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Children prostate juice recipe buy generic confido 60 caps online, observers, and passers-by are 59 25 16 13 especially susceptible to being unaware of the 56 41 37 26 60 injury, even if specifically asked, and are 65 25 10 16 prone to late presentation. An anterior entrance wound is commonly visible to the naked eye (use a penlight if necessary) or there may be Ultrasonography warning signs. Gonioscopy, performed after wound closure, may also be helpful (see Table 24?7 for literature data on the disWith extreme caution, ultrasonography may be tribution of the entry sites). Inaccuracies have been described in numerous individual case reports and large studies. Wood may cause problems by giving an image similar to the most important diagnostic question is that caused by air. Unfortunately, the margin of error of radiological methods is greatest when the object is closest to the eyewall. The vast majority of eyes ference is seen whether vitrectomy is performed Pthat develop endophthalmitis do so before 8 during the first or the second week after injury ; the patient presents. The potential for complications is determined as nLancaster criteria: Unless a giant magnet can pull a small steel much by statistical luck as by surgical expertise and is ball 1 mm in diameter with a force of over 50 times its weight at a 106 distance of 20 mm, and unless a hand magnet will pull such a ball significant : the retinal detachment rate reached 27% in one study105 and increased from 2% preoperatively in contact with its tip with a force over 5,000 times its weight, they are not ophthalmologically effective. If the vitreous has been completely removed from around a small posterior break (see Fig. The retinopexy scar requires the crystalline lens, and the vitreous substitute Ptime to reach meaningful strength,122 advo. It has been found useful in some studies for open globe injuries,95 especially if peripheral rA good surgeon is defined not by how small an extraction is created but by the low rate of complications associated with surgivitrectomy cannot be performed satisfactorily and cal management. Objects entering the eye only partially represent a unique management dilemma; nails and fishhooks are common examples (see Fig. The reports and the data are conflicting; it is therefore prognosis is nonetheless better today than even in the impossible to cite an overall prognostic figure. Shape factor in the penetration of cessful extraction of particles of iron from the inferior of intraocular foreign bodies. Magnetische retained in the posterior segment: management options intraokulare Fremdkorper im hinteren Augenaschnitt. Serious firetoxicity caused by the bimetallic electrochemical action works-related eye injuries. Old and new techniques in the management foreign body simulating extrascleral extension of uveal of intraocular foreign bodies. Histology of wound, vitreous, dimensional localization and compositional evaluation and retina in experimental posterior penetrating eye of intraocular and orbital foreign bodies. Intravitextraction of posterior segment foreign bodies in 40 real phaco chopper fragment missed by computed cases. Lakits A, Prokesch R, Scholda C, Bankier A, Weninger foreign bodies with a cannulated extrusion needle.

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Anatomy Normal Physiology of Axoplasmic Transport the optic nerve consists of approximately 1 mens health 6 week workout discount confido 60caps without a prescription. In the case of the optic nerve, the neuron licular portion (5?9 mm) and (iv) intracranial portion soma is the ganglion cell body in the retina. The ated axons traverse the retina in the retinal nerve fbre layer, axons are second-order neurones and though termed as exit the eye through the optic nerve head, acquire myelin a nerve the optic nerve is actually a tract identical to sheaths outside the globe and travel as the optic nerve. Eighty per cent of then partially decussate and pass as the optic chiasma and the fibres of the optic nerve originate from the macular later the optic tract to terminate in the lateral geniculate body. Hence, diseases of the macula and optic nerve has a slow component (proteins and enzymes) that progresses can mimic each other. Retrograde axoplasmic ripheral nerves possess Schwann cells, fbroblasts and transport of lysosomes and mitochondria (from the brain to macrophages. As with white matter of the brain, the optic the eye) also occurs at an intermediate rate. The axons of the optic nerve acquire myelin sheaths proximal to the lamBlood Circulation of the Optic Nerve ina cribrosa and do not possess a neurilemma. Direct injury by penetrating trauma or indirect injury by concussional and rotational forces, and/or 6. Clinical Features Diseases affecting the optic nerve give rise to visual disturbances but can sometimes be asymptomatic and remain unnoticed (as in early papilloedema). Localization of a lesion producing visual disturbance to the optic nerve can almost always be made by careful clinical examination including visual acuity, colour vision, pupillary reactions, visual feld and ophthalmoscopic appearance of the optic nerve head. Sometimes visual disturbance in diseases affecting the optic nerve may be more subtle and may affect aspects of visual function other than visual acuity such as loss of contrast sensitivity, diminished stereoacuity and decrease in brightness of objects. Retinal diseases affecting the macula generally have normal pupillary reactions and an abnormal photostress test (see Chapter 10). Systematic Approach to Differential Diagnosis this can be made by categorizing the patient on the basis of: l Whether one or both eyes are affected l the pattern of visual field loss l the appearance of the optic nerve head or optic disc. Visual feld defects are best detected by Goldmann kinetic perimetry (full feld) and Humphrey automated centrocaecal scotomas (Fig. The feld defects caused by the appearance of the optic disc may be normal, swolvarious optic neuropathies are of different patterns but they len or oedematous, hyperaemic or pale, in different disorcan be broadly classifed as either (i) central (Fig. Swollen optic disc or disc oedema (true acquired disc papillomacular bundle) oedema must be distinguished from pseudo swelling) A. Unilateral l Papillitis or optic neuritis involving the nerve head l Optic neuritis (sudden visual loss) (sudden loss of vision with subsequent improvement) l Compressive lesion (slowly progressive visual loss) l Anterior ischaemic optic neuropathy (sudden loss of B. Bilateral vision usually without improvement) l Orbital tumours (slowly progressive visual loss) l Poor nutrition, tobacco?alcohol neuropathy l Papillophlebitis or optic disc vasculitis (rapid loss of l Drug-induced vision without improvement) l Toxin-induced l Central retinal vein occlusion (may or may not be l Hereditary optic atrophy associated with profound visual impairment) l Infltration of the optic nerves: sarcoidosis, leukael Infltrative disorders (impaired vision) mias, etc.


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It cannot rise above the mean causes either a cumulative rise of pressure or transient blood pressure androgen hormone vitamins confido 60caps with visa, since at that point the circulation will increments. It is most accurately measured While these are the principal factors determining proby manometry, wherein a small cannula is inserted into longed changes in the intraocular pressure, other factors the anterior chamber and connected with a small-bore can exert more temporary effects. Such a technique is used experimentally on animals but its clinical application is 1. The sclera is only very slightly ies: It is obvious that the pressure in the eye will follow elastic and is rendered tense by the internal pressure, alall such variations; thus it follows faithfully the pulse lowing the intraocular pressure to be measured by the and respiratory rhythms. An increase in permeability of the capillaries, allowing standard weight or fattened by a measured pressure with the formation of a plasmoid aqueous with high protein considerable accuracy. Such a method is used clinically in content, will increase its osmotic pressure relative to tonometry (see Tonometry in Chapter 11). The result thus that of the blood and thus raise the pressure in the eye, obtained, usually recorded as mm Hg, by standardization a process accentuated if the drainage channels become with a manometer on experimental animals, is referred to clogged. This can be demonstrated experimentally, and in clinical condithe vascularized tissues of the eye, particularly the uveal tions such changes are induced by the use of glycerol by tract, differ in no respect in their general metabolism from mouth or mannitol intravenously. Volumetric changes within the globe are immediately transformed into pressure changes owing to the indisNon-vascularized Tissues of the Eye tensibility of the sclera; if extra fluid, such as a vitreous haemorrhage, were forced into the eye its tension would the non-vascularized tissues of the eye?the cornea and rise abruptly. A blockage of the circulation of aqueous, on the other and so far as our present knowledge goes, they depend for hand, has a profound effect in raising the ocular tension. Chapter | 2 Physiology of the Eye 19 phosphates (phosphorylation) in the production of pyruvic the Cornea acid; and radioactive tracers have found this to occur the cornea has low energy requirements, which are necparticularly in the cortical layers. In all tissues this chemiessary for the replacement of its tissues and the maintecal process is affected by enzymes, such as hexokinase, nance of transparency. Transparency depends essentially which have been demonstrated in the lens; in this process on its state of relative dehydration, which is maintained oxygen is not required. For the further catabolism of pyruby an active transference of fuid outwards through the vate, oxygen is sometimes used. A fall of oxygen in the aqueous derived from the blood, but in metabolic activity or an increase in the permeability of by which enzymes it is used in the lens is not yet clear. The essential process is probably anaerobic and in the the essential physiological differences between the lens there are a number of enzymes which break down cornea and the sclera are that in the cornea the fbrils pyruvate to lactic acid and water. Lactic acid is found in are arranged in a regular latticework, in a ground subconsiderable quantity in the aqueous humour when the lens stance of mucopolysaccharide, whereas the fbres of the is present; this is not so in the aphakic eye. Agents which sclera are irregularly arranged, and that the former tissue appear to participate in this process are glutathione and is bound by cellular membranes which control the traffc ascorbic acid (vitamin C) which, reacting together, probaof fuid. The the cornea derives its nourishment from three sources former, both as reduced and oxidized glutathione, occurs oxygen directly from the air, solutes from the perilimbal in very high concentration in the lens, particularly in the capillaries and the aqueous humour.

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The triage team leader may be the same as the triage ofcer in a small hospital; in a larger facility prostate oncology specialists scholz buy confido 60 caps cheap, this coordination function is probably best assigned to someone else, for instance an administrative ofcer or the head nurse. In a very large hospital, three diferent people should assume the three functions. After performing triage, the surgeon and the only anaesthesia nurse go to the operating theatre. The triage ofcer in the emergency room is an experienced female nurse, because she is the only one who can organize things. Administration of tetanus prophylaxis, antibiotics, analgesics and other medication as prescribed. Arranging for an orderly fow of categorized casualties to the operating theatre or to designated areas for continuing resuscitation, delayed, or minimal treatment. The disaster plan may be nominative, designating by name the triage ofcer and triage groups: who is in charge of setting up i. The surgeon in theatre will see patients he or she has not previously examined and who may not have a known name or signed consent form. Outside the mass casualty situation this would be regarded as negligent practice, and so another mental adjustment is required. The shift system may need to be changed in order to deal with the increased workload: 2 twelve-hour shifts instead of 3 eight-hour ones, for example. During a crisis the hospital team will be under severe emotional and physical stress. All staf members will need to pace themselves in order to perform efciently and maintain a professional attitude. As mentioned before, during armed confict there may be a mass arrival of new casualties every day for weeks on end. Subsequently, a strict 18-hour operating schedule was instituted: the team was able to maintain this schedule for three months. Some, out of a misplaced sense of professional duty, fnd it difcult to accept that they need to rest; rest must be insisted upon. Working for extended periods without sleep only results in hospital staf no longer being able to adequately treat the new patients who continue to arrive. Besides the original hospital site, any alternative sites (building, underground shelter, etc. The equivalent in cases of natural disaster is the destruction of the hospital premises and/or its access routes (earthquake, landslide, tsunami, etc.

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This person must know how to mens health hrithik roshan purchase confido with a visa organize the emergency room/triage area and have a good understanding of the functioning and capacity of the hospital. Even more importantly, the hospital team must be able to live with the decisions taken by the triage ofcer. Staf members, relatives, and military commanders might try to infuence the triage decisions; nevertheless, these should be made on purely medical grounds. This can be especially difcult in a public hospital where friends and family members of the hospital staf may be among the victims. Deciding priority of treatment solely on the basis of medical need and resources available when the injured include close relatives of the personnel may be a heart-wrenching decision. As a consequence, the experience of the triage ofcer and the respect with which the personnel hold the triage ofcer must be beyond reproach. Triage Ofcer No task in medicine requires greater understanding, skill, and judgement than the categorization of casualties and the establishment of priorities for treatment. Any clinical role or supervision by the head nurse will depend on the particular circumstances of the hospital involved. The usual emergency reception/admissions room may not be large enough to accommodate a large infux of wounded. A large and extendable area capable of serving as a triage department should be pre-selected. The area should be cleared of all inpatients, and be large enough to permit easy movement of casualties and medical personnel. Once triaged, patients should be transferred out of the triage department to the operating theatre or designated wards. Category I patients, requiring resuscitation and immediate surgery, might be put in a pre-operative intensive care unit near the operating theatre while waiting for an operating table to free up. This group is composed of many patients who are lucid, frightened (because of the shooting and shelling), panicky, and often in pain. Organization and basic stafng of this space are important in order to identify and isolate such patients, give them rapid treatment, and then discharge them. Some provisions should be made for the well-regulated visit of friends and relatives to all seriously-injured patients. This comes under the necessary security measures to be implemented (see Section 9. Blankets and sheets are required in the triage area, as are lines on which to hang infusions. Complete sets of supplies for triage should be prepared and stored in boxes or trunks which can easily be carried to the triage area from an accessible storage space. Needless to say, these triage boxes should be inspected regularly for the expiration date of their components.

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In posterior blepharitis prostate artery embolization order confido, the meibomian glands are inflamed, leading to blockage and cyst formation. It occurs along the inner edge of the eyelid where it touches the eyeball, and can also cause crusting, irritation and missing eyelashes. Lid hygiene involves scrubbing the eyelids with baby shampoo followed by warm compresses several times a day. If the inflammation is severe, 40 corticosteroid drops or ointment may be required. In severe cases?when the condition recurs and there is excessive redness and irritation?in addition to the lid hygiene and topical treatment, oral doxycycline or minocycline 100 mg q. Usually, when blepharitis becomes severe, the patient should see an ophthalmologist. Hordeolum A Hordeolum (or stye) is an acute infection involving the eyelash follicles (external hordeolum) or meibomian glands (internal hordeolum) and is commonly caused by Staphylococcus. Chalazion Chalazion is a chronic infection of a meibomian gland, which may be the result of a chronic hordeolum. If the lesion does not resolve in a couple of weeks, incision and curettage from the inside of the lid through the conjunctiva may be needed. It is important to make the correct diagnosis before appropriate treatments can be initiated. Bacterial Conjunctivitis Bacterial conjunctivitis is usually characterized by pus (purulent) discharge. The most common cause of mild conjunctivitis and blepharitis is Staphylococcus aureus. Most mild conjunctivitis can be treated with topical antibiotic drops and/or ointment. Any of the following antibiotics can be used for mild conjunctivitis: sulfacetamide, erythroymycin, bacitracin, tetracycline and others. If the infection is severe, culture for identification of the bacteria should be done. Infection by Pseudomonas and Klebsiella can cause severe corneal destruction and can lead to blindness. If either of these bacterium are present in the culture, the patient should be treated by an ophthalmologist. The conjunctiva is diffusely red 42 because of the vascular reaction, and it may have watery discharge. If the infection appears to be severe, an antibiotic drop or ointment such as tetracycline 1% twice a day for five days may be used to prevent secondary infection.

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Cases of secondary iron overload include ineffective erythropoiesis (where erythroid cells are destroyed near the site of their development within the bone marrow) such as thalassemia syndromes man health 30 60 caps confido for sale, congenital dyserythropoietic anemias and sideroblastic anemias, other forms of liver disease, and congenital atransferrinemia. An acquired form of this condition may result from too much intravenous iron or too many blood transfusions. Symptoms the clinical manifestations of hemochromatosis usually appear after significant iron accumulation?generally after the age of 40. Symptoms appear earlier in males than in females due to the loss of iron through menstruation in women. Many patients with hemochromatosis are asymptomatic and are diagnosed only as a result of family screening, or after blood tests suggest increased iron. Early signs are nonspecific and can include weakness, lethargy, increased skin pigmentation, hair loss, impotence, joint pains, vertigo, and loss of memory. Iron deposition in heart muscle may cause arrhythmias or degeneration of the muscle itself (resulting in cardiomyopathy). Patients with hemochromatosis are also at increased risk for diabetes and pancreatic cancer. Iron deposition in the liver leads to enlargement and elevation in liver enzymes (Figure 3). This may cause right upper quadrant pain and predispose patients to fibrosis, cirrhosis and cancer. Hepatocellular carcinoma develops in 30% of patients with cirrhosis due to hemochromatosis, and the incidence of hepatocellular carcinoma increases with age, reaching almost 50% in patients over 60 years of age. Most of the outward manifestations of hemochromatosis are the result of iron deposition in the organs. Arthritis develops in 25?30% of patients and initially involves the second and third metacarpophalangeal joints (Figure 4). Thereafter, a progressive polyarthritis involving the wrists, hips, knees, and spine may ensue. Hypogonadism is the result of decreases in follicle stimulating hormone and luteinizing hormone secretion (from iron deposition in the anterior pituitary gland) and is manifested through impotence in males and amenorrhea in females. Primary testicular failure and atrophy may also occur from iron deposition in the testes. The surfaces of the liver are smooth and convex in the superior, anterior and right lateral regions. Indentations from the colon, right kidney, duodenum and stomach are apparent on the posterior surface (Figure 5).

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Patients with a history of hypersenthe usual dose is intravenous drip infusitivity to prostate cancer outside the prostate generic confido 60caps otc the ingredients of the sion of 0. Patients with acute intracranial Patients with congenital abnormalities of hematomas (in patients with suspectglycerin or fructose metabolism (severe ed acute intracranial hematomas, if hypoglycemia may occur) the drug is administered without rulTo be administered with caution in the ing out the presence of an intracranial following cases: hematoma, in the event of transient 1. For the intravenous preparation, intracranial pressure decreases, so the patients with kidney disorders drug should not be administered until 4. For the intravenous preparation, the bleeding source has been treated patients with diabetes insipidus and the risk of renewed hemorrhage (3) Isosorbide has been ruled out) Nonproprietary name 2. In the case of preparations with added Isobide fructose, patients with hereditary frucAction tose intolerance (as such patients canDecreases vitreous volume not metabolize fructose normally, Dosage and administration hypoglycemia, etc. Patients with urinary retention or renal Contraindications function disorders Patients with acute intracranial hema3. Elderly patients administered without ruling out the pres(2) Glycerin ence of an intracranial hematoma, in the Nonproprietary name event of transient hemostasis due to Glycerin intracranial pressure, bleeding may Action resume when intracranial pressure Decreases vitreous volume decreases, so the drug should not be Dosage and administration administered until the bleeding source 50% glycerin p. Patients with urinary retention or renal Headache, dizziness, thirst, nausea, diarfunction disorders rhea, rigor, diuresis, and for the intrave3. Methods of observing the fundus oculi red-free light is recommended for the detection As a rule, in observation of the optic disc and of tiny defects in the retinal nerve fiber layer. In observation should be conducted with sufficient the case of a fundus camera not having a red-free light. Observation points for the optic disc and retito sufficiently magnify the fundus image, and in nal nerve fiber layer this sense, observation using a direct ophthalmothe four methods for observing the fundus scope is recommended. Except when the ocular oculi discussed above are used as appropriate in medium is highly opaque, which makes observaorder to evaluate whether or not there are any tion with a direct ophthalmoscope difficult, indiabnormalities due to glaucoma in the optic disc rect ophthalmoscopy using a lens with a low and retinal nerve fiber layer. Observation methmagnification, such as 14 or 20 D, is unsuitable ods can roughly be divided into (1) qualitative for observation because the optic disc image will assessment and (2) quantitative assessment. In Shape of optic disc this case, a lens for observing the fundus oculi is Shape of the cup of the optic disc (referred to used in slit-lamp microscopy. Using a slit beam, the width Hemorrhaging of the optic disc (referred to and depth of the cup can be observed with strong in the following as disc hemorrhage) magnification. Caution is Defects in the retinal nerve fiber layer required in this case, as the image is inverted. A stereoscopic camera speaking, in myopic eyes of 8 D or below, provides optimum results. The shape of the angle of 45 degrees or more in recording the retioptic disc is unrelated to age, sex, body nal nerve fiber layer. It varies widely from approximately methods mentioned above can be used to a suffi0. The size of the optic disc shows no 55 correlation with age from the age of around 10 camera, it stands out as an indicator of cup on.

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In congenital strabismus these symptoms are not obtrusive since the vision of one eye is suppressed or false retinal correspondences develop; in these cases marked n? Moreover androgen hormone balance cheap confido 60 caps visa, contracture of the antagonists of the parafurther temporally in A and nasally in B. Since the retinal image is thus Chapter | 27 Incomitant Strabismus 437 thrown further to the periphery of the retina where the eye should be carefully investigated. Sometimes in cases of mild Changes in Long-standing Paralysis paresis the limitation of movement of the eye may be so In long-standing paralysis secondary contractures in the slight as to be unidentifiable. In such cases the diplopia must be investigated by more Tenon capsule and muscle sheaths reduce the extent of delicate tests. In a dark room a red glass is placed before incomitance and lead to clinical features that begin to one eye and a green one before the other to distinguish resemble comitant squint (Flowchart 27. The positions of of a Case of Ocular Paralysis the images are accurately recorded upon a chart with nine this is essentially directed to (i) evaluation of the squint squares marked upon it (Fig. In other cases these features are too slight to decide documenting the baseline defect and reviewing the imthe diagnosis and special examination techniques must be provement on follow-up. The first step is to cover one eye in order to determine separation of the images between the two eyes and may whether the diplopia is uniocular or binocular. If it is decided that the diplopia is binocular, the patient the paralysis on follow-up. The dotted arrows show the positions of the false image in different parts of the field of diplopia. Similarly, in looking down and to the right, the false image will be lower than the true and tilted. By careful study of the pattern of diplopia alone, the paralysed muscle can be identifed, but it must be remembered that these tests are purely subjective. In many cases the patients are uncooperative or their intelligence is obscured by intracranial disease, or contracture of the antagonistic muscles may have set in. Consequently, the answers are not infrequently discordant, and accurate diagnosis may be extremely diffcult or impossible. The dotted arrows show the positions of the false image in especially if this eye has the greater acuity of vision. If the feld is divided into areas as shown, in these data, if concordant, are suffcient to diagnose the vertical palsies the paresis is due to failure of the sameparalysis. The false image, which is frequently tilted and named rectus muscle (in the left superior area, the left the fainter of the two, is determined by the direction in superior rectus) or the most crossed-named oblique muswhich the images are most separated from each other, in cle (right inferior oblique). In all cases the most peripheral which case it is displaced farthest in the direction of the image belongs to the palsied eye. By covering one failure is due to the same named muscle for the right eye on eye it can be shown which eye this image belongs to. First decide whether the diplopia is horizontal or vertical image is that of the right eye, and green in front of the left from the history of the patient and by testing with red eye. However, by this method, fne details regarding tilting and green goggles, red in front of the right eye.

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There should be no tracking of the portion of the treasury contributed or earned by a specific girl 9 prostate cancer purchase genuine confido line. Troop and service unit treasuries that are used for activities and projects must always further the mission of Girl Scouting and may not be co-mingled with or used to fund participation in events sponsored by competing youth-serving organizations, including, but not limited to, Cub Scouts, Boy Scouts, Girls on the Run, Girls Inc. Troop and service unit treasuries must be spent on Girl Scout and troop experiences only. Procedure: Girls and parents together decide upon the amount and frequency of dues. Policy: New troops or groups may ask, but not require, parents to donate to a one-time startup fee when the troop begins meeting. Troops may also request periodic contributions toward specific troop activities/trips. While troop membership will not be denied based on an inability to pay these fees, participation in troop activities may depend on ability to contribute. Policy: Money-earning refers to activities troops and service units engage in to earn revenue that directly supports the troop or service unit. Troops and service units are accountable for income and expenses and must submit Finance Reports as indicated in the procedures below. Money-earning activities may not raise funds on behalf of another non-profit organization. New troops that form after one or both product programs may conduct limited moneyearning activities if needed to fund planned troop activities. Troops and service units may, without further notice to Council, participate in the following money-earning activities: a. Troops and service units should consult the section for a list of appropriate money-earning activities. The troop co-leader must also submit a report on the results of the activity to the service unit co-director within two weeks of the completion of the activity. The service unit must also submit a report on the results of the activity to their Volunteer Support Specialist within two weeks of the completion of the activity. Girl-led, Beyond the Troop Events are considered money-earning activities for the sponsoring troop or service unit when the event budget allows for a profit. The volunteer event director submits a Beyond the Troop Event Application, and other supporting documents, to the Council Risk Management department (riskmanagement@gsgatl. Once all paperwork is received and training is verified, approval may be granted for the event. The final Event Finance Report must be submitted to the Council within 45 days of the close of the event. Any event that lasts more than three consecutive days requires contacting Council Risk Management for further direction prior to any planning or incurring any expense. Funding for Take Action Projects Take Action projects are projects conducted to complete a Girl Scout Journey or one of Girl Scouts Highest Awards (Gold, Silver and Bronze). Take Action projects are girl-led and focus on addressing the root cause of a community issue in a sustainable way.


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