What could be used as a thesis statement for "Araby"?

"Araby" is part of the Dubliners series of short stories by James Joyce, who uses his own personal experiences in the creation of his characters and situations. Joyce makes his characters and their descriptions very real by using ordinary examples that the reader can relate to. The reader becomes invested in the outcome as he or she hopes that the boy will be able to impress Mangan's sister. The reader even shares his loss when he comes away from the bazaar disillusioned.

In any essay on fiction, a thesis statement (usually one sentence) is contained in the first paragraph and is intended to reveal the main point of the essay while at the same time ensuring that the writer retains his focus and the reader is inspired to read on. A good thesis statement therefore needs some basic elements which are related to the themes. Consider the main themes which will help form a thesis statement.

In "Araby," a thesis statement could discuss all or any of the main themes (innocence and loss of innocence, alienation, the effect of religion on Irish society, and transformation as the boy takes his first steps towards maturity). In discussing the theme of innocence which dominates the story, the boy makes every effort to keep his promise to Mangan's sister, that he will bring her something from the bazaar. Only once he enters the big hall does he begin to question his intentions and wonder why he has gone to so much trouble as he says, "Remembering with difficulty why I had come..." The boy's obsession with Mangan's sister drives his desires and reveals that loss of innocence can be a painful experience as the boy recognizes his efforts as futile.

What is the theme of the story "The Three strangers" by Thomas Hardy?

Thomas Hardy’s short story “The Three Strangers” is about what happens when three different guys arrive at a party uninvited, one at a time. The first one is a criminal, the second is the hangman who’s scheduled to put the criminal to death, and the third is the criminal's brother.

What’s the theme of the story?

Well, sometimes you define “theme” as “a broad topic that comes into play throughout the story.” In that case, the themes of "The Three Strangers" include hunger, theft, crime, punishment, sympathy, and justice; friendship, family, neighborliness, strangers, and outsiders; births and christenings, etc.

More often, in discussing literature, you define “theme” as “something true about life (or society or humanity) that the story reveals.”

In that case, here are some themes we can take from “The Three Strangers.”

1. People often jump to conclusions and make the wrong assumptions. We need to pay attention to details and not allow ourselves to be unduly influenced by first impressions.

 As you read the story, you’re led to believe that the third stranger who crashes the party is the criminal that everybody’s looking for. And of course, that’s who the townspeople capture. But then they realize that it was really the first stranger who they should have been after, and now they can’t catch him because it’s too dark.

2. Showing good hospitality to others often requires restraint.

As the party goes on, we see that the family who’s hosting it has to make some sacrifices. The guests are drinking too much mead, but the hosts let it happen so that they don’t upset anyone. The musicians keep playing when the hosts asked them to take breaks, but they just let it slide. One guest does something rude and annoying to the hostess, who ignores it. Part of the reason that the party is so much fun is because the hosts are willing to relax and not insist that everything be done a certain way.

3. We can label people with words like “criminal” or “thief,” but that doesn’t change the fact that we’re all still human and have certain things in common.

Toward the end of the story, after the constable has led the townspeople on the hunt for the criminal, two of the strangers sneak back into the house and share a snack together:

“The other had by this time finished the mead in the mug, after which, shaking hands heartily at the door, and wishing each other well, they went their several ways.”

It was the criminal and the hangman! With his “criminal” label shed, the man was just a man, whose company was enjoyed by the other. They ate together, shook hands, and offered kind words to each other.

4. True authority is earned by actions and respect, not conferred by titles or symbols.

Check out how silly and ineffectual the constable is in this story, even though he’s supposedly in charge of the hunt to find the criminal. Here he is, talking about how he can’t start the search unless he has his staff (his stick) with him:

“'But I can't do nothing without my staff--can I, William, and John, and Charles Jake? No; for there's the king's royal crown a painted on en in yaller and gold, and the lion and the unicorn, so as when I raise en up and hit my prisoner, 'tis made a lawful blow thereby. I wouldn't 'tempt to take up a man without my staff--no, not I. If I hadn't the law to gie me courage, why, instead o' my taking up him he might take up me!'”

With this ridiculous speech, the constable reveals how he’s cowardly and how he hides behind the staff as a symbol of authority. He wears a gray uniform and calls himself a king’s man. But none of that confers true authority on him.

It’s important to note that these are the themes that just one reader has noticed in “The Three Strangers.” You could use the content of the story to draw out many other different themes, or you could interpret the ones listed here in different ways.

How are the themes of "There Will Come Soft Rains" and "The Veldt" similar? What are some examples to prove it?

While "The Veldt" is a critique on neglectful parenting, the reason for the neglect is caused by an unhealthy reliance on technology. The general theme of the danger of technology is illustrated in "The Veldt" and "There Will Come Soft Rains." In both stories, technology has advanced to the point when houses are equipped to perform nearly all domestic tasks. In "The Veldt," the family has a Happylife Home: 

 . . . which had cost them thirty thousand dollars installed, this house which clothed and fed and rocked them to sleep and played and sang and was good to them. Their approach sensitized a switch somewhere and the nursery light flicked on when they came within ten feet of it. Similarly, behind them, in the halls, lights went on and off as they left them behind, with a soft automaticity. 

The home in "There Will Come Soft Rains" is equally efficient. It announces the date and schedule for the family. It cooks the food, cleans up messes, and even reads poetry in the evenings. 

The problem, in both stories, is that humans have allowed this technology to overtake their lives. In "The Veldt," George and Lydia have allowed the nursery to become their children's parent. With no mature guidance, their children become spoiled and they eventually use the nursery (technology) to destroy their parents. In "There Will Come Soft Rains," the family has been annihilated by a nuclear explosion. The same principle applies in this story. Humans have utilized technology to destroy themselves. 

Bradbury offers a critique of consumerism in both stories. People buy these homes with the notion that their lives will be easier and they will therefore be happier. There is nothing inherently bad about a home of convenience. But the message in these stories is that if humanity is not thoughtful about the ways they are using (and being used by) technology, the results can be destructive. George and Lydia are guilty of allowing technology to control their lives. Their children become spoiled and destructive. The governments in "There Will Come Soft Rains" have chosen nuclear war to solve their problems. Again, this is a devastating application of technology. 

What is drug resistance?

Causes and Symptoms

Drug resistance occurs whenever microorganisms such as bacteria, viruses, or fungi that have been exposed to a chemical agent develop the ability to resist that agent. The most clinically important form of drug resistance is the ability of bacteria to develop resistance to antibiotics.

An antibiotic attacks a bacterial cell by interfering with a vital biochemical process needed by the organism. Antibiotics generally are engineered to kill bacteria while leaving body cells unharmed. This bacteria-specific approach creates a safe way of killing pathogens while keeping the affected person safe from harm.

Bacteria can develop resistance to an antibiotic in several ways, and that resistance may be propagated through the evolutionary process of natural selection. Selection is the “weeding out” of those individuals in a population who fail to adapt to changing conditions, leaving a smaller number of “tougher” individuals. If environmental pressure (such as an antibiotic treatment) is placed on any population of organisms, the only individuals who will survive and reproduce are those resistant to that pressure.

Resistance to a particular antibiotic arises in a bacterial cell by random genetic mutation. Because a particular cell is genetically altered and survives the antibiotic treatment that destroys other bacteria of the same kind, it is able to survive, unlike its susceptible relatives. The small, resistant population that is left can perpetuate infection despite the presence of antibiotics. Nonpathogenic bacteria, too, are affected by this selective pressure, and the development of antibiotic resistance in organisms that do not ordinarily cause infection can still have a powerful impact on disease processes.

The human body contains billions of bacteria of many different kinds. These bacteria fill large and small environmental niches in the microflora that human beings carry in and on their bodies. When one or more of these susceptible bacteria types are eliminated by an antibiotic, their niches are left empty. This leaves room for the resistant bacteria that are left to multiply in greater numbers. When these surviving organisms grow to such large numbers, the mix of “normal (nonpathogenic) flora” is disturbed, and normally harmless organisms can cause disease in those circumstances. Additionally, some of these organisms may have the ability to transfer resistance genes to pathogenic bacteria.

The ability to resist a particular antibiotic is encoded as genetic information in deoxyribonucleic acid (DNA) molecules. Bacterial DNA is located in a special bacterial chromosome found in the cytoplasm of a bacterial cell. Additionally, bacterial DNA may be found on small, circular fragments of DNA called plasmids. These plasmids are separate from the bacterial chromosome and carry special information needed for the bacteria to survive under adverse environmental conditions. Plasmids carry “mating” genes, which allow the bacteria to transfer a plasmid from one bacteria to another. They also carry genes that make a bacteria resistant to a particular antibiotic. Consequently, plasmids are of particular importance because they allow antibiotic resistance to be transferred between bacteria.

Two bacterial cells may exchange plasmids by direct contact in a process known as conjugation. Not all plasmids can be exchanged in this way, but the genetic information that encodes for resistance may be transferred from a plasmid that cannot be exchanged to one that can. This occurs when a small piece of DNA known as a transposon breaks away from one plasmid and attaches itself to another. A transposon may also break away from a bacterial chromosome and attach itself elsewhere on the chromosome or onto a plasmid.

Antibiotic resistance may also be transferred between bacteria indirectly by a bacteriophage in transduction. A bacteriophage is a virus that attaches itself to a bacterial cell. The virus sometimes incorporates DNA from the invaded bacterial cell into its own DNA. The virus may then transfer this DNA to the next bacterial cell to which it attaches. In this way, it can transfer drug resistance between bacteria that are unable to undergo conjugation.

The various ways in which genetic information can be exchanged between bacteria may result in organisms with resistance to multiple drugs. Some bacteria are known to be resistant to at least ten different antibiotics. They carry a series of genes on their plasmids able to make enzymes that can degrade and destroy antibiotics. For example, bacteria able to resist penicillin treatments carry an enzyme called penicillinase that destroys penicillin, thus protecting the bacteria. Other genes may code for a change in the structure of bacterial sites to which an antibiotic binds, reducing or eliminating its effect.

