What is neonatology?

Science and Profession

Neonatology has grown dramatically since its beginnings in the late 1960s, and neonatologists have become an integral part of the obstetric-pediatric team at major medical centers throughout the world. In addition to being cared for by physicians who specialize in neonatology, some neonatal infants, in particular those who are critically ill or premature, are cared for by nurse practitioners with the specialty certification of neonatal nurse practitioner (NNP). In large part because of an ever-expanding technological base and marked advances in scientific research, these health-care professionals have changed the outlook for premature and sick newborns.

As a subspecialty of pediatrics, neonatology is concerned with the most critical time of transition and adjustment—the first four weeks of life, known as the neonatal period—whether the infant is healthy (a normal birth) or sick (as a result of genetic problems, obstetric complications, or medical illness). By the early 1970s, it had become increasingly clear to health administrators that hospitals throughout the United States had varying abilities to care for medical and pediatric cases requiring the most sophisticated staff and equipment. Consequently, they developed a system that designated hospitals as either level I (small, community hospitals), level II (larger hospitals), or level III (major regional medical centers, also called tertiary care centers). It was in the last group that the most advanced neonatal care could be given. In these major centers, there are two types of nurseries: the routine nursery, for normal, healthy infants, and the neonatal intensive care unit (NICU), for sick or high-risk infants.

Routine nurseries are the temporary home of the vast majority of newborns. The services of the neonatologist are rarely needed here, and the general pediatrician or family practitioner observes and examines the infant for twenty-four to forty-eight hours to be sure that it has made a smooth transition from intrauterine to extrauterine life. These babies soon leave the hospital for their homes. Those neonates with minor problems arising from multiple births, difficult deliveries, mild prematurity, or minor illnesses are easily managed by a primary care physician in consultation with a neonatologist, perhaps at another hospital.

It is in the NICU that the most difficult situations present themselves. Here, several teams of pediatric subspecialists—surgeons, cardiologists, anesthesiologists, and highly trained nurses, along with many other health professionals—are led by a neonatologist, who coordinates the team’s efforts. These newborns have life-threatening conditions, often as a result of extreme prematurity (more than six weeks earlier than the expected date of delivery), major birth defects (genetic or developmental), severe illnesses (such as overwhelming infections), or being born to drug- or alcohol-addicted mothers. They require the most advanced technological and medical interventions, often to sustain life artificially until the underlying problem is corrected. It is in this setting that the most dramatic successes of neonatology are found.

After hours of being inside a forcefully contracting uterus and sustaining the stress of passing through a narrow birth canal, the newborn emerges into a dry, cold, and hostile environment. The umbilical cord, which has provided oxygen and nutrients, is clamped and cut; the fluid-filled lungs must now exchange air instead, and the respiratory center of the infant’s brain begins a lifetime of spontaneous breathing, usually heralded by crying. The vast majority of neonates make this extraordinary adjustment to extrauterine life without difficulty. The newborn is evaluated, first at one minute and again at five minutes after birth, and scored on five physical signs: heart rate, breathing, muscle tone, reflexes, and skin tone. These Apgar scores, named for neonatology pioneer Virginia Apgar, evaluate the need for immediate resuscitation. A brief physical examination follows, which can identify other life-threatening abnormalities.

It is essential to remember that the medical history of a neonate is in fact the medical and obstetric history of its mother, and seemingly normal infants may develop problems shortly after birth. Risk factors include very young or middle-aged mothers; difficult deliveries; babies with Rh-negative blood types; mothers with diabetes mellitus, kidney disease, or heart disease; and concurrent infections in either the mother or the baby. Anticipating these problems of the healthy newborn by using the Apgar scores and the results of the physical examination allows the proper assignment of the infant to the nursery or NICU.

The NICU is a daunting place containing high-tech equipment, a tangle of wires and tubes, the sounds of beeps and alarms, and tiny, fragile infants. All this technology serves two simple purposes: to monitor vital functions and to sustain malfunctioning or nonfunctioning organ systems. Looked at individually, however, the machines and attachments become much more understandable. The incubator, perhaps the most common device, maintains a warm, moist environment of constant temperature at 37 degrees Celsius (98.6 degrees Fahrenheit). Small portholes with rubber gloves allow people to touch the child safely. Generally, the infants will have small electrodes taped on their chests, connected to video monitors that record the heart and breathing rates and that will sound alarms if significant deviations occur. These monitors will also record blood pressure through an arm or thigh cuff. To ensure immediate access to the blood, for delivering medications and taking blood for testing, catheters (plastic tubes) are placed into larger arteries or veins near the umbilicus, neck, or thigh (in adults, intravenous access is found in the arms).

The remaining equipment is used for the very serious business of life support, in particular the support of the respiratory system. Maintaining adequate oxygenation is critical and can be accomplished in several ways, depending on the baby’s needs. The least stressful are tubes placed in the nostrils or a face mask, but these methods require that breathing be spontaneous although inadequate. More often, unfortunately, neonates with the types of problems that bring them to an intensive care unit cannot breathe on their own. In these cases, a tube must be connected from the artificial respirator into the windpipe (the endotracheal tube). Warm, moistened, oxygen-rich air is delivered under pressure and removed from the lungs rhythmically to simulate breathing. Tranquilizers and paralytic agents are used to calm and immobilize the infant. Sick or premature infants are also generally unable to feed or nurse naturally, by mouth. Again, several methods of feeding can be employed, depending on the problems and the length of time that such feedings will be needed. For the first few days, simple solutions of water, sugar, and protein can be given through the intravenous catheters. These lines, because of the very small, fragile blood vessels of the newborn, are seldom able to carry more complex solutions. A second method, known as gavage feeding, employs tubing that is inserted through the nose directly into the stomach. Through that tube, infant formula (water, sugar, protein, fat, vitamins, and minerals) and, if available, breast milk can be given.

As the underlying problems are resolved, the infant is slowly weaned, first feeding orally and then breathing naturally. Next, the infant will be placed in an open crib, and gradually the tangled web of tubes and wires will clear. With approval from the neonatologist, the baby is transferred to the routine nursery, a transitional home until discharge from the hospital is advisable.

Diagnostic and Treatment Techniques

Neonatology has amassed an enormous body of knowledge about normal neonatal anatomy and physiology, disease processes, and, most importantly, how to manage the wide variety of complications that can occur. Specific treatment protocols have been developed and are practiced uniformly in all NICUs. Short-term stays (twenty-four to forty-eight hours) are meant to observe and monitor infants with respiratory distress at birth that required immediate intervention. Long-term stays, lasting from several weeks to months, are the case for the sickest newborns, most commonly those with severe prematurity and low birth weight (less than 1,500 grams), respiratory distress syndrome (also known as hyaline membrane disease), congenital defects, and drug or alcohol addictions.

Infants born prematurely make up the majority of infants at high risk for disability and death, and each passing decade has seen younger and younger babies being kept alive. While many maternal factors can lead to preterm delivery, often no explanation can be found. The main problem of prematurity lies in the functional and structural immaturity of vital organs. Weak sucking, swallowing, and coughing reflexes lead to an inability to feed and a danger of choking. Lungs that lack surfactant, a substance that coats the millions of tiny air sacs (alveoli) in each lung to keep them from collapsing and sticking together after air is exhaled, cause severe breathing difficulty as the infant struggles to reinflate the lungs. When premature delivery is inevitable but not immediate, lung maturity can be increased by administration of steroids to the mother. An immature immune system cannot protect the newborn from the many viruses, bacteria, and other microorganisms that exist. Inadequate metabolism causes low body temperature and inadequate use of food or medications. Neurological immaturity can lead to intellectual or developmental disabilities, blindness, and deafness.

Aggressive management of the preterm baby begins in the delivery room, with close cooperation between the obstetrician and the neonatologist. Severely preterm infants, some born after only twenty weeks of pregnancy, require immediate respiratory and cardiac support. Placement of the endotracheal tube, assisted ventilation with a handheld bag, and delicate chest compressions similar to the cardiopulmonary resuscitation (CPR) performed on adults to stimulate the heartbeat are each accomplished quickly. Once the respiratory and circulatory systems have been stabilized, excess fluid will be suctioned, while a brief physical examination is performed to note any abnormalities that require immediate attention. As soon as transport is considered safe, the newborn is sent to the NICU. If the infant has been delivered at a small community hospital, this may involve ambulance or even helicopter transport to the nearest tertiary care center.

Once in the unit, the neonate will be placed in an incubator and attached to video monitors that record heart rate, breathing, and blood pressure. The endotracheal tube can now be attached to the respirator machine, and intravenous or intra-arterial catheters will be placed to allow the fluid and medication infusions and the blood drawing for the battery of tests that the neonatologist requires. Feeding methods can be set up as soon as the infant has stabilized. Within a short time after delivery, the premature newborn has had a flurry of activity about it and is surrounded by the most sophisticated equipment and staff available. Supporting the immature organs becomes the first priority, although the ethical issues of saving very sick infants must soon be addressed as complications begin to occur. Nearly 15 percent of surviving preterm infants with a birth weight of less than two thousand grams have serious physical and mental disabilities after discharge. The majority, however, grow to lead normal, healthy lives.

