What is angiography?

Indications and Procedures

Angiography (also called arteriography) is a procedure utilized for the detection of abnormalities in arteries of the heart, brain, or other organs. The procedure is carried out when symptoms suggest the narrowing or blockage of an artery, most frequently in the heart or brain. Such symptoms include chest pain or similarly associated discomfort in the region of the stomach or left side of the body. Even if pain is absent, shortness of breath may indicate a cardiac or pulmonary problem. Slurred speech or vision may likewise suggest narrowing of an artery in the brain. Angiography can therefore indicate the likelihood of a heart attack or stroke, as well as other problems which may produce similar symptoms, such as blood clots or cancer.

The patient must avoid food or drink for approximately eight hours prior to the procedure. A catheter is inserted through the skin, usually in the groin area, and placed into the artery to be examined. A sedative is not necessary, although it may be given to the patient to aid in relaxation.

Once the catheter is in place, a radiopaque dye is injected, and x-ray photographs of the area in question are taken. The procedure generally takes about three hours.

Uses and Complications

Since any blockage or narrowing of an artery will result in accumulation of the radiopaque dye, the radiologist can pinpoint the site of the block. Based on the symptoms, the physician can discuss the diagnosis and recommend further procedures.

The most common complication associated with angiography is the mild discomfort resulting from insertion of the catheter. The dye itself may cause a slight burning sensation, and on rare occasions it may trigger an allergic response. In 1 to 2 percent of cases, more serious complications develop. If the blockage results from an atherosclerotic plaque or from a blood clot, in rare circumstances a piece of this material may break off and lodge elsewhere in the arterial system. The result can be a stroke or heart attack.

Bibliography

"Coronary Angiography." Medline Plus, June 22, 2012.

"CT Angiography (CTA)." Radiological Society of North America, July 2, 2012.

Dranov, Paula. Heart Disease. New York: Random House, 1990.

"Extremity Angiography." Medline Plus, December 10, 2012.

Higgins, Charles B., and Albert de Roos. Cardiovascular MRI and MRA. Philadelphia: Lippincott Williams & Wilkins, 2002.

Karch, Amy Morrison. Cardiac Care: A Guide for Patient Education. New York: Appleton-Century-Crofts, 1981.

Ludinghausen, Michael. Clinical Anatomy of Coronary Arteries. New York: Springer, 2003.

Prince, Martin R., et al. 3-D Contrast MR Angiography. New York: Springer, 2003.

Rosenblum, Laurie. "Angiography." Health Library, May 20, 2013.

Rutherford, Robert B., ed. Vascular Surgery. 7th ed. Philadelphia: Saunders/Elsevier, 2010.

How is poetry from the past different from modern poetry?

English language poetry has changed significantly in the last 250 years. Before the dawn of the Romantic age in 1785, poetry tended to be filled with elevated diction, strewn with allusions to classical literature, and replete with personifications of abstract concepts. Sonnets and long epic poems were popular in Shakespeare's time. However, simple ballads, verses that were often sung in everyday speech or dialect, were also common. William Wordsworth and Samuel Taylor Coleridge cooperated in introducing a dramatic change to poetry known as the "lyrical ballad," a form that attempted to bring poetry more into the grasp of the common man by using the words of everyday speech but maintaining a metrical pattern and beauty of language. These poems used traditional verse forms but shunned the excessive high-brow language and personifications of abstract objects that poems had used before. Poets like Keats, Shelley, and Byron brought much beauty, philosophy, and even humor to their poems, still using regular rhythm and rhyme.

The Victorian poets, such as Alfred, Lord Tennyson and Elizabeth Barrett Browning, built on the foundation of the Romantics and continued expressing their various themes in traditional rhymed forms or blank verse. However, in the last half of the 19th century, experiments in poetry by Robert Browning in England and Emily Dickinson and Walt Whitman in America presaged more freedom in the forms of poetry. By extensive use of enjambment and caesura, Browning achieved a sense of the rhythms of regular speech in his dramatic monologues, although they actually used consistent rhythm and meter. Emily Dickinson usually wrote in a traditional ballad format known as the fourteener (28 syllables in a stanza), but her frequent use of erratic capitalization and punctuation as well as near rhyme added flexibility to her verse. Whitman gave up the use of traditional verse forms altogether for some of his poems, preferring long, descriptive, unrhymed lines. 

In the 20th century, poetry changed dramatically, indicating the dawn of the Modernist era. Extremely influential during this period was Ezra Pound, who introduced the technique of Imagism. Imagist poems used a minimalist approach, preferring short poems whose purpose was simply to evoke a single image in the reader's mind. Although Imagism did not take over English poetry, it influenced it significantly. Wide variations in verse forms became the norm as poets tended to abandon consistent rhythm, meter, and rhyme schemes for the rhythms of natural speech or for inconsistent rhymes and rhythms. Not only that, but the subject matter of poetry changed to reflect the disillusionment of modern society. Rather than providing pat answers, Modernist poetry often prefers questions or deliberate obscurity. "The Wasteland" by T.S. Eliot and "The Second Coming" by W.B. Yeats are two good examples. Not all modern poets, however, fall into the "anything goes" camp. Robert Frost, America's best-known and best-loved poet for half of the 20th century, used primarily traditional verse forms for his poems. Modern poets have the option of drawing on the rich traditions of any of the poetry that precedes them, from the traditional verse forms of the 18th and 19th centuries to the Imagism and free verse of the 20th century.

Why in the future will it be necessary to replace fossil fuels with alternative energy sources?

Alternative sources are the necessity of the present and future for two significant reasons: their limited quantity and the pollution potential of fossil fuels.

Fossil fuels have driven and are driving our development. However, there is only a limited quantity of fossil fuels in this world. The reason for this is simple. It takes millions of years for these fuels to form and hence they are also called non-renewable resources. Given the ever increasing demand for fuels, we are in the danger of running out of these fuels in the next 50-100 years or so.

Another issue with fossil fuels is the generation of carbon dioxide and other greenhouse gases upon combustion. These gases are the main cause of global warming and climate change. A lot of emphasis is being placed on replacing these fuels to prevent or minimize the impacts of climate change.

Thus, sooner or later we will have to replace these fossil fuels with alternative energy sources, such as solar power, wind power, etc.

Hope this helps.

Can you give me a summary of Matilda by Roald Dahl?

Matilda by Roald Dahl is the story of a gifted, extraordinarily talented girl born to boring, unimaginative parents. From the time she is born, Matilda is different than other children. She is a genius who finds an outlet from her parents when she teaches herself to read, and finds refuge in the local library. Her parents find her to be a trying child who they wish would vegetate in front of the television. Instead, Matilda would rather read or do mathematical computations far above her years. Matilda applies her brilliance to trick her parents and she discovers that she has telekinetic abilities that allow her to move things with her mind.

