Monday, April 30, 2012

What does Owl Eyes discover, and why is this shocking in The Great Gatsby?

Owl Eyes discovers that the books in Gatsby's library are real; he is surprised because he knows that the parties are contrived and the guests are "brought."


In Chapter Three, Gatsby has a replicated hôtel de ville for his mansion. There on the imitative West Egg, he throws lavish parties every couple of weeks. A corps of caterers arrive to erect an outdoor pavilion and set up buffet tables that hold all sorts of attractive hors d'oeuvre and appetizing fowl and other meats. There is even an authentic bar with a brass rail replete with liquors and cordials that is set up for the guests.


During the party Nick and Jordan seek Gatsby in his mansion, and they enter the library where "a stout middle-aged man with huge owl-eyed spectacles" is seated upon a table, staring at the shelves that hold leather-bound books. Assuming that Nick and Jordan think Gatsby's pretentious parties and his home are all for show as he does, the man asks them what they think about the books. Rather nonplussed, they look at Owl Eyes.



"Absolutely real--have pages and everything. I thought they'd be nice durable cardboard....Here! Lemme show you."



Hurrying to a shelf, he takes down Volume One of the "Stoddard Lectures" [This is the same book that Tom Buchanan has on his shelf in Chapter One.]



"This fella's a regular Belasco [famous playwright and director]. It's a triumph. What thoroughness! What realism! Knew when to stop, too – didn't cut the pages. But what do you want? What do you expect?"



Owl Eyes, whose appearance resembles the billboard with Doctor T. J. Eckleburg who wears "a pair of enormous yellow spectacles," observes more than than other people do. For, he obviously suspects Gatsby of assuming a role since he and other guests have been "brought" to the party.

Sunday, April 29, 2012

What are all the malapropisms in Romeo and Juliet?

A malapropism is the incorrect use of a word in place of one that sounds phonetically similar.  For example, “A doctor gave me an anecdote.”  In this instance, “anecdote” is mistakenly used for “antidote.”   Common malapropisms are “electric—eclectic,” “obtuse—abstruse,” “home—hone,” and “behest—beset.”  Often humorous, malapropisms in literature can either convey narrative confusion or can serve as a characterizing device to show the ignorance or wit of a particular character.


Touted as one of the most clever word smiths in the English language, William Shakespeare is known for his play on words, puns, and dialogic jargon.  Thus, it is no surprise that malapropisms often appear in his plays.  In the romantic tragedy of Romeo and Juliet, there are several malapropisms that are absurd and humorous, that not only provide comedic relief but present insights into character natures.


  • “Oh, he’s the courageous / captain of compliments” (II. iv. 19-20).  In this malapropism that also functions as an alliteration, the word “compliments” is arguably misused for the word “complements.”  This is evidenced by the string of “complements” or additional attributes that the Prince of Cats possesses.

  • “If you be he, sir, I desire some confidence with you” (II. iv. 64).  Here, the Nurse wants Romeo to be a “confidant,” which is a trusted friend to discuss private matters.  The malapropism is confidence for confidant.  In addition, it has been noted that the malapropism could be confidence for conference.  Regardless, confidence is still the wrong word choice. 

  • “She will indite him to some supper” (II. iv. 65). In this line spoken by Benvolio, the young man misuses “indite” for “invite.”  Indite is the writing of a sonnet or composition, suggesting Shakespeare is not only poking fun at the Nurse’s request, but poking fun at his own craft.

  • “But, I’ll warrant you, when I say so, she looks as pale as any clout in the versal world” (II. iv. 101-102).  Here, the nurse mistakenly uses “versal” for “universal,” which is not only a humorous error, but is a pun on the “versal world,” meaning the world of play writing.

  •  “No, I know it begins with some other letter, and she / hath the prettiest sententious of it” (II. iv. 106-107). Again, the Nurse uses a malapropism for the word “sententious.”  In this section, the Nurse is commenting on the spelling of Romeo’s name and she uses “sententious” instead of “sentences.”  The fact that the Nurse is the most frequent user of malapropisms conveys her as a comedic, and somewhat ignorant character.

What is ectopic pregnancy?


Causes and Symptoms

Although ectopic pregnancies can occur without any known cause, several factors increase a woman’s risk. Studies have shown an increase in ectopic pregnancies in women with previous pelvic inflammatory disease (PID). Intrauterine devices (IUDs), so effective at preventing pregnancies, do not increase the risk of ectopic pregnancy. However, when a woman with an IUD does get pregnant, the risk for an ectopic pregnancy is increased, especially for women using an IUD containing progestin at the time of conception. There is also an increased risk in women who have had tubal ligations and other surgeries of the Fallopian tubes.





Endometriosis, multiple induced abortions, fertility treatments, anatomical abnormalities in the uterus or Fallopian tubes, and pelvic adhesions also may increase a woman’s chance of ectopic pregnancy. In general, women whose Fallopian tubes are damaged for any reason have a higher risk. The risk is heightened because damage slows the progress of the developing embryo through the tube, allowing the embryo to be mature enough to implant itself before reaching the uterus. Another factor that may increase the chances of ectopic pregnancy is smoking. Nicotine slows the movement of cilia in the Fallopian tubes, thus slowing the progress of the embryo.


The symptoms of an early ectopic pregnancy are similar to those of any early pregnancy, except that spotting, cramping, and pain, especially on only one side of the abdomen, may occur as the embryo grows. Hormone levels mimic early pregnancy but usually do not rise as high as in a normal intrauterine implantation. If the tube ruptures, bleeding, severe pain, low blood pressure, and fainting may occur.


Transvaginal ultrasounds and blood tests, along with physical examination, are often used to determine the presence of an ectopic pregnancy.




Treatment and Therapy

If a tubal ectopic pregnancy is diagnosed early enough, methotrexate, a chemical that attacks quickly growing cells, may be administered via injection, and surgery may be avoided. The drug causes the death of the embryo. Surgical removal is now less common than is management with methotrexate; when surgery is performed, however, it is usually done through laparoscopy. In conservative surgery, the Fallopian tube is preserved, while in radical surgery, it is removed. Following surgery, methotrexate may be administered to help remove any remaining tissues from the pregnancy. Because there is no known way to implant the removed embryo in the uterus, surgical removal also results in the death of the embryo. For shock associated with tubal rupture, treatments may include intravenous fluids, oxygen, and blood transfusion.




Bibliography


A.D.A.M. Medical Encyclopedia. "Ectopic Pregnancy." MedlinePlus, February 26, 2012.



American Academy of Family Physicians. "Ectopic Pregnancy." FamilyDoctor.org, January 2011.



Carson, Sandra Ann, ed. Ectopic Pregnancy. Philadelphia: Lippincott-Raven, 1999.



Carson-DeWitt, Rosalyn, and Andrea Chisholm. "Ectopic Pregnancy." Health Library, September 10, 2012.



Hey, Valerie, et al., eds. Hidden Loss: Miscarriage and Ectopic Pregnancy. 2d ed. London: Women’s Press, 1997.



Leach, Richard E., and Steven J. Ory, eds. Management of Ectopic Pregnancy. Malden, Mass.: Blackwell Science, 2000.



Preidt, Robert. "Ultrasound Best Detector of Dangerous Ectopic Pregnancies, Study Finds." HealthDay, April 23, 2013.



Stabile, Isabel. Ectopic Pregnancy: Diagnosis and Management. New York: Cambridge University Press, 1996.

What is the rising action of "The Lady or the Tiger?"

When figuring out the rising action of a story, think of a plot diagram that is shaped somewhat like a triangle. The top of the triangle is the climax of the story, so right before the story reaches that final revelatory point, the rising action takes place. The big question to be decided at the climactic point of the story is whether the princess will inform her lover which door to choose to save his life. Therefore, the climax would be the point that the young man opens the door and the answer is revealed. Part of the rising action is when the man is walking into the arena and looks up to the princess for help. However, the author discusses the dilemma facing the princess by describing how she has wrestled with the decision. Right before the man is to choose a door, there are two paragraphs explaining her internal deliberations--should she kill him or allow him to marry another? The rising action right before the revealing climax is the princess struggling with her decision.



"Would it not be better for him to die at once, and go to wait for her in the blessed regions of semi barbaric futurity? And yet, that awful tiger, those shrieks, that blood! Her decision had been indicated in an instant, but it had been made after days and nights of anguished deliberation."



As shown above, the "anguished deliberation" is the rising action displayed before the climax of the story.

Saturday, April 28, 2012

What is a good song that represents To Kill a Mockingbird?

When we think of songs that "represent" things, there are a few things to consider:


1. Sound - does the sound of the song match the feeling of the novel? If I picked a heavy metal song to represent a Curious George book, that would say something about the feeling I get from the book. 


2. Lyrical Relationship - do the lyrics have any special tie to the content of the book? This isn't always necessary, especially with music that isn't lyrical, but it is a good consideration. 


3. Message - what overall message does the song send? 


4. Avoiding "On the Nose" Choices - this is hard. It can be tempting to choose a song that very, very closely matches the theme and feeling of the book. This is a mistake because it doesn't allow any imagination in the listener/reader. An example would be choosing a song about a sinking ship to represent the Titanic. When the relationship between the pieces (sinking ships) is already established, the reader/listener doesn't get the chance to make those connections for herself. 


Given all of this, I recommend the song "Helicopter" by the band Branches to represent To Kill a Mockingbird. 

What is the relationship between self-destructive behavior and addiction?


Programmed Behavior?

