What is Crouzon syndrome?

Risk Factors

Those most at risk for Crouzon syndrome are children of parents with the disorder, children whose parents do not have the disorder but who carry the gene that causes the disorder, and children whose fathers are at an older age at the time of conception.

Etiology and Genetics

Crouzon syndrome is inherited as an autosomal dominant disorder, meaning that a single copy of the mutation is sufficient to cause full expression of the syndrome. An affected individual has a 50 percent chance of transmitting the mutation to each of his or her children. Many cases of Crouzon syndrome, however, result from a spontaneous new mutation, so in these instances affected individuals will have unaffected parents.

Most individuals with Crouzon syndrome carry a mutation in a gene called FGFR2, which is found on the long arm of chromosome 10 at position 10q26. FGFR2 encodes a protein known as fibroblast growth factor receptor 2. Like many similar receptors, this protein has multiple functions, but one particularly important effect is to signal the appropriate population of stem cells to develop into bone cells during embryonic and fetal development. It is believed that mutations in this gene result in an overstimulation by the receptor protein that can cause the bones of the skull to prematurely fuse.

Mutations in a second gene, FGFR3, found on the short arm of chromosome 4 at position 4p16.3, have also been known to be associated with Crouzon syndrome, although patients with these mutations also exhibit a characteristic skin condition known as acanthosis nigricans (dark, thick, velvety skin in body folds, often in the neck and armpit area). The gene product is another fibroblast growth factor receptor, one that is more commonly associated with achondroplastic dwarfism.

Symptoms

The main signs and symptoms of Crouzon syndrome include flattened top and back of head; flattened forehead and temples; midface that is small and located farther back in the face than normal; beaklike nose; compression of nasal passages, often causing reduced airflow through the nose; a large, protruding lower jaw; misalignment of teeth; and a high-arched, narrow palate, or cleft palate. Other symptoms and complications that can result from Crouzon syndrome include hearing loss, deformity of middle ears, absence of ear canals, Ménière’s disease (dizziness, vertigo, or ringing in the ears), vision problems, crossed eyes or involuntary eye movement, curvature of the spine, headaches, fused joints (in some cases), and acanthosis nigricans (small, dark, velvety patches of skin).

Screening and Diagnosis

A doctor can usually diagnosis Crouzon syndrome at birth or in early childhood based on the patient’s physical signs and symptoms. Tests are taken to confirm the diagnosis. They may include x-rays, a test that uses radiation to take a picture of structures inside the body, especially bones; a magnetic resonance imaging (MRI) scan, a test that uses magnetic waves to make pictures of the inside of the body; and a computed tomography (CT) scan, a type of x-ray that uses a computer to make pictures of the inside of the body. Genetic testing to confirm mutations in the FGFR2 or FGFR3 gene may be used if the clinical findings are not sufficient to make a diagnosis.

Treatment and Therapy

There is no cure yet for Crouzon syndrome. Because the molecular cause is now known, scientists are exploring ways to block the processes that lead to early fusion of the sutures without affecting other important growth processes. These efforts are currently restricted to experimental animals, but human advances may be on the horizon.

Many of the symptoms can be treated with surgery. In addition, orthodontic treatment, eye and ear treatment, and supportive treatment are usually needed. Good dental care is also an important aspect of managing the care of children with Crouzon syndrome.

There are a number of surgeries used to treat the symptoms of Crouzon syndrome. They include craniectomy, which involves removal and replacement of portions of the cranial bone. This surgery is done as early as possible after birth to prevent pressure on and damage to the brain and to maintain a skull shape that is as normal as possible. Surgery to treat exophthalmos (protrusion of one or both eyeballs) is done directly on the eye sockets or on the bones surrounding the eye sockets to help minimize exophthalmos. Surgery to treat protruding lower jaw is often very successful in normalizing the appearance of the jaw by removing a portion of the jawbone. Surgery can also be done to repair a cleft palate.

Braces and other orthodontic treatments are usually necessary to help correct misalignment of teeth. An ophthalmologist (eye specialist) and otolaryngologist (ear, nose, and throat specialist) should monitor infants and children with Crouzon syndrome. These specialists can check for problems and provide corrective treatment as necessary. Supportive treatment for the disease includes special education for children with intellectual disabilities.

Prevention and Outcomes

There is no known way to prevent Crouzon syndrome. If a patient has Crouzon syndrome or has a family history of the disorder, he or she can talk to a genetic counselor when deciding to have children.

Bibliography

Alan, Rick. "Crouzon Syndrome." Health Library. EBSCO, 3 June 2014. Web. 22 July 2014.

Dalben, Gda S., B. Costa, and M. R. Gomide. “Oral Health Status of Children with Syndromic Craniosynostosis.” Oral Health and Preventive Dentistry 4.3 (2006); 173–79. Print.

Jones, Kenneth Lyons, Marilyn Crandall Jones, and Miguel del Camp Casanelles. Smith's Recognizable Patterns of Human Malformation. 7th ed. Philadelphia: Elsevier, 2013. Print.

Kelly, Evelyn B. Encyclopedia of Human Genetics and Disease. 2 vols. Santa Barbara: Greenwood, 2013. Print.

Kjaer, I., et al. “Abnormal Timing in the Prenatal Ossification of Vertebral Column and Hand in Crouzon Syndrome.” American Journal of Medical Genetics 90.5 (2000): 386–89. Print.

Perlyn C. A., et al. “A Model for the Pharmacological Treatment of Crouzon Syndrome.” Neurosurgery 59.1 (2006): 210–15. Print.

Suppose people in China start using the same amount per person as we do in the United States. How many barrels per year will they use then?

I assume you are referring only to crude oil consumption. The United States in 2015 consumed 6.97 billion barrels of petroleum products. The population of the United States in 2015 was approximately 321 million and the population of China was approximately 1.4 billion.

If the per capita crude oil consumption in China were to equal that in the US, the total crude oil consumed in China would be approximately 6.97*10^9/321*10^6*1.4*10^9. This is approximately equal to 3.03*10^10 or 30.3 billion barrels of crude oil.

If people in China start to consume crude oil at the same rate as those in the United States they would consume approximately 30.3 billion barrels of crude oil in a year.

The global production of crude oil in 2015 was approximately 35.5 billion barrels. If the Chinese consume as much crude oil as Americans, they would use up almost all the crude oil produced on Earth.

What lessons does "The Possibility of Evil" teach about human nature?

One lesson the story teaches is that (some) people are duplicitous. In other words, they are "two-faced." Miss Strangeworth is kind to everyone's face but as soon as they are out of earshot, she is critical and judgmental. She plays the role of the amiable neighbor in public. But in private, she is condescending and, at times, even spiteful and hateful towards others. 

This duplicity shows Miss Strangeworth's feelings of superiority. She feels that it is her duty to send these anonymous letters. She thinks that she is somehow more righteous, ethical, and logical and therefore in a position to judge other people. She has a warped Messianic complex. The fact that she does this anonymously shows cowardice, but Miss Strangeworth is so conceited that she probably doesn't even consider this to be a cowardly practice. 

So, even someone like Miss Strangeworth, who seems like a good person on the surface, is capable of evil. The title suggests the possibility of evil in anyone and particularly, in people like Miss Strangeworth. She is not really helping these people because she is not giving constructive criticism. She is simply being insulting and condescending. 

Her use of anonymous criticism is somewhat similar to the hate speech and ugly comments we see on the internet today. Going under an anonymous screen name gives some people the notion that they can say anything, with no consequences. It is easier to be self-righteous and judgmental when one is removed from those whom she/he is criticizing. 

This story shows negative aspects of human nature: duplicity, self-righteousness, and cowardice. 

How did artists and writers capture the effects of the Great Depression?

Many artists, photographers, and writers depicted the desperation, despair, cruelty, and harsh conditions of the Great Depression.

The Public Works of Art Project that was part of President Franklin D. Roosevelt's New Deal employed artists to enhance public buildings. These paintings often depicted workers of the era. For example, The New Deal, an affresco [a technique of mural painting on wet plaster] by Conrad A. Albrizio, depicts the various occupations of the Public Works program with President Roosevelt in a pair of overalls standing behind a seated worker. This work is dedicated to Roosevelt.

Certain paintings by individual artists depict the despair and desperation of men who have lost their jobs in the Depression. For instance, On the East River, 1934, depicts a man lying on a newspaper with his coat as the pillow; another man is holding his head in despair. Another painting, Waterfront by Raphael Soyer (1934) depicts a number of homeless people lying before the storefronts on a pier.

Photographers such as Dorothea Lange, Walker Evans, and Russell Lee were commissioned by the government to document the migrant workers and farmers and their living conditions. The most famous of these photographs is the picture of a mother and her three children by Lange, who wrote,

 I saw and approached the hungry and desperate mother, as if drawn by a magnet....She told me her age, that she was thirty-two. She said that they had been living on frozen vegetables from the surrounding fields, and birds that the children killed. She had just sold the tires from her car to buy food. [She] seemed to know that my pictures might help her, and so she helped me. There was a sort of equality about it.

Probably the most famous of novels set in the Great Depression is John Steinbeck's The Grapes of Wrath. This novel depicts the hardships endured by the farmers of Oklahoma, whose livelihoods were destroyed by the Dust Bowl and the Depression. The narrative follows the lives of the Joad family as they take their worldly possessions and migrate to California in the hope of finding jobs. In his narrative, Steinbeck has intercalary chapters which recreate scenes of the lives of the poor families in their desperate hopes during the 1930's..
Another of Steinbeck's works, Of Mice and Men is also set during the Depression. Its narrative depicts the empty lives of the disenfranchised men who travel from job to job as "bindle stiffs." They never make enough money to save for their futures, but simply live from day-to-day.

Come Back to Sorrento (1932), by Dawn Powell is another novel set during the Depression. It depicts the silent despair of people who live in a small town.
They Shoot Horses, Don't They? by Horace McCoy (1935) is also novel set during the Great Depression. In its narrative, people endure great pain as they dance during a marathon which awards a prize to the last couple standing.

Where did Maniac Magee sleep when he ran away?

Maniac Magee ran away from his aunt and uncle's home, where he had lived since he was orphaned at three-years-old.  He ran until he arrived in Two Mills, Pennsylvania.  Two Mills was close to where he had lived with his parents before their death.  

When Maniac first arrived in Two Mills, he made his home in "the deer shed at the Elmwood Park Zoo."  He stayed there unnoticed for a few days.  He ate the same food as the deer.

Soon Maniac met the Beale family.  He visited with them for awhile and had dinner with the family.  When it was getting late, Mr. Beale offered to drive Maniac home.  When they were in the car, Mr. Beale discovered that the boy did not have a real home.  When he found this information out, the man "made a U-turn right there and headed back."  After Mrs. Beale discovered that Maniac was homeless, she insisted that he stay with them.  Amanda gave up her room so that Maniac could sleep there.

Explain what will happen if mass of the mercury drop increases?

The question is not very clear if you are referring to a particular case or you want to know the general effect of increase in mass of a mercury drop. I will answer the more general question.

If the mass of a mercury drop were to increase, while keeping other physical parameters constant, this would also cause an increase in the density of mercury. Density of a substance is the ratio of its mass to its volume. Thus, an increase in mass, while keeping the volume constant, will increase the density of the substance.

An increase in the density of mercury will affect its various engineering applications. Mercury is commonly used to measure pressure using mercury barometers (devices in which a rise in the level of mercury in a tall column is measured as an indicator of pressure). An increase in mercury's density will mean that it will rise to lower height in the barometer and hence 1 atmosphere pressure will no longer be equal to 76 cm of mercury (it will, in fact, be less than 76 cm).

Similarly, more dense mercury will also be able to support more weight due to higher buoyancy. 

Hope this helps. 

In chapter 19 of The Hunger Games, who else is affected by the Gamemakers changing the rules?

The rule change by the Gamemakers in chapter 19 changes everything for Katniss. She can have a real ally in Peeta, as she won't have to kill him in the end. When she hears the change in rules, her first thought is to meet up with him and she seems to genuinely want to be his ally and help him when she realizes he's hurt. Of course, she is also totally aware of the fact that not helping him would mean severe judgement from everyone in District 12 and the importance of playing up their romance. Katniss is always aware of how "on display" she is in the games.

Even though the rule change gives Katniss an edge, it also benefits the tributes from District 2, the only district with both tributes still alive. Katniss is certain that Cato and Clove will be working together from here on out. Since they are from one of the districts that trains their children for the games, this is seriously dangerous news, but Katniss can't dwell on it. She's too busy finding Peeta and nursing him back to health. 

In the poem "The Old Woman's Message," where are the similes and what are their meanings? How do the similes contribute to the overall meaning of...

This poem has several similes in which the poet compares one thing to another using the word "like." First, the old woman's sons are "like fruit borne by birds." The woman has just noted that ripe fruit, when it falls, falls near the trunk, figuratively its "mother." In the same way, she wishes her boys, now that they are "ripe" and grown up, would come to her side. However, her sons are not like that kind of fruit. They are like fruit that birds pick up and carry far from the tree. This represents how her sons have moved away from their childhood home.

Next, the old woman uses three similes to describe her condition, showing that she is very old and coming to the end of her life. She says her "hands are like broom sticks." This suggests they are bony and rough; they have lost the fleshiness of youth and middle age. She says she is "dry like a carved image." This suggests the dry, thin skin of old age and the weight loss that makes her seem hard rather than supple. She says, "I sway like a dry falling leaf." Elderly people often have balance issues, or their joints and muscles don't function as well, so when they walk, they totter or move from side to side. This image harks back to the beginning of the poem where the speaker mentions the fruit tree. But the picture of the dry falling leaf speaks of autumn and the end of life; falling leaves are dead leaves. 

The similes add emotion to the poem and emphasize the various meanings. Birds are often symbolic both of freedom and of impending doom; the fact that the birds have carried the fruit, that is, her sons, far away shows that they have gained their freedom, but that this is an unhappy reality for the old woman. The similes she uses to describe herself show she is frail and needy and are meant to arouse sympathy and pity, hopefully having the effect of bringing the old woman's sons quickly to her side.

What is Salvia divinorum?

History of Use

Salvia divinorum was first used by indigenous peoples in the mountains of southern Mexico for religious purposes. To the Mazatec people, its use allowed transcendence and communion with higher powers. In the 2000s, Salvia became the most commonly used hallucinogen in the United States, although not for spiritual reasons. Its increased use has been linked to the availability of information about it on the Internet, to the belief that it is fairly safe, to its legality in many parts of the world, to its potent and short-lived hallucinogenic effects, and to its being undetectable in routine drug tests.

Effects and Potential Risks

Salvia’s psychoactive component, salvinorin A, selectively activates a specific type of opioid receptor, the kappa-opioid receptors (KOR). These are found in several areas of the central nervous system, including the hypothalamus, the claustrum, the central gray matter of the midbrain, and the spinal cord. A few minutes after stimulation, KORs cause vivid dissociative effects, including depersonalization and sensory confusion. Additionally, KOR stimulation decreases one’s sensation of pain and increases urination and perspiration. The effects of smoked Salvia typically last fewer than thirty minutes. If chewed, the effects can persist for about one hour.

There does not appear to be significant risk of addiction with Salvia. Salvinorin A has no affinity for the mu (µ) opioid receptors, which are stimulated by substances such as heroin and morphine and have been implicated in the reward system that drives addiction.

Although nonaddictive, Salvia is not harmless. Its vivid hallucinogenic effects can be unpleasant and can produce heightened anxiety or panic. Other negative symptoms include paranoia, thought blocking, and mental slowing. Moreover, because it is a non-water-soluble compound, the long-term effects of salvinorin A are unpredictable.

Bibliography

Babu, Kavita, Christopher R. McCurdy, and Edward Boyer. “Opioid Receptors and Legal Highs: Salvia divinorum and Kratom.” Clinical Toxicology 46 (2008): 146–52. Print. Describes the psychoactive effects of Salvia and its increasing popularity as a recreational drug.

Brown, David Jay. “Salvia on Schedule.” Scientific American 301.2 (2009): 20–21. Print. Reviews the debate surrounding the regulation of saliva and discusses the potential effects of criminalizing the drug on research efforts studying the drug’s medicinal properties.

Mysels, David. “The Kappa-Opiate Receptor Impacts the Pathophysiology and Behavior of Substance Use.” American Journal on Addictions 18 (2009): 272-76. Print. Reviews research on the kappa-opiate receptor and its role in substance abuse and addiction.

Sanders, Laura. “Lab Study Probes Psychoactive Drug.” Science News 179.2 (2011): 15. Print. Describes the psychopharmacological effects of Salvia.

Please elaborate on why the Struldbrugs lament the perpetuity of their lives.

Gulliver assumes that immortality would give him the opportunity to amass more money, to "excel all others in Learning," and to become a walking, talking encyclopedia of knowledge because he would have seen so much. However, the Struldbrugs are not happy about living forever because their lives are totally miserable.  

They are typically pretty normal until they reach the age of thirty, and then they grow "melancholy and depressed," a condition which worsens as they age. They remain living, but they do not remain young, and this is the key to their misery. They grow more irritable, greedy, depressed, and self-centered as time passes. Once they reach eighty years old, they are declared dead under the law, their property passes to their children, and they are able to retain only a small portion of their fortunes (or they are supported by the public if they are poor, a fact for which they are resented). Moreover, because language changes, they eventually can no longer understand anyone around them and they live "like Foreigners in their own Country." Finally, they are "despised and hated" by everyone. It is not the educational opportunity Gulliver imagines it to be.

Is this a good essay about how opposite themes are portrayed in Romeo and Juliet?First of all, Romeo, and Juliet is the most famous love story in...

There are plenty of good ideas in this essay, but it definitely needs some organization and to be broken up into paragraphs. Also, unless your teacher indicates you can use the first person I in your essay, eliminate it. The first three sentences seem fine for an introduction though I've made a few edits:

First of all, Romeo and Juliet is possibly the most famous love story in English literature. Love is naturally the play’s dominant theme. The play focuses on the intense love that springs up between Romeo and Juliet despite the bloody feud between their families.

Following these sentences you need another introductory type sentence about hate. It's always good to insert actual quotes from the play to back up your points and there are numerous possibilities—maybe use the quote about "hell" involving Tybalt and Benvolio. Then you need a strong thesis statement indicating that the point of your essay is about how the opposites of love and hate fill the play.

You probably need at least two body paragraphs for your essay. You have the choice of two directions in this. Each paragraph could deal with a different topic. For example, the first body paragraph could be about the secret love between Romeo and Juliet. The second paragraph would then be about the hatred between the families. Make sure to use specific scenes from the play to provide evidence. Direct quotes are important as well. Or your body paragraphs could combine the two themes and juxtapose an example of love with an example of hate.

So, in your first body paragraph make sure to provide a topic sentence which tells what the paragraph will be about. I've lifted a sentence from your essay and provided editing to give an example of a possible topic sentence for the paragraph on hate:

The hate between the Montagues and Capulets is deadly, long standing and it seems neither side is willing to put it to an end.

Then give examples of this hate (the fight in Act I, Scene 1 or when Tybalt becomes enraged at seeing Romeo at the party). Also make sure you provide your opinion about those examples. For instance, you might indicate that the feud is immature or childish (especially the "thumb biting" episode in Act I, Scene 1). Provide at least two examples of hatred in the play and your opinion about those examples. 

Do basically the same thing in your second paragraph. Write a good topic sentence, provide examples of love in the play (Romeo and Juliet first meeting, the balcony scene, their wedding) and then give your opinion about those examples, such as "Juliet's beauty overwhelms Romeo and he seems to instantly forget Rosaline as he compares Juliet to a bright light and a jewel in Act III, Scene 5 when he first sees her."

For your conclusion, I have edited your last two sentences. Two sentences, however, do not make a good conclusion, so you'll need more:

In conclusion, there are two very strong emotions in the play, love and hate. The play portrays the chaos and passion of being in love and how hatred can make that love difficult.

Your essay should be four or five paragraphs and make sure that each of your paragraphs has 5-8 sentences or more. Don't forget the thesis statement should be the last sentence in the introduction and that each body paragraph needs a good topic sentence.

In Romeo and Juliet Act 4, Scene 5, what two meanings can be ascribed to the word "note" as it is used in line 113?

In this scene, the nurse discovers Juliet's lifeless body and assumes that she has died. She cries out and summons her parents who are devastated. They had prepared for Juliet's betrothal to Paris and her death was obviously the last thing they expected. What they evidently do not realise is that their daughter is actually in a death-like sleep brought on by a powerful sleeping potion which friar Lawrence had provided as part of the plan to have her later meet up with Romeo and then leave Verona. 

In the confusion caused by the tragedy, all the wedding arrangements have to be changed to those of a funeral. It is at this point that Peter, one of the Capulet's servants, converses with the musicians who had been hired to play at the funeral. He requests that they play him a happy song to cheer him up, considering that it was such a sad occasion. The musicians are not very cooperative and thus begins a verbal barrage between Peter and them.  

At some point, Peter says that he will not pay the musicians if they don't play. In response, the first musician tells him that he will, in retaliation, call him a serving-creature. Peter's response is:

Then will I lay the serving-creature's dagger on
your pate. I will carry no crotchets: I'll re you,
I'll fa you; do you note me?

He means that he will knock the musician on his head with his dagger and will not bear his insults. He further threatens the musician by stating that he will 're' and then 'fa' him. These are obvious references to musical notes but used in a different context. Peter means that he will play these notes on the musician's head with his dagger. It is a threat to knock him about the head.  

To make sure that the musician understands him properly, he asks him 'do you note me?' The word is used as a pun in this instance and means, "Are you taking note of what I'm saying?" or "Have you heard what I've just said?" The word can also refer to a musical note since Peter has been using references to these throughout their inane argument.

This piece of inane humour seems quite out of place within the context of what has happened and may have, as its purpose, the provision of some comic relief. It could also be a diversion from the tragic circumstances at play here and may be used to remind the audience about the iniquities of life, that everything is tied together and that there is a thin line between tragedy and comedy, life and death, etcetera. Be that as it may, it is all one or, as we may say, "It is all part of life." 

What are some quotes from To Kill a Mockingbird about how racism affects Jem?

Jem watches the Tom Robinson trial with hope and faith in his father and the judicial process. To him, it is easy to see that Tom should go free based on the evidence. Jem even suffers through Mr. Gilmer's cross-examination without losing heart like Dill does, so when the verdict comes back "guilty," he is crushed and forced to face the reality of racism. First he cries, then he tries to find a logical explanation, and then he becomes bitter. Scout describes Jem's reaction on the way home from the trial in chapter 22:

"It was Jem's turn to cry. His face was streaked with angry tears as we made our way through the cheerful crowd. 'It ain't right,' he muttered, all the way to the corner of the square where we found Atticus waiting. . . . 'No son, it's not right'" (212).

In chapter 23, Atticus helps Jem understand what happened and why Tom was convicted in spite of all the evidence. Jem needs to identify the problem, so he first questions if the decision was made because rape is a capital offense in Alabama. Atticus says that's not the problem. The problem is twelve white men not being able to let go of tradition and their loyalty to racial prejudice to let Tom go free. Then Jem asks why good people aren't on juries, which is a good question, and one that helps him get to the heart of the matter. Atticus explains that a jury filled with boys like Jem would have let Tom go free, but when it is a white man's word against a black man's in Alabama, Tom would never go free.

A few months go by, and life returns to normal in Maycomb. Scout has an interesting experience in her third grade class as they discuss what is happening in Germany between the Jews and Hitler. Miss Gates, the teacher, talks about how horrible Hitler is to discriminate against and persecute Jews. Scout finds this hypocritical because after the trial she heard Miss Gates say that she was glad someone taught the black community a lesson by convicting Tom. Scout needs help understanding the discrepancy between the way Germans treat Jews and the way people in Maycomb treat blacks, so she asks Jem about it later at home. Jem clearly shows that he is embittered by the racism question by now and yells at Scout:

"Jem was suddenly furious. He leaped off the bed, grabbed me by the collar and shook me. 'I never wanta hear about that courthouse again, ever, ever, you hear me? You hear me? Don't you ever say one word to me about it again, you hear? Now go on!'" (247).

It would seem that the realization of racism and all that it does and is has affected Jem deeply. He has crossed over from childhood and entered into the raw realities of racism in his community, and he will never be the same again.

Which character best serves as George Bernard Shaw's spokesperson in Arms and the Man? How?

One of the best ways to see who speaks for the playwright in Arms and the Man by George Bernard Shaw is to read the Preface. Shaw is notorious for writing long, entertaining essays as prefaces to his plays which explore many of the issues he is addressing and guide his audiences in interpreting his plays.

This play was first performed in 1894 and was written partly in response to the real, historical Serbo-Bulgarian War of 1885, a war deeply unpopular with the Serbians and eventually concluded by a treaty which actually changed very little.

Shaw's aim in the play was to show that war is not glamorous and heroic, but a grimly practical business. He makes fun of what he considers the silly romantic posturing of Sergius and uses the persona of Captain Bluntschli, a reluctant soldier with few illusions, to express his opinions. In one way, the marriage in the end is a triumph of the realism of the "chocolate cream soldier" over romantic ideals, but even more profoundly, it is a statement that real love and romance are not about verbal hyperbole and roleplaying, but about sharing ideas and goals in everyday life.

At the beginning of 1998, the annual consumption of ice cream is in the U.S. was 12,582,000 pints and growing at a rate of 212,000,000 pints per...

The data given with regards to the population of US in 1998 written in mathematical form: 

Population: `P = 268 924 000`

Annual consumption of ice cream: `C = 12 582 000`

Rate of annual consumption of ice cream: `(dC)/dt = 212 000 000`

Rate of population growth in the US in 1998: `(dP)/dt = 1856000`

Since we are told that:

annual per capita growth = (annual consumption) / (population size)

We can use calculus, specifically the quotient rule to determine the annual per capita consumption of ice cream increasing at that time.

The formula is as follows:  

`d/dx [C/P] = [P * (dC/dt) - C * (dP/dt)] / (P^2)`

`d/dx [C/P] = [(268924000 * 212 000 000) - (12 582 000 * 1 856 000)]/ (268924000^2)`

`d/dx [C/P] = 0.788`

The annual per capita consumption of ice cream increased at that time in 1998 was 0.788

How was life after the Louisiana Purchase?

Life continued to move forward after the Louisiana Purchase. President Jefferson sent the explorers, Lewis and Clark, to explore part of the Louisiana Purchase. They came back with geographic information and scientific information about the land we had just purchased from France.

Life in the United States continued to grow and develop. Many people continued to farm. Slavery continued to be important in the South. As the Industrial Revolution began, more people started to work in factories. These factories were located in the cities, leading to an increase in the population of the cities. The North was mainly industrial while the South was mainly agricultural.

Eventually, we began to develop the American System. We began to protect our industries by putting tariffs on products made in other countries. This helped our new industries grow. We began to improve our transportation system. The National Road was expanded and new canals, such as the Erie Canal, were built. We also developed our national bank.

The Louisiana Purchase helped our country grow. As our country grew, so did life in the United States.

What does Santiago dream about in The Old Man and the Sea?What does Santiago dream about in The Old Man and the Sea by Hemingway?

Santiago dreams of the lions that played on the beaches of Africa, where he once visited after going on a sailing ship years ago.

When he was much younger and saw the lions cavorting and wrestling in the sand with each other on the African coast, Santiago found them very vital and full of youthful energy. In fact, he admired their exuberance and strength. Now, he does not dream of his deceased wife or anyone else; instead, he only dreams of the young cats that once played on the beaches because he has always admired their youth, energy, and strength.

He only dreamed of places now and of the lions on the beach. They played like young cats in the dusk and he loved them as he loved the boy.

Just as he talks of the great players Joe DiMaggio and Dick Sisler and great managers John McGraw and Leo Durocher, Santiago finds a focus for his thoughts so that he, too, can persevere and endure. Now, after eighty-four days, the old man knows that he must prove his strength and abilities when he goes out. So, he sleeps and dreams of the young, vital lions before he goes out in search of fish as he bolsters his strength.

After his battle with the marlin, it is a discouraged and exhausted Santiago who returns with only the bones of the great fish. But, he has certainly fought hard, and brought the marlin next to his boat only to have it devoured by sharks. Nevertheless, in an act of renewal of his spirit, Santiago, who is exhausted, beaten, and battered, retains his ability to dream and his indomitable spirit. He lies down and dreams again of the lions, undefeated. 

What do the stories from Cuyloga teach True Son?

Cuyloga imparts his wisdom on True Son three times in the novel. In chapter four, Half Arrow relays the words of Cuyloga to True Son as the boy is on his way to the white settlement. He advises True Son to handle his captivity with "patience and cheerfulness" so that he does not awaken the suspicions of the whites. He tells True Son to wait for the right moment to attempt escape. Cuyloga says, "It is better to wait for your cause to be ripe like a persimmon on the snow before you fight back." 

True Son remembers the second story of his father when it is revealed that he will be living in Paxton Township. He recalls the "Peshtank story" about the atrocities committed by the whites against a group of Conestoga Indians who came to live with the whites and adopted Christianity. The story highlights the brutality of the whites and fact they could not be trusted. Remembering it further increases True Son's bitterness over having to live in the Butler household. Later, however, some of his hatred seems to diminish as he grows to love his white brother Gordie. 

In the final chapter, Cuyloga sends True Son back to the whites after the boy warns the white settlers in the flat boat of the impending Indian attack. Cuyloga reminds the boy that he took him in and made him part of his family. He taught him how to speak with a "straight tongue" and the difference between right and wrong. Obviously Cuyloga taught True Son well. The boy shows an amazing ability to discern the wrongs committed by both the whites and the Indians. He sees no difference between the killing of children by the whites or the Indians. Unfortunately, Cuyloga has to end his relationship with his adopted son. He tells True Son that if they ever meet again he will either kill him or be killed.

Why does Crooks say that George, Lennie, and Candy will never attain their dream of owning their own land?

Crooks is the black stable buck in Steinbeck's novella Of Mice and Men. Because of racism and segregation he lives by himself in a room in the barn. In chapter four most of the workers, including George, have gone into Soledad, leaving Lennie, Candy and Crooks behind. Lennie is in the barn playing with his puppy when he sees Crooks's light. He stands at the doorway, and despite initial protests, Crooks invites Lennie into the room. Lennie, as he often does, is soon talking about the rabbits he will take care of when he and George get their own place. Crooks scoffs at the idea that a worker could ever get his own land. He tells Lennie,

"Ever’body wants a little piece of lan’. I read plenty of books out here. Nobody never gets to heaven, and nobody gets no land. It’s just in their head. They’re all the time talkin’ about it, but it’s jus’ in their head.”

A little later when Candy, who is looking for Lennie, comes into Crooks's room he too announces that the three men will soon be getting their own place. When Candy tells Lennie they can make money on rabbits, Crooks again repeats his criticism:

“You guys is just kiddin’ yourself. You’ll talk about it a hell of a lot, but you won’t get no land. You’ll be a swamper here till they take you out in a box. Hell, I seen too many guys. Lennie here’ll quit an’ be on the road in two, three weeks. Seems like ever’ guy got land in his head.” 

Candy then claims that they even have the money, which he is contributing and the dream will soon be realized. Crooks is still disbelieving and questions the whereabouts of George. He says,

“An’ where’s George now? In town in a whorehouse. That’s where your money’s goin’. Jesus, I seen it happen too many times. I seen too many guys with land in their head. They never get none under their hand.” 

Eventually, however, Crooks is convinced that the dream is a possibility and even offers to join the men. He says,

“ . . . . If you . . . . guys would want a hand to work for nothing—just his keep, why I’d come an’ lend a hand. I ain’t so crippled I can’t work like a son-of-a- bitch if I want to.”

He is then appropriately interrupted by Curley's wife who is, of course, looking for Curley. She lashes out at Crooks when he asks her to leave and he ultimately lies to Candy about not wanting to join them. Not only is Crooks's dream destroyed by Curley's wife, but the other men's dream as well, as she is the cause of the tragedy which follows in chapter five and six.   

What exploration quotes are found in "The Minister's Black Veil"?

It is likewise possible to find quotes that explore the consequences of being the only person honest enough in his community to admit the truth about humanity: that we are all sinners who try to conceal our essential sinfulness from the world.  Because no one else is will to own up to this truth, Mr. Hooper is shunned and avoided by people who used to welcome him. 

It grieved him, to the very depth of his kind heart, to observe how the children fled from his approach, breaking up their merriest sports, while his melancholy figure was yet away off.  Their instinctive dread caused him to feel more strongly than aught else, that a preternatural horror was interwoven with the threads of the black crepe.

Mr. Hooper gives up a great deal in order to tell the truth.  And this quotation also begins to explore humanity's fearful and cowardly nature in the description of his parishioners' "instinctive dread" toward the minister's truth-telling (which is horrifying even to himself).  Similarly,

Among all its bad influences, the black veil had the one desirable effect of making its wearer a very efficient clergyman.  By the aid of his mysterious emblem -- for there was no other apparent cause -- he became a man of awful power over souls that were in agony for sin.

Such a quotation continues to explore human nature.  It seems that misery must love company, and those sinners -- rather than feeling isolated and misunderstood -- feel their load lightened when they believe that their minister is not dissimilar to them.  They seem to take comfort in the fact that another person is, perhaps, even more sinful than they.

What is renal failure?

Causes and Symptoms

Renal failure, also called kidney failure, renal insufficiency, or end-stage renal disease (ESRD), can be defined as a decline in kidney function sufficient to result in the retention of metabolic waste material in the body. The loss of the ability of the kidneys to excrete waste material is often progressive, culminating in complete renal failure in untreated cases. Although kidney disease can occur at any age, most cases occur in adults, frequently as a complication of diabetes and/or hypertension.

There are three major causes of renal failure. The first, prerenal, results from obstruction of the renal artery because of vascular causes such as hypertension. The decreased blood flow to the kidney causes tissue destruction and loss of renal function. Prerenal causes may also be linked to liver disease and congestive heart failure. The second major cause of renal failure is a direct breakdown of kidney function as a result of inflammatory processes associated with infection. Certain drugs may also have toxic effects on kidney function. The third major cause of renal failure is postrenal, which refers to obstructions that block the flow of urine from the kidney.

The body cannot survive without at least one functioning kidney. As a consequence of renal failure, toxic metabolic wastes accumulate in the bloodstream, such as urea nitrogen produced in the metabolism of proteins. Renal failure also results in disturbances of electrolyte balance, associated with high levels of sodium, potassium, and other salts. Other complications include compromised cardiovascular function, pulmonary
edema, gastrointestinal symptoms, chronic fatigue, and infections.

Treatment and Therapy

Acute renal failure can be treated effectively with hemodialysis and/or kidney transplantation. The hemodialysis machine has made it possible to extend the lives of many patients. This external device filters the blood as it traverses fluid-bathed semipermeable membrane filters that remove metabolic wastes while permitting the retention of essential blood components. Blood leaves the body and returns postfiltration through a fistula or access joint inserted under the skin to link arterial and venous blood flow. Dialysis
must be carried out on a regular basis and requires several hours.

The best treatment for renal failure is a kidney transplant. Sadly, there are not enough donor kidneys to meet the need; patients who do receive organ donations may wait for years before transplantation occurs. As of 2013, United Network for Organ Sharing data show that about one million people in the United States have ESRD and more than 95,000 are on the waiting list to receive a kidney donation. Research continues on an artificial kidney that would replicate the delicate filtering functions of the kidney’s glomeruli. A study published in the journal Nature Medicine in April 2013 reported that scientists have been able to bioengineer working kidneys in rats. While the kidneys lacked the full function of normal kidneys and much more work needs to be done, the milestone represents a promising step towards the goal of creating fully functional artificial kidneys from the cells of patients in need of a transplant.

Bibliography

Aronoff, George. Kidney Failure: The Facts. New York: Oxford University Press, 1996.

Brenner, Barry M. et al., eds. Brenner and Rector’s The Kidney. 9th ed. Philadelphia: Saunders/Elsevier, 2012.

HealthDay. "'Bioengineered' Kidneys Show Promise in Rat Study." MedlinePlus, April 15, 2013.

MedlinePlus. "Kidney Failure." MedlinePlus, May 20, 2013.

Mitch, William E., and Saulo Klahr, eds. Handbook of Nutrition and the Kidney. 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2010.

Molitoris, Bruce A., and William Finn, eds. Acute Renal Failure. Philadelphia: W. B. Saunders, 2001.

Savitsky, Diane. "Kidney Failure." Health Library, October 31, 2012.

What is nitrous oxide?

History of Use

Nitrous oxide was first synthesized in the late eighteenth century. By the mid-nineteenth century, it was being used by dentists for pain relief and as an anesthetic. Because of the euphoria it induces, it came to be known as laughing gas. Today, it is used in medical settings for minor procedures that do not require loss of consciousness and to augment other anesthetics and sedatives.

Along with other inhalants, nitrous oxide is used as a recreational drug
to induce a psychoactive (mind-altering) effect. Most first-time and frequent users are minors. The most common sources for nitrous oxide are whipped-cream aerosols, for which nitrous oxide is the propellant, and whippits, which are small and tapered cylinders containing nitrous oxide that are used to pressurize reusable, commercial or home-use, whipped-cream dispensers.

Effects and Potential Risks

In clinical settings, nitrous oxide has few adverse effects. Recreational use can have serious consequences, however. Abusers inhale nitrous oxide to obtain a rapid high similar to that obtained when using alcohol. The initial euphoria, lightheadedness, and disinhibition are soon followed by agitation, then drowsiness.

Abusers must inhale frequently to maintain a high. With intense, repeated inhaling, the nitrous oxide replaces oxygen in the lungs. The result is hypoxia
, which deprives the whole body, including the brain, of its needed supply of oxygen. An abuser can lose consciousness, stop breathing, and even die. Abusers may inhale the nitrous oxide through a plastic or paper bag or other such device, which can lead to suffocation. Nitrous oxide can damage the outer layer and deeper tissue of the nose, mouth, windpipe, and lungs.

Long-term use of nitrous oxide can break down myelin, a fatty tissue that surrounds and protects some nerve fibers. Loss of myelin can result in muscle spasms and tremors and permanent problems with coordination, walking, and talking. Inhaling nitrous oxide while under the influence of alcohol or ketamine can cause brain toxicity and death.

Bibliography

Kuhn, Cynthia, Scott Swartwelder, and Wilkie Wilson. Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy. 3rd ed. New York: W. W. Norton, 2008. Print.

National Survey on Drug Use and Health. “Trends in Adolescent Inhalant Use: 2002 to 2007.” NSDUH Report, 16 Mar. 2009, 136–38. Print.

"Nitrous Oxide Facts." DrugInfo. Australian Drug Foundation, 20 May 2015. Web. 26 Oct. 2015.

Savelli, Lou. Street Drugs: Pocketguide. Flushing, NY: Looseleaf Law, 2008.

Wolfson, Sam. "Is the Growth in Nitrous Oxide Misuse a Laughing Matter?" Guardian. Guardian News and Media, 13 Aug. 2014. Web. 26 Oct. 2015.

What is Watson's attitude like toward Holmes before they meet Helen Stoner in The Speckled Band?

The short story "The Adventure of the Speckled Band," by Sir Arthur Conan Doyle, is written from the perspective of Dr. John Watson during one of his many adventures with the detective Sherlock Holmes. This story takes place early in their partnership, and Watson claims that he is quite in awe of Mr. Holmes' process of investigation. Watson admires the way Mr. Holmes makes his deductions and says that there was "no keener pleasure" than to follow him during his cases.

When Dr. Watson wakes early in the morning to Mr. Holmes summoning him to hear the case of Helen Stoner, he is excited. Watson has grown to look forward to these cases. While he is still adjusting to some of Holmes' strange behaviors, he has come to be expectant of the strange and brilliant intuitions of his companion's mind. One could say that Dr. Watson admires Mr. Holmes' capability and is enjoying their eventful partnership.

In of Mice and Men, is the novel or film more successful in demonstrating Lennie’s struggles in society?

Making this comparison, we might take into account the power of the spoken word to represent mental capacity. Also, we have three works to consider here as Of Mice and Men has been made into a feature film twice. 

The 1939 film version of Of Mice and Men presents a sympathetic but slow-witted Lennie. Lennie speaks slowly, often comically, and is depicted as a happy-go-lucky dullard. The 1992 version of the book presents Lennie with a speech affectation that characterizes him as mentally and socially handicapped in ways that serve to articulate his challenges vividly. 

The 1992 film brings Lennie to life as a person struggling to live in the world, prone to rage at times, and so gives us a very successful demonstration of Lennie's social challenges. The light-heartedness of the 1939 film is admirable and perhaps makes Lennie more sympathetic than he is in the 1992 film. Yet, Lennie's struggles are not as clearly communicated in that original film version. 

On the page, Lennie's difficulties are clearly delineated, especially in the conversations between Lennie and George. George repeatedly defines Lennie's challenges and his social deficiencies in ways that allow the reader to understand the nature of Lennie's plight. 

Lennie's trouble with memory is introduced early in the novel and is connected to a difficulty understanding what is expected of him in the world. 

"O.K. - - O.K. I'll tell ya again. I ain't got nothing to do. Might jus' as well spen' all my time tellin' you things then you forget 'em, and I tell you again." 

George's warnings and advice for Lennie as they get the job and start life on the ranch further indicate Lennie's specific struggles to learn how to behave in a social environment. The directness of these remarks makes a comparison to the power of the 1992 film somewhat difficult. 

The 1992 film powerfully articulates Lennie's social challenges and his mental state, vividly expressing his tendency to be enraged. This lack of control is important. However, the book presents a concrete and direct set of characterizations of Lennie. 

Ultimately, the film may be taken as the sharper and clearer representation of Lennie's struggles because of it's exploration of Lennie's dark side. 

What is a chemical reagent for protein?

The Biuret reagent is used to test for the presence of protein in foods. It may be used qualitatively to detect the presence or absence of protein, as well as quantitatively to measure the total concentration of protein using spectrometric methods.

The Biuret reagent contains:

• Hydrated copper sulfate


• Potassium hydroxide solution


• Potassium sodium tartrate

When using the Biuret reagent to test for protein, positive and negative control samples should be prepared as follows:

• 
  Positive control: egg whites


• 
  Negative control: distilled water

Results are interpreted as follows:

• 
  No color change (solution remains blue): proteins not present


• 
  Violet color: proteins are present


• 
  Pink color: peptides are present

The color changes are the result of copper ions forming a violet-colored chelate complex with peptide bonds. Peptide bonds connect amino acids in proteins. The higher the concentration of peptide bonds in the sample, the greater the intensity of the violet color.

What is folate as a dietary supplement?

Overview

Folate, a B vitamin, plays a critical role in many biological processes. It
participates in the crucial biological process known as methylation and plays an
important role in cell division: Without sufficient amounts of folate, cells
cannot divide properly. Adequate folate intake can reduce the risk of heart
disease and prevent serious birth defects and disorders, and it may lessen the
risk of developing certain forms of cancer.

Requirements and Sources

Folate requirements rise with age. The official U.S. and Canadian recommendations for daily intake of folate (in micrograms) are as follows: infants to six months of age (65) and seven to twelve months of age (80); children age one to three years (150) and four to eight years (200); children age nine to thirteen years (300); children and adults age fourteen and older (400); pregnant females (600); and nursing females (500).

Folate deficiency was fairly common in the developed world, causing thousands of children to be born with preventable birth defects. However, in 1998, widespread fortification of cereal products began in Canada and the United States. As a result, the prevalence of folate deficiency is decreasing in these countries. Deficiency appears to be most common today among African Americans, Hispanics, Asians, and Pacific Islanders, and among younger people and persons who are overweight.

Various drugs may impair the body’s ability to absorb or utilize folate. These
drugs include antacids, bile acid sequestrants (such as
cholestyramine and colestipol), H2 blockers, methotrexate,
oral medications used for diabetes, various antiseizure medications
(carbamazepine, phenobarbital, phenytoin, primidone, and valproate), sulfasalazine
and possibly other nonsteroidal-anti-inflammatory-type
drugs, high-dose triamterene, nitrous oxide, and the
antibiotic trimethoprim-sulfamethoxazole. In addition, some of these drugs might
put pregnant women at higher risk of giving birth to children with various kinds
of birth defects; taking folate supplements may help reduce this risk.

Oral contraceptives may also affect folate slightly, but there appears to be no need for supplementation. Good sources of folate include dark green leafy vegetables, oranges, other fruits, rice, brewer’s yeast, beef liver, beans, asparagus, kelp, soybeans, and soy flour.

Therapeutic Dosages

For most uses, folate should be taken at nutritional doses, about 400 mcg daily for adults. However, higher dosages, up to 10 milligrams (mg) daily, have been used to treat specific diseases. Before taking more than 400 mcg daily, it is important to make sure that one does not have a vitamin B12 deficiency.

A particular kind of digestive enzyme taken as a supplement, pancreatin, may interfere with the absorption of folate. A person can avoid this by taking the two supplements at different times of the day.

Therapeutic Uses

The use of folate supplements by pregnant women dramatically decreases the risk
that their children will be born with a serious condition called neural tube
defect, which consists of problems with the brain or spinal
cord. Folate supplements may also help prevent other types of birth disorders,
such as defects of the heart, palate, and urinary tract; conversely, drugs that
impair folate action may increase the risk of birth defects. An observational
study suggests that folate supplements may reduce this risk in pregnant women
taking such drugs.

Folate also lowers blood levels of homocysteine, which in turn has been hypothesized to reduce the risk of heart disease and other conditions. Studies conflict on the optimum dose of folate for this purpose; 100 to 400 mcg may produce some homocysteine-lowering effects, while 800 mcg daily may lead to maximum effects. Note, however, that there is no meaningful evidence that reducing homocysteine is beneficial and considerable evidence that it is not. Overall, studies of folate supplementation for reducing cardiovascular risk have failed to show benefit. On a more positive note, a double-blind, placebo-controlled study of 728 Danish elderly people with high homocysteine and relatively low folate intake found that the use of folate supplements slowed the progression of age-related hearing loss. Folate supplementation might also improve mental function in elderly persons with high homocysteine levels.

Based on preliminary evidence, folate has been suggested as a treatment for
depression. One double-blind, placebo-controlled trial found
that folate supplements at a dose of 500 mcg daily may help antidepressants work
more effectively in women, but perhaps not in men. However, another study
randomized 909 older adults with mild depression to different treatment groups,
which included a group that took folate (400 mcg) and vitamin B12 (100
mcg) daily for two years. Folate and vitamin B12 were no better than
placebo at improving depressive symptoms.

Observational studies hint that a deficiency in folate might predispose people
to develop cancer of the cervix, colon, lung, breast, pancreas, and mouth, and
that folate supplements may help prevent colon cancer, especially when taken for
many years or by people with ulcerative colitis. However, observational studies
are notoriously unreliable; large double-blind, placebo-controlled
studies are needed to prove a treatment effective. One such
study performed on folate for cancer prevention among one thousand people for five
years found folate ineffective for preventing early colon cancer. However, a much
smaller study involving ninety-four persons with colon polyps
(a precancerous condition) found that folate may reduce the risk of recurrent
polyps in a three-year period.

High-dose folate (10 mg daily) might be helpful for normalizing abnormalities in the appearance of the cervix (as seen under a microscope) in women taking oral contraceptives, but it does not appear to reverse actual cervical dysplasia. Also, some evidence suggests that folate supplements might reduce risk of stroke. Folate deficiency may also increase the risk of Alzheimer’s disease, although this has not been proven.

Folate supplements may reduce drug side effects in persons taking the drug methotrexate for certain conditions. Folate may also reduce side effects of the antiseizure drug carbamazepine.

Folate supplements may help medications in the nitroglycerin family remain effective. Folate supplementation may reduce blood arsenic levels in people who have been exposed to this toxic substance.

Very high dosages of folate may be helpful for gout, although some authorities suggest that it was actually a contaminant of folate that caused the benefit seen in some studies. Furthermore, other studies have found no benefit.

Based on intriguing but not definitive evidence, folate in various dosages has been suggested as a treatment for bipolar disorder, osteoarthritis (in combination with vitamin B12), osteoporosis, restless legs syndrome, rheumatoid arthritis, seborrheic dermatitis, and vitiligo (splotchy loss of skin pigmentation). Other conditions for which folate has been suggested include migraine headaches and periodontal disease. Finally, folate does not appear to be helpful for enhancing mental function in the elderly.

Scientific Evidence

Birth defects and disorders. Strong evidence shows that the regular use of folate by pregnant women can reduce the risk of neural tube defect by 50 to 80 percent. Less direct evidence suggests that folate can help prevent other kinds of birth defects and disorders, especially among women using medications that interfere with folate.

Depression. One study found that people with depression who do
not respond well to antidepressants are likely to have low
levels of folate. A ten-week, double-blind, placebo-controlled trial of 127
persons with severe major depression found that folate supplements at a dose of
500 mcg daily significantly improved the effectiveness of fluoxetine
(Prozac) in female participants. Improvement in male
participants was not significant, but blood tests taken during the study suggested
that higher intake of folate might be necessary for men.

Methotrexate side effects. Methotrexate is used in cancer chemotherapy and in treating inflammatory diseases such as rheumatoid arthritis and psoriasis. While often highly effective, methotrexate can produce a number of severe side effects. These include liver toxicity and gastrointestinal distress. In addition, the use of methotrexate is thought to raise levels of homocysteine, potentially increasing the risk of heart disease.

Supplementation with folate may help. Methotrexate is called a “folate antagonist” because it prevents the body from converting folate to its active form. This inactivation of folate plays a role in methotrexate’s therapeutic effects. This leads to a dilemma: Methotrexate use can lead to folate deficiency, but taking extra folate could theoretically prevent methotrexate from working properly.

However, evidence suggests that people who take methotrexate for rheumatoid arthritis, juvenile rheumatoid arthritis, or psoriasis can safely use folate supplements. Not only does the methotrexate continue to work properly; its usual side effects may decrease too.

For example, in a 48-week, double-blind, placebo-controlled trial of 434 persons with active rheumatoid arthritis, the use of folate helped prevent liver inflammation caused by methotrexate. This effect allowed more participants to continue methotrexate therapy; the development of liver inflammation often requires people to stop using the drug. A slightly higher dose of methotrexate was needed to reach the same level of benefit as taking methotrexate alone, but researchers felt doing so was worth it.

In the foregoing study, folate supplements did not reduce the incidence of mouth sores and nausea. However, in other studies, folate supplements did reduce these side effects, both in persons receiving methotrexate for rheumatoid arthritis and in those with psoriasis. In addition, two studies of people with rheumatoid arthritis found that the use of folate supplements corrected the methotrexate-induced rise in homocysteine without affecting disease control.

Folate supplements have been found safe only as supportive treatment in the specific conditions noted. It is not known, for example, whether folate supplements are safe for use by persons taking methotrexate for cancer treatment.

Safety Issues

Folate at nutritional doses is extremely safe. The only serious potential problem is that folate supplementation can mask the early symptoms of vitamin B12 deficiency (a special type of anemia), potentially allowing more irreversible symptoms of nerve damage to develop. For this reason, when taking more than 400 mcg daily, it is important check one’s B12 level.

Very high dosages of folate, greater than 5 mg (5,000 mcg) daily, can cause digestive upset. The maximum recommended dosage of folate for pregnant or nursing women is 1,000 mcg daily (800 mcg if eighteen years of age or younger).

Media reports that the use of folate by pregnant women may increase their risk of breast cancer are based on a single study of highly questionable validity. This report is not considered a significant concern, but further research is needed.

As mentioned, the antiseizure drug phenytoin may interfere with folate
absorption. However, folate may reduce the effectiveness of phenytoin. Persons
taking phenytoin should consult with a physician about the proper dosage of
folate.

Persons who are taking the drug methotrexate for rheumatoid arthritis, juvenile rheumatoid arthritis, or psoriasis can safely take folate supplements at the same time. However, if one is taking methotrexate for any other purpose, one should not take folate except on the advice of a physician.

Important Interactions

Persons may need to take extra folate if also using aspirin and other
anti-inflammatory medications, drugs that reduce stomach acid (such as antacids,
H2 blockers, and proton pump inhibitors), bile acid
sequestrants (such as cholestyramine and colestipol), carbamazepine, estrogen
replacement therapy, nitrous oxide, oral contraceptives, oral hypoglycemic drugs,
phenobarbital, primidone, sulfa antibiotics, triamterene, valproic
acid, or the antibiotic trimethoprim-sulfamethoxazole.

Persons taking phenytoin may need more folate. However, too much folate can interfere with this medication and can cause seizures. Physician supervision is essential.

Folate may boost the effectiveness of drugs in the nitroglycerin family. For persons taking pancreatin (a proteolytic enzyme), it may be advisable to separate the dose of pancreatin from the dose of folate by a minimum of two hours to avoid absorption problems.

For persons taking methotrexate for rheumatoid arthritis, juvenile rheumatoid arthritis, or psoriasis: Evidence suggests that folate supplements may reduce side effects of the drug without decreasing its benefits. Nonetheless, physician supervision is highly recommended. Note that for persons taking methotrexate for other conditions, folate might decrease the drug’s effectiveness. Finally, green tea and black tea may decrease the absorption of folic acid into the bloodstream.

Bibliography

Durga, J., M. P. van Boxtel, et al. “Effect of Three-Year Folic Acid Supplementation on Cognitive Function in Older Adults in the FACIT Trial.” The Lancet 369 (2007): 208-216.

Durga, J., P. Verhoef, et al. “Effects of Folic Acid Supplementation on Hearing in Older Adults.” Annals of Internal Medicine 146 (2007): 1-9.

Ebbing, M., et al. “Mortality and Cardiovascular Events in Patients Treated with Homocysteine-Lowering B Vitamins after Coronary Angiography.” Journal of the American Medical Association 300 (2008): 795-804.

Gamble, M. V., et al. “Folic Acid Supplementation Lowers Blood Arsenic.” American Journal of Clinical Nutrition 86 (2007): 1202-1209.

Gilbody, S., T. Lightfoot, and T. Sheldon. “Is Low Folate a Risk Factor for Depression? A Meta-analysis and Exploration of Heterogeneity.” Journal of Epidemiology and Community Health 61 (2007): 631-637.

Lawrence, J. M., et al. “Do Racial and Ethnic Differences in Serum Folate Values Exist After Food Fortification with Folic Acid?” American Journal of Obstetrics and Gynecology 194 (2006): 520-526.

Walker, J. G., et al. “Mental Health Literacy, Folic Acid and Vitamin B12, and Physical Activity for the Prevention of Depression in Older Adults.” British Journal of Psychiatry 197 (2010): 45-54.

Wang, X., et al. “Efficacy of Folic Acid Supplementation in Stroke Prevention.” The Lancet 369 (2007): 1876-1882.

What is hepatitis B?

Definition

Hepatitis B is a liver disease caused by the hepatitis B virus (HBV). Most
hepatitis B infections clear up within one to two months without treatment. When
the infection lasts more than six months, it can develop into chronic hepatitis B,
which can lead to chronic inflammation of the liver, cirrhosis (scarring of the liver), liver cancer, liver failure, or death.

Causes

HBV is spread through contact with the body fluids of an infected person. These fluids include blood, semen, vaginal fluids, and saliva. A woman with hepatitis can pass the virus to the fetus during birth. HBV is not spread through food or water.

Risk Factors

The following factors may increase one’s risk of getting hepatitis B: having
sex with someone infected with hepatitis B or who is a carrier of
hepatitis B; injecting illicit drugs, especially with shared needles; having more
than one sexual partner; being a man who has sex with men; and living in the same
home with someone who is infected with hepatitis B.

Another risk factor is employment as someone who has contact with human body fluids. These workers include first aid or emergency workers, funeral directors, medical personnel, rescue workers, firefighters, police personnel, dentists, and dental assistants.

Other risk factors are having a sexually transmitted disease when
having contact with hepatitis B; traveling to areas of the world where hepatitis B
is common, such as China, southeast Asia, and sub-Saharan Africa; receiving a
blood transfusion before 1992 (the year a more reliable test to screen blood was
developed); receiving multiple transfusions of blood or blood products, as do
hemophiliacs (a risk that has been greatly reduced with modern blood screening
techniques); working or being a patient in a hospital or long-term care facility;
working or being incarcerated in a jail or prison; being bitten so that the skin
is broken by someone whose saliva contains the virus; and receiving hemodialysis
treatment.

Symptoms

Symptoms may appear about 25 to 180 days after one is exposed to the virus. The most common symptoms are yellowing skin and eyes (jaundice), fatigue that lasts for weeks or even months, abdominal pain in the area of the liver (upper right side of the abdomen), loss of appetite, nausea, vomiting, joint pain, low-grade fever, dark urine and light-colored stool, widespread itching, and rash.

Screening and Diagnosis

A doctor will ask about symptoms and medical history and will perform a
physical exam. Hepatitis B is diagnosed with blood tests. These blood tests are
also used to monitor the virus’s effect on the liver. For chronic cases, the
patient may need a liver biopsy (the removal of a sample
of liver tissue for testing).

Treatment and Therapy

If the patient has an uncomplicated case, he or she can expect to recover completely. Persons with chronic hepatitis B may be treated with medication to help reduce the activity of the virus and also to prevent liver failure. These medications include interferon alfa-2b (Intron A) injection, lamivudine (Epivir-HBV) oral medication, adefovir (Hepsera) oral medication, and entecavir (Baraclude) oral medication.

Persons who have chronic hepatitis B should avoid further injury to the liver by avoiding alcohol and certain medications, dietary supplements, and herbs. One should discuss these supplements and herbs with a doctor before taking.

One can prevent spreading the infection to others by notifying one’s own doctors, dentists, and sexual partner or partners; by avoiding donating blood or organs for transplant; and by discussing one’s hepatitis B status with a doctor during pregnancy or before becoming pregnant to ensure the baby receives treatment.

Prevention and Outcomes

Hepatitis B can be prevented with a vaccination. It consists of three injections that are given over a period of six months. Protection is not complete without all three injections. The Centers for Disease Control and Prevention (CDC) recommend that all infants receive the vaccine within their first year (the first dose at birth, the second at one to two months, and the third between six and fifteen months), and those who were not vaccinated as infants may be vaccinated up to the age of eighteen. Above the age of eighteen, the vaccine is recommended only for those at increased risk of contracting the disease.

In addition, to prevent the transmission of hepatitis B, one should use condoms during sexual intercourse or should abstain from sex, limit the number of sexual partners, avoid injecting drugs and avoid sharing needles or syringes, and avoid sharing personal items that might have blood on them (such as razors, toothbrushes, manicuring tools, and pierced earrings). Persons who get a tattoo or a body piercing should ensure that the artist or piercer properly sterilizes the equipment. Infection can occur if the tools have another person’s blood on them.

Health care and public safety workers should get vaccinated against hepatitis B; should always follow routine barrier precautions and safely handle needles and other sharp instruments; should wear gloves when touching or cleaning up body fluids on bandages, tampons or sanitary pads, and linens; and should cover open cuts or wounds.

Pregnant women should have a blood test for hepatitis B. Infants born to women with hepatitis B should be treated within twelve hours of birth.

Bibliography

Boyer, Thomas D., Teresa L. Wright, and Michael P. Manns, eds. Zakim and Boyer’s Hepatology: A Textbook of Liver Disease. 6th ed. Philadelphia: Saunders, 2011.

Feldman, Mark, Lawrence S. Friedman, and Lawrence J. Brandt, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 9th ed. 2 vols. Philadelphia: Saunders, 2010. Print.

Frank, Steven A. Immunology and Evolution of Infectious Disease. Princeton: Princeton UP, 2002. Print.

"Hepatitis B." World Health Organization. WHO, July 2015. Web. 30 Dec. 2015.

Lehrer, Jenifer K. "Hepatitis B." MedlinePlus. Natl. Lib of Health, 20 Nov. 2014. Web. 30 Dec. 2015.

Palmer, Melissa. Dr. Melissa Palmer’s Guide to Hepatitis and Liver Disease. Rev. ed. Garden City Park: Avery, 2004. Print.

Pan American Health Organization. World Health Organization. Control of Diphtheria, Pertussis, Tetanus, “Haemophilus influenzae” Type B, and Hepatitis B Field Guide. Washington, DC: Author, 2005. Print.

"Viral Hepatitis—Hepatitis B Information." Centers for Disease Control and Prevention. Dept. of Health and Human Services, 31 May 2015. Web. 30 Dec. 2015.

What is the relationship between punishment and social psychology?

Introduction

Punishment can be defined as an action taken based on a person’s undesired behavior. It is intended to prevent future occurrence of the unwanted behavior by changing how the person behaves. It is a social mechanism used to help ensure the balanced functioning of a family, group, organization, or a society.

There are two main elements to punishment. First, appropriate behavior is arbitrary; it is determined by communal agreement regarding right and wrong behavior. Punishment attempts to foster and ensure what the group has determined to be appropriate, moral behavior. Second, punishment symbolizes power. The French philosopher Michel Foucault argued that punishment should be understood as an expression of power because, without the power to punish a person behaving in an undesirable manner, chaos could occur.

When a member of any social unit, small or large, goes against the group’s accepted norms, it disrupts the unit. To regain balance or homeostasis, action may be needed, and a member of the social unit may punish the wrongdoer. Punishment may take the form of making some kind of amends. This could range from a token act to exile (temporary or permanent) or even to death.

A Brief History

One of the earliest records of punishments levied by a society can be found in a legal code developed in Babylon in about 2000 BCE, during the reign of Hammurabi, which listed corrective measures for wrongdoing. The Mosaic law recorded in the Pentateuch of the Old Testament is another early set of codes. Near the end of the first century CE, corporal punishment was increasingly applied to slaves and lower-class citizens, while punishments for higher-class citizens generally took the form of compensation.

During the reign of the Roman emperor Justinian in the sixth century, an attempt was made to match the severity of punishment to the level of the offense. More than a century later, laws became increasingly localized, although they generally followed the dictates of the Roman Catholic Church. Many of these laws were centralized during the reign of Charlemagne.

When William the Conqueror became king of England following the Norman invasion, he centralized power around himself as monarch. Any wrongdoing therefore became a crime against the king. He established the process of trial by ordeal to address those who violated the law, who were known as enemies of the king. Much of the punishment, official and unofficial, was directed at the offenders’ bodies, through forms of torture.

It was not until the age of reason that major changes began to occur. With the development of social contracts, crimes were considered to have been committed against society, and people began to be viewed as rational beings able to make rational choices. It was during this period that the classical school offered new foundations of punishment as represented in the writings of Cesare Beccaria and Jeremy Bentham. These scholars believed that a person had free will and could make a rational choice whether to commit an offense. People made their choices by weighing the pleasure of the action against the punishment for it. Therefore, the punishment should fit the crime; be proportionate to the violation; be uniform and equal; be certain, swift, and severe; and deter and prevent.

Over the centuries, scholars have continued to debate what is effective punishment. For if punishment does not bring about the desired changes, then it does not serve its purpose.

Philosophies of Punishment

Most punishments are designed to prevent wrongdoers from repeating their acts and to deter people from committing undesired acts. There are four main philosophies of punishment. They are retribution (just deserts), deterrence, rehabilitation, and control (incapacitation).

Retribution has often been linked to revenge, taking an eye for an eye. Under this philosophy of punishment, justice is served if the punishment is equivalent to the wrongdoing: offenders get what they deserve (their just deserts). This has been the basis of much legal code.

As a philosophy of punishment, deterrence attempts to either restrict certain behaviors or encourage people to avoid them. Punishments aimed at deterring crime are designed to cause people to lose as much or more from committing an undesired behavior as they stand to gain from the behavior. Such punishments should cause a person to chose not to engage in the undesired behavior. However, punishment should not be excessive, as this might have negative overall results.

Rehabilitation seeks to change the offender so the person will not repeat the act. Under this philosophy, it is believed that the offender suffers from some sort of needs or deficiencies, and these deficiencies need to be addressed for the individual to change. Punishment should be individualized to address the offender’s needs and deficiencies.

Control is based on the rationale that if the offender is incapacitated, the person cannot repeat the unacceptable behavior. Although establishing control over an offender does not keep the individual from desiring to commit an undesirable act, it effectively contains the person and prevents the individual from acting inappropriately. Control may take the form of restricting the person’s movement or simply supervising the person.

Moral Development

An important consideration of punishment is whether the offender knows right from wrong. The process of learning what society has deemed right and wrong requires the moral development of the individual. This learning process is described differently by various psychological schools.

The psychoanalytic school describes this as a child learning to act in a manner in which the child will experience positive feelings and avoid negative feelings. Sigmund Freud focused on the development of the child’s personality during the learning process, whereas Erik H. Erikson examined how children internalize the teachings of both parents to win and keep their love.

The cognitive school is represented by the theorists Jean Piaget and Lawrence Kohlberg. Piaget presented his theory that as children develop, they gain respect for rules and justice. The development process begins in a premoral period, a period in which children have little awareness of rules but simply act in a way that gives them pleasure. Then at about school age, children begin to develop an awareness of rules that they regard as absolute. They believe that either an act is right or wrong; they also believe in imminent justice, or that any wrong act will be punished in some way.

In the final stage in Piaget’s process of cognitive development, children begin to surrender the absoluteness of rules for a more relative understanding of the nature of rules. This change comes from an awareness that rules are arbitrary social agreements and on occasion can be challenged, as rules should serve human needs. As a result, rules can be violated to serve the needs of a person. After experiencing and seeing others violate rules and go unpunished, children begin to accept the idea of reciprocal punishment, which is a more rehabilitative form of punishment.

Kohlberg developed on Piaget’s theory by extending the development process. He created a three-level development process in which each level had two stages. This development process was unidirectional. Once a person has moved to a higher level of development, the individual could not regress to a lower level.

Kohlberg’s first level was preconventional morality. At this level, a child follows rules to avoid punishment and to receive rewards. The punishment determines how bad an act is: The more severe the punishment, the worse the wrong. A child conforms to rules to seek rewards and self-satisfaction.

In conventional morality, a child seeks approval of others and tries to avoid shame. A child begins to experience understanding of others (empathy) and to conform to rules out of a desire to cooperate with others.

In postconventional morality, the third level, the child’s moral reasoning is based on a broader understanding of justice and right and wrong. Sometimes the child’s understanding of right and wrong is in conflict with the established rules and therefore justifies challenging rules. In the second stage within the third level, universal justice, the child is able to transcend any conflict through an ideal reasoning process.

Learning

Behaviorists and cognitivists have applied principles of reinforcement and punishment to change behavior. Both reinforcement and punishment can be positive or negative and are used to condition a person to act within the range of acceptable or desired behavior.

Reinforcement is a reward people receive for performing the desired or appropriate behavior. It is intended to increase the possibility of people’s adopting the behavior. A positive reward is receiving something the person wants and a negative reward is having something removed that the person does not want. In identifying appropriate reinforcers, an individual’s personal economy—the value a person places on an item or an action—must be determined. Individualizing reinforcers makes them more effective in accomplishing the goal of change.

Punishment is used to prevent or change undesired behavior and to decrease the possibility of it recurring. A positive punishment is the gaining of something unwanted, and a negative punishment is the loss of something wanted. Either punishment is undesirable for the recipient.

A major difference between behavorists, such as B. F. Skinner, and cognitivists, such as Albert Bandura, is the cognitive factor of learning. Skinner did not accept that humans have free will but believed that their actions are environmentally determined. Bandura argued the value of observation and modeling. He proposed that a person could learn by observing the rewards and punishments another person received for behavior. Some studies, including that by Robert E. Larzelere and his associates, have suggested that a more effective disciplinary response can be produced by combining reasoning and punishment rather than using reasoning alone.

Bibliography

Castro, Nicolas. Psychology of Punishment: New Research. Hauppage: Nova, 2013. Digital file.

Cusac, Anne-Marie. Cruel and Unusual: The Culture of Punishment in America. New Haven: Yale UP, 2010. Print.

Horne, Christine. The Rewards of Punishment: A Relational Theory of Norm Enforcement. Stanford: Stanford UP, 2009. Print.

Larzelere, Robert E., et al. “Punishment Enhances Reasoning’s Effectiveness as a Disciplinary Response to Toddlers.” Journal of Marriage and the Family 60 (1998): 388–430. Print.

Miltenberger, Raymond G. Behavior Modification: Principles and Procedures. 5th ed. Belmont: Wadsworth, 2012. Print.

Molm, Linda D. “Is Punishment Effective: Coercive Strategies in Social Exchange.” Social Psychology Quarterly 57.2 (1994): 75–94. Print.

Oswald, Margit E., Steffen Bieneck, and Jorg Hupfeld-Heinemann, eds. Social Psychology of Punishment of Crime. Malden: Wiley, 2009. Print.

Russo, Jennifer P., and Nicholas M. Palmetti. Psychology of Punishment. New York: Nova, 2011. Digital file.

Sparks, Richard, and Jonathan Simon. The SAGE Handbook of Punishment and Society. Los Angeles: SAGE, 2013. Digital file.

What is elder health?

Overview

The health and functionality of the elderly can be highly variable, but the elderly differ from younger people in that the elderly are more likely to have chronic conditions, such as high blood pressure. The elderly are increasingly using complementary and alternative medicine (CAM), but they utilize it less than younger adults. Most elderly persons who use CAM do so as a complement to standard medicine, not as a substitute for (or an alternative to) CAM.

CAM use by elders is associated with poorer overall health, although people with life-threatening conditions do not appear more likely to use CAM. Prescription medications and surgery, the main conventional treatments, are often lifesaving but have special risks for elders because of their greater tendency to have multiple chronic conditions.

Because of their higher incidence of illness, seniors can especially benefit from evidence-based medicine (EBM) instead of CAM exclusively. More research on the effectiveness of both CAM and conventional medicine in the elderly is needed.

Why Seniors Are Different

Although many seniors are physically and mentally healthy, old age is the time
of life when people are most likely to suffer from chronic diseases such as
arthritis, heart disease, cancer, and
diabetes. Some people develop these diseases at earlier
ages, are successfully treated, and live full and productive lives. Their
illnesses are manageable or, in some instances, have been cured. Others have had
relatively little illness throughout their lives but develop chronic conditions as
they age. Some get older without having any serious conditions. Still others
develop debilitating illness at relatively young ages, do not improve much with
treatment or do not receive treatment, and reach their elder years already
disabled and with limited mobility and ability to handle daily activities.
Nonetheless, people who live to be age sixty-five and older (those who are
considered elderly) are frequently healthy.

Even for healthy seniors, physical changes occur. The organs are less
efficient. The kidneys take longer to filter waste from the blood, and lung
capacity decreases. The immune system weakens. Variation in
health among elders, however, is large. A person’s chronological age does not
necessarily indicate that person’s level of health or functionality. Still, the
elderly differ from younger people in that they are more likely to have chronic
conditions. Acute diseases, such as colds and influenza,
decline with age.

Using CAM

The elderly and the very young (children younger than age five years) use conventional medicine more than other age groups. It remains unclear what age group is most likely to use CAM. All age groups, however, are increasing their use of CAM, but older adults still appear somewhat less likely to use CAM. Estimates of CAM use by elders vary from 30 to 66 percent across surveys, in part because studies consider different CAM therapies. It is difficult to estimate CAM use by seniors because some research studies do not report age differences, while others use a variety of age cut-offs (such as fifty-two-plus, sixty-five-plus, and seventy-seven-plus) when studying older adults.

Seniors usually use CAM in addition to standard treatments. That is, they use
complementary
therapies in seeking to alleviate symptoms and pain, to
manage the side effects of conventional treatment, or for finding a cure. Most
seniors do not use alternative therapy alone; instead, they use alternative
therapy as a complement to standard medicine. This is true for most people,
regardless of age, in the United States and in other developed countries.

Demographics

A 2008 study of mostly U.S.-focused research examined the demographics of CAM users. The study found that CAM users are more educated than the general population but are not necessarily higher earners. This pattern also holds for seniors. One reason why seniors use CAM less often may be that many elders are less educated than younger adults. Educated persons are often informed consumers who also tend to seek information about topics with which they are unfamiliar. For many in the United States, CAM is little known.

The importance of income in determining CAM use is less clear, and it appears to play a role independent of education level. It is also not certain if elderly women are more likely to use CAM therapies than are elderly men, although CAM use is higher among younger women. CAM use based on one’s ethnicity also does not fall into a clear pattern.

CAM is often used by people with chronic conditions. Because the elderly frequently have such conditions, some will use CAM. CAM is also more likely to be used by people with multiple health problems, which many elderly experience too. CAM use is associated with poorer overall health, in all age groups, although people with life-threatening conditions do not appear more likely to use CAM. There is no strong evidence that, for example, people with cancer are more likely to use CAM. The elderly who use only CAM tend to be younger and healthier than those using only standard medicine or a combination of standard medicine and CAM. Elderly CAM users tend to be more health conscious, or more seriously ill, than non-CAM users.

Attitudes and one’s philosophy of life play only small parts in determining CAM use by the elderly, although these factors were found to be more significant for younger adults who use CAM. The elderly are more likely than younger adults to say that they want their doctors to make their health decisions. It appears that elders’ use of CAM is often a pragmatic decision based on health status and the desire to alleviate symptoms, rather than on philosophy and interest in cultural alternatives.

Evidence-Based Medicine

Evidence-based medicine (EBM) is a growing movement focused on the use of empirical, scientific standards to evaluate treatments. EBM encourages health professionals to use treatments that have been shown by careful study to be effective. At its best, EBM promises high-quality research of CAM modalities and conventional medicine. Because seniors have more health problems, are often taking multiple medications, and are more likely than other age groups to develop conditions for which surgery is the most common treatment, evidence-based research is especially important for this age group.

For many CAM modalities, evidence of effectiveness is limited. There is also
little evidence for the effectiveness of some conventional therapies. One example
is chronic back pain, which affects more seniors than younger adults.
Back
pain is one of the most common conditions for which seniors
use CAM (others conditions being arthritis, heart disease, allergy, and diabetes).
Recent research suggests that back surgery may be overused and that the more
invasive types of back surgery may be especially risky for seniors. Some research
exists on back pain and CAM.

A 2003 study evaluated the best available evidence on several CAM treatments of
back pain, finding that massage had positive outcomes. Spinal
manipulation (including chiropractic) was moderately helpful.
The quality of the studies on acupuncture was poor, but acupuncture
appeared to be more effective than no treatment or “sham treatment” (in which a
doctor simulated acupuncture treatment). The risks of all three CAM treatments for
back pain were relatively low.

Another CAM modality that has received initial though inadequate study is
homeopathy. A 2009 study of persons with chronic low back
pain who were followed for two years found that the subjects showed significant
improvement and decreased use of prescription medications. Because the elderly are
more likely to have low back pain than younger persons, continued research on
various treatment modalities for this health problem might have benefits for this
age group.

EBM is still relatively new and sometimes meets with resistance from both conventional and CAM practitioners. The latter sometimes argue that CAM therapies are not taken seriously by conventional doctors, even when evidence of their effectiveness exists. A 2005 article on chiropractic practices suggests that EBM is mostly used to justify the use of conventional medicine. The process of determining what treatment modalities are effective can be expected to continue slowly and contentiously.

Careful evaluation of the evidence for treatment is nonetheless superior to giving treatment for which little or no evidence of effectiveness exists. The greater incidence of illness and treatment of older adults means they will especially benefit from the further development of EBM.

Treatment Types

The main conventional treatments for all persons are prescription medications and surgery. Both are often lifesaving, but each treatment modality has some special risks for the elderly. CAM could prove to be one way to address these risks.

Because they have more illnesses, the elderly are more likely to be taking
multiple medications, the interactions of which are often unknown, even if there
have been good studies of the individual drugs. Conventional drugs often are not
tested on seniors, even though they take more of them. Thus, evidence on
prescription drugs that is specific to seniors is sparse. The need for
evidence-based CAM is especially important in the case of the elderly who take
many medications, because CAM can reduce the chances of drug
interactions, such as when massage is used instead of
medication for back pain. Some CAM treatments, however, may themselves interact
with conventional medications. One example is St. John’s
wort, an herbal preparation that is often used to treat
depression. This preparation can interact with antidepressants such as alprazolam (Xanax).

The elderly are also more likely than younger adults to have conditions that are surgically treated. Surgical technologies and methods have improved significantly in a short time, increasing the chance that surgery will benefit seniors. Even the very old are increasingly considered candidates for surgical treatment.

Surgery, however, is always risky, and the elderly are at greater risk than younger people. Chronic high blood pressure, multiple chronic conditions, and a weaker immune system can make surgery more dangerous for an elderly person and can lead to a longer recuperation time. Alternatives to surgery would be of special benefit to seniors. Less healthy seniors have increased risk of complications and morbidity from surgery. The possibility of cognitive decline in seniors who are surgically treated also remains a concern, though a 2009 study indicates that surgery does not contribute to long-term cognitive decline in seniors. This issue requires further study. The effect of CAM in aiding postsurgical healing also deserves increased research.

Evidence on all medical modalities, CAM and conventional, is particularly inadequate for the elderly. The aging of the U.S. population and in societies across the world underscores the critical need for continued research.

Bibliography

Aleccia, JoNel. “Surgery in the Super Old: Success at What Price?” Available at http://www.msnbc.msn.com/id/28282424. Article looking at the pros and cons of surgery on very old persons.

American Society of Anesthesiologists. “Surgery, Illness Do Not Increase Cognitive Decline for Older Patients.” Available at http://www.medicalnewstoday.com/articles/168756.php. Article summarizing a study with a control group showing that surgery does not contribute to long-term cognitive decline in seniors.

Bishop, Felicity L., and G. T. Lewith. “Who Uses CAM? A Narrative Review of Demographic Characteristics and Health Factors Associated with CAM Use.” Evidence-Based Complementary and Alternative Medicine 7, no. 1 (2008): 11-28. Available at http://ecam.oxfordjournals.org/cgi/content/full/7/1/11. Peer-reviewed article providing an overview of demographic and health factors of CAM users.

Cherkin, Daniel C., et al. “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.” Annals of Internal Medicine 138 (2003): 898-906. Peer-reviewed article summarizing reviews of randomized, controlled trials from research published since 1995 on massage therapy, spinal manipulation, and acupuncture as treatments for nonspecific back pain.

Cherniak, Paul, and Neil S. Cherniack. Alternative Medicine for the Elderly. New York: Springer, 2003. Book giving balanced, detailed, critical evaluation of CAM treatments for seniors.

Napoli, Maryann. “Is Back Surgery Worth It? An Interview with a Leading Researcher.” HealthFacts 32 (2007): 1-3. Interview of Richard A. Deyo, a preeminent researcher on back pain treatment, which includes his comments on back surgery for seniors.

Villanueva-Russell, Yvonne. “Evidence-Based Medicine and Its Implications for the Profession of Chiropractic.” Social Science and Medicine 60 (2005): 545-561. Peer-reviewed article examining the limitations of evidence-based medicine while supporting the development of new methodologies to evaluate the effectiveness of chiropractic and other CAM treatments.

Witt, Claudia M. “Homeopathic Treatment of Patients with Chronic Low Back Pain.” Clinical Journal of Pain 25 (2009): 334-339. Peer-reviewed article evaluating the effect of homeopathic treatment for persons with low back pain.