Why was Sonnet 75 by Edmund Spenser so popular?

Edmund Spenser's own popularity plus the popularity of the sonnet form combined with Spenser's refreshing twist on the love sonnet sequence to make Sonnet 75 very popular in his own day. Five years before the Amoretti sequence of sonnets was published, of which Sonnet 75 is a part, Spenser had released the first three books of The Faerie Queen. This epic poem honoring Queen Elizabeth catapulted Spenser, and with him English poetry, into the realm of poetic prowess previously reserved for foreign poets on the European continent. The lengthy poem was heralded as the finest English poem of its generation.

Around the same time, fellow English poet Philip Sydney had popularized the sonnet series in his Astrophil and Stella. Like conventional Petrarchan sonnets, Sydney's poems focused on the man's love of a married woman and dealt with illicit passions. This sequence made sonnets very popular from 1591 to 1600. 

Spenser published Amoretti in 1595, at the height of this English sonnet season. However, Spenser's series broke with Petrarchan tradition by developing a love affair that was consistent with Christian morality. The poems are autobiographical and represent Spenser's wooing of his second wife, Elizabeth Boyle. Rather than being filled with the angst of star-crossed lovers, the series follows a successful courtship that ends with a jubilant wedding. Although some less controlled passions occur in the beginning of the series, as the poems progress through the Christian calendar of Lent and Easter, they extol the virtues of Christian piety and self-control in love. Thus by the time the sequence reaches Sonnet 75, the poet has won the love of his Elizabeth, and this picture of the two of them on the beach with the poet proclaiming the eternal nature of his passion is very satisfying and pleasant. The celebration of a legitimate relationship fully consistent with religious principles but just as deeply passionate is what made this poem so appealing to its English audience in Queen Elizabeth's day.

What is diaper rash?

Causes and Symptoms

Nearly all babies have diaper rash at some time during their infancy. Whether
cloth diapers or disposable diapers are used does not affect whether the baby will
develop this rash. Prolonged contact with a soiled diaper is the most likely cause
of diaper rash.

The incidence of diaper rash typically peaks in babies who are eight to twelve
months old. When a baby starts on solids or juices, occasional diaper rash is
likely to occur. Sometimes when new foods are fed to the baby, the baby’s body may
not be able to digest the food completely; enzymes in the food can cause diaper
rash. These enzymes can break down a baby’s skin, causing irritation and even
sores known as dermatitis. Acid in foods and juices can also cause
irritation; a bright red scald around the urethral opening or on the buttocks can
result when the baby cannot digest the acid in such foods as tomatoes or orange
juice.

Interaction between the baby’s urine and bacteria on the baby’s skin produces
ammonia. Ammonia can be caustic to the diaper area, causing burns. Prolonged
wetness can cause the rash to form bumps, which then become white-headed pimples
and even weeping areas. These white-headed, weeping pimples are likely to appear
if a baby sleeps in a wet diaper for ten to twelve hours or if a baby has a cold,
sore
throat, or ear infection.

Another cause of diaper rash is yeast infections, such as candidiasis.
A rash from a yeast infection is fiery red and bumpy; it may have scaly edges. The
rash caused by candidiasis may appear when a baby has been ill, since some
antibiotics taken for certain illnesses may destroy the bacteria that
control the growth of yeast in the body.

Babies are likely to get diaper rash when they have had
diarrhea or an illness. Diarrhea burn is indicated by a bright red burn encircling the baby’s anus after a bout with diarrhea. Streptococcal bacteria may also produce diaper rash; often, diaper rash caused by strep infection will appear after other members of the family have been infected. This rash will be bright red, with swollen areas near the rectum. There may also be slits in the skin.

There are also inorganic causes of diaper rash. A diaper that fits too snugly may cause a rash. Usually, such a rash is shiny and red but not sore. Sensitive skin may also develop a rash when exposed to fabric softeners, detergents, and various toiletries. Such rashes are often tiny red blisters. If the baby wears cloth diapers, a rash can occur if the diaper has been washed in a detergent that contains an enzyme or bleach. The plastic in some disposable diapers can also cause red patches.

Treatment and Therapy

The best way to eliminate diaper rash is to keep a baby clean and dry. Caregivers
should remove wet or soiled diapers as soon as they are aware of them. The baby
should be washed with warm water and dried off at each diaper change. If there is
a rash, the baby should be allowed, whenever possible, to lie with the diaper area
uncovered. If air is allowed to move around the diaper area, it is less likely
that a rash will form, and if one does occur, it is more likely that the rash will
heal. Therefore, the baby’s diapers should not be fastened too tightly to the
skin. Topical agents that form a barrier to the skin's surface can also prevent
diaper rash.

If the baby’s diaper rash is caused by a yeast infection, then antifungal
medication will be needed to clear up the problem. Severe diaper rash caused by
prolonged wetness can sometimes be controlled by using extra-absorbency disposable
diapers. Topical corticosteroids can be useful if the diaper rash is due to
allergic contact dermatitis.

If the diaper rash appears to be a result of irritation from detergents used in
washing cloth diapers, then the diapers should be washed in milder detergents.
Drying diapers in a very hot dryer or in the sunshine will kill organisms that can
cause rashes. If all else fails, boiling diapers for a half hour or more will
destroy most bacteria.

Diaper rash can be prevented by coating the diaper area with a protective ointment
such as petroleum jelly. If a diaper rash does develop, the ointment can prevent
further spread of the rash. Care must be taken, however, because medicated
ointments can prevent the stay-dry liner of disposable diapers from drawing
moisture away from the body, making the rash worse.

A physician should be consulted for a diaper rash that resembles a chemical burn,
develops blisters, or becomes infected. A secondary infection, which must be
treated by a doctor, is a fairly common complication of diaper rash. A urinary tract
infection may develop from uncontrolled diaper rash.

Perspective and Prospects

Undoubtedly, diaper rash has been around since babies began to wear diapers. It
can be largely prevented through vigilant caregivers who make sure that diapers
are changed as soon as they become soiled or wet. Nevertheless, when a baby is
sick or sensitive skin comes in contact with irritants such as detergents, it is
likely that diaper rash will occur.

Bibliography

Blume-Peytavi, U., et al. "Prevention of
Diaper Dermatitis in Infants—A Literature Review." Pediatric
Dermatology 31.4 (2014): 413–29. Print.

Illingworth, Ronald S.
The Normal Child: Some Problems of the Early Years and Their
Treatment. 10th ed. New York: Churchill Livingstone, 1991.
Print.

Jones, Sandy.
Crying Baby, Sleepless Nights: Why Your Baby Is Crying and What
You Can Do About It. Rev. ed. Boston: Harvard Common Press,
1992. Print.

Kemper, Kathi J.
The Holistic Pediatrician: A Pediatrician’s Comprehensive Guide
to Safe and Effective Therapies for the Twenty-five Most Common Ailments
of Infants, Children, and Adolescents. 2nd ed. New York:
HarperCollins, 2007. Print.

Leach, Penelope.
Your Baby and Child: From Birth to Age Five. Rev. ed.
New York: Knopf, 2010. Print.

Mayo Clinic. "Diaper
Rash." Mayo Clinic. Mayo Foundation for Medical Education
and Research, 22 May 2012. Web. 12 Feb. 2015.

Sullivan, Michele G.
“Diaper Rash: Common, Yet Poorly Understood.” Pediatric
News 38.9 (2004): 43. Print.

Woolf, Alan D., et
al., eds. The Children’s Hospital Guide to Your Child’s Health and
Development. Cambridge: Perseus, 2002. Print.

In Geoffrey Chaucer's The Canterbury Tales, is the "Wife of Bath's Tale" consistent with her personality?

Geoffrey Chaucer's medieval poem The Canterbury Tales tells the story of a group of pilgrims on their way to the shrine of the martyr Thomas Becket. On their way to the shrine the pilgrims pass the time by telling each other tales. These tales not only entertain, but also reflect on the character's own personalities.

The Wife of Bath is a remarkable character. We don't expect to see such a boldly outspoken female character in Middle Ages' literature, but the Wife has been married five times and she knows more than a thing or two about how to handle a man and get what she wants out of a relationship. In the lengthy prologue to her tale she bluntly discusses how she manipulates men to get her way, and how she insists on having the power in her relationships:

I'll have a husband—I'm not quitting yet--

And he will be my debtor and my slave,

And in the flesh his troubles will be grave

As long as I continue as his wife.

Her favorite husband, the fifth, put up quite a struggle for power, and the couple actually came to blows at one point, but eventually the Wife won out:

But in the end, for all we suffered through,

We finally reached accord between us two.

