evaluation with imaging studies can be done.

Radiologic Diagnosis
As the ligaments binding the scaphoid and lunate bones are damaged, the scaphoid begins to move out of its normal position and rotationally sublux. This leads to several noticeable findings on radiographic examination.

On AP plain films of the wrist, an abnormally large gap between the scaphoid and lunate bones can oftentimes be seen. This is known as the Terry Thomas sign, in reference to the British comedian with a sizeable gap between his two front teeth (or David Letterman or any other person with a gap in their teeth, sign).

AP Wrist
Generally, a scapholunate interval of > 2mm is suspicious and > 4 mm is virtually diagnostic for scapholunate dislocation or instability.

Lateral Wrist
Lateral X-rays of scapholunate instability may also demonstrate an increased capitolunate angle > 15 degrees as well as increased scapholunate angle > 60 degrees.

Arthrography
While fairly sensitive, plain films will sometimes fail to see the early signs of scapholunate instability when the ligaments are torn but the scaphoid has yet to sublux. In these situations when suspicion is high, or when plain films have already detected the dislocation and further evaluation is needed to plan treatment, arthrography is the next logical step in radiologic evaluation.

The wrist can be divided into three discrete compartments with ligamentous borders that prohibit the movement of fluid from one compartment to the next. The scapholunate ligaments comprise part of this border and any tear can be diagnosed on arthrography when contrast injected into one compartment can be seen abnormally flowing into a neighboring compartment.

However, while often diagnostic, contrast leakage does not always signal a significant tear within the ligaments but instead may only represent a ligamentous perforation without significant consequences. If this is suspected to be the case, contrast injection can be coupled with CT scan or MRI of the joint to directly assess the health of the carpal ligaments. Furthermore, CT scan or MRI can directly determine the site and length of ligament tears and is a critical tool when planning any surgical repair.

Treatment
Because scapholunate injuries can sometimes present without symptoms yet if left untreated can eventually result in further carpal derangement and debilitating osteoarthritis, prompt diagnosis and repair is extremely important.

If the injury is thought to be minimal, conservative treatment with splinting and NSAIDS can be used to provide symptomatic relief. However, any significant degree of injury necessitates surgical correction. The overall aim of surgery is to restore a normal orientation of the scaphoid with the proximal pole appropriately articulating with the radius and to correct any other abnormalities that have occurred if the original injury was undiagnosed and uncorrected.

Numerous surgical techniques have been described, but generally revolve around soft tissue repair, where the carpal ligaments are modified or restored, or limited carpal arthrodesis, where the wrist bones are either orthopedically fixed or fused.

If scapholunate insufficiency is left untreated long enough, further shifts of the carpal bones can occur, eventually leading to a syndrome known as scapholunate advanced collapse, or SLAC:

As the scaphoid moves further from the lunate, the normal load-bearing ability of the capitolunate joint disappears. Among other things, this results in the migration of the capitate bone proximally, driving a further wedge between the scaphoid and lunate.


text:
Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Posterior sternoclavicular dislocation

An unusual dislocation at the sternoclavicular joint that is usually the result of compressive forces on the shoulder girdle. The forces of posterior compression transmit through the fulcrum of the costoclavicular ligament and result in posterior dislocation. Alternatively, a direct blow to the anteromedial clavicle can result in posterior dislocation.

Classically described in American football players who get "dog piled" while in a lateral position. Our case happens to be a rugby player who sustained a tackle injury. It can certainly happen in a MVC when the forces are just right.

People who sustain this unusual injury can also sustain some pretty serious associated injuries. These include:
 * 1) Direct trauma to the great vessel origins, or brachiocephalic vein. Mediastinal hematoma is usually present.
 * 2) Respiratory distress from compression on the trachea.
 * 3) Voice change from compression of the recurrent laryngeal nerve.
 * 4) Pneumothorax

Radiologic Findings
Special plane film views are described, but few people know these, and even fewer can read them. CT is the modality of choice because it delineates the anatomy of the joint so well. It also demonstrates the degree of separation, and can also show additional diagnoses. (see associated injuries) If clinical suspicion is high... go directly to CT.

Case
A young rugby player who sustained an injury (takcle?), and complained of severe sternum pain. Interestingly, he later complained of some dysphagia.

Our patient underwent closed reduction of the dislocation with good results. He did not have one of the serious complications listed above. I guess the dysphagia resolved.


text:
Diagnostic Radiology/Musculoskeletal Imaging/Trauma/Triangular Fibrocartilage Complex Tears andUlnocarpal Impaction

TFCC was first described in 1981 by Werner and Palmer as the ligamentous and cartilaginous structures that suspend the distal radius and ulnar carpus from the distal ulna. It is the major ligamentous stabilizer of the distal radioulnar joint (DRUJ) and the ulnar carpals.

Functions

 * Provides for a continuous gliding surface for flexion-extension and translational movements of the forearm and for stable rotational movements of the radiocarpal unit about the ulnar axis.
 * Suspends the ulnar carpus from the dorsal ulnar face of the radius and cushions the forces directed through the ulnocarpal axis.

Mechanisms of Injury to TFCC

 * falls onto pronated hyperextended wrist
 * twisting w/ palmar rotation
 * forced ulnar deviance, such as batting a baseball, subjects the TFC to heavy loads
 * associated with distal radius fractures
 * ulnocarpal impaction syndrome (see below)

Symptoms
TFCC injuries cause ulnar-sided wrist pain, frequently with clicking or crepitus and tenderness between the ulna and triquetrum.