The tendency toward negative thinking and self-destructive behavior might be psychologically programmed at birth. In 1987, researchers in Stockholm studied the records of 412 alcoholics, drug addicts, and persons who committed suicide to see if obstetric procedures were linked to harmful events later in life, as data from the United States seemed to indicate.


The results of the study also showed that people who committed suicide by asphyxiation had close association with asphyxia at birth; those who died by violent mechanical means had experienced a mechanical birth trauma; and people who became addicts were born to women who had been given opiates or barbiturates during labor. The research team concluded that obstetric procedures should be reexamined in light of a possible imprint for self-destructive behavior that manifests later in a person’s life.




Self-Esteem

Birth is only the first opportunity for the kind of psychic trauma that can put a person on a self-destructive spiral toward substance abuse or suicide. Early exposure to sexual abuse has been found to cause profound dissociation and lead to alcohol and drug abuse.


Other notable factors, such as parental unemployment, exposure to violence in the home, or being bullied at school, all can drain self-esteem, according to researchers. Being separated from parents, either physically by protective services or emotionally because of parental substance abuse, significantly increases the risk of self-destructive behavior.




Suicidal Ideation

Self-destructive thoughts can lead to dangerous actions. Suicidal thoughts build along a continuum from mild self-criticism to angry self-attacks and thoughts of suicide. Self-destructive behaviors exist in parallel, on a continuum that ranges from accident proneness to drug abuse, alcoholism and other compulsions to premature death.



Substance abuse is considered the third major risk factor for suicide, behind previous suicide attempts and depression. Substance abuse is a slow form of suicide. Research has shown that people who drink heavily and use drugs die several years earlier, on average, than the general population.




Human Drives

Research suggests that visceral influences—drive states such as hunger, thirst, sexual desire, emotions, physical pain, and addictive cravings—can “crowd out” a person’s better intentions with the sole mission of mitigating the visceral urge. All focus turns to the moment and the drive. During binges, the thoughts of cocaine addicts, for example, are focused solely on the drug; sleep, money, survival, loved ones, and other responsibilities lose significance.


This change in focus also is evident in binge eating. Binge eaters have high standards and expectations of themselves and are acutely sensitive to the demands of others. When they feel they have fallen short of expectations, they become negatively self-conscious, resulting in emotional distress, anxiety, and depression. To escape from this painful state of being, binge eaters narrow their attention to immediate stimuli and avoid thinking on a broader level, researchers say.




Genetic Factors and Environmental Trauma

People who suffer the sorts of trauma mentioned above and who are
genetically predisposed to addiction are at the highest risk for substance abuse. Some people are more prone to substance abuse through inheritance of gene mutations such as D2A1, the dopamine receptor found in 69 percent of severe alcoholics, 40 to 55 percent of persons with post-traumatic stress disorder, and 20 percent of nonalcoholics.


Dopamine works with serotonin in areas of the brain responsible for emotion and attention. Abnormal serotonin levels in substance abusers’ brains are linked to a mutation of the enzyme tryptophan oxygenase, which breaks down tryptophan.


Teenagers who receive important social supports such as family counseling after traumatic events fare better than those who are left to cope alone, whether they have the gene mutations or not. Recovery from substance abuse requires finding new pleasure-inducing activities, coping mechanisms, relaxation methods, and relapse prevention.




Bibliography


Baumeister, Roy F., and Steven J. Scher. “Self-Defeating Behavior Patterns among Normal Individuals: Review and Analysis of Common Self-Destructive Tendencies.” Psychological Bulletin 104.1 (1988): 3–22. Print.



Firestone, Robert W., and Richard H. Seiden. “Suicide and the Continuum of Self-Destructive Behavior.” Journal of American College Health 38.5 (1990): 207–13. Print.



Frederick, Calvin J., Harvey L. P. Resnik, and Byron J. Wittlin. “Self-Destructive Aspects of Hard Core Addiction.” Archives of General Psychiatry 28.4 (1973): 579–85. Print.



Heatherton, Todd F., and Roy Baumeister. “Binge Eating as Escape from Self-Awareness.” Psychological Bulletin 110.1 (1991): 86–108. Print.



Jacobson, Bertil, et al. “Perinatal Origin of Adult Self-Destructive Behavior.” Acta Psychiatrica Scandinavica 76.4 (1987): 364–71. Print.



Rodriguez-Srednicki, Ofelia. “Childhood Sexual Abuse, Dissociation, and Adult Self-Destructive Behavior.” Journal of Child Sexual Abuse 10.3 (2002): 75–89. Print.

What is some biographic information about Julius Caesar?

Julius Caesar was born in 100 BCE (in what would become the month of July), to a Patrician family that was prestigious but not particularly wealthy. It was for this reason that Caesar grew up in what was basically a middle-class neighborhood. His mother managed an Insula, which was like a Roman apartment building. This enabled Caesar to learn a lot of languages and cultures from a young age, a skill that would prove instrumental to his career.  


Caesar’s father might not have been rich, but his mother was intelligent, and his aunt was married to Gaius Marius, one of the most influential figures in Roman history. The effects of Julius Caesar and his family on Roman politics and history is hard to overstate. Rome definitely went through a bit of a rough patch during Caesar’s youth and young adulthood because of a feud between Marius and Sulla. That is how Caesar somehow ended up a priest, married a girl far younger than him, and entered the army. 


Historians debate the effectiveness of Caesar’s military campaigns, but he definitely made himself very wealthy and filled Rome's coffers. He made some controversial moves, too. His most successful campaigns were in Gaul (mostly modern-day France). Caesar worked his way up. He was hardworking and intelligent. He served lower-level positions in Roman politics and government, including quaestor and praetor, before being consul, which was the highest office, on January 1, 44 BCE—the same year he was assassinated. 


The biggest controversy involving Caesar was his march on Rome in 49 BCE. This was a result of his disagreement with Pompey (who happened to be married to his daughter Julia), and resulted in the bloody civil war that caused much of the senate to flee. It did not make Caesar popular. His rule was rocky. He was dictator, but he claimed his goal was to make Rome stable. When he followed Pompey to Egypt, Caesar learned the Egyptians had killed him already, and Caesar had to settle a dispute there, too. It involved putting Cleopatra on the throne. Caesar also fathered a son with her.  Caesarean was Caesar’s only acknowledged son by birth, but he was not considered legally legitimate in Rome.  


In 44 BC, a group of senators assassinated Julius Caesar publicly and violently. Caesar’s Master of the Horse was Mark Antony, a hot-headed distant relative of his. Antony was loyal to Caesar, and high-placed politically. He expected to be named Caesar’s successor. When Caesar named his grand-nephew Octavius (Octavian) his heir, it caused a stir. 


Antony and Octavius Caesar battled it out until they decided to join forces and track down the rest of the assassins instead of fighting each other. That resulted in another bloody civil war for Rome, and then some quiet rule where Rome was ruled by a triumvirate of Antony, Octavius, and Lepidus. Conflict emerged again. Eventually, Octavius Caesar defeated Antony and became the sole leader of Rome. He was the first Roman emperor, Augustus.

Friday, April 27, 2012

Why did the European alliance systems develop before World War I?

In the late 1800's, there was a lot of distrust between the major powers of Europe.  A lot of the tension was caused because of competition for colonies in Africa.  Nations formed alliances as a result of this distrust and to protect themselves from aggression.  Germany, Austria-Hungary and Italy formed the Triple Alliance (1882) because of their dislike of France and Russia.  Germany, in particular, was surrounded on both sides by these powers and felt the need to expand its military power through the alliance.  France and Russia responded by forming an alliance twelve years later.  These alliances also were formed to forge economic ties through trade agreements but were mostly aimed at military protection.   By 1907, Britain, France, and Russia formed a formal alliance that would endure until the beginning of World War I.  Germany and Austria-Hungary were committed to their Alliance for the duration of World War I, but Italy would join the side of Britain and France.  So while the Alliances were initially created to forge a sense of security, they actually led to a very large conflict in Europe.  

Thursday, April 26, 2012

What is blood pressure?


Structure and Functions

When the left ventricle of the heart beats, it pumps five liters of
blood per minute to the aorta, through the arteries, and into the arterioles. As
these blood vessels decrease in diameter, they create resistance to blood flow and
the pressure of the blood against their walls increases. This blood pressure is
expressed as two numbers measured in millimeters of mercury (mmHg) by a
sphygmomanometer. The first number, called the systolic
pressure, is the maximum pressure that occurs when the heart contracts and the
ventricle is emptying its blood. The second number, called the diastolic pressure,
is the minimum pressure that occurs when the heart relaxes and the ventricle is
filling with blood before the next contraction.



Blood pressure depends on the strength of the heart muscle, the volume and
thickness of blood being pumped, and the diameter and flexibility of the blood
vessels, all of which may vary with age, health, and physical condition. Blood
pressure is also affected by activity, diet, hydration, emotional stress, physical
pain, tobacco use, weight (including pregnancy), abrupt changes in body position,
and medication and drugs (including caffeine and alcohol).