The bridle he put wholly in my hand

To have complete control of house and land

The Wife of Bath's tale is concerned with the same topic. In this tale a knight rapes a girl and is sentenced to die unless he can, within one year, find out what it is that women want the most. He searches the land but is unable to find out, until he meets an old hag who tells him that what women desire most is power over men. As a reward for her information, the knight must marry the old hag. They fight for control of the relationship, but the knight finally acquiesces:

The knight gave it some thought, then gave a sigh,

And finally answered as you are to hear:

"My lady and my love and wife so dear,

I leave to your wise governance the measure;

You choose which one would give the fullest pleasure

And honor to you, and to me as well.

I don't care which you do, you best can tell.

What you desire is good enough for me."

"You've given me," she said, "the mastery?

The choice is mine and all's at my behest?"

"Yes, surely, wife," said he, "I think it best."

Like the Wife, the old woman gains what she wants the most and wins control of the man. In this way, the woman in the tale reflects the personality of the Wife—they both want power and know how to gain it.

What is the outline of To Kill a Mockingbird?

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How does Lord of the Flies show how society can survive with authoritative restraint?

Lord of the Flies presents a negative example, showing "what makes things break up like they do." One could imagine how the story could have ended differently if the boys had scrupulously followed the rules they set up for themselves at the beginning of the novel. At their first meeting, Ralph and Jack are both on the same page, and when the boys decide to have a signal fire, Jack states, "I agree with Ralph. We've got to have rules and obey them." With the orderly division of labor the boys set up for building shelters, tending the signal fire, and hunting, life on the island could have been idyllic. But it would have required the boys to submit unfailingly to the authority of the rules and to restrain their impulses. Unfortunately, in their first experience with fire, the boys overdo it, and the fire rages uncontrolled, producing their first casualty. Later, Jack, who has divided the choir boys into hunters and ones who watch the signal fire, gets carried away with hunting and draws the fire-keepers into the hunt, causing the fire to go out just as a ship passes the island. This shows how easily and quickly the boys could have been rescued if they had only submitted themselves to the original authoritative restraints on their behavior. If the boys had tended the fire according to the rules and not followed their desire for meat and hunting, the ship would have seen them, and their brief experience as castaways would have ended successfully. 

What is shock?

Causes and Symptoms

The primary goal of the cardiovascular system is to provide blood flow, carrying oxygen and other nutrients to all tissues to meet their requirements. The cardiovascular system performs this function by maintaining a blood pressure high enough to push sufficient blood flow throughout the body, especially the vital organs. To keep the blood pressure up, the heart must pump sufficient amounts of blood even when the demand for increased blood flow to some tissues occurs. The blood vessels also play an important role in maintaining blood pressure. The heart and the blood vessels work in a coordinated manner to maintain blood pressure and blood flow.

A healthy heart is capable of adjusting the strength of its beats and the rate of its beats (the heart rate) to produce enough flow to match the demands placed on it by the tissues of the body. For example, during exercise, the exercising muscles require greater blood flow. If the heart does not pump the increased amount of blood that is necessary, then the blood pressure will fall. Hormones such as adrenaline help the heart beat faster and harder to meet the increased demand for blood by the muscles.

The blood vessels (vasculature) have a special structure and function to help maintain blood pressure. The arteries and veins are elastic in nature and squeeze on the blood like an inflated balloon does to the air inside it. In addition, the walls of blood vessels have special muscle tissue, called smooth muscle, that can contract to make the vessels’ internal diameter smaller, which helps keep pressure up. If the vessels’ internal diameter becomes too small, however, then the blood flow through them will decrease. The concept of blood vessels getting narrow and making it more difficult to push blood through is termed resistance to flow or vascular resistance. The balance of blood flow produced by the heart (cardiac output) and vascular resistance keeps blood pressure at the proper level. When one or both of these components falter, cardiac output and blood pressure fall, which, if untreated, leads to shock.

When the cardiovascular system cannot supply adequate blood flow to the essential organs to sustain their function, the body is said to be in shock. A reduction in cardiac output is the primary problem in shock. There are two major ways in which cardiac output can decrease enough to cause shock. When the ability of the heart to pump falls 40 percent from its normal capacity, it is termed cardiogenic shock. Cardiogenic shock may occur after a heart attack, heart valve disease, lung collapse, and other disorders.

Cardiogenic shock may occur in several ways. The most common cause is a myocardial infarction (heart attack). During a heart attack, the heart is damaged, and like any other muscle when injured, it does not have the strength to pump much blood. Thus, cardiac output goes down and a fall in blood pressure will follow. Cardiogenic shock will progress to death if medical treatment is not rapidly obtained. After a myocardial infarction, while the heart is still healing, it has a reduced ability to pump blood. Exercise, even light exercise such as walking, must be resumed gradually. If it is not, the heart may not be able to pump enough blood to supply muscles even though demand for more flow is only slightly increased. This inability to meet the oxygen demand of the heart will cause further damage to the heart.

In cardiac tamponade, a type of obstructive circulatory shock, the stiff but pliable sac surrounding the heart (pericardium) fills with fluid or swells. This takes up room in the sac, squeezing the heart and prohibiting it from filling adequately from beat to beat. Therefore, the amount of blood pumped decreases, and a drop in blood pressure occurs. Cardiac tamponade can occur for several reasons. It can occur rapidly after trauma or heart surgery if the heart is punctured and bleeds into the pericardial sac. Cardiac tamponade occurs much more slowly when excess fluid is produced by the pericardium or when the pericardium becomes swollen. Both of these conditions can be caused by an infection.

A less common form of cardiogenic shock is caused by an extremely high heart rate. Normally, the heart beats at a rate between sixty and one hundred beats per minute. When the heart rate exceeds one hundred, the resulting condition is called tachycardia. Occasionally, in some people, the heart rate can go rapidly up to near two hundred beats per minute. The time between beats becomes so short that the heart does not have enough time to refill and cardiac output falls. If this condition persists, the blood pressure may fall, causing shock. When this occurs, the combination of the rapid heart rate and low blood pressure may cause a myocardial infarction.

Shock caused by a problem in the vascular system, not by a primary decrease in heart function, is generally termed
hypovolemic shock. It is characterized by a lack of sufficient blood volume returned to the heart by the vascular system. Hypovolemic shock can be caused by a decrease in the body’s total blood volume.

Excessive bleeding (hemorrhage) is the most common form of hypovolemic shock. The blood vessels are elastic in nature, and they must remain filled with blood for arterial pressure to be maintained. In addition, enough blood must be in the veins to push it back to the heart, to be pumped through the lungs and back out into the arteries. When blood loss is slight, the body attempts to compensate by contracting the veins and arteries, thereby maintaining enough pressure and sufficient cardiac output. When enough circulating blood volume is lost, approximately 15 percent to 20 percent, hypovolemic shock occurs.

There are other ways in which blood volume may decrease. When a person is burned severely, plasma (the fluid in which blood cells are suspended) is lost through the burn sites. Enough can be lost to cause hypovolemic shock. Different forms of dehydration can also result in shock. Prolonged diarrhea, vomiting, and sweating can ultimately result in shock if the person does not drink enough liquids to replace fluid lost. All of these conditions lead to a loss in the circulating blood volume and subnormal return of blood to the heart, and thus reduced cardiac output.

A virtual loss in blood volume may also occur, resulting in neurogenic shock. Sometimes anesthesia, hypoxia (inadequate oxygen), low blood sugar, spinal cord injuries, or damage to the brain stem can cause the vascular smooth muscle around the arteries and veins to relax. This results in a loss of arterial and venous pressure. Blood tends to accumulate in the veins and is not returned to the heart, and cardiac output falls. A systemic (entire body) allergic reaction can cause a similar response, called anaphylactic shock. Severe infections, usually bacterial, can cause septic shock, which has a death rate of approximately 40 percent. In this type of shock, the immune system of the body responds to the infection. However, this response can cause damage to blood vessels or cause a release of chemicals that cause the vessels to dilate (expand). All types of shock can be deadly if they are not promptly treated.

Applications

In spite of the different causes of circulatory shock, the symptoms are quite common in nearly all cases of shock. The pulse (heart rate) is usually rapid and feeble. Breathing is generally rapid and shallow, and the person may feel dizzy. The skin is pale, cool, and sometimes moist. The mouth is dry, and thirst is intense. Blood pressure is decreased. Some of these signs are attributable to the body’s attempt to alleviate the problem.