Ulnocarpal Impaction Syndrome
Ulnocarpal Impaction Syndrome is impingement of distal ulna on carpi which may arise from positive ulnar variance or non union of distal ulnar fracture. It is a common inciting cause of degenerative tears. (Note: those with positive ulnar variance can develop TFCC tears, and those with TFCC tears often demonstrate positive ulnar variance.) Patients with a torn TFCC display positive ulnar variance (radial shortening) on average 4.6 mm versus 2.5 mm for no tear and dorsal angulation of 24° versus 12° for no tear.
 * increased ulnar variance leads to loading of the ulnocarpal joint and resultant lunotriquetral disruption, lunate chondral lesion, and triangular fibrocartilage complex tears
 * during marked ulnar deviation, compressive load on TFCC, particularly w/ positive ulnar variance, may increase markedly

Radiologic Findings

 * may show flattening, subchondral sclerosis or cysts, and/or lytic changes in lunate and/or triquetrum with similar changes seen over the distal ulna
 * patients may have positive ulnar variance
 * in subtle cases, a pronation grip radiograph may demonstrate ulnar variance

Figures 1 and 2. Note the positive ulnar variance and lunotriquetral impaction on this patient. There are subchondral cysts in the ulnar styloid, indicating degenerative changes from chronic impaction. Subsequent contrast injection into the DRUJ has extravasated into the radialcarpal joint, indicating TFCC tear.

Fig. 3 Note in this patient that the contrast injected into the midcarpal joint has extravasated into the radialcarpal joint and DRUJ, indicating tear of the TFCC.

Fig. 4 Another patient with ulnar impaction syndrome. Note the degenerative changes (osteophytes and subchondral cysts) in the distal ulna, scaphoid and lunate (white arrows), along with positive ulnar variance.


text:
User talk:Mijokijo

Franco Gasperoni
See page 3: ;-).

(The voting rules are clear - this note is just for fun)

--Krischik 06:46, 31 August 2005 (UTC)

title: User talk:Mijokijo


text: Portuguese/Contents/Personal Pronouns of Object


text:
User:Cdyson37~enwikibooks

I am also on Wikipedia:EN as cdyson37

title: User:Cdyson37~enwikibooks


text:
Dialectical Behavioral Therapy

This is the start of Dialectical Behavior Therapy Wiki

DBT is based upon the work of Marsha M. Linehan, Ph.D. who developed this treatment for people with /Borderline Personality Disorder/, see Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan ISBN 0898620341.

Table of Contents

 * /Core Mindfulness Skills/
 * Observe
 * Describe
 * Participate
 * Non-Judgmentally
 * One-Mindfully
 * Effectively
 * Wise Mind

 * /Emotion Regulation Skills/
 * Identifying and labeling emotions
 * Understanding the function of emotions
 * Identifying obstacles to changing emotions
 * Reducing vulnerability to “emotion mind”
 * Increasing positive emotional events
 * Increasing mindfulness to current emotions
 * Taking opposite action
 * Applying distress tolerance techniques

 * /Interpersonal Effectiveness Skills/
 * Attending to Relationships
 * Balancing Priorities vs. Demands in Life and Relationships
 * Options for Intensity of Asking or Saying No, and Factors to Consider in Deciding
 * Objective Effectiveness
 * Relationship Effectiveness
 * Self-Respect Effectiveness

 * /Distress Tolerance Skills/
 * /Distracting/
 * /Self-soothing/
 * /Improving the moment/
 * /Thinking of pros and cons/.
 * /Radical Acceptance/
 * /Turning the mind/ toward acceptance
 * /Willingness/ versus /Willfulness/.

title: Dialectical Behavioral Therapy


text:
Dialectical Behavioral Therapy/Core Mindfulness Skills

 * Observe
 * Describe
 * Participate
 * Non-Judgmentally
 * One-Mindfully
 * Effectively
 * Wise Mind


text:
Talk:Ada Programming/Archive 1

Other Language Libraries
The IO Pages in "Other Language Libraries" are misplaced sinces there are two hooks allready. One in "Predefined Language Library" (Entry "Ada") and one in "Language Features" (Entry "Input Output").

--Krischik 13:45, 25 Nov 2004 (UTC)

AI302
since Programming:Ada:Packages:Ada already allow for Ada 2005 I don't think that the AI302 need to be described.

--Krischik 14:01, 25 Nov 2004 (UTC)

Added to bookshelf
I have taken the liberty to add the book to the IT bookshelf on the main page of WikiBooks. I rated it 50% = Maturing. --14 Dec 2004 (UTC)

mention tasking earlier?
Shouldn't the section "Conclusion" mention that Ada provides the means to get tasking right by offering language means? Maybe in the paragraph on the advantages of spec/body, strong/weak typing.

(I'm not in a position to add such things :-) -- Georg

 * Shure. Anyone to voleteer? (I'm currently involved in adding more chapters since there are more voleteers for improving existing chapters then for creating new ones.)

 * BTW: Good work on Programming:Ada:Subtypes

 * --Krischik 08:18, 17 Dec 2004 (UTC)

Development stage

 * I've upgraded the development stage of the book to 75%, and also using the templates described at Help:Development stages. It has to be marked in the following places:
 * Template:Computer Science bookshelf (appears in Computer Science)
 * Programming languages bookshelf
 * Programming:Ada
 * --suruena 11:50, 31 Mar 2005 (UTC)

Sorting in category
Currently almost all the pages in Category:Ada programming language are sorted by the page name, so all appear at P heading. By adding we can sort by the key. I think the key should usually be the second or the last word in the title to get a kind of index of terms in the book. Another category could be used to sort by a chapter number in order to get a kind of table of contents. ManuelGR 00:29, 28 Dec 2004 (UTC)

 * For the second word I meant all the string after stripping Programming:Ada, i.e. I think there are two possibilities for the key of Programming:Ada:Libraries:Container:Booch:

 * # Libraries:Container:Booch
 * # Booch

 * The question is whether we want to put together full branches or want to sort by concrete items. ManuelGR 00:57, 28 Dec 2004 (UTC)

 * I did not know that - otherwise I would have made all category links like that. Anyway: concrete items! There will be some very large branches - like the pragma or attribute branch. And there is the "least suprise" argument: concrete is allwas concrete.