Frequent exposure to antibiotics increases the evolutionary pressure in bacterial populations and increases the likelihood that resistance will develop. An important factor in the emergence of antibiotic resistance is the misuse of antibiotics. For example, antibiotics have no effect on viruses but are often used against viral illnesses. A study published in 1997 revealed that at least half of all patients in the United States who visited doctors’ offices with colds, upper respiratory tract infections, and bronchitis received antibiotics, even though 90 percent of these illnesses are caused by viruses. The same study showed that almost one-third of all antibiotic prescriptions were used for these kinds of illnesses. It is also important to remember that misuse can include underutilizing prescribed drugs, such as may stem from poor patient compliance with medical directions. Failure to take as directed, typically until the whole course of antibiotics has been consumed, may encourage the development of drug resistance, as the antibiotics will not have the opportunity to exert their full effect on the bacteria causing the problem. The bacteria that survive
the partial course may be more likely to be resistant to that drug, making future administrations less effective.

This misuse of antibiotics has been one of the strongest forces pushing the selection of antibiotic-resistant bacteria—but this is not only because of its use in humans. Specifically, even if doctors stop overprescribing antibiotics, other factors are at work. In 2000, an estimated fifty million pounds of antibiotics were used in the United States; half that amount was used for veterinary and agricultural purposes. Antibiotics are administered in huge doses to farm animals to keep them healthy and allow them to grow larger. These drugs are even being used in the petroleum industry for cleaning pipelines. The World Health Organization (WHO) noted a sharp decrease in the incidence of antibiotic-resistant bacterial strains in Denmark after antibiotic use in livestock was all but eliminated in 1998.

A final factor in the increase in antibiotic resistance is the use and overuse of substandard and counterfeit antimicrobial agents in developing countries. In Nigeria, for example, WHO has estimated that there are twenty thousand unlicensed medical stands scattered throughout the country. These street vendors do not require prescriptions to dose patients. Additionally, the common use of antibiotics in developing nations to “sterilize” households risks the development of cross-resistant bacterial strains.

Several public health concerns have arisen as a result of drug resistance. Since the mid-twentieth century, multiple antibiotic resistance has emerged in bacteria, causing pneumonia, gonorrhea, meningitis, and other serious illnesses.

In the 1980s, drug-resistant tuberculosis emerged as a public health concern. In 1991, in New York City, for example, 33 percent of all tuberculosis infections were resistant to at least one drug, and 19 percent were resistant to both of the most effective drugs used to treat the disease. Because of resistance, many tuberculosis patients require treatment with four drugs for several months. Some patients are required to be directly observed by a health care worker every time they take a dose of medication to ensure compliance. The use of multiple drugs and the need for increased numbers of health care workers greatly increase the cost of treating tuberculosis.

A new challenge appeared in 1997, when patients in Japan and the United States developed infections caused by a highly resistant strain of the bacteria known as Staphylococcus aureus. This bacteria is an organism often found on human skin, and it can cause potentially fatal infections when it enters the bloodstream. Shortly after the development of penicillin in the 1940s, it was reported that some strains of this organism, initially highly susceptible to penicillin, had developed resistance to it by producing an enzyme that inactivated it (penicillinase). In response, scientists developed a new generation of penicillins (including methicillin) that could withstand penicillinase. Within a few years, many strains of
staphylococci
developed resistance to methicillin and to all classes of penicillins and related drugs through a different mechanism, an alteration in the bacterial cell wall component to which these drugs bind. Few drugs remained active against these strains of methicillin-resistant S. aureus (MRSA); the most reliable and the mainstay of treatment for these infections was vancomycin. In 1997, vancomycin-resistant Staphylococcus aureus (VRSA) emerged, threatening to cause major public health problems. Fortunately, in part owing to strict practices of isolation and to heightened awareness of the potential for life-threatening, untreatable infections, VRSA has not become a frequent cause of infection. MRSA, however, once found primarily in hospitals and nursing homes, is now frequently found to cause community-acquired infections, including some fatal infections in high school athletes (infected through minor traumatic wounds) and in children with complications of influenza.

Another problem bacteria is pneumococcus. This bacterial species was once completely sensitive to penicillin, but then, according to bacteriologist Perry Dickinson, up to 55 percent of the pneumococcal strains became penicillin-resistant. The group most at risk for infection with the drug-resistant Streptococcus pneumoniae (DRSP) is children age six or younger. The resistant strains are a serious threat among children, but pneumococcus is still vancomycin-sensitive, and some derivatives of penicillin remain effective.

As might be expected, hospitals and nursing homes, where antibiotic usage is highest, are the sites where antibiotic resistance is most common and most complex. The last few decades of the twentieth century saw the development of high levels of resistance among gram-negative bacilli in addition to the gram-positive organisms previously discussed. These organisms frequently cause nosocomial (hospital-acquired) pneumonia, urinary tract infections, surgical wound infections, and other complications. MRSA continues to be a problem in hospitals as well as in the community. It is a major cause of surgical wound infections and infections related to intravenous devices, including hemodialysis accesses. Although VRSA has not yet emerged as a common pathogen, another gram-positive organism, the enterococcus, has acquired resistance to penicillins and vancomycin; vancomycin-resistant enterococci (VRE) are an important cause of nosocomial infections. These bacteria often give rise to infections in the urinary tracts of patients, but they are also the cause of meningitis, septicemia, and endocarditis. Most frequently, Enterococcus is found in children, the elderly, HIV-infected individuals, or the immunologically compromised, whose immune systems are not fully functioning.

Treatment and Therapy

In the context of emerging drug resistance, treatment of most infections requires a culture of the pathogen as well as laboratory testing to establish the antibiotics to which the cultured strain is susceptible, a process that lasts several days. A physician may prescribe an antibiotic in the meantime, using knowledge of prevalent antibiotic susceptibility patterns. Laboratory results may subsequently confirm the effectiveness of that choice or guide the selection of a replacement.

The rapidity with which microorganisms develop resistance to antibiotics has been a challenge to pharmaceutical companies, which are working to create a widening array of safe and effective new therapies. Some efforts aim at expanding previously developed lines of antibiotics. For example, a number of drug classes have been derived from penicillins. These “beta-lacatam” antibiotics have a common mechanism of action on bacterial cell walls; modifications have extended their spectrum of activity against an ever-widening variety of organisms and have stabilized them against the activity of penicillinase-like inactivating enzymes. Some of these newer agents include carbapenems and monobactams.

The expanding classes of previously developed drugs include the quinolone antibiotics, derived from nalidixic acid, an early drug for urinary tract infections. Likewise, teicoplanin is chemically related to the glycopeptide vancomycin.

A number of entirely new antibiotics have been developed since the late twentieth century. One of the most promising superdrugs, linezolid, developed to combat antibiotic resistance, falls into a category of antibiotics called oxazolidinones. These drugs act at an early stage in the synthesis of protein by bacteria. Without protein production, bacteria cannot multiply, and they die. The antibiotic linezolid is effective against many gram-positive bacteria, including MRSA, VRSA, VRE, and penicillin-resistant pneumococci. In hospital trials involving patients with MRSA infections, linezolid produced clinical success in more than 83 percent of the patients. The drug can be taken orally or injected, making it quite versatile. Robert Moellering of Harvard University Medical School suggested that this versatility is convenient for patients because they can complete their therapy at home. This drug has also been shown to have few side effects. The streptogramins (qunupristin/dalfopristin) and lipopeptides (daptomycin) are other newly developed classes active against gram-positive bacteria.

While much of the experience and knowledge of drug resistance centers on bacteria, similar problems occur in viruses, fungi, and parasites. Human immunodeficiency virus (HIV) rapidly developed resistance to the early antiretroviral drugs. Despite enormous research and development efforts, drug resistance continues to pose challenges in the treatment of HIV infection. Likewise, malaria and tuberculosis are two highly adaptable organisms responsible for a huge proportion of deaths worldwide. Both have developed resistance to many of the available drugs, compounding the difficulties in treating and preventing these infections, particularly in underdeveloped countries with limited resources.

Perspective and Prospects

Several different strategies have been suggested for handling the problem of drug resistance. In general, these strategies involve educating the public and health care workers; monitoring antibiotic, antiviral, and antifungal use; and promoting research into methods to deal with resistant pathogens.

The general public should be aware of the proper use of these medicines as well. Many patients expect to be given antibiotics for illnesses that do not respond to them, such as viral infections. Similarly, they may pressure physicians into prescribing antiviral or antifungal medications even when physicians are aware that these drugs are useless. Patients must learn to understand the difference between a bacterial and a viral infection and how each is treated. Patients must also be educated not to use another person’s medicines or an old supply of medicines that they have saved from previous illnesses. Finally, patients must learn to take the entire course of medicines. Often, patients who begin to feel better may fail to take the entire amount prescribed. This leads to an increased risk of drug-resistant infection if they do not completely eliminate the original infection.

All health care workers should be aware of the importance of avoiding the spread of resistant pathogens from one patient to another. In the late 1990s, about two million Americans per year acquired nosocomial infections. These infections were responsible for about eighty thousand deaths per year. The most important factors in reducing the rate of nosocomial infections are frequent and thorough hand washing, glove changes, and disinfectant applications.

Children should be immunized at a young age against pneumococcal infections. Children who are immunized do not get the infections; hence, no antibiotics are needed, and no extra antibiotics enter into the general population. Additionally, children who are ill should be kept home from day care centers. Day care centers are potentially dangerous incubators, where disease may run rampant. In these places, children spread bacterial infections among themselves, often amplifying pathogenicity and drug resistance. This can be avoided by isolating sick children at home.