The body has several defense mechanisms to help avoid circulatory shock. Several reflex systems function to maintain cardiac output and blood pressure. The body has sensors in the cardiovascular system that tell the brain what the pressure is in the arteries and the veins. When the brain senses a change in either or both of these pressures, it calls on its defenses.

When the arterial pressure sensors tell the brain that blood pressure is falling, the brain produces several responses. Through the nerves, the brain can make the heart beat faster and with greater force. In addition, the nerves can cause vascular smooth muscle to contract, making the vessels squeeze against the blood and increasing pressure. When the smooth muscle contracts, the veins squeeze blood back to the heart to enable it to pump more. The brain can also cause the release of adrenaline into the blood. This hormone can also cause the heart to beat harder and faster. The combined actions of this reflex mechanism attempt to compensate for the decreased cardiac output and blood pressure; however, these responses are only temporary before the person progresses to decompensation and death.

The sensors in the large veins and atria of the heart can cause a different response. Since most (75 percent) of the blood in the body is in the veins at any point in time, a 10 percent to 15 percent decrease in volume triggers the release of a hormone called vasopressin into the blood, which constricts the blood vessels to increase both arterial and venous pressure. The increase in venous pressure squeezes more blood back to the heart to improve cardiac output. The squeeze on the arteries raises blood pressure. Vasopressin also causes the kidneys to retain water. This fluid retained by the kidney is returned to the blood to keep up the vascular volume.

Specialized blood vessels in the kidneys can also initiate a reflex response to a decrease in blood pressure. The kidneys release a hormone called renin into the blood. Renin activates another hormone, angiotensin, which is a powerful constrictor of blood vessels. Angiotensin increases the release of yet another hormone, aldosterone, which helps the kidneys reabsorb more fluid. All of the above reflexes work together to increase blood volume, cardiac output, and blood pressure, in an attempt to alleviate shock. Despite these mechanisms to prevent shock, however, the by-products of these reflexes actually produce negative effects in the body that eventually lead to more damage.

When average arterial blood pressure falls below 60 millimeters of mercury (mmHg), the blood flow to the blood vessels supplying the heart (coronary vessels) cannot be maintained. When this occurs in shock, it happens at a time when the heart needs its critical supply of oxygen. In fact, the heart is trying to beat harder and faster, which increases its need for oxygen. As a result, the heart can weaken. When weakened, it pumps less and thus cannot bring the pressure back to normal. The heart becomes weaker and weaker. This condition is termed cardiac failure. In addition to cardiac failure caused by reduced coronary blood flow, the body can produce a hormone called myocardial depressant factor (MDF). This hormone directly causes a weakening of the heart that is independent of coronary blood flow. MDF also causes the body’s bacterial defense system to function poorly. The maintenance of heart function is important to defend against shock.

Because the blood vessels contract in most of the body during shock, blood flow to nonessential tissues such as skin, muscle, bone, and the intestines is reduced, depriving these tissues of oxygen. These tissues can tolerate short periods of low oxygen supply, but if shock persists for more than a few minutes, these tissues revert to other energy sources. The end products of these alternative energy sources are acids, which can begin a process of tissue damage. If this process is not controlled or reversed, tissues can die. If a critical amount of tissue in an organ dies, the organ cannot function and may fail. Acid produced by other tissues gets into the blood and can directly decrease the function of the heart and its ability to respond to beneficial reflex signals. Acid production makes it more difficult for the body to fight shock.

Derangements in blood clotting can occur during shock. Blood clots can form in the early stages of shock, blocking small vessels. This causes a loss of oxygen that results in acid production. Increased acid in the blood can increase the rate of formation of blood clots. Thus, the clotting system can start a vicious cycle that increases the severity of shock.

Even when shock is not bacterial in origin, the body needs its bacteria-fighting systems. During shock, the bacterial defenses are weakened. Normally, bacteria from the intestines constantly enter the blood and are rapidly neutralized. If this does not occur, endotoxic shock can intensify the already existing shock. Therefore, a capable bacteria-fighting system is important in defending against shock.

In shock, the blood vessels of the heart and brain are spared the constriction experienced by all other tissue blood vessels. In fact, arteries in these organs relax to permit as much blood flow as possible, maintaining oxygen supply to these vital organs. Even so, when very low blood pressure persists (less than 50 mmHg), the brain’s function decreases. At this point, the brain sends fewer of the beneficial reflex signals to the heart and blood vessels. The final result is a continuous decline in blood pressure and death. Maintenance of brain blood flow is a very important factor in surviving shock.

Treatment and Therapy

Emergency procedures in response to circulatory shock entail contacting emergency service providers such as paramedics and keeping the victim warm and flat on his or her back, with slightly elevated legs. The victim must get medical attention immediately.

Treatment of shock can vary depending on the cause. In many cases, shock can be effectively treated with intravenous (IV) fluids and medication. Some cases require surgical intervention. In all cases, the status of body fluids must be monitored and treated. The body’s blood volume is one of the most important things to maintain.

It is particularly important to optimize blood volume in forms of
hypovolemic shock. With hemorrhagic shock, whole blood is given intravenously to replace lost blood. In other forms of hypovolemic shock, different intravenous fluids are usually given. In burn shock, when the blood’s plasma weeps from the burn sites, blood plasma is the medicine of choice to restore lost volume. IV fluids are immediately started to restore lost volume until the needed blood products can be acquired. When hypovolemia is caused by excessive diarrhea, vomiting, or sweating, IV fluids are given to replenish lost volume.

In other cases of shock, special drugs are needed to alleviate the symptoms. Shock caused rapidly by a myocardial infarction, with cardiac arrest, can be immediately supported by cardiopulmonary resuscitation (CPR), provided by a trained individual. After resumption of the heartbeat, the heart can be helped with several types of drugs. In the case of sustained tachycardia, a drug such as amiodarone can lower the very rapid heart rate to normal, allowing the heart to fill properly and pump adequate blood. Cardiac tamponade must be corrected to allow the heart to pump usual amounts. If the onset is rapid, as when it is caused by chest trauma, then the fluid in the pericardial sac may need to be removed immediately. A needle is placed into the sac, and the excess fluid is removed to alleviate the pressure around the heart. If fluid accumulates slowly as with an infection and is recognized early, appropriate drug treatment for the infection may resolve the problem. In cases of shock in which acidosis is a complication or even a potential complication, sodium bicarbonate, a chemical that can reduce the acidity of blood, may be given. There is no universal treatment for the complex process of shock. For example, hemorrhage may become complicated by heart failure and/or septic shock. Each case must be treated in accordance with the patient’s existing conditions.

Perspective and Prospects

Chinese writings of more than three thousand years ago indicate that a connection exists between the heart and blood. Until the second century CE, it was thought that arteries carry air, not blood. Through the Middle Ages, it was believed that spirits are the essence of life or vitality. This belief encouraged bloodletting as a treatment for many ailments, including shock. Leeches were applied to remove the evil spirit causing the sickness. This was not a very successful mode of therapy.

It was not until the seventeenth century that blood transfusions were tried, with the first successful experiments conducted by Richard Lower. In the 1660s, Jean-Baptiste Denis administered lamb’s blood to a sixteen-year-old boy who was very weak and who had a high fever. The condition of the boy, who had been bled several times, improved for a short period of time. Others continued to experiment with transfusion as the remedy for loss of blood, but until the discovery of blood typing at the turn of the twentieth century, most attempts were of limited success.

The practice of giving transfusions greatly increased after the discovery of blood types in 1901 by Karl Landsteiner, who won the 1930 Nobel Prize in Physiology or Medicine for his work. By 1920, blood could be transfused from a bottle thanks to the work of Luis Agote, who in 1914 discovered that citrated blood will not clot after being removed from the body. Blood banking was established in the 1930s after Andre Bagdasarovin discovered in 1932 that citrated blood can be stored at forty degrees Fahrenheit (four degrees Celsius).

All types of shock are treated by determining and correcting the underlying cause. Oxygen is given during shock to improve the amount of circulating oxygen to the tissues. In hypovolemic shock, the goal is to improve the amount of circulating volume. This volume is replaced by intravenous fluids until blood products are available. Potent intravenous cardiac drugs that improve the contractions of the heart, improve blood pressure, or cause vasoconstriction may be used in cardiogenic and other types of shock. Mechanical devices have been developed (an intra-aortic balloon pump and a ventricular assist device) to use in severe cardiogenic shock that has not responded to traditional therapy. Synthetic epinephrine (adrenalin) is the first-line treatment for anaphylactic (allergic reaction) shock. It causes the smooth muscle in the bronchioles (tubes into the lungs) to relax and constricts blood vessels. Other treatments may include oxygen, antihistamines, and corticosteroids. Septic shock is treated with IV antibiotics and fluids. Shock is a dangerous process that can occur for a variety of reasons. Quick detection and medical treatment are required to prevent negative outcomes.