Congenital defects are common, and it is estimated that the majority of miscarriages are a direct result of congenital defects that are incompatible with life. Many infants that do survive development and delivery die shortly after birth despite the most sophisticated and heroic attempts to intervene. The causes of such defects are arbitrarily assigned to two broad categories, although a combination of these factors is the most likely explanation: genetic errors (such as breaks, doubling, and mutations) and environmental insults (such as chemicals, drugs, viruses, radiation, and malnutrition). In the United States, the most common birth defects that require immediate intervention include heart problems, spina bifida (an open spine), and tracheoesophageal fistulas and esophageal atresias (wrongly connected or incomplete wind and food pipes).

The birth of a malformed infant is rarely expected, and the neonatologist’s team plays a key role in its survival. Congenital heart disease is the most prevalent life-threatening defect. During development in utero, the umbilical cord supplies the necessary oxygen; it is not until birth, when that lifeline is cut, that the neonate’s circulatory and respiratory systems acquire full responsibility. At delivery, all may appear normal, and the one-minute Apgar score may be high. Several minutes later, however, the pink skin color may begin to darken to a purplish blue (cyanosis), indicating that insufficient oxygen is being extracted from the air. Immediately, the infant receives rescue breathing from the bag mask. Upon admission to the neonatal unit, the source of the cyanosis must be determined. A chest x-ray may provide significant information about the anatomy of the heart and lungs, but special tests are usually needed to pinpoint the problem. Catheters that are threaded from neck or leg vessels into the heart can reveal the pressure and oxygen content of each chamber in the heart and across its four valves. Echocardiograms, video pictures similar to sonograms generated by sound waves passing through the chest, enhance the data provided by the x-rays and catheterizations, and a diagnosis is made. Based on the physical signs and symptoms of the newborn, a treatment plan is devised.

Because of the nature of congenital defects and structural abnormalities, their correction generally requires surgery. Openings between the heart’s chambers (septal defects), valves that are too narrow or do not close properly, and blood vessels that leave or enter the heart incorrectly are all common defects treated by the pediatric heart surgeon. Because of the delicacy of the operation and the vulnerability of the newborn, surgery may be postponed until the baby is larger and stronger while it is provided with supplemental oxygen and nutrients. The risk of such operations is high, and depending on the degree of abnormality, several operations may be required.

Another group of infants who have benefited from advances in neonatology are those born to drug-addicted women. The lives of these infants are often complicated by congenital defects and life-threatening withdrawal symptoms. For example, heroin-addicted babies are quite small, are extremely irritable and hyperactive, and develop tremors, vomiting, diarrhea, and seizures. The newborn must be carefully monitored in the unit, and sedatives and antiseizure medications are given, sometimes for as long as six weeks. Cocaine and its derivatives frequently cause premature labor, fetal death, and maternal hemorrhaging during delivery. Infants that do survive often have serious congenital defects and suffer withdrawal symptoms. The risk of acquired immunodeficiency syndrome (AIDS) adds another dimension to an already complicated picture.

Perspective and Prospects

Throughout human history, maternal and neonatal deaths have been staggering in number. Ignorance and unsanitary conditions frequently resulted in uterine hemorrhaging and overwhelming infection, killing both mother and baby. Highly inaccurate records from the beginning of the twentieth century in New York City show maternal death rates averaging 2 percent; in fact, the rate was probably greater, since most births occurred at home. Neonatal deaths from respiratory failure, congenital defects, prematurity, and infection loom large in these medical records. The expansion of medical, obstetric, and pediatric knowledge and technology that began after World War II has dramatically lowered maternal and infant mortality. It should not be forgotten, however, that nonindustrialized nations, the majority in the world, remain devastated by the neonatal problems that have plagued civilization for thousands of years.

Ironically, the problems associated with neonatology in Western nations are now at the other end of the spectrum: saving and prolonging life beyond what is natural or “reasonable.” As neonatology advanced scientifically and technically, saving life took precedence over ethical issues. The famous and poignant story of Baby Doe in the early 1980s illustrates the dilemmas that occur daily in neonatal intensive care units. Baby Doe was a six-pound, full-term male born with Down syndrome and severe congenital defects of the heart, trachea, and esophagus. These malformations were deemed surgically correctable, although the underlying problem of Down syndrome, a disease characterized by intellectual disabilities and particular facial and body features, would remain. The parents did not agree to any operations and requested that all treatment be withheld. Baby Doe was given only medication for sedation and died within a few days. The case was later related by the attending physician in a letter to the New England Journal of Medicine, sparking enormous controversy. On July 5, 1983, a law was passed in effect stating that all newborns with disabilities, no matter how seriously afflicted, should receive all possible life-sustaining treatment unless it is unequivocally clear that imminent death is inevitable or that the risks of treatment cannot be justified by its benefit. The legislators believed that Baby Doe had been allowed to die because of his underlying condition of Down syndrome.

Since then, attorneys, ethicists, juries, and courts have used the example of Baby Doe, and the law that grew from it, to interpret many cases that have come to light. Life-and-death decisions are made on a daily basis in the neonatal care unit. They are always difficult, but they usually remain a private matter between the parents and the neonatologist. These cases become public matters, however, when the family disagrees with the medical staff. Then the question of what is in the best interest of the child is compounded by who will pay for the treatments and who will care for the baby after it is discharged.

Such ethical dilemmas will continue as expertise and technology grow. A multitude of questions, previously relegated to philosophy and religion, will arise, and the benefits of saving a life will have to be weighed against its quality and the resources necessary to maintain it.

Bibliography

Behrman, Richard E., Robert M. Kliegman, and Hal B. Jenson, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia: Saunders, 2007. Print.

Bradford, Nikki. Your Premature Baby: The First Five Years. Toronto: Firefly, 2003. Print.

Crisp, Stuart, and Jo Rainbow, eds. Emergencies in Paediatrics and Neonatology. 2nd ed. Oxford: Oxford UP, 2013. Print.

Cunningham, Nicholas, ed. Columbia University College of Physicians and Surgeons: Complete Guide to Early Child Care. New York: Crown, 1990. Print.

Gomella, Tricia Lacy. Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. 7th ed. New York: McGraw, 2013. Print.

Levin, Daniel L., and Frances C. Morriss, eds. Essentials of Pediatric Intensive Care. 2nd ed. New York: Churchill, 1997. Print.

MacDonald, Mhairi G., Mary M. K. Seshia, and Martha D. Mullett, eds. Avery’s Neonatology: Pathophysiology and Management of the Newborn. 6th ed. Philadelphia: Lippincott, 2005. Print.

Martin, Richard J., Avroy A. Fanaroff, and Michele C. Walsh, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 10th ed. 2 vols. Philadelphia: Saunders, 2015. Print.

Meeks, Maggie, Maggie Hallsworth, and Helen Yeo, eds. Nursing the Neonate. 2nd ed. Malden: Wiley, 2013. Print.

Moore, Keith L., T. V. N. Persaud, and Mark G. Torchia. The Developing Human: Clinically Oriented Embryology. 9th ed. Philadelphia: Saunders, 2013. Print.

Ruhlman, Michael. Walk on Water: Inside an Elite Pediatric Surgery Unit. New York: Viking, 2003. Print.

Sadler, T. W. Langman’s Medical Embryology. 12th ed. Baltimore: Lippincott, 2012. Print.

Sinha, Sunil, Lawrence Miall, and Luke Jardine. Essential Neonatal Medicine. 5th ed. Malden: Wiley, 2012. Print.

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

What is blindness?

Causes and Symptoms

The major cause of blindness among older adults in the Western world is
glaucoma. The aqueous fluid produced inside the eye fails to drain properly and causes pressure to build up. In extreme cases, the eyeball becomes hard. Without prompt treatment, the outer layer of the optic nerve starts to deteriorate. The patient can still see straight ahead but not off to the side. When the cone of forward vision has narrowed to less than 20 degrees (called tunnel vision), the patient is considered legally blind.

Cataracts
are another common defect of vision among the elderly. The lens of the eye develops dark spots that interfere with light transmission. Cataracts are not caused by an infection or a tumor but instead are a normal part of the aging process, like gray hair. There is no known treatment to retard or reverse the growth of cataracts, though they may be surgically removed.

Macular degeneration
and diabetes mellitus
can cause blindness as a result of hemorrhages from tiny blood vessels in the retina. The macula is a small region in the middle of the retina where receptor
cells are tightly packed together to obtain sharp vision for reading or close work. With aging, blood circulation in the macula gradually deteriorates until the patient develops a black spot in the center of the field of view. Advanced diabetes also causes blood vessel damage in the eye. In serious cases, fluid can leak behind the retina, causing it to become detached. The resulting visual effect resembles a dark curtain that blacks out part of the scene.

Trachoma
is a blinding eye disease that afflicts millions of people in poor parts of the world. It is a contagious infection of the eyelid similar to conjunctivitis (commonly known as pinkeye). If untreated, it causes scarring of the cornea and eventual blindness. Trachoma is caused by a virus that is spread by flies, in water, or by direct contact with tears or mucus.

Many kinds of injuries may cause blindness. Car accidents, sports injuries, chemical explosions, battle wounds, and small particles that enter the eye all can result in a serious loss of vision.

Treatment and Therapy

An indispensable tool in the treatment of serious eye problems is the laser. Its intense light focused into a tiny spot, the laser’s heat can burn away a ruptured blood vessel or weld a detached retina back into place. For
glaucoma patients, medication to reduce fluid pressure in the eye may be effective for a while. Eventually, a laser can be used to burn a small hole through the iris in order to improve fluid drainage. The laser can be used only to prevent blindness, however, and not to restore sight.