 * Libraries:Container:Booch
 * Container:Booch
 * Booch

 * --Krischik 08:26, 28 Dec 2004 (UTC)

 * MediaWiki is full of magic! I agree with you about the concrete stuff. BTW, we have a Spanish wikibook on Ada. I will probably pick some ideas from this one for the other and I hope, viceversa. ManuelGR 19:32, 28 Dec 2004 (UTC)

 * I'm creating stubs for every keyword that don't have an article yet. I'm agree that for the Ada programming language Category the best option is to sort with the name of the keyword. But for the Ada unfinished article I thinl it should be better to sort with the key "Keywords:id" so anyone who goes to that category to complete articles can see how many keywords needs to be done, and so on. I think it could be done also with other pages that are in that category, like "Special" ones. Of course, the same policy for the Ada unfinished article category. What do you think? --suruena 21:31, 31 Mar 2005 (UTC)

 * Note that Wiki categegories are case sensitive (thank you Martin for pointing me this!), so procedure is not the same as Procedure  . The later is the preferred form. --suruena 14:35, 3 Apr 2005 (UTC)

 * I've classified Programming:Ada at  (modified the key: Ada -> blank space) because it is the main page (it's more visible this way than at the "A"). --suruena 14:35, 3 Apr 2005 (UTC)

Things to look out for
I think this text might be better in Programming:Ada:Basic - in front of the hello world.

--Krischik 20:44, 14 Feb 2005 (UTC)

 * I agree, it's too large for the main page. Maybe language history should be separated in a different page too. ManuelGR 21:36, 14 Feb 2005 (UTC)

 * I was thinking that too. Mind you - most of history is copied from wikipedia - so we might just refear to wikipedia anyway --Krischik 04:33, 15 Feb 2005 (UTC)

 * It might be, I don't see a clear way for they to evolve differently. Maybe this version might be more informal and concise? By the way, in Wikipedia we have the policy of mentioning in the Summary field from what page has been copied something. This is aimed to track changes and recognize the contributions to its original authors (although an unregistered user does not seem to request too much credit, as is this case). ManuelGR 21:22, 15 Feb 2005 (UTC)

title: Talk:Ada Programming/Archive 1


text:
Talk:Ada Programming/Coding conventions

Coding conventions
IMHO, this book should follow the standard coding conventions, e.i. the style of the RM examples: You know, the old style. That is:
 * Keywords are in boldface
 * Identifiers in mixed case, with two exceptions:
 * When interfacing with other languages (like in packages Interfaces.C and Interfaces.COBOL)
 * In Ada 83 every language element was written in upper-case (identifiers, attributes, pragmas...) except keywords.
 * Identifiers of named types do not start with "T" or always end with "_Type" or "_T" (altough the latter is used sometimes, for example in formal parameters of generics, it is not a naming convention for every type).
 * A named access type of another named type has the same name ended with "_Ref", or with "_Ptr" if it is a general access type.
 * The keywords , ... go at the end of the line, and not at the start.

Person; Programmer Object  Person.Object Skilled_In : Language_List; ;    Abstract_Object    ; Class_Member_1 (This :     Object); Class_Member_2 (This :    Object); Class_Member_3 (This :  Object;                              That :     Object); Class_Member_4 (This : Object); Class_Member_5 Object; Programmer;

Some projects use a different code convention (it's only a convention after all), but I think in a tutorial like this we should teach the standard one. The GNAT Coding Style Manual specifies this convention in more detail, altough introduces some rules like: For example:
 * When the if, elsif or else keywords do not fit on the same line with the condition and the then keyword, <tt>then</tt> should be aligned with <tt>if</tt>, and conditions should preferably be split before an <tt>and</tt> or <tt>or</tt> keyword.
 * The same rules applies to while loops (the <tt>loop</tt> keyword aligned with the <tt>while</tt>), subprogram definition (ditto with the <tt>is</tt> keyword)...
 * When a big sentence must be split, put the operator not at the end of that line but at the start of the next one.

long_condition_that_has_to_be_split continued_on_the_next_line ... ;

It also introduces some awkward rules relating to comments, for example, but I think this style manual is a good start, and can be applied even to new Ada 2005 constructions:

Person; Programmer Object  Person.Object Printable.Object Skilled_In : Language_List; ; Programmer;

Another advantage of this coding convention is that we could use the <tt>-gnaty</tt> option of GNAT to enforce these rules. The GNAT Pretty Printer also helps to convert old code to that convention. I propose to use 3 spaces for indentation (See Style Checking), and it is a good idea to use a maximum line size because source code cannot be resized (on small screens this is a problem, and maybe someday it will be printed in a real book!). With the <tt>-gnaty</tt> switch GNAT by default enforces a maximum line size of 79 characters, maybe reducing 10 characters is OK ( <tt>gcc -gnaty -gnatyM69</tt>).

And making a bot (in Ada, of course :-) that watchs for miscompiled examples (syntax only: <tt>-gnats</tt>) or code that do not follows the style guide of the book would be superb.

Well, In my opinion it is important to reach an agreement in this topic, so every one that contributes to this book should express his/her opinion! Thank you!