Bibliography

American College of Emergency Physicians. Pocket First Aid. New York: DK, 2003.

Avraham, Regina. The Circulatory System. Philadelphia: Chelsea House, 2000.

Bhimji, Shabir. "Cardiac Tamponade." MedlinePlus, 14 May 2013.

Dugdale III, David C., and David Zieve. "Anaphylaxis." MedlinePlus, 30 May 2012.

Dugdale III, David C., and David Zieve. "Cardiogenic Shock." MedlinePlus, 22 June 2012.

Heller, Jacob L., and David Zieve. "Hypovolemic Shock." MedlinePlus, 8 Jan. 2012.

Heller, Jacob L., and David Zieve. "Septic Shock." MedlinePlus, 14 Jan. 2010.

Holcomb, Susan Simmons. “Helping Your Patient Conquer Cardiogenic Shock.” Nursing 32, no. 9 (September, 2002). 32cc1–32cc6.

Klein, Deborah G. “Shock and Sepsis.” In Introduction to Critical Care Nursing, edited by Mary Lou Sole, Deborah G. Klein, and Marthe J. Moseley. 6th ed. St. Louis, Mo.: Saunders/Elsevier, 2013.

Marx, John A., et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia: Mosby/Elsevier, 2010.

McCoy, Krisha, and Peter Lucas. "Shock." Health Library, 11 Oct. 2012.

Porth, Carol M., and Glenn Matfin. “Heart Failure and Circulatory Shock.” In Essentials of Pathophysiology, edited by Carol M. Porth. 3d ed. Philadelphia: Lippincott Williams & Wilkins, 2010.

"Shock." MedlinePlus, 19 July 2013.

What two emotions are pulling Mr. Gatz?

Mr. Gatz seems to be torn between grief and pride. He obviously very much grieves his son's death, his "eyes leaking isolated and unpunctual tears," even though death is no longer something to which he, as an older man, is unaccustomed. One never expects one's child to die first, and Mr. Gatz left Minnesota as soon as he read about the news of his son's death in the Chicago papers. Nick says that Mr. Gatz's eyes "[see] nothing" when he arrives, and Gatsby's father can only insist that the man who killed him "'must have been mad.'"

However, when Mr. Gatz really looks around him at the magnificent mansion his son had worked for, purchased, and lived in, his grief "mixed with an awed pride." He insists that the family always knew that his son had a bright future ahead of him because he was always so very intelligent and hardworking. He insists that Gatsby would have been great and helped to "'build up the country'" like James J. Hill, who was a prominent railroad executive known as the Empire Builder during his lifetime.

What is anxiety?

Causes and Symptoms

Anxiety is a subjective state of fear, apprehension, or tension. In the face of a
naturally fearful or threatening situation, anxiety is a normal and understandable
reaction. When anxiety occurs without obvious provocation or is excessive,
however, anxiety may be said to be abnormal or pathological (existing in a disease
state). Normal anxiety is useful because it provides an alerting signal and
improves physical and mental performance. Excessive anxiety results in a
deterioration in performance and in emotional and physical discomfort.

There are several forms of pathological anxiety, known collectively as the anxiety
disorders. According to the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders(DSM-5), the anxiety disorders
include separation anxiety disorder, selective mutism, specific
phobias, social anxiety disorders (formerly known as social
phobia), panic
disorder, panic attack, agoraphobia, and
generalized
anxiety disorder as well as substance- or medication-induced
anxiety disorder, anxiety disorder due to another medical condition, other
specified anxiety disorder, and unspecified anxiety disorder. The anxiety
disorders are distinguished from one another by characteristic clusters of
symptoms. The estimated lifetime prevalence of any anxiety disorder is
approximately 15 percent, while the twelve-month prevalence rate is approximately
10 percent. Women are 60 percent more likely than men to experience an anxiety
disorder over their lifetime.

In previous editions of the DSM, posttraumatic stress disorder (PTSD) and
adjustment disorder with anxious mood were categorized as anxiety disorders, but
PTSD and adjustment disorders are now recognized as trauma- and stressor-related
disorders. Obsessive-compulsive disorder (OCD) was also categorized as an anxiety
disorder in previous editions of the DSM, but the DSM-5 includes OCD in a new
chapter, titled "Obsessive-Compulsive and Related Disorders," in light of the
growing body of evidence that indicates OCD is distinct from the anxiety disorders
and to reflect its relation to other disorders characterized by obsessive
preoccupations and repetitive behaviors, such as body dysmorphic disorder,
trichotillomania, hoarding disorder, and excoriation.

Generalized anxiety disorder is thought to be a biological form of anxiety
disorder in which the individual inherits a habitually high level of tension or
anxiety that may occur even when no threatening circumstances are present.
Generally, these periods of anxiety occur in cycles that may last weeks to years.
In the United States, the lifetime prevalence of generalized anxiety disorder is
approximately 5 percent, and women are twice as likely as men to be affected.

Evidence suggests that generalized anxiety disorder may be related to
abnormalities in common neurotransmitter receptor complexes found in many brain
neurons, possibly resulting from abnormal serotonergic and noradrenergic
neurotransmission. Other altered neurotransmitters thought to be involved in
generalized anxiety disorder include gamma-aminobutyric acid (GABA) and dopamine.
Generalized anxiety disorder has 32 percent heritability, suggesting a possible
genetic basis that manifests with environmental influence. Adverse life events,
including unemployment, disability, illness, or a history of physical or emotional
trauma, represent significant risk factors for developing generalized anxiety
disorder.

Panic disorder has a lifetime prevalence of about 5 percent in the United States,
and the female-to-male ratio is 2:1. This disorder usually begins in late
adolescence or early adulthood. Panic disorder is characterized by recurrent and
unexpected attacks of intense fear or panic. Each discrete episode lasts about
five to twenty minutes. These episodes are intensely frightening to the
individual, who is usually convinced he or she is dying. Because people who suffer
from panic attacks are often anxious about having another attack (so-called
secondary anxiety), they may avoid situations in which they fear an attack may
occur, in which help would be unavailable, or in which they would be embarrassed
if an attack occurred. This avoidance behavior may cause restricted activity and
can lead to agoraphobia, the fear of leaving a safe zone in or around the home.
Thus, agoraphobia (literally, “fear of the marketplace”) is often secondary to
panic disorder.

Panic disorder appears to have a biological basis. In those people with panic
disorder, panic attacks can often be induced by sodium lactate infusions,
hyperventilation, exercise, or hypocalcemia (low blood calcium). Highly
sophisticated scans show abnormal metabolic activity in the right parahippocampal
region of the brain of individuals with panic disorder. The parahippocampal
region, the area surrounding the hippocampus, is involved in emotions and is
connected by fiber tracts to the locus ceruleus, a blue spot in the pons portion
of the brain stem that is involved in arousal.

In addition to known biological triggers for panic attacks, emotional or
psychological events may also cause an attack. To be diagnosed as having panic
disorder, however, a person must experience attacks that arise without any
apparent cause. The secondary anxiety and avoidance behavior often seen in these
individuals result in difficulties in normal functioning. There is an increased
incidence of suicide attempts in people with panic disorder; up to one in five
have reported a suicide attempt at some time. Risk factors for panic disorder
include significant life stressors, a history of sexual or physical abuse in
childhood, anxious temperament, and cigarette smoking.

A phobia is an abnormal fear of a particular object or situation. Simple phobias
are fears of specific, identifiable triggers such as heights, snakes, flying in an
airplane, elevators, or the number thirteen. Social anxiety disorder (previously
known as social phobia) is an exaggerated fear of being in social settings where
the affected person fears he or she will be open to scrutiny by others. This fear
may result in phobic avoidance of eating in public, attending church, joining a
social club, or participating in other social events. Phobias often have a
childhood onset.

In classic psychoanalytic theory, phobias were thought to be fears displaced from
one object or situation to another. It was thought that this process of
displacement took place unconsciously. Many psychologists now believe that phobias
are either exaggerations of normal fears or that they develop accidentally,
without any symbolic meaning. For example, fear of elephants may arise if a young
boy at a zoo is accidentally separated from his parents. At the same time that he
realizes he is alone, he notices the elephants. He may then associate elephants
with separation from his parents and fear elephants thereafter. However, there is
no clear consensus on how phobias develop. Some researchers believe that phobias
may be due to a maladaptive activation of an evolutionarily defined fear
pathway.