Once Matilda goes to kindergarten, her teacher, Miss Honey, realizes that she is a genius but even Matilda is unaware of her hidden talent. Miss Honey takes Matilda under her wing and nurtures her. While they share time in Miss Honey’s modest cottage, Matilda finds out that Miss Trunchbull, the abusive headmistress of the school, is Miss Honey’s unscrupulous aunt. Matilda uses her telekinetic skills to scare off Miss Trunchbull. When the chalk independently writes a message on the classroom chalkboard, Miss Trunchbull leaves, never to return.

Matilda’s parents move away leaving her with Miss Honey, who challenges the child’s intellect.

An airplane is heading N 10 degrees E at 260 mph. A 16 mph wind blows from the W. Find the plane's resultant velocity and direction. Use vector method

Hello!

Let the x-axis be from W to E and the y-axis from S to N. Then the own velocity of an airplane is represented by the vector

`V_1=lt260*sin(10^o),260*cos(10^o)gt`  (in mph).

The wind velocity is represented by the vector

`V_2=lt16,0gt`  ("blows from the W" means "to the E").

The combined velocity is

`V=V_1+V_2=<x_0,y_0> =`

`=lt260*sin(10^o)+16,260*cos(10^o)gt approx lt61.15,256.05gt.`

The magnitude of V (the speed) is `sqrt(x_0^2+y_0^2) approx263.25` (mph).

The direction is `arctan(y_0/x_0) approx76.57^o,` which means `90^o-76.57^o=13.43^o` "N to the E".

The answer: the speed is about 263.25 mph, the direction is about N 13.43 degrees E.

What is mononucleosis?

Causes and Symptoms

Mononucleosis is caused by the Epstein-Barr virus
, which is transmitted through infected saliva or by blood transfusions. It has an incubation period of four to six weeks. The saliva may remain infective for as long as eighteen months, and after the primary infection, the virus may be present in the nasal secretions and shed periodically for the rest of the host’s life. Many cases occur in adolescents—hence the popular name “the kissing disease.” The virus can be cultured from the throat of 10 to 20 percent of most healthy adults. The incidence of mononucleosis varies seasonally among high school and college students but does not vary among the general population. The disease is fairly common in the United States, Canada, and Europe and occurs in both sexes.

Mononucleosis is characterized by fever, fatigue, anorexia, a sore throat
, chills, a skin rash, bleeding gums, red spots on the tonsils, malaise, and periorbital edema. Lymph nodes in the neck enlarge, and splenomegaly develops in about half of patients. In a small number of patients, liver involvement with mild jaundice occurs.

The diagnosis is made by several different tests, such as the differential white blood count. In mononucleosis, lymphocytes and monocytes make up greater than 50 percent of the blood cells, with a figure of more than 10 percent being atypical. The leukocyte count is normal early in the disease but rises during the second week. Serology studies show an increase in the heterophile antibody titer, although the monospot test is more rapid and can detect the infection earlier and is widely used. Children under four years of age often test negative for heterophil antibodies, but the test will identify 90 percent of cases in older children, adolescents, and adults.

Treatment and Therapy

The treatment of mononucleosis is mainly supportive, since the disease is self-limiting. The patient is usually placed on bed rest during the acute stage of the disease, and activity is limited to prevent rupture of the enlarged spleen, usually for at least two months. Acetaminophen (such as the brand Tylenol) is given for the fever, and saline gargles or lozenges may be used for the sore throat. Patients need to increase their fluid intake. Many doctors use corticosteriods such as prednisone during the course of the disease to lessen the severity of the symptoms. If rupture of the spleen occurs, emergency surgery is necessary to remove the organ.

Complications are uncommon but may include rupture of the spleen, secondary pneumonia, heart involvement, neurologic manifestations such as Guillain-Barré syndrome, meningitis, encephalitis, hemolytic anemia, and orchitis (inflammation of the testes).

Perspective and Prospects

Viruses, such as the one responsible for mononucleosis, were first studied in the 1930s, and they remain a challenge to laboratory investigators. Most information about viruses has come from studying their effects, rather than the viruses themselves. The majority of methods for destroying or controlling viruses are ineffective. There is no prevention for many of the diseases caused by viruses, such as infectious mononucleosis. It may be reassuring to know that the disease seldom causes severe complications if the symptoms are treated and medical care is given to those infected with the Epstein-Barr virus.

Bibliography

Alan, Rick. "Mononucleosis." Health Library, March 25, 2013.

Beers, Mark H., et al., eds. The Merck Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, N.J.: Merck Research Laboratories, 2011.

Dreher, Nancy. “What You Need to Know About Mono.” Current Health 2 23, no. 7 (March, 1997): 28–29.

Harkness, Gail, ed. Medical-Surgical Nursing: Total Patient Care. 10th ed. St. Louis, Mo.: Mosby, 1999.

Kimball, Chad T. Colds, Flu, and Other Common Ailments Sourcebook. Detroit, Mich.: Omnigraphics, 2001.

Litin, Scott C., ed. Mayo Clinic Family Health Book. 4th ed. New York: HarperResource, 2009.

"Mononucleosis." Mayo Clinic, December 19, 2012.

"Mononucleosis." MedlinePlus, May 15, 2012.

Shrader, Laurel, and John Zonderman. Mononucleosis and Other Infectious Diseases. Rev. ed. New York: Chelsea House, 2000.

Sompayrac, Lauren. How Pathogenic Viruses Work. Boston: Jones and Bartlett, 2002.

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

Why does Aunt Alexandra accept that the Cunninghams may be good people, but are not our kind of folks?

In Chapter 23, Atticus tells the children that one person in the Cunningham family was in favor of acquitting Tom Robinson during the jury's deliberation. Jem tells Atticus that he'll never understand those people as long as he lives, and Atticus says that he just has to get to know them. Atticus explains that the Cunninghams have integrity and respect other people. He says they've never taken anything from anybody ever since they migrated from the New World. While Atticus is describing the positive attributes of the Cunningham family, Aunt Alexandra is listening while she "hooks" a rug. Scout mentions that she's going to invite Walter Cunningham Jr. over when school starts. Alexandra says, "We'll see about that" (Lee 299). Scout is surprised and asks why not. Aunt Alexandra says, "Jean Louise, there is no doubt in my mind that they're good folks. But they're not our kind of folks" (Lee 299). Aunt Alexandra tells Scout that the Cunninghams are tacky and dirty. She mentions that they like to fiddle, and have a drinking streak in their family. Scout begins to argue with Alexandra and wants to know why she can't invite Walter over. Alexandra says, "Because---he---is---trash, that's why you can't play with him" (Lee 301). Alexandra is prejudiced towards families who come from a lower social class. She views Walter's family with contempt because she feels they are "beneath" them. Alexandra accepts the fact that the Cunninghams are good folks, but cannot look past their socioeconomic status.

What page does Reverend Sykes tell Scout to stand for her father when Atticus passes?