Blood pressure is a commonly measured indicator of the body’s state of health,
along with body temperature, pulse rate (number of heartbeats per minute), and
respiratory rate (number of breaths per minute). It can be measured noninvasively
using a sphygmomanometer, which may be electronic and automatic or mercury-based
and require manual inflation and deflation. With the patient seated or lying down,
an inflatable cuff is wrapped firmly around the upper arm at the level of the
heart with the lower edge of the cuff 1 inch above the crease in the elbow. The
arm should be bare and any sleeve should be pushed or rolled up without
constricting circulation. If the meter is electronic, then the cuff will
automatically inflate and deflate when activated and a digital reading will be
displayed. If the meter is manual, then a health care provider will place the bell
of a stethoscope over the large artery on the inside of the elbow, just below the
cuff. The cuff is then inflated by quickly squeezing a rubber bulb until the gauge
reads 10–30 mmHg higher than the expected systolic pressure but no higher than 210
mmHg. No sound should be heard through the stethoscope. A valve is opened so that
the cuff deflates slowly; the pressure reading should drop 2–3 mmHg per second.
When the sound of pulsing blood is first heard through the stethoscope, the
reading on the gauge is the systolic pressure. As the cuff continues to deflate,
this sound will disappear and the reading on the gauge at that point is the
diastolic pressure. Blood pressure should be checked at least every year or two.
It should be checked more often during illnesses and medical treatments.




Disorders and Diseases

The average blood pressure for healthy adults is 120 over 80 mmHg (written as
120/80). A systolic pressure of 120 to 139 mmHg or a diastolic pressure of 80 to
89 mmHg is considered to be slightly elevated, a condition called prehypertension.
A systolic pressure of at least 140 mmHg or a diastolic pressure of at least 90
mmHg is considered to be elevated, a condition called hypertension.
In some cases, hypertension has no known direct medical cause; however, in other
cases, it is secondary to other health conditions such as kidney disease.
Potential risk factors for hypertension include obesity;
anxiety, trauma, or pain; poor cardiovascular fitness; obstetric disorders such as
preeclampsia; sickle cell crisis; pancreatitis; medications such as oral
contraceptives, beta-2 agonists, and monoamine oxidase inhibitors; drugs such as
caffeine, cocaine, amphetamines; and withdrawal from alcohol or opiates. Chronic
hypertension is a risk factor for heart attack, stroke, and
aneurysm.


The goal of hypertension treatment is to get the resting blood pressure below
140/90. In some cases, this may be accomplished solely with lifestyle changes,
which should be tried before drug therapy is begun. These lifestyle changes
include discontinuing alcohol consumption and tobacco use, reducing dietary salt
and sugar intake, eating foods low in saturated fat, performing regular
low-intensity exercise such as walking, and getting sufficient sleep and stress
relief. When these changes alone are insufficient, one or more medications may be
prescribed, such as diuretics, beta-blockers, calcium-channel blockers, or
angiotensin-converting enzyme (ACE) inhibitors.


While hypertension is diagnosed from specific elevated blood pressure
measurements, hypotension is diagnosed by symptoms of low blood flow
rather than solely by blood pressure numbers. These symptoms include
light-headedness, weakness, visual disturbance, and fainting.


To increase the volume and thickness of blood being pumped, patients with
hypotension are typically instructed to drink more liquids (excluding caffeinated
and alcoholic beverages) and ingest more salt. They must also avoid dehydration
from excess sweating and hot showers or baths. To improve the resistance in blood
vessels, patients may wear compression stockings and should regularly perform
moderate exercise. Little is known about the causes of hypotension and few
medications are available to raise low blood pressure safely.




Perspective and Prospects

Direct measurement of arterial blood pressure was first reported by Reverend
Stephen Hales in 1733. He inserted a glass tube in a horse’s artery and found that
the column of blood rose to a vertical height of more than eight feet. Pressures
were later measured with columns of water and saline, but they still required an
unwieldy length of tube. Eventually, a mercury column was used because mercury is
more than thirteen times as dense as water and the column length was more
manageable. Sphygmomanometers today no longer use mercury, but the standard unit
of mmHg remains.




Bibliography


Alwan, Heba, et al. "Epidemiology of Masked
and White-Coat Hypertension: The Family-Based SKIPOGH Study." PLoS
One
9.3 (2014): E92522. Web. 21 Aug. 2014.



Beune, Erik J. A. J., et al. "Culturally
Adapted Hypertension Education (CAHE) to Improve Blood Pressure Control and
Treatment Adherence in Patients of African Origin with Uncontrolled
Hypertension: Cluster-Randomized Trial." PLoS One 9.3
(2014): E90103. Web. 21 Aug. 2014.



Fortmann, Stephen P.,
and Prudence E. Breitrose. The Blood Pressure Book: How to Get It
Down and Keep It Down
. 3rd ed. Boulder: Bull, 2006.
Print.



Gatzoulis, Michael A.
OCL Pulmonary Arterial Hypertension. Oxford: Oxford UP,
2011. Print



Humbert, Marc, et al.
Pulmonary Vascular Disorders. Basel: Karger, 2012.
Print.



Kowalski, Robert E.
The Blood Pressure Cure: Eight Weeks to Lower Blood Pressure
without Prescription Drugs
. Hoboken: Wiley, 2008.
Print.



Rubin, Alan L.
High Blood Pressure for Dummies. Hoboken: Wiley, 2010.
Print.



Shibao, Cyndya, et al.
"Evaluation and Treatment of Orthostatic Hypotension." Journal of
the American Society of Hypertension
7.4 (2013): 317–24.
Print.

Wednesday, April 25, 2012

What is hygiene?


Definition

Hygiene involves more than cleanliness; it encompasses the habits humans practice to reduce the risk of receiving and transmitting infectious diseases.






Types of Hygienic Practice


Handwashing. Studies have shown that handwashing is the single most effective way to protect oneself from illness and to avoid passing microorganisms to others. Hands should be washed often, particularly before preparing food; after handling uncooked meat; before eating; after using the toilet; after changing a diaper; after sneezing, coughing, or blowing one’s nose; before inserting and removing contact lenses; after gardening or working in dirt or soil; and after touching animals or cleaning up after them. The Centers for Disease Control and Prevention (CDC) notes that this crucial form of prevention may not always be an option in lower income countries, where clean water and soap are not abundant resources, a reality that often contributes to the rapid spread of disease.


One should wash hands in clean, preferably warm, running water with a lathering liquid or bar soap. Hands should be rubbed together, making sure the soap contacts all skin surfaces, for a minimum of fifteen to twenty seconds. The soap should then be rinsed off with running water. Hands may be dried with a clean cloth towel, paper towel, or air dryer.


If soap and water are not available, one can use an alcohol-based hand sanitizer. Hands should be rubbed together until the alcohol evaporates and the hands are dry.



Showering and bathing. Bathing or showering with comfortably hot, clean water and liquid or bar soap that lathers removes dirt and sweat that contain microorganisms and also moisturizes the skin to create a more efficient barrier. Clean and moisturized skin also promotes the healing of cuts, abrasions, burns, and rashes.



Oral hygiene. Brushing and flossing one’s teeth after meals
protect the teeth and gums from dental caries, or cavities, and
periodontal disease. Regular visits to a dentist and dental hygienist keep the
oral cavity clean and allow for the early detection and treatment of tooth, gum,
and mouth diseases.



Covering coughs and sneezes. When a person sneezes or coughs,
saliva and other mucus containing bacteria and viruses are released as
droplets into the air. To limit transmission, sneezes and coughs should be covered
using a disposable tissue, a handkerchief, one’s sleeve, or one’s hand, which
should be washed as soon as possible after coughing or sneezing into it.



Environmental hygiene. Housekeeping is important because disinfecting surfaces, especially in the kitchen and bathroom, kills disease-causing bacteria. All cloth towels should be washed in hot water with detergent. Dishes should be washed with dish soap and hot water.




Impact

Hygiene practices, especially handwashing, reduce the incidence of illness, lower the cost of medical care associated with illness, decrease the number of lost days from work and school, and potentially save lives.




Bibliography


American Medical Association. “Hand Washing, Alcohol-Based Rubs Help Curb Influenza Outbreaks.” American Medical News 52.6 (2009). Print.



Centers for Disease Control and Prevention. An Ounce of Prevention Keeps the Germs Away: Seven Keys to a Safer, Healthier Home. Atlanta: CDC, 2002. Print.



Heymann, David L., ed. Control of Communicable Diseases Manual. 18th ed. Washington, DC: Amer. Public Health Assn., 2004. Print.



"Hygiene in Lower Income Countries." Centers for Disease Control and Prevention. CDC, 24 June 2014. Web. 31 Dec. 2015.



Marriot, Norman G., and Robert B. Gravani. Principles of Food Sanitation. 5th ed. New York: Springer, 2006. Print.



Wallace, Robert B., ed. Maxcy-Rosenau-Last Public Health and Preventive Medicine. 15th ed. New York: McGraw, 2007. Print.

What is psychosurgery?


Introduction

In the early twentieth century, the treatment of mental disease was limited to psychotherapy for neurotics and long-term care of psychotics in asylums. In the 1930’s, these methods were supplemented by physical approaches using electroconvulsive therapy (ECT), or shock therapy, and brain operations. The operations, psychosurgery, were in vogue from the mid-1930s to the mid- to late 1960s. They became, and still are, hugely controversial, although their use had drastically declined by the last quarter of the twentieth century. Controversy arose because, for its first twenty-five years of existence, crude psychosurgery was too often carried out on inappropriate patients.












ECT developed after the 1935 discovery that schizophrenia
could be treated by convulsions induced through camphor injection. Soon, convulsion production was accomplished by passage of electric current through the brain, as described in 1938 by Italian physicians Ugo Cerletti and Lucio Bini. ECT was most successful in alleviating depression and is still used for that purpose. In contrast, classic psychosurgery by bilateral prefrontal leukotomy (lobotomy) is no longer done because of its bad effects on the physical and mental health of many subjects. These effects included epilepsy and unwanted personality changes such as apathy, passivity, and low emotional responses. It should be remembered, however, that psychosurgery was first planned to quiet chronically tense, delusional, agitated, or violent psychotics.