Selective mutism is an anxiety disorder that causes individuals who are normally
capable of speaking to become unwilling or unable to speak in anxiety-producing
situations. Selective mutism is often related to social anxiety disorder and
separation anxiety disorder, and it typically has a childhood onset.

In addition to the anxiety disorders described, abnormal anxiety may be caused by
a variety of drugs and medical illnesses. Common drugs involved in substance- or
medication-induced anxiety include caffeine, alcohol, stimulants in cold
preparations, nicotine, and many illicit drugs, including cocaine and
amphetamines. Medical illnesses that may cause anxiety include thyroid disease,
heart failure, cardiac arrhythmias, cancer, and schizophrenia.

Treatment and Therapy

When an individual has difficulty with anxiety and seeks professional help, the
cause of the anxiety must be determined. Before the etiology can be determined,
however, the professional must first determine if the patient has an anxiety
disorder. People with anxiety disorders often complain primarily of physical
symptoms that result from the anxiety. These symptoms may include motor tension
(muscle tension, trembling, and fatigue) and autonomic hyperactivity (shortness of
breath, palpitations, cold hands, dizziness, gastrointestinal upset, chills, and
frequent urination).

When an anxiety disorder is suspected, effective treatment often depends on an
accurate diagnosis of the type of anxiety disorder present. Accurate diagnosis
requires both physical and psychological evaluations, as it is very important to
rule out nonpsychiatric medical conditions causing anxiety. A variety of
medications can be prescribed for the treatment of anxiety disorders, including
selective
serotonin reuptake inhibitors (SSRIs),
serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic
antidepressants, and benzodiazepines.

In addition, several types of psychotherapy can be used. For example, patients
with panic disorder can be educated about the nature of their panic attacks,
reassured that they will not die from it, and taught coping methods to ride out
attacks. This process avoids the development of secondary anxiety, which
complicates the panic attack. Patients with phobias can be treated with
systematic
desensitization, in which they are taught relaxation
techniques and are given graded exposure to the feared situation so that their
fear lessens or disappears. Other effective therapeutic approaches for the
treatment of anxiety disorders include individual or group psychotherapy and
cognitive-behavioral therapy. Physical activity, particularly aerobic exercise and
yoga, have also been shown to improve anxiety symptoms.

Perspective and Prospects

Anxiety has been recognized since antiquity and was often attributed to magical or
spiritual causes, such as demonic possession. Ancient myths provided explanations
for fearful events in people’s lives. Pan, a mythological god of mischief, was
thought to cause frightening noises in forests, especially at night; the term
“panic” is derived from his name. An understanding of the causes of panic and
other anxiety disorders has evolved over the years.

Sigmund Freud (1856–1939) distinguished anxiety from fear. He considered fear to be an expected response to a specific, identifiable trigger, whereas anxiety was a similar emotional state without an identifiable trigger. He postulated that anxiety resulted from unconscious, forbidden wishes that conflicted with what the person believed was acceptable. The anxiety that resulted from this mental conflict was called an “anxiety neurosis” and was thought to result in a variety of psychological and physical symptoms. Psychoanalysis was developed to uncover these hidden conflicts and to allow the anxiety to be released.

Freud’s theories about anxiety are no longer clinically accepted. Many
psychiatrists now believe that many instances of anxiety disorders have a
biological cause and that they are more neurological diseases than psychological
ones. This is primarily true of generalized anxiety disorder and panic disorder.
It is recognized that anxiety can also be triggered by drugs (legal and illicit)
and a variety of medical illnesses.

Psychological causes of anxiety are also recognized. Unlike with Freud’s conflict
theory of anxiety, most modern psychiatrists consider personality factors, life
experiences, and views of the world to be the relevant psychological factors in
the development of anxiety disorders. Although anxiety disorders have a high
prevalence compared to other mental disorders, the pharmacological and therapeutic
treatments for anxiety are well established, highly effective, and long
lasting.

Bibliography

American Psychiatric
Association. Diagnostic and Statistical Manual of Mental Disorders:
DSM-5. 5th ed. Arlington: Author, 2013. Print.

Barlow, David H.
Anxiety and Its Disorders. 2nd ed. New York: Guilford,
2004. Print.

Bourne, Edmund J.
The Anxiety and Phobia Workbook. 5th ed. Oakland: New
Harbinger, 2011. Print.

Chalmers, John A., et al. "Anxiety Disorders
Are Associated with Reduced Heart Rated Variability: A Meta-Analysis."
Frontiers in Psychiatry 5 (2014): 1–24. EBSCO
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Davidson, Jonathan,
and Henry Dreher. The Anxiety Book. New York: Penguin,
2003. Print.

Ghinassi, Cheryl
Winning. Anxiety. Santa Barbara: Greenwood, 2010.
Print.

Hunsley, John, Katherine Elliott, and Zoe
Therrien. "The Efficacy and Effectiveness of Psychological Treatments for
Mood, Anxiety, and Related Disorders." Canadian Psychology
55.3 (2014): 161–76. Print.

Kahn, Jeffrey P.
Angst: Origins of Anxiety and Depression. New York:
Oxford UP, 2013. Print.

Kleinknecht, Ronald A.
Mastering Anxiety: The Nature and Treatment of Anxious
Conditions. New York: Plenum, 1991. Print.

Leaman, Thomas L.
Healing the Anxiety Diseases. New York: Plenum, 1992.
Print.

Muskin, Philip R.,
Patricia L. Gerbarg, and Richard P. Brown. Complementary and
Integrative Therapies for Psychiatric Disorders. Philadelphia:
Elsevier, 2013. Print.

Saul, Helen.
Phobias: Fighting the Fear. New York: Arcade, 2001.
Print.

Sheehan, David V.
The Anxiety Disease. New York: Bantam Books, 1983.
Print.

Stahl, S. M., and Bret
A. Moore. Anxiety Disorders: A Guide for Integrating
Psychopharmacology and Psychotherapy. London: Routledge, 2013.
Print.

Terluin, Berend. "To What Extent Does the
Anxiety Scale of the Four-Dimensional Symptom Questionnaire (4DSQ) Detect
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Tompkins, Michael A.
Anxiety and Avoidance: A Universal Treatment for Anxiety, Panic,
and Fear. Oakland: New Harbinger, 2013. Print.

Compare and contrast John Updike's story "A&P" and James Joyce's story "Araby."

"A&P" and "Araby" have a similar plot: we have a first-person narrator, a young teenage boy, describing a particular encounter with a highly attractive and desirable teenage girl; the boy has to struggle to stay focused as he works to achieve what he wants; and in the end, the boy does not get the girl in any sense or even win her attention, and the boy feels a more intense frustration than when the story began. Themes of failed gestures, failed connections, and disappointment can be found in both stories.

They also both have a similar setting in a small town where the narrators feel trapped and limited, the older adults are authoritative and unsympathetic, and there's a pervading sense of poverty and shortage. In "A&P," the narrator, Sammy, feels the impending stress that will result from his quitting his job in his awkward and unsuccessful attempt at standing up for the hot girls who got chided for coming into the store dressed only in swimsuits. Likewise, in "Araby," the unnamed narrator has only a few coins to buy a gift for his crush; it's not enough, he can't afford anything at the bazaar even when he finally gets there, and he comes home empty-handed. "A&P" ends with intense sadness ("my stomach kind of fell") and so does "Araby" ("my eyes burned with anguish and anger").

Despite these similarities, it's often more interesting to look at how two stories like these diverge. For example, even though both stories are brimming with imagery and figurative language, Sammy in "A&P" seems to use those devices to objectify the girls in the story, focusing on their body parts and the way their clothes fit, while the unnamed narrator in "Araby" uses figurative language to glorify his crush, focusing on her beauty and allure. Also, we sense a vastly different tone between the stories: "A&P" comes off as casual and cool while "Araby" is deeply serious. And though both stories build quickly to a tense climax, "Araby" does so against a background of severe religious constraint, while "A&P" touches more on the tension between social classes.

So far, we've brushed the surface of each of these aspects of both stories: plot, tone, the representation of women, etc. Both stories have such depth that they invite a closer, detailed look at any one aspect.

How would chapters 25-26 change if they were told from the point of view of Mrs. Finney?

This is an interesting question because Mrs. Finney is a relatively minor character in Walk Two Moons. To look at these chapters from her point of view changes the experience for the reader quite a bit. 