At the end of Chapter 21, on page 283 of the Grand Central Publishing Edition of the novel To Kill a Mockingbird, Reverend Sykes tells Scout to stand up because Atticus is passing. The entire balcony of African Americans stands up to pay their respects to Atticus for defending Tom Robinson. Even though Tom Robinson was found guilty by a prejudiced jury, the African American community greatly appreciated Atticus for his valent effort throughout the court case. In Chapter 22, Atticus receives numerous gifts from the African American community the day after the trial. His eyes swell with tears when he sees the hunks of pork, vegetables, and fruit piled in his kitchen. Calpurnia tells him that the food was surrounding the back porch in the morning when she woke up. Atticus tells Calpurnia that he is very greatly for their gifts of appreciation, and says, "Tell them---tell them they must never do this again. Times are too hard..." (Lee 286).

What is hoarding?

Origins and Symptoms

The precise cause of hoarding remains elusive. Research has sought to establish a relationship between the disorder and biological and environmental factors. In the fifth edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), hoarding disorder is categorized along with obsessive-compulsive disorder (OCD)—an anxiety disorder in which obsessions and fears promote compulsive or repetitive behaviors the person feels driven to accommodate. In the past, it was believed that hoarding might be a subset of OCD. However, not every case includes obsession or compulsivity, and anxiety is another prominent characteristic of other hoarding cases.

For a diagnosis of hoarding disorder, the behavior must either cause distress to the individual or impairment in the person's functioning. About 60 percent of hoarders also buy compulsively. Hoarding may be comorbid with OCD, clinical depression, attention-deficit disorder, psychosis, or other disorders; however, these other conditions cannot better explain the behavior for a hoarding disorder diagnosis to be made.

Common denominators among hoarders, though difficult to identify, do exist. Stressful life events and social isolation both appear to be risk factors. Most have problems with decision-making, perfectionism, categorical organization, and risk assessment. Hoarding shows no real response to early life deprivation, and thoughts tend to focus upon loss when the hoarder is forced to discard items, regardless of the item’s objective worth or value. Hoarders may anticipate a need for the item at some unknown point or keep items as memory triggers. Still others acquire items they find exceptional.

Assorted items such as newspapers, magazines, and articles of clothing may line walls in stacks that reach the ceiling, allowing limited access to areas of the house and threatening to collapse upon persons needing access. Hoarded material covers floors, tables, chairs, and beds, obstructing movement in the residence. Also, many hoarders collect items that were purchased years earlier and still remain in the original wrapping.

Effects of Hoarding

Of the millions of persons in the United States who are thought to be hoarders, many began to exhibit signs of the disorder during adolescence. Some come from homes in which a family member engaged in hoarding. However, most family members of hoarders seem to be embarrassed by the conditions produced by hoarding and may even end all communication with the hoarder. Spouses may seek divorces or become hoarders themselves. A hoarder left alone will often continue to hoard until friends, family, neighbors, or local authorities intervene.

Animal hoarding involves keeping more pets than can be properly cared for. Animal waste, decayed food and vermin, nonexistent sanitation procedures, and a deteriorating house lead to long-lasting health problems for animals and human residents. The effects on overcrowded, underfed, medically neglected animals legally constitute animal cruelty. Animals that survive such conditions often require extensive rehabilitation; some animals never recover. Humans face high ammonia levels, insect and rodent infestations, parasitic diseases, and food-related illnesses. More than a third of object hoarders also hoard animals, according to the Anxiety and Depression Association of America.

Treatment

The main goal of treating people who hoard is to change behaviors, including the compulsion to hoard. Oftentimes, this involves changing the relationship a person has with his or her possessions, which is a long, slow process that can involve discarding one item at a time.

Hoarders may benefit from therapists or professional organizers. Also, therapists could, with the hoarder’s help, formulate guidelines for throwing items away. For example, the “two-year rule” suggests that if something has not been used in the past two years, chances are it will never be used and should probably be discarded. Another strategy is to work together to formulate and implement a list of practical questions that the hoarder can ask him- or herself when confronted with the decision of whether to acquire an item.

Cognitive-behavioral therapy (CBT) can also help hoarders become aware of the mental, emotional, and behavioral patterns that encourage hoarding. Hoarders might be urged, for example, to remove magazines and newspapers from the home after a certain period, to sort mail sorted daily (eliminating all junk mail), and to employ filing cabinets items such as bills, tax statements, and other important papers. In cases of comorbid anxiety or clinical depression, medication may reduce the negative feelings associated with discarding. Although hoarding cannot be cured, it can, with behavior modification, medication, and determination, be kept under control.

In cases of animal hoarding, the causes tend to be more serious and, therefore, require more deliberate treatment. Animal hoarders often suffer from dementia, emotional attachment difficulties, and an inability to interpret clearly. Difficult to treat successfully, animal hoarding requires extended psychological care long after the animals have been removed from the home. Also, psychologists recommend the involvement of animal welfare, police, health agencies, friends and family members, and the community in continued follow-up measures to prevent relapses.

Bibliography

Adee, Sally. “Possessed by Possessions.” New Scientist 221.2962 (2014): 44. Academic Search Complete. Web. 28 Oct. 2015.

Arluke, Arnold, and Celeste Killeen. Inside Animal Hoarding: The Case of Barbara Erickson and Her 552 Dogs. Lafayette: Purdue UP, 2009. Print.

Bratiotis, Christiana, Cristina Sorrentino Schmalisch, and Gail Steketee. The Hoarding Handbook: A Guide for Human Service Professionals. New York: Oxford UP, 2011. Print.

Frost, R. O., G. Patronek, and E. Rosenfield. “Comparison of Object and Animal Hoarding.” Depression and Anxiety 28.10 (2011): 885–91. Print.

Jabr, Ferris. “Step Inside the Real World of Compulsive Hoarders.” Scientific American. Nature America, 25 Feb. 2013. Web. 29 Oct. 2015.

Neziroglu, Fugen, Jerome Bubrick, and Jose A. Yaryara-Tobias. Overcoming Compulsive Hoarding: Why You Save and How You Can Stop. Oakland: New Harbinger, 2004. Print.

Steketee, Gail, and Randy Frost. Stuff: Compulsive Hoarding and the Meaning of Things. New York: Mariner, 2011. Print.

Tompkins, Michael A., and Tamara L. Hartl. Digging Out: Helping a Loved One Manage Clutter, Hoarding, and Compulsive Acquisitions. Oakland: New Harbinger, 2009. Print.

How is Curley's wife an archetype for all women?

Many of the characters in Of Mice and Men can be read as archetypes or symbols of a certain type of person or character in fiction. Lennie is the archetypal "wise fool," whose foolishness allows for unpretentious insights; George is the "everyman," representing an ordinary person; Slim is a symbol of the hero; etc.

Curley's wife can be read two ways. On one hand, she is the Biblical figure of Eve, the source of temptation and the downfall of man. Consider her appearance: too much make-up, red shoes and fingernails, ostrich feathers. Not only does she look like the stereotypical "whore," she also knows her sexual power and uses it to flirt with and tempt the ranch hands. Her symbolism as Eve is complete when Lennie, who has been fascinated by her from the beginning, can't resist petting her hair and accidentally breaks her neck. With that action of temptation, Lennie and George lose the final opportunity for their ranch, their own Garden of Eden.  