Cataracts formerly were a major cause of blindness among older people. Once the eye lens starts to become cloudy, nothing can be done to clear it. Cataract surgery to remove the defective lens and to insert a permanent, plastic replacement has become common. In the United States, more than a million cataract surgeries are performed annually, with a success rate that is greater than 95 percent.

The infectious eye disease called
trachoma has been known for more than two thousand years. Effective modern treatment uses sulfa drugs taken orally, combined with antibiotic eyedrops or ointments. Unfortunately, reinfection is common in rural villages where most people have the disease and sanitation is poor. The World Health Organization has initiated a public health program to teach parents about the importance of cleanliness and frequent eye washing with sterilized water for their children.

Perspective and Prospects

Various techniques have been developed for helping sightless people to live a self-reliant lifestyle. Using a white cane or walking with a trained dog allows a blind person to get around. Biomedical engineers have designed a miniature sonar device built into a pair of glasses that uses reflected sound waves to warn the wearer about obstacles.

The Braille system of reading, using patterns of raised dots for the alphabet, was invented in 1829 and is still widely used. For blind students, voice recordings of textbooks, magazines, and even whole encyclopedias are available on tape. A recent development is an optical scanner connected to a computer with a voice simulator that can read printed material aloud.

The National Federation of the Blind was founded in 1940. Its goals are to assist the blind to participate fully in society and to overcome the still-prevalent stereotype that the blind are helpless. Blind men and women hold jobs as engineers, teachers, musical performers, ministers, insurance agents, computer programmers, and school counselors. As society becomes more sensitive to all forms of disability, opportunities for blind people continue to expand.

Bibliography:

American Foundation for the Blind (AFB). AFB, 2013.

Buettner, Helmut, ed. Mayo Clinic on Vision and Eye Health: Practical Answers on Glaucoma, Cataracts, Macular Degeneration, and Other Conditions. Rochester, Minn.: Mayo Foundation for Medical Education and Research, 2002.

Johnson, Gordon J., et al., eds. The Epidemiology of Eye Disease. 2d ed. New York: Oxford UP, 2003.

Maurer, Marc. “Reflecting the Flame.” Vital Speeches of the Day 57 (Sept. 1, 1991): 684–90.

MedlinePlus. "Cataract." MedlinePlus, Mar. 20, 2013.

MedlinePlus. "Vision Impairment and Blindness." MedlinePlus, Apr. 2, 2013.

Morrison, John C., and Irvin P. Pollack. Glaucoma: Science and Practice. New York: Thieme, 2003.

National Federation of the Blind. NFB, 2013.

Peninsula Center for the Blind. The First Steps: How to Help People Who Are Losing Their Sight. Palo Alto, Calif.: Peninsula Center, 1982.

Sardegna, Jill, et al. The Encyclopedia of Blindness and Vision Impairment. 2d ed. New York: Facts On File, 2002.

Westcott, Patsy. Living with Blindness. Austin, Tex.: Raintree, 2000.

How does Act 5 Scene 1 give insight into the main themes of Macbeth?

Act 5, Scene 1, is the scene were Lady Macbeth sleepwalks and seems to struggle with her guilt over the monster that her husband has become.  She seems to lament Lady Macduff's death, a brutal act about which her husband did not even consult her.  Although Lady Macbeth had everything to do with Duncan's murder, she seems to be struggling now, wondering "who would have thought the old man to have so much blood in him?" (5.1.41-42).  Lady Macbeth seems to be reliving the night on which they murdered Duncan when she, ironically, told Macbeth not to dwell on what they'd done because it would drive them mad.  Now, her guilt seems to be doing just that -- making her crazy -- and so this scene helps to develop the themes of guilt and madness in the play. 

Further, the doctor says that "Unnatural deeds / Do breed unnatural troubles" (5.1.75-76).  In killing a king (while he slept), the Macbeths have committed a crime against nature; even Macbeth was afraid that he would never be able to sleep peacefully again, and now it is Lady Macbeth who cannot sleep peacefully because of their crime.  Thus, this scene helps to develop the theme of unnatural crimes and their effect on those who commit them.

What are some allusions in Chapter One of A Separate Peace by John Knowles?

An allusion is a reference made to someone or something that the reader, or a character, might know or understand. This helps to extract familiar knowledge about a topic and apply it to the story at hand to understand a specific point or theme more profoundly. For example, in Chapter One of A Separate Peace, Gene walks down Gilman Street and describes it for the reader. He says the following:

"The houses were as handsome and as unusual as I remembered. Clever modernizations of old Colonial manses, extensions in Victorian wood, capacious Greek Revival temples line the street" (10).

The above passage alludes to three different historical time periods in an effort to describe the setting and what the houses look like. 

Next, when Gene finds the infamous tree from which he and Phineas jumped so many times that summer of 1942, he says the following:

"It had loomed in my memory as a huge lone spike dominating the riverbank, forbidding as an artillery piece, high as the beanstalk" (13).

With this description there are a couple of similes that help the allusion develop fully. First, "an artillery piece" refers to an offensive piece of military hardware or a battlement. This is a strong, and possibly violent, reference to war or fighting. Then, the allusion to "the beanstalk" refers to the familiar tale of "Jack and the Beanstalk." This brings to mind an image of a very tall, powerful, and almost immeasurable plant. 

A third allusion in Chapter One is made when Phineas and Gene are hurrying back for dinner. They are about to be late if they don't hurry, so Gene starts to walk faster. Phineas calls this Gene's "West Point stride" (18). West Point is the United States' military academy. This reference brings to mind soldiers obediently, stiffly, but probably quickly falling into line without completely running.

What is fracture repair?

Indications and Procedures

A fracture is a break in a bone, either partial or complete, resulting from an applied force that is greater than the bone’s internal strength. The most common causes of fractures are accidents and trauma.

Fractures are usually treated by reduction and immobilization. Reduction, which may be either closed or open, refers to the process of returning the fractured bones to their normal position. Closed reduction is accomplished without surgery by manipulating the broken bone through overlying skin and muscles. Open reduction requires surgical intervention. The broken pieces are exposed and returned to their normal positions. Orthopedic appliances may be used to hold the bones in the proper position (internal fixation); the most common appliances are stainless-steel pins and screws, but metal plates and wires may also be employed. These devices can be left in the body indefinitely or may be surgically removed after healing is complete. Local anesthesia is usually used with closed reductions; open reductions are performed in an operating room under sterile conditions, using general anesthesia.

After reduction, the broken bone and accompanying body part must be placed in an anatomically neutral position. Immobilization is generally accomplished by the use of a cast. Casts are usually made of plaster, but they may be constructed of inflatable plastic.

Individual ends of a single fractured bone are sometimes held in position by external pins and screws (external fixation). Holes are drilled through the bone, and pins are inserted as described above. The pins on opposite sides of the fracture site are then attached to each other with threaded rods and locked in position by nuts. This process allows a fractured bone to be immobilized without using a cast.

Traction, the external application of force to overcome muscular resistance and hold bones in a desired position, may also be used to immobilize a fracture. Commonly, holes are drilled through bones and pins are inserted; the ends of these pins extend through the surface of the skin. Part of the body is fixed in position through the use of a strap or weights. Wires are attached to the pins in the body part to be stretched. Force is applied to the wires via weights or tension until the broken bone parts are in the desired position. Traction is maintained until complete healing has occurred.

Uses and Complications

All broken bones must be held in position until healing takes place. The complications associated with repairing fractures include infection, which is rare, and loss of function. The potential for loss of function is minimized by placing the limb in an anatomically neutral position prior to the application of a cast.

The techniques of fracture repair have not changed radically in decades. New methods, however, are being tried. For example, electromagnetic fields are used with fractures that do not heal spontaneously. Such fields induce the growth of osteoblasts, which are bone-forming cells.

Bibliography

Browner, Bruce D., et al. Skeletal Trauma: Basic Science, Management, and Reconstruction. 4th ed. Philadelphia: Saunders/Elsevier, 2009.

Eiff, M. Patrice, and Robert L. Hatch. Fracture Management for Primary Care. 3d ed. Philadelphia: Saunders/Elsevier, 2012.

“Fractures.” MedlinePlus, May 15, 2013.

Gregg, Paul J., Jack Stevens, and Peter H. Worlock. Fractures and Dislocations: Principles of Management. Cambridge, Mass.: Blackwell Science, 1996.

Gustilo, Ramon B., Richard F. Kyle, and David C. Templeman, eds. Fractures and Dislocations. St. Louis, Mo.: Mosby, 1993.

“Helping Fractures Heal (Orthobiologics).” OrthoInfo, January 2010.

Hodgson, Stephen F., ed. Mayo Clinic on Osteoporosis: Keeping Bones Healthy and Strong and Reducing the Risk of Fractures. Rochester, Minn.: Mayo Clinic, 2003.

Magee, David J. Orthopedic Physical Assessment. 5th ed. St. Louis, Mo.: Saunders/Elsevier, 2008.

Ruiz, Ernest, and James J. Cicero, eds. Emergency Management of Skeletal Injuries. St. Louis, Mo.: Mosby, 1995.

Salter, Robert Bruce. Textbook of Disorders and Injuries of the Musculoskeletal System. 3d ed. Baltimore: Williams & Wilkins, 1999.

How did Bruno and Shmuel's friendship benefit Shmuel?