First let's look at what happens in chapters 25 and 26. In chapter 25, Sal and Phoebe join the Finneys for dinner, which is a wildly chaotic experience in comparison to what they are used to. Dinner at the Finneys is not only more crowded than what Phoebe is used to, but also the food is less healthy than what Phoebe usually eats at home. Since Phoebe is struggling with the disappearance of her mother, she takes out some of her feelings on the dinner spread, much to her dinner mates' annoyance. After Sal and Phoebe leave the Finney household, Sal invites Phoebe to stay over at Sal's house. Then Phoebe returns home to find her father struggling with household chores and, of course, the absence of his wife. 

In chapter 26, Sal struggles with Phoebe's picky habits as a house guest and they return to the Finney house. Mr. and Mrs. Finney are playing in the leaves with a couple of their kids before they sneak off for an intimate moment. Ben tells Phoebe and Sal that Mary Lou is on a date. That night, Sal's father hears Phoebe crying by herself and Sal remembers when she was in Phoebe's position after her mother left. 

Right away we know that if those chapters are from Mrs. Finney's point of view, the reader is going to lose everything that occurs outside of the Finney household. This includes Phoebe's father's struggles at home, Sal's struggles with Phoebe as a house guest, and Phoebe's "birds of sadness." We're also going to miss out on Sal's feelings towards Ben and Sal's inside knowledge of Phoebe's mother's disappearance. 

Not a lot is known about Mrs. Finney, but we do know that she has a lot of children and a loving relationship with her husband. In chapter 25 she "straggles" in the door, is bombarded by her children, greets her husband, and serves fried chicken for dinner. From Mrs. Finney's point of view, this is most likely just another night until Phoebe voices her complaints about the unhealthiness of the dinner. Mrs. Finney doesn't know about Phoebe's missing mother, so from her point of view, Phoebe's attitude is probably a little annoying. Mrs. Finney seems a little exasperated to be lectured by Phoebe about cholesterol, but she finds Phoebe some muesli to eat and dinner continues in its usual hectic manner. In chapter 26 Mr. and Mrs. Finney are enjoying a Saturday with their children before they sneak away to the roof for some alone time. From Mrs. Finney's point of view, it's probably another normal Saturday. The reader gets a feeling that the Finneys' marriage is very loving and that they're able to sneak in some time for each other despite their chaotic lives. Mary lou is on a date, so maybe Mrs. Finney spends a little time thinking about that, but Mary lou isn't the oldest child, so even this is most likely not a novel event. 

So you can see that changing the point of view from Sal to Mrs. Finney changes the experience entirely. In Mrs. Finney's life, chapter 25 and 26 are full of completely normal events with the addition of Sal and Phoebe, but what are a couple of extra kids in an already full house? In contrast, from Sal's point of view, the events of her life are anything but normal. Phoebe's mother has disappeared, which brings up memories of her own mother's absence. 

What is orthopedic surgery?

Indications and Procedures

Orthopedic surgery encompasses a number of different procedures carried out to repair injuries affecting the skeletal system and
joints or to repair tissues associated with these structures. Such surgery may also attempt to correct associated neurological injury. In addition, orthopedic surgery is used to correct musculoskeletal problems that may be congenital in origin.

Among the congenital conditions for which orthopedic surgery may be warranted are
bowlegs (valgus knees) and knock-knees
(varus knees). In the case of bowlegs caused by a congenital malformation, one or both legs are bent outward at the knee. In knock-knees caused by congenital conditions, the knees are curved inward, causing the lower legs to twist away from the body.

Treatment begins with a thorough evaluation of the problem. Based on x-ray analysis, an orthopedic surgeon may make a decision as to whether surgery can be used in the correction of the problem. During the surgical procedure itself, the affected limbs are properly aligned; they are splinted upon completion of the surgery. The chances of success are greatest in younger children. In an analogous situation, if a limb is twisted during fetal development, the child may exhibit misalignment of the structure following birth. Since bone at this stage of life is only beginning its growth, maintaining the limb in a splint may correct the problem. If necessary, the surgeon may decide to realign the limb at the joint through orthopedic surgery.

Tumors that originate in bone are uncommon. If they occur, such growths must be removed as quickly as possible because of the speed with which they spread to adjacent and distant structures in the body if the tumor is cancerous. The first signs of

bone cancer include pain and swelling in the affected region. Spontaneous fractures may occur. X-ray and biopsy analyses are necessary to confirm the diagnosis of cancer. If the tumor is benign, it may be removed through surgery. Osteomas, which are tumors that arise from connective tissue within the bone, may require radiation or chemotherapy in addition to surgical removal.

Commonly, orthopedic surgery is used to correct fractures or dislocations. As with any procedure, a thorough evaluation is necessary prior to a final decision. This evaluation often includes x-ray and computed tomography (CT) analyses. If the injury involves the spine, treatment must both correct the problem and prevent secondary injury to the spinal cord. Fractures to the vertebral column may produce fragments that pose a threat to the spinal cord. Under these conditions, orthopedic surgery is used to immobilize or straighten the spinal column; this may involve external braces or an internal brace such as a Harrington distraction rod. The patient may be immobilized for weeks to months, depending on the extent of the injury and the course of treatment.

Uses and Complications

One of the most common applications of orthopedic surgery is the repair of trauma or fractures to bones. For example, a blow to the face, either intentional or accidental, may result in fractures to the nose or facial bones. Injuries to other skeletal structures, including the spine, may also result from the incident. This is particularly true if the source of the injury was an automobile accident. Upon clinical examination by a physician, it may be apparent that facial bones have been fractured. X-ray analysis may be used to confirm the initial diagnosis. Proper repair and restoration of features will be the primary concern of the orthopedic surgeon, assuming that the injuries are not life-threatening. In the event of facial injuries, damage to teeth and other periodontal regions will also be a consideration. In many cases, wire fixation may be a sufficient course of treatment. If more severe, the fracture may require screw-plate fixation, particularly in complicated fractures.

If uneventful or uncomplicated, the healing of such injuries usually requires about six weeks of immobilization. The procedure and immobilization, however, are inherently uncomfortable. If a muscle tear is severe or significant, resulting in a pull to the bone or joint, an associated fracture may heal improperly because of the dislocation of tissue. Proper evaluation of surgical options, including the use of metallic plates, can limit any such complications.

Although cancers originating in bone tissue are uncommon, they nevertheless present problems for the orthopedic surgeon. Fractures related to tumor development are generally treated in much the same way as uncomplicated breaks. If damage to the bone, either through the tumor itself or as a result of therapy, is severe, even surgical repair may not be sufficient to heal the structure and allow mobility or normal function. If the fracture is near the joint, the bone may require realignment or resection, resulting in a shortening of the structure. In some cases, internal fixation with polymethylmethacrylate bone cement may be used to augment repair.

Perspective and Prospects

The introduction of Computed tomography (CT) scanning technology in the 1970s allowed for much more detailed evaluation of bone and joint injuries. Much of the technology is best applicable in a post-traumatic situation, evaluating the result of injury rather than its cause. Magnetic resonance imaging (MRI) is based on different technology but produces results that are similar to CT scans.

The destruction of bone as a function of aging or of disease is not well understood. Degenerative bone disease as a result of arthritis
is among the most common of arthritic conditions, affecting nearly half of middle-aged adults in some manner. Such conditions, particularly among the elderly, remain to be fully addressed.

The ability to carry out bone transplants, developed extensively in the latter half of the twentieth century, allowed for at least partial replacement of damaged bone. Replacement structures may come from the patient’s own body or from a cadaver. In addition, orthopedic technology has resulted in prostheses for the replacement of most joints in the body.

Joint replacements are dramatic. Individuals with crippling deformities can have nearly normal function restored through replaced joints. The most commonly replaced joints include hips and knees. Other joints can also be replaced. Individuals who have their hips and knees replaced usually start walking on the replaced joint in the first or second postoperative day. Complete rehabilitation requires several months.

Bibliography

Bentley, George, and Robert B. Greer, eds. Orthopaedics. 4th ed. Oxford, England: Linacre House, 1993.

Brotzman, S. Brent, and Kevin E. Wilk. Clinical Orthopaedic Rehabilitation. 2d ed. Philadelphia: Mosby, 2003.

Callaghan, John J., Aaron Rosenberg, and Harry E. Rubash, eds. The Adult Hip. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 2007.

Doherty, Gerard M., and Lawrence W. Way, eds. Current Surgical Diagnosis and Treatment. 13th ed. New York: Lange Medical Books/McGraw-Hill, 2010.

Griffith, H. Winter. Complete Guide to Symptoms, Illness, and Surgery. 6th ed. New York: Perigee, 2012.

Mulholland, Michael W., et al., eds. Greenfield’s Surgery: Scientific Principles and Practice. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2011.

Tapley, Donald F., et al., eds. The Columbia University College of Physicians and Surgeons Complete Home Medical Guide. Rev. 3d ed. New York: Crown, 1995.

McPhee, Stephen J., and Maxine A. Papadakis, eds. Current Medical Diagnosis and Treatment. Los Altos, Calif.: Lange Medical, 2011.

Zollinger, Robert M., Jr., E. Christopher Ellison, and Robert M. Zollinger, Sr. Zollinger’s Atlas of Surgical Operations. 9th ed. New York: McGraw-Hill, 2011.

What is ringworm?

Causes and Symptoms

Ringworm is a skin


disease characterized by itching and redness. Despite its name, it is caused by a fungal infection
, not a worm. The skin in areas affected with ringworm often contains round lesions that are colored red, have scaly borders, and contain normal-appearing skin in their centers. Alternatively, the lesions can simply be scaly, red patches with no clearly defined shape. Typically, these lesions are relatively small, approximately 1 inch in their largest dimension. Complications of ringworm include spread to the scalp, hair, or nails of the fingers or toes.

The lesions of ringworm are caused by species of fungi that are members of the genus
Trichophyton. The most common pathogen is Trichophyton rubrum. Ringworm appears on exposed areas of the body, often on the face and arms. Cats are the most common means of transmitting the Trichophyton pathogen from one person to another.

Examination of scrapings from skin lesions is used to diagnose ringworm. Species of Trichophyton can be tentatively identified by their microscopic structure. Culturing material from a skin lesion provides a definitive diagnosis.

Treatment and Therapy

The treatment of ringworm involves both the patient and any carriers. The patient can be treated effectively with any of several creams applied to the skin that are available without a prescription. Their use should be continued for one to two weeks after the skin lesions have cleared. Other drugs are available but require a physician’s prescription. They are used for more extensive lesions or when fingernails or toenails are involved. Body ringworm usually responds within four weeks of treatment. The carrier should be identified and treated. Avoiding contact with infected household pets or clothing that has been worn by an infected person can prevent ringworm.

Perspective and Prospects

Tinea species cause infections in other parts of the body: tinea capitis on the scalp, tinea pedis on the feet, and tinea cruris in the groin region. Ringworm must be differentiated from several other diseases that also cause round skin lesions: psoriasis, syphilis, pityriasis rosea, and systemic
lupus erythematosus. The lesions of psoriasis usually appear on the elbow, knees, and scalp. Syphilis lesions usually appear on the mucous membranes of the genitals or on the palms of the hands or soles of the feet. Although pityriasis rosea often begins with a single round lesion, many more usually follow. The classic skin lesion of lupus is butterfly-shaped and covers the nose and cheeks. The presence of a cat or other domestic pet is often an important element in establishing a diagnosis of ringworm.

Bibliography

Badash, Michelle. "Ringworm." Health Library, September 10, 2012.

Berman, Kevin. "Ringworm." MedlinePlus, May 24, 2011.

Burns, Tony, et al., eds. Rook’s Textbook of Dermatology. 8th ed. 4 vols. Hoboken, N.J.: Wiley-Blackwell, 2010.

Goldsmith, Lowell A., Gerald S. Lazarus, and Michael D. Tharp. Adult and Pediatric Dermatology: A Color Guide to Diagnosis and Treatment. Philadelphia: F. A. Davis, 1997.

Lamberg, Lynne. Skin Disorders. Philadelphia: Chelsea House, 2001.

Mackie, Rona M. Clinical Dermatology. 5th ed. New York: Oxford University Press, 2003.

MedlinePlus. "Tinea Infections." MedlinePlus, April 11, 2013.

Middlemiss, Prisca. What’s That Rash? How to Identify and Treat Childhood Rashes. London: Hamlyn, 2002.

Turkington, Carol, and Jeffrey S. Dover. The Encyclopedia of Skin and Skin Disorders. 3d ed. New York: Facts On File, 2007.

Weedon, David and Geoffrey Strutton. Weedon's Skin Pathology. 3d ed. repr. New York: Churchill Livingstone/Elsevier, 2011.

How do I write a review for Leo Tolstoy's "How Much Land Does a Man Need"?

The purpose of a review, also called a critical review, is to evaluate the quality of any text. To evaluate the text, you analyze the text to look for strengths and weaknesses.

A critical review begins with a very brief summary. The summary should focus on identifying the central theme of the story and what key events help develop that central theme. It can be said that the central theme in Leo Tolstoy's "How Much Land Does a Man Need?" concerns the consequence of greed. To illustrate the consequences of greed, the protagonist Pahom is tempted to purchase more and more land at cheaper prices. He is finally offered the greatest amount of land at what he thinks is the cheapest price yet--he can purchase as much land as he can claim on foot for one thousand roubles. Yet, he overestimates how much walking he can physically endure and how long it will take him, which costs him his life.

After briefly summarizing the story, you would next write your evaluation based on your analysis. To analyze the story, look at the literary devices and literary elements Tolstoy uses to develop his theme. Literary elements are all elements that are essential for telling a story such as plot, characters, and theme, whereas literary devices are the extra goodies authors use to develop the work and theme such as figurative language, symbolism, and foreshadowing. As you analyze these things, ask yourself if Tolstoy uses them well.

You can also ask yourself questions like the following:
Are the characters believable? Is the plot believable? Is the plot overly predictable? Is the story memorable? Is the message good but the story weak in some way?

As they are presented in the novel, Charlotte Lucas and Mr. Collins seem well matched. To what extent do you agree with this statement?

I very much agree with this statement.  Charlotte admits that "'[she] is not romantic,'" and she has really only hoped for marriage because it is the most socially-acceptable way for an upper-class woman of small income to dispose of herself.  At twenty seven years old, a plain woman like Charlotte has relatively few prospects, and it is unlikely that she will be asked to marry anyone else.  She only really wants "an establishment," a life of her own where she will not be a burden on or embarrassment to her family.

Mr. Collins's reasons for wanting to marry are as unromantic as Charlotte's: he believes it is the right thing for a clergyman to do, his patroness -- Lady Catherine de Bourgh -- thinks he should, and he believes that it will make him happy.  When he proposes to Elizabeth, he says nothing about love, and Charlotte doesn't require love in a relationship either.  On the contrary, she believes that it is better to know one's marriage partner as little as possible before actually getting married.  Mr. Collins must not disagree with this position since he asks Charlotte to marry him after spending just one evening alone with her family. 

Once they are married, Charlotte encourages him to spend as much as in his garden as possible, and he prefers to sit in a room that overlooks the road so that he can see when anyone is coming while she prefers a sitting room at the back of the house.  It sometimes happens that they go an entire day without seeing each other, except at meals, and they seem to get along perfectly well.  Each seems happy with their choice, and this leads me to believe that they are well-matched.

What is Edwards syndrome?

Risk Factors

Edwards syndrome can occur at any maternal age but occurs more frequently with advanced maternal age (more than thirty-five years). In addition, slightly more than 50 percent of infants with Edwards syndrome have a paternal age greater than forty years. There is no racial or ethnic predilection to the syndrome. The in utero female-to-male ratio is 1 to 1. However, more male fetuses die in utero or are spontaneously aborted and thus live births are approximately 80 percent female. Individuals with a translocation of chromosome 18 material are at a 50 percent risk of transmitting the complete syndrome (all cells affected) to their progeny.

Etiology and Genetics

An error in gamete (sperm or oocyte) division resulting in meiotic nondisjunction (failure of a replicating chromosome to divide) is the typical etiology of Edwards syndrome. In 95 percent of cases, the somatic cells contain three copies of chromosome 18 rather than the normal two. This extra genetic material is responsible for the multiple anomalies and developmental and cognitive deficits present with this syndrome. The remaining 5 percent of cases exhibit mosaicism (trisomy in some but not all cells) or translocation (extra chromosome 18 genetic material is attached to a normal chromosome). In some infants with mosiacism or translocation, associated anomalies may be less and the individual may phenotypically appear unaffected. Developmental and cognitive function varies from severe to normal in these individuals. Complete trisomy (affecting all cells) and mosaicism are not inherited but result from a de novo (new) mutation. Translocation trisomic individuals have a 50-percent chance of each offspring inheriting complete trisomy 18.

Symptoms

Prenatally, intrauterine growth deficiency accompanied by polyhydramnios (a large volume of amniotic fluid due to defective fetal swallowing) is common. Anomalies may be detected by fetal ultrasound.

Postnatally, the affected infant presents with classic signs and symptoms. They include central nervous system malformations (microcephaly with a prominent occiput, hydrocephaly, and neural tube defects); cardiac defects (ventricular and atrial septal defects, coarctation of the aorta); skeletal anomalies (growth retardation, clenched fist with index finger overlapping the middle finger and fifth finger overlapping the fourth, rocker bottom feet); gastrointestinal defects (omphalocele, malrotation); head and face issues (microphthalmia, micrognathia, microstomia, and low-set, malformed ears); and genitourinary obstruction. Feeding difficulties, developmental delay, and mental retardation are almost always present.

Screening and Diagnosis

Screening for aneuploidy can be done during the first trimester of the pregnancy from weeks ten to fourteen. The evaluation includes maternal age, fetal nuchal translucency, fetal heart rate, maternal serum free beta human chorionic gonadotrophin (beta-hCG), and maternal serum pregnancy-associated plasma protein-A (PAPP-A). These factors are successful in predicting approximately 90 percent of affected fetuses with a 3-percent false positive rate. Positive screening is then followed by definitive prenatal testing, including the analysis of fetal cells obtained by either chorionic villus sampling or amniocentesis.

When prenatal screening is not performed, infants are diagnosed after delivery as a result of common prevalent features and anomalies and clinical instability. Cytogenetic testing confirms the diagnosis.

Treatment and Therapy

The diagnosis of Edwards syndrome requires thoughtful clinical decision-making. Because of the high mortality rate of this syndrome and inability to offer a cure, comfort measures only may be offered to the infant. In surviving infants, appropriate health care services are offered depending on the types of anomalies and degree of developmental delay and mental retardation present.

Prevention and Outcomes

Currently, there are no known preventive strategies. The spontaneous prenatal death rate is high. With prenatal diagnosis, elective termination of the pregnancy is often performed.

For live-born infants, the prognosis is grim, with the median survival of live-born complete trisomic cases being less than one month. Between 90 and 95 percent die within the first year of life. Survival up to the third decade of life has been reported. Some affected individuals are institutionalized and others are cared for in the home.

Care providers should be alert to abnormal fetal growth patterns. Prenatal ultrasound and laboratory testing can be offered. After birth, all infants require a thorough physical examination and follow-up of any abnormalities.

Bibliography

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Crider, Krista S., Richard S. Olney, and Janet D. Cragan. “Trisomies 13 and 18: Population Prevalences, Characteristics, and Prenatal Diagnosis, Metropolitan Atlanta, 1994–2003.” American Journal of Medical Genetics, Part A 146.7 (2008): 820–6. Print.

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Tucker, Megan E., Holly J. Garringer, and David D. Weaver. “Phenotypic Spectrum of Mosaic Trisomy 18: Two New Patients, a Literature Review, and Counseling Issues.” American Journal of Medical Genetics, Part A 143.5 (2007): 505–17. Print.

What is anxiety? Does it cause cancer?

Description of the problem: A key feature of anxiety is
the perception of an imminent or future threat, regardless of the accuracy of the
perception. Although in some cases, anxiety can be brought on by exaggerated or
unrealistic appraisals of threat, in the case of cancer, anxiety is a normal and
expected reaction to a serious and potentially life-threatening disease.

Excessive anxiety that is interfering with an individual's daily life warrants
further evaluation. Vital to the assessment of clinically significant anxiety is
the extent to which anxiety meaningfully impairs the ability to function. For
example, extreme anxiety may prevent an otherwise able patient or loved one from
continuing to work, or it may interfere with medical care when a patient’s fearful
avoidance prevents or delays receipt of tests or treatments.

The American Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders (5th ed., 2013) recognizes several distinct types
of anxiety disorders, including generalized anxiety disorder, panic
disorder, panic
attacks, specific phobias, social anxiety disorder,
separation anxiety disorder, agoraphobia, and selective mutism, as well as
substance- or medication-induced anxiety disorder, anxiety disorder due to another
medical condition, other specified anxiety disorder, and unspecified anxiety
disorder. Anxiety may also be a prominent feature of depression or
an adjustment disorder (a short-term psychological reaction to a stressful event),
both of which are common among cancer patients.

The experience of being a cancer patient can contribute to the development of
anxiety disorders in several ways. For example, a patient may develop a phobia of
particular objects or procedures such as needles or diagnostic tests that were
associated with highly stressful experiences. After cancer care, some patients may
experience symptoms of posttraumatic stress disorder, a
trauma- and stress-related disorder characterized by recurrent intrusive memories
and flashbacks, avoidance of reminders of stressful events, and hyperarousal
symptoms such as sleep difficulties and irritability. Anxiety may have origins in
medical causes such as certain types of tumors or physiological side effects from
some treatments.

Prevalence: Not surprisingly, research suggests that the vast majority of cancer patients experience anxiety at some point during their illness. Far fewer develop clinical anxiety disorders. Although several studies have suggested an increased prevalence of anxiety disorders among cancer patients, others suggest little or no difference in this prevalence when cancer patients are compared with the general population. Reported rates of anxiety disorders are usually lower when assessed using formal diagnostic criteria and range from 10 to 30 percent.

Assessment: In the clinical setting, anxiety is most commonly
assessed face to face by a primary care provider or by a provider with special
expertise in mental health, such as a psychiatrist, psychotherapist, or a clinical
psychologist. The assessment is usually in the form of an interview to establish
the nature, duration, and severity of symptoms according to established criteria,
whether according to the diagnostic standards set out by the American Psychiatric
Association or some other diagnostic system.

Numerous standardized questionnaires are also available to measure anxiety in
clinical and research settings. These questionnaires ask respondents to
self-report the frequency or severity of various symptoms commonly associated with
anxiety. Examples of anxiety assessment questionnaires that have been used with
cancer patients include the Beck Anxiety Inventory, the State-Trait Anxiety
Inventory, and the Hospital Anxiety and Depression Scale.

Treatment and therapy: Anxiety related to medication or disease is usually first treated by managing the underlying condition causing symptoms. However, in many cases, anxiety is treated as a condition in its own right. Effective interventions for anxiety include both medical and psychological treatment options.

Medical management of anxiety usually entails treatment with an anxiolytic
(antianxiety) or antidepressant medication, the latter particularly when signs of
a depressed mood are present. The class of drugs known as benzodiazepines, which includes clonazepam (Klonopin),
alprazolam (Xanax), and diazepam (Valium), are sometimes used for short-term
treatment, although longer-term treatment with benzodiazepines is controversial
due to physical dependence and withdrawal symptoms. Commonly prescribed
antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as
paroxetine and sertraline (Zoloft), serotonin-norepinephrine reuptake inhibitors
(SNRIs) such as venlafaxine (Effexor) and duloxetine (Cymbalta), and to a lesser
extent tricyclic antidepressants such as imipramine (Tofranil) and clomipramine
(Anafranil).

Psychological treatments include individual psychotherapy (talk therapy), group
therapy, family therapy, and certain mind-body interventions. Anxiety is highly
responsive and often easily treated with appropriate therapy. In particular,
research heavily supports the efficacy of cognitive-behavioral therapy, which
encompasses a variety of therapeutic techniques. Broadly speaking, the goals of
cognitive-behavioral therapy for anxiety are to guide patients toward a more
balanced and rational appraisal of their concerns and to encourage behaviors that
reduce or neutralize anxieties rather than exacerbate them. Other frequently used
therapeutic approaches include training in relaxation techniques, mindfulness
meditation, and hypnosis. Biofeedback may also be effective in
helping patients recognize and manage physical symptoms of anxiety by, for
example, reducing muscle tension and cardiovascular reactivity to stress.

American Psychiatric
Association. Diagnostic and Statistical Manual of Mental
Disorders. 5th ed. Washington: Author, 2013. Print.

Antony, Martin M.,
Susan M. Orsillo, and Lizabeth Roemer, eds. Practitioner’s Guide to
Empirically Based Measures of Anxiety. New York: Kluwer
Academic/Plenum, 2001. Print.

Baum, Andrew, and
Barbara L. Andersen, eds. Psychosocial Interventions for
Cancer. Washington: American Psychological Assoc., 2001.
Print.

Cho, William C. S., ed.
Evidence-Based Non-Pharmacological Therapies for Palliative
Cancer Care. Dordrecht: Springer, 2013. Print.

Ladas, Elena J., and Kara M. Kelly.
Integrative Strategies for Cancer Patients: A Practical Resource
for Managing the Side Effects of Cancer Therapy. Hackensack:
World Scientific, 2012. Print.