The other way readers can analyze Curley's wife is as an archetype for all women who are oppressed by a patriarchal society. She isn't even given a name, but instead referred to as either a temptress, as discussed above, or as a possession of Curley's. Though her dialogue shows her to be cruel and despicable, it also reveals her lack of choices in the male-dominated world she inhabits. In chapter 4, when the ranch hands go off to Suzy's for the night, Curley's wife wanders into the barn where Lennie, Crooks, and Candy are talking. She says:

"'You bindle bums think you're so damn good. Whatta ya think I am, a kid? I tell ya I could of went with shows. Not jus' one, neither. An' a guy tol' me he could put me in pitchers…' She was breathless with indignation. '—Sat'iday night. Ever'body out doin' som'pin'. Ever'body! An' what am I doin'? Standin' here talkin' to a bunch of bindle stiffs—a nigger an' a dum-dum and a lousy ol' sheep—an' likin' it because they ain't nobody else.'"

As insulting as this speech is, it also shows that Curley's wife has dreams like George and Lennie, and, like them, is trapped and will never achieve them. Later in the book she talks about having the chance to run away to Hollywood when she was 15 and not taking it. As horrible as she is, her limited options in life are pitiable and her state of confinement is clear.

What is hematology?

Science and Profession

Most branches of medical science study a particular organ that is made of specific tissues and is located in a definite part of the body. Hematology is unique because its subject, the blood, is a liquid tissue constantly in motion and therefore in constant contact with every other tissue and organ of the body.

It has been estimated that blood travels about sixteen kilometers (ten miles) per hour. It takes six seconds for blood to travel from the heart to the lungs, about eight seconds to travel from the heart to the brain, and only fourteen seconds to travel from the heart all the way to the toes. Hematologists studying these shifting currents of the blood are able to detect patterns that allow the early discovery of many disorders of the blood itself and of the organs that it supplies.

Blood is a complex material composed of approximately 55 percent plasma and 45 percent cells, which are also called formed elements. The plasma, or liquid portion of the blood, is about 90 percent water and 10 percent substances dissolved or suspended in that water. Part of that 10 percent consists of a remarkable array of substances, including nutrients, gases, salts, wastes, and hormones being transported around the body. The other, larger part of the 10 percent is another remarkable array: plasma proteins such as fibrinogen, albumin, and globulins with a great diversity of functions to accomplish. The modern hematologist’s ability to measure and monitor all these plasma components precisely has greatly aided physicians in the treatment of innumerable diseases.

Beyond an analysis of the ingredients of the plasma, hematologists focus on the normal and abnormal conditions of the blood’s cells. An individual has around twenty-five trillion red blood cells; ten million of these cells die or are destroyed each second, and two hundred billion new ones need to be made each day. Hematologists discovered that these tiny, biconcave discs packed with hemoglobin transport the vast majority of the oxygen constantly needed by every cell of every organ for energy production.

Before each red blood cell is released from the bone marrow where it is produced, the bulk of its living nucleus is expelled. A small amount of nuclear material remains as a fine network in these young cells, called reticulocytes. The number of reticulocytes released into the blood is an indication of the activity of the bone marrow. Hematologists use this number both to diagnose conditions such as anemia in its various forms and to assess the patient's response to treatment.

Not only the total number and maturity but also the shape, diameter, and flexibility of red blood cells can give the hematologist important information. For years, such information was gathered by laborious manual methods. Electronic counters can now obtain this information with great speed and even greater accuracy.

Hematologists can also gauge the effectiveness of red blood cells by seeing how much hemoglobin they contain. The amount of this red pigment present, and therefore functioning, was once estimated by being matched against progressively darker-colored glass “standards.” Now this figure too is accurately determined using a precise photoelectric technique.

Another useful test is called the packed cell volume (PCV) test. It not only reveals the proportion of the red blood cells to the plasma but also allows the calculation of those cells' average size and hemoglobin content.

An equally common blood investigation is the erythrocyte sedimentation rate (ESR). The erythrocytes, the term that hematologists use to describe red blood cells, normally fall slowly down through the plasma in a standard tube. A very rapid sedimentation rate demonstrates a disturbance in the plasma proteins that may be very dangerous. Usually, the faster the erythrocytes settle out, the sicker the patient, with a wide variety of inflammations as possible causes.

Beginning in the mid-twentieth century, an increasing number of radioactive tests were developed by which hematologists could more accurately assess total blood volume and the survival time of red blood cells or platelets in circulation. Assessing total volume is important. A loss of more than one liter (two pints) is quite dangerous because it can cause a total collapse of the blood vessels.

This reaction gives a clue about the importance of a second kind of blood cell, the platelet, and its work in stopping bleeding. When a blood vessel is first cut, platelets (or thrombocytes) rush to the site. They swell into irregular shapes, become sticky, and clog the cut, creating a plug. The smallest blood vessels rupture hundreds of times a day, and platelets alone are able to make the necessary repairs. If the cut is too large, then platelets, which are like sponges filled with diverse and biologically active compounds, disintegrate. Their ingredients react with numerous clotting factors in the plasma to initiate clot formation.

Hematologists check blood samples carefully to ascertain whether their patients possess the normal number of platelets—more than a trillion for the average adult. Since platelets live only about ten days, it is necessary to monitor those patients who exhibit significantly low amounts of these cells. If their bone marrow is not constantly replacing these platelets, these patients might bleed to death from a small cut. Doctors must also monitor any tendency toward the formation of too many platelets, as this can lead to thrombophlebitis, the blockage of a vein by a blood clot.

As with red blood cells, the widespread use of electronic counters has made the measurement of the numbers of platelets and of white blood cells (the third type of blood cell) rapid, efficient, and extremely accurate.

White blood cells are hardest to count because they are the least numerous, making up only 0.1 percent of the total blood. Their number also varies dramatically, from four thousand to eleven thousand per cubic centimeter of blood, according to the individual, the time of day, the outside temperature, and many other ordinary factors.

Hematologists can deduce the degree of maturity of circulating white blood cells from the appearance of their nuclei. There are five kinds of white blood cells (or leukocytes), whose normal proportions in the blood are quite specific and change drastically if an infection is present. The number of monocytes, for example, is normally 5 percent of the total number of white blood cells. If typhus, tuberculosis, or Rocky Mountain spotted fever organisms are present, that number will rise to 20 or 30 percent. The normal 60 percentage of neutrophils will increase to 75 percent or more in the presence of pneumonia or appendicitis.

Diagnostic and Treatment Techniques

Blood to be tested by a hematologist is withdrawn from a vein. A thin smear or film of the blood is placed on a glass slide and stained to bring out identifying features more prominently. The microscope then reveals the proportion of different cell types and any variation from the normally expected amount. This examination alone may give an immediate diagnosis of a particular blood disorder. For example, a red blood cell count that is less than four million or more than six million per cubic centimeter of blood is considered unusual and is probably an indication of disease.