Shmuel benefited greatly from his friendship with Bruno throughout the novel. Shmuel mentions to Bruno that the majority of the children in the concentration camp are unhappy, and not friendly. Bruno's friendship provides Shmuel emotional relief which allows Shmuel an opportunity to engage in friendly conversation and vent his frustrations while imprisoned at Auschwitz. Shmuel suffers from malnutrition and is constantly hungry. Bruno, who has access to plenty of food, brings Shmuel bread and cheese to eat when he visits him. The food that Bruno brings has a nutritional value which benefits Shmuel. Also, towards the end of the novel Shmuel asks Bruno if he can help him find his father. Bruno offers to help Shmuel search for his father, which is a risky task on Bruno's part. Bruno provides support for his friend by sneaking under the fence and helping Shmuel look for his father. Although the boys do not find Shmuel's father, their close friendship provides both boys with a sense of belonging and gratification to an otherwise bleak situation.

What are Christian and Faithful willing to buy at Vanity Fair? What does this suggest about their values?

Christian and Faithful entered Vanity Fair and were immediately recognized as outsiders by their speech, dress, and behavior. They were offered many valuable goods that were on display at the Fair, but Christian and Faithful refused to even look at them. They were not willing to buy anything. This shows that they were not tempted by riches or material possessions. There was nothing there that could add to their happiness. This shows that their attention was on Heaven and Christ. The only goods they desired were spiritual goods, whatever could increase their faith. They were willingly to buy only Truth. The falseness of material goods was not in any way a part of the Truth. Where their treasure was, there was their heart, and their treasure was in Heaven.

Why did Leper spend the night on Mt. Katahdin in Maine?

Leper Lepellier is the oddball or misfit of the group of boys at Devon school in 1942-1943. He is very interested in nature and experiencing the outdoors in a peaceful way. He's usually in his own little world because of his unusual interests. For example, he likes to cross-country ski, look at snails, and find beaver dams, whereas the other boys his age are interested in sports. Gene says that Leper has many vagaries, or unpredictable, random acts of weirdness that no one really understands. In chapter nine, Gene explains Leper with this example:

". . . such as the time he slept on top of Mount Katahdin in Maine where each morning the sun first strikes the United States territory. On that morning, satisfying one of his urges to participate in nature, Leper Lepellier was the first thing the rising sun struck in the United States" (124).

This passage shows that Leper has random ideas that he follows through with on a whim. He's also an idealist and very naïve. He doesn't seem to think through his ideas before he acts on them, either. Later, this behavior gets Leper in trouble as he is unprepared mentally for enlisting in the army and suffers a mental breakdown.

Describe Miss Emily's house by the time of her death.

Before her death, Miss Emily stopped giving painting lessons at her house, and she essentially closed it off to everyone except for herself and her servant.

By the time of her death, Emily's house is in a state of utter decay, and as such it functions as a symbol of the dying traditions she had clung to in her life.

Let's take a look at some details that show how shabby, dusty, and dilapidated Emily's home had become:

1.  "Now and then we would see her in one of the downstairs windows--she had evidently shut up the top floor of the house--..."

The fact that Emily seems to have closed off the entire upper level before her death reveals that the home is "dying," or that it's in a state of disuse. Of course, we find out later that she was--brace yourself--keeping the dead body of her lover upstairs, so the upper level was quite literally a place for the dead.

2. "And so she died. Fell ill in the house filled with dust and shadows..."

Here we see that "dust and shadows" pervaded her home. Both dust and shadows are remnants or vestiges of what is no longer in existence, so they're appropriate symbols for the dying Southern ideals that Emily struggled to hold onto.

3. "She died in one of the downstairs rooms, in a heavy walnut bed with a curtain, her gray head propped on a pillow yellow and moldy with age and lack of sunlight."

The "yellow and moldy" pillow is, we're told, is not just old but has also been kept in the dark.

4. "A thin, acrid pall as of the tomb seemed to lie everywhere upon this room ... upon the valance curtains of faded rose color, ... the man's toilet things backed with tarnished silver, ... a collar and tie, as if they had just been removed, which, lifted, left upon the surface a pale crescent in the dust."

Above are the most relevant parts of the description of the upper room into which the townspeople finally gain access. Here, the descriptive details of decay and rotting hit their climax. "Acrid pall of the tomb" is self-explanatory, but notice also how the color of the curtains is "faded," how the silver of the toiletry items is "tarnished," and how when some other items are picked up, they leave a "pale crescent in the dust."

In Of Mice and Men, what evidence can prove that George feels guilty for Lennie's death?

George's actions after shooting Lennie reflect a sense of guilt.

George experiences a great deal of guilt after shooting Lennie. His actions show remorse for what he has done. When looking at the gun, George "threw it from him, back up on the bank, near the pile of old ashes." As he "shivered," George rids himself of the weapon, wanting to get rid of it and eliminate it from memory. He is not proud of what he has done, and his reaction towards the gun reflects the shame he feels about it.

When the other men approach George, he speaks and carries himself in a manner that reflects guilt. For example, when Carlson approaches George and asks him to describe what happened, George speaks "tiredly." This shows how guilt has caused emotional fatigue in George's heart. As Carlson continues to question him, George's voice "was almost a whisper." Later on in the exchange, Steinbeck writes that George "looked steadily at his right hand that had held his gun." Like Lady Macbeth, who wants to rid herself of that "spot," George stares at the hand that pulled the trigger, and feels regret about it. When Slim has to steady George at the end of the novella, it is only because his shakiness reflects guilt over what he did to his best friend.

What does Sheila promise to take off from the booklet in Judy Blume's Tales of a Fourth Grade Nothing?

In Chapter 7 of Judy Blume's Tales of a Fourth Grade Nothing, Sheila agrees to take off the line she added to the cover of their booklet that reads "handwritten by miss sheila tubman."

In Chapter 7, Peter has been assigned to work on a group project with two of his classmates who live near him, Jimmy Fargo and Sheila Tubman. Their project is to make a poster, write a booklet, and present an oral report about transportation in New York City. At one point, they agree the boys should each write five pages of the booklet while Sheila does the other ten. Peter raises the concern that, if this is to be a group project, all the handwriting in the booklet should look the same—it shouldn't be obvious which kid did what part of the project. Sheila agrees that, since she has the best handwriting, she should copy all of their written work into the one booklet.

On the day Sheila makes the cover for their booklet during one of their after-school meetings, Jimmy notices that, though Sheila put all their names on the cover of the booklet, she also gave herself special recognition by identifying herself as the one wrote the booklet by hand. Jimmy and Peter are furious because they had all agreed that, if it was to be a group project, they should each get the exact same credit as the other members of the group. Sheila objects at first, but when Jimmy threatens to rip up the cover, she finally agrees and turns the line that reads "handwritten by miss sheila tubman" into a decoration of "sixteen small flowers" (50).

What is the difference between the concept of marketing and the marketing concept?

There are five different concepts of marketing, and one of those is the marketing concept.  The other four concepts of marketing include the production concept, the product concept, the selling concept, and the social marketing concept. 

The marketing concept focuses on a firm evaluating the needs of the market, or consumers, and meeting consumers needs better than the competition. The production concept is based on putting goods and services into the market in large quantities and are relatively inexpensive.  This concept may apply to some superstores, like Wal-Mart. The product concept is that consumers will want a good or service for its quality, name, innovation or reputation. A good example of the product concept in the market is the iPod.

The selling concept is the idea that consumers will want only those products that are heavily sold to them. For example, a door to door vacuum cleaner salesman is following the selling concept. The social marketing concept focuses on the health and well-being of the individual. The social marketing concept attempts to change beliefs and behaviors of consumers to interest them in new goods and services, and may also simultaneously try to convince consumers other goods and services are undesirable. An example of social marketing is drinking sugar-free drinks versus sugary drinks. 

How is religion used to justify the acts of terrorists?

Morals are sets of principles that guide human actions for the purpose of attaining a goal that can be said to be good or beneficial. The deepest morals cover the most basic topics such as a right to life, the avoidance of dishonesty, and the rights of people to own things without fear of having them taken without cause. Many people are in agreement about these basic morals as they are beneficial to all. This mutual agreement is known as the Social Contract. This might encompass an agreement not to kill, in order to avoid being killed, or an agreement not to steal, in order to avoid being the target of theft.

Religions teach that the underlying goal of morality is the appeasement of a higher being or God. This is what is ultimately considered good. Religions adopt a more absolutist belief system than what is present in the secular Social Contract.

When morals appear to be in conflict, an ethical dilemma occurs, which needs to be resolved before action can be taken. Under the social contract, it is popular to identify which course of action is a "greater good," which means the action that will best serve the goal of the deepest morals. Therefore, it is better to steal than to kill; it is better to kill one innocent than to kill twenty innocents.

Religions sometimes do not adhere to this form of ethical logic, always holding paramount the need to honor God and casting aside any other course of action that can be seen as not honoring God. Therefore, when a religion has a violent precedent in its history and has beliefs that God at some time called people to behave violently, it is easy for members of such a religion to justify violence as bringing honor to God. There is no ethical dilemma in their minds as they do not see killing in this situation as bad. While in the secular world a choice to kill in a situation is often seen as a lesser of two evils, to a terrorist killing may not be an evil at all, so long as they are doing it in the name of their God.

What is one attitude that can be considered the key to conflict resolution?

Conflict is an inevitable part of any relationship, be it in the work place, at home, or even on the street with complete strangers. Conflict resolution is not as inevitable, but it is essential to maintaining one's overall health and mental well-being. Many companies have conflict resolution policies, a designated set of steps to follow in the event a conflict occurs. Families may also have an informal/unspecified conflict resolution "policy," based on the values and demographics of the family. Whatever the environment is in which the conflict occurs, there is one attitude that can be considered key in all conflict resolution situations: having the willingness to see the other side of the issue. 

It's human nature to desire to be understood and validated. When a conflict occurs, it happens most often because Person A and Person B each believe themselves to be right, and the other to be wrong. If neither is willing to see the other person's side, the conflict can escalate quickly. No one wants to be in the wrong, so both people stand their ground and refuse to acknowledge the possibility that the other person could be right. 

With an attitude of willingness to see the other side, however, the path to conflict resolution can be faster and easier. If the people involved ask questions to clarify the position of the other side, rather than focusing solely on stating their own position, everyone learns. For example:

Person A: I can't believe you went over my head and emailed the boss about that! (This is not a question, and can immediately put Person B on the defensive.)

Instead:

Person A: You emailed the boss rather than coming to me first; why did you feel like that was the only course of action?

Person A has communicated, through the second question, a willingness to hear Person B speak. Person B can then respond in kind. 

Rather than, 

Person B: Because you never listen to what I have to say! (Again, not a question, so Person A's only response is one of defense.) 

Person B could say,

Person B: If I had emailed you directly, what would you have said? 

Giving the other person the opportunity to speak can open up lines of communication and show a willingness to see the other person's side of the issue; this is a key element in conflict resolution. 

All people desire to feel heard and to have their values and position on an issue at least appear to be considered. When people involved in a conflict ask questions and listen to the opposing position, they invite the opportunity to learn and to resolve a conflict much faster. 

How much can we trust the validity of Victor’s story in Frankenstein?

Victor seems, in many ways, like a reliable narrator, so we can trust that the bulk of his narrative is true.  One of the things that makes him so reliable is the fact that he continues to claim that he has done nothing wrong. Although he, at times, professes to feeling great guilt at various stages of his life, at other times -- especially in the end -- he argues that there has been nothing unethical about his behavior.  In his final hours, he tells Captain Walton, "'During these last days I have been occupied in examining my past conduct; nor do I find it blameable.'" If Victor believed that he had done something wrong, then his defensiveness might color his narrative, leading him to stretch the truth if not lie outright, in such a way as to incur our sympathy and make him seem somehow less responsible for the story's events.  However, since he thinks that his conduct has been appropriate, he has no reason to conceal anything.

Further, the creature himself confirms much of what Victor has said in the final pages of the novel, when he speaks to Captain Walton.  He, likewise, has no reason to lie.  He has no need to impress Walton or set any record straight, so he has no motive to dissimulate either.  Thus, Victor's total inability to take responsibility for the tragedies of this story and the corroboration of the creature he made, render him a fairly reliable narrator. We can say that Victor's recounting of the facts of the story is trustworthy, but we may then judge his behavior for ourselves. 

Under what conditions is it better to be haploid? Diploid?

A haploid cell is represented by the symbol (n) and represents the single set of chromosomes contributed by a sex cell or gamete to a future offspring. Therefore, a sperm or egg cell is haploid.

A diploid cell is represented by the symbol (2n) and is the chromosome complement found in any somatic cell--body cell. 

In order to ensure the chromosomes of a sexually reproducing species remain constant from generation to generation, the sex cells must be haploid. By the reduction division accomplished by meiosis, a testis or ovary cell will give rise to haploid gametes. During fertilization, the two haploid nuclei of the gametes fuse to become a diploid zygote or fertilized egg. Therefore, the (2n) organism that is produced contains both a maternal and paternal set of chromosomes.

From this first diploid cell, the process of mitosis occurs resulting in an organism which has diploid body cells. During mitotic cell division, the chromosomes of the nucleus are replicated and the cell divides into two daughter cells after cytokinesis, which are genetically identical to the parent cell.

To answer the question then-- it is "better" for sex cells to be haploid and for body cells to be diploid in order for the chromosome number of the species to be maintained from generation to generation. The conditions refer to whether an organism is reproducing in which case it would require haploid gametes or merely growing, repairing or maintaining its body which would require diploid cells.

What is hereditary spherocytosis?

Risk Factors

Having a family member with spherocytosis increases an individual’s risk of developing the condition.

Etiology and Genetics

Most cases of hereditary spherocytosis result from a mutation in the ANK1 gene, found on the short arm of chromosome 8 at position 8p11.21. This gene encodes the ankyrin protein, which is a major cell membrane protein found on the surface of erythrocytes (red blood cells). Ankyrin is believed to interconnect with protein molecules called alpha spectrin and beta spectrin, which are major components of the erythrocyte cytoskeleton. The reduction or loss of ankyrin molecules on the cell surface distorts this cytoskeleton, causing the cells to assume the spherical shape characteristic of the disease. Mutations in the alpha spectrin gene, erythrocytic 1 (SPTA1, at position 1q21) or beta spectrin gene, erythrocytic ( SPTB, at position 14q24.1–q24.2) are also known to cause erythrocytes to be spherical and thus result in symptoms associated with spherocytosis. Finally, rare cases of hereditary spherocytosis have been associated with mutations in two other genes that encode structural protein components of the erythrocyte cytoskeleton: solute carrier family 4 (anion exchanger), member 1 (Diego blood group) (SLC4A1 at position 17q21.31) and erythrocyte membrane protein band 4.2 (EPB42 at position 15q15–q21).

Spherocytosis resulting from mutations in the SPTA1 gene is inherited as an autosomal recessive disorder, but all other varieties of the disease are inherited in an autosomal dominant fashion. In autosomal recessive inheritance, both copies of the SPTA gene must be deficient in order for the individual to be afflicted. Typically, an affected child is born to two unaffected parents, both of whom are carriers of the recessive mutant allele. The probable outcomes for children whose parents are both carriers are 75 percent unaffected and 25 percent affected. In autosomal dominant inheritance, however, 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 dominant hereditary spherocytosis, however, result from a spontaneous new mutation, so in these instances affected individuals will have unaffected parents.

Symptoms

Symptoms of spherocytosis include jaundice, pallor, shortness of breath, fatigue, and weakness. Symptoms in children include irritability and moodiness. Additional symptoms include hemolytic anemia and gallstones.

Screening and Diagnosis

The doctor will ask about a patient’s symptoms and medical history and will perform a physical exam. Tests may include an examination of the spleen; blood tests; liver function tests; osmotic and incubated fragility tests to diagnose hereditary spherocytosis; and Coombs’ test, an antiglobulin test to examine red blood cell antibodies.

Treatment and Therapy

Patients should talk with their doctors about the best plans for them. Among treatment options, a daily 1-milligram dose of folic acid and consideration for blood transfusions are recommended during periods of severe anemia.

Surgical removal of the spleen can cure the anemia. The abnormal shape of blood cells remain, but the blood cells are no longer destroyed in the spleen. Currently, meningococcal, Haemophilus, and pneumococcal vaccines are administered several weeks before splenectomy. Lifetime penicillin prophylaxis is recommended after surgery to prevent dangerous infections. The surgery is not recommended for children under the age of five. There is a lifetime risk of serious and potentially life-threatening infections.

Prevention and Outcomes

Because spherocytosis is an inherited condition, it is not possible to prevent the disease. Regular screening of individuals at high risk, however, can prevent the risk of complications of the disease with early treatment.

Bibliography

Delaunay, J. “The Molecular Basis of Hereditary Red Blood Cell Membrane Disorders.” Blood Reviews 21.1 (J2007): 1–2. Print.

Gallagher, Patrick G. “Disorders of the Red Cell Membrane: Hereditary Spherocytosis, Elliptocytosis, and Related Disorders.” Williams Hematology. Ed. Marshall A. Lichtman et al. 7th ed. New York: McGraw, 2006. Print.

Genetics Home Reference. "Hereditary Spherocytosis." Genetics Home Reference. US NLM, 21 July 2014. Web. 25 July 2014.

Gersten, Todd. "Congenital Spherocytic Anemia." MedlinePlus. US NLM/NIH, 24 Feb. 2014. Web. 25 July 2014.

Kalfa, Theodosia A., Jessica A. Connor, and Amber H. Begtrup. "EPB42-Related Hereditary Spherocytosis." GeneReview. Ed. Roberta A. Pagon et al. Seattle: U of Washington, Seattle, 1993–2014. NCBI Bookshelf. Natl. Center for Biotechnology Information. 13 Mar. 2014. Web. 25 July 2014.

Kohnle, Diana. "Spherocytosis." Health Library. EBSCO, 30 Sept. 2013. Web. 25 July 2014.

National Human Genome Research Institute. "NIH Researchers Identify Genetic Cause of Anemia Disorder." Genome.gov. NHGRI, 28 Feb. 2012. Web. 25 July 2014.

Tracy, Elisabeth T., and Henry E. Rice. “Partial Splenectomy for Hereditary Spherocytosis.” Pediatric Hematology. Eds. Max J. Coppes and Russell E. Ware. Philadelphia: Saunders, 2008. Print.

in A Tale of Two Cities, what support can be given for the idea that revenge and justice conflict depending on what a person deems justifiable?

Perhaps the best example to support the question of individual interpretations of revenge and justice is in the relationship of Madame Therese Defarge and her husband, Ernest Defarge.