-- suruena 17:12, 18 Mar 2005 (UTC)

 * I think that having a common style accross the book is desirable but don't have a preference. About keywords I think it is better to use a template rather than directly linking to the keyword page and putting it in bold. See the Spanish wikibook implementation at es:Template:Ada/Reservada. This way not only the text around keywords is reduced but also we can change the face style and link later on. Other question is whether linking to a different page for every keyword or a single page with a section for each keyword (thus linking with #keyword). The second choice has the advantage that all the links will be blue from the beggining. ManuelGR 21:37, 18 Mar 2005 (UTC)

 * Great idea! I was looking for the wikicode equivalent to CSS, to use not only for keywords but also for strings and numeric constants. Templates could be the answer. I've created Template:Adakw for the keywords. I prefer to link every keyword with its own page, but it's true that all those red links are ugly. One possibility is reference the keywords to Programming:Ada:Keywords now, and in the future change the Template to link to its own page (except the table Template:Ada/Keywords, that allways must link to its own page). -- suruena 10:59, 19 Mar 2005 (UTC)

 * Well GNAT Pretty Printer would be good - however is't only available to GNATPro users as AdaCore has not release the sources yet. And it would only work on "working demos" - But then - "working demos" are prefered anyway (I keep them as SourceForge). An automated converter could be put together with AdaCL's Text-Filter-Lib without problem. --Krischik 10:10, 19 Mar 2005 (UTC)

 * I have never heard about that lib. If gnatpp only works with complete examples is a real problem, because few snippets will work. Nowadays the book has few source code, so we could even make every change without a bot, but in the future it will not be so easy. At w:Wikipedia:Bots are listed the requirements, I suppose that our bot could meet all. -- suruena 11:06, 19 Mar 2005 (UTC)

 * I was wrong, the rule that splits a line before an operator comes from the GNU coding conventions, and not from the GNAT Coding Style Manual (in the source code of GNAT the operator is left at the end of the line). I prefer the GNU style (although it is for C :-) because in my opion it's more readable. But the RM uses the other convention, so I think we should use that one. Maybe we could make a section for coding conventions explaining other common ones too (for example, the one that puts the keyword at a new line, like in SPARK). -- suruena 20:44, 29 Mar 2005 (UTC)

title: Talk:Ada Programming/Coding conventions


text:
Dialectical Behavioral Therapy/Core Mindfulness Skills/Observe

Observe: is simply experiencing with awareness your feelings, your thoughts, and sensations directly without the use of words.

The ability to observe yourself requires an ability to step back from yourself. This process of stepping back, also called Teflon Mind, is a way to re-orient to the present moment. Teflon mind is based on the idea of the non-stick cooking surface to which food does not stick. Teflon Mind allows you to not get stuck.

Preoccupation, rumination, and distraction are some of the ways people get stuck. Observe is important because it helps you become like a blank slate upon which you can write.


text:
Dialectical Behavioral Therapy/Core Mindfulness Skills/Participate

Participate is the skill of throwing yourself into your objectives whole-heartedly without self-consciousness. Participate is the “go for it” feeling you have when you enthusiastically pursue an activity meaningful to you. Participate is the satisfying experience of becoming absorbed completely in what you are doing.

also see Dialectical Behavioral Therapy/Core Mindfulness Skills/Participate and Flow


text:
Talk:Ada Programming/New Picture

New Picture
There has been some discussion about the Logo being a bit old. Now I have received some alternatives which I would put to discussion:

 * http://www.niestu.com/wiki-logo/military-1.jpg
 * http://www.niestu.com/wiki-logo/civilian-1.jpg

--Krischik 19:12, 27 Mar 2005 (UTC)

 * What license would have these images? They should be GFDL or under the public domain. They are nice, although they do not scale very well: when zoom out they will look a bit confusing. It would be good to have the source composite images for future enhancements, or for translation into other languages (You guessed, I'm thinking about the Spanish wikibook). ManuelGR 19:41, 27 Mar 2005 (UTC)

 * I created the montages, and gladly put my own work in the public domain. However, the source images were downloaded randomly from the net, and many of them are no doubt copyright by their respective owners.  The law on such "sampling" seems rather vague, though I would not recommend commercial use of the images.  I welcome contributions of freely-usable versions of the objects, and would be happy to re-create the montages using them.  I made the images the same size as the banner image on the C++ wiki page, which Martin pointed me to when we originally discussed them.  I do have the original GIMP *.xcf files, if you'd like to substitute parts, like the text.  --Caracal

 * Great job! I prefer the civilian one: IMHO the montage is better and it is also politically correct. But, don't you think the vehicles are very small? --suruena 20:23, 29 Mar 2005 (UTC)

I have always liked these two "classic" logos, specially the second: I don't know whether they can be freely used, but if there are more people that want any of these images as the new logo we could write the authors. --suruena 20:09, 29 Mar 2005 (UTC)
 * http://www.cs.kuleuven.ac.be/~dirk/.image/adalogo-new.gif
 * http://sigada.org/logos/

 * I like them too, although I would slightly prefer a logo specific for the wikibook. Some variation on that theme would be good. ManuelGR 21:57, 29 Mar 2005 (UTC)

 * Some variation of what logo? Of the second one (SIGAda Ada Letters' logo )? I suppose we have to request permission to make any change to any of those two logos. --suruena 08:59, 31 Mar 2005 (UTC)

 * I meant a variation on the theme common to those logos, i.e. to create a new logo from scratch but using the same concept, a ship orbiting around a globe. You don't need permission to do that. ManuelGR 20:57, 31 Mar 2005 (UTC)

