What is the most important dialogue in the novel The Boy in the Striped Pajamas?

There are numerous scenes that include important dialogue throughout the novel The Boy in the Striped Pajamas. One of the most significant conversations takes place in Chapter 4, between Bruno and his sister, Gretel. In Chapter 3, Gretel explains to Bruno that their new house is called Out-With. In Chapter 4, Gretel follows Bruno into his room and looks out of his window for the first time. Gretel looks at the people through the window and asks Bruno, who they are and what sort of place is this. Bruno tells her that it's not as nice as home, and when Gretel asks where all the girls are, he says that they must be in a different part. Boyne then gives a description of the massive fence surrounding the small homes and buildings. Gretel tells Bruno that she doesn't understand what kind of place they are in, and Bruno mentions how nasty it looks. Gretel says to Bruno that she thinks the huts are modern types of houses, then concludes that they are in the countryside. Gretel elaborates as to why they are in the countryside, but recalls that she learned in geography class that there were farmers and animals in the country. Bruno disagrees with her and brings up the fact that there are no animals in sight and mentions the dismal condition of the ground. Gretel admits that they are probably not in the countryside, and asks Bruno, who all those people are and what are they doing. Boyne then gives a description of the people wheeling wheelbarrows and working like they are in a chain gang. When Bruno tells Gretel to "Look over there," he points to a group of children who are getting yelled at by soldiers (Boyne 37). Gretel says that it must be some sort of rehearsal and tells Bruno that she wouldn't want to play with the dirty children she sees. Bruno agrees that it does, in fact, look dirty, and says that maybe the children don't bathe. Gretel sarcastically asks, "What kind of people don't have baths?" (Boyne 38). Bruno responds by saying, people who don't have any hot water. After Gretel leaves Bruno's room, Bruno notices that all the people are wearing the same pair of striped pajamas.

I feel that the dialogue between Gretel and Bruno throughout Chapter 4 is the most important in the novel because their conversation reveals that they are living next to a concentration camp. Boyne uses their dialogue to describe the physical features of their environment, as well as the activities the prisoners are engaged in. The fence, housing, landscape, and the attire of the prisoners is mentioned throughout this chapter. The audience can surmise that the name Out-With is a mispronunciation of Auschwitz from the previous chapter, following Bruno and Gretel's dialogue in Chapter 4.

What is the Beck Depression Inventory (BDI)?

Introduction

The Beck Depression Inventory (BDI) is an assessment used to measure the presence and severity of
depression. It was developed in 1972 by psychiatrist Aaron T. Beck, who earned his PhD in psychiatry from Yale University in 1946. He became interested in psychoanalysis and cognition during his residency in neurology. Beck was the assistant chief of neuropsychology at Valley Forge General Hospital during the Korean War. He graduated from the Philadelphia Psychoanalytic Institute in 1956 and began research to validate psychoanalytic theories. However, his research did not support his hypotheses, so he began to develop cognitive therapy for depression. He developed several depression screening tests, including the Beck Depression Inventory.

The Nature of Depression

Depression is a mental state characterized by extreme feelings of sadness, dejection, and lack of self-esteem. Depression affects men and women, young and old, of all races and socioeconomic statuses. According to statistics from the Substance Abuse and Mental Health Services Administration (SAMHSA) combined data from the 2008 to 2012 National Surveys on Drug Use and Health, approximately 15.2 million adults in the United States experience a major depressive episode (MDE) each year. Of the respondents surveyed from 2008 to 2012, 38.3 percent of adults who had an MDE within the past year did not talk to a professional about it. Of those who did seek professional help, 48 percent talked to a health professional such as a general practitioner or family doctor, while 10.7 percent talked to a health professional and an alternative service professional, and 2.9 percent talked to an alternative service professional only. In 2012, the World Health Organization reported that more than 350 million people of all ages experienced depression, with 1 million suicide deaths reported annually. In 2001, the World Health Organization (WHO) asserted that by the year 2020, depression would be the second greatest cause of premature death in the world.

Depression is a common and costly mental health problem, seen frequently in primary-care settings. Between 5 and 13 percent of those seen in a physician’s office have a major depressive disorder. Depression is more prevalent in the young, female, single, divorced, separated, and seriously ill and those with a history of depression.

The National Institute of Mental Health reports that in 2002 the annual total direct and indirect costs of serious mental illness, including depression, were about $317 billion; in July 2013 the New York Times estimated that these annual costs approached $500 billion. According to a study published in May 2010 by the Journal of General Internal Medicine, 25 percent of people in the United States with major depression are not diagnosed with the condition, and fewer than 50 percent receive treatment for it. Therefore, it has been proposed that routine depression screening may be instrumental in early identification and improved treatment of depressive disorders. Side effects from medications, medical conditions such as infection, endocrine disorders, vitamin deficiencies, and alcohol or drug abuse can cause symptoms of depression. The possibility of physical causes of depressive symptoms can be ruled out through a physical examination, medical history, and blood tests. If a physical cause for depression is excluded, a psychological evaluation, called a depression screening, should be performed. This screening includes a history of when symptoms started, the length of time they have been present, the severity of symptoms, whether such symptoms have been experienced previously, the methods of treatment, and whether any family members have had a depressive disorder and, if so, what methods were used to treat them.

The
Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed., 2013) is the standard for diagnosing depression. DSM-5 criteria for a major depressive episode, require a depressed mood or loss of interest or pleasure, in addition to five or more of the following symptoms during a single two-week period that are a change from previous functioning: lack of energy, thoughts of death or suicide, sleep disturbances, changes in appetite, feelings of guilt and worthlessness, poor concentration, and difficulty making decisions. Depression screening questionnaires assist in predicting an individual’s risk of depression.

Self-Rating with the BDI

The BDI is a self-rating scale that measures the severity of depression and can be used to assess the progress of treatment. It consists of twenty-one items and is designed for multiple administrations. Modified, shorter forms of the BDI have been designed to allow primary care providers to screen for depression. Each symptom of depression is scored on a scale of 0 for minimal to 3 for severe. Questions address sadness, hopelessness, past failure, guilt, punishment, self-dislike, self-blame, suicidal thoughts, crying, agitation, loss of interest in activities, indecisiveness, worthlessness, loss of energy, insomnia, irritability, decreased appetite, diminished concentration, fatigue, and lack of interest in sex. A score less than 15 indicates mild depression, scores from 15 to 30 indicate moderate depression, and a score greater than 30 indicates severe depression.

Bibliography

American Medical Association, ed. Essential Guide to Depression. New York: Pocket, 2000. Print.

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

American Psychological Association. "Beck Depression Inventory (BDI)." American Psychological Association. American Psychological Association, 2014. Web. 25 Feb. 2014.

Greden, J. “Treatment of Recurrent Depression.” In Review of Psychiatry. Ed. J. Oldham and M. Riba. Vol. 20. Washington, DC: American Psychiatric P, 2001. Print.

Greist, J., and J. Jefferson. Depression and Its Treatment. 2d ed. New York: Warner, 1994. Print.

Moyer, Christine S. "Depression Often Undiagnosed, As Symptoms Vary among Patients." American Medical News. American Medical Association, 8 June 2010. Web. 25 Feb. 2014.

National Institute of Mental Health. "Major Depressive Order among Adults." National Institute of Mental Health. National Institutes of Health, n.d. Web. 25 Feb. 2014.

Rampel, Catherine. "The Half-Trillion-Dollar Depression." New York Times. New York Times, 2 July 2013. Web. 25 Feb. 2014.

Scholten, Amy. "Depression." Health Library. Health Library, 30 Sept. 2013. Web. 25 Feb. 2014.

Substance Abuse and Mental Health Services Administration. "More than One Third of Adults with Major Depressive Episode Did Not Talk to a Professional." NSDUH Report 20 Feb. 2014. Digital file.

World Health Organization. "Depression: Fact Sheet No. 369." World Health Organization Media Centre. WHO, Oct. 2012. Web. 25 Feb. 2014.

What is carnitine as a dietary supplement?

Overview

Carnitine is a substance used by the body to turn fat into energy. It is not normally considered an essential nutrient because the body can manufacture all it needs. However, supplemental carnitine could in theory improve the ability of certain tissues to produce energy. This has led to the use of carnitine for various muscle diseases and heart conditions.

Requirements and Sources

There is no dietary requirement for carnitine. However, some people have a
genetic defect that hinders the body’s ability to make carnitine. In addition,
diseases of the liver, kidneys, or brain may inhibit carnitine production. Certain
medications, especially the antiseizure drugs valproic acid
(Depakene) and phenytoin (Dilantin), may reduce carnitine levels; however,
whether taking extra carnitine would be helpful has not been determined. Heart
muscle tissue, because of its high energy requirements, is particularly vulnerable
to carnitine deficiency.

The principal dietary sources of carnitine are meat and dairy products. To obtain therapeutic dosages, however, a supplement is necessary.

Therapeutic Dosages

Typical adult dosages for the diseases described here range from 500 to 1,000 milligrams (mg) three times daily. For children, one study used 50 mg per kilogram twice daily, up to a maximum of 4 grams daily.

Carnitine is taken in three forms: L-carnitine (for heart and other
conditions), propionyl-L-carnitine (for heart conditions), and acetyl-L-carnitine
(for Alzheimer’s
disease). The dosage is the same for all three forms.

Therapeutic Uses

Carnitine is primarily used for heart-related conditions. Some evidence
suggests that it can be used along with conventional treatment for
angina to improve symptoms and reduce medication needs. When
combined with conventional therapy, it may or may not help prevent medical
complications or sudden cardiac death in the months following a heart
attack.

Lesser evidence suggests that it may be helpful for a condition called
intermittent claudication (pain in the legs after walking due to narrowing of the
arteries) and for congestive heart failure. In addition, a few studies suggest
that carnitine may be useful for cardiomyopathy.

Carnitine may also be helpful for improving exercise tolerance in people with
chronic
obstructive pulmonary disease (COPD), also known as
emphysema. One should not attempt to self-treat any of the
foregoing serious medical conditions or use carnitine as a substitute for standard
drugs.

Growing, if not entirely consistent, evidence suggests that L-carnitine or acetyl-L-carnitine, or their combination, may be helpful for improving sperm function and thereby provide benefits in male infertility. Two studies found evidence that carnitine is helpful for Peyronie’s disease, a condition affecting the penis.

Carnitine has also shown promise for improving mental and physical fatigue in the elderly. Some studies have found evidence that one particular form of carnitine, acetyl-L-carnitine, might be helpful in Alzheimer’s disease, but the two most recent and largest studies found no benefit. One review evaluated published and unpublished double-blind, placebo-controlled trials and concluded that acetyl-L-carnitine may only be helpful for very mild Alzheimer’s disease.

In preliminary trials, acetyl-L-carnitine has shown some promise for the
treatment of depression or dysthymia (a milder condition related to
depression). Some evidence suggests that carnitine may be useful for improving
blood sugar control in people with type 2 diabetes. Better evidence suggests
benefit with acetyl-L-carnitine for a major complication of diabetes, diabetic
peripheral neuropathy (injury to nerves of the extremities caused by
diabetes). Acetyl-L-carnitine might help prevent diabetic
cardiac autonomic neuropathy (injury to the nerves of the heart caused by
diabetes). However, one study found that carnitine supplements had an adverse
effect on triglyceride levels in people with diabetes.

Much weaker evidence suggests possible benefits for neuropathy caused by the
chemotherapy drugs cisplatin and paclitaxel.
Weak evidence hints that carnitine might help reduce liver and heart toxicity
caused by the chemotherapy drug adriamycin.

Some evidence suggests that carnitine may be able to improve cholesterol profile. One small study demonstrated a beneficial effect of L-carnitine on anemia and high cholesterol in persons on hemodialysis for chronic renal failure.

A genetic condition called fragile X syndrome can cause behavioral
disturbances such as hyperactivity, along with intellectual disability, autism,
and alterations in appearance. A preliminary study of seventeen boys found that
acetyl-L-carnitine might help to reduce hyperactive behavior associated with this
condition. Evidence for the effectiveness of L-carnitine in attention deficit disorder
(ADD) has been mixed.

Celiac
disease is an autoimmune disease affecting the digestive
tract. Fatigue is a common symptom of the disease. One small double-blind trial
found evidence that the use of L-carnitine at a dose of 2 g daily might help
alleviate this symptom.

Weak evidence hints that carnitine may help people with degeneration of the
cerebellum (the structure of the brain responsible for voluntary muscular
movement). One small study suggests carnitine may be helpful for reducing symptoms
of chronic fatigue syndrome. Another study suggests that carnitine may be of value
for treating hyperthyroidism and for severe liver disease. A substantial
study marred by poor design (specifically, far too many primary endpoints) found
equivocal evidence that L-carnitine, taken at dose of 500 mg three times daily,
might be more effective than placebo for the treatment of fibromyalgia.

Other weak evidence suggests that carnitine may be helpful for decreasing the muscle toxicity of AZT (a drug used to treat HIV infection). Other weak evidence hints that the acetyl-L-carnitine might reduce nerve-related side effects caused by HIV drugs in general.

One study failed to find carnitine effective for promoting weight loss, although another found that carnitine might lead to improvements in body composition (fat-muscle ratio). Carnitine is widely touted as a physical performance enhancer, but there is no real evidence that it is effective, and some research indicates that it is not.

Little to no evidence supports other claimed benefits, such as treating
irregular heartbeat, Down syndrome, muscular dystrophy, and alcoholic fatty liver
disease. However, in a randomized trial involving twenty-five persons with liver
cirrhosis and early brain dysfunction (hepatic encephalopathy) associated with
severe forms of this condition, carnitine appeared to significantly improve the
function of both the liver and the brain after three months of treatment.

Scientific Evidence

Angina. Carnitine might be a good addition to standard therapy for angina. In one controlled study, two hundred persons with angina (the exercise-induced variety) either took 2 g daily of L-carnitine or were left untreated. All the study participants continued to take their usual medication for angina. Those taking carnitine showed improvement in several measures of heart function, including a significantly greater ability to exercise without chest pain. They were also able to reduce the dosages of some of their heart medications (under medical supervision) as their symptoms decreased.

The results of this study cannot be fully trusted because researchers did not use a double-blind protocol. Another trial with a double-blind, placebo-controlled design tested L-carnitine in fifty-two people with angina and found evidence of benefit.

In addition, several small studies (some of them double-blind) tested propionyl-L-carnitine for the treatment of angina and also found evidence of benefit.

Intermittent claudication. People with advanced hardening of the arteries, or atherosclerosis, often have difficulty walking because of a lack of blood flow to the legs, a condition called intermittent claudication. Pain may develop after walking less than half a block. Although carnitine does not increase blood flow, it appears to improve the muscle’s ability to function under difficult circumstances.

A twelve-month, double-blind, placebo-controlled trial of 485 persons with intermittent claudication evaluated the potential benefits of propionyl-L-carnitine. Participants with relatively severe disease showed a 44 percent improvement in walking distance, compared with placebo. However, no improvement was seen in those persons with mild disease. Another double-blind study followed 245 people and also found benefit.

Similar results have been seen in most other studies of L-carnitine or propionyl-L-carnitine. Propionyl-L-carnitine may be more effective for intermittent claudication than plain carnitine.

Congestive heart failure. Several small studies have found that carnitine, often in the form of propionyl-L-carnitine, can improve symptoms of congestive heart failure. In one trial, benefits were maintained for sixty days after treatment with carnitine was stopped.

After a heart attack. L-carnitine has shown inconsistent promise for use after a heart attack. A double-blind, placebo-controlled study followed 101 people for one month after those persons had experienced a heart attack. The study found that the use of L-carnitine, in addition to standard care, reduced the size of the infarct (dead heart tissue).

In the months following a severe heart attack, the left ventricle of the heart often enlarges, and the pumping action of the heart becomes less efficient. Some evidence suggests that L-carnitine can help prevent heart enlargement but that it does not improve heart function. In a twelve-month, double-blind, placebo-controlled study of 472 persons who had just had a heart attack, the use of carnitine at a dose of 6 g per day significantly decreased the rate of heart enlargement. However, heart function was not significantly altered.

A three-month, double-blind, placebo-controlled study of sixty persons who had just had a heart attack also failed to find improvements in heart function. (Heart enlargement was not studied.)

Results consistent with the foregoing studies were seen in a six-month double blind, placebo-controlled study of 2,330 people who had just had a heart attack. Carnitine failed to produce significant reductions in mortality or heart failure (serious decline in heart function) over the six-month period. However, the study did find reductions in early death. (For statistical reasons, the meaningfulness of this last finding is questionable. Reduction in early death was a secondary endpoint rather than a primary one.) Carnitine is used with conventional treatment, not as a substitute for it.

Diabetic neuropathy. High levels of blood sugar can damage the nerves leading to the extremities, causing pain and numbness. This condition is called diabetic peripheral neuropathy. Nerve damage may also develop in the heart, a condition called cardiac autonomic neuropathy. Acetyl-L-carnitine has shown considerable promise for diabetic peripheral neuropathy and some promise for cardiac autonomic neuropathy.

Two fifty-two-week, double-blind, placebo-controlled studies, involving a total of 1,257 people with diabetic peripheral neuropathy, evaluated the potential benefits of acetyl-L-carnitine taken at 500 or 1,000 mg daily. The results showed that the use of acetyl-L-carnitine, especially at the higher dose, improved sensory perception and decreased pain levels. In addition, the supplement appeared to promote nerve fiber regeneration. A small study found some potential benefits for cardiac autonomic neuropathy.

Male sexual function. Carnitine has shown promise for improving
male sexual function. One double-blind, placebo-controlled study of 120 men
compared a combination of propionyl-L-carnitine (2 g per day) and
acetyl-L-carnitine (2 g per day) with testosterone for the treatment of male
aging symptoms (sexual dysfunction, depression, and fatigue). The results
indicated that both testosterone and carnitine improved erectile function, mood,
and fatigue, compared with placebo. However, no improvements were seen in the
placebo group. This is an unusual occurrence in studies of erectile dysfunction,
so it casts some doubt on the study results.

A double-blind study of forty men evaluated propionyl-L-carnitine (2 g per day)
in diabetic men with erectile dysfunction who had not
responded well to Viagra. The results indicated that carnitine significantly
enhanced the effectiveness of Viagra. In another double-blind study, a combination
of the propionyl and acetyl forms of carnitine enhanced the effectiveness of
Viagra in men who suffered from erectile dysfunction caused by prostate
surgery.

Male infertility. Growing evidence suggests that L-carnitine or
acetyl-L-carnitine, or their combination, may be helpful for improving sperm
quality and function, thereby benefiting male
infertility. For example, in one double-blind,
placebo-controlled study of sixty men, the use of combined L-carnitine (2 g per
day) and acetyl-L-carnitine (also at 2 g per day) significantly improved sperm
quality.

Chronic obstructive pulmonary disease (COPD). Evidence from three double-blind, placebo-controlled studies enrolling a total of forty-nine people suggests that L-carnitine can improve exercise tolerance in COPD, presumably by improving muscular efficiency in the lungs and other muscles.

Alzheimer’s disease. Numerous double-blind or single-blind studies involving a total of more than fourteen hundred people have evaluated the potential benefits of acetyl-L-carnitine in the treatment of Alzheimer’s disease and other forms of dementia. However, while early studies found evidence of modest benefit, two large and well-designed studies failed to find acetyl-L-carnitine effective.

The first of these studies was a double-blind, placebo-controlled trial that enrolled 431 participants for one year. Overall, acetyl-L-carnitine proved no better than placebo. However, because a close look at the data indicated that the supplement might help people who develop Alzheimer’s disease at an unusually young age, researchers performed a follow-up trial. This one-year, double-blind, placebo-controlled trial evaluated acetyl-L-carnitine in 229 persons with early onset Alzheimer’s. No benefits were seen here either. One review of the literature concluded that acetyl-L-carnitine may be helpful for mild cases of Alzheimer’s disease, but not for more severe cases.

Mild depression. A double-blind study of sixty elderly persons with dysthymia (a mild form of depression) found that treatment with 3 g of carnitine daily for two months significantly improved symptoms, compared with placebo. Positive results were seen in two other studies too, one of depression and one of dysthymia.

Hyperthyroidism. Enlargement of the thyroid (goiter) can
be due to many causes, including cancer and iodine deficiency. In some cases,
thyroid enlargement occurs without any known cause, resulting in benign
goiter.

Treatment of benign goiter generally consists of taking thyroid hormone pills. This causes the thyroid gland to become less active, and the goiter shrinks. However, undesirable effects may result. Symptoms of hyperthyroidism (too much thyroid hormone) can develop, including heart palpitations, nervousness, weight loss, and bone breakdown.

A double-blind, placebo-controlled trial found evidence that the use of L-carnitine could alleviate many of these symptoms. This six-month study evaluated the effects of L-carnitine in fifty women who were taking thyroid hormone for benign goiter. The results showed that a dose of 2 or 4 g of carnitine daily protected participants’ bones and reduced other symptoms of hyperthyroidism.

Carnitine is thought to affect thyroid hormone by blocking its action in cells. This suggests a potential concern—carnitine might be harmful for people who have low or borderline thyroid levels to begin with. This possibility has not been well explored.

Peyronie’s disease. Peyronie’s disease is an inflammatory
condition of the penis that develops in stages. In the first stage, penile pain
occurs with erection; next, the penis becomes curved; finally, erectile
dysfunction may occur. Many medications have been tried for Peyronie’s disease,
with some success. One such drug is tamoxifen, which is better known as a
treatment to prevent breast cancer recurrence. A three-month, double-blind study
compared the effectiveness of acetyl-L-carnitine to the drug tamoxifen in
forty-eight men with Peyronie’s disease. Acetyl-L-carnitine (at a dose of 1 g
daily) reduced penile curvature, while tamoxifen did not; in addition, the
supplement reduced pain and slowed disease progression to a greater extent than
tamoxifen.

Safety Issues

L-carnitine in its three forms appears to be quite safe. However, persons with
low or borderline-low thyroid levels should avoid carnitine because it might
impair the action of thyroid hormone. Persons on dialysis
should not receive this (or any other supplement) without a physician’s
supervision. The maximum safe dosages for young children, pregnant or nursing
women, and those with severe liver or kidney disease have not been
established.

Important Interactions

Persons taking antiseizure medications, particularly valproic acid (Depakote, Depakene) but also phenytoin (Dilantin), may need extra carnitine. Persons taking thyroid medication should not take carnitine except under a physician’s supervision.

Bibliography

Arnold, L. E., et al. “Acetyl-L-Carnitine (ALC) in Attention-Deficit/Hyperactivity Disorder.” Journal of Child and Adolescent Psychopharmacology (2007): 791-802.

Cavallini, G., et al. “Carnitine Versus Androgen Administration in the Treatment of Sexual Dysfunction, Depressed Mood, and Fatigue Associated with Male Aging.” Urology 63 (2004): 641-646.

Gentile, V., et al. “Preliminary Observations on the Use of Propionyl-L-Carnitine in Combination with Sildenafil in Patients with Erectile Dysfunction and Diabetes.” Current Medical Research and Opinion 20 (2004): 1377-1384.

Maestri, A., et al. “A Pilot Study on the Effect of Acetyl-L-Carnitine in Paclitaxel- and Cisplatin-Induced Peripheral Neuropathy.” Tumori (2005): 135-138.

Malaguarnera, M., L. Cammalleri, et al. “L-Carnitine Treatment Reduces Severity of Physical and Mental Fatigue and Increases Cognitive Functions in Centenarians.” American Journal of Clinical Nutrition 86 (2007): 1738-1744.

Malaguarnera, M., M. P. Gargante, et al. “Acetyl-L-Carnitine Treatment in Minimal Hepatic Encephalopathy.” Digestive Diseases and Sciences 53 (2008): 3018-3025.

Rossini, M., et al. “Double-Blind, Multicenter Trial Comparing Acetyl-L-Carnitine with Placebo in the Treatment of Fibromyalgia Patients.” Clinical and Experimental Rheumatology 25 (2007): 182-188.

Sima, A. A., et al. “Acetyl-L-Carnitine Improves Pain, Nerve Regeneration, and Vibratory Perception in Patients with Chronic Diabetic Neuropathy.” Diabetes Care 28 (2004): 89-94.

Smith, W., et al. “Effect of Glycine Propionyl-L-Carnitine on Aerobic and Anaerobic Exercise Performance.” International Journal of Sport Nutrition and Exercise Metabolism 18 (2008): 19-36.

Youle, M., and M. Osio. “A Double-Blind, Parallel-Group, Placebo-Controlled, Multicentre Study of Acetyl-L-Carnitine in the Symptomatic Treatment of Antiretroviral Toxic Neuropathy in Patients with HIV-1 Infection.” HIV Medicine 8 (2007): 241-250.

What is epididymitis?

Definition

Acute epididymitis is an
inflammation of the epididymis. This is a structure shaped like a tube that surrounds and attaches to each testicle. The epididymis helps transport and store sperm cells.

Chronic epididymitis causes pain and inflammation in the epididymis. There is often no swelling of the scrotum. Symptoms can last six weeks or more, but this type is less common.

Causes

Epididymitis is most often caused by bacterial infections such as those of
the urinary tract, by sexually transmitted diseases (STDs)
such as chlamydia and gonorrhea, by infection of the urethra
(urethritis), by infection of the prostate (prostatitis),
and by tuberculosis. Other causes include injury, viral infections
such as mumps, genital abnormalities, treatment with the heart rhythm drug
amiodarone (cordarone), and chemotherapy to treat bladder cancer.

Risk Factors

Risk factors for epididymitis include infection of the genitourinary tract (bladder, kidney, prostate, or testicle), narrowing of the urethra, use of a urethral catheter, infrequent emptying of the bladder, recent surgery or instrumentation of the genitourinary tract (especially prostate removal), birth disorders of the genitourinary tract, unprotected sex, and disease that affects the immune system. Most at risk are boys and men ages fifteen to thirty years and men older than age sixty years.

Symptoms

Symptoms usually develop within a day and include pain in the testes; sudden redness or swelling of the scrotum; hardness, a lump, or soreness (or all three) in the affected testicle; tenderness in the nonaffected testicle; groin pain; chills; fever; inflammation of the urethra; pain during intercourse or ejaculation; pain or burning, or both, during urination; increased pain while having a bowel movement; lower abdominal discomfort; discharge from the penis; and blood in the semen.

Screening and Diagnosis

A doctor will ask about symptoms and medical history and will perform a physical exam. Tests may include a urinalysis to check for a high white blood cell (WBC) count and the presence of bacteria; a urine culture to identify the type of bacteria present; a culture of discharge from the penis; a blood test to measure the white blood cell count (WBC); and an ultrasound (a test that uses sound waves to examine the scrotum).

Treatment and Therapy

Treatment is essential to prevent the infection from worsening. Treatment may
include bed rest. The patient should stay in bed to keep the testicles from moving
and to promote healing. Bed rest might be necessary until the swelling subsides.
Another treatment is antibiotics, prescribed for bacterial
infections. If the patient has an STD, his partners will also need treatment.
Another treatment is oral anti-inflammatory medication, which includes drugs such
as ibuprofen, to help reduce swelling.

The patient may need to wear an athletic supporter for several weeks. Taking baths can ease the pain and help relieve swelling. One should not have sex until treatment is completed. Finally, surgery may be needed in severe cases that return.

Prevention and Outcomes

To help decrease the risk of developing epididymitis, one should practice safer sex. One can protect against STDs by using condoms. Finally, one should empty one’s bladder when feeling the need to do so.

Bibliography

Centers for Disease Control and Prevention. “Sexually Transmitted Diseases Treatment Guidelines 2010.”Available at http://www.cdc.gov/std/treatment/ 2010.

Lunenfeld, Bruno, and Louis Gooren, eds. Textbook of Men’s Health. Boca Raton, Fla.: Parthenon, 2007.

National Institutes of Health. “Men’s Health.” Availableat http://health.nih.gov/category/menshealth.

Schrier, Robert W., ed. Diseases of the Kidney and Urinary Tract. 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2007.

Simon, Harvey B. The Harvard Medical School Guide to Men’s Health. New York: Free Press, 2004.

What kinds of thoughts are being expressed by Macbeth when he sees a dagger suspended in the air in front of him?

During the dagger soliloquy, Macbeth ponders the possibility of murdering Duncan. He recognizes that he is seeing a bloody, murderous dagger suspended in front of him and that this apparition cannot be real. Further, he questions his own thoughts and mental state when he sees this dagger, wondering if he should trust his own mental facilities to correctly guide him to the appropriate actions. Shakespeare uses this soliloquy to accomplish two things. First, he sets the viewer up to understand the mental delirium that Macbeth undergoes as he questions his ability to commit Duncan's murder. Second, he sets an eerie mood for the murder itself by utilizing the imagery of ghosts, witches, and the moonlight to suggest evildoing. During this section of the play, Macbeth accepts the actions that he is going to take in killing Duncan and commits himself to the evil that he plans to pursue. In questioning his actions so fervently before committing the crime, Macbeth clearly begins the play as a good man who slowly unravels due to a number of external factors.

In Frankenstein, how is the setting of the story significant to the plot? How does the setting help further the story?

One of the major themes in Frankenstein by Mary Shelley is the relationship between nature and nurture. Victor Frankenstein is almost prototypically urbane and sophisticated, a typical man of the Enlightenment, well traveled and a product of upper class European city culture. Although his monster is a creation of this culture, it is also a tabula rasa (blank slate), an emblem of humanity in the state of nature. As such, the monster shows how humanity is influenced by three different types of settings.

The first setting is "civilized" Ingolstadt, a university town. In this setting, of a sophisticated "modern" environment, two things happen. First, a monstrosity is created, suggesting that Shelley is warning us that scientific culture run amok can produce monsters. Second, the creator, Victor, acts with inhumanity towards his creation, not properly nurturing it. This suggests that urban Enlightenment culture may be losing its moral compass.

The rural setting to which the monster escapes allows for the monster to remain alive and undiscovered, and learn human language and manners. This is meant in part to show how the monster's character is formed by its interaction with others -- that it responds to the experience of kindness by learning generous behavior and to enmity by acts of revenge. 

The third setting and frame of the novel is the Arctic, an area of pure nature, in which humans exist only precariously. Despite the harshness of this setting, it is also Edenic, and the monster's escape into it shows him being welcomed in nature in a way he is not in civilization. Also, the setting has the sort of exoticism that works well for an adventure story.

What does the room in the tower in "The Lady of Shallot" look like?

The lady lives in a tower in a castle on an island which flows toward Camelot. The castle has "four grey walls" and "four grey towers." There is a window in her room which may open on a hinge ("casement" - line 25). The roof of her tower may overhang the walls. The speaker mentions how Lancelot is a bow shot's distance away from her bower eaves. It may be that her window is located just below the eaves. The window might also have some type of balcony branching out; this is mentioned in line 154. 

In her room, she has a loom with which she weaves the images she sees in the mirror. She can not look directly out the window because of the curse. So, with her back to the window, she looks into the mirror which reflects what would be seen through the window. The mirror is probably raised, facing the window, and tilted some degree downward so that she can see what is on the ground below. In line 110, the speaker notes that the lady "made three paces thro' the room." This is when she decides to turn around and walk to finally look out of the window. With only three paces, this illustrates how close to the window she had always been. This highlights how tempting it must have been to simply turn and look. 

What is the difference between drama and prose?

Drama refers to plays, which are written to be acted on a stage by people playing the parts of characters. Prose is usually meant to be read privately by an individual (though speeches are almost always written in prose) and is the kind of writing we associate with both fiction and nonfiction books. Think of drama as plays and prose as novels, short stories or essays.

Drama is more traditionally connected to cultures with lower literacy, where people could watch and listen to stories they might not be able to read. Prose is connected to the rise of literacy, as well as the ever-lowering costs of printing. Both being able to read and afford printed matter meant people could go off privately with a book, journal or pamphlet and read and ponder the work in solitude, though prose works were often read aloud as well, both in the home and, in the case of pamphlets, on the street.

Though the division is not sharp, drama is associated with community: the idea is that people go en masse to see a performance. Prose is often tied to the rise of the private individual, reading alone.

What happens in Chapters 9 through 12 of The Human Comedy?

In Chapter 9, "The Veteran," in William Saroyan's novel The Human Comedy, Homer Macauley, the main character, gets into a conversation with a Spanish-American War veteran. In Chapter 10, "The Ancient History Class," Homer and Hubert Ackley III get into a verbal argument in Miss Hicks's ancient history class, as they both like Helen Eliot. Homer challenges Hubert about why he feels superior because he's rich, and Hubert in turn calls Homer a "common fanfaron" (page 48), a word that Homer does not understand. Though they apologize to each other, Miss Hicks insists that they stay after school--a prospect that neither of them likes because they are competing in a track meet.

In Chapter 11, "The Human Nose," Miss Hicks asks the students what they have learned, and Homer goes off on a long history of the human nose. The point he is making is that everyone, regardless of their social class, has a nose. Therefore, the distinctions we make between people are not as critical as they seem. Finally, in Chapter 12, Mr. Byfield, the track coach, comes to tell Miss Hicks that he spoke to the principal, Mr. Ek, and that Mr. Ek said that Hubert should be allowed to go to the track meet. Mr. Byfield is more concerned with Hubert because Hubert is wealthy, but Miss Hicks speaks about how she cares more about the integrity of her students and how they behave than about what class they come from. Eventually, both boys go to the track meet, but Homer arrives later and falls as he begins running. Hubert stops all the participants from running until Homer is standing up again, and Hubert and Homer tie in the race. 

What is the relationship between hospitals and infectious disease?

Definition

Infections acquired in hospitals and health care facilities effect about one in every twenty-five patients admitted to acute-care or long-term-care facilities in the United States according to the Centers for Disease Control and Prevention (CDC). In 2011 this meant approximately 722,000 people in acute-care hospitals had healthcare-associated infections (HAIs), also called nosocomial infections, leading to about 75,000 deaths. To be diagnosed as nosocomial, the infection must not be associated with the admitting diagnosis and must occur because of a patient’s exposure to the surrounding pool of infectious agents. The infection usually becomes clinically evident after forty-eight hours (and during hospitalization) or within thirty days of discharge. These infectious agents can colonize a person’s skin, respiratory tract, genitourinary tract, gastrointestinal tract, and bloodstream.

Causes

Most hospital acquired infections are caused by bacteria, viruses, or parasites. The causative organisms can be introduced through endotracheal (ET) intubation, catheterization, gastric drainage tubes, and intravenous procedures for medication delivery, blood transfusions, or nutrition supplementation. Infection also occurs through surgical procedures and by health care workers’ failing to wash their hands before procedures and between encountering patients. Other risk factors for hospital acquired infections include prolonged hospitalization, the severity of the patient’s underlying illness, the prevalence of antibiotic-resistant bacteria from the prolonged use or overuse of antibiotics, contaminated air-conditioning systems, contaminated water systems, lack of an appropriate ratio of nurses to patients, and overcrowding of beds. Later studies suggested that the uniforms and laboratory coats of hospital personnel may also help transfer pathogens. Also, it has been suggested that the shedding of epithelial tissues from the patients onto their hospital clothing may contribute to infections. Other reservoirs of contamination include stethoscopes, blood pressure cuffs, bed pans, water pitchers, telephones, and other objects. Airborne infections in hospitals may contribute to infections that include tuberculosis and herpes varicella.

Among the most common hospital acquired infections are pneumonia and urinary tract infections. In terms of the latter, the common procedure of placing a catheter into the bladder for delivery of medication, for measuring urinary output, for the relief of pressure, or for other medical reasons creates a port of entry for infectious agents. The healthy bladder is normally sterile; it contains no harmful bacteria or other organisms. The catheter can pick up bacteria or organisms from the urethra, providing an easy route to the bladder. This infection can occur because of improper sterilization techniques,which creates a mechanical entry for infection through, for example, multiple tries to insert the catheter; even the composition of the catheter can lead to infection of the bladder. It is now recognized that a major cause of nosocomial infection is the picking up of bacteria, such as Escherichia coli (E. coli), or other organisms from the intestinal tract and transferring them to the bladder. Irritation from the catheter’s insertion and prolonged use of the catheter can transfer bacteria (and a fungus called Candida). An infection caused by an indwelling catheter will need long-term treatment with antibiotics; this long-term treatment can compromise the patient’s immune system, thereby causing further harm.

Nosocomial pneumonia is another leading hospital-acquired infection, accounting for about 157,500 cases in US acute-care hospitals in 2011. Bacteria and other microorganisms enter the respiratory system through procedures treating respiratory illnesses. The placement of ET tubes for mechanical ventilation is of primary concern. If ETtubes are inserted (such as by a paramedic) while the patient is outside a hospital or even in an emergency room, the risk of infection is greater. The introduction of aids for ensuring adequate ventilation often lead to infection. Aspiration from the nose, throat, and lungs is a direct pathway for introduction of microorganisms.

Surgery accounts for similar numbers of all US nosocomial infections. Agents of infection include contaminated surgical equipment, the contaminated hands of health care providers, contaminated dressings, trauma wounds, burn wounds, and pressure sores from prolonged bed rest or wheel chair use. The continuous delivery of medications, transfusions, antibiotics, or nutrients through the bloodstream by intravenous (IV) routes is yet another common cause of infection. Improper technique causes bacteria to enter the body at the placement of IVs and increases the risk of infection the longer the IVs are in place. Infections in the blood are of special concern because they can produce disseminating infections. Gastrointestinal procedures, such as colonoscopy; obstetric procedures; and kidney dialysis can also lead to major infections.

Antibiotic
resistance has led to an increase in several other nosocomial
infections, including superinfections. Generally, the major causative pathogens
for hospital acquired infections relate to the location of the involved body
system or systems, except for the bloodstream, which when infected can cause
dissemination of the infection to all major organs. By classifying major pathogens
according to the organ systems they affect, one can differentiate among these
varying pathogens. The major pathogens for the genitourinary system are
gram-negative enterics, fungi, and enterococci. Bloodstream infectious agents are
usually coagulase-negative staphylococci, enterococci, fungi,
Staphylococcus aureus, Enterobacter species,
Pseudomonas, and Acinetobacter baumannii
(which causes substantial antimicrobial resistance). Surgical-site infections
include S. aureus, Pseudomonas,
coagulase-negative staphylococci, and (rarely) enterococci, fungi,
Enterobacter species, and E. coli.

Ventilator-associated pneumonia (VAP) is designated as either early or late onset. Early onset begins within the first three to four days of mechanical ventilation. The infections are usually antibiotic-sensitive and are most often caused by S. pneumoniae, H. influenza, or S. aureus. Late-onset infections that are antibiotic-resistant and are main causative agents are those caused by Ps. aeruginosa, Actinobacter spp., and Enterobacter spp. Other pneumonias caused by gram-negative bacterium are Klebsiella pneumoniae, Legionella, or methicillin-resistant Staphyloccocus aureus (MRSA), known as the superbug.

A relatively new hospital-acquired infection is colitis, caused by the organism
Clostridium difficile
. This gram-positive, anaerobic, spore-forming bacillus is responsible for antibiotic-associated diarrhea and colitis. The infection is caused by a disturbance of the normal bacterial flora in the colon, precipitated by antibiotic therapy. The colonization of C. difficile releases two toxins: toxin A, an endotoxin, and toxin B, a cytotoxin, leading to mucosal inflammation and damage of the colon.

Risk Factors

Although all hospital patients are susceptible to nosocomial infections, young children, especially those in the neonatal intensive care unit (ICU); adult ICU patients; the elderly; and patients with compromised immune systems are more likely to acquire these infections. Other risk factors include having underlying diseases such as chronic lung disease, diabetes, or cardiac disease; being obese; being malnourished; having a malignancy; having a remote infection; using prophylactic antibiotics; and hospitalization before surgery (especially for twelve hours or longer), which increases the patient’s exposure to the reservoir of infectious agents.

Symptoms

The primary sign of infection is fever. A person’s
admission temperature and those temperatures recorded at the time of
hospitalization and after hospitalization are paramount for recognizing a
developing infection. Other symptoms of infection include an increased respiratory
rate; increased pulse rate; sweating, especially at night; chest pain; productive
phlegm with coughing or an inability to cough; pain and discharge from the nose or
mouth; fatigue; difficulty and pain with swallowing; nausea; vomiting; excessive
diarrhea; pain with urination or blood present in urine; reduced urine output;
redness and swelling with pustular discharge around surgical wounds or openings in
sutures from skin closures with exposure to subcutaneous tissues; and the
development of skin rashes.

Screening and Diagnosis

The foregoing signs and symptoms suggest infection. One should consult a doctor immediately if any of these symptoms are present during or after hospitalization. The first diagnostic tool is a complete physical examination, which includes laboratory studies and X rays. Other tests include extensive blood testing, with a complete blood count that looks for an increase in infection-fighting white blood cells; a complete urinalysis that includes culture and checks for a sensitivity to antibiotics; two blood samples drawn twenty minutes apart for culture and sensitivity; sputum for culture and sensitivity; and wound cultures for culture and sensitivity. Ancillary tests include abdominal X rays or computed tomography (CT) scans (detailed X rays that identify abnormalities of fine tissue structure); kidney X rays; kidney, liver, and pancreas function tests; blood gas tests; and tests for fungus infective agents.

Treatment and Therapy

While waiting for the laboratory culture and sensitivity results, which may
take up to forty-eight hours to complete, one should begin broad-spectrum
antibiotic therapy. This usually includes penicillin,
cephalosporins, tetracycline, or erythromycin, and
supplemental oxygen if needed. The doctor will need to know if the patient is
allergic to certain antibiotics or if the patient has been on prolonged antibiotic
therapy. It is usual to combine antibiotics for therapy, so, for best results, the
doctor must determine if the infecting organism is gram-positive or gram-negative
or whether it is anaerobic bacteria, resistant bacteria, or fungi. Once the
causative agent for infection has been identified, aggressive therapy begins.
Recommended treatments include vancomycin, imipenem plus cilastatin, meropenem,
azteonam, piperacillin plus tazobactam, ceftazidme, and cefepime. If MRSA is
suspected, limezoid can be used.

Other treatments that can be used to supplement antibiotic therapy include pulmonary hygiene and respiratory treatments, aggressive wound care, fever control until the antibiotics show evidence of effectiveness, body cleansing, changing of hospital garments, and extreme sterile techniques when treating the patient (which may include putting the patient in reverse isolation for protection of further exposure to infections). Close monitoring of cardiac status, urine output, and pulmonary functions is recommended. The changing of catheters, IV lines, gastrointestinal (GI) tubes, and other invasive forms of exposure may also be ordered by the doctor. The hospital’s medical team and infectious disease control team will monitor the patient’s status and present complete documentation of the case.

Prevention and Outcomes

The recommendations for the prevention of infections acquired in hospitals and other health care facilities cover a broad geographic, demographic, cultural, and ecological spectrum. The recommendations are based on the type of causative agents as precursors for disease in the associated populations. Requirements, although based on sound science, can sometimes be misinterpreted or even ignored. A good foundation for practice is to bring together basic infection-control measures and the history of epidemiology. Historically, this practice could be said to have begun in the nineteenth century with Florence Nightingale, who believed respiratory secretions could be dangerous, and with Ignaz Semmelweis, a nineteenth century obstetrician who demonstrated that routine handwashing could prevent the spread of puerperal fever. Joseph Lister, a nineteenth century professor of surgery, was the first to realize the connection between the suppuration of wounds and the discoveries of the fermentation process (by chemist and microbiologist Louis Pasteur) in the mid-nineteenth century. Lister published his findings in 1867 and was credited with helping to start the practice sterilizing operating rooms with carbolic acid.

The CDC began hospital surveillance in the United States in the 1960s. The 1970s saw the introduction of training courses in disease prevention and the establishment of the CDC’s Division of Healthcare Quality and Promotion for hospital infection programs and the National Nosocomial Infections Surveillance System. The Study on the Efficacy of Nosocomial Infection Control was conducted in the early 1970s. The Healthcare Infection Control Practices Advisory Committee was formed in 1991 and, in 2005, hospitals began contributing surveillance to the National Healthcare Safety Network, which was reworked with a comparison study in 2007. The initiatives created by these agencies and programs provide guidelines for improvement in the prevention of hospital acquired infections.

These guidelines include adopting infection control programs in accordance with the CDC to track trends in infection rates, ensuring that one practitioner is available for every two hundred beds in hospitals and other health care facilities, identifying high-risk medical procedures, strict adherence by medical staff and visitors to handwashing policies, and other sterilization techniques. These include using sterile gowns, gloves, masks, and barriers; sterilizing reusable equipment, including ventilators, humidifiers, or other respiratory equipment that comes in contact with a patient’s respiratory tract; frequently changing wound dressings and using antimicrobial ointments; removing nasalgastric and endotracheal tubes as soon as possible; using antibacterial-coated venous catheters; preventing infection by airborne microbes through wearing masks (by hospital personnel and patients); limiting the use of high-risk procedures such as urinary catheterization; isolating patients with known infections; and reducing the general use of antibiotics.

Bibliography

Clancy, Carolyn. “Simple Steps Can Reduce Health Care-Associated Infections: Navigating the Health Care System.” Rockville, Md.: Agency for Healthcare Research and Quality, 2008. Available at http://www.ahrq.gov/consumer/cc/cc070108.htm.

"Healthcare-Associated Infections (HAIs): Data and Statistics. CDC. Centers for Disease Control and Prevention, 15 Oct 2015 Web. 31 Dec. 2015.

Helms, Brenda, et al. “Improving Hand Hygiene Compliance: A Multidisciplinary Approach.” American Journal of Infection Control 38, no. 7 (2010): 572-574. Print.

Heymann, David L., ed. Control of Communicable Diseases Manual. 19th ed. Washington, D.C.: American Public Health Association, 2008. Print.

Kuehnert, Matthew J., et al. “Methicillin-Resistant Staphylococcus aureus Hospitalizations, United States.” Emerging Infectious Diseases 11, no. 6 (2005). Print.

Kushner, Thomasine Kimbrough. Surviving Healthcare: A Manual for Patients and Their Families. New York: Cambridge University Press, 2010. Print.

Peleg, Anton Y., and David C. Hooper. “Hospital-Acquired Infections Due to Gram-Negative Bacteria.” New England Journal of Medicine 362, no. 19 (2010): 1804-1813. Print.

Turnock, Bernard, J. Public Health: What It Is and How It Works. 3d ed. Sudbury, Mass.: Jones and Bartlett, 2004. Print.

Weber, David J., et al. “Role of Hospital Surfaces in the Transmission of Emerging Health Care-Associated Pathogens: Norovirus, Clostridium difficile, and Acinetobacter Species.” American Journal of Infection Control 38, no. 5, suppl. (2010): S25-S33. Print.

How would you rate President Kennedy and President Johnson on domestic issues?

Both President Kennedy and President Johnson had lofty ambitions for their domestic programs. While both men made accomplishments with their goals, President Johnson had more success than President Kennedy.

While President Kennedy was in office, several things were accomplished. Minimum wage increased to $1.25. Women’s rights were expanded. The Presidential Commission on the Status of Women was created. The Equal Pay Act of 1963 was passed. Jobs were creating in the defense industries and in the field of space exploration.

President Johnson accomplished much more. President Johnson wanted to have a legacy similar to the legacy of Franklin D. Roosevelt. Many programs were passed as a result of his Great Society program. Health insurance was provided to the elderly through the Medicare program. Poor people got health insurance with the Medicaid program. The Head Start program allowed disadvantaged kids a chance to start school at an earlier age. The Neighborhood Youth Corp and the Job Corps provided jobs for young people. The VISTA program allowed people to work in underdeveloped regions of the United States to help improve the lives of the people living in these regions. More money was given to public schools as a result of the Elementary and Secondary Education Act.

Under President Johnson, three important civil rights laws were passed. The Civil Rights Act of 1964 ended segregation in public facilities. The Voting Rights Act ended the practice of using poll taxes and literacy tests to deny African-Americans the right to vote. The Civil Rights Act of 1968 ended discrimination in housing sales and rentals.

There are reasons why President Johnson got more accomplished than President Kennedy. President Johnson knew how to work with Congress. President Kennedy didn’t campaign for Democrats running for Congress in 1960. Thus, these representatives didn’t feel they owed anything to President Kennedy, especially when it came to some of the controversial issues such as civil rights. President Johnson, however, had done many things for other elected officials. He knew how to apply pressure to them to get his ideas passed. President Johnson expected help on key issues because he had helped these people in the past. Another issue that was significant was the assassination of President Kennedy. He had less time in office than President Johnson had to accomplish all of the goals of his domestic agenda.

Both President Kennedy and President Johnson had many goals for their domestic agenda. While both men had accomplishments with their domestic agendas, President Johnson got more accomplished than President Kennedy did.

What does peace have do with the book Seedfolks?

Like in The Secret Garden, when a story revolves around growing something out of the ground, you can bet that the author means to show something else growing, too: something metaphorical, usually positive, maybe even miraculous. If you've read The Secret Garden or seen the movie, you know that the girl grows flowers, but on a deeper level, she's developing independence and growing out of her sour, spoiled self and into a cheerful girl who cares for others.

The same thing is going on in Seedfolks, just with a bunch of characters instead of one. Each of them is trying to deal with or get over some type of personal turmoil. By tending the garden, staying busy, creating something meaningful, and finding companionship, all of these characters find some measure of inner peace. They start out lonely, or frightened, or frustrated, but by the time they get down to digging in the dirt and making something grow, their state of mind is more peaceful than before.

Take Curtis, for example. Before he gets involved in the garden, he's vain: he's obsessed with building his muscles. He was totally in love with Lateesha, but he lost her and he can't get over it. So he starts to work in the garden, and after creating something other than bigger muscles, he realizes that he takes pride in the garden. Because that's something outside of himself, he starts to become less egotistical and more mature. It's a more peaceful state of mind: he goes from being frustrated to being closer to happy.

Why did Americans become interested in expanding overseas in the late 1800s?

Americans became interested in expanding overseas in the late 1800s. We had already expanded from the Atlantic Ocean to the Pacific Ocean. Americans now wanted to take the concept of Manifest Destiny worldwide. We were trading around the world. We understood how important it was for us to be able to protect that trade. Without overseas colonies, it would be difficult to protect our trade.

We also believed that our way of life was superior. We believed it our duty to spread our superior way of life to people who lived in less developed regions of the world.

We also knew that other countries had colonies throughout the world. We knew that to be considered a world power, we needed to have colonies. It seemed that having colonies was closely connected with the status of being a world power country.

We also wanted to have military bases around the world. Having colonies would allow us to do that. We needed a place that our military could use if a war occurred. Having colonies would allow us to create military bases around the world.

The United States was focused on becoming a world power in the late 1800s. Having colonies was part of that plan.

What are some of the stories about Arthur (Boo) Radley in To Kill a Mockingbird?

In the opening chapter of Harper Lee's To Kill a Mockingbird, the first story we are told about Arthur (Boo) Radley is that, when he was 18 years old, he started spending time with a bunch of trouble-making boys. One night, they stole a cheap vehicle, were arrested, and were convicted upon "charges of disorderly conduct disturbing the peace, assault and battery, and using abusive and profane language in the presence and hearing of a female" (Chapter 1). All the boys except Arthur were sent to the industrial school, where they received high-quality educations. Mr. Radley felt it best to keep Arthur under his own care and received permission from the judge to keep him under house arrest.

The second story we learn in the first chapter is that, after 15 years of house arrest, at the age of 33, Arthur was apparently driven insane enough to drive a pair of scissors into his father's leg as Mr. Radley passed by Arthur while Arthur was working on his scrapbook. According to Miss Stephanie Crawford's rumors, Mr. Radley refused to have his son sent to an asylum. He did, however, concede to jail time but without pressing any charges. The "sheriff hadn't the heart to put him in the jail alongside Negroes, so Boo was locked in the courthouse basement" until the town council insisted Arthur be taken under Mr. Radley's care again (Chapter 1).

Other stories we learn about Arthur are myths about his sneaking out at night, watching Miss Stephanie through her bedroom window in the middle of the night, and poisoning the pecans that fell onto his lawn.

What situation does Sidi find herself in at the end of the play?

Sidi is faced with the decision to choose between marrying Lakunle or Baroka at the end the play. Initially, Sidi does not marry Lakunle because he refuses to pay the bride-price, claiming that it is a savage custom. Sidi values traditional African customs and receiving a payment as a bride-price is very important to her. She also denies Baroka's attempt to marry her, claiming that he is too old. Sidi's decision to initially deny the Bale marriage because of his age is considered a modern view of marriage. This is one example of conflict between tradition and modernity that Soyinka depicts throughout the play. At the end of the play, Sidi loses her virginity to Baroka, which means that she has to either marry the Bale, or marry Lakunle and not accept payment for her bride-price because she is no longer a maid. According to Yuroba tradition, if a woman is not a virgin, the groom does not have to pay the bride-price. Sidi makes the decision to marry Baroka instead of receiving no payment and marrying Lakunle.

Who was the man in the Red Sweater in Call of the Wild?

The man in the red sweater is a dog-breaker who teaches Buck the Law of Club and Fang. 

Buck lives a very comfortable lifestyle on Judge Miller’s ranch.  He is a pampered pet.  Yet when he is stolen by Manuel, he is not quite ready to be a sled dog.  He still believes that his word is law. The man in the red sweater teaches him to obey the person with the club. 

A stout man, with a red sweater that sagged generously at the neck, came out and signed the book for the driver. That was the man, Buck divined, the next tormentor, and he hurled himself savagely against the bars. The man smiled grimly, and brought a hatchet and a club. (Ch. 1) 

This man’s only job is to “break” Buck.  In other words, he will hit him with a club enough times that Buck will stop fighting.  From then on, Buck understands that you do what a man with a club says.  By extension, he soon also learns that he needs to obey stronger dogs (that is the “fang” part of the law).  Buck puts up a fight, but he eventually learns it is futile to disobey a man with a club. 

For the last time he rushed. The man struck the shrewd blow he had purposely withheld for so long, and Buck crumpled up and went down, knocked utterly senseless.

"He's no slouch at dog-breakin', that's wot I say," one of the men on the wall cried enthusiastically. (Ch. 1) 

It does not take Buck long to learn the ways of the wild.  In the wild, you do what you are told, whether it is by the man or the dog.  Being on a sled-dog team is serious business.  If a dog doesn’t listen, either to the lead dog or to the human in charge, there will be consequences.  This is the Law of Club and Fang.

How did the Great Depression affect Americans?

The Great Depression of the 1930s had a profound and generally negative effect on the lives of many Americans. By 1933, the unemployment rate had nearly doubled, meaning fifteen million people did not have work. Some areas suffered particularly badly; the unemployment rate in Harlem, for example, reached 50 percent. (See the first reference link provided.)

The Great Depression caused the crime rate to increase. Many unemployed people turned to prostitution or theft to feed their families. Suicide rates also increased. (See the second reference link provided.)

Socially, the Great Depression also brought a decline in the number of divorces (as the process became too costly), but witnessed a rise in the so-called "Poor Man's Divorce." This is another term for abandonment, as men simply left their families to fend for themselves. The birth rate declined, too, as couples avoided the expense caused by having additional children. Instead, they educated themselves on methods of birth control and put off marriage for as long as possible. (See the second reference link provided.)

What is angina?

Causes and Symptoms

Usually located below the sternum, angina may radiate down the left arm and/or left jaw, or down both arms and jaws. It is ischemic in nature, meaning that the pain
is produced by a variety of conditions that result in insufficient supply of oxygen-rich blood to the heart. Some examples include arteriosclerosis (hardening of the arteries), atherosclerosis (arteries clogged with deposits of fat, cholesterol, and other substances), coronary artery spasms, low blood pressure, low blood volume, vasoconstriction (a narrowing of the arteries), anemia, and chronic lung disease.

Precipitating factors for angina include physical exertion, strong emotions, consumption of a heavy meal, temperature extremes, cigarette smoking, and sexual activity. These factors can cause angina because they may increase heart rate, cause vasoconstriction, or divert blood from the heart to other areas, such as the gastrointestinal system. Angina usually lasts from three to five minutes and commonly subsides when the precipitating factors are relieved. Typically, it should not last more than twenty minutes after rest or treatment.

Diagnosis consists of a physical examination which includes a chest X ray to determine any obvious lung or structural cardiac abnormalities; blood tests to screen risk factors such as lipids or to detect enzymes that can indicate if a heart attack has occurred; electrocardiography (ECG or EKG) to look at the electrical activity of the heart for evidence of damage or insufficient blood flow; nuclear studies such as thallium stress tests, which measure myocardial perfusion; and cardiac catheterization and coronary angiography to evaluate the anatomy of the coronary arteries, the location and nature of artery narrowing or constriction, and to assess the muscular function of the heart, including cardiac output.

Treatment depends on the specific cause of the angina. Three types of drugs are the most common form of treatment: nitrates, to increase the supply of oxygen to the heart by dilating the coronary arteries; beta-blockers, to lower oxygen demand during exercise and improve oxygen supply and demand; and calcium blockers, to decrease the work of the heart by decreasing cardiac contractility. A study published in March 2013 found that the drug Ranexa (ranolazine) might reduce symptoms of angina in patients with type 2 diabetes.

Bibliography

Dranov, Paula. Random House Personal Medical Handbook: For People with Heart Disease. New York: Random House, 1991.

McGoon, M. The Mayo Clinic Heart Book. 2d ed. New York: William Morrow, 2000.

Pantano, James. Living with Angina: A Practical Guide to Dealing with Coronary Artery Disease and Your Doctor. New York: First Books, 2000.

Parker, James M., and Philip M. Parker, eds. The 2002 Official Patient’s Sourcebook on Angina. San Diego, Calif.: Icon Health, 2002.

Zaret, Barry L., Marvin Moser, and Lawrence S. Cohen, eds. Yale University School of Medicine Heart Book. New York: William Morrow, 1992.

What is karyotyping?

The Cell and Chromosomes

Every cell in the human body—except for red blood cells—contains a nucleus with rod-shaped structures called "chromosomes." The chromosomes, in turn, contain the genes, which are the units that transmit heredity from parents to offspring.

The forty-six individual chromosomes in a human cell exist as twenty-three pairs of so-called homologues. Homologous chromosomes are similar in size and appearance. The first twenty-two pairs of homologues are referred to as "autosomes," while pair number twenty-three contains two dissimilar chromosomes known as the X and Y chromosomes, which determine sex. Sperm and egg cells each have twenty-three chromosomes, or half the usual number. When a sperm fertilizes an egg, the normal chromosome number (forty-six) is reestablished in the first cell of life, the zygote.

Cells reproduce by mitosis, a process of simple division, the result being two identical daughter cells, each containing forty-six chromosomes. Since chromosomes contain the genetic information, it follows that mitosis must proceed with precision every time a cell divides. During the earliest stages of embryonic development, however, mistakes sometimes occur and the cells wind up with more or fewer chromosomes. This malfunction of mitosis is called "nondisjunction," and the incorrect number of chromosomes is passed to all the cells in the developing embryo. This leads to a variety of abnormal conditions, all of which can be diagnosed with the procedure known as "karyotyping."

Procedure and Interpretation

A karyotype is an analysis of all the chromosomes in a single cell. The prefix “karyo-” refers to the nucleus, the part of the cell where chromosomes reside; the suffix “-type” means characterization. Thus, a karyotype is a characterization of a nucleus in terms of its chromosomes.

Karyotypes are performed on embryos to diagnose chromosomal abnormalities and on adults who suspect chromosomal aberrations that could be passed on to offspring. Although a karyotype can be constructed from almost any cell in the body that contains a nucleus, it is most often performed on white blood cells, which are easily harvested from a routine blood sample.

The procedure is simple. Once the blood is collected, the white cells are separated from the red. In the laboratory, the white blood cells are then stimulated to undergo mitosis. At the stage of mitosis when the chromosomes are most visible, the process is chemically halted. The chromosomes are then stained to make them more visible, after which they are photographed and the individual chromosomes cut out and rearranged as homologous pairs in descending order by size. Each pair of chromosomes is also given a number, the largest pair being designated number 1. Then, another photograph is taken of the chromosomes in the rearranged format. The result is the karyotype. The entire process, from collecting the blood sample to growing the cells to preparing the karyotype, takes from one to three weeks.

Once the karyotype has been created, it is ready to be interpreted by a cytogeneticist, an expert in the study of chromosomes. The most common disorders visible with karyotyping are Down syndrome, an extra copy of chromosome number 21; Klinefelter syndrome, a male with an extra X chromosome, resulting in sterility and the development of some feminine features; and Turner syndrome, a female missing an X chromosome, resulting in sterility and a masculine body build.

Perspective and Prospects

Karyotyping was first reported in the mid-1950s when chromosomes were examined in fetal cells collected from amniotic fluid. This was the beginning of the discipline of prenatal genetic diagnosis. At the time, there was no ultrasound to guide the needle through the amniotic membrane, which increased the risk of damaging the fetus. The karyotyping itself required four or five weeks of cell culture and was not always successful.