In Chapter XII of Book the Third, Sydney Carton has entered the wine shop in St. Antoine, and Madame Defarge recognizes him as a Evremonde (remember that Charles Darnay and he look alike). Her husband concurs that there is a resemblance, but he feels that in her vengeance against the uncles Evremonde, the brothers who are responsible for the death of Therese Defarge's brother and sister, "one should stop somewhere." Brutally, she replies, "At extermination."

Monsieur Defarge does not agree that exterminating the entire family is just, pointing out that the wife of the one Marquis, the mother of Charles, sought to make amends and the good Dr. Manette, father of Lucie, the wife of Charles, has suffered terribly in the past and just recently. Mme. Defarge argues that Manette is not a true friend of the Republic. Furthermore, she informs her husband that she has had "this race," the family of Evremonde, in her register for a long time, doomed to destruction and extermination. She further explains her justification for avenging the death of her brother, her sister, and the unborn child, all of whom died at the hands of the Evremondes:

"...those dead are my dead, and that summons to answer for those things descends to me!"

Yet Defarge thinks she should not carry her revenge to the point of extermination of Darnay's family. Therese Defarge insists that she is justified, saying to her husband,

"Then tell Wind and Fire where to stop...but don't tell me."

M. Defarge appeals again to his wife to spare Darnay and his wife, who he feels are innocent, but she insists again, "Tell the Wind and the Fire where to stop; not me!"

What can you tell about Antonio's character through his interactions with other characters in Act 1?

The first act of The Merchant of Venice reveals much about Antonio. The first line of the play is his: “In sooth, I know not why I am so sad.” His friends try to cheer him up and discern the reason for his sadness, to no avail. They reveal that he has lots of money on and in his ships, but he claims anxiety about his fortune has nothing to with feeling melancholy. When Bassanio arrives, Antonio demonstrates his generosity and affection for the young man by borrowing money for him: “My purse, my person, my extremest means, / Lie all unlock'd to your occasions.”

However, a more aggressive side of Antonio emerges when he encounters Shylock. Even as he asks to borrow money from him, Antonio argues with Shylock about charging interest. He has a history of contention with the man, a Jewish moneylender. In the conversation, he refers to Shylock as “the devil,” “an evil soul,” and “a villain.” Then Antonio either bravely or foolishly agrees to borrow money on the penalty of a pound of his flesh if he does not repay Shylock on time. The first act shows that Antonio is benevolent and self-sacrificing, though arguably self-righteous and blinded by prejudice.

What is the relevance of the displacement defense mechanism to pastoral counseling?

A good counselor doesn't explain a lot or offer a lot of solutions. Instead, she helps a person work through their own problems and come to their own conclusions. The client is the one engaged in the critical work of self-development. The counselor is there to guide, support, structure, and facilitate the process. To be effective, a counselor needs to have a very broad and deep understanding of human behavior and psychology. 

Displacement is a common defense mechanism (i.e. behavior humans use to cope with negative feelings). It occurs when a person has a goal or a desire that they believe to be either impossible to achieve, or unacceptable in the first place. In displacement, a person acts out their perceived impossible goal on an individual that has nothing to do with their true goal. Here's one example:

Imagine a person who is subject to verbal abuse, beratement, and constant mistreatment by his boss at work. He wants to defend himself, but he doesn't know how to stand up for himself. Perhaps he fears being fired, or maybe he is ashamed. He wishes he could change the situation, but he doesn't honestly believe he can. Deep down, he knows he'll never stand up to his boss. Yet at home, the man acts out his goal by being verbally abusive toward his children. Though his children have nothing to do with his real goal (to stand up to his boss), he displaces his anger and aggressiveness onto them. This is an example of displacement. In most cases, it is a maladaptive behavior with negative consequences.

A competent counselor will be able to recognize when a person is using the displacement defense mechanism, and will have tools at her disposal to help the client learn better, more adaptive coping mechanisms. In the case of man who is subject to abuse at work, the counselor may begin to work with him on assertiveness strategies. At the same time, she may explore with her client the possibility that the anger he displays toward his children at home is displaced. Exploring this possibility provides space for the man to begin to heal his relationship with his children, and with other folks in his life.

What does Scout want for Boo Radley?

Scout is a little girl who loves to play outside and socialize with neighbors. She can't imagine how anyone would want to stay in the house all day, every day like Boo Radley does. The kids even think that maybe his father forced him to stay inside—maybe even chained him up! Scout asks Miss Maudie why Boo Radley doesn't come out of the house in chapter 5. Miss Maudie simply says that he doesn't want to come out. Scout says, "Yessum, but I'd wanta come out. Why doesn't he?" (44). Miss Maudie explains that Boo's father was a foot-washing Baptist, which means he was very strict, and that might be part of the reason Boo doesn't come outside.

The next thing that Scout wants for Boo is to have friends. In chapter 4 she finds some gum in a knothole of the Radleys' tree. Later the kids find pennies, carved soaps, a medal Boo had won for spelling, and an old pocket watch. Scout doesn't make the connection between the gifts and Boo at first, and thinks it's Miss Maudie who has been leaving them. Yet this is Boo's way of making an effort to have friends. Then, when Mr. Nathan Radley fills up the hole with cement, their lines of communication with Boo are cut off and Scout cries (chapter 7).

For the most part, though, Scout probably wants Boo Radley to be understood by the community who makes him out to be a neighborhood bogeyman or phantom. She and Boo share a common experience of being misunderstood and not accepted for who they are. When Atticus reads The Gray Ghost to Scout after Boo saves the children's lives from Bob Ewell's attack, she makes a connection between a character in the book and Boo Radley:

"An' they chased him 'n' never could catch him 'cause they didn't know what he looked like, an' Atticus, when they finally saw him, why he hadn't done any of those things. . . Atticus, he was real nice. . ."

"Most people are, Scout, when you finally see them" (281).

The above passage is about a character in a book, but it also relates to Boo Radley. One of the main themes surrounding Boo is that he is misunderstood and gossiped about because he is different from other people. People say he's the reason for anything bad that happens in Maycomb, for example, but this isn't true. It's not right for people to use Boo Radley as a topic for entertainment, either. Scout learns that she must get to know someone before passing judgment, and she wishes for Boo's sake that everyone would do that for him.

Describe two reasons for balancing chemical equations.

Chemical equations are balanced in order to: 1) satisfy the Law of Conservation of Mass, and 2) establish the mole relationships needed for stoichiometric calculations.

The Law of Conservation of Mass: 

The Law of Conservation of Mass states that mass cannot be created or destroyed. Therefore, mass is not gained or lost in a chemical reaction. This means that the total mass of the reactants in a chemical reaction is equal to the total mass of the products. In order for the mass of the reactants to be equal to the mass of the products, there must be the same number of each type of atom on the reactant and product sides of the equation. Balancing chemical equations ensures that the same numbers of each type of atom are present on both sides of the equation.

Stoichiometric Calculations:

Stoichiometric calculations are used to predict the amount of substance in one part of a chemical equation based on the amount of substance in another part of the chemical equation. The relationship between the two substances is described by their mole ratio. The mole ratio between two substances is the same as the ratio of their coefficients. Balancing chemical equations ensures the correct ratio of moles between the substances in a chemical reaction.

What is implosion in behavior therapy?

Introduction

Implosion, along with in vivo and imaginal flooding, is categorized as a prolonged/intense exposure therapy. It is used in the treatment of fears, phobias, anxiety disorders, and negative emotional reactions such as anger. The therapist asks the client to imagine exaggerated, horrifying scenes that are constructed from the client’s report of stimuli that evoke fear or anxiety, supplemented by the therapist’s list of hypothesized cues. The therapist helps the client maintain a high level of fear or anxiety regarding these scenes until the anxiety response spontaneously subsides (implodes).

There are two types of hypothesized cues. One type consists of stimuli not reported by the client but inferred by the therapist to be related to the client-reported cues. The other type consists of cues that are identified by the therapist based on psychoanalytic theory. The therapist validates these hypothesized cues by observing the client for emotional responses, such as sweating, restlessness, facial flushing, or negative comments, during their presentation. Hypothesized cues that do not elicit signs or reports of discomfort are discarded by the therapist. Cues that elicit strong emotional responses are expanded and repeated. Hypothesized cues are considered to be more potent than client-reported cues because of their presumed greater proximity to the original traumatic episode.

During therapy, the client is instructed to “lose” him- or herself in the scenes described by the therapist, which are embellished with graphic and sometimes surreal imagery. For example, a snake-phobic subject might be asked to imagine being stalked and swallowed by a monster snake or having millions of tiny snakes slithering up his or her nose and into the mouth and ears. The therapist also probes for evidence of unresolved inner conflicts, such as anxiety about sex, through interviews with the client about childhood experiences and relationships. Relevant themes, as suggested by psychoanalytic theory, are incorporated into new scenes for the client to visualize and act out. Scene presentation is also dynamic, with material evolving on the basis of client feedback. For example, a client who was being treated for impotence spontaneously recalled an episode when his first-grade teacher ridiculed him for not being able to write the number six in front of the class. This memory was incorporated into a subsequent implosion session by the therapist.

The supposition underlying implosion therapy is that continuous and inescapable exposure to a stimulus that elicits fear or anxiety in the absence of reinforcement or negative consequences will eventually weaken the anxiety-eliciting power of the stimulus. This principle derives from classical studies of Pavlovian fear conditioning in which a neutral stimulus (conditioned stimulus) that predicts an aversive stimulus (unconditioned stimulus) acquires the ability to elicit a conditioned fear response. This learned fear response can be extinguished by subsequently presenting the conditioned stimulus without the unconditioned stimulus. Subsequent research has shown that extinction involves new learning rather than unlearning and that this new learning is specific to the extinction context. Psychologist Mark E. Bouton, a pioneer of the view that Pavlovian extinction is context dependent, has discussed its implications for exposure-based therapies in general.

Intense/prolonged exposure therapy is rapid and advantageous for clients who want immediate relief. Ethical considerations have been raised about the extreme level of discomfort that clients experience when undergoing implosion or flooding and the possibility that treatment may exacerbate a client’s anxiety. Clients may have to imagine a disturbing scene for more than an hour and rehearse the scenes outside of the therapeutic setting. A 1980 survey of exposure therapists, however, revealed serious negative side effects in only 9 of 3,493 clients (0.26 percent).

History and Evaluation of Implosion

Implosion was developed by the psychologist Thomas G. Stampfl in 1957 and outlined in a series of papers coauthored with psychologist Donald J. Levis from 1966 to 1969. Freudian psychodynamic concepts guide identification of hypothesized anxiety-eliciting stimuli; principles of Pavlovian and instrumental conditioning are invoked to explain acquisition, maintenance, and extinction of anxiety reactions. Stampfl and his colleagues claimed high success rates using this unique integrated approach and reported marked changes in symptomatology within one to fifteen one-hour sessions. Despite such reports, growth in the use of implosion was slow, a situation that psychologist Robert H. Shipley blamed on uncertainty about the technique and concern about its potential for worsening a client’s condition.

A 1973 review by psychologist Kenneth P. Morganstern was highly critical of exposure-therapy research. Case studies did not control for spontaneous remission of symptoms. Laboratory (analogue) studies tended to use mildly phobic subjects with little potential relevance to clinical populations. Moreover, experimental confounds made it impossible to draw any firm conclusions about the relative efficacy of implosion, flooding, and systematic desensitization. While exposure therapy has since gained widespread acceptance, the distinction between implosion and flooding is often blurred, and the terms are frequently used synonymously to refer to prolonged/intense exposure to anxiety-eliciting stimuli.

Exposure Therapy

Exposure therapies have gained recognition as efficient and effective treatments for post-traumatic stress disorders (PTSD). A 1998 study reported that eighteen of twenty-four infants were successfully treated with flooding for post-traumatic feeding disorders and that treatment prognosis correlated with four behavioral measures, including passive refusal to swallow food and not chewing/sucking/moving food placed in the mouth for more than five seconds. Success has also been reported for treating veterans with combat trauma and victims of physical and sexual assault.

Advances in technology have allowed therapists to use
virtual reality or computer-simulated exposure to replace in vivo exposure, which is not always practical, affordable, or safe. A 2007 review reported positive results of virtual reality exposure for combat veterans and a victim of the September 11, 2001, terrorist attacks. Whether this approach will come to replace implosion or imaginal flooding will depend on the outcome of studies using well-controlled, robust randomized trials with clinically identified populations and long-term follow-ups.

Bibliography

Abramowitz, Jonathan S., Brett J. Deacon, and Stephen P. H. Whiteside. Exposure Therapy for Anxiety: Principles and Practice. New York: Guilford, 2011. Print.

Bouton, Mark E. “Context and Ambiguity in the Extinction of Emotional Learning: Implications for Exposure Therapy.” Behaviour Research and Therapy 26.2 (1988): 137–49. Print.

Gregg, Lynsey, and Nicholas Tarrier. “Virtual Reality in Mental Health.” Social Psychiatry & Psychiatric Epidemiology 42.5 (2007): 343–54. Print.

Morganstern, Kenneth P. “Implosive Therapy and Flooding Procedures: A Critical Review.” Psychological Bulletin 79.5 (1973): 318–34. Print.

Neudeck, Peter, and Hans-Ulrich Wittchen, eds. Exposure Therapy: Rethinking the Model—Refining the Method. New York: Springer, 2012. Print.

Shipley, Robert H. “Implosive Therapy: The Technique.” Psychotherapy: Theory, Research, and Practice 16.2 (1979): 140–47. Print.

Sisemore, Timothy A. The Clinician's Guide to Exposure Therapies for Anxiety Spectrum Disorders: Integrating Techniques and Applications from CBT, DBT, and ACT. Oakland: New Harbinger, 2012. Print.

Spiegler, Michael D., and David C. Guevremont. Contemporary Behavior Therapy. 5th ed. Belmont: Wadsworth, 2010. Print.

What is gynecology?

Science and Profession

Gynecology is the branch of medical science that treats the functions and diseases unique to women, particularly in the nonpregnant state. A gynecologist is a licensed medical doctor who has obtained specialty training. Unlike many fields in medicine that are clearly defined by surgical or nonsurgical practice, gynecology involves both. In the early nineteenth century, gynecology was closely tied to general surgery. In fact, one of the first reported cases of abdominal surgery in which the patient survived and was cured of a condition occurred in 1809, with the successful removal of a massive ovarian tumor by Ephraim McDowell (without the benefit of anesthesia or antibiotics).

Gynecology is much more than just a surgical field. With the tremendous progress made in the basic sciences and medical sciences by the twenty-first century, gynecology has come to involve a broad spectrum of medical fields, including developmental and congenital disorders relating to puberty and adolescence, sexually transmitted infections (STIs) and other infectious diseases, contraception, menstrual disturbances, endocrinology, early pregnancy issues, infertility, preventive health, problems related to menopause, incontinence, and oncology, specifically dealing with cancers of the reproductive system (such as the ovaries, uterus, and breasts). Although much gynecologic care is provided by medical doctors, routine gynecologic care is also often provided by nurse practitioners (especially those with specialty certification in women’s health) and certified nurse midwives.

Many of the medical problems dealt with in gynecology have far-reaching social, ethical, and legal consequences. Among the most controversial issues in medicine involve abortion and STIs (such as human immunodeficiency virus, or HIV), both of which are conditions commonly managed by gynecologists. Another example of a common problem managed by gynecologists with important social implications is contraception. Female steroid hormones were among the first biological substances to be purified in the laboratory in the twentieth century. These hormones were then intentionally fed to animals for their contraceptive effect and eventually given to human beings as well in the form of the birth control pill. The birth control pill is an invention that has been widely credited with providing women with a relatively easy means to control their own fertility. Many social scholars would argue that women’s ability to harness their own fertility was key in enabling women to delay childbearing, pursue education and careers, and take roles in society that were formerly occupied almost exclusively by men.

To understand gynecology, it is first necessary to have a working knowledge of relevant female anatomy and physiology. Broadly, the female reproductive organs are divided into two groups, external and internal. Within each group are many specific components, most of which are analogous to structures in the male because they are derived from the same sources during embryological development. The external organs are the vulva (the fleshy “lips” covered with skin), vagina, and clitoris; the internal organs are the uterus (including the cervix), Fallopian tubes, and ovaries. These organs mature during puberty and communicate with regions of the brain, specifically the hypothalamus and pituitary, to coordinate function.

The vagina is a tube of tissue that connects the vulva with the uterus. In adult females, it is nine to ten centimeters in length. When a woman is standing upright, the vagina extends upward and backward from the opening to the uterus. There is a slight cup-like expansion near the uterus. It is here that the actual connection between the vagina and uterus is made through a muscular structure called the cervix. The muscles of the vagina are normally constricted, thus closing the tube. The vagina can stretch to accommodate a penis during intercourse and a fetus during birth.

The cervix is a ring of muscle; the central opening is called the cervical os. Throughout most of the month, the cervical os forms a tight barrier. When the lining of the uterus is sloughed during a menstrual period, the cervix relaxes slightly. During childbirth, the cervix dilates to ten centimeters (about four inches).

The uterus is a hollow, thick-walled, muscular organ. It normally forms a right angle with the vagina, angling upward and anteriorly. The bladder is immediately anterior to the uterus. In a nonpregnant woman, the uterus is pear-shaped. In a woman who has never been pregnant, it is eight centimeters in length, six centimeters wide, and four centimeters thick. It increases in size during pregnancy; after birth, it shrinks but does not quite return to its size prior to pregnancy. The lining of the uterus is shed approximately every twenty-eight days during a normal menstrual period.

The Fallopian tubes are two canals that transport eggs from the ovaries to the uterus. The Fallopian tube is the site where sperm meet the egg and fertilization occurs. The tubes are wide near the ovaries and become narrow toward the uterus. The ovaries are two almond-shaped bodies found in the pelvic cavity, and they brush up against the Fallopian tubes. The ovaries are about 3.5 by 2 by 1.5 centimeters in size, although there can be much variation. The ovaries contain eggs, which are released at monthly intervals between puberty and menopause.

Diagnostic and Treatment Techniques

Many gynecologic visits are done for routine screening of healthy women. When a patient presents with a problem or complaint, a good history from the patient regarding the nature of the problem is crucial for diagnosis. The history is almost always followed by a physical examination. Probably the best known diagnostic technique in gynecology is the pelvic examination. Women should have routine screening examinations beginning at age twenty-one, or three years after onset of sexual activity, whichever age is first. The purpose of the examination is to confirm normal anatomy, rule out pathological conditions, and prevent the development of cancers through early screening tests such as the Pap test.

The pelvic examination is typically performed with the woman on her back, knees apart, with feet and legs supported by stirrups. Visual inspection of the external genitalia is performed; this involves inspecting the pubic region to ensure normal secondary sexual development as well as to look for abnormalities such as unusual lesions on the labia, which may indicate infections (by fungi, bacteria, viruses, or parasites), skin conditions (such as eczema), or cancer. The next portion is a bimanual examination. The examiner places one hand on the patient’s abdomen and gently inserts two fingers of the other hand into the patient’s vagina; gloves are worn at all times. The examiner proceeds to feel the uterus and ovaries by gently pushing them toward the anterior abdomen. The external hand on the abdomen serves as a counterforce to enable the examiner to feel the contours of the uterus and ovaries and hence to assess their size.

The last portion of the examination is a visual inspection of the interior of the vagina and the surface of the cervix. Because the vagina is normally closed, a device called a speculum is carefully placed in the vaginal canal. The speculum has two “blades”; each blade is analogous to a tongue depressor, which pushes the tongue out of the way to enable inspection of the throat. The blades are then slowly opened to part the vaginal tissues and enable visualization of the vaginal canal and cervix. The vaginal walls and cervix are inspected for abnormalities, and the consistency of vaginal fluid is noted. If any abnormalities are noted, cultures or biopsies may taken to facilitate diagnosis. When indicated, a Pap test is performed by swabbing the exterior of the cervix as well as the cervical canal. The cells that are obtained from the swab can then be sent to the pathology laboratory for analysis to screen for precancer or cancer of the cervix.

Although the bimanual examination is the mainstay of office practice, this examination is but a small fraction of diagnostic modalities commonly employed by gynecologists. A complete physical examination, including clinical breast examination, is often performed for a comprehensive survey to aid in diagnosis. When abnormalities are suspected, imaging techniques and laboratory tests can be invaluable in diagnosis. For instance, when a pelvic mass is felt on bimanual examination, the gynecologist may order an ultrasound to better characterize the mass. Laboratory tests such as CA-125 levels may be indicated to help differentiate the pelvic mass from a benign growth versus a malignancy, such as of the ovary.

Other diagnostic tests commonly employed in gynecological office practices are blood and urine tests for pregnancy, blood or culture tests (for STIs such as HIV, syphilis, gonorrhea, chlamydia, and herpes), and biopsies of the external genitalia, which may assist in diagnosing skin conditions such as lichen sclerosis or precancers. If an endocrinologic abnormality is suspected, then blood tests to check the levels of various hormones (such as thyroid hormone, follicle-stimulating hormone, or prolactin) can help pinpoint the problem. In a patient with urinary incontinence, urodynamic testing, which records the pressures of the bladder and abdomen under different conditions, may help diagnose and characterize the type of incontinence.

A number of diagnostic tests commonly employed by gynecologists require going to an operating room, most often because of the need for patient sedation or anesthesia. One example is hysteroscopy, whereby a small camera mounted on a cannula is introduced through the cervix to visualize the cervical canal and uterine lining. Hysteroscopy can be useful in the diagnosis of polyps or fibroids (benign tumors of the uterus) which may be causing abnormal vaginal bleeding. Another example is diagnostic laparoscopy, whereby a small camera mounted on a cannula is introduced into the abdominal and pelvic cavity to inspect for abnormalities such as pelvic scarring, masses, or endometriosis, a condition in which cells resembling the uterine lining are found in the pelvic or abdominal cavities.

Gynecologic providers have a vast array of treatment options available to them. In the office setting, common treatment modalities include the use of antibiotics for uncomplicated cervical infections, such as chlamydia and gonorrhea, or for vaginal infections, such as trichomoniasis. Another problem commonly treated in the office setting is undesired fertility. A number of contraceptive modalities exist, including the prescription of birth control pills, the placement of an intrauterine device (IUD), or the injection of sustained-release hormones. In women experiencing menopausal symptoms such as hot flashes, hormonal pills or other medications may be prescribed. Women with chronic pelvic pain may be treated with medications such as antidepressants or anticonvulsants. Urinary incontinence may respond to bladder training, pessaries, or medications.

In the operating room, procedures may be carried out in a controlled setting to treat disease. A woman with abnormal vaginal bleeding caused by fibroids who no longer desires childbearing may receive a hysterectomy, with or without removal of the ovaries. If a woman is interested in retaining her uterus, the fibroids can be isolated and removed surgically through a common surgical procedure called a myomectomy. In women who desire permanent sterilization, a common surgical procedure performed by gynecologists is tubal ligation. Another common surgical procedure is the removal of pelvic masses such as ovarian cysts. Endometriosis or pelvic scars can be removed or destroyed through laparotomy (also known as abdominal surgery) or laparoscopy (minimally invasive abdominal surgery). When a Pap test or biopsy indicates noninvasive cancer of the cervix, treatment is possible through excision of the part of the cervix surrounding the cancer. In women with urinary incontinence not helped by medical management, surgery may be indicated to treat the problem. Women who are infertile as a result of blocked Fallopian tubes can be treated with in vitro fertilization. In this procedure, eggs are harvested from the woman in the operating room, and fertilization is performed in the laboratory. When the embryos are sufficiently developed, they are placed in the uterine cavity through an office procedure.

Perspective and Prospects

The formation of a medical field specific to women’s diseases largely began in the nineteenth century. At the time, the treatment of women’s diseases was inextricably linked with the role of women in society. In the nineteenth century, women were often viewed as frail and limited by their cyclical physiology and childbearing role. Consequently, they were excluded from the male-dominated spheres of politics, professional careers, and education. For instance, influential psychiatrist Henry Maudsley (1835–1918) wrote about the harm that higher education would cause to the physiologic development of postpubescent girls. Edward Clarke (1820–77), a Harvard Medical School professor, wrote in 1873 that higher education might develop the intellect, but at the expense of the reproductive organs, leading to painful menstrual periods and abnormal uterine function.

The field has evolved dramatically since then, with much of the evolution tied to changes in the role of women in society as well as to technological and scientific advances. In the twenty-first century, one of the major forces changing gynecological practice (as well as many other fields of medicine) is the concept of evidence-based medicine. This movement is based on the idea that medical practice must be guided by scientific evidence as well as good intentions. Without objective evidence that a treatment is effective, even the best of intentions can result in patient harm. Although a physician may practice evidence-based medicine, this does not mean that clinical judgment and the tailoring of treatments to fit individual patients should be ignored. In fact, applying scientific evidence in an automatic way to all patients is not endorsed. Gynecologists most often practice evidence-based medicine either by examining the available literature themselves, by using evidence-based medical summaries developed by others, or by using evidence-based protocols developed by others.

One example of evidence-based medicine guiding clinical practice involves Pap testing. Although the classical teaching had been that Pap tests were recommended on a yearly basis, this frequency was not based on any direct evidence that this protocol would lead to better outcomes than screening less frequently. Consequently, both the US Preventive Services Task Force and the American Cancer Society have suggested lengthening the period between successive Pap tests in women thirty years of age or older who have had negative results on three or more consecutive Pap tests. In fact, the Preventive Services Task Force recommends Pap tests be performed “at least every three years” rather than every year. The optimum use of limited resources is of concern to patients, physicians, health maintenance organizations (HMOs), and insurance companies alike; the careful application of evidence-based medicine to appropriate situations in medical practice can result in the best overall benefit for all parties involved.

Bibliography

Berek, Jonathan S., and Emil Novak, eds. Berek and Novak’s Gynecology. 15th ed. Philadelphia: Lippincott Williams & Wilkins, 2012.

Clifford, Annie, et al. Obstetrics, Gynaecology and Women's Health on the Move. London: Hodder Arnold, 2012.

Collins, Sally, et al. Oxford Handbook of Obstetrics and Gynaecology. 3rd ed. Oxford: Oxford University Press, 2013.

Doherty, Gerard M., and Lawrence W. Way, eds. Current Surgical Diagnosis and Treatment. 12th ed. New York: Lange Medical Books/McGraw-Hill, 2006.

Kasper, Dennis L., et al., eds. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005.

Norsigan, Judy, and Boston Women’s Health Collective. Our Bodies, Ourselves: A New Edition for a New Era. Rev. ed. New York: Touchstone, 2011.

Norwitz, Errol R. Obstetrics and Gynecology at a Glance. 4th ed. Malden, Mass.: Wiley, 2013.

Rushing, Lynda, and Nancy Joste. Abnormal Pap Smears: What Every Woman Needs to Know. Rev. ed. Amherst, N.Y.: Prometheus Books, 2008.

Scott, James R., et al., eds. Danforth’s Obstetrics and Gynecology. 10th ed. Philadelphia: Lippincott Williams & Wilkins, 2008.

Speroff, Leon, and Marc A. Fritz. Clinical Gynecologic Endocrinology and Infertility. 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2011.

Stenchever, Morton A., et al. Comprehensive Gynecology. 5th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.

Stewart, Elizabeth Gunther, and Paula Spencer. The V Book: A Doctor’s Guide to Complete Vulvovaginal Health. New York: Bantam Books, 2002.

Tierney, Lawrence M., Stephen J. McPhee, and Maxine A. Papadakis, eds. Current Medical Diagnosis and Treatment. 50th ed. Los Altos, Calif.: Lange Medical Publications, 2011.

Weschler, Toni. Taking Charge of Your Fertility. 10th anniversary ed., Rev. ed. New York: Collins, 2006.