It often becomes necessary to study not only the circulating blood cells but also the original cells within the bone marrow that produce the erythrocytes, thrombocytes, and leukocytes. To do so, the hematologist must use a long, thin needle to remove a sample of the marrow from within the tibia (shinbone) of a child or the pelvis (hipbone) or sternum (breastbone) of an adult. This test can provide a reliable diagnosis of a specific blood disorder.

The blood disorders that hematologists are routinely called on to diagnose and treat include diseases of the red blood cells, white blood cells, platelets, and clotting factors and failures of correct blood formation.

Disorders involving a deficiency of red blood cells or their hemoglobin are called anemias. There are many types of anemia, which are named, distinguished, and treated according to their causes. Some anemias exist because of a lack of the materials needed to build red blood cells: iron, vitamin B12, and folic acid. Other anemias are caused by a shortening of the life span of red blood cells or by inherited abnormalities in hemoglobin. Still others are attributable to chronic infections or cancer.

Iron-deficiency anemia is by far the most common; it is particularly prevalent in women of childbearing age and in children. In young children who are growing rapidly, constant increase in muscle mass and blood volume will cause anemia unless a high enough level of iron is present in the diet. All women between puberty and the menopause lose iron with the menstrual flow of blood and, therefore, are always prone to iron-deficiency anemia. A pregnant woman is even more likely to develop this condition, as iron is literally removed from her body and transferred through the placenta to the developing fetus.

The symptoms of iron-deficiency anemia may include a reduced capacity for physical work, paleness, breathlessness, increased pulse, and possibly a sore tongue. The hematologist witnessing small, misshapen red blood cells deficient in hemoglobin will recommend an increase in iron in the diet. The hematologist will also send the patient for various gastrointestinal tests because of the possibility of internal bleeding or failure of the intestine to absorb iron properly.

Another class of anemias involves a lack of vitamin B12 or folic acid. Without the help of these two substances, the bone marrow cannot build red blood cells correctly. Folic-acid deficiency anemias are diagnosed when the hematologist finds bizarre cells called megaloblasts in the patient’s bone marrow. Both vitamin B12 and folic acid can be added to the diet or given by injection. The problem may stem, however, not from an insufficient amount of vitamin B12 in the diet but from the inability of the stomach lining to produce a substance called intrinsic factor. In this case, the patient will never be able to absorb the vitamin properly and is said to suffer from pernicious anemia.

Those anemias characterized by the early and too-frequent destruction of red blood cells are grouped together as hemolytic anemias. Some of these disorders are acquired, while others are inherited. In both types, hemoglobin from the destroyed red blood cells can be detected by the hematologist in the plasma, the urine, or the skin, where it causes the yellowing called jaundice.

Because the many types of anemia are so common, hematologists find that the diagnosis and treatment of these diseases form a large part of their everyday practice. All types of leukemia, on the other hand, are quite rare. They are caused by a change in one kind of primitive blood cell in the bone marrow. The result is uncontrolled growth of these cells, which do not mature but rather invade the blood as badly functioning cells. Leukemia is often thought of as cancer of the blood.

Although it is not known what causes leukemia in a particular person, the disease seems to be associated with certain factors, including injury by chemicals or radiation, viruses, and genetic predisposition. Many cases of acute leukemia occur in either children under fourteen or adults between fifty-five and seventy-five years of age. In children, it is almost always a disorder in the bone-marrow cells that produce the white blood cells, called lymphocytes. This disorder is called acute lymphoblastic leukemia, or ALL. Adult leukemia usually occurs in the bone marrow that forms some other type of white blood cell and is called acute nonlymphoblastic leukemia, or ANLL (also known as acute myelocytic leukemia, or AML).

Hematologists diagnose both conditions by their shared symptoms: abnormal bone-marrow tissue and a lack of normal white blood cells and platelets in the circulating blood. The patient will often have been referred to the hematologist because of an uncontrollable infection (due to lack of normal white blood cells) or uncontrollable bleeding (due to lack of normal platelets). In both children and adults, anemia usually accompanies acute leukemia because defective bone marrow is not able to produce red blood cells properly either.

Less rare than acute leukemia are the various chronic types. One type, called chronic granulocytic leukemia (CGL) (also chronic myeloid leukemia or CML), occurs most often after the age of fifty. Unfortunately, its early symptoms are few and vague, so that the disease may have progressed greatly before its presence is even suspected. By such time, an enormous enlargement of the spleen, along with elevations in both white blood cell and platelet counts, can be noted.

Two stages are usually seen in chronic granulocytic leukemia. Early treatment can relieve all symptoms, shrink the spleen, and return all blood cells to normal values. Eventually, however, the leukemic condition recurs, and the patient usually lives an average of only three years. Bone marrow transplantation from a suitable donor and a more recent process in which one’s own marrow is removed, irradiated, and returned to the bones have increasingly become the recommended treatments for this condition.

A second type of chronic leukemia is known as chronic lymphatic leukemia (CLL). Unlike most of the other leukemias, CLL has no known cause, but it is most often found in male patients over the age of forty. Often quite symptomless, it is only discovered by chance. The hematologist is able to diagnose CLL by an increased proportion of abnormal white blood cells present in the blood. Surprisingly, this form of leukemia can vary from a case that remains symptomless, with the patient surviving twenty years or more, to a rapidly progressing case with increasing anemia and constant infections.

The third major class of disorders diagnosed and treated by hematologists consists of those involving abnormal bleeding
. The diagnosis is quite simple. The hematologist notes whether bleeding from a tiny puncture in the ear lobe stops within three minutes, as it should. If the bleeding does not stop, the determination of the cause may be difficult; it may involve too few platelets or abnormal or missing clotting factors.

Very precise tests of an increasingly sophisticated nature are now used by hematologists to determine whether a bleeding disorder is attributable to inheritance (as with hemophilia), a vitamin K deficiency, or a side effect of medication or is secondary to a type of leukemia.

Perspective and Prospects

That blood and the vessels that carry it are important to life and health was evident even to ancient peoples. Around 500 BCE, Alcmaeon of Croton, a Greek philosopher and medical theorist, was the first to discover that arteries and veins are different types of vessels. A century later, Hippocrates observed that blood, left to stand, settles into three distinct layers. The top layer, the largest, is a clear, straw-colored liquid that is now called plasma. The middle layer is a narrow white band that is now known to contain white blood cells. The bottom, quite large layer contains the cells that are now called red blood cells.

Very little else of value seems to have been learned about the blood until the seventeenth century, which witnessed many discoveries in medical science. In 1628, William Harvey, an English doctor, demonstrated scientific evidence of circulation. He found proof of a circular route and of the purpose of circulation. By 1661, the Italian scientist Marcello Malpighi reported seeing the tiny vessels called capillaries in the lungs of a frog.

Another giant step toward modern hematology occurred in the 1660s due to the efforts of Richard Lower of England and Jean-Baptiste Denis of France. Almost simultaneously, they accomplished blood transfusions from dog to dog and, soon after, from animal to human. Some transfusions were very successful; others were fatal to the patient. Almost 250 years would pass before the reason for success or failure would be learned.