History and Context of Psychosurgery

Psychosurgery is believed to have originated with the observation by early medical practitioners that severe head injuries could produce extreme changes in behavior patterns. In addition, physicians of the thirteenth to sixteenth centuries reported that sword and knife wounds that penetrated the skull could change normal behavior patterns. Regardless, from the mid-1930s to the mid-1960s, reputable physicians performed psychosurgery on both indigent patients in public institutions and on the wealthy at expensive private hospitals and universities.


Psychosurgery was imperfect and could cause adverse reactions, but it was performed because of the arguments advanced by powerful physician proponents of the method; the imperfect state of knowledge of the brain at the time; the enthusiasm of the popular press, which lauded the method; and many problems at overcrowded mental hospitals. The last reason is thought to have been the most compelling, as asylums for the incurably insane were hellish places. Patients were beaten and choked by attendants; incarcerated in dark, dank padded cells; and subjected to many other indignities. At the same time, little could be done to cure them.




Lobotomy

The two main figures in psychosurgery were António Egas Moniz, the Portuguese neurologist who invented lobotomy, and the well-known American neuropathologist and neuropsychiatrist Walter Freeman, who roamed the world persuading others to carry out the operations. The imperfect state of knowledge of the brain in relation to insanity was expressed in two theories of mental illness. A somatic (organic) theory of insanity proposed it to be of biological origin. In contrast, a functional theory supposed life experiences to cause the problems.


The somatic theory was shaped most by Emil Kraepelin, the foremost authority on psychiatry in the first half of the twentieth century. Kraepelin distinguished twenty types of mental disorder, including dementia praecox (schizophrenia) and manic-depressive (bipolar) disorder. Kraepelin and his colleagues viewed these diseases as genetically determined, and practitioners of psychiatry developed complex physical diagnostic schema that identified people with various types of psychoses. In contrast, Sigmund Freud was the main proponent of the functional theory. Attempts to help mental patients included ECT as well as surgical removal of tonsils, sex organs, and parts of the digestive system. All these methods had widely varied success rates that were often subjective and differed depending on which surgeon used them. By the 1930s, the most widely effective curative procedures were several types of ECT and lobotomy (psychosurgery).


The first lobotomy was carried out on November 12, 1935, at a hospital in Lisbon, Portugal. There, Pedro A. Lima, Egas Moniz’s neurosurgeon collaborator, drilled two holes into the skull of a female mental patient and injected ethyl alcohol directly into the frontal lobes of her brain to destroy nerve cells. After several such operations, the tissue-killing procedure was altered to use an instrument called a leukotome. After its insertion into the brain, the knifelike instrument, designed by Egas Moniz, was rotated like an apple corer to destroy chosen lobe areas.


Egas Moniz—already a famous neurologist—named the procedure prefrontal leukotomy. He won a Nobel Prize in Physiology or Medicine in 1949 for his invention of the procedure. Within a year of his first leukotomy, psychosurgery (another term invented by Egas Moniz) spread through Europe. Justification for its wide use was the absence of any other effective somatic treatment and the emerging concept that the cerebral frontal lobes were the site of intellectual activity and mental problems. The selection of leukotomy target sites was based on two considerations: using the position in the frontal lobes where nerve fibers—not nerve cells—were most concentrated and avoiding damage to large blood vessels. Thus, Egas Moniz targeted the frontal lobe’s centrum ovale, which contains few blood vessels.


After eight operations—50 percent performed on schizophrenics—Egas Moniz and Lima stated that their cure rates were good. Several other psychiatric physicians disagreed strongly. After twenty operations, it became fairly clear that psychosurgery worked best on patients suffering from anxiety and depression, while schizophrenics did not benefit very much. The main effect of the surgery was to calm patients and to make them docile. Retrospectively, it is believed that Egas Moniz’s evidence for serious improvement in many cases was very sketchy. However, many psychiatric and neurological practitioners were impressed, and the stage was set for wide dissemination of psychosurgery.




Lobotomy Procedures

The second great proponent of leukotomy—the physician who renamed it lobotomy and greatly modified the methodology used—was Freeman, professor of neuropathology at George Washington University Medical School in Washington, D.C. In 1936, he tested the procedure on preserved brains from the medical school morgue and repeated Egas Moniz’s efforts. After six lobotomies, Freeman and his associate James W. Watts became optimistic that the method was useful to treat patients exhibiting apprehension, anxiety, insomnia, and nervous tension, while pointing out that it would be impossible to determine whether the procedure had effected the recovery or cure of mental problems until a five-year period had passed.


As Freeman and Watts continued to operate, they noticed problems, including relapses to the original abnormal state, a need for repeated surgery, a lack of ability on the part of patients to resume jobs requiring the use of reason, and death due to postsurgical hemorrhage. This led them to develop a more precise technique, using the landmarks on the skull to identify where to drill entry holes, cannulation to assure that lobe penetration depth was not dangerous to patients, and use of a knifelike spatula to make lobotomy cuts. The extent of surgery also varied, depending on whether the patient involved was suffering from an affective disorder or from schizophrenia. Their method, the “routine Freeman-Watts lobotomy procedure,” became popular throughout the world.


Another method used for prefrontal lobotomy was designed by J. G. Lyerly in 1937. He opened the brain so that psychosurgeons could see exactly what was being done to the frontal lobes. This technique also became popular and was used throughout the United States. Near the same time, in Japan, Mizuho Nakata of Nigata Medical College began to remove from the brain parts of one or both frontal lobes. However, the Freeman-Watts method was most popular as the result of a “do-it-yourself manual” for psychosurgery that they published in 1942. Watts’s book theorized that the brain pathways between cerebral frontal lobes and the thalamus regulate intensity of emotions in ideas, and acceptance of this theory led to better scientific justification of psychosurgery.


Another lobotomy procedure that was fairly widespread was Freeman’s transorbital method, designed not only to correct shortcomings in his routine method but also as an attempt to aid many more schizophrenics. The simple, rapid, but frightening procedure drove a transorbital leukotome (similar in appearance to an ice pick, thus the popularity of the term "ice pick lobotomy" for the procedure) through the eye socket, above the eyeball, and into the frontal lobe. Subjects were rendered unconscious with ECT, and the procedure was done before they woke up. Use of this method gained many converts and, gruesome as it sounds, the method caused less brain damage than other psychosurgery procedures. It was widely used at state hospitals for the insane and was lauded by the press as making previously hopeless cases normal immediately.


Subsequently developed stereotaxic surgical techniques, such as stereotactic cingulatory, enabled psychosurgeons to create much smaller lesions by means of probes inserted into accurately located brain regions, followed by nerve destruction through the use of radioactive implants or by cryogenics. Currently, psychosurgery is claimed to be an effective treatment for patients with intractable depression, anxiety, or obsessional problems and a method that improves the behavior of very aggressive patients. Opponents say that these therapeutic effects can be attained by means of antipsychotic and antidepressant drugs. The consensus is that psychosurgery can play a small part in psychiatric treatment when long-term use of other treatments is unsuccessful and patients are tormented by mental problems.




Mode of Action of Psychosurgery

Collectively, the brain’s limbic system is composed of the hippocampus, amygdala, hippocampal and cingulate gyri, limen insulae, and posterior orbital regions of cerebral frontal lobes. This system, its components linked by nerve pathways, controls emotional expression, seizure activity, and memory storage and recall. Moreover, cerebral lobe limbic system connections from the dorsal convexity of a frontal lobe comprise two pathways running to the cingulate gyrus and hippocampus and the hypothalamus and midbrain. The frontal lobe orbital surface also projects to the septal area of the hypothalamus. The limbic brain architecture therefore yields two neurotransport circuits in a frontolimbic-hypothalamic-midbrain axis. These are a medial frontal, cingulate, hippocampus circuit (MFCHC) and an orbital frontal, temporal, amygdala circuit (OFTAC), which control hypothalamic autonomic and endocrine action. The MFCHC and OFTAC connect in the septa, preoptic area, midbrain, and hypothalamus.


The original Egas Moniz lobotomy divided the frontolimbic structures, and its bad effects were due to the disabling impairment of frontal lobe function. Psychosurgery on the anterior cingulate gyrus and on the thalamofrontal bundle (bimedial leukotomy) divided different parts of the same main circuit. Orbital undercutting severs red nerve tracts running from the posterior orbital cortex to the limbic system. Although psychosurgery is currently an uncommon procedure, when it is performed, the methods used are lower medial quadrant leukotomy, making lesions just before the fourth ventricle; stereotactic-subcaudate-tractotomy, making lesions with rear halves in the subcaudate area; removal of the anterior two inches of the cingulate gyrus; and stereotactic limbic leukotomy, lesioning the lower medial frontal lobe quadrant. These operations cause varied endocrine and autonomic disconnections and are thus chosen to suit the mental condition being treated.




Diagnosis and Treatment

Diagnosis of a need for psychosurgery is based on observation of symptoms supporting abnormal psychological behavior. Examples are extremes of aggression, anxiety, obsession, or compulsiveness, as well as psychoses other than schizophrenia. The exclusion of schizophrenics, except for those having marked anxiety and tension, is based on data supporting poor responses by schizophrenics to lobotomy and other leukotomies. Surveys have shown that good surgical outcomes were obtained in only 18 percent of schizophrenics who underwent lobotomy, as compared with 50 percent of depressives.


Psychosurgery’s unfavorable record between 1935 and 1965, and its postoperative irreversibility, speak to the need for careful study before suggesting such brain surgery. In addition, many members of the medical community believe that the choice of psychosurgery should be based on the long-term nature of symptoms untreatable by other means as well as a severe risk of suicide. In most countries, before psychosurgery is attempted, other methods must be exhausted, such as repeated ECT, prolonged psychoanalysis, and aggressive pharmaceutical treatments with antipsychotic drugs. Some sources suggest, as criteria for choosing psychosurgery, the persistence of symptoms for more than ten years of treatment under conditions where all possible nonsurgical methodology has been exhausted after its aggressive use. Others believe it inhumane to require a decade of illness before allowing the possibility of a cure.


Symptom severity is another hugely important criterion for psychosurgery. Examples of this are the complete inability to work at a job or carry out household chores, as well as long-term and severe endogenous depression. It is also suggested that patients who have strong psychological support from their families and stable environments are the best candidates. Careful assessment of patient symptoms, handicaps, and problems should always be carried out. Formal rating scales, personality assessment via school and work records, and information coming from close relatives or friends are also viewed as crucial.


In most of the world, the use of psychosurgery has declined sharply throughout the late twentieth and early twenty-first centuries and is limited to a very small number of patients not helped by existing chemotherapeutic or psychoanalytical methodology. Only a few countries, such as China and Russia, continue to perform psychosurgery regularly. A wide variety of new techniques have made psychosurgery capable of destroying smaller and smaller targets. In the twenty-first century, the focus of psychosurgery research has also begun to shift from the destruction of brain tissue to the stimulation of said tissue using implanted electrodes. As knowledge of the brain and its functioning increases, it appears possible that modern psychosurgery may yet prove to be useful where other methods fail.




Bibliography


Dully, Howard, and Charles Fleming. My Lobotomy. New York: Three Rivers, 2008. Print.



El-Hai, Jack. The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness. Hoboken: Wiley, 2007.



Fulton, John F. Frontal Lobotomy and Affective Behavior: A Neuropsychological Analysis. New York: Norton, 1951. Print.



Illes, Judy, and B. J. Sahakian. The Oxford Handbook of Neuroethics. Oxford: Oxford UP, 2011. Print.



Lader, Malcolm H., and Reginald Herrington. Biological Treatments in Psychiatry. 2d ed. New York: Oxford UP, 1996. Print.



Raz, Mical. The Lobotomy Letters: The Making of American Psychosurgery. Rochester: U of Rochester P, 2013. Print.



Rodgers, Joann Ellison. Psychosurgery: Damaging the Brain to Save the Mind. New York: Harper, 1992. Print.



Sachdev, Perminder S., and Xiaohua Chen. "Neurosurgical Treatment of Mood Disorders: Traditional Psychosurgery and the Advent of Deep Brain Stimulation." Current Opinion in Psychiatry 22.1 (2009): 25–31. Print.



Turner, Eric A. Surgery of the Mind. Birmingham: Carmen, 1982. Print.



United States. Department of Health and Human Services. Public Health Service. Stereotactic Cingulotomy as a Means of Psychosurgery. By Ernes Feigenbaum. Rockville: n.p., 1985. Print.



Valenstein, Elliot S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic, 1986. Print.



Valenstein, Elliot S., ed. The Psychosurgery Debate: Scientific, Legal, and Ethical Perspectives. New York: Freeman, 1980. Print.

What does it mean when someone says, "speak and give your child a father" to Hester?

In Chapter Three, Reverend Dimmesdale and the other ministers attempt to compel Hester to name her co-sinner, the father of her young baby.  Although she has just been released from prison and is beginning the next stage of her punishment for the crime of adultery, she refuses to give his name because she would prefer to "'endure his agony, as well as [her own].'"  


Someone from the crowd yells to her on the scaffold to "'Speak; and give your child a father!'"  This person obviously believes that the appropriate thing for her to do is confess the name of her child's father because her child will never be able to have a father if she is unwilling to name the man.  Only if she speaks his name will he be able to come forward and claim his place as the father of her child, a position that is his responsibility.  Hester's response is that her child will have her heavenly Father, and that is all.

Tuesday, April 24, 2012

How does the poem's lack of title impact it?

The lack of title for this poem means that the reader has little idea what the poem could refer to or discuss when it begins.  We are, figuratively, in the dark as far as what the poem seeks to address or how it will address it.  Poem titles, as opposed to titles of novels or plays, tend to carry more meaning and can even provide some insight into the topic of the text that we wouldn't otherwise have.  


However, this poem, rather than lead with such a hint, begins immediately with an imperative statement, and starting with such a command helps to strengthen the intensity of the opening line.  The directive, "Do not [...]," helps to immediately establish the mood of the poem as demanding and even a little beseeching.

What was the eventual fate of Ptolemy XII?

Ptolemy XII was a king of Egypt who was a Macedonian.  During his time as king, he maintained strong relations with Rome.  Egypt eventually became a client kingdom of Rome.  This meant that for the good of the kingdom, they submitted to Rome's authority.  Under this system, they could have Rome's protection, and also avoid invasion by Rome itself.


Eventually, the citizens of Alexandria rose up against Ptolemy because they disagreed with his decisions to align himself with Rome.  They forced him to leave Egypt, and he found sanctuary in Rome.  Meanwhile, his daughter ruled in his place.  Ptolemy tried to unsuccessfully to gain the support of the Romans to help him reclaim his throne from his daughter.  He finally found Aulus Gabinius, who was a military commander.  He paid him to help attack his kingdom with an army.  He then reclaimed the throne and had his daughter executed.  He died shortly after he became king again.

What is substance abuse?


Overview

According to the 2014 US National Survey on Drug Use and Health, an estimated 27.0 million Americans aged twelve years and older (10.2 percent of the population) used illicit drugs within one month of the survey. This total includes psychoactive prescription drugs used for nonmedical reasons.




Marijuana was the most commonly used illegal drug in 2014, followed by the nonmedical use of prescription-type psychotherapeutics (including pain relievers, tranquilizers, stimulants, and sedatives), cocaine, and hallucinogens. Drug abusers comprise all ages. Many abused substances have addictive properties; the user becomes dependent on the regular use of the substance and experiences withdrawal symptoms when use is discontinued. Symptoms of withdrawal range from depression and anxiety to seizures, depending on the substance of abuse and the length of use.


Society has determined that the use of illegal substances is harmful; thus, laws are applied to protect both the individual and society from the harmful consequences of their use.




Abuse of Legal Substances




Tobacco

Tobacco can be smoked or chewed. Nicotine, contained in tobacco, is highly addictive; it is a psychoactive substance that produces temporary physical and mood-altering effects in the brain. Nicotine also is a vasoconstrictor (blood vessel constrictor); thus, it increases the risk of cardiovascular disease.


Tobacco also is a well-known carcinogen, and tobacco’s use is the
leading cause of preventable illness and death in the United States. There are a
number of known tobacco-related cancers. In addition to lung, throat, and
mouth cancer, tobacco has been associated with cancers of the nasal cavity,
esophagus, stomach, pancreas, breast, kidney, bladder, and cervix. The smoking of
tobacco results in lost time at work either because of smoking breaks or because
of respiratory illnesses, which are more common in smokers.


According to the US National Cancer Institute and the Centers for Disease Control and Prevention:


•Cigarette smoking causes an estimated 480,000 deaths each year, including approximately 42,000 deaths from exposure to secondhand smoke (2015).


•Lung
cancer is the leading cause of cancer death among both men
and women in the United States; 90 percent of lung cancer cases are linked to
cigarette smoking in the United States.


•Persons who smoke are up to six times more likely than nonsmokers to have a heart
attack, and the risk increases with the number of cigarettes smoked. Smoking also
causes most cases of chronic lung disease, including chronic obstructive pulmonary
disease (COPD).


•In 2013, approximately 17.8 percent of adults in the United States were cigarette smokers. Approximately 20.5 percent of American men and 15.3 percent of American women were current cigarette smokers in 2013, according to the US Centers for Disease Control and Prevention.


•In 2013, 15.7 percent of high school students were current cigarette smokers, the lowest rate in twenty-two years.





Alcohol

Alcohol consumption involves the ingestion of ethanol (C2H5OH), which is a component of alcoholic beverages (beer, wine, and hard liquor). Alcoholism is a chronic condition in which a person is dependent upon regular ingestion of alcoholic beverages. Alcoholics are unable to control their drinking and continue to drink even though doing so interferes with their health, interpersonal relationships, or work.


Alcohol abuse refers to excessive drinking—enough to cause problems in daily life—without complete dependence upon the substance. The combination of alcohol abuse and tobacco use markedly increases the risk of cancers of the oral cavity. Approximately 50 percent of cancers of the mouth, pharynx (throat), and larynx (voice box) are associated with heavy drinking. Even in nonsmokers, a strong association exists between alcohol abuse and cancers of the upper digestive tract, including the esophagus, the mouth, the pharynx, and the larynx.





Prescription Medication


Prescription drug abuse involves the ingestion of medication that has been obtained without a prescription or that is used inappropriately (that is, not according to prescription instructions). According to the 2010 National Survey on Drug Use and Health, 2.4 million Americans used prescription drugs nonmedically for the first time within the past year, averaging 6,600 initiates per day.


Not infrequently, prescription drug abusers take medication with alcohol or
combine stimulants and depressants. These combinations increase the risk of
permanent damage to the user’s health or death. Commonly abused types of
prescription medications include opioids such as hydrocodone
(Vicodin), oxycodone (OxyContin, Percocet), and morphine;
central nervous system depressants, including benzodiazepines such as alprazolam (Xanax) and diazepam
(Valium), barbiturates such as phenobarbital (Luminal Soduim and
pentobarbital (Nembutal), and non-benzodiazepine sleep medications such as
zolpidem (Ambien) and eszopiclone (Lunesta); and stimulants
such as dextroamphetamine (Dexedrine) and methylphenidate (Ritalin). Narcotics and
central nervous system depressants cause drowsiness and respiratory depression;
stimulants can cause seizures, irregular heartbeat, paranoia, and dangerously
elevated body temperatures.


In some cases, a prescription may be obtained from a health care professional by feigning symptoms such as pain; however, most health care professionals are adept at spotting a drug abuser. Most abused prescription medication is purchased from a drug trafficker or stolen by the user.




Abuse of Illegal Substances

Illegal substances have the added risk of containing contaminants, which can
increase the health risk. For example, marijuana may be mixed with phencyclidine
(PCP). PCP was developed as an anesthetic, but its medical use was discontinued a
few years after its introduction because of its harmful effects on the brain. It
is not uncommon for an abuser of illegal substances to combine a drug with other
illegal substances, prescription drugs, or alcohol.





Marijuana

Smoked marijuana and smoked tobacco are chemically similar; thus, like cigarettes, the greatest health hazard of marijuana is from smoking the substance. The psychoactive component of marijuana leaves is delta-9-tetrahydrocannabinol (THC), which is a relatively safe drug. However, smoked marijuana is a health risk. Scientific analyses have identified a minimum of six thousand of the same chemicals in marijuana smoke that are present in tobacco. The chief difference between the two plants is that marijuana contains THC and tobacco contains nicotine. Moreover, one of the most potent carcinogens in tobacco smoke, Benzo[a]pyrene, is present in larger quantities in marijuana smoke.


Another factor increasing the carcinogenic risk is in the way it is inhaled. Marijuana smokers frequently inhale and hold the smoke in their lungs for an extended time to increase the drug’s effects; this practice increases the amount of tar deposited in the respiratory tract by about a factor of four.





Cocaine and Crack Cocaine


Cocaine is the most abused central
nervous system stimulant in the United States and is a frequent cause of emergency
room visits. Ingestion of cocaine can produce seizures, strokes, or heart attacks.
Some users claim that it is not addictive because it does not produce physical
withdrawal symptoms, which do occur with alcohol or heroin addiction. However,
cocaine has powerful psychological addictive properties. Users will often go to
extraordinary lengths to obtain the drug.





Methamphetamine


Methamphetamine is a highly addictive
street drug that can be readily and inexpensively manufactured from the
ingredients of common household products. Psychological effects of the substance
include agitation, depression, euphoria, mood disturbances, psychosis, and violent
behavior. In addition to being less expensive than cocaine, its effects are longer
lasting.


The use of methamphetamine can result in permanent injury to the brain, heart, and lungs. Furthermore, the volatile substances used in its manufacture can lead to fires and explosions.





Heroin


Heroin (diacetylmorphine) is a potent
analgesic (painkiller). It is abused for the intense euphoria it produces. It is
highly addictive, as tolerance to the drug develops quickly. As a result, users
need more of the drug to achieve the same effects. When injected intravenously,
heroin produces a greater degree of euphoria than other opiates, such as
morphine.




Treatment

Many substance abusers either deny that they have a problem or simply state that
the pleasure derived from the substance outweighs the negative impact on their
life; thus, treatment is often initiated by a triggering event or by the urging of
another person.


A triggering event may be conviction for driving under the influence, a health
condition (such as pancreatitis or cirrhosis of the liver), a threat of
divorce, a threat of a job loss, or a threat of loss of child custody. A spouse,
relative, coworker, or boss may be influential in initiating treatment. However,
some substance abusers ignore a triggering event or advice from others and
continue to abuse substances.


A number of treatment options are available to substance abusers. These vary markedly by the type of substances and by individual circumstances. In some cases, a brief intervention by a health care professional may be sufficient. Other cases require enrollment in an outpatient program, which includes counseling. More severe cases require an inpatient program.


The following steps are involved in treatment for persons requiring inpatient or intensive outpatient treatment:



Detoxification. For most drug addictions, detoxification (also called detox) is necessary. Sedatives
are often necessary to reduce withdrawal symptoms, which may include shaking,
confusion, or hallucinations. Withdrawal may last one or two weeks and may require
inpatient care at a hospital or a treatment center.



Reprogramming. A recovering substance abuser, with the help of
professionals skilled in substance abuse treatment, learns new skills and
formulates a treatment plan. The plan should include behavior-modification
techniques, counseling, goal setting, and use of self-help manuals or Internet
resources.



Psychological counseling. Counseling on an individual or a group
basis is an essential treatment component. Group
therapy is particularly valuable because it allows
interaction with other substance abusers. It promotes the idea that one’s problems
are not unique. Therapy may include the presence of a spouse or other family
members. Family support is a significant component of the recovery process.



Medication. Following medication for detox, long-term
pharmaceutical treatment may be used in some cases. Oral medications such as
disulfiram, acamprosate, and naltrexone are used for the treatment
of alcoholism. These medications produce unpleasant physical reactions such as
flushing, headaches, nausea, and vomiting. Methadone is commonly used in the treatment of heroin
addiction; however, its use is controversial. Critics claim that treating
recovering addicts with methadone is simply substituting one addictive drug for
another. Despite this opinion, many former addicts claim that they never could
have ended their heroin habit without help from methadone.



Follow-up support. Aftercare programs and support groups are
essential for the recovering substance abuser. These programs help the abuser to
avoid (or manage) relapses and deal with the necessary lifestyle changes to
maintain a drug-free existence. For alcoholics, regular attendance at a support
group such as Alcoholics Anonymous (AA) is often an important component of
follow-up care. Follow-up often includes psychological and medical care.


Substance abuse commonly is a component of other mental health disorders. For persons with mental health issues, psychological counseling or psychotherapy may be recommended. Substance abusers also can have medical conditions that require treatment. These conditions include hypertension (high blood pressure), diabetes, heart disease, and liver disease (such as cirrhosis of the liver). If a substance abuser remains drug-free, some medical conditions may decrease in severity or may resolve. Treatment for depression or anxiety also may be a part of follow-up.


Beyond counseling and medication, other modalities may be helpful. For example, in September 2010, researchers at the University of California, Los Angeles, released the results of a clinical trial involving a unique new therapy that applies electrical stimulation to a major nerve emanating from the brain. The technique, trigeminal nerve stimulation, achieved an average of a 70 percent reduction in depression in the eight-week study period.



Inpatient treatment. For persons with a serious substance abuse
problem, inpatient care is often necessary. These programs include detox followed
by counseling, group therapy, and medical treatment. A benefit of an inpatient
program is that it greatly reduces the risk of a patient gaining access to harmful
substances. Regular outpatient follow-up also is essential.


Many medical centers include treatment for substance abuse. Stand-alone facilities
also are present throughout the United States and other developed nations. Some
provide care in a basic, clinical setting while others function in a resort-like
setting. One well-known facility is the Betty Ford Center
in Rancho Mirage, California, which was founded by former US first lady Betty
Ford. The nonprofit residential facility offers inpatient, outpatient, and day
treatment for recovering substance abusers and addicts. It also provides
prevention and education programs for family members (including children) of
substance abusers and addicts.



Support groups. A variety of support groups are available to a
substance abuser who admits he or she has a problem. Treatment centers may have
their own support groups or may refer patients to outside programs they deem
suitable. A recovering alcoholic may have to try a variety of resources before
finding the best fit.



Religious support. Churches and synagogues often sponsor support
for recovering alcoholics. Members can use available services, which are often
integrated with other organizations and social services in the community. Although
nonsectarian and nondenominational, AA is a faith-based organization as
exemplified by its twelve-steps program. The twelve steps include the
acknowledgement of the existence of a supreme being.




Genetic Factors

Significant evidence exists that genetic factors are involved in the development of substance abuse and addiction, particularly alcoholism. The interaction of genes and environmental factors that influence substance dependence is a complex scientific topic.


Since 1989, the US-government-funded Collaborative Studies on the Genetics of
Alcoholism (COGA) has been tracking alcoholism in families. COGA researchers have
interviewed more than 14,000 people and sampled the DNA of 300 extended families.
They have found evidence for the existence of several alcohol-related genes. COGA
researchers are increasingly convinced that different types of alcoholics are
representative of a number of genetic variations.




Social Implications

Substance abuse has a tremendous impact on society. For example, many people are
injured or killed by substance abusers who drive under the influence of one or
more psychoactive substances. Family members of substance abusers suffer from the
emotional and financial burden placed on them by a substance abuser. Furthermore,
substance abusers accrue countless hours of lost and unproductive work.


All developed nations have extensive legislation regarding substance abuse and age limits for legal substances. For example, in the United States the legal drinking age is twenty-one years and the legal smoking age is eighteen years. However, some nations have more lenient restrictions. Some substances deemed illegal by one government are considered legal by another.


An example of a substance with varying degrees of legality is marijuana. The substance is deemed illegal by the US federal government; however, the recreational use of marijuana is legal in Colorado, Washington, Oregon, and Washington, DC. The use of medical marijuana remains a contentious topic. Medical marijuana has been legalized in some US states to allow usage for legitimate medical reasons, such as for glaucoma or for pain relief from cancer. However, there is a concern that the substance will be dispensed for frivolous, nonmedical reasons or diverted for illegal use.




Bibliography


Fisher, Gary, and Thomas Harrison. Substance Abuse: Information for School Counselors, Social Workers, Therapists, and Counselors. 5th ed. Boston: Allyn, 2013. Print.



Ketcham, Katherine, et al. Beyond the Influence: Understanding and Defeating
Alcoholism
. New York: Bantam, 2000. Print.



Larsen, Laura. Drug Abuse Sourcebook. Detroit: Omnigraphics2014. Print.



Liptak, John, and
Ester A. Leutenberg. The Substance Abuse and Recovery
Workbook
. Duluth: Whole Persons, 2008. Print.



Marion, Nancy E., and Willard M. Oliver. Drugs in American Society: An Encyclopedia of History, Politics, Culture, and the Law. Santa Barbara: ABC-CLIO, 2015. Print.



Miller, William.
Rethinking Substance Abuse: What the Science Shows, and What We
Should Do about It
. New York: Guilford, 2010. Print.



Seixas, Judith.
Children of Alcoholism: A Survivor’s Manual. New York:
Harper, 1986. Print.



United States. Substance Abuse and Mental
Health Services Administration. Results from the 2014 National
Survey on Drug Use and Health: Summary of National Findings
.
Rockville: Substance Abuse and Mental Health Services Admin., 2015. PDF
file.

Monday, April 23, 2012

What is incontinence?


Causes and Symptoms

Continence is a skill acquired in humans by the interaction of two processes: socialization of the infant and maturation of the central nervous system. Without society’s expectation of continence, and without broadly accepted definitions of appropriate behavior, the concept of “incontinence” would be meaningless. There are many causes for urinary incontinence. Three broad (interrelated and often overlapping) categories are physiologic voiding dysfunction, factors directly influencing voiding function, and factors affecting the individual’s capacity to manage voiding.




The causes of physiologic voiding dysfunction involve an abnormality in bladder or sphincter function, or both. The bladder and sphincter have only two functions: to store urine until the appropriate time for urination and then to empty it completely. Voiding dysfunction involves the failure of one or both of these mechanisms. Four basic types of voiding dysfunction can be distinguished: detrusor instability, genuine stress incontinence, outflow obstruction, and atonic bladder.


Detrusor instability is a condition characterized by involuntary bladder (detrusor muscle) contraction during filling. While all the causes of bladder instability are not fully understood, it can be associated with the following: neurologic disease (brain and spinal cord abnormalities), inflammation of the bladder wall, bladder outlet obstruction, stress urinary incontinence, and idiopathic (spontaneous or primary) dysfunction. Detrusor instability usually causes symptoms of frequency, urgency, and possibly nocturia or enuresis.


Genuine stress incontinence is caused by a failure to hold urine during bladder filling as a result of an incompetent urethral sphincter mechanism. If the closure mechanism of the bladder outlet fails to hold urine, incontinence will occur. This is usually manifested during physical exertion or abdominal stress (such as coughing or sneezing). It can occur in either sex, but it is more common in women because of their shorter urethra and the physical trauma of childbirth. Men can experience stress incontinence following traumatic or surgical damage to the sphincter.


Obstruction of the outflow of urine during voiding can produce various symptoms, including frequency, straining to void, poor urinary stream, preurination and posturination dribbling, and a feeling of urgency with resulting leakage (urge incontinence). In severe cases, the bladder is never completely emptied and a volume of residual urine persists. Overflow incontinence can result. Common causes of bladder outlet obstruction are prostatic enlargement, bladder neck narrowing, or urethral obstruction. Functional obstruction occurs when a neurologic lesion prevents the coordinated relaxation of the sphincter during voiding. This phenomenon is termed detrusor-sphincter dyssynergia.


An atonic bladder—one with weak muscle walls—does not produce a sufficient contraction to empty completely. Emptying can be enhanced by abdominal straining or manual expression, but a large residual volume persists. The sensation of retaining urine might or might not be present. If sensation is present, frequency of urination is common because only a small portion of the bladder volume is emptied each time. Sensation is often diminished, and the residual urine volume can be considerable (100 to 1,000 milliliters). Overflow incontinence often occurs.


An acute urinary tract infection can cause transient incontinence, even in a fit, healthy young person who normally has no voiding dysfunction. Acute frequency and urgency with disturbed sensation and pain can result in the inability to reach a toilet in time or to detect when incontinence is occurring. If an underlying voiding dysfunction is also present, an acute urinary tract infection is likely to cause incontinence.


Many drugs can also disturb the delicate balance of normal functioning. The most obvious category consists of diuretics, those drugs that increase urinary discharge; a large, swift production of urine will give most people frequency and urgency. If the bladder is unstable, it might not be able to handle a sudden influx of urine, and urge incontinence can result. Sedation can affect voiding function directly (for example, diazepam can lower urethral resistance) or can make the individual less responsive to signals from the bladder and thus unable to maintain continence. Other commonly prescribed drugs have secondary actions on voiding function. Not all patients, however, will experience urinary side effects from these drugs.


Various endocrine disorders can upset normal voiding function. Diabetes can cause polydypsia (extreme thirst), requiring the storage of a large volume of urine. Glycosuria (sugar in the urine) might encourage urinary tract infection. Thyroid imbalances can aggravate an overactive or underactive bladder. Pituitary gland disorders can result in the production of excessive urine volumes because of an antidiuretic hormone deficiency. Estrogen deficiency in postmenopausal women causes atrophic changes in the vaginal and urethral tissues and will worsen stress incontinence and an unstable bladder.


Several bladder pathologies can also cause incontinence by disrupting normal functioning. A patient with a neoplasm (abnormal tissue growth), whether benign or malignant, or a stone in the bladder occasionally experiences incontinence as a symptom. These are infrequent causes of incontinence.


Often it takes something else in addition to the underlying problem to tip the balance and produce incontinence. This is especially true for elderly and disabled persons who are delicately balanced between continence and incontinence. For example, immobility—anything that impedes access—is likely to induce incontinence. Immobility can be the result of the gradual worsening of a chronic condition, such as arthritis, multiple sclerosis, or Parkinson’s disease, until eventually the individual simply cannot reach a toilet in time. The condition may be acute—an accident or illness that suddenly renders a person immobile might be the start of failure to control the bladder.


In the case of children, most daytime wetting persists until the child reaches school age. It is less common than bedwetting (enuresis), and the two often go together. One in ten five-year-old children, however, still wets the bed regularly. With no treatment, this figure gradually falls to 5 percent of ten-year-olds and to 2 percent of adults. It is twice as common in boys as in girls, has strong familial tendencies, and is associated with stressful events in the third or fourth year of life. A urinary tract infection is sometimes the cause.


Fecal, as opposed to urinary, incontinence is generally caused by underlying disorders of the colon, rectum, or anus; neurogenic disorders; or fecal impaction. Severe diarrhea increases the likelihood of having fecal incontinence. Some of the more common disorders that can cause diarrhea are ulcerative colitis, carcinoma, infection, radiation therapy, and the effect of drugs (for example, broad-spectrum antibiotics, laxatives, or iron supplements). Fecal incontinence tends to be a common, if seldom reported, accompaniment.


The pelvic floor muscles support the anal sphincter, and any weakness will cause a tendency to fecal stress incontinence. The vital flap valve formed by the anorectal angle can be lost if these muscles are weak. An increase in abdominal pressure would therefore tend to force the rectal contents down and out of the anal canal. This might be the result of congenital abnormalities or of later trauma (for example, childbirth, anal surgery, or direct trauma). A lifelong habit of straining at stool might also cause muscle weakness.


The medulla and higher cortical centers of the brain have a role in coordinating and controlling the defecation reflex. Therefore, any neurologic disorder that impairs the ability to detect or inhibit impending defecation will probably result in incontinence, similar in causation to the uninhibited or unstable bladder. For example, the paraplegic can lose all direct sensation of and voluntary control over bowel activity. Neurologic disorders such as multiple sclerosis, cerebrovascular accident, and diffuse dementia can affect sensation or inhibition, or a combination of both. Incontinence occurs with some people suffering from dementia because of a physical inability to inhibit defecation. With others, it occurs because the awareness that such behavior is inappropriate has been lost.


Severe constipation with impaction of feces is probably the most common cause of fecal incontinence, and it predominates as a cause among the elderly and those living in extended care facilities. Chronic constipation leads to impaction when the fluid content of the feces is progressively absorbed by the colon, leaving hard, rounded rocks in the bowel. This hard matter promotes mucus production and bacterial activity, which causes a foul-smelling brown fluid to accumulate. If the rectum is overdistended for any length of time, the internal and external sphincters become relaxed, allowing passage of this mucus as spurious diarrhea. The patient’s symptoms usually include fairly continuous leakage of fluid stool without any awareness of control.


Most children are continent of feces by the age of four years, but 1 percent still have problems at seven years of age. Fecal incontinence or conscious soiling in childhood (sometimes referred to as encopresis) has, like nocturnal enuresis (nighttime urinary incontinence), long been regarded as evidence of a psychiatric or psychologic disorder in the child. The evidence, however, does not support the claim that incontinent children are disturbed.


Such children usually have fastidious, overanxious parents who are intent on toilet training. The child is punished for soiling, so defecation tends to be inhibited, both in the underwear and in the toilet. When toilet training is attempted, the child may be repeatedly seated on the toilet in the absence of a full rectum and be unable to perform. The situation becomes fraught with anxiety, and bowel movements become associated with unpleasantness in the child’s mind. The child therefore retains feces and becomes constipated. Defecation then becomes difficult and painful as well.




Treatment and Therapy

The two primary methods of treating urinary incontinence involve medical and surgical intervention (drug therapy and surgery) and bladder training.


Many drugs can be prescribed to help those with urinary incontinence. Often the results are disappointing, although some drugs can be useful for carefully selected and accurately diagnosed patients. Drugs are often used to control detrusor instability and urge incontinence by relaxing the detrusor muscle and inhibiting reflex contractions. This therapy is helpful in some patients. Sometimes when the drug is given in large enough doses to be effective; however, the side effects are often so troublesome that the therapy must be abandoned. Drugs that reduce bladder contractions must be used cautiously in patients who have voiding difficulty, since urinary retention can be precipitated. Careful assessment must be made of residual urine. Drug therapy is also used with caution in patients with a residual volume greater than 100 milliliters. Some drugs are used in an attempt to prevent stress incontinence by increasing urethral tone. Phenylpropanolamine and ephedrine, those most often used, are thought to act on the alpha receptors in the urethra.


Drug therapy can also be used to relieve outflow obstruction. Phenoxybenzamine is commonly used, but this drug can have dangerous side effects, such as tachycardia (an abnormally fast heartbeat) or postural hypotension. If the bladder does not contract sufficiently to ensure complete emptying, drug therapy can be attempted to increase the force of the voiding contractions. Carbachol, bethanechol, and distigmine bromide have all been used with some success. Other drugs might be useful in treating factors affecting incontinence—for example, antibiotics to treat a urinary tract infection or laxatives to treat or prevent constipation.


Many drugs can exacerbate a tendency to incontinence. For those who are prone to incontinence, medications and dosage schedules are chosen that will have a minimal effect on bladder control. For example, a slow-acting diuretic, in a divided dose, can help someone with urgency and weak sphincter tone to avoid incontinence. An analgesic might be preferable to night sedation for those who need pain relief but who wet the bed at night if they are sedated.


Turning to surgical intervention, none of the several surgical approaches that have been used in an attempt to treat an unstable bladder has gained widespread use. Cystodistention (stretching the bladder under general anesthesia) and bladder transection, for example, are presumed to act by disturbing the neurologic pathways that control uninhibited contractions. Many vaginal and suprapubic procedures are available to help correct genuine stress incontinence in women. Surgery can also be used to relieve outflow obstruction—for example, to remove an enlarged prostate gland, divide a stricture, or widen a narrow urethra.


In cases of severe intractable incontinence, major surgery is an option. For those with a damaged urethra, a neourethra can be constructed. For those with a nonfunctioning sphincter, an artificial sphincter can be implanted. In some patients, a urinary diversion with a stoma (outlet) is the only or best alternative for continence. Although a drastic solution, a urostomy might be easier to cope with than an incontinent urethra, because an effective appliance will contain the urine.


Urinary incontinence is occasionally the result of surgery, usually urologic or gynecologic but sometimes a major pelvic or spinal procedure. Such iatrogenic incontinence can be caused by neurologic or sphincter damage, leading to various dysfunctional voiding patterns.


Several different types of bladder training or retraining are distinguishable and can be used in different circumstances. The most important element for success is that the correct regimen be selected for each patient and situation. A thorough assessment identifies those patients who will benefit from bladder training and determines the most appropriate method. Other factors that contribute to the incontinence should also be treated (for example, a urinary tract infection or constipation), because ignoring them will impair the success of a program.


Bladder training is most suitable for people with the symptoms of frequency, urgency, and urge incontinence (with or without an underlying unstable bladder) and for those with nonspecific incontinence. The elderly often have these symptoms. Patients with voiding dysfunction, other than an unstable bladder, are unlikely to benefit from bladder training.


The aim of bladder training is to restore the patient with frequency, urgency, and urge incontinence to a more normal and convenient voiding pattern. Ultimately, voiding should occur at intervals of three to four hours (or even longer) without any urgency or incontinence. Drug therapy is sometimes combined with bladder training for those with detrusor instability.


Bladder training aims to restore an individual’s confidence in the bladder’s ability to hold urine and to reestablish a more normal pattern. Initially, a patient keeps a baseline chart for three to seven days, recording how often urine is passed and when incontinence occurs. This chart is reviewed with the program supervisor, and an individual regimen is developed. The purpose is to extend the time between voiding gradually, encouraging the patient to practice delaying the need to void, rather than giving in to the feeling of urgency. Initially, the times chosen can be at set intervals throughout the day (for example, every one or two hours) or can be variable, according to the individual’s pattern as indicated by the baseline chart. When the baseline chart reveals a definite pattern to the incontinence, it might be possible to set voiding times in accordance with and in anticipation of this pattern.


A pattern of voiding is set for patients throughout the day (timed voiding). Usually no pattern is set at night, even if nocturia or nocturnal enuresis is a problem. Patients are instructed to pass urine as necessary during the night. Sometimes the provision of a suitable pad or appliance helps to increase confidence and means that, if incontinence does occur, the results will not be disastrous. If urgency is experienced, patients are taught to sit or stand still and try to suppress the sensation rather than to rush immediately to the toilet. A normal fluid intake is encouraged because the goal is to have the patient continent and able to drink fluids adequately.


As patients achieve the target intervals without having to urinate prematurely or leaking, the intervals can gradually be lengthened. The speed of progress depends on the individual and on other variables, such as the initial severity of symptoms, motivation, and the amount of professional support. Patients usually remain at one time interval for one to two weeks before it is increased by fifteen to thirty minutes for another two weeks. Once the target of three- to four-hour voiding without urgency has been achieved, it is useful to maintain the chart and set times for at least another month to prevent relapse.


Some people find that practicing pelvic muscle exercises helps to suppress urgency. Any weakness in the pelvic floor muscles will cause a tendency not only to urinary incontinence but also to fecal stress incontinence. Mild weakness can respond to pelvic muscle exercises similar to those used in alleviating the symptoms of stress incontinence, but with a concentration on the posterior rather than the anterior portion of the pelvic muscles. Rectal tone is assessed by digital examination, during which the patient is instructed to squeeze. Regular contractions on the posterior portion of the pelvic muscles are then practiced often for at least two months (usually in sets of twenty-five, three times a day).


In cases of fecal impaction, a course of disposable phosphate enemas—one or two daily for seven to ten days, or until no further return is obtained—is the treatment of choice. A single enema is seldom efficient, even if an apparently good result is obtained, because impaction is often extensive: The first enema merely clears the lowest portion of the bowel. If fecal incontinence persists once the bowel has been totally cleared (a plain abdominal X ray can be helpful in confirming this), the condition is assumed to be neurogenic in origin rather than caused by the impaction.




Perspective and Prospects

Historically, most health professionals have been profoundly ignorant of the causes and management of incontinence. Incontinence was often regarded as a condition over which there was no control, rather than as a symptom of an underlying physiologic disorder or as a symptom of a patient with a unique combination of problems, needs, and potentials. The unfortunate result of such limited understanding was passive acceptance of the symptom of incontinence. Incontinence, often viewed as repulsive, is often a condition that is merely tolerated. As public recognition of the implications of incontinence has increased, however, the stigma associated with it has slowly decreased. It has become common knowledge that millions of Americans suffer from incontinence, and most pharmacies and supermarkets have a section for incontinence products.


At one time, incontinence was primarily regarded as a “nursing” problem, with nurses providing custodial care—keeping the patient as clean and comfortable as possible and preventing pressure ulcers from developing. Gradually, nurses were not alone in acknowledging that incontinence was a symptom requiring investigation and intervention; those in other health professions also began to realize this need. In the 1980s, research funds began to be allocated for the study of incontinence. In 1988, US surgeon general C. Everett Koop estimated that $8 billion was being spent by the federal government on incontinence in nursing homes in the United States annually.


As incontinence began to be recognized by the public as a health problem rather than as an inevitable part of aging, more people admitted having the symptoms of incontinence and sought medical attention. It has been estimated that, of all cases of incontinence, more than one-third can be cured, another one-third can be dramatically improved, and most of the remainder can be significantly improved.




Bibliography


Arnold-Long, Mary. "Fecal Incontinence: An Overview of the Causes, Treatments, and Interventions to Address Bowel Incontinence in the Elderly." Long-Term Living 59.10 (2010): 50–53. Print.



Dierich, Mary, and Felecia Froe. Overcoming Incontinence: A Straightforward Guide to Your Options. New York: Wiley, 2000. Print.



Jeter, Katherine, Nancy Faller, and Christine Norton, eds. Nursing for Continence. Philadelphia: W. B. Saunders, 1990. Print.



Khandelwal, C., and C. Kistler. "Diagnosis of Urinary Incontinence." American Family Physician 87.8 (2013): 543–50. Print.



Nathanson, Laura Walther. The Portable Pediatrician: A Practicing Pediatrician’s Guide to Your Child’s Growth, Development, Health, and Behavior from Birth to Age Five. 2nd ed. New York: Harper, 2002. Print.



Newman, Diane Kaschack. Managing and Treating Urinary Incontinence. 2nd ed. Baltimore: Health Professions Press, 2009. Print.



Parker, William, Amy Rosenman, and Rachel Parker. The Incontinence Solution: Answers for Women of All Ages. New York: Fireside, 2007. Print.



Randall, Brain. "Urinary Incontinence—Male." Health Library, September, 27, 2012.



Stahl, Rebecca J. "Neurogenic Bladder—Child." Health Library, March 1, 2013.



Vasavada, Sandip P., et al., eds. Female Urology, Urogynecology, and Voiding Dysfunction. New York: Marcel Dekker, 2005. Print.

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