Although Ada is very well known for being used in embedded systems and education, I think is also used in very large and complex applications for workstations. And in my opinion we're agree that Ada can (and should) be used in far more applications, like desktop applications (anyway is a true multipurpose language). Maybe the logo should show those areas to promote it. And Caracal, I'm sorry: to talk is cheap, but I don't known what to add to one of your logos to reflect this change :-) --suruena 08:54, 31 Mar 2005 (UTC)

Wikimedia Commons would be a good source of images for a totally GFDL or public domain composition. Check for example http://commons.wikimedia.org/wiki/Category:Technology ManuelGR 19:11, 7 Apr 2005 (UTC)

-- Check these two images, might be good: http://extra.shu.ac.uk/nrc/section_3/pioneers/byron.html http://www.nypl.org/research/chss/victoria/ref/ps_cps_cd3_047.html I myself like the current image better than proposed one, but thats only my opinion. If you find first image to be acceptable, I will try and find larger image. Just post here, as I'm new to this wiki stuff ;-) Both are surely public domain, as they are from first part of 19th century. About logos, well IMHO these two military-1.jpg and civilian-1.jpg actually portray only one use of Ada - embedded system development.

New Picture: Ada Mascot
I've used the new Ada Mascot picture in the first page of the book. I think it provides a better look for the book. Lady Ada has still a prominent space in the first page, where her name is mentioned. If nobody is against this, I plan to replace the image of her in Template:Ada/Navigation so the new look is applied to all the pages. --ManuelGR (discuss • contribs) 13:51, 21 July 2018 (UTC)

 * I'll change now the picture. Given that there was previous consensus in replacing the former picture and that the now one is both more modern and related to the Ada community, I think it won't raise opposition. But please, if you are against it, don't restrain yourself to comment. The change can be reverted in any moment. --ManuelGR (discuss • contribs) 11:22, 22 July 2018 (UTC)

 * I've changed the picture again for two reasons:
 * In order to have an own logo for the wikibook. This has been done using the colors of Wikibooks' logo and adding "Ada Programming WIKIBOOK" as legend
 * The Ada Mascot seems to be not specially appreciated, but I think there is nothing out there more appropriate. At least, I think this new color palette improves the aesthetics of the image, although that is subjective, of course.
 * --ManuelGR (discuss • contribs) 19:00, 7 April 2022 (UTC)

title: Talk:Ada Programming/New Picture


text:
Dialectical Behavioral Therapy/Core Mindfulness Skills/Non-Judgmentally

Nonjudgmentally and Cognitive Therapy

•	See, but don’t evaluate. Take a nonjudgmental stance. Just the facts. Focus on the “what,” not the “good” or “bad,” the “terrible” or “wonderful,” the “should” or “should not.”

•	Unglue your opinions from the facts, from the “who, what, when, and where.”

•	Accept each moment, each event as a blanket spread out on the lawn accepts both the rain and the sun, each leaf that falls upon it.

•	Acknowledge the helpful, the wholesome, but don’t judge it. Acknowledge the harmful, the unwholesome, but don’t judge it.

•	When you find yourself judging, don’t judge your judging. Linehan, pg.113

 * "Men are disturbed not by things that happen but by their opinions of the things that happen." Epictetus, A.D. 55-135

The ancient wisdom of Epictetus anticipated cognitive therapy by about 2000 years. Epictetus suggests you are disturbed by your judgments about things, not the things themselves. He suggests that the way we think about things affects how we feel about them. Likewise, cognitive therapy and the skill non-judgmentally suggest alternative ways to think about things to change your mood. There are three fundamentals of cognitive therapy.

•	First, the viewpoint you “choose” is vital to your mood. If you can “choose” the way you view things you can change your mind.

•	Second, mood and thought are linked. If you change one you change the other.

•	Third, the methods of cognitive therapy work on your thoughts and beliefs to change your mood. The challenge of cognitive therapy: “Is there another way to see things?”

Feelings and thoughts are so well blended that we rarely think that the association matters. It does. Feelings influence how you think, and thoughts affect how you feel.

To illustrate how thoughts generate feelings consider:

•	If you opine that someone is disrespecting you, angry feelings arise.

•	If you judge yourself a failure, sadness or disappointment follow.

•	Comparing yourself to people which are richer, prettier, or smarter prompt feelings of envy.

•	Gratitude follows thoughts about those who are less fortunate, hungry, or homeless.

All-or-Nothing Thinking.

All-or-nothing thinking distorts your worldview into polarized extremes. Some polarities are quite familiar: good & bad, right & wrong, black & white, beautiful & ugly, should & should not, in & out, either-or, win & lose, life or death, off & on, and on and on. This sort of splitting the world encourages idealization on one side and devaluation on the other. The problem with split thinking is that reality is not polarized. Reality is a unified whole with all the parts inter-related. You cannot appreciate the unity of reality if you have a fixed (polarized) perspective because it prejudices your point of view.

A big red nose… You might believe that a small fault makes it impossible for a person to be “good” inside. Such a rigid style of thinking limits your ability to engage ideas of future change and growth. Polarized thinking tends to magnify errors and decrease your ability to adjust to circumstances. All-or-nothing thinking is exacerbated when you are in emotion mind.

When you are under the influence of emotion mind, you may feel there is only one way to think about a situation. If depressed, you feel as if there are no options – it’s hopeless. If angry, you are RIGHT and he is WRONG. If anxious, it is safe in here and dangerous out there. There is always more than one way of thinking about things. In reasonable mind, you can explore some of these options. Wise Mind integrates the emotional problems with reasonable solutions.

Labeling.

Good & bad, terrible & wonderful, and right & wrong are just opinions. You may feel there is no other way to think about things, but your belief may be a trap. Once you label something, your mind is trapped by that identification. Consider Bad Mountain, how is it “bad”? When you judge, you label (or evaluate) something as one way or another. Judging is an opinion or belief. Practicing taking a non-judgmental stance helps you escape the trap of your judgments. Labeling is not a problem with a rotten tomato, it will always be bad. But things once defined, tend to remain fixed in the mind (the importance of first impressions). For example, labeling someone sloppy may quickly lead to dismissing this person entirely.

How would you label losing your job? Emotion Mind would come up with words like “unfair”, “bad”, and “disastrous.” Reasonable Mind might be able to describe the lost job as a crisis and an opportunity.

In Wise Mind, a job loss is stressful, a challenge to start something new, and a chance to re-evaluate your career. Thus, the loss is more bearable. You will gain a better perspective of your situation when you step back, observe & describe the experience, gather more facts, and let go of your opinions. Seeing a job loss as an opportunity is an example of flexibility of thinking. Your mood will change as you notice the alternatives and shift your perspective. When difficulties arise, you will have more options if you can spend more time with the questions words (who, what, when, where) and less time with an emotion-based point of view.

Mental Filtering.

Mental filtering screens out facts or opinions that don’t fit with your current belief. Do you see a part or the whole? Strive to be like the blanket spread on the lawn – there is no filter, it accepts the rain and the sun. Look at the big picture.

Over-generalization.

The basis of this cognitive distortion is that you take an isolated case and apply it to all others. Rather than looking at each case individually, you make decisions based upon your feelings. “I never say the right thing.” “We always do things your way.”  As you become more self-aware you will notice the words “always” and “never” as a signal to step back and look for the facts.

Discounting the Positive.

This cognitive distortion rejects affirmations, positives, and compliments as if they didn’t count. Too often people fall into the habit of disqualifying the positive comments directed toward them. Accept compliments graciously. When somebody says something nice to you say “thank you.”

Jumping to Conclusions or Mind Reading.

You may believe you know what a person is thinking. You don’t. Jumping to conclusions comes from faulty, incomplete, or distorted assumptions about others. If a friend is late or forgets to call you, she could be tied up in traffic or she may be stuck in an urgent situation, why jump to the conclusion she is commenting on your worth as a person? If you see the world through your insecurities, then your insecurities distort incoming information. Remember the adage about what happens when you assume! U could make an ass out of u and me.

Magnification.

Take a difficult event. Now, exaggerate the importance of this event and make the meaning of it momentous. “This is terrible, it means I’m ruined, I’ll never be able to recover.” This magnification makes a bad situation worse. Oppose emotional magnification with reasonable assessment. From a detached point of view you can ask, “How important is this really?” Will I remember it in 3 years, 3 months, 3 days, or even 3 hours?

The problem with magnification is that intense thoughts generate equally intense emotions. Focusing on the facts without evaluation or judging will have a calming effect, improve your mood and help you choose the wisest course of action.  Emotional Reasoning.

•	I don’t like this; therefore it is bad.

•	I like him; therefore he is a good guy.

•	I’m scared about this test; therefore I will flunk.

When emotions rule, feelings are mistaken for facts. “Emotion mind” takes over. Emotional reasoning makes stress worse, depression deeper, anxiety higher, and anger hotter. The antidote is an activated Wise Mind which clarifies what the situation is and considers from where the emotions are coming. When you say you can’t stand it, do you really mean you don’t like it? Ask yourself, “Am I over-reacting and making this situation worse?” “Could I stand it a little bit longer?” “Should” and “Shouldn’t” Statements.

Albert Ellis dubbed the unrealistic use of “shoulds” musterbation. Such as:

•	People should not be rude.

•	Drivers should not cut you off in traffic.

•	Life should be fair.

Other words that put unnecessary pressure on you are “must”, “ought”, and “have to.”

Reality is as it is and as it should be. Reality follows the laws of the universe as it should. An opinion that reality should be different than it IS is not reality-based. Try to be a blanket and accept reality as it is.

Some “shoulds” are really a demand in disguise. If you rigidly hold to unrealistic expectations, you will often be angered because people will not behave the way you feel they must. Your ability to be flexible and accept is healthy. Change unrealistic demands to healthy preferences.

A thought, “he should help me” is really a demand, “I want you to help me”. The belief he should help me prompts feelings of anger. The demand I want you to help me is more respectful.

Conclusion

The goal of non-judgmentally is to see things from non-polarized perspectives. Flexibility of thinking is characterized by the ability to entertain other points of view. Consider too how you would think about something if you were feeling better. Strive to be factual and unglue your opinions from the facts, you could try to see things from some else’s point of view. Instead of polarized extremes, activate your Wise Mind to find balance, unity, and acceptance.

Reality does not come labeled, magnified, polarized, filtered, or discounted. You distort reality in those ways. Embrace reality by stepping back a bit and non-judgmentally looking at the bigger picture.

Who, what, when, and where questions reveal facts which are not as disturbing as opinions. Assumptions, like opinions, close the mind to facts. An open mind allows for possibilities, options and surprises. Too often, people tend to judge themselves and others in either excessively positive terms (idealization or “what I like”) or excessively negative terms (devaluation or “what I don’t like”). The goal is not to be more balanced in your judgments, but rather to drop judging in most situations.


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Dialectical Behavioral Therapy/Core Mindfulness Skills/Describe

Describe is putting words on experience and experience into words.

Describe: the ability to put verbal labels to (internal and external) events is essential for self-control.

Putting words on one’s experience is the first step toward taking control of your mind. Describing is thinking with words and includes your internal dialogue as well as verbal and written expression. This sort of talking to yourself helps you become focused. It is a way to overcome distractions because you learn to redirect your thinking to your here-and-now experience. As you practice describe, you will become clearer about what you are doing and what you want to do.

Time spent describing is an investment. Make consistent use of a journal, to-do list, calendar and organizer.

See Dialectical Behavioral Therapy/Core Mindfulness Skills/Observe


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Dialectical Behavioral Therapy/Core Mindfulness Skills/One-Mindfully

ONE-MINDFULLY.
Summary
 * ''•	Do one thing at a time. When you are eating, eat.  When you are walking, walk.  When you are bathing, bathe.  When you are working, work.  When you are in a group, or a conversation, focus your attention on the very moment you are in with the other person.  When you are thinking, think.  When you are worrying, worry.   When you are planning, plan.  When you are remembering, remember.  Do each thing with all of your attention.
 * •	If other actions, or other thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing – again, and again, and again.
 * •	Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.
 * •	If other actions, or other thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing – again, and again, and again.
 * •	Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.
 * •	If other actions, or other thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing – again, and again, and again.
 * •	Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.
 * •	Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.
 * •	Concentrate your mind. If you find you are doing two things at once, stop and go back to one thing at a time.

One-mindfully is sustained attention on the present moment which develops concentration. This skill is easier when you are interested in something and much harder when you are not. When you are doing something that you totally love, focusing on it whole-heartedly is easy. Intense total involvement follows from passionate interest. But how do you focus your mind when the activity is not as compelling as your favorite thing to do?

This paper seeks to explain the mindfulness skill one-mindfully in conjunction with the other DBT skills of emotional regulation, interpersonal effectiveness, distress tolerance, and the core mindfulness skills. One-mindfully is one of the “How” to take hold of your mind skills, along with non-judgmentally and effectively. The other mindfulness skills describe “What” to do to take hold of you your mind and include observe, describe, and participate. I have adopted the format of expanding Linehan’s instructions regarding one-mindfully with my explanations one-by-one.

Do one thing at a time.

When you are eating, eat.
 * The essence of mindfulness is acting with undivided attention.  One-mindfully is the discipline of doing one thing at a time with awareness. One-mindfully is the opposite of how most people operate.  Most of us think that if we do several things at once, we will accomplish more, but in the behavior laboratory those instructed to do one thing at a time actually accomplished more than those instructed to multi-task.
 * There are several advantages to doing one thing at a time besides increased productivity. When thoughts are racing, concentrating on one thing slows the mind.  Doing one thing at a time decreases anxiety by focusing the mind on one thing, pushing from one’s mind preoccupations and worries.
 * Like a guard at the palace gate who is alert to everything that happens you must be aware of every thought, emotion, and distraction. Such mindful watching brings your attention back to the present moment.  Doing one thing at a time is like driving a car and takes constant adjustments regarding the road and traffic.  But instead of a steering wheel and gas pedal, to stay in the present moment use the skills observe (just noticing the experience) and describe (putting words on the experience and the experience in words).  Using words this way makes you aware of what you are doing.
 * Like a guard at the palace gate who is alert to everything that happens you must be aware of every thought, emotion, and distraction. Such mindful watching brings your attention back to the present moment.  Doing one thing at a time is like driving a car and takes constant adjustments regarding the road and traffic.  But instead of a steering wheel and gas pedal, to stay in the present moment use the skills observe (just noticing the experience) and describe (putting words on the experience and the experience in words).  Using words this way makes you aware of what you are doing.
 * Like a guard at the palace gate who is alert to everything that happens you must be aware of every thought, emotion, and distraction. Such mindful watching brings your attention back to the present moment.  Doing one thing at a time is like driving a car and takes constant adjustments regarding the road and traffic.  But instead of a steering wheel and gas pedal, to stay in the present moment use the skills observe (just noticing the experience) and describe (putting words on the experience and the experience in words).  Using words this way makes you aware of what you are doing.

 * It is not unusual to mindlessly eat while watching TV, reading the paper, or walking around. Eating mindfully is very different experience than the way you normally eat.  Mindfully eating concentrates on the eating experience.  Only in the present moment do you experience the sensations of eating.  When you are present you can taste, feel, and smell the fleeting sensations of your food.  Mindful eating entails the effort to taste flavors, smell scents, and feel textures.  Slow down to observe and describe the experience of eating.  You are more likely to notice when you are feeling full when eating this way.  If you pay attention to the sensation of satiety, you will probably stop eating sooner.  Eating with sustained attention on the present moment helps you learn self-control and self-discipline.

When you are walking, walk.

 * Walking, too, can be a way to take hold of your mind. This is mentioned in the describe section, “…say in your mind… walking, step, step, step…” Describing walking this way increases awareness of your self and environment.  Your mind will slow as you focus on your movement.

When you are bathing, bathe.

 * Some people have a routine they go through every time they shower that allows them to concentrate on their actions mindfully. Bathing offers many opportunities of self-soothing.  Bathing with sustained attention is peaceful and calming.  Those moments of the day when you are bathing may help you cope with stress, relieve anxiety, and cultivate mindfulness.
 * Notice how water appears, feels, and sounds. Notice the smell of soap and shampoo.  Notice the difference between wet and dry, hot and cold.  Notice the transitions between turning on the water, getting in the water, wetting hair, shampooing, soaping, turning off the water, and drying.  You will have the opportunity to repeat your observations daily.

When you are working, work.

 * Work offers many opportunities for doing one thing at a time and overcome distractions. You may be surprised at how much you can be done if you set your mind to it.  Such a commitment to work helps you learn mastery, the feeling of being competent and in control.

 * Many people have told me that they do not have the same sorts of problems at work that they do at home. They admit that they are not willing to work for themselves as they are for others.  Are you
 * willing to work for what you want?

 * What is your life’s work? How does your work express you and your place in the world?  What attitude do you bring to the work you do?  What part of your work is play and what part of play is work?