In 1688, the Dutch scientist Antoni van Leeuwenhoek was able to describe and measure red blood cells accurately. He also observed that they changed shape to squeeze through tiny blood vessels. It was almost a hundred years later, in the 1770s, that Englishman Joseph Priestley found that the oxygen in the air changed dark blood from the veins into a bright red color. Only in the 1850s did the German researcher Otto Funke find within those red blood cells the compound hemoglobin, which is affected by the presence or absence of oxygen.

Although the first research on blood clotting was done by William Hewson in 1768, the disease called hemophilia, or the failure of the blood to clot, was not described until 1803, by John Otto.

In the United States in the early twentieth century, Karl Landsteiner discovered why certain blood can be safely transfused: the existence of the ABO blood types. This renowned hematologist was still advancing his science forty years later when he discovered the Rh system of blood types.

Another renowned hematologist, Max Perutz, worked steadily from 1939 to 1978 to understand fully the structure and function of the hemoglobin molecule. The 1940s had seen another breakthrough when Edwin Cohn, another American, discovered how to separate and purify the various plasma proteins. His work gave fellow hematologists the tools to study individual plasma components in order to learn the exact role of each in the blood. Since that time, scores of hematologists have so advanced this medical science that blood seems to have yielded most of its secrets. The ability of hematologists to treat so many types of anemia, leukemia, and other blood disorders successfully is the fruit of their tireless work.

Bibliography

American Society of Hematology. http://www.hematology.org

Avraham, Regina. The Circulatory System. Philadelphia: Chelsea House, 1989.

Bick, Roger L. Disorders of Thrombosis and Hemostasis: Clinical and Laboratory Practice. 3d ed. Philadelphia: Lippincott Williams & Wilkins, 2002.

Eads, Jennifer R., Neal J. Meropol, and Jerry L. Spivak. "Update in Hematology and Oncology: Evidence Published in 2012." Annals of Internal Medicine 158, no. 10 (May 2013): 755–760.

Hoffman, Ronald, et al., eds. Hematology: Basic Principles and Practice. 6th ed. Philadelphia: Saunders/Elsevier, 2013.

Kaushansky, Kenneth, et al., eds. Williams Hematology. 8th ed. New York: McGraw-Hill, 2010.

Rodak, Bernadette F., George A. Fritsma, and Elaine M. Keohane, eds. Hematology: Clinical Principles and Applications. 4th ed. St. Louis, Mo.: Saunders/Elsevier, 2012.

Tortora, Gerard J., and Bryan Derrickson. Introduction to the Human Body: The Essentials of Anatomy and Physiology. 9th ed. Hoboken, N.J.: John Wiley & Sons, 2012.

In Paradise Lost, why does God allow Satan to leave hell?

Milton first offers a partial explanation, saying that hell isn't powerful enough to hold Satan: 

No bounds / prescribed, No bars of hell nor all the chains / Heaped on him there . . . can hold [him] . . .

This, however, is more Satan's perspective than God's, a description of his will to ultimate power, his pride and overestimation of himself, and his complete unwllingness to bow to any other force than himself.

We knows this because Milton then fleshes out this earlier explanation to show that it is God's will, not Satan's, that Satan roam the earth. Milton says it is with God's permission that Satan is set free. God sets Satan free for two reasons: first, because by trying to do evil, Satan will make himself more and more deserving of eternal punishment: he will "heap on himself damnation." Second, it will enrage Satan that his attempts at evil will be met with and overpowered by the Son of God, Jesus, who will "bring forth / Infinite goodness, grace and mercy." (This passage doesn't name Jesus, but that is what Milton means by "infinite goodness, grace and mercy.") People will turn from Satan towards the good and Satan will essentially implode with overwhelming rage because he will see that he is ineffective. Satan can't bear the thought of being powerless. But like it or not, instead of hurting others, the "confusion, wrath and vengeance" he tries to sow among humans will boomerang back to him. 

The passage explaining this is below:

So stretched out huge in length the Arch-Fiend lay,

Chained on the burning lake; nor ever thence
Had risen, or heaved his head, but that the will
And high permission of all-ruling Heaven
Left him at large to his own dark designs,
That with reiterated crimes he might
Heap on himself damnation, while he sought
Evil to others, and enraged might see
How all his malice served but to bring forth
Infinite goodness, grace, and mercy, shewn
On Man by him seduced, but on himself
Treble confusion, wrath, and vengeance poured.

What is listeriosis?

Definition

Listeriosis is a food-borne illness that can lead to death in newborns and in
persons with compromised immune systems. Infants born to women infected with
listeriosis may have meningitis (brain infection) or
bacteremia (bacterial blood infection). Infected infants who
survive may suffer neurological damage and developmental delays. Listeriosis can
cause the death of a fetus of an infected pregnant woman.

Up to 65 percent of deaths from food-borne illnesses in the United States are caused by listeriosis. About twenty-five hundred people become ill with listeriosis per year in the United States, and, of these, five hundred die. The numbers of the infected may be greater, but such cases have not been identified, likely because symptoms were mild.

Causes

Listeriosis is caused by the bacterium
Listeria monocytogenes, a pathogen that
lives in water and soil. It is resistant to refrigeration and is found in
ill-prepared or subsequently contaminated meats and vegetables, particularly in
luncheon meats, hot dogs, soft cheeses, cole slaw, and unpasteurized milk.

Risk Factors

Pregnant women have twenty times the risk of developing listeriosis as others,
according to the Centers for Disease Control and Prevention, and an estimated
one-third of listeriosis cases occur during pregnancy. Other persons at risk are
those with compromised immune systems, such as persons with the acquired immune deficiency
syndrome (AIDS), who have a three hundred times greater risk
for listeriosis compared with healthy persons. In addition, others who are at risk
include persons with cancer, kidney disease, or diabetes; persons who have had an
organ transplant and who take immunosuppressant drugs; persons taking
glucocorticosteroids; and persons age sixty years and older.

Symptoms

Infected persons may present with nausea, vomiting, diarrhea, and fever.
Newborn infants may have jaundice, pneumonia, skin rash, lethargy, and vomiting.
Symptoms may occur anytime from two to seventy days from when the contaminated
food was consumed. Healthy people may have mild symptoms or no symptoms. Pregnant
women may have mild symptoms, but her fetus remains at risk for infection.

Screening and Diagnosis

If listeriosis is suspected, the blood, urine, or feces is screened for L. monocytogenes. Also, a spinal fluid test may be used for screening, and the amniotic fluid of a pregnant woman may be tested.

Treatment and Therapy

Treatment is with antibiotics such as ampicillin.
Infected newborns are also treated with antibiotics.

Prevention and Outcomes

Active measures can help to avoid infection. One should thoroughly cook all meats, wash all vegetables, and avoid unpasteurized milk products. Uncooked meats should be separated from vegetables and other foods during food preparation.

As soon as possible after food preparation, the preparer should wash his or her hands and any cutting boards and knives used to prepare uncooked foods.