Physicians need to be aware of the proper ways to use antibiotics. Microbiologists have suggested better instruction in antibiotic use in medical schools, more continuing education on the subject for practicing physicians, and the development of computer programs to aid physicians in selecting antibiotics. Some have suggested that all physicians prescribing antibiotics in hospitals be required to consult with physicians who specialize in infectious diseases. Standardized order forms that include guidelines for the proper use of each antibiotic have also been proposed. Additionally, doctors who have been thoroughly educated must learn not to accede to patient demands for antibiotics, and they must defer antibiotic use in self-limiting infections that will heal on their own. They must also avoid prescribing antibiotics over the phone.

Researchers agree that monitoring antibiotic use is critical in fighting drug resistance. A study published in 1997 demonstrated the effectiveness of education and monitoring in reducing resistance. Physicians in Finland were educated in the proper use of the antibiotic erythromycin, and use of the drug was monitored. In 1992, 16.5 percent of bacteria known as group A Streptococci were resistant to erythromycin. In 1996, only 8.6 percent were resistant. Some experts have proposed using computers to share information about antibiotic use and resistance among as many health care facilities as possible.

Faster development of new antibiotics for use on multiply resistant bacteria is another improvement. Researchers stress, however, that these new antibiotics must be used only when necessary, in order to avoid promoting resistance to them. Consequently, new antibiotics are used sparingly.

Other methods have been proposed for minimizing antibiotic resistance. Because patients often expect or demand prescriptions when they visit physicians, some experts have suggested that the physician write a lifestyle prescription when drug use is not appropriate. Such a prescription would explain why antibiotics should not be used in a particular situation and would give the patient specific instructions on how to treat the illness without them.

Eliminating the routine use of antibiotics in farm animals would be of great help. As the Danish study suggests, the risk of resistant bacterial strains in livestock could be reduced, making human lives safer as well.

International concerns over antibiotic resistance have been at such a height that in 2000, eight international medical societies gathered to spend a full day discussing the problem. They called this event Global Resistance Day, and the medical professionals discussed the dilemma and solutions for global antibiotic resistance.

Bibliography

"Antibiotics." MedlinePlus, 23 July 2013.

"Antimicrobial (Drug) Resistance." National Institute of Allergy and Infectious Diseases, 3 Apr. 2012.

"Antimicrobial Resistance." World Health Organization, May 2013.

Brooks, G. F., et al., eds. Jawetz, Melnick, and Adelberg’s Medical Microbiology. 25th ed. New York: McGraw-Hill, 2010.

Fischback, M. A., and C. T. Walsh. “Antibiotics for Emerging Pathogens.” Science 325, no. 5944 (August 28, 2009): 1089–93.

Levy, Stuart B. The Antibiotic Paradox: How the Misuse of Antibiotics Destroys Their Curative Powers. 2d ed. Cambridge, Mass.: Perseus, 2002.

Mayo Clinic Staff. "Antibiotics: Misuse Puts You and Others at Risk." Mayo Clinic, 4 Feb. 2012.

Shnayerson, Michael, and Mark J. Plotkin. The Killers Within: The Deadly Rise of Drug Resistant Bacteria. Boston: Little, Brown, 2003.

Walsh, Christopher. Antibiotics: Actions, Origins, Resistance. Washington, D.C.: ASM Press, 2003.

What is gender dysphoria?

Causes and Symptoms

The exact cause of gender dysphoria is not clearly understood or universally agreed upon. Many believe that the condition is not pathological. Others feel that gender dysphoria results from multiple pathways that can work alone or together. These pathways result from an individual’s psychological, sociocultural, biological, and genetic factors and background. Relevant terms in any discussion of gender dysphoria include "sex," which refers to the physical characteristics associated with being either male or female, and "gender," which refers to the culturally defined roles and behaviors associated with a given sex. Concepts related to gender dysphoria include "transsexualism," which refers to people who actively identify with the opposite sex and choose to live as a member of that sex, and "transgender," a catch-all term for people whose gender identity does not match traditional expectations for their sex.

A psychiatrist or psychologist typically makes the diagnosis of gender dysphoria. Diagnostic criteria for both childhood and adult forms have been established by the American Psychological Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM). ("Gender dysphoria" appears in the fifth edition, published in 2013, and represents a renaming of the diagnosis from previous editions, where it appeared as "gender identity disorder.") To carry a diagnosis of childhood gender dysphoria, a child must have an onset of symptoms before puberty. The majority of children resolve their gender dysphoria; others have a continuation of symptoms into adolescence or adulthood. Some people are first diagnosed as adults. Once gender dysphoria is diagnosed in adults, it tends to have a chronic course.

To meet the criteria for diagnosis, an individual must have a cross-gender identification exceeding the desire for perceived cultural advantages of being the other sex. A persistent discomfort with the person's sex or with the gender role of that sex must exist. The disturbance must cause clinically significant distress in important areas of functioning. Gender dysphoria is not necessarily concurrent with disorders of sexual development, a condition in which an individual may be born with ambiguous genitalia (intersexuality). Gender dysphoria is also independent of sexual orientation, occurring in people who identify as both homosexual and heterosexual.

Treatment and Therapy

The World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association) has a set of guidelines established for the standards of care for gender dysphoria. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People identifies multiple therapeutic approaches to gender dysphoria. These include changes in gender expression and role (cross-dressing and other behavioral changes, either full or part time), hormone replacement therapy (estrogen or testosterone to either feminize of masculinize the body), sex reassignment surgery, and psychotherapy. Therapy should proceed focusing on resolving any comorbid psychological disorders, promoting acceptance, and discussing further treatment options.

Hormone therapy can be given to adolescents to delay puberty. This allows time for an individual to explore gender identity and to make a gender transition more conspicuously. In the United States, estrogen or testosterone can be given to an individual who is eighteen and who demonstrates knowledge about the benefits and risks, has spent a prescribed period living in the desired role or a period of psychotherapy, and demonstrates readiness.

Sex reassignment surgery is the final step that some people with gender dysphoria choose to pursue. Genital reconstruction can occur in both males and females. An individual who is anatomically female may also desire removal of the breasts, uterus, ovaries, and Fallopian tubes, as well as liposuction and other aesthetic procedures. For someone who is anatomically male, surgery may include breast implants, facial feminization surgery, and voice surgery.

Perspective and Prospects

Gender dysphoria exists in every culture. It has been recorded as early as Hippocrates, who is credited with the first classification system for what was called Scythian disease. Magnus Hirschfeld coined the term “transvestism” in 1915, describing individuals who cross-dress. In 1949, David Caudwell coined the term “transsexual.” In 1966, Harry Benjamin developed a Sex Orientation Scale to differentiate the various forms of transvestism and transsexualism. Since then, there has been extensive debate concerning the correct classification and terminology surrounding gender dysphoria and transgenderism.

The diagnosis of gender identity disorder was added to the DSM in 1987. The transgender community campaigned for many years, with eventual success, to have this classification changed, as many transgender people found it offensive and incorrect to label gender dysphoria as a disorder. People argue that concepts of gender roles are socially constructed and therefore wonder how a society can define, scientifically, what a “normal” gender identity is. Many people support the idea that transgendered people are leading the way in redefining and updating traditional concepts of gender.

Bibliography

American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: Author, 2013.

"Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression." American Psychological Association, 2011.

Brown, Mildred L., and Ann Rounsley. True Selves: Understanding Transsexualism—For Families, Friends, Coworkers, and Helping Professionals. San Francisco: Jossey-Bass, 1996.

Cohen-Kettenis, Peggy T., and Friedemann Pfäfflin. Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices. Thousand Oaks, Calif.: Sage Publications, 2003.

"Gender Identity Disorder." MedlinePlus, February 13, 2012.

"Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." 7th version. World Professional Association for Transgender Health, 2011.

World Health Organization. International Statistical Classification of Diseases and Related Health Problems: 10th Revision–ICD-10. 2d ed. Geneva, Switzerland: Author, 2000.

What reaction happens when you mix sand and water?

When we mix sand and water, no reaction takes place. The sand simply settles down at the bottom of the water container. This is because sand is heavier than water and hence cannot float in water. The sand can be separated from the water by simple filtration and can be obtained in its original condition after drying. Since no chemical reaction takes place, we can term this reaction as a physical reaction (as gravity and density are responsible for this reaction). The separation of sand from water is called gravity separation. 

In comparison, if we mix something like salt or sugar in water, they will react and make the water salty or sweet. Sand causes no such changes in the quality of water.

Hope this helps. 

What happens if you pour 1 tablespoon of sugar into 500 ml of water?

Sugar is highly soluble in water. At room temperature (20 degrees Celsius), 100 ml of water can dissolve as much as 204 gm of sugar. A tablespoon holds about 10-15 grams of sugar (depending on how much sugar you can get into it safely).

Thus, all the sugar in a tablespoon will easily dissolve in 500 ml of water (unless the water is frozen), since sugar has high solubility in water. One may need to mix it with a teaspoon or tablespoon, though.

We can also increase the solubility further by heating the water. As the temperature of water goes up, its ability to dissolve things like sugar and salt increases. As the water cools down, the extra sugar (beyond the saturation limit at that temperature) separates out of the solution. One can observe this through a simple experiment at home. 

Hope this helps.

What is tennis elbow (lateral epicondylitis)?

Tennis elbow (lateral epicondylitis) is a medical condition that is characterized by inflammation of the tendons of the forearm and the outside of the elbow. It is typically caused by overuse of the forearm and results in pain and other symptoms. The term tennis elbow is somewhat misleading. While the name suggests that playing tennis causes this condition, many other activities can lead to tennis elbow. These activities usually involve repetitive motion. Treatment for tennis elbow may include icing the affected area, taking medication, or receiving steroid injections. Some patients may require surgery, which is followed by a period of rehabilitation.

Cause

Tennis elbow is usually caused by repetitive strenuous use of the forearm. Certain activities, like playing tennis, can contribute to the condition. Tennis players are especially susceptible to the condition if they use poor techniques or improper equipment. For example, an individual who has a poor backhand technique may develop tennis elbow. Racquetball and squash are two other sports that can lead to tennis elbow. The condition can also be caused by other repetitive activities, particularly ones that involve twisting or gripping with the hands. Such activities include painting, using a screwdriver, cutting meat, and pruning bushes. Therefore, painters, carpenters, butchers, and professional gardeners are at risk of developing tennis elbow.

The forearm has a muscle called the extensor carpi radialis brevis (ECRB). If the ECRB becomes damaged, tennis elbow may result. Damage to the ECRB typically occurs when the muscle is overworked and small tears develop in a tendon that connects the ECRB to the lateral epicondyle, or the bony prominence on the outside of the elbow. Inflammation of the area often results from this damage.

Symptoms

Tennis elbow causes several symptoms that develop slowly. Pain on the outside of the elbow is the most common symptom, and it usually worsens over time. The pain may spread to the forearm and wrist. People with tennis elbow sometimes experience a burning sensation and tenderness in the area and may have weak grip strength. Someone with tennis elbow may find it difficult to hold a cup, turn a doorknob, turn a key, shake hands, or perform similar simple tasks.

Diagnosis

Tennis elbow is diagnosed during a medical examination. The doctor will give the patient a physical exam and take a medical history. The patient will be asked to move his or her arm, wrist, and fingers in different directions. The doctor will also ask the patient which activities cause pain or other symptoms. Based on the physical exam and medical history, the doctor can usually diagnose the patient with tennis elbow. Sometimes, additional tests are needed to rule out other problems. For example, X-rays can determine whether the patient has arthritis of the elbow. Because neck problems such as a herniated disk or arthritis can cause pain in the arm, a magnetic resonance imaging (MRI) test may be needed to rule out other issues. Furthermore, an electromyography (EMG) can reveal if the patient has nerve compression, which is a condition that results in symptoms similar to tennis elbow.

Treatment

Treatment for tennis elbow is not always necessary, as the condition often goes away on its own. For people who do need treatment, several options are available. The simplest form of treatment is rest. The patient should not subject the affected arm to any strenuous activity. This includes participating in sports and performing difficult work tasks. People who have developed tennis elbow from playing a sport should evaluate their equipment and playing techniques to determine whether any adjustments should be made to ease stress on the arm.

Icing the affected area for fifteen minutes several times a day is another simple form of treatment. Physicians may also advise patients with tennis elbow to take over-the-counter pain medications—such as aspirin, ibuprofen, or naproxen—to reduce pain and inflammation. In addition, wearing an orthotic (such as a strap, brace, band, or splint) may be helpful for some people.

Tennis elbow is sometimes treated with steroid injections. A doctor will inject the affected muscle with an anti-inflammatory steroid, such as cortisone. Some patients may also require physical therapy, which often includes exercises that help strengthen the forearm and promote muscle healing. Some doctors may recommend shock wave therapy to treat tennis elbow, but this treatment option is not common. Shock wave therapy involves sending sound waves to the elbow to help with the healing process.

Up to 95 percent of people with tennis elbow respond positively to these treatments. However, if a patient does not see any improvement after six to twelve months of treatment, surgery may be necessary. Typically, tennis elbow surgery involves removing damaged muscle and reconnecting undamaged muscle to bone. Two main surgical approaches are available: open surgery and arthroscopic surgery. In open surgery, the surgeon makes an incision over the elbow. In arthroscopic surgery, the surgeon makes several smaller incisions. Following surgery, the patient may need to wear a splint that immobilizes the arm for about a week. After the splint is removed, the patient can begin performing rehabilitation exercises. Tennis elbow surgery has an 80 to 90 percent success rate.

Bibliography

Mayo Clinic Staff. "Tennis Elbow." Mayo Clinic. Mayo Foundation for Medical Education and Research. 29 June 2013. Web. 26 Mar. 2015. http://www.mayoclinic.org/diseases-conditions/tennis-elbow/basics/definition/con-20043041

"Tennis Elbow (Lateral Epicondylitis)." OrthoInfo. American Academy of Orthopaedic Surgeons. Web. 26 Mar. 2015. http://orthoinfo.aaos.org/topic.cfm?topic=a00068

"What to Do about Tennis Elbow." Harvard Health Publications. Harvard University. 1 May 2007. Web. 26 Mar. 2015. http://www.health.harvard.edu/diseases-and-conditions/what-to-do-about-tennis-elbow

How does operations management contribute to the achievement of the success of an organization?

Operations management refers to the management of resources to produce a good or provide a service.  A manager must ensure that resources are used to create a good or provide a service as efficiently as possible and as effectively as possible.

A good operations manager will see to it that there is no waste in the production process, for example, materials not being used properly, people being scheduled inefficiently, or machines breaking down.  Waste in the process means that there is less profit for the company. If I have more people scheduled than I need, I must pay them even if they are not producing, and that means higher expenses and less revenue. If I have stacks and stacks of materials standing by, too far in advance, I have tied up the company's money in a way that is not producing any revenue.  If I manage so that there is too much production and inventories build up, I have the expense of storing my inventory, and it is yielding no revenue for the company at all.  Managing to avoid all of these difficulties is a large part of a company's success, the ability to keep expenses low and production at just the right point to be able to sell what is demanded as it is being demanded. Like any other kind of manager, an operations manager helps the company by minimizing expense and maximizing revenue.

A good operations manager will also concern him or herself with quality control. If goods of poor quality are produced, this will cause returns of the product and ultimately will harm a company's reputation. Good management of quality control entails motivating everyone in the company to pay attention to quality and to report any problems immediately. It also entails inspecting the products made and possibly following up with customer surveys.  A problem in quality can thus be attended to.  Checking on one's equipment is important as well.  An operation manager who ignores equipment problems does so at his or her peril, since these can lead to poor quality in production. Operations management includes checking on the quality of the raw materials used in the production process.  If these are of poor quality, what is produced is likely to be of poor quality, too. Without management of quality, a company is not going to be successful.

What event upset Brian so much in Hatchet?

In Gary Paulsen's novel Hatchet, the main character, Brian, crash-lands into the wilderness in a small plane. Only two people are in the plane--just him and the pilot--and the pilot dies. Brian is left to fend for himself and hope to get rescued.

Although his time and thoughts are largely occupied with finding food and shelter, Brian is also bothered by thoughts about something that he calls the Secret. He thinks of it often and even has dreams about it. 

Readers don't find out exactly what it is until later in the story, but here it is: Before Brian got on the plane, he had seen his mother kissing a stranger. And it was this fact that his mom was cheating on his dad that caused their divorce.

Here's all we know about it in Chapter 1, while Brian is still in the plane:

"What he knew and had not told anybody, what he knew about his mother that had caused the divorce, what he knew, what he knew—the Secret."

The Secret gets revealed slowly to readers as Brian keeps thinking about it, and we get all the awful details in Chapter 7:

"Then he crawled back into the shelter and fell again to the sand but could not sleep at first, could do nothing except lie there, and his mind decided then to bring the memory up again. In the mall. Every detail. His mother sitting in the station wagon with the man. And she had leaned across and kissed him, kissed the man with the short blond hair, and it was not a friendly peck, but a kiss. A kiss where she turned her head over at an angle and put her mouth against the mouth of the blond man who was not his father and kissed, mouth to mouth, and then brought her hand up to touch his cheek, his forehead, while they were kissing. And Brian saw it. Saw this thing that his mother did with the blond man. Saw the kiss that became the Secret that his father still did not know about, know all about."

Of course, this bothers Brian immensely. He held the Secret inside and didn't tell his mom or his dad; he worried that what he'd seen had caused the divorce, and it made him feel ill and distressed.

What is menstruation?

Process and Effects

Menstruation is the monthly discharge of bloody fluid from the uterus. It occurs in humans and in other primates (apes and monkeys), but not in all mammals; for example, horses, cats, and dogs do not menstruate. The menstrual fluid consists of blood, cells, and debris from the endometrial lining of the uterus, and mucus and other fluids. The color of the discharge varies from dark brown to bright red during the period of flow. The menstrual discharge does not normally clot after leaving the uterus, but it may contain endometrial debris that resembles blood clots. The flow lasts from four to five days in most women, with spotting (the discharge of scant fluid) possibly continuing for another day or two. The volume of fluid lost ranges from ten to eighty milliliters, with a median of about forty milliliters. The blood in the menstrual discharge amounts to only a small fraction of the body’s total blood volume of about five thousand milliliters, so normal physiological functioning is not usually impaired by the blood loss that occurs during menstruation.

The first menstruation (menarche) typically begins between the ages of eleven and fourteen, when a girl goes through puberty; the last episodes of menstruation occur some forty years later at the time of menopause. Menstruation does not occur during the months of pregnancy or for the first few months after a woman has given birth.

Menstruation is the most visible event of the woman’s monthly menstrual cycle. The average length of the menstrual cycle in the population is about 29.1 days, but it may vary from sixteen to thirty-five days, with variation occurring between different individuals and in one individual from month to month. Girls who have just gone through puberty and women who are approaching the menopause tend to have more variation in their cycles than do women in the middle of their reproductive years. There is also an age-related change in cycle length: Cycles tend to be relatively long in teenagers, then decrease in length until a woman is about forty years old, after which cycles tend to lengthen and become irregular.

Hormones cause menstruation to be coordinated with other events in the menstrual cycle. Uterine function is regulated by two hormones,
estrogen and progesterone, which are produced in the ovaries. In turn, the production of estrogen and progesterone is controlled by follicle-stimulating hormone (FSH) and luteinizing hormone (LH), both of which are produced in the pituitary gland. The hormones from the ovaries and from the pituitary have mutual control over each other: they participate in a feedback relationship. The fact that females produce ova only once a month, in a cycle rather than continuously, is the result of a change in the feedback relationships between the ovarian and pituitary hormones as the menstrual cycle proceeds.

In the first half of the cycle, the follicular phase, a predominant negative feedback effect keeps pituitary hormone levels low while allowing estrogen to increase. Day one of the menstrual cycle is defined as the day of the onset of the menstrual flow. During the days of menstrual bleeding, levels of estrogen and progesterone are low, but FSH levels are high enough to cause the growth of follicles in the ovary. As the follicles start to grow, they secrete estrogen, and increasing amounts are secreted as the follicles continue to enlarge over the next five to ten days. The estrogen exerts negative feedback control over the pituitary: FSH and LH production is inhibited by estrogen, so levels of these hormones remain low during the follicular phase. Besides producing estrogen, the growing follicles contain ova that are maturing and preparing for ovulation. Meanwhile, estrogen acts on the uterus to cause the growth of the endometrial lining. The lining becomes thicker and its blood supply increases; glands located in the lining also grow and mature. These uterine changes are known as endometrial proliferation.

As the woman nears the middle of her cycle, a dramatic change in hormonal feedback occurs. The increasing secretion of estrogen shifts the hormonal system into a positive feedback mode, whereby an increase in estrogen stimulates the release of LH and FSH from the pituitary instead of inhibiting it. Thus, at the middle of the cycle (around day fourteen), simultaneous peaks in levels of estrogen, LH, and FSH occur. The peak in LH triggers ovulation by causing changes in the wall of the follicle, allowing it to break open to release its ovum. Although a group of follicles has matured up to this point, usually only the largest one ovulates, and the remainder in the group die and cease hormone production.

Following ovulation, negative feedback is reestablished. The follicle that just ovulated remains as a functional part of the ovary; it becomes transformed into the corpus luteum, a structure that produces estrogen and progesterone throughout most of the second half of the cycle, the luteal phase. During this phase, the combined presence of estrogen and progesterone reestablishes negative feedback over the pituitary, and LH and FSH levels decline. A second ovulation is prevented because an LH peak is not possible at this time. The combined action of estrogen and progesterone causes the uterus to enter its secretory phase during the second half of the cycle: The glands in the thickened endometrium secrete nutrients that will support an embryo if the woman becomes pregnant, and the ample blood supply to the endometrium can supply the embryo with other nutrients and oxygen. If the woman does in fact become pregnant, the embryo will secrete a hormone that will ensure the continued production of estrogen and progesterone, and because of these hormones, the uterus will remain in the secretory condition throughout pregnancy. Menstruation does not occur during pregnancy because of the high levels of estrogen and progesterone, which continually support the uterus.

If the woman does not become pregnant, the corpus luteum automatically degenerates, starting at about the twenty-fourth day of the menstrual cycle. As the corpus luteum dies, it fails to produce estrogen and progesterone, so levels of these hormones decrease. As the amounts of estrogen and progesterone drop, the uterus begins to produce prostaglandins, chemicals that act as local signals within the uterus. The prostaglandins cause a number of changes in uterine function: blood flow to the endometrium is temporarily cut off, causing the endometrial tissue to die, and the uterine muscle begins to contract, causing further changes in blood flow. The decreased blood flow and the muscle contractions contribute to the cramping pain that many women feel just before and at the time of menstrual bleeding. Menstrual bleeding starts when the blood flow to the endometrium is reestablished and the dead tissue is sloughed off and washed out of the uterus. This event signals the start of a new menstrual cycle.

Complications and Disorders

Many disorders involving menstruation exist. Toxic shock syndrome is a disease that, while not caused directly by menstruation, sometimes occurs during menstruation in women who use tampons to absorb the menstrual flow. The symptoms of toxic shock syndrome—fever, rash, a drop in blood pressure, diarrhea, vomiting, and fainting—are caused by toxins produced by the bacterium Staphylococcus aureus. This bacterium is normally present in limited numbers within the vagina, but the use of high-absorbency tampons is associated with a higher-than-normal bacterial growth and toxin production. Toxic shock syndrome requires immediate medical attention, since it may be fatal if left untreated. Women can reduce the risk of toxic shock syndrome by changing tampons often, using lower-absorbency types, and alternating the use of tampons and sanitary napkins.

Amenorrhea is defined as the absence of menstruation. It is usually, but not always, coincident with a lack of ovulation. Amenorrhea may be primary (the woman has never menstruated) or secondary (menstrual cycles that were once normal have stopped). The condition is usually associated with abnormal patterns of hormone secretion, but the problem in hormone secretion may itself be merely the symptom of some other underlying disorder. One of the most common situations leading to both primary and secondary amenorrhea is low body weight, caused by malnutrition, eating disorders, or sustained exercise. Body fat has two roles in reproduction: it provides energy needed for tissue growth and cell functions, and it contributes to circulating estrogen levels. Loss of body fat may create a situation in which the reproductive system ceases to function because of low estrogen levels and because of lack of needed energy. The result is seen as amenorrhea. Emotional or physical stress may also cause amenorrhea, because stress results in the release of hormones that interfere with the reproductive hormones. Ideally, amenorrhea is treated by removing its cause; for example, a special diet or a change in an exercise program can bring about an increase in body fat stores, or stress levels can be reduced through changes in lifestyle or with counseling. Ironically, sometimes birth control pills are prescribed for women with amenorrhea. The pills do not cure the amenorrhea, but they can counteract some of the long-term problems associated with it, such as changes in the endometrial lining and loss of bone density.

Dysmenorrhea refers to abnormally intense uterine pain associated with menstruation. It is estimated that 5 to 10 percent of women experience pain intense enough to interfere with their school or work schedules. Dysmenorrhea may be primary (occurring in women with no known disease) or secondary (caused by a disease condition such as a tumor or infection). Studies have shown uterine prostaglandin levels to be correlated with the degree of pain perceived in primary dysmenorrhea, and drugs that interfere with prostaglandins offer an effective treatment for this condition. These drugs include aspirin, acetaminophen, ibuprofen, and naproxen; some formulas are available without a doctor’s prescription, but the stronger drugs require one. Secondary dysmenorrhea is best managed by removing the underlying cause; if this is not possible, the antiprostaglandin drugs may be useful in controlling the pain.

Menorrhagia is excessive menstrual blood loss, usually defined as more than eighty milliliters of fluid lost per cycle. This condition can have serious health consequences because of the loss of red blood cells, which are essential for carrying oxygen to tissues. Women who have given birth to several children are more likely to suffer from menorrhagia, possibly because of enlargement of the uterine cavity and interference with the mechanisms that limit menstrual blood flow. Women who have diseases that interfere with blood clotting may also have menorrhagia. Although the menstrual discharge itself does not usually form clots after it leaves the uterus, clots do form within the uterine endometrium; these clots normally prevent excessive blood loss. Treatment for menorrhagia may begin with iron and vitamin supplements to induce increased red blood cell production, or transfusions may be used to replace the lost red blood cells. If this is unsuccessful, treatment with birth control pills, destruction of the endometrium by laser surgery, or a hysterectomy (surgical removal of the uterus) may be necessary.

Endometriosis is a condition in which endometrial cells from the uterus become misplaced within the abdominal cavity, adhering to and growing on the surface of internal organs. The outside of the uterus, the oviducts (fallopian tubes), the surface of the ovaries, and the outer surface of the intestines can all support the growth of endometrial tissue. Endometriosis is thought to arise during menstruation, when endometrial tissue enters the oviducts instead of being carried outward through the cervix and vagina. Through the oviducts, the endometrial tissue has access to the abdominal cavity. Since the misplaced endometrial tissue responds to hormones in the same way that the normal endometrium does, it undergoes cyclic changes in thickness and attempts to shed at the time of menstruation. Endometriosis results in intense pain during menstruation and can cause infertility because of interference with ovulation, ovum or sperm transport, or uterine function. Endometriosis is treated with birth control pills or with drugs that suppress menstrual cycles, or the endometrial tissue may be removed surgically.

Premenstrual syndrome (PMS) is a set of symptoms that occurs in some women in the week before the start of menstruation, with the symptoms disappearing once menstruation begins. Researchers and physicians who study PMS have struggled to devise a standard definition for the disorder, but the list of possible symptoms is lengthy and varies from woman to woman and even within one woman from month to month. The possible symptoms include both psychological and physical changes: irritability, nervous tension, anxiety, moodiness, depression, lethargy, insomnia, confusion, crying, food cravings, fatigue, weight gain, swelling and bloating, breast tenderness, backache, headache, dizziness, muscle stiffness, and abdominal cramps. A diagnosis of PMS requires that the symptoms show a clear relation to the timing of menstruation and that they recur during most menstrual cycles. Researchers estimate that 3 to 5 percent of women have PMS symptoms that are so severe that they are incapacitating, but that milder symptoms occur in about 50 percent of all women.

Because of the variability in symptoms between women, some researchers believe that there are several subtypes of PMS, each with its own cluster of symptoms. It is possible that each subtype has a unique cause. Suggested causes of PMS include an imbalance in the ratio of estrogen to progesterone following ovulation; changes in the hormones that control salt and water balance (the renin-angiotensin-aldosterone system); increased levels of prolactin (a hormone that acts on the breast); changes in amounts of brain chemicals; altered functioning of the biological clock that determines daily rhythms; poor diet or sensitivity to certain foods; and psychological factors such as attitude toward menstruation, stresses of family or professional life, and underlying personality disorders. Studies evaluating these theories have yielded contradictory results, so that no one cause of PMS has yet been found. Current treatments for PMS include dietary therapy, hormone administration, and psychological counseling, but no treatment has been found effective in all PMS patients.

An interesting phenomenon associated with menstruation is menstrual synchrony, also known as the “dormitory effect.” Among women who live together, menstrual cycles gradually become synchronized, so that the women begin to menstruate within a few days of one another. Researchers have found that this phenomenon probably occurs because of
pheromones, chemical signals that are produced by an individual and that have an effect on another individual. Pheromones act on the brain through the sense of smell, even though there may not be an odor that is consciously perceived.

Perspective and Prospects

Early beliefs about menstruation were based on folk magic and superstition rather than on scientific evidence. Even today, some cultures persist in believing that menstruating women possess deleterious powers: that the presence of a menstruating woman can cause crops to fail, farm animals to die, or beer, bread, jam, and other foods to be spoiled. Some people believe that these incidents will occur even if the menstruating woman has no evil intention. Because of the possibility of these events, some cultures prohibit menstruating women from interacting with others. In the most rigorous example of such a taboo, some societies require that menstruating women live in special huts for the duration of the bleeding period.

Folk beliefs about menstruating women have been bolstered by religious views of menstruating women as “unclean” and in need of purification. In Orthodox Judaism, there are detailed proscriptions to be observed by a menstruating woman, including the avoidance of sexual intercourse. Seven days after her menstrual flow has stopped, the Orthodox Jewish woman undergoes a ritual purification, after which she may resume sexual relations with her husband. Early Christians absorbed the Jewish belief in the uncleanliness of a menstruating woman and prohibited her from entering church or receiving the sacraments. These injunctions were lifted by the seventh century, but the view of women as spiritually and bodily impure persists in some Christian groups to this day.

Many couples abstain from intercourse during the woman’s menstrual period. There is no medical justification for this behavior; in fact, research has demonstrated that intercourse can alleviate menstrual cramping, at least temporarily. Still, surveys have shown that a majority of both men and women think that it is wrong for a woman to have intercourse while menstruating.

There are also persistent beliefs that women’s physical and mental abilities suffer during menstruation. In fact, this was the predominant medical opinion up through the nineteenth and early twentieth centuries. Medical writings from this time are filled with injunctions for women to rest and to refrain from exercise and intellectual strain while menstruating. It was a common belief that education could actually cause physical harm to women. Some men used this advice as justification for excluding women from equal opportunities in education and employment. Starting in the late nineteenth century, however, scientific studies clearly demonstrated that education has no harmful effects and that there is no diminution of intellectual or physical performance during menstruation. Nevertheless, the latter finding has been one that the general population finds difficult to accept.

The latest view of menstruation is that, far from being harmful, menstrual bleeding is directly beneficial to a woman’s health. Margie Profet, an evolutionary biologist at the University of California, theorized that menstruation evolved as a means of periodically removing disease-causing bacteria and viruses from the woman’s uterus. These organisms might enter the uterus along with sperm after sexual activity. In Profet’s view, the energetic cost of replacing the blood and tissue lost through menstruation is more than outweighed by the protective benefits of menstruation. Her theory implies that treatments that suppress menstruation, as birth control drugs sometimes do, are not always advantageous.

The suppression of menstruation through extended or continuous cycling with combined hormonal contraception has recently been reexamined for various benefits, including increased contraceptive efficacy. Some clinicians and consumers have embraced this concept, which can be done with any continuous (no placebo or no-pill interval) use of a monophasic combined oral contraceptive pill, the Ortho Evra patch, or NuvaRing. New formulations of combined oral contraceptives include Seasonale and Seasonique, both of which result in menstrual bleeding every three months, and Lybrel, which eliminates cycles for one year. Other formulations have shortened the one week pill-free interval, resulting in shorter and lighter menses.

Bibliography

Ammer, Christine. The Encyclopedia of Women's Health. 6th ed. New York: Facts on File, 2009.

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

Covington, Timothy R., and J. Frank McClendon. Sex Care: The Complete Guide to Safe and Healthy Sex. New York: Pocket Books, 1987.

Golub, Sharon. Periods: From Menarche to Menopause. Newbury Park, Calif.: Sage, 1992.

Loulan, JoAnne, and Bonnie Worthen. Period: A Girl’s Guide to Menstruation. Rev. ed. Minnetonka, Minn.: Book Peddlers, 2001.

"Menopause." MedlinePlus, July 1, 2013.

"Menstruation." MedlinePlus, May 28, 2013.

"Premenstrual Syndrome." MedlinePlus, April 29, 2013.

Quilligan, Edward J., and Frederick P. Zuspan, eds. Current Therapy in Obstetrics and Gynecology. 5th ed. Philadelphia: W. B. Saunders, 2000.

Rako, Susan. No More Periods? The Risks of Menstrual Suppression and Other Cutting-Edge Issues in Women’s Reproductive Health. New York: Harmony Books, 2003.

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

How is Bruno from The Boy in the Striped Pajamas a round and a dynamic character?

All characters in a work of fiction serve a purpose in telling a story for the reader. The manner in which a character is portrayed in a story allows him or her to come to life in the mind of the reader. In the book, Bruno fulfills the role of a dynamic and round character because he experiences significant changes, and throughout the process of change, he experiences certain events that cause him to become conflicted about his beliefs.

In a work of fiction, a dynamic character is someone who experiences a change over time. This change is generally a result of a conflict or major crisis that the character faces. Round characters encounter contradictory situations that compel them to undergo transformations. In Bruno’s case, he is introduced to the reader as a young, naïve nine-year old boy who grew up with everything he had ever wanted—a big house with maids, parents who cared for him, and a group of good friends. When he and his family move out of Berlin into the new house, he peers out his room window and sees the children in the concentration camp, and comments about how they don’t look friendly at all. At this point, he had no idea it was Auschwitz.

Later in the book, we see how Bruno’s attitude begins to change, especially when he continues to look out of his bedroom window at the concentration camp. He realizes that as much as he watched the people behind the fences and barbed wire, he had never stopped to think what all of it meant. He recognizes that “ as often as he had watched the people, all the different kinds of people in their striped pajamas, it had never occurred to him to wonder what it was all about”.

When he meets Shmuel, he notices that Shmuel is skinny, and his skin looks gray, but is oblivious as to why. He thinks that Shmuel must have dozens of friends who play together for hours a day. He even tells Shmuel that Germans are superior. When Shumel relays the story of how he ended up at the camp, Bruno somehow believes they experienced the same because he too was forced to move. Bruno also has a difficult time believing that the trains they rode on to the camp were different. This is evident when he states that “Shmuel looked very sad when he told this story and Bruno didn’t know why; it didn’t seem like such a terrible thing to him, and after all much the same thing had happened to him.”

When Shumel displays a dislike for the soldiers, Bruno faces an internal conflict because although he dislikes Leutenant Kotler, he reasons that they must not all be bad because his father, also a soldier, is a good man. Nonetheless, Bruno slowly realizes that something is horribly wrong. He begins to notice Shumel’s hands: “Bruno couldn’t help but notice that it was like the hand of the pretend skeleton that Herr Liszt had brought with him one day when they were studying human anatomy.”

We notice Bruno’s most important change when he decides to help Shumel look for his father. During that moment, he truly becomes altruistic. Unfortunately, he is killed before he can truly comprehend the horrific realities of Auschwitz.

What is fish oil as a dietary supplement?

Overview

Fish
oil contains omega-3 fatty acids, one of the two main classes
of essential fatty acids, or EFAs. (The other main type is omega-6.) Essential
fatty acids are special fats that the body needs for optimum health.

Interest in the potential therapeutic benefits of omega-3 fatty acids began when studies of the Inuit (Eskimo) people found that although their diets contain an enormous amount of fat from fish, seals, and whales, they seldom have heart attacks. This is presumably because those sources of fat are very high in omega-3 fatty acids.

Subsequent investigation found that the omega-3 fatty acids found in fish oil
have various effects that tend to reduce risk of heart disease
and strokes. However, research into whether the use of fish oil
actually prevents these diseases, while somewhat positive, remains incomplete and
somewhat inconsistent. In recognition of this, the U.S. Food and Drug
Administration (FDA) has allowed supplements containing fish
oil or its constituents to carry a label that states “Supportive but not
conclusive research shows that consumption of EPA [eicosapentaenoic acid] and DHA
[docosahexaenoic acid] omega-3 fatty acids may reduce the risk of coronary heart
disease.”

In addition, a slightly modified form of fish oil (omega-3-acid ethyl esters) has been approved by the FDA as a treatment for hypertriglyceridemia (high triglycerides). This specially processed product, sold under the trade name Lovaza (formerly Omacor), is widely advertised as more effective than ordinary fish oil. However, it should be noted that Omacor has undergone relatively little study itself; the prescribing information notes only two small trials to support its effectiveness for this use. This is a far lower level of evidence than usually required for drug approval and also substantially lower than the body of evidence supporting standard fish oil as a treatment for high triglycerides.

Fish oil has also shown promise as an anti-inflammatory treatment for conditions such as rheumatoid arthritis, menstrual pain, and lupus. In addition, it may be helpful for various psychiatric conditions.

Requirements and Sources

There is no daily requirement for fish oil. However, a healthy diet should provide at least 5 grams (g) of essential fatty acids daily.

Many grains, fruits, vegetables, sea vegetables, and vegetable oils contain significant amounts of essential omega-6 and omega-3 fatty acids, but oil from cold-water fish is the richest natural source of omega-3 fats. It is commonly stated that people require a certain optimum ratio of omega-3 to omega-6 fatty acids in the diet; however, there is no real evidence that this is true, and there is some evidence that it is false.

Therapeutic Dosages

Typical dosages of fish oil are 3 to 9 g daily, but this is not the upper limit. In one study, participants ingested 60 g daily.

The most important omega-3 fatty acids found in fish oil are called eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). To match the dosage used in several major studies, one should take enough fish oil to supply about 2 to 3 g of EPA (2,000-3,500 milligrams [mg]) and about 1 to 2.5 g of DHA daily (1,000-2,500 mg). Far higher doses have been used in some studies; conversely, one study found blood-pressure-lowering effects with a very low daily dosage (0.7 g) of DHA.

DHA and EPA are not identical and might not have identical effects. Some evidence hints that DHA may be more effective than EPA for thinning the blood and for reducing blood pressure. The reverse may be true for reducing triglyceride levels, but study results are conflicting.

Some manufacturers add vitamin E to fish oil capsules to keep the oil from becoming rancid. Another method is to remove all the oxygen from the capsule. Also, if possible, one should purchase fish oil products certified as free of significant levels of mercury, toxic organochlorines, and polychlorobiphenyls (PCBs).

Flaxseed
oil also contains omega-3 fatty acids, although of a
different kind. Flaxseed oil has been suggested as a less smelly substitute for
fish oil. However, it is far from clear whether flaxseed oil is therapeutically
equivalent to fish oil.

Therapeutic Uses

Consumption of fish oil alters the body’s production of certain substances in
the class of chemicals called prostaglandins. Some prostaglandins
increase inflammation while others decrease it. The prostaglandins whose
production is enhanced by fish oil fall into the anti-inflammatory category. Based
on this, fish oil has been tried as a treatment for early stages of
rheumatoid
arthritis, with positive results. It is thought to
significantly reduce symptoms without causing side effects and may magnify the
benefits of standard arthritis drugs. However, while some standard medications can
slow the progression of the disease, there is no evidence that fish oil can do
this. Much weaker evidence hints that fish oil might be helpful for the related
disease ankylosing spondylitis.

Fish oil’s apparent anti-inflammatory properties are the likely explanation for its apparent benefit in dysmenorrhea (menstrual pain), as seen in two studies. Similarly, fish oil may be helpful for the autoimmune disease lupus. (However, two studies failed to find fish oil helpful for kidney disease caused by lupus.) Evidence has been mixed regarding whether fish oil is beneficial for Crohn’s disease or ulcerative colitis, conditions in which parts of the digestive tract are highly inflamed. More recently, however, two well-designed trials enrolling a total of 738 persons convincingly failed to find any benefit for omega-3 fatty acid supplementation in the prevention of Crohn’s disease relapse.

Incomplete evidence hints but does not prove that fish or fish oil might help prevent death caused by heart disease. This effect seems to result from several separate actions. The best documented involves reducing high triglyceride levels; studies enrolling more than two thousand people have substantiated this use. In addition, fish oil might raise HDL (good) cholesterol levels, thin the blood, lower levels of homocysteine, prevent dangerous heart arrhythmias, slow heart rate, improve blood vessel tone, and decrease blood pressure. These effects also support findings that fish oil may help prevent strokes. However, results are conflicting on whether people with angina should take fish oil or increase intake of fatty fish; one large study actually found that fish oil increased risk of sudden death.

For a number of theoretical reasons, it has been suggested that fish oil and
its constituents (especially a slightly modified form of EPA called ethyl-EPA)
might have positive effects on various psychiatric disorders, most notably
depression. However, there is no convincing evidence that
low levels of omega-3 fatty acids in the bloodstream lead to even mild depression.
Moreover, larger trials have generally failed to demonstrate a beneficial effect
of fish oil-related products in depressed persons. Preliminary, and not altogether
consistent, evidence hints that high doses of fish oil may produce benefits in
bipolar disorder, reducing risk of relapse and improving emotional state.

Other preliminary, and again not altogether consistent, evidence hints that
fish oil might enhance the effectiveness of standard drugs (such as
phenothiazines) for schizophrenia. One trial of eighty-one adolescents and young
adults (considered at very high risk) found that daily omega-3 fatty acid
supplements for twelve weeks delayed transition to a first full psychotic episode
(such as schizophrenia) within one year.

Fish oil has also shown a bit of promise for borderline personality disorder. In one study, DHA failed to augment the effectiveness of standard therapy for attention deficit disorder (ADD). However, two studies that evaluated the potential benefits of fish oil combined with omega-6 fatty acids found some evidence of benefit for this condition. Finally, one small trial found evidence that the use of fish oil might decrease anger and aggressiveness in people with a history of aggressive behaviors, substance abuse, and problems with the law.

Small studies also suggest that fish oil may be helpful in Raynaud’s phenomenon (a condition in which a person’s hands and feet show abnormal sensitivity to cold temperatures), sickle cell anemia, and a form of kidney disease called IgA nephropathy. Also, according to some studies, but not all, fish oil may help treat the undesired weight loss often experienced by people with cancer. In addition, highly preliminary evidence hints that DHA might enhance the effects of the cancer chemotherapy drug doxorubicin and decrease side effects of the chemotherapy drug irinotecan.

Use of fish oil by pregnant women might help prevent premature birth, although evidence is somewhat inconsistent. In addition, the use of fish oil by pregnant women may support healthy brain function and help prevent eczema and allergies in offspring.

Intriguing, but unreliable, evidence hints that fish oil, or its constituents, might be helpful for treating kidney stones or alleviating the symptoms of chronic fatigue syndrome. Results are inconsistent regarding whether the use of fish oil can decrease seizure frequency in people with epilepsy.

One study found that insulin metabolism in 278 young, overweight persons improved on a calorie-restricted diet rich in fish oil from seafood or supplements compared with those on a diet low in fish oil, suggesting that fish oil may help delay the onset of diabetes in susceptible persons. Fish oil has also been proposed as a treatment for many other conditions, including diabetic neuropathy, allergies, and gout, but there has been little real scientific investigation of these uses.

Some studies suggest that fish oil combined with omega-6 essential fatty acids may augment the effectiveness of calcium in the treatment of osteoporosis. One promising, but highly preliminary, double-blind, placebo-controlled study suggests that the same combination therapy may improve symptoms of the severe neurological illness called Huntington’s disease.

Use of a fish oil product as part of a total parenteral (intravenous feeding) nutrition regimen may help speed recovery after major abdominal surgery. For several other conditions, the current balance of the evidence suggests that fish oil is not effective.

For example, despite widely publicized claims that fish oil helps asthma, most preliminary studies have failed to provide evidence that it is effective, and one study found that fish oil can actually worsen aspirin-related asthma. However, there is some evidence that the use of fish oil could help prevent exercise-induced asthma in athletes. In a randomized-controlled trial with long-term follow-up, women who took fish-oil during late pregnancy reduced the risk of asthma in their children up to sixteen years later.

One study found that fish oil did not benefit the lung function of persons with cystic fibrosis. Similarly, a sixteen-week, double-blind, placebo-controlled study of 167 persons with recurrent migraine headaches found that fish oil did not significantly reduce headache frequency or severity. Conflicting results have been seen in other, much smaller trials of fish oil for migraines.

One study found weak evidence that the use of fish oil might decrease aggressive behavior in young girls (but, in this study, not in young boys). Another study found benefit in developmental coordination disorder (a condition in which children display a lack of physical coordination and problems with learning and behavior).

Fish oil is also sometimes recommended for enhancing immunity in human immunodeficiency virus (HIV) infection. However, one six-month, double-blind study found that a combination of the omega-3 fatty acids in fish oil plus the amino acid arginine was no more effective than placebo in improving immune function in people with HIV. Fish oil, however, might help persons with HIV gain weight.

In one large, randomized-controlled trial, diets rich in fish and omega-3 fatty acids from fish were associated with a significant reduction in the risk of developing colorectal cancer among men in a twenty-two-year period. Another study provides preliminary evidence for the benefits of fish oil in reducing the risk of prostate cancer. On balance, there is still relatively little evidence that the consumption of fish oil reduces cancer risk.

Preliminary studies have suggested that fish oil could help symptoms of multiple sclerosis; however, the largest double-blind study on the subject found no difference between people taking fish oil and those taking olive oil (used as a placebo). Although one study found fish oil somewhat helpful in psoriasis, a much larger study found no benefit.

DHA has been evaluated as a possible treatment for male infertility, but a double-blind trial of twenty-eight men with impaired sperm activity found no benefit. Combination therapy with gamma-linolenic acid (GLA) and fish oil failed to prove effective for cyclic breast pain.

One study failed to find fish oil more effective than placebo for treating stress. DHA also has been tried for slowing the progression of retinitis pigmentosa (a condition in which the retina gradually degenerates), but without much success. In observational studies, people who happen to consume a diet rich in omega-3 fatty acids seem to lower their risk of age-related macular degeneration (the most common cause of blindness in the elderly). However, in the absence of randomized-controlled trials, it is not possible to say whether or not it is omega-3 that produces this benefit.

Studies of fish oil have failed to find it helpful for Alzheimer’s disease, whether for slowing its progression or improving symptoms. Also, one well-designed study failed to find any benefit of fish oil for enhancing memory and mental function in older adults without dementia in a twenty-six-week period. Use of essential fatty acids in the omega-3 family has also shown some promise for the treatment of nonalcoholic fatty liver.

Scientific Evidence

Heart disease prevention. Studies on fish or fish oil for preventing cardiovascular disease, slowing the progression of cardiovascular disease, and preventing heart-related death have returned somewhat contradictory results. A major review published in 2004 failed to find trustworthy evidence of benefit, and a subsequent study actually found that the use of fish oil increases risk of sudden death in people with stable heart disease. A 2008 systematic review found that fish oil was associated with modestly reduced cardiac mortality, but not sudden cardiac death, in eleven studies with more than thirty-two thousand participants.

The reliability of these results is limited by the inclusion of trials that were of low to moderate in quality. Though not entirely consistent, on balance the evidence does suggest that regularly consuming oily fish or taking omega-3 fatty acid supplements can reduce the risk of cardiovascular events (such as heart attacks) and deaths.

A 2009 review pooled data from eight trials examining the effect of omega-3 fatty acids on prevention of cardiac death in almost twenty-one thousand persons with coronary heart disease. This review separated persons into two general groups (those with previous myocardial infarction versus those with angina history) and found that omega-3 supplementation reduced risk of sudden cardiac death in persons with previous myocardial infarction, but increased risk in persons with angina. Though compelling, this finding may be limited because it was derived from a retrospective analysis of original data reorganized into subgroups.

A gigantic study (more than eighteen thousand participants) published in 2007 was widely described in the media as finally proving that fish oil helps prevent heart problems. However, this study lacked a placebo group; therefore, it failed to provide reliable evidence.

As noted, fish oil is hypothesized to exert several separate effects that act together to help protect the heart. The most important action of fish oil may be its apparent ability to reduce high triglyceride levels. Like cholesterol, triglycerides are a type of fat in the blood that tends to damage the arteries, leading to heart disease. According to most studies, fish oil supplements can reduce triglycerides by as much as 25 to 30 percent. In a detailed review of forty-seven randomized trials, researchers concluded that fish oil can significantly reduce triglyceride levels with no change in total cholesterol levels and only slight increases in HDL (good) cholesterol and LDL (bad) cholesterol.

A slightly modified form of fish oil (omega-3-acid ethyl esters) has been approved by the FDA as a treatment for elevated triglycerides. However, in some studies, the use of fish oil has markedly raised LDL cholesterol, which might offset some of the benefit. A 2009 review of thirty trials involving about fifteen hundred persons with type 2 diabetes demonstrated that marine-derived omega-3 polyunsaturated fatty acids (mean dose 2.4 g per day) lowered triglyceride levels but increased LDL cholesterol after an average twenty-four weeks of treatment.

Stanols and sterols (or phytosterols) are naturally occurring substances found in various plants that can help to lower cholesterol in persons with normal or mildly to moderately elevated levels. A study investigating the possible benefit of combining a phytosterol with fish oil found that together they significantly lowered total cholesterol, LDL-cholesterol, and triglycerides, and raised HDL (good) cholesterol in persons with undesirable cholesterol profiles.

Fish oil has been specifically studied for reducing triglyceride levels in people with diabetes, and it appears to do so safely and effectively. It also seems to remain effective in persons who are already using statin drugs to control lipid levels (people both with and without diabetes). However, one study found that the standard drug gemfibrozil is more effective than fish oil for reducing triglycerides.

Some but not all studies suggest that fish, fish oil, or EPA or DHA separately may also raise the level of HDL (good) cholesterol and possibly improve other aspects of cholesterol profile. This too should help prevent heart disease. Additionally, fish oil may help the heart by thinning the blood and by reducing blood levels of homocysteine, though not all studies have found a positive effect.

Studies contradict one another on whether fish oil can lower blood pressure, but on balance the supplement does seem to exert a modest positive effect. A six-week, double-blind, placebo-controlled study of fifty-nine overweight men suggests that the DHA in fish oil, not the EPA, is responsible for this benefit.

Evidence is conflicting on whether fish oil helps prevent heart arrhythmias. A large Italian trial involving almost seven thousand participants found that fish oil may modestly reduce the risk of death or admission to the hospital for cardiovascular reasons in persons with congestive heart failure. Finally, fish oil may slightly reduce heart rate. This effect could contribute to preventing heart attacks and other heart problems.

Rheumatoid arthritis. The results of numerous small, double-blind trials indicate that omega-3 fatty acids in fish oil can help reduce the symptoms of rheumatoid arthritis. One small study suggests that it may help persons with rheumatoid arthritis to lower their dose of nonsteroidal anti-inflammatory medication (such as ibuprofen). The benefits of the fish oil effect may be enhanced by a vegetarian diet. Simultaneous supplementation with olive oil (about two teaspoons daily) may further increase the benefits. However, unlike some conventional treatments, fish oil probably does not slow the progression of rheumatoid arthritis.

Menstrual pain. The regular use of fish oil may reduce the pain of menstrual cramps. In a four-month study of forty-two young women age fifteen to eighteen years, one-half the participants received a daily dose of 6 g of fish oil, providing 1,080 mg of EPA and 720 mg of DHA daily. After two months, they were switched to placebo for another two months. The other group received the same treatments in reverse order. The results showed that these young women experienced significantly less menstrual pain while they were taking fish oil.

Another double-blind study followed seventy-eight women, who received either fish oil, seal oil, fish oil with vitamin B12 (7.5 mcg [micrograms] daily), or placebo for three full menstrual periods. Significant improvements were seen in all treatment groups, but the combination of fish oil and vitamin B12 proved most effective, and its benefits continued for the longest time after treatment was stopped (three months). The researchers offered no explanation why vitamin B12
should be helpful.

Bipolar disorder. A four-month, double-blind, placebo-controlled
study of thirty people suggests that fish oil can enhance the effects of standard
treatments for bipolar disorder, reducing risk of relapse and improving
emotional state. Eleven of the fourteen persons who took fish oil improved or
remained well during the course of the study, while only six of the sixteen given
placebo responded similarly. Another small study found that ethyl-EPA (a modified
form of EPA) is helpful for the depressive phase of bipolar disease.

Depression. A four-week, double-blind, placebo-controlled trial evaluated the potential benefits of fish oil in twenty persons with depression. All but one participant were also taking standard antidepressants and had been taking them for at least three months. By week three, the level of depression had improved to a significantly greater extent in the fish oil group than in the placebo group. Six of ten participants given fish oil, but only one of ten given placebo, showed at least a 50 percent reduction in depression scores by the end of the trial. (A reduction of this magnitude is considered a cure.)

A double-blind, placebo-controlled study of seventy people who were still
depressed despite standard drug therapy (such as selective serotonin reuptake
inhibitors) found that additional treatment with ethyl-EPA
improved symptoms. Similar add-on benefits were seen in other double-blind studies
of ethyl-EPA or mixed essential fatty acids. However, one study failed to find
benefit with fish oil as an add-on treatment. Another double-blind study failed to
find DHA alone helpful for depression. A third, relatively large
placebo-controlled study found no benefit for fish oil in improving mental
well-being among 320 older adults without a diagnosis of depression.

Postpartum depression. The effectiveness of fish oil
supplementation in treating or preventing perinatal (including postpartum)
depression is unclear. A small preliminary study of women found that fish oil was
significantly more effective than placebo at alleviating postpartum
depression. However, another small, placebo-controlled study
was unable to show a benefit in women with depression, whether before or after
delivery. In addition, a 2009 trial of 182 pregnant women with suspected low
intake of DHA found that daily DHA supplementation (with or without arachidonic
acid) did not reduce risk of postpartum depression, compared with placebo. Also,
in another, much larger study involving 2,399 women, researchers found that fish
oil capsules (a combination of DHA 800 mg per day and EPA 100 mg per day) did not
prevent postpartum depression. It also did not improve the cognitive and language
development in their children up to four years after their birth.

Raynaud’s phenomenon. In small, double-blind studies, fish oil has been found to reduce the severe finger and toe responses to cold temperatures that occur in Raynaud’s phenomenon. However, these studies suggest that a higher-than-usual dosage must be used to get results, perhaps 12 g daily.

Osteoporosis. There is some evidence that essential fatty acids may enhance the effectiveness of calcium in osteoporosis. In one study, sixty-five postmenopausal women were given calcium with either placebo or a combination of omega-6 fatty acids (from evening primrose oil) and omega-3 fatty acids (from fish oil) for eighteen months. At the end of the study period, the group receiving essential fatty acids had higher bone density and fewer fractures than the placebo group. However, a twelve-month, double-blind trial of forty-two postmenopausal women found no benefit.

The explanation for the discrepancy may lie in the differences between the women studied. The first study involved women living in nursing homes, while the second study looked at healthier women living on their own. The latter group of women may have been better nourished and already receiving enough essential fatty acids in their diet.

Lupus. Lupus is a serious autoimmune disease that can cause numerous problems, including fatigue, joint pain, and kidney disease. One small, thirty-four-week, double-blind, placebo-controlled crossover study compared placebo with daily doses of EPA (20 g) from fish oil. Seventeen persons completed the trial. Of these, fourteen showed improvement when taking EPA, while only four did so when treated with placebo. Another small study found similar benefits with fish oil in a twenty-four-week period. However, two small studies failed to find fish oil helpful for lupus nephritis (kidney damage caused by lupus).

Attention deficit disorder (ADD). Based on evidence that essential fatty acids are necessary for the proper development of brain function in growing children, essential fatty acids have been tried for the treatment of ADD and related conditions. A preliminary double-blind, placebo-controlled trial found some evidence that a supplement containing fish oil and evening primrose oil might improve ADD symptoms. However, a high dropout rate makes the results of this trial somewhat unreliable. Another small study examined fish oil in children with ADD who had thirst and skin problems. Benefits were seen with fish oil, but the benefits also occurred with placebo and did so to about the same extent.

Safety Issues

Fish oil appears to be generally safe. The most common problem is fishy burps. However, there are some safety concerns to consider.

For example, it has been suggested that some fish oil products contain excessive levels of toxic substances such as organochlorines and PCBs. If possible, one should try to purchase fish oil products certified not to contain significant levels of these contaminants. Various types of fish contain mercury, but this has not been a problem with fish oil supplements, according to some reports.

Fish oil has a mild blood-thinning effect; in one case report, it increased the
effect of the blood-thinning medication warfarin (Coumadin). Fish oil does not
seem to cause bleeding problems when it is taken by itself or with aspirin.
Nonetheless, people who are at risk of bleeding complications for any reason
should consult a physician before taking fish oil.

Fish oil does not appear to raise blood sugar levels in people with diabetes. Nonetheless, persons with diabetes should not take any supplement except on the advice of a physician.

Fish oil may modestly increase weight and lower total cholesterol and HDL (good) cholesterol levels. It may also raise the level of LDL (bad) cholesterol; however, this effect may be short-lived.

Persons deciding to use cod liver oil while finishing their fish oil supplement should avoid exceeding the safe maximum intake of vitamins A and D. These vitamins are fat soluble, which means that excess amounts tend to build up in the body, possibly reaching toxic levels. The official maximum daily intake of vitamin A is 3,000 mcg for pregnant women and other adults. The bottle label will help one determine how much vitamin A one is receiving. (It is less likely that a person will get enough vitamin D to produce toxic effects.)

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