 * When you are in a group, or a conversation, focus your attention on the very moment you are in with the other person.

 * Skills class is an opportunity to practice one-mindfully by devoting your full attention to learning skills.

When you are thinking, think.
 * In conversation, your ability to be interpersonally effective increases by practicing one-mindfully. No matter how nervous you are with another person, focusing your attention on the very moment you are in liberates you from troubling emotions such as doubt, worry, stress, and fear.  Letting go of troubling emotions sounds easy but is so hard.  But focusing with complete involvement leaves no room in consciousness for distractions like troubling emotions.

'''When you are worrying, worry. '''
 * Thinking this way is hard work! To think one-mindfully, try practicing the “How” skills observe, describe and participate with your thoughts in your mind.  Observe is useful because you must be aware of where your attention is at all times.  Observe is your mind’s eye, the witness to the fragile products of your thinking, your ideas.  Describe is putting words on thoughts and your thoughts into words.  When you enter into the experience of thinking completely, forgetting yourself, you are participating.  Think without the distraction of judging.  Effective thinking is flexible, intuitive and includes multiple perspectives.  An inquisitive and open-minded attitude helps you see yourself and others from fresh perspectives.

 * An effective therapy for worry: set aside 30 minutes a day to worry.  Go to the same place each day and try to spend the whole 30 minutes worrying.  During the rest of the day, banish worries from your mind, reminding yourself that you will attend to that particular worry during your worry time.  If you practice worrying one-mindfully, during the rest of the day, you will let go of your worries and free your mind to do something else.

When you are planning, plan.

 * The essence of planning is setting goals. A workable goal is specific, measurable, action-oriented, realistic, and time-conscious.  Your intention to make the future a certain way is an appropriate here-and-now activity.  Make plans for a life worth living.  Use a calendar and a list of things to do to schedule small steps to a future you want.

When you are remembering, remember.

 * A note about memory: there are voluntary and involuntary memories. Voluntary memories are the memories you choose to have and involuntary memories come unbidden.

 * When you are remembering, you are not playing back a tape of the event – you are attending to the present moment mentally retrieving the past. Voluntary memory is a mental event grounded in your historical experience.  There is an act of will in each memory.  One could say that memory is conjuring the past, i.e., evoking or calling forth as if by magic.  Note that memory takes effort, and if you want to remember something, you need to spend time remembering as many of the connected events as possible.

 * Involuntary memories are intrusive, come unbidden, and can be quite distracting. One way to reduce the effect of intrusive memories of the past is to use the mindfulness techniques outlined here.  It may seem backwards, but the Wise Mind way to deal with intrusive memories is to observe and describe them non-judgmentally (without an opinion about it).  Avoid avoiding memories.  Attend to your memory by attending to the present memory – non-judgmentally observe and describe it, and participate with it, if you can.  Accepting your memory is not approving of its’ content.  Notice it and then effectively go back to what you are doing.  When you are not remembering, focus on the present moment.

Do each thing with all of your attention.

 * Sustained mental attention or concentration is a powerful tool to bring to your daily activities. Doing each thing with all your attention will assist you doing what is needed in each situation.  Connecting yourself to your activities with attention is a simple idea, but the benefit of doing one thing with all your attention is enormous.
 * If other actions, or other thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing – again, and again, and again. The effort of doing each thing with sustained mental attention requires a commitment.   At first, you may only be able to focus your attention for a second.  But try, try again.
 * If other actions, or other thoughts, or strong feelings distract you, let go of distractions and go back to what you are doing – again, and again, and again. The effort of doing each thing with sustained mental attention requires a commitment.   At first, you may only be able to focus your attention for a second.  But try, try again.

 * For many the problem is letting go of distractions. Letting go of distractions (especially memories) may feel like abandonment.  Abandonment is a scary word for many, because they have been hurt so many times.  Letting go of certain memories may feel like abandonment.  You are leaving your old self (painful memories) and creating a new self.

 * Awareness of your attention gives you the opportunity to direct it to one thing or another. Distractions will come from all directions.  Let distractions go and turn your mind toward what you are doing.  Returning to what you are doing is powerful.
 * A deceptively simple strategy when you find your thoughts wandering astray is to say to yourself, “Be here now” and turn your mind toward what you are doing.

Concentrate your mind.

 * Concentration is the gathering of the mind, bringing all the parts together, uniting the mental faculties. Attention is focusing on a selected object.  Intuition, desire, and curiosity naturally concentrate your mind.  Concentration is one of the qualities of Wise Mind.If you find you are doing two things at once, stop and go back to one thing at a time.

 * Focusing on one thing in the moment does not mean that one cannot do complex tasks requiring many simultaneous activities. Like the dancer on the dance floor, at one with the music and her partner, attend completely to what you are doing.  Dancing integrates many processes – listening, moving, looking, and balance, but you are still doing only one thing.


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Dialectical Behavioral Therapy/Core Mindfulness Skills/Wise Mind

Wise Mind is the integration of emotion mind and reasonable mind. Emotion mind is characterized by mood dependent behavior, i.e. behavior that is determined by the current emotional state. Emotion mind is problematic because people often act impulsively under the effect of strong emotions. Reasonable mind, in contrast to emotion mind, is cool and deliberate. Reasonable mind is the product of learning, experience, and knowledge. Wise mind is the integration of emotion mind and reasonable mind but goes beyond both of them.

Wise Mind is a state of mind in which you experience yourself as being calm, centered, and in control of your emotions.

In Wise Mind, you act in accordance with your beliefs, principles, and values which deepens feelings of coherence and integrity.

Wise Mind is strengthened by practicing all skills, especially Core Mindfulness Skills.