Persons at high risk for listeriosis should avoid soft cheese unless the label on the product indicates the cheese was made with pasteurized milk. Deli meat, cold salad, soft cheese, and pâté should be avoided by pregnant women.

Bibliography

Bortolussi, Robert. “Listeriosis: A Primer.” CMAJ: Canadian Medical Association Journal 179 (2008): 795-797.

Cheung, Vincent Y., and Wilma L. Sirkin. “Listeriosis Complicating Pregnancy.” CMAJ: Canadian Medical Association Journal 181 (2009): 821-822.

Khare, Manjiri. “Infectious Disease in Pregnancy.” Current Obstetrics and Gynaecology 15 (2005): 149-156.

U.S. Department of Health and Human Services. National Toxicology Program. “Listeria and Food Poisoning.” Available at http://cerhr.niehs.nih.gov/common/listeria.html.

U.S. National Institutes of Health. “Listeriosis.” Available at http://www.nlm.nih.gov/medlineplus/ency/article/001380.htm.

What is an epic hero's greatest weakness called? What is Odysseus's?

Homer’s Odyssey is a heroic epic that recounts Odysseus’ ten-year journey to return to his homeland after the Trojan War.  Traditionally in literature, an epic hero possesses certain characteristics that serve as defining features of the genre.  In this instance, Odysseys is the epic hero and his weakness is referred to as his tragic flaw, or harmartia.  A tragic flaw causes the hero’s eventual downfall, or in heroic epics, causes immense obstacles and creates foes.  In the Odyssey, Odysseus’ weakness can be seen as his pride, or hubris.  Odysseus is a strong and courageous warrior who bravely leads his men back from Troy, but he often finds himself in situations caused by his own arrogance.  For example, in Book Nine, when Odysseus very wisely tells the cyclops Polyphemus that his name is “Nobody,” Polyphemus cries out that “Nobody has attacked me!”  This enables Odysseus and his men to escape, but Odysseus’ prideful nature causes him to turn back and yell his real identity to the cyclops, which in turn leads to destruction by Poseidon’s wrath.   Upon learning the identity of his son’s attacker, Poseidon unleashes a massive storm on Odysseus’ travel and he is forced to wander for an even longer duration.  Therefore, it is Odysseus’ pride that causes his epic struggle to return home. 

What does Dr. Manhattan mean when he tells Adrian Veidt, "In the end? Nothing ends, Adrian. Nothing ever ends" ?

In chapter twelve, after Adrian Veidt— also known as Ozymandias— enacts his scheme to end the Cold War tension between Russia and the United States by leveling major cities around the world and blaming the attack on an alien force, he seeks validation from Dr. Manhattan:

“Jon, wait, before you leave... I did the right thing, didn't I? It all worked out in the end” (27).

This is when Dr. Manhattan questions the arbitrary nature of “the end.” To Dr. Manhattan, there is no such thing as a beginning, middle, or end; these are distinctions that he no longer makes as an omnipotent, god-like being. Additionally, Dr. Manhattan hints that Veidt’s extreme action, which has admittedly positive implications in establishing world peace, will have long-term effects that Veidt cannot predict. Indeed, in chapter ten, Rorschach puts his journal that has clues pertaining to Veidt’s involvement in the attack into the mail to be delivered to journalists. The end of Watchmen has Alan Moore brilliantly leaving the series on an ambiguous note as a frazzled journalist must add extra material to a newspaper, and he reaches for Rorschach’s journal to read it for the first time. The implication here is that Veidt’s actions are not an “end.” As Dr. Manhattan notes, there is no definitive end.

What is the esophagus?

Structure and Function

The esophagus lies between the spine and the trachea and is part of the digestive system. The esophagus, however, does not produce or secrete any digestive enzymes, and absorption of nutrients in this part of the digestive system is almost nil. The esophagus pierces the diaphragm as it moves through the thoracic cavity and into the abdominopelvic cavity, where it joins with the stomach.

All parts of the digestive system have four tunics (tissues): from superficial to deep, tunica serosa, tunica muscularis, tunica submucosa, and tunica mucosa. Tunica serosa anchors the esophagus in the mesentery. Tunica muscularis is composed of smooth muscle fibers arranged in circular and longitudinal fibers. These two layers of muscles are important as they are able to squeeze the food bolus (chewed mass of food) and move it down toward the stomach. The muscles are involuntary and perform peristaltic contractions behind the bolus, pushing it downward, as if a tennis ball were being pushed through a leg of panty hose. Tunica submucosa is a layer of loose connective tissue; blood vessels and nerves, including the important submucosa plexus, are found in this layer. The innermost layer, tunica mucosa, is comprised of epithelial cells and is the layer in contact with the bolus. Of all the tunics, tunica mucosa is the most variable along the length of the digestive system. The epithelium here is stratified squamous
epithelial tissue to protect the esophagus from sharp or dangerous food items, such as bones, hot pizza, or insufficiently chewed carrots.

The esophagus has an upper and a lower sphincter. When one swallows, the upper sphincter relaxes. In a coordinated effort, the larynx pulls forward and the epiglottis clamps down to cover this opening into the respiratory system (lungs). Glands produce mucus to lubricate food as it passes along the lumen. The lower sphincter closes once the bolus has passed into the stomach. Failure to do so would allow stomach acids to leak up into the esophagus, causing what is commonly called heartburn or acid indigestion, more properly known as gastroesophageal reflux disease.

Disorders and Diseases

The most common medical problem with the esophagus is gastroesophageal reflux disease (GERD), which is caused when the lower sphincter fails to close properly. Stomach contents, which are acidic, then leak into the esophagus and irritate it. Left untreated, GERD can damage the esophagus.

Barrett’s esophagus is a disease often is found in patients with GERD. In Barrett’s esophagus, the tissue that lines the esophagus, tunica mucosa, is replaced by tissue that is more similar to tissue lining the intestines. The process is called intestinal metaplasia. Barrett’s esophagus may lead to the development of esophageal cancer,
but this is a rare event. It should be emphasized that not all patients with GERD develop Barrett’s esophagus and that very few people with Barrett’s esophagus develop cancer. The cause of Barrett’s esophagus is unknown, as is the cause of esophageal cancer.

Bibliography

"Digestive System." MedlinePlus, January 14, 2013.

"Esophagus Disorders." MedlinePlus, June 12, 2013.

Johnson, Leonard R., ed. Gastrointestinal Physiology. 7th ed. Philadelphia: Mosby/Elsevier, 2007.

Mayo Clinic. Mayo Clinic on Digestive Health: Enjoy Better Digestion with Answers to More than Twelve Common Conditions. 2d ed. Rochester, Minn.: Author, 2004.

Scanlon, Valerie, and Tina Sanders. Essentials of Anatomy and Physiology. 6th ed. Philadelphia: F. A. Davis, 2012.

Wood, Debra, Daus Mahnke, and Brian Randall. "Heartburn—Overview." Health Library, March 18, 2013.