Today, karyotyping is commonly used to diagnose chromosomal abnormalities in both fetuses and live individuals. It is considered an absolutely safe procedure, the only risks being those inherent in penetrating the amniotic sac with a needle. Also, although the advent of ultrasound has greatly reduced the risk to the fetus, the possibility always exists of inadvertently collecting maternal cells when the mother’s tissues are penetrated.

Since the 1970s, dyes have been added to karyotypes to highlight the chromosomes for identification purposes. Today, when abnormalities are found on a karyotype, researchers can then examine the individual genes for deletions and duplications using molecular cytogenic procedures, such as fluorescence in situ hybridization (FISH) and comparative genomic hybridization (CGH). For instance, in the multicolor FISH method called "spectral karyotyping (SKY)," fluorescent dyes highlight specific regions of the chromosomes. A device called an "interferometer" is used to detect slight color variations invisible to the human eye and then assign visible colors to the homologous chromosomes. The SKY method is superior to traditional karyotyping with chemical stains because it more clearly identifies chromosomes that are damaged or that contain fragments of other, nonhomologous chromosomes.

Thanks to advances in computer technology and the Human Genome Project, digital karyotyping was developed in 2002. Unlike traditional karyotyping, digital karyotyping maps representative DNA fragments, known as "tags," and computationally models these tags to determine whether abnormalities are present in the sample. This genomic method is now being used for cancer research, among other applications.

Bibliography

A.D.A.M. Medical Encyclopedia. "Karyotyping." MedlinePlus, November 2, 2012.

Harris, Henry. The Cells of the Body: A History of Somatic Cell Genetics. Cold Spring Harbor, N.Y.: Cold Spring Harbor Laboratory Press, 1995.

Krogh, David. Biology: A Guide to the Natural World. 5th ed. San Francisco: Benjamin Cummings, 2010.

McGraw-Hill Concise Encyclopedia of Science and Technology. 6th ed. New York: McGraw-Hill, 2009.

National Human Genome Research Institute. "Frequently Asked Questions About Genetic Testing." National Institutes of Health, US Department of Health and Human Services, October 13, 2011.

National Human Genome Research Institute. "Spectral Karyotyping (SKY)." National Institutes of Health, US Department of Health and Human Services, April 30, 2013.

O'Connor, Clare. "Karyotyping for Chromosomal Abnormalities." Nature Education, 2008.

Tian-Li Wang, et al. "Digital Karyotyping: An Update of Its Applications in Cancer." Molecular Diagnosis & Therapy 10, no. 4 (2006): 231–237.

Vogel, F., and A. G. Motulsky. Vogel and Motulsky’s Human Genetics: Problems and Approaches. 4th rev. ed. New York: Springer, 2010.

What is Stachybotrys?

Definition

The pathogen
Stachybotrys is a mold that grows on wet cellulose-containing
materials. Stachybotrys produces a number of mycotoxins,
including several trichothecenes and a hemorrhagic protein called hemolysin.
Memnoniella
is a related fungus that has similar growth characteristics and
produces similar mycotoxins.

Natural Habitat and Features

Stachybotrys is a black or grey fungus (mold) with worldwide distribution. Stachybotrys grows on wet cellulose-containing material such as hay, leaves, paper, wood, wall board, textiles, rugs, drywall, and insulating materials. Stachybotrys is a fairly slow grower and may be overrun by other molds growing on cellulose-containing substrates.

Stachybotrys requires wet conditions to grow; however, Stachybotrys spores can remain dormant under dry conditions for several years and can resume active growth and mycotoxin production when water becomes available. The Stachybotrys mycotoxins can also retain their potency over several years without active Stachybotrys growth. Stachybotrys frequently grows in buildings that have been flooded by leaking pipes or toilets, rain infiltration, or natural disasters, including hurricanes.

Stachybotrys spores are often hard to grow in culture. Some studies have reported that cellulose-based media or cornmeal media is best for cultured Stachybotrys growth.

Stachybotrys spores are not as readily spread by air as are most mold spores. Several published studies have been unable to collect any airborne Stachybotrys spores, even though the buildings in question may be contaminated with many square meters of Stachybotrys growth. Relying on airborne samples only has led many indoor air investigators to falsely conclude that Stachybotrys was not growing in the structures under investigation. Because Stachybotrys spores are not readily dispersed in the air and are hard to grow in culture, all mold sampling studies that suspect Stachybotrys growth should take surface, tape, or building material samples from the building.

Pathogenicity and Clinical Significance

Localized Stachybotrys infections have been reported. Viable Stachybotrys was isolated from the lungs of a seven-year-old boy living in a water damaged farmhouse with heavy Stachybotrys growth. The boy, who experienced severe fatigue, chronic coughing, and lung hemorrhage, completely recovered after cleanup of his mold-infested home. Unpublished observations have reported Stachybotrys growth in nasal sinuses; however, the main health concerns are connected to the mycotoxins and allergens produced by Stachybotrys.

The Stachybotrys mycotoxins were first reported as contaminants of animal feed and human food. In the 1940’s, there were reports of domestic animals dying in the Soviet Union after eating Stachybotrys-infested hay. In later years, attention has been focused on humans who are exposed to high levels of Stachybotrys and its mycotoxins in indoor air and dust.

Stachybotrys produces a wide range of mycotoxins, including the
trichothecenes satratoxin, roridan, and deoxynivalenol. The amounts and types of
triochothecenes produced vary considerably depending on environmental conditions
and the Stachybotrys strain. The trichothecene mycotoxins damage
the immune and nervous systems, inhibit
protein
synthesis, and can cause vomiting. Animal studies have
reported that exposure to small amounts of trichothecenes can damage brain
cells.

Stachybotrys also produces a protein called hemolysin, which causes lung hemorrhage in nonhuman animals and may be linked to human lung hemorrhage. In the 1990’s, life-threatening lung hemorrhage was reported in ten infants in Cleveland, Ohio, who lived in water-damaged homes. Airborne levels of Stachybotrys, Aspergillus, and other molds were much higher in the homes of the infants with lung hemorrhage than in the control homes.

The allergens and mycotoxins from Stachybotrys can also worsen
asthma and nasal problems. Several studies have reported
that heavy indoor exposure to Stachybotrys and other molds is
associated with significantly poorer lung function and significant deficits in
many neuropsychiatric parameters, such as reaction times, color vision, memory,
concentration, grip strength, and vocabulary.

The ideal way to control Stachybotrys and its mycotoxins is to
prevent exposure to the mold. The best way to control
Stachybotrys growth is to prevent indoor water damage. All
cases of indoor water damage, standing water, or visible mold growth should be
cleaned within twenty-four hours to prevent growth of
Stachybotrys and other fungi and bacteria. For large cases of
water damages, one should contact a flood remediation company. Several guides are
available for mold remediation, including the U.S. Environmental Protection Agency’s
“Guide to Mold Remediation in Schools and Commercial Buildings” (available at
http://www.epa.gov/mold/mold_remediation.html).

Several studies have reported that clean up and water remediation of homes with heavy Stachybotrys growth are associated with less asthma, fatigue, and concentration and memory problems in the occupants of the contaminated home.

Drug Susceptibility

Because Stachybotrys does not appear to cause human infection, antifungal drugs are generally not used to treat persons who have been exposed to Stachybotrys. However, some studies have reported that the use of the bile-binding drug cholestryamine may be useful in speeding human excretion of trichothecene mycotoxins. Other research has suggested that eating a well-balanced diet that is high in antioxidants (vitamins A, C, and E, and l-carnitine and coenzyme Q10) can reduce the toxic effects of many mycotoxins.

Bibliography

Elidemir, Okam, et al. “Isolation of Stachybotrys from the Lung of a Child with Pulmonary Hemosiderosis.” Pediatrics 104 (1999): 964-966. A case report of viable Stachybotrys growing in the lungs of a seven-year-old boy.

Etzel, Ruth, et al. “Acute Pulmonary Hemorrhage in Infants Associated with Exposure to Stachybotrys atra and Other Fungi.” Archives of Pediatric and Adolescent Medicine 152 (1998): 757-762. This study reports on ten previously healthy infants who experienced sudden pulmonary hemorrhage. Airborne levels of Stachybotrys and Aspergillus were much higher in case homes versus control homes.

Kilburn, Kaye. “Neurobehavioral and Pulmonary Impairment in 105 Adults with Indoor Exposure to Molds Compared to 100 Exposed to Chemicals.” Toxicology and Industrial Health 25 (2009): 681-692. This paper provides thorough documentation that a group of 105 mold-exposed persons experienced significant deficits in lung function, reaction times, color vision, memory, grip strength, and vocabulary.

Samson, Robert, Ellen Hoesktra, and Jens Frisvad. Introduction to Food and Airborne Fungi. 7th ed. Utrecht, the Netherlands: Central Bureau for Fungal Cultures, 2004. This guide provides much information about Stachybotrys and many other indoor fungi. Includes useful identification keys, photographs, and diagrams.