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Life-Saving Things an Exercise Stress Test Can Tell You
Cardiovascular disease is the leading cause of death in the U.S., so it should go without saying that monitoring your heart health is imperative
What exactly is a stress test?
One of the most effective tools at your doctor's disposal when it comes to monitoring heart health is a stress test, which gives information on whether an artery may or may not be significantly blocked. Unfortunately, most Americans are more likely to adapt to stress than quell it.
How is a stress test usually performed?
Stress testing can be done in several ways. "Traditionally a patient is placed on a treadmill and runs at various rates; a bicycle may also be used," says South Florida cardiologist Adam Splaver, MD. The doctor administering the test will monitor to see how much exercise the patient's heart can manage before an abnormal rhythm starts or blood flow to the heart drops.
What does a stress test reveal?
According to David Greuner, MD, surgical director at NYC Surgical Associates, stress tests can help closely examine symptoms like chest pain, shortness of breath, or heart palpitations, check whether your heart medications are working, and determine the probability of having heart disease and need for further testing.
"Doctors may also recommend a stress test if you are starting a new exercise regimen to see if the level of exercise is right for you and what your heart can handle." In fact, there are a number of things to bear in mind when starting a new exercise plan.
How to prepare
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Before you take a stress test, according to Dr. Greuner, your doctor will advise you not to smoke, eat or drink anything except for water four hours before the test, and to not eat or drink anything with caffeine 12 hours before the test. Your doctor may also ask you not to take certain heart medications the day of your test. You may also want to read up on the 16 heart-health secrets your cardiologist wants you to know.
What to expect
During the stress test, a technician will put electrodes on your chest to monitor your heart, these will be attached to an EKG machine (an EKG shows the heart's electrical activity as line tracings on paper) to monitor your heart's electrical activity during the test. "First your heart rate and blood pressure will be monitored at rest, then the test will begin and you will either start walking on a treadmill or pedaling on a stationary bike," explains Dr. Greuner. "The test will gradually increase in difficulty and you'll continue to exercise until you feel exhausted." Here are some other tests that can detect silent heart disease.
Dobutamine or adenosine stress test
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Aside from the standard test, there are other stress tests such as the dobutamine or adenosine stress test, which is for people unable to exercise. "During this test, a doctor administers a drug to make the heart respond as if they were exercising and monitors the patient to determine if there are any blockages in the arteries," explains Dr. Greune. "A stress echocardiogram can visualize the motion of the heart's walls and pumping while the heart is stressed to potentially identify a lack of blood flow."
Nuclear stress test
sfam photo/Shutterstock
Another type of stress test is the nuclear stress test, which uses a small amount of radioactive substance to determine the health of the heart and blood flow to the heart. "It's used to help determine which parts of your heart are not working effectively," explains Dr. Greuner. Check out the five tests for your heart that can save your life.
Is there a chance that results can be wrong?
As with any medical test, there is always room for error and inaccurate results with a stress test. "While an exercise stress test can pick up on a significant blockage, a smaller blockage may be missed and not be picked up," says Dr. Greuner who goes on to explain that if you're taking heart medications this can also have an effect on the results, which is why your doctor may ask you to stop taking certain medications before the test.
Keep demographics in mind
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Not finding heart disease when it's there is called a false negative, but it's also possible to have a false positive: Your doctor might think you have heart issues when you're actually fine. The risk of this happening increases depending on who is being tested. "For example, if a 22-year-old woman has a positive stress test, the likelihood of her having coronary artery disease is low and indicates a false positive," notes Dr. Splaver. "However if a 65-year-old male diabetic hypertensive with a family history of cardiovascular disease has a negative stress test, it is most likely a false negative." Clearly the patient's demographic characteristics play a large role in interpreting any stress test and therefore having a skilled cardiologist is key. If you have risk factors, here are 15 life-saving tips on preventing heart disease.
Knowing risk factors is imperative
Given the room for error, it's imperative to be aware of the symptoms of heart disease and your risk factors of getting it, such as having a family history. Check out the five heart disease risk factors not a lot of people know about. You also should keep your doctor informed of all symptoms. "A stress test should be used as a tool to determine the probability of a patient having coronary artery disease, but shouldn't be used to completely rule it out or diagnose someone," cautions Dr. Greuner.
Lastly, remember that many factors are in your control. Here are some easy ways to incorporate heart-boosting activities to your daily life.


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Chapter 1- Outline
Todd Switzer
Introduction:My topic is on Post Traumatic Stress Disorder (PTSD) and the effects it has on Veterans.My biggest concern is wondering if veterans are receiving the care they need, and the effects ofthese treatments on them to treat PTSD. Also, PTSD is defined as a mental health condition that'striggered by a terrifying event (Chamberlin, Sheena, 2012). Symptoms may include flashbacks,nightmares and severe anxiety, as well as uncontrollable thoughts about the event (Chamberlin,Sheena, 2012). I chose to focus on Veterans because I have several in my family and I was raisedto respect and honor our heroes. Overall the number one mental health concern for Veterans isPTSD based on the multiple stress accumulated on veterans during their time overseas.Additionally, PTSD has been around as long as humans have been around, traumatic andterrifying events happen every day to someone in the world. I was curious as to how medicalprofessionals treat such a broad and big mental health issue in todays society.Furthermore, my research will be conducted on Veterans in the NortheasternPennsylvania area who receive treatment at Wilkes-Barre VA Hospital. I plan to do a survey thatwill focus on the veterans age, gender, wars fought in , branch of military, time in the militarywhen first PTSD symptoms occurred, treatment being received, symptoms, and if there issomething missing you wish to be added in your treatment plan. PTSD was not diagnosed as amental health concern until after the Vietnam War (Chamberlin, Sheena, 2012). Before the warmany Veterans suffered from PTSD but were simply told it was a side effect of war. Theyreferred to this as Shell Shock before PTSD was diagnosed. World War I & II Veterans neverreceived treatment for PTSD because it was not considered a medical issue during this era.
PTSD can lead to many negative health issues and if not diagnosed the Veteran will be unable toreceive the care needed. Among the highest outcomes of PTSD would be sleep deprivation,alcohol or substance abuse, depression, nightmares, social discomfort, uncontrollable stress,aggressive outbursts, and sometimes suicide. PTSD not only affects the entire family but alsosociety as well.Furthermore, this research is very important because many Veterans commit suicide eachyear and could be prevented if they received help. The military rate of suicide is 22 per 100,000and now exceeds the general population of the United States which is 18 per 100,000 (Lee,2012). In my opinion every Veteran returning home from overseas should be screened forPTSD. The treatment for PTSD is very broad and treatment is very different for each individual.We see PTSD in movies and on television shows with war heroes returning home to theirfamilies, having a hard time returning back to society. After a traumatic event has happened itscars the individual, and healing that scare is something we need to do a better job at here in theUnited States.Also creating more awareness and how you can assist a loved one who is seeking medicalassistance may save his/her life. Suicide prevention hotlines are a big part of VA hospitalsprotocol and are handled very professionally. They also offer many social groups where Veteransmeet and talk about their issues when returning to society and the scars suffered overseas. I wantto gather research from Veterans first hand to help access the care they are being offered, andlook at what they feel would benefit them further if it was offered to them.Statement of the Problem
Research is very important in this area because PTSD is a newer medical illness. Thereare many people who suffer from PTSD who receive little to no help. The side effects forsomeone who has PTSD are never good and in most cases cause more damage than already hasbeen done. Awareness and social groups should be given to any Veteran returning home in needof anything for physical, emotional, or social injury. Treatment may be different for every patientso more research and possible treatment options should be the primary goal for this illness.Purpose of the Study:The purpose of this research is to gather first-hand information on the care beingprovided to Veterans who suffer from PTSD. I plan to do a survey and distribute to as manyVeterans as I can at the Wilkes-Barre VA Hospital to get their perspective regarding the carebeing provided to them. I would like to see if age plays a factor as well. It is apparent to me thatPTSD was not diagnosed until after the Vietnam War. If you have Veterans from that war andyoung Veterans coming home from Iraq, I wander if they receive the same care. The oldergeneration of Veterans who have PTSD never received care until much later, while Veteranstoday are receiving care a lot quicker due to all the awareness.Research Question:What are the effects of PTSD on veterans, and the attendant care required?Sub Question 1: What is Post-Traumatic Stress Disorder?Sub Question 2: What symptoms are associated with PTSD?Sub Question 3: What are the advantages of receiving care for PTSD?Sub Question 4: What funding is being done on research for PTSD/ qualityof care?
Sub Question 5: What are the changes observed in patients who receive care?
Null Hypothesis:There is no difference between early treatment, attendant care, and symptomimprovement in veteransHypothesis:Are there enough veterans being treated early enough when symptoms first occur and dotheir symptoms improve after care is given? Are health professionals observing the signs earlyenough when caring for veterans with PTSD? Are the symptoms broadcasted well enough as toanyone can access them? Are there examples of veterans who received care posted for others toobserve? Are there increases in funding for PTSD now that awareness is so high?Definition of Terms:Post-Traumatic Stress Disorder- Post-traumatic stress disorder (PTSD) is a debilitating anxietydisorder that occurs after experiencing or witnessing a traumatic event that involves either a realor perceived threat of injury or death. This can include a natural disaster, combat, an assault,physical or sexual abuse, or other trauma ("Dictionary,).Flash Backs-recurrent and abnormally vivid recollection of a traumatic experience, as a battle, sometimesaccompanied by hallucinations ("Dictionary,).
Shell ShockAlso called: combat neurosis, loss of sight, memory, etc, resulting from psychological strain during prolonged engagement in warfare ("Dictionary,).Stress- the physical pressure, pull, or other force exerted on one thing by another; strain("Dictionary,)
Sleep Deprivationthe condition of being robbed of sleep, in real life or in experiment, as opposed to beingunable to sleep ("Dictionary,).Substance AbuseLongterm, pathological use of alcohol or drugs, characterized by daily intoxication, inability to reduceconsumption, and impairment in social or occupational functioning; broadly, alcohol or drug addiction ("Dictionary," ).Depression-A condition of general emotional dejection and withdrawal; sadness greater and more prolonged than that warranted by any objective reason ("Dictionary,).DelimitationsResearch will be conducted on Veterans who receive care through the Wilkes-Barre VAhospital only. Male or Female Veterans are both welcome. Veterans must be diagnosed withPTSD to take the survey. The more age fluctuations the better so I get data from Veterans frommany different wars and time periods. They must be eighteen years or older, and they arerequired to be eighteen before being able to join the military. Any branch of the military iswelcome.
Limitations Only give survey to Veterans who are in the VA hospital receiving care so not just anyoneon the street is filling out the survey which could jeopardize the data. Veterans are usuallyrespectable so lying about answers is usually not the case but some may not list all the symptomsthey are suffering from out of toughness. Patients may not take the survey seriously and justwrite down random responses.AssumptionsI assume the Veterans who take this survey to fill it out with honesty and show genuinecare for the data I am collecting, and dont try to hide certain symptoms or treatments that maybe false. I expect every Veteran to list one thing they believe should be added into their care tohelp treat PTSD. This may spread the awareness of each Veterans opinion to share with many inthe hope to help hopefully some Veterans needing assistance.Significance of StudyThe research will help generate knowledge and awareness: Knowledge in the sense thatwe should always be adding possible care outcomes to patients. Each patients care is differentfor PTSD, so providing numerous treatment options will help provide the highest level of carefor all veterans. I anticipate this research also helps Veterans get tested for PTSD whensymptoms are low before they escalate quickly. The research will also allow me to assess andview events from a Veterans point of view rather than a medical professionals point of view.This will also help structure PTSD in several different eras through several different branches ofthe military.
References1. Chamberlin, E., & Sheena, M. (2012). Emasculated by trauma: A social history of
Chapter 2Research Question: What are the effects of PTSD on veterans, and the attendant care required?Hypothesis: Is there enough veterans being treated early enough when symptoms first occur anddo their symptoms improve after care is given.
Prediction: A greater awareness for those coming home that require medical, social, andfinancial support for their PTSD symptoms. With the numerous wars more men/women arereturning home with PTSD symptoms and are they receiving the care they need as well as followup care.
IntroductionPost-Traumatic Stress DisorderHistory and the beginning of PTSD3. Chamberlin, E., & Sheena, M. (2012). Emasculated by trauma: A social history of
The article discusses the history of post-traumatic stress disorder (PTSD) and similar traumainduced nervous disorders in the context of U.S. social history. It is said that military physiciansgradually changed their views of the masculinity of soldiers in light of the phenomenonsometimes called shell shock and combat fatigue. The author notes the high incidence of PTSDamong U.S. soldiers deployed in Operation Enduring Freedom (OEF) and Operation IraqiFreedom (OIF). In this context, PTSD has purportedly been medicalized.
2. Kolk, B., &Najavits, L. M. (2013). Interview: What is PTSD really? Surprises, twists ofhistory, and the politics of diagnosis and treatment. Journal of Clinical Psychology, 69(5), 516522. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=86980700&site=ehost-live
The article presents a discussion about the psychological disorder post-traumatic stress disorder(PTSD), particularly commenting on issues of diagnosis and treatment. It addresses thediagnostic criteria of PTSD as recognized by the Diagnostic and Statistical Manual for MentalDisorders (DSM), the political connotations of PTSD due to the frequency of veterans presentingwith symptoms, and the social aspects of PTSD.
111. Hart, R.H. (2003). A Face of War: PTSD. The Psychiatric times.Vol.06-Section: 01;Pgs: 20:50. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=10054516&site=ehost-live
A Background story about a veteran who suffered from PTSD. Irish Tom" was thefirst war veteran I knew who suffered from shell shock. I met him in December 1939when I was 10 years old, and although I never saw him again after 1942, I can stillpicture him in my mind. He was a tall, lean-fleshed man who appeared old in yearsfor someone in his 40s. His hands shook, his voice was tremulous, and there was adistant look in his eyes as though he were somewhere else. "A casualty of the GreatWar," was what adults said about him in whispering tones. One of the first to sufferfrom shell shock, which was PTSD before its classification.
The purpose of this case study is to present the complex contribution of combat-related posttraumatic stress disorder (PTSD) to suicide and international standards of treatment amongveterans deployed to the Middle East. CONCLUSIONS: PTSD carries increased physical andpsychological health risk in combat soldiers. Internationally, guidelines for PTSD promotecognitive behavior therapies, specifically exposure therapy, as first line treatment; however,implementation varies among countries. PRACTICE IMPLICATIONS: Evidence supports thebenefit of exposure-based psychotherapy for combat-related PTSD. Commonly prescribedantidepressants and other psychotherapy treatments may not be as beneficial.
4. Haley, S. A. (1985). Some of my best friends are dead: Treatment of the posttraumaticStress disorder patient and his family. Family Systems Medicine, 3(1),17-26. Retrieved from: http://search.ebscohost.com
Presents a brief historical review of combat psychiatry and argues the inadequacy of earlierpsychoanalytic theories to fully appreciate the deforming impact of combat on psychicstructures. The psychotherapy of Vietnam combat veterans poses unusual challenges becausemajor traumas occur at a developmentally vulnerable time and under conditions of minimalsocial support. Difficulties are often triggered by the death of a close friend. The psychotherapistmay be drawn into this chaotic maelstrom and is necessarily at risk. A detailed case report of a25-yr-old Black married ex-Marine combat veteran illustrates the difficulties of treatingposttraumatic stress disorder.
3. Bullman, T. A. & Kang, H. K. (1996). The risk of suicide among wounded Vietnamveterans. American Journal of Public Health, 86(5), 662-662... Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=9606201935&site=ehost-live
This study was undertaken to determine whether an association exists between combat traumaand risk of post service suicide among Vietnam veterans. Methods: Risk of suicide for 34534veterans who were wounded in Vietnam was evaluated for severity of wound and number oftimes wounded. Results: There was a trend of increasing risk of suicide with increasedoccurrence of combat trauma, the highest relative risk (1.82, 95% confidence interval [CI] =1.12, 196) being observed for those veterans who were wounded more than once andhospitalized for a wound. In comparison with the US male general population, veteranshospitalized because of a combat wound or wounded more than once had a significantlyincreased risk of suicide (standardized mortality ratios [SMRs] of 1.22 [95% CI = 1.00, 1.46] and1.58 [95% Cl = 1.06, 2.26], respectively). Those wounded more than once and hospitalized had
the highest increased risk of suicide (SMR = 1.73, 95% CI = 1.10, 2.60). Conclusions: This studysuggests that, among wounded Vietnam veterans, there is an increased risk for suicide associatedwith increased occurrence of combat trauma.
With the large number of Veterans experiencing posttraumatic stress disorder (PTSD) andchronic pain, the purpose of this article is to review the prevalence of PTSD and chronic pain,the theoretical models that explain the maintenance of both conditions, and the challenges facedby providers and families who care for these patients. The Department of Veterans Affairs(VA)/Department of Defense (DOD) VA/DOD Clinical Practice Guideline for Management ofPost-Traumatic Stress with special attention to chronic pain are presented. Limited scientificevidence supports specific care and treatment of PTSD and chronic pain, and this challengesproviders to investigate and research potential treatment options. Integrated care modelsdesigned for working with these patients are reviewed, including a focus on the techniques andstrategies to address not only PTSD and chronic pain, but other conditions, including substancedependence and depression. A specific focus on headaches, back pain, and neuropathic painfollows, including treatment recommendations such as pharmacological, psychotherapeutic, andcomplementary approaches, given the high rates of these pain complaints for Veterans in PTSDclinical programs. Integrated care is presented as a viable solution and approach that challengesclinicians and researchers to develop innovative, scientifically based therapeutics and treatmentsto enhance the recovery and quality of life for Veterans with PTSD and chronic pain.
Wars1. Cifu, D. X., Taylor, B. C., Carne, W. F., Bidelspach, D., Sayer, N. A., Scholten, J., & HagelCampbell, E. (2013). Traumatic brain injury, posttraumatic stress disorder, and pain diagnoses inoif/oef/ondveterans.Journal of Rehabilitation Research & Development, 50(9), 1169-1176.Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=93923241&site=ehost-live
To identify the prevalence of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD),and pain in Veterans from Operation Iraqi Freedom/Operation Enduring Freedom/Operation NewDawn (OIF/OEF/OND), Veterans who received any inpatient or outpatient care from VeteransHealth Administration (VHA) facilities from 2009 to 2011 were studied. A subset of Veteranswas identified who were diagnosed with TBI, PTSD, and/or pain (head, neck, or back) asdetermined by their International Classification of Diseases-9th Revision-Clinical Modificationcodes. Between fiscal years 2009 and 2011, 613,391 Veterans accessed VHA services at leastonce (age: 31.9 +/- 9.6 yr). TBI diagnosis in any 1 year was slightly less than 7%. When datafrom 3 years were pooled, 9.6% were diagnosed with TBI, 29.3% were diagnosed with PTSD,and 40.2% were diagnosed with pain. The full polytrauma triad expression (TBI, PTSD, andpain) was diagnosed in 6.0%. Results show that increasing numbers of Veterans fromOIF/OEF/OND accessed VHA over a 3 year period. Among those with a TBI diagnosis, themajority also had a mental health disorder, with approximately half having both PTSD and pain.While the absolute number of Veterans increased by over 40% from 2009 to 2011, the proportionof Veterans diagnosed with TBI and the high rate of co morbid PTSD and pain in this populationremained relatively stable.
2. Resnick, H. S., Foy, D. W., Donahoe, C. P., & Miller, E. N. (1989). Antisocial behavior andpost-traumatic stress disorder in Vietnam veterans. Journal of Clinical Psychology, 45(6), 860-
Assessment data from 118 Vietnam-era veterans seeking psychological services at two LosAngeles Veterans Administration Medical Centers were analyzed to examine the potentialrelationships between number of pre-adult and adult antisocial behaviors, as defined in theDiagnostic and Statistical Manual of Mental Disorders (DSM-III; American PsychiatricAssociation, 1980) criteria for antisocial personality disorder, level of combat exposure, anddevelopment of combat-related post-traumatic stress disorder (PTSD). Results of hierarchicalregression analyses indicated that combat exposure level was related significantly to PTSDsymptomatology, whereas number of pre-adult antisocial behaviors was not. However, bothcombat exposure level and pre-adult behaviors, which were not correlated significantly, wererelated significantly to number of adult antisocial behaviors. There were no significantinteraction effects. Results were consistent with a theoretical model of PTSD development thatemphasizes the role of trauma vs. premorbid character logical factors. In addition, the significantassociation between combat exposure and adult antisocial behavior indicates that trauma mayplay a role in the development and/or maintenance of adult antisocial behaviors observed insome Vietnam veterans.
Investigates the early memories of Vietnam War veterans with posttraumatic stress syndrome inthe U.S. Reflection of less social interest; Pursuance of more negative outcomes and themes;Victims of excessive or incorrect school discipline. Looks at early memories of veterans withPTSD and their experiences with PTSD. The first Veterans with PTSD struggled simply becausePTSD was considered just a symptom of war.
17Defense VA/DOD Clinical Practice Guideline for Management of Posttraumatic Stressincludes irritability, severe agitation, and anger as specific symptoms thatfrequently co-occur with PTSD. For the first time, the guideline includes nine specificrecommendations for the assessment and treatment of PTSD-related anger,irritability, and agitation. This article will review the literature on PTSD and itsassociation with anger and aggression. We highlight explanatory models for theseassociations, factors that contribute to the occurrence of anger and aggression inPTSD, assessment of anger and aggression, and effective anger managementinterventions and strategies.
3. Wilk, J. E., West, J. C., Duffy, F. F., Rae, D. S., Hoge, C. W., &Herrell, R. K. (2013).Use of evidence-based treatment for posttraumatic stress disorder in armybehavioral healthcare. Psychiatry: Interpersonal & Biological Processes, 76(4),336-348. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=92692412&site=ehost-liveTo identify the extent to which evidence-based psychotherapy (EBP) andpsychopharmacologic treatments for posttraumatic stress disorder (PTSD) areprovided to U.S. service members in routine practice, and the degree to which theyare consistent with evidence-based treatment guidelines. Method: We surveyed themajority of Army behavioral health providers (n = 2,310); surveys were obtainedfrom 543 (26%). These clinicians reported clinical data on a total sample of 399service member patients. Of these patients, 110 (28%) had a reported PTSDdiagnosis. Data were weighted to account for sampling design and no responses.Results: Army providers reported 86% of patients with PTSD received evidencebased psychotherapy (EBP) for PTSD. As formal training hours in EBPs increased,reported use of EBPs significantly increased. Although EBPs for PTSD were reportedto be widely used, clinicians who deliver EBP frequently reported not adhering to allcore procedures recommended in treatment manuals; less than half reported usingall the manualized core EBP techniques. Conclusions: Further research is necessaryto understand why clinicians modify EBP treatments, and what impact this has ontreatment outcomes. More data regarding the implications for treatmenteffectiveness and the role of clinical context, patient preferences, and clinicaldecision-making in adapting EBPs could help inform training efforts and the waysthat these treatments may be better adapted for the military.
18This study addresses two issues: treatment changes on the MCMI of Vietnamveterans with PTSD and test-retest reliability of the Million Clinical MultiaxialInventory (MCMI). Fifty Vietnam veterans carefully were identified for the diagnosisPost-Traumatic Stress Disorder (PTSD). They were admitted to a Special PTSDTreatment Unit that consisted of an intense S-week period with the focus on therevivified Vietnam experience. They also were given the MCMI at two points in time,treatment inception and 35 days later at discharge. Results show that 17 of 20scales on the MCMI changed in the negative direction as a result of treatment. Also,the MCMI has adequate test-retest reliability, and the personality scales (with theexception of Borderline) have higher reliability coefficients than do symptom scales.The use of the MCMI is encouraged both as a monitor of treatment for theseveterans and for its stability.
19relationship building, the development of emotional and cognitive connections withthe trauma, recognition of the divergence between pre- and post-trauma values,modifying one's sense of self, establishing meaning for the trauma, andreestablishing appropriate self-management and social skills. The authorsemphasize the importance of the therapistveteran relationship to clientengagement in the recovery process. Case vignettes are included to illustratemodel dynamics.
Flash Backs1. Russell, S. S. (2013). Veterans' stories: What they may have to tell us - apersonal reflection. Urologic Nursing, 33(2), 92-96. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=86861350&site=ehost-liveIt has been said that we learn much from war. Not only how to conduct it and tobe successful, but we learn how the body works and how to assist in regainingfunction. Without our veterans, much of today's medical knowledge would not benearly as complete. We have learned how to care for and celebrate our veteranswhen they return from the war. Vietnam veterans can share what it is like tocome home to a country that is not only entirely different, but even antagonistic,to the veteran as a person. This article will consider the types of homecomingexperiences veterans have encountered while also introducing examples of themedical knowledge that has been gained from the struggles of those who havefought, and often died, for our country.
20Stress1. Nash, W. P., & Watson, P. J. (2012). Review of VA/DOD clinical practiceguideline on management of acute stress and interventions to preventposttraumatic stress disorder. Journal of Rehabilitation Research &Development., 49(6), 637-648. Retrievedfrom:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=79731016&site=ehost-liveThis article summarizes the recommendations of the Department of VeteransAffairs (VA)/Department of Defense (DOD) VA/DOD Clinical Practice Guidelinefor Management of Post-Traumatic Stress that pertain to acute stress and theprevention of posttraumatic stress disorder, including screening and earlyinterventions for acute stress states in various settings. Recommendedinterventions during the first 4 days after a potentially traumatic eventinclude attending to safety and basic needs and providing access to physical,emotional, and social resources. Psychological first aid is recommended formanagement of acute stress, while psychological debriefing is discouraged.Further medical and psychiatric assessment and provision of brief, traumafocused cognitive-behavioral therapy are warranted if clinically significantdistress or functional impairment persists or worsens after 2 days or if thecriteria for a diagnosis of acute stress disorder are met. Follow-up monitoringand rescreening are endorsed for at least 6 months for everyone whoexperiences significant acute posttraumatic stress. Four interventions thatillustrate early intervention principles contained in the VA/DOD ClinicalPractice Guideline are described.
Sleep Depravation1. Lewis, V., Creamer, M., &Failla, S. (2009). Is poor sleep in veterans a functionof post-traumatic stress disorder? Military Medicine, 174(9), 948-951.Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=44204038&site=ehost-liveSubstantial research has demonstrated an association between posttraumatic stress disorder (PTSD) and quality of sleep, particularly in veteranpopulations. The exact nature of this relationship, however, is not clear. Thepossibility that poor sleep is a more general experience among veterans hasnot been explored to date, with most studies focusing only on veteran
21populations with PTSD. This pilot study aimed to explore whether sleepdisturbance is common to veterans generally or simply those with PTSD. Datawere collected from a community sample of 152 Australian Vietnam warveterans, 87 of whom did not meet criteria for PTSD. All those with PTSD and90% of those without PTSD reported clinically significant sleep disturbance,indicating that serious sleep problems are common across the veteranpopulation. Despite the limitations of this initial study, these results highlightthe importance of ensuring that research into sleep disorders in veterans withPTSD pays attention to the potential etiological role of other military factors,including deployments.
Substance Abuse1. Seidel, R. W., Gusman, F. D., &Abueg, F. R. (1994). Theoretical and practicalfoundations of an inpatient post-traumatic stress disorder and alcoholismtreatment program. Psychotherapy: Theory, Research, Practice,Training, 31(1), 67-78. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=pdh&AN=199446047-001&site=ehost-liveDescribes the structure and process of an inpatient program for thetreatment of posttraumatic stress disorder (PTSD) and alcoholism. Thetherapeutic community setting uses lifespan developmental and sociallearning models to provide patients with (1) a framework for understandingwhat has happened to them, (2) tools for more effective coping, (3) an arenato experience the discomfort of previous coping mechanisms, and (4) theanxiety/pleasure of creating and practicing a new and more effectiverepertoire of skills. The program is divided into 3 phases. Phase 1 focuses onsolidifying motivation for change through assessment, education, andinterpersonal work. Phase 2 represents the action stage, and incorporatesexposure-based therapy in a developmental framework to address traumaissues. Phase 3 emphasizes maintenance and generalization of patients'learning via modified relapse prevention training.
22exposed veterans in the Afghanistan and Iraqi military theaters ofoperations. International Journal of Methods in Psychiatric Research, 21(1), 516. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=73176897&site=ehost-liveFew studies have investigated the natural history of post-traumatic stressdisorder (PTSD). Project VALOR (Veterans' After-discharge LongitudinalRegistry) was designed as a longitudinal patient registry assessing the courseof combat-related PTSD among 1600 male and female Veterans who servedin Operation Enduring Freedom (OEF) in Afghanistan or Operation IraqiFreedom (OIF). Aims of the study include investigating patterns andpredictors of progression or remission of PTSD and treatment utilization. Thestudy design was based on recommendations from the Agency for HealthcareQuality and Research for longitudinal disease registries and used a prespecified theoretical model to select the measurement domains for datacollection and interpretation of forthcoming results. The registry will include1200 male and female Veterans with a recent diagnosis of PTSD in theDepartment of Veteran Affairs (VA) electronic medical record and acomparison group of 400 Veterans without a medical record-based PTSDdiagnosis, to also allow for case-control analyses. Data are collected fromadministrative databases, electronic medical records, a self-administeredquestionnaire, and a semi-structured diagnostic telephone interview. ProjectVALOR is a unique and timely registry study that will evaluate the clinicalcourse of PTSD, psychosocial correlates, and health outcomes in a carefullyselected cohort of returning OEF/OIF Veterans.
23and satisfaction with health care among 490 patients. Results: Veterans from NewYork City reported better health and more satisfaction that their providers listenedto them. Patients with more PTSD symptoms reported poorer health, moreSeptember 11-related symptoms, and less satisfaction with care and were morelikely to seek care outside the Veterans Affairs system. Conclusions: Proximity to theSeptember 11 terrorist attacks had little relationship to patients' perceptions of theirhealth and health care, whereas PTSD symptoms had a pervasive effect. Patientswith PTSD symptoms may require outreach programs to assist them in dealing withcatastrophic events, regardless of their proximity to the events.
2. Twamley, E. W., Baker, D. G., Norman, S. B., Pittman, J. O. E., Lohr, J. B., &Resnick,S. G. (2013). Veterans health administration vocational services for operation Iraqifreedom/operation enduring freedom veterans with mental health conditions.Journal of Rehabilitation Research & Development, 50(5), 663-670. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=90133101&site=ehost-liveHigh rates of mental health conditions and unemployment are significant problemsfacing Veterans of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF).We examined two national Veterans Health Administration (VHA) databases fromfiscal years 2008-2009: a larger database (n = 75,607) of OIF/OEF Veterans withposttraumatic stress disorder, depression, substance use disorder, or traumaticbrain injury (TBI) and a smaller subset (n = 1,010) of those Veterans whoseemployment was tracked during their participation in VHA vocational services. Only8.4% of Veterans in the larger database accessed any vocational services andretention was low, with most Veterans attending one or two appointments. Veteranswith TBI and with more mental health conditions overall were more likely to accessvocational services. Only 2.2% of Veterans received evidence-based supportedemployment. However, supported employment was effective, with 51% of thoseVeterans receiving it obtaining competitive work. Effect sizes quantifying the effectof supported employment provision on competitive work attainment, number ofjobs, job tenure, and retention in vocational services were large. Given the highsuccess rate of supported employment for these Veterans, additional supportedemployment specialists for this population would be expected to improve workoutcomes for post-9/11 Veterans who want assistance returning to work.
3. Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J., Hamblen ,J. L., & Friedman, M. J. (2009). Veterans with history of mild traumatic brain injuryand posttraumatic stress disorder: Challenges from provider perspective. Journal ofRehabilitation Research & Development, 46(6), 703-715. Retrieved from
24http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=48075779&site=ehost-liveThe Department of Veterans Affairs (VA) has separate clinical structures and careprocesses for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).However, because veterans are returning from the wars in Iraq and Afghanistan withTBI (most frequently mild TBI [mTBI]) and PTSD, the VA needs to evaluate currentservice delivery systems. We conducted key informant interviews with 40 providersfrom across the United States who represented separate clinical teams providingspecialized TBI or PTSD services. We identified challenges providers perceive inscheduling and engaging patients with co-occurring mTBI and PTSD (mTBI/ PTSD) intreatment, determining the etiology of patients' presenting problems, coordinatingservices, and knowing whether or how to alter standard treatments. We foundconsensus that patients with mTBI/PTSD often have other morbidities requiringspecialized treatment, including pain and sleep disturbance. Another importanttheme we found was the need for patient and family educational material onmTBI/PTSD or pain and mTBI/PTSD and provider education tailored to providerspecialty. Together, findings point to the need for guidance for providers on bestpractices to assess and treat mTBI/PTSD given available information, a systematicapproach toward patient and provider education, and research to build the evidencebase for practice.
The present study examined psychological coping styles and mental healthtreatment histories in veterans with PTSD. This study also served as a replicationand extension of an earlier investigation that assessed the prevalence of PTSD inWorld War 11, Korea, and Vietnam combat veterans who were seeking medicaltreatment. Thirty-six combat veteran medical patients were compared to 38 war-eracontrols. Nearly a third of the combat veterans met psychometric criteria for PTSD;none of the controls met these criteria. Both PTSD-positive subjects and mentalhealth treatment seekers showed a significantly greater use of emotion-focusedcoping. Results also showed that Vietnam combatants were more likely to havereceived individual mental health treatment. These findings and their treatmentimplications are discussed.
2. Bormann, J. E., Hurst, S., & Kelly, A. (2013). Responses to mantram repetitionprogram from veterans with posttraumatic stress disorder: A qualitativeanalysis. Journal of Rehabilitation Research & Development., 50(6), 769-784.Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=90169700&site=ehost-liveThis study describes ways in which a Mantram Repetition Program (MRP) was usedfor managing posttraumatic stress disorder (PTSD) symptoms in 65 outpatientVeterans with PTSD. The MRP consisted of six weekly group sessions (90 min/wk.)on how to (1) choose and use a Mantram, (2) slow down thoughts and behaviors,and (3) develop one-pointed attention for emotional self-regulation. Critical incidentresearch technique interviews were conducted at 3 mo.post intervention as part of alarger randomized clinical trial. The setting was an academic-affiliated Departmentof Veterans Affairs hospital in southern California. Categorization and comparison ofthe types and frequency of incidents (i.e., triggering events) were collected.Participants reported a total of 268 triggering events. Content analysis of theoutcomes resulted in 12 discreet categories, including relaxing and calming down,
26letting go of negative feelings, thinking clearly and rationally, diverting attentionaway from triggering events, focusing attention, refining Mantram skills, dealingwith sleep disturbances, coming back from flashbacks, slowing down,communicating thoughts and feelings more effectively, feeling in touch spiritually,and letting go of physical pain. The study shows that the MRP was helpful inmanaging a wide range of emotional reactions in Veterans with PTSD.
3. Burke, H. S., Degeneffe, C. E., & Olney, M. F. (2009). A new disability forrehabilitation counselors: Iraq war veterans with traumatic brain injury and posttraumatic stress disorder. Journal of Rehabilitation, 75(3), 5-14. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=45463593&site=ehost-liveTraumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) areconsidered the "signature" injuries of military personnel serving in the Iraq war. Analarming number of returning veterans are incurring a combination of these twodisabilities. TBI and PTSD combined presents an array of challenges for injuredpersons that are experienced differently by those separately affected by TBI orPTSD. Hence, the combination of TBI and PTSD presents a new disabilityclassification for the rehabilitation counseling profession. There is an acute need todevelop and facilitate specialized care and rehabilitative services for veteransimpacted by this nascent disability. We highlight neurobiological, behavioral, andphysiological characteristics associated with combat-incurred TBI/PTSD injuries.Additionally, we offer recommendations for rehabilitation counseling professionalsand researchers to consider in response to our review of the current system ofveteran care, common barriers to rehabilitation and societal re-integration, andavailable resources for military personnel impacted by TBI and PTSD.
4. Cook, J. M., Dinnen, S., O'Donnell, C., Bernardy, N., Rosenhack, R., & Hoff, R.(2013). Iraq and Afghanistan veterans: National findings from VA residentialtreatment programs. Psychiatry: Interpersonal & Biological Processes, 76(1),retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=85872953&site=ehost-liveA quality improvement effort was undertaken in Department of Veterans Affairs'(VA) residential treatment programs for Posttraumatic Stress Disorder (PTSD) acrossthe United States. Qualitative interviews were conducted with over 250 directors,providers, and staff during site visits of 38 programs. The aims of this report are todescribe clinical issues and distinctive challenges in working with veterans from Iraqand Afghanistan and approaches to addressing their needs. Providers indicated thatthe most commonly reported problems were: acute PTSD symptomatology; othercomplex mental health symptom presentations; broad readjustment problems; and
27difficulty with time demands of and readiness for intensive treatment. Additionalconcerns included working with active duty personnel and mixing different eras intherapy. Programmatic solutions address structure (e.g., blended versus era-specifictherapy), content (e.g., physical activity), and adaptations (e.g., inclusion of family;shortened length of stay). Clinical implications for VA managers and policy makersas well as non-VA health care systems and individual health care providers arenoted.
ConclusionThe goal of this research is to provide helpful information to the men andwomen returning from war who show early signs of PTSD. Also the Veteransresearch being done is to evaluate the level of care being provided to these bravemen and women who protect us and keep us safe. Providing knowledge andawareness as well as early signs will help keep more veterans alive past their timeas soldiers. This work is also designed to provide knowledge of PTSD from the startas well as the effects it takes on both the mental as well as the social health of anindividual. The evaluations are designed to show where individuals are receivingcare and what steps should be taken to provide improved care.
Chapter IIIMethodologyResearch DesignAcross sectional research design will be utilized to assess the impact of quality of care onveterans with PTSD. The survey will be given to veterans who are receiving care at the Wilkes
Barre VA Hospital. The survey will focus on the quality care they are receiving for PTSD. Therewill be various questions asking age, branch, years served, wars fought in, education level, andage when diagnosed with PTSD, symptoms, care being given for PTSD, improvements needed tocare, treatment trajectory, and several others to determine percentages regarding PTSD care forveterans.ParticipantsThe design of this study will be a cross sectional design. Sample size for this study willbe determined using G*Power 3.1.7. An a priori power analysis will be computed to reach 80%power using an alpha value set at .05. Recruitment will remain open until the minimum numberof participants are recruited.Research will be conducted on Veterans who receive care through the Wilkes Barre VAhospital only. Male and female Veterans will be recruited for this study. Veterans must bediagnosed with PTSD to take participate. Participants must be over the age of 18. Any branch ofthe military is eligible. All veterans taking the survey will be recruited from the VA Hospital inWilkes Barre Pennsylvania. The entire study should take approximately an hour to complete.There will be only one survey and no follow ups with the veterans.MaterialsDemographics.The primary researcher will be in charge of developing the demographic questionnaire and IRBwill be responsible for reviewing and accepting the questionnaire before it will be presented tothose taking part in the study. Any age is welcome as long as they are a veteran suffering fromPTSD and receiving care through WB VA hospital. Any race, military branch, gender, and ageare all accepted. Veterans will have to be receiving care at this facility for PTSD to be eligible for
the survey. Gender, Age, Race, County of residence, Branch(s) served, Tour dates & Areastoured, M.O.S. in military, years served in military, rank earned before discharge.SurveysA researcher designed survey will be used to measure quality of care among Veterans. Thissurvey will be evaluated by a fellow Marywood faculty for validity purposes.Questions will be developed to measure: year when PTSD first was diagnosed, age when noticedPTSD, current age, PTSD symptoms, care receiving from PTSD, how would you rank yourPTSD care (scale), how you feel your care could be improved, military honors such as ribbonsand medals earned, how you were treated when first diagnosed with PTSD, has your treatmentimproved, how could PTSD care be improved for veterans, health concerns in general, healthconcerns from PTSD, and medication for PTSD.ProcedureAfter obtaining my Marywood IRB approval, recruitment of participants will begin witha convince sample where the primary researcher (PI) travel to the VA hospital and ask veterans toparticipate. The PI will contact the suicide prevention coordinator at the Wilkes Barre VA andrequest permission to be included when veterans have group for those suffering from PTSD.Forms for informed consent will first be read to the veterans and those who wish to participate inthe study will sign them before receiving the survey. I plan to take surveys with me to a groupmeeting and read them the request form followed by asking permission for those who would liketo help me with my graduate professional contribution. There will be no personal informationcollected on the survey making it confidential and anonymous, and impossible to track back tothem. Once the survey is completed, participants will be given the opportunity to ask anyquestions and will be thanked for their time.
Data AnalysisData will be collected from all the surveys. All data will be entered into an excelspreadsheet using SPSS. Analyzing the timeframe they were diagnosed with PTSD will helpcalculate which generation they were in for example Vietnam, Gulf War, and Iraq etc. Analysiswill compare different generations of veterans to see if care varied depending on generation andif care has improved for veterans today as opposed to the Vietnam era. This study seeks todetermine if age, generation, and time frame served in the military correlates to how care hasbeen provided to veterans.Research Question.What are the effects of PTSD on veterans, and the attendant care required?Sub Question 1: Who suffers from Post-Traumatic Stress Disorder?Sub Question 2: What symptoms do veterans with PTSD suffer from?Sub Question 3: What are the advantages veterans receive when being treatedfor PTSD?Sub Question 4: What funding has been done that benefits veterans withPTSD and the quality of care for veterans?Sub Question 5: What observable changes in veterans who receive care areobserved and documented?SummaryOverall this study will help develop awareness from generation to generation and help toprovide awareness as to changes in care for veterans suffering from PTSD. I hope the results ofthis research show that care has improved since first being diagnosed during the Vietnam erawhen medical assistance was extremely low. I plan to gather information from a range of
different veterans age wise to help get a broad understanding of the symptoms and care and seeif there is a correlation between the generation and the symptoms and care for each veteran. Theparticipants will hopefully take my survey seriously and provide me with information that willhelp benefit other veterans suffering from similar mental illnesses. I plan to design the surveymyself and gather the data myself with no help in this professional contribution.I plan to limit my region to the Northeast Pennsylvania territory focusing on veteranswho receive care at one specific location which is the Wilkes Barre VA Hospital. Participants willhave to have a medically diagnosed illness of PTSD and be receiving care for the symptoms atthe VA hospital. The survey will be some scale rankings as well as questions with space providedfor the participants to write their overall thoughts without being limited to a one word response.PTSD has changed over the generations and I strongly believe we still struggle with providingcare for those who need it, especially those suffering from mental illness.References1. Blake, D. D., Cook, J. D., & Keane, T. M. (1992). Post-traumatic stress disorderand coping in veterans who are seeking medical treatment. Journal of ClinicalPsychology, 48(6), 695-704. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=9302070996&site=ehost-live2. Bormann, J. E., Hurst, S., & Kelly, A. (2013). Responses to mantram repetitionprogram from veterans with posttraumatic stress disorder: A qualitativeanalysis. Journal of Rehabilitation Research & Development., 50(6), 769-784.Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=90169700&site=ehost-live
3. Bullman, T. A., & Kang, H. K. (1996). The risk of suicide among wounded Vietnamveterans. American Journal of Public Health, 86(5), 662-662. 6p.4charts. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=9606201935&site=ehost-live4. Burke, H. S., Degeneffe, C. E., & Olney, M. F. (2009). A new disability forrehabilitation counselors: Iraq war veterans with traumatic brain injury and
32post-traumatic stress disorder. Journal of Rehabilitation, 75(3), 5-14.Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=45463593&site=ehost-live5. Chamberlin, E., & Sheena, M. (2012). Emasculated by trauma: A social historyof post-traumatic stress disorder, stigma, and masculinity. Journal ofAmerican Culture, 35(4), 358-365. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=83711222&site=ehost-live6. Cifu, D. X., Taylor, B. C., Carne, W. F., Bidelspach, D., Sayer, N. A., Scholten, J.,& Hagel Campbell, E. (2013). Traumatic brain injury, posttraumatic stressdisorder, and pain diagnoses in oif/oef/ondveterans.Journal of RehabilitationResearch & Development, 50(9), 1169-1176. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=93923241&site=ehost-live7. Cook, J. M., Dinnen, S., O'Donnell, C., Bernardy, N., Rosenhack, R., & Hoff, R.(2013). Iraq and Afghanistan veterans: National findings from VA residentialtreatment programs. Psychiatry: Interpersonal & Biological Processes, 76(1),Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=85872953&site=ehost-live8. Copeland, L. A., Fletcher, C. E., & Patterson, J. E. (2005). Veterans' health andaccess to care in the year after September 11, 2001. MilitaryMedicine, 170(7), 602-606. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=17734113&site=ehost-live9. Degun-Mather, M. (2001). The value of hypnosis in the treatment of chronicPTSD with dissociative fugues in a war veteran. ContemporaryHypnosis, 18(1), 4-13. Retrieved from :http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=6148789&site=ehost-live10.Gibson, C. (2012). Review of posttraumatic stress disorder and chronic pain:The path to integrated care. Journal of Rehabilitation Research &Development, 49(6), 753-776. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=79730536&site=ehost-live11.Haley, S. A. (1985). Some of my best friends are dead: Treatment of the posttraumatic stress disorder patient and his family. Family Systems Medicine,3(1), 17-26. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=pdh&AN=1986-01768-001&site=ehost-live12.Hart, RH. (2003). A Face of War: PTSD... The Psychiatric times. 06-01; 20:50.Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=10054516&site=ehost-live13.Hayman, P. M., Sommers-Flanagan, R., & Parsons, J. P. (1987). Aftermath ofviolence: Posttraumatic stress disorder among Vietnam veterans. Journal ofCounseling & Development, 65(7), 363. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=4979270&site=ehost-live14.Hyer, L., Woods, M. G., & Boudewyns, P. A. (1989). Early recollections ofVietnam veterans with PTSD. Individual Psychology: The Journal of Adlerian
33Theory, Research & Practice, 45(3), 300. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=9099601&site=ehost-live15.Hyler, L., Woods, M. G., Bruno, R., & Boudewyns, P. (1989). Treatmentoutcomes of Vietnam veterans with PTSD and the consistency of themcmi. Journal of Clinical Psychology, 45(4), 547-552. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=11966916&site=ehost-live16.Kolk, B., & Najavits, L. M. (2013). Interview: What is PTSD really? Surprises,twists of history, and the politics of diagnosis and treatment. Journal ofClinical Psychology, 69(5), 516-522. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=86980700&site=ehost-live17.Lee, E. A. (2012). Complex contribution of combat-related post-traumaticstress disorder to veteran suicide: Facing an increasingchallenge. Perspectives in Psychiatric Care, 48(2), 108-115. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=73930131&site=ehost-live18.Lewis, V., Creamer, M., & Failla, S. (2009). Is poor sleep in veterans a functionof post-traumatic stress disorder? Military Medicine, 174(9), 948-951.Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=44204038&site=ehost-live19.Magruder, K. M., & Yeager, D. E. (2008). Patient factors relating to detectionof posttraumatic stress disorder in department of veterans affairs primarycare settings. Journal of Rehabilitation Research & Development, 45(3), 371381. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=33993779&site=ehost-live20.Marshall, R. P. (1995). A general model for the treatment of post-traumaticstress disorder in war veterans. Psychotherapy: Theory, Research, Practice,Training, 32(3), 389-396. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=pdh&AN=199600405-003&site=ehost-live21.Nash, W. P., & Watson, P. J. (2012). Review of va/dod clinical practice guidelineon management of acute stress and interventions to prevent posttraumaticstress disorder. Journal of Rehabilitation Research & Development., 49(6),637-648. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=79731016&site=ehost-live
22. Resnick, H. S., Foy, D. W., Donahoe, C. P., & Miller, E. N. (1989). Antisocial behaviorand post-traumatic stress disorder in Vietnam veterans. Journal of ClinicalPsychology, 45(6), 860-866. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=11975774&site=ehost-live23.Rosen, R. C., Marx, B. P., Maserejian, N. N., Holowka, D. W., Gates, M. A.,Sleeper, L. A., Vasterling, J. J., & Kang, H. K. (2012). Project valor: Designand methods of a longitudinal registry of posttraumatic stress disorder
34(PTSD) in combatexposed veterans in the Afghanistan and Iraqi militarytheaters of operations. International Journal of Methods in PsychiatricResearch, 21(1), 5-16. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=73176897&site=ehost-live24.Russell, S. S. (2013). Veterans' stories: What they may have to tell us - apersonal reflection. Urologic Nursing, 33(2), 92-96. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=86861350&site=ehost-live25.Sayer, N. A., Rettmann, N. A., Carlson, K. F., Bernardy, N., Sigford, B. J.,Hamblen , J. L., & Friedman, M. J. (2009). Veterans with history of mildtraumatic brain injury and posttraumatic stress disorder: Challenges fromprovider perspective. Journal of Rehabilitation Research &Development, 46(6), 703-715. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=48075779&site=ehost-live26.Seidel, R. W., Gusman, F. D., & Abueg, F. R. (1994). Theoretical and practicalfoundations of an inpatient post-traumatic stress disorder and alcoholismtreatment program. Psychotherapy: Theory, Research, Practice,Training, 31(1), 67-78. Retrieved from:http://search.ebscohost.com/login.aspx?direct=true&db=pdh&AN=199446047-001&site=ehost-live27.Staples, J. K., Hamilton, M. F., & Uddo, M. (2013). A yoga program for thesymptoms of post-traumatic stress disorder in veterans. Military Medicine,178(8), 854-860. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=89768620&site=ehost-live28.Taft, C. T., Creech, S. K., & Kachadourian, L. (2012). Assessment andtreatment of posttraumatic anger and aggression: A review. Journal ofRehabilitation Research & Development, 49(6), 777-788. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=79731022&site=ehost-live29.Twamley, E. W., Baker, D. G., Norman, S. B., Pittman, J. O. E., Lohr, J. B., &Resnick, S. G. (2013). Veterans health administration vocational services foroperation Iraqi freedom/operation enduring freedom veterans with mentalhealth conditions. Journal of Rehabilitation Research & Development, 50(5),663-670. Retrieved from: http://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=90133101&site=ehost-live30.Wilk, J. E., West, J. C., Duffy, F. F., Rae, D. S., Hoge, C. W., & Herrell, R. K.(2013). Use of evidence-based treatment for posttraumatic stress disorder inarmy behavioral healthcare. Psychiatry: Interpersonal & BiologicalProcesses, 76(4), 336-348. Retrieved fromhttp://search.ebscohost.com/login.aspx?direct=true&db=afh&AN=92692412&site=ehost-live

subset: commoncrawl


text:
Among the baggage (week 3)
5 Lot, who was traveling with Abram, had also become very wealthy with flocks of sheep and goats, herds of cattle, and many tents. 6 But the land could not support both Abram and Lot with all their flocks and herds living so close together. 7 So disputes broke out between the herdsmen of Abram and Lot. (At that time Canaanites and Perizzites were also living in the land.)
8 Finally Abram said to Lot, "Let's not allow this conflict to come between us or our herdsmen. After all, we are close relatives! 9 The whole countryside is open to you. Take your choice of any section of the land you want, and we will separate. If you want the land to the left, then I'll take the land on the right. If you prefer the land on the right, then I'll go to the left."
Who are you traveling with?
What you decide to pack you will have to carry with you wherever you go.
they each had so much baggage, the land that was provided to them couldn't hold the capacity of their baggage.
Lots baggage became Abrams and Abrams became lots.
Abrams wealth became lots wealth and Lots wealth became Abrams wealth. They were too Wealthy.
But the land was unable to support them as long as they stayed together.
as long as they stayed together, they would continue to build up and overflow. The land only had so many resources for them to survive off of.
7 and there was quarreling between the herdsmen of Abrams livestock and the herdsmen of Lot's livestock.
Even though they were fighting on the outside with each other, they were fighting internally with what was on the inside of them.
Their fighting caused others to fight too. Their anger caused others to be angry too.
Abram wanted peace. Lot wanted wealth.
What you have in your baggage, is how you will react with those around you.
Anger fights Joy
Rejection fights acceptance
Fear fights confidence
Sometimes its not even those around us that we are fighitng. Its ourselves we are fighting with.
My own anger is fighting my own joy
My rejection is fighting acceptance
My fears are fighting truth.
Abram recognized the fighting. He recognized what it was doing to not only himself, but his nephew. He was willing to LET GO.
So Abram said, "we should separate"
Abram had enough sense to allow separation before bitterness, resentment , and jealousy became a part of him.
We would rather "deal" with what we have, than to let go of what we know we should?
Sometimes we have to be so felt up Iike Abram, open our eyes to what our baggage is doing to us internally and to our hearts that we have to say enough is enough.
Sometimes the people who are traveling aren't meant to travel with you anymore.
Sometimes the people who are traveling with you causing you to carry excess baggage.
Sometimes it's our own choices that creates heavy baggage.


text:
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Sweet lychee flavour concentrate from Capella.
A very authentic ripe tasting Lychee not like that of others, this offers a true representation of the fruit and isn't too sweet just sweet enough. It can be used an a stand alone vape by some but many people use this as a mixer to add to other fruits and creams. A very versatile concentrate which is surprisingly popular. Let others know your mixes and pop a review on to help us out if you like.
These are Naturally and Artificially Flavoured
Bottle sizes available : 10ml, 50ml, 100ml, 472ml
Capella flavours are to be used to make your own E Liquid, do not vape these as they are. These can also be used in food.
For DIY Eliquid you will need:-
If you need any advice about mixing and creating recipes just send us an email and we will try our best to help. 😊
I am a new vaper, The capella flavours are very good to experiment with and the service from rainbow is first class.26 days without a cig so far after 40 odd years smoking.
Smells nice and authentic but not tried yet
This is one of those E-juices (iFlava) I vaped when I stopped smoking and could not tell what it was. A year later a girl friend told me it was "Lychee". I absolutely loved it and bought this at £2 for 10ml before I knew.
I can tell you this flavor smells just like that Ejuice. So looking forward to it after steeping.
From research Solo mild: 6% - 9% Solo strong 12% - 15% As a Base 5% - 10% As an accent 1% - 3%
Regards TwoTone;-)
Bought this to try my hand at some lychee lemonade mixes.. ended up with a fantastic cool lymo refreshers mix... need more.. and is good standalone, more real lychee than canned lychee taste.
Taste jus like lychee should a nice taste pairs well with sweet strawb
Not great as a stand alone for me but works great in fruit mixes
Nice sweet lyche for tropical mixes
This has a light fresh taste of lychee which is very accurate, and makes a very good base when paired with other lychee flavours.
Lovely sweet and fruity taste - goes well with a Pear mix
Add a bit of Pink Chamagne with this and then you have a lovely fizzy Lychee drink
Great vape with koolada added to give it a chill


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Savinelli: Fantasia Rusticated Brown (320 KS) (6mm)
Product Number: 002-033-41377
Savinelli's signature "320 KS" Author offers wealth of texture dressed in the Fantasia's crisp-lined rustication, the bulbous bowl feeling even more sublime in hand. The dark stain pairs well, then, to the series' defining stem of burnt sienna and blue hues arranged in a mosaic pattern.-Truett Smith
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The pipe you see is the pipe you receive. Click here to see our photography process.
Measurements & Other Details
- Length: 5.32 in./135.13 mm.
- Weight: 2.50 oz./70.87 g.
- Bowl Height: 1.64 in./41.66 mm.
- Chamber Depth: 1.30 in./33.02 mm.
- Chamber Diameter: 0.92 in./23.37 mm.
- Outside Diameter: 1.92 in./48.77 mm.
- Stem Material: Acrylic
- Filter: 6mm
- Shape: Author
- Finish: Rusticated
- Material: Briar
- Country: Italy


text:
Barnes, S.L. (2005). Black church culture and community action. Social Forces, 84(2): 967-994.
Billingsley, A. (1999). Mighty like a river: The black church and social reform. NY: Oxford University Press.
Brown, R.K., & Brown, R.E. (2003). Faith and works: Church-based social capital resources and African-American political activism. Social Forces, 82(2): 617-641.
Calhoun-Brown, A. (1996). African-American churches and political mobilization: The psychological impact of organizational resources. The Journal of Politics, 58(4): 935-953.


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Hello everyone, i've been trying very hard to get this to work, unfortunately I can't figure it out. This must be so easy for y'all but I am still learning so please take it easy. I am trying to write a countup timer for a ball in freefall. I want my code to do just 3 little things; count up the time once started, show a small clock on the game screen and to stop counting when it collides with a surface. I managed to code.... something.... but it's not working correctly.
(ps: so far, I only managed to detect the collision, but i can't figure out how to stop the timer without stopping the game. Also, this code is in a very crude format, the miliseconds are not rounded as I'd like to. EG: 456.19273 miliseconds.);
public GUIStyle timerStyle;
private float miliseconds = 0f;
private float seconds = 0f;
private float minutes = 0f;
private string stringMiliseconds = "0000";
private string stringSeconds = "00";
private string stringMinutes = "00";
void Update (){
miliseconds += Time.deltaTime * 1000;
if (miliseconds > 999) {
seconds += 1;
miliseconds = 0;}
if (seconds > 59) {
minutes += 1;
seconds = 0;}
void FormatTimer() {
if (miliseconds < 10) {
stringMiliseconds = "0" + miliseconds.ToString ();}
else { stringMiliseconds = miliseconds.ToString ();}
if (seconds < 10) {
stringSeconds = "0" + seconds.ToString ();}
else { stringSeconds = seconds.ToString ();}
if (minutes < 10) {
stringMinutes = "0" + minutes.ToString ();}
else { stringMinutes = minutes.ToString ();}
void OnGUI() {
GUI.Label (new Rect ( 150, 90, 300, 30), "TIMER", timerStyle);
FormatTimer ();
GUI.Label (new Rect ( 150, 45, 300, 90), stringMinutes + " : " + stringSeconds + " : " + stringMiliseconds, timerStyle);
void OnCollisionEnter (Collision collision) {
Debug.Log ("COLLISION DETECTED");
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text:
As my kids get older I keep finding these quotes by various people ringing in my ears. I am the biggest influencer in my child's life…NOT the pastor, teacher, and even friends. ME. Yes, there are other influencers in our kids lives…but my point is that I am number 1.
It is a basic desire of the human heart to have a close knit family, right?! So how do we keep engaging our kids as they get older and their schedules start to fill up? How do we create an environment that helps build a strong family bond through these formative years? I always love a good family vacay, that seems to fill up both my kids and my emotional tank…but I want to connect with my kids in unique and fun ways more often than once a year. Maybe the solution is starting a new tradition, a tradition such as (deep breath)… family night? Hear me out, I have kids 10 years old and younger so I think I have at least 2 more years where we can implement family night and our kids won't completely revolt.
Family night starts by designating one night a week or even one night every month to spending intentional time together as a family. Or maybe it's as simple as recognizing the time when you are all together already and maximizing that time! For example, the breakfast or dinner hour could be used more intentionally as family time. It doesn't have to be gourmet breakfast…like throw doughnuts at your kids once a week, or order a pizza! The point is to be face to face, making eye contact, being present, and trying to engage your kids.
There are so many unique ways you can connect with your family and build your relationship this week! Tailor your time together to what your family loves: are you outdoorsy, homebodies, artsy? Or maybe you aren't sure what your family loves, try it all!
Here are some ideas to get you started:
Mystery Ride
Get the kids in the car on a whim and simply tell them you are taking them on a "mystery ride." A mystery ride is basically a surprise destination…like to get ice cream or putt putt golf!
Fire & S'mores
Board Game Night- everyone gets to pick a board game!
Serve Day- pick a local organization you could help out together as a family!
Bike Ride
Beach Day
Devotion Time- read a bible story and pray together
Treat Your Kids To The Dollar Store! (Our kids think this is the best thing ever)
Attend a local High School/College Football, Baseball, or Soccer game
The key to a "successful" family night: keep your expectations low. Inevitably there will be meltdowns, quarrels, and it won't be this magical family time you have envisioned. Prepare yourself for those moments, and know that it's ok…you haven't failed! Doing things together as a family won't always feel easy and fun, but rather it's about creating the space to build your relationships with one another. Trust me, fun will be had, memories will be made, even if there are some unpleasant moments mixed in too.
What family activities have been a hit in your home, care to share? I always love fresh ideas!


text:
Boris Dining Chair is backordered. We will ship it separately in 10 to 15 days.
Materials | Genuine Leather and Teak
Dimensions | 50cm (w) x 87cm (h) x 55cm (d)
Pre - order for October 2019 delivery
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text:
The pavilion of Serbia makes for a significant example within the debate surrounding Venice's nation-based system. Housed in what once was the Yugoslavian pavilion, the exhibition space is, in the words of artist Ivan Grubanov, still inhabited "by the ghost of [the] nation," whose name remains engraved on the building's façade. Grubanov represented Serbia at the 56th Venice Biennale, where he participated with an installation ominously titled United Dead Nations, featuring the flags of republics and countries that had ceased to exist during the biennial's run in what was "a mirror held at the very concept of the Venice Biennale."
Installation view of Ivan Grubanov's United Dead Nations at the 2015 Venice Biennale. Image courtesy Galerie Loock.
The particularity of the Serbian pavilion stems from the fact that the artists representing the newborn republic — the current Republic of Serbia just turned 11 — have assumed a new nationality after the breakup of Yugoslavia. Well beyond the Giardini of Venice, this discrepancy affects the way they produce art, inasmuch as artists from Serbia are still negotiating the terms by which they define their identity and work.
"For me as an immigrant, an artist and a twin there is an urgency to locate a space of multiplicity and a space where art can happen. I look for a … somewhere." says Milena Dragicevic, who is representing Serbia at the 57th Biennale. For artists from Serbia and its diaspora, places of self-expression are often defined by their mutability or their transitory nature; "I look for a space without borders, a space with blurred edges, a space of inside out, a space that is wet and dry, a space where I can leak colour and where I can leak form."
Installation view of Milena Dragicevic's works in Venice.
The indefinite nature of what Dragicevic defines a "somewhere" calls attention to the very structure of the pavilion, clarifying that a building — or any structure, either physical or abstract — aiming to represent a fixed national identity is becoming a less and less suitable model. For Grubanov, his artistic production emphasizes "the shifting framework of the notion of nation. Nation does not have a fixed definition nor a fixed form, it is constantly morphing and it seems we are living in the age when these shifts are taking meaningful and dramatic changes. The globalized age [...] either calls for transnational models that enable faster flow of capital and people, or causes fissures in the identities of peoples on the margins of these processes."
"Enclavia," the name aptly chosen by curator Nikola Šuica for the group exhibition (Vladislav Šćepanović and Dragan Zdravković are showing alongside Dragicevic) on show at Venice's Serbian pavilion this year, speaks about the exhibition space's status as one of the meeting points between Western and Eastern worlds, two poles between which artists from Serbia — and the country's artistic scenes — seem to be caught. Dragicevic's case as a Canadian Serb living in the UK is exemplary in this sense; her paintings from the series Erections for Transatlantica exemplify that the divide between two worlds separated from the Atlantic Ocean can be, at the same time, a "space of becoming, transformation and exposure, [...] and a space of envelopment and of erasure."
Installation view of the 2017 Serbian pavilion in Venice.
For Ivan Grubanov the notion of national identity is tied to economic and political forces; and it can be simplified "into two categories: the nations of subjects of these processes and the nations of objects, the ones who inflict the dominant currents and the ones the dominant currents are inflicted upon." says Grubanov. If the artist can identify with what he calls the "objects" of history, "with the ones the dominant currents are inflicted upon, the periphery, the antagonized, the abstract" as opposed to history's subjects, the country and the creative production of artist from Serbia continues to be largely informed by this dialectic.
Vladislav Šćepanović's paintings, presented in Venice this year, look at these two poles, intertwining war imagery with the symbols of Western Life — namely the logos of the World Bank, YouTube, Google or Apple — raising uneasy question as to the place Serbia, a country that has aspired to an ideal of development but also suffered the consequences of its brutal logics, has on the world map.
"In a country recovered from war and conflicts and in economic, political and social transition on its way to become a member of the EU, the crisis of today's world comes to the fore in a more direct manner" according to Maja Kolarić, curator of the 2017 Pančevo biennial. For artists from Serbia and its diaspora, the notion of "transition" seems to be inextricable from their production and the Serbian pavilion remains informed by this aspect. Beyond the difficult development of the country's art scene, the ghost of a dead nation and its history of civil war, artists from Serbia are reclaiming their right to be more than merely the representatives of a nation, both in Venice and elsewhere.


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2019: Brooklyn Voted Gennaro's Catering Hall Best Catering Hall!
Gennaro's Catering Hall
6602 13th Ave.
(718) 236-7252 – www.gennaroscatering.com
If you're looking for a great place to host a great event, then look no further than Gennaro's Catering Hall. The full-service establishment brings the finest in Italian home cooking to any affair. They feature everything you need, including birthdays, celebrations, anniversaries, engagements, bridal showers, baby showers, rehearsal dinners, weddings, memorial services, gift openings, corporate meetings, receptions dinners, open houses, client appreciation events and all seasonal events & holidays. There's nowhere in the borough that features a more comprehensive stable of events to allow you to celebrate in style.
2017: Brooklyn Voted Dyker Beach Golf Course Best Catering Hall!
Dyker Beach Golf Course
1030 86th Street (718) 836-9722 www.dykerbeachgc.com
At Dyker Beach Golf Course, they offer the amenities and service of Manhattan-style catering complemented by sprawling green views of their beautiful 6,438-yard par 72 course. The traditional clubhouse, which features a full-service bar and grill that serves American pub food, is a great way to accommodate early arriving guests, or perfect for a small rehearsal dinner.


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You can provide a design, or I can design your idea for a flat fee of $5. My prices are flexible, just ask. Return to main site.
Price breakdown (shipping not included):20 buttons, design provided: $10 35 buttons, design provided: $1450 buttons, design provided: $2075 buttons, design provided: $30100 buttons, design provided: $40150 buttons, design provided: $60
Shipping cost:★ Free shipping on orders of 150+ buttons★ Standard domestic: $5, arrives in 3-5 business days★ Priority domestic: $7, arrives in 2-3 business days★ International parcel: $14, arrives in 10-14 business days
Image requirements: ★ Large, good resolution images in JPG, PNG, TIFF, PSD file types★ If you're not sure if your image works, I can peep it & let you know★ 1" buttons are small, bold designs with big text & a square aspect ratio work best★ Small text will not be legible★ No extra fees for color or multiple designs
Turn around time: ★ 1 week + shipping time (usually 3-5 business days)★ Turn around may vary slightly depending on volume of orders ★ Let me know what date you need them to arrive by, and I will make it happen
Payment:★ I accept paypal, venmo, check, and cash in person for local orders★ Payment is appreciated at the time your order is confirmed, unless it's a local order being paid for in cash upon deliveryMade in Olympia, WA by a trans artist trying to eke out a living.
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text:
Lighting is a great addition to make your venue really stand out and give it that WOW factor!
3 Monkeys Audiovisual offer a range of Lighting packages suited for many venues, including school halls/ undercover areas, churches, town hall, gym, theatre and more.
Request a quote online or call us on (08) 9228 1681 to find out how we can make your venue really stand out.


text:
Quotes from My Bright Abyss, Christian Wiman.
I picked up a book the other day that was one of the texts in a course I took several years ago at Regis. This was the second time I reread the book. Christian Wiman, who considers himself primarily a poet, wrote My Bright Abyss which is a compilation of journal entries.
One can almost hear him thinking as he lingers over experiences about God. The book does not have a story line except for the fact that while writing this book he was diagnosed with a life-limiting illness. He admits that not only does this reality affect his writing, it is at the core of it.
A quote on the back cover states: "A book that will give light and strength, even to those who find themselves unable to follow its difficult path." (Adam Kirsch, The New Yorker) I count myself among those who have found the path at times difficult but it was worth reading from cover to cover if only because many of the quotes stand on their own in expressing prose laden with spiritual insights.
Thus I include here a series of quotes taken out of a book apt for poet and spiritual person alike:
"All love abhors habit, and poetry is a species of love."
"Sometimes God calls a person to unbelief in order that faith may take new forms."
"…this is how you ascertain the truth of spiritual experience: it propels you back toward the world and other people, and not simply more deeply within yourself."
"What we call doubt is often simply dullness of mind and spirit, not the absence of faith at all, but faith latent in the lives we are not quite living, God dormant in the world to which we are not quite giving our best selves."
"So much of faith has so little to do with belief, and so much to do with acceptance."
"To experience grace is one thing; to integrate it into your life is quite another."
"Faith can not save you from the claims of reason, except insofar as it preserves and protects that wonderful, terrible time when reason, if only for a moment, lost its claim on you."
"…faith is not a new life…it is the old life newly seen."
"One must learn to be in unknowingness without being proud of it."
"God's absence is always a call to his presence. Abundance and destitution are two facets of the one face of God, and to be spiritually alive in the fullest sense is to recall one when we are standing squarely in the midst of the other."
"Revelation, like creation, arises not merely out of nothingness, but by means of it."
"…to strike the harp of heaven make death a friend."" (Eugenio Montale, translationJohnathan Galassi)
"…if grace woke me to God's presence in the world and in my heart, it also woke me to his absence. I never truly felt the pain of unbelief until I began to believe."
"But if you find that you can not believe in God, then do not worry yourself with it. No one can say what names or forms God might take, nor gauge the immensity of unbelief we may need to wake up our souls."
Thank you to Mary Jo Leddy who selected this book as required reading for the course: The Imagination of Spirit at Regis College.


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The E5000 (E5000形) is a class of four DC electric locomotives operated by Tokyo Metropolitan Bureau of Transportation (Toei) in Japan.
Four locos (numbered E5001 to E5004) were delivered from Kawasaki Heavy Industries in 2005 for use in hauling linear-motor powered Ōedo Line trainsets to the Magome Workshops on the Asakusa Line in Ōta, Tokyo for heavy overhaul from 2006 following the completion of the Shiodome Link Line.[1] They are single-ended locomotives which work as permanently coupled pairs.[2]
Tokyo Metro Namboku Line, Toei Asakusa Line, Toei Mita Line, Toei Shinjuku Line, Toei Ōedo Line
Toei Mita Line, Tokyo, Tokyo Metropolitan Bureau of Transportation, Track gauge, Acceleration
Toei Shinjuku Line, Hitachi, Kawasaki Heavy Industries, Keio Line, Keio Sagamihara Line
Track gauge, Tokaido Main Line, 3 Ft 6 In Gauge Railways, Japanese National Railways, UIC classification of locomotive axle arrangements
Track gauge, 3 Ft 6 In Gauge Railways, Tractive effort, 4-6-2, Steam locomotive
Hokkaido, Japanese National Railways, JNR Class D51, Steam locomotive, Wheel arrangement