If man gave authority to the government to rule, why are people suffering from debts given out by the government? And who gave them right to print...

To answer this question, we must first examine your statement that people have debts that are “given out by the government.”  This is not true. People are generally in debt to other people, either individuals or companies.  Of course, the government does enforce debts so if you owe a person money, they can go to court and get the government to order you to pay. This is perfectly reasonable. One reason why people give consent to be governed is so that the government will protect their property. If I loan you part of my property (money), and you refuse to pay me back, it makes sense that I would want the government to help me recover my property.  In other words, we should not say that the government has given us the debt and we should not be surprised if people want the government to help them collect debts that people owe them.

Now, there are times when you might owe the government money. This would occur if you failed to pay your taxes or other fees.  We tend to hate taxes, but most people would admit they are necessary so that the government can have money to fund things like the police and schools. If we want government, we must be willing to give some of our money to the government so it will be able to do the things we need it to do.  In this case, I suppose we could say that the government is “giving out” debt, but it is entirely understandable that we should be required to help pay for our government.

As far as printing money goes, this is something we want the government to do in order to protect our property. It is much easier for us to have a strong and wealthy economy if we have money (rather than a barter system). Therefore, we want to have money in our economy. It is better for us if the government (rather than private enterprises) prints the money because then we know it is backed by the government and we know it will keep its value.  In other words, almost everyone would want the government to be in charge of printing the money.

On Halloween night, Bob Ewell was found dead. Did Sheriff Tate’s actions represent the ideas expressed by President Lincoln in the Gettysburg...

The Gettysburg Address is a tribute to the men who died in one of the bloodiest battles of the Civil War. Lincoln ultimately says that men from both sides of the battle died to preserve a government "of the people, by the people, [and] for the people." This means that the government should be responsible to the people; hence, the government should tell the people what it is doing, what it is involved in, and why. Since Sheriff Tate works for the government, he should tell the people of Maycomb County that Boo Radley saved the Finch children by killing Bob Ewell. Sheriff feels justified, though, that to protect Boo Radley's privacy is more important than telling the citizens what actually happened. Tate defends Boo Radley as follows:

"I never heard tell that it's against the law for a citizen to do his utmost to prevent a crime from being committed, which is exactly what he did, but maybe you'll say it's my duty to tell the town all about it and not hush it up. . . To my way of thinkn', Mr. Finch, taking the one man who's done you and this town a great service an' draggin' him with his shy ways into the limelight--to me, that's a sin. . . If it was any other man it'd be different. But not this man, Mr. Finch" (276).

So the answer would be no; Sheriff Tate's actions do not represent the ideas expressed by President Lincoln in the Gettysburg address. But the next question would be if there are some exceptions to the rules in some cases.

What is rotator cuff surgery?

Indications and Procedures

The shoulder is considered to be the most flexible joint in the human body. It has a ball-and-socket structure that permits a wide range of motion, but this same structure also predisposes the shoulder to a very high risk of injury. To counter this risk, the shoulder is stabilized by a group of four muscles, collectively known as the rotator cuff: the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. The signs and symptoms of rotator cuff injuries include point tenderness around the region of the humeral head deep within the deltoid muscle, pain and stiffness within the shoulder region within a day of participating in activities that involve shoulder movements, and difficulty in producing overhead motions involving the upper arm. Pain often occurs at night as a result of sleeping positions that put excess pressure on the joint. Occasionally, a clicking noise can be heard emanating from the joint upon movement or the patient may experience a “sticking point” when shoulder movements are attempted.

Injuries to the rotator cuff can mimic other common shoulder region problems, including bursitis
(inflammation of a bursa, a soft, fluid-filled sac that helps cushion surfaces that glide over one another) and tendinitis
(inflammation of a tendon). Injuries to the rotator cuff include impingement and tears. Impingement occurs when the rotator cuff tendons are pinched because of a narrowing of the space between the acromion (shoulder blade) process and the rotator cuff. This narrowing commonly occurs with aging, but it can also be traumatically induced. Sports that commonly put excess stress on the rotator cuff include baseball, swimming, and tennis. Besides a traumatic injury, chronic impingement of the rotator cuff tendons can cause partial or complete tears.

To evaluate the extent of shoulder dysfunction, the physician will conduct a physical examination to determine range of motion and use diagnostic procedures such as x-rays, an arthrogram (an x-ray after a tracer dye has been injected into the shoulder), magnetic resonance imaging (MRI), and ultrasound. Nonsurgical interventions include rest, ice immediately following an injury or heat twenty-four hours afterward, painkillers, anti-inflammatory medications, and physical therapy.

Rotator cuff surgery is usually recommended when there is little improvement in shoulder function or pain reduction after a course of noninvasive therapies. Surgery to correct rotator cuff tears is more successful if the procedure is performed within three months of the date of injury. Surgery can be a classic open procedure, requiring a 2- to 3-inch incision in the shoulder, or less traumatic arthroscopy, which requires only a small incision, half an inch or less, just large enough to accommodate the instruments and a video camera apparatus. Occasionally, the surgeon will use a combination of the open procedure and arthroscopy. Either general anesthesia, in which the patient is asleep, or local anesthesia, in which the region is “frozen” but the patient is awake, can be used for the procedure. With local anesthesia, a light sedative may also be used to put the patient at ease, but not asleep.

Acromioplasty reduces the impingement of the rotator cuff tendons. In this procedure, a portion of the bone underneath the acromion is shaved in order to give the tendons more room to move and prevent them from becoming pinched. This process is often included in rotator cuff surgical repairs. In rotator cuff repairs, the torn tendons are reattached to the humerus (upper arm bone). The open surgical procedure requires a relatively large incision through the shoulder as well as cutting through the deltoid muscle. Any scar tissue that has formed is removed, and a small ridge is cut into the top of the humerus. Small holes are drilled into the bone, and the tendons are sutured to the bone using these holes as anchors. The surgeon will also correct any other problems encountered, such as removing bone spurs, shaving down the acromion, or freeing up ligaments that may be pressing against the tendons.

During arthroscopic surgery, these extra procedures are not done. After the small incision is made into the shoulder, a thin tube is inserted. This tube contains the surgical instruments as well as a video camera that is used to guide the repair procedure. Arthroscopic surgery is becoming more common and is preferred for small tears, as it limits the amount of surgical intervention, reduces surgical risks, and quickens recovery time. If more extensive damage is discovered, then the surgeon may elect to combine the arthroscopic procedure with open surgery. However, arthroscopic tear repair has advanced tremendously, to the point that tears previously thought to be irreparable or too extensive are now being completed with arthroscopy.

Uses and Complications

The varying outcomes from rotator cuff surgery range from almost full recovery to no improvement at all. The degree of recovery is dependent upon the extent of damage to the rotator cuff as well as patient compliance with physical therapy after surgery. If the tendon has been torn for a long time, then it may not be reparable.

As with all surgical procedures, the patient may have an adverse reaction to the anesthesia. This risk is greater if the person is obese or has a cardiovascular, pulmonary, or metabolic condition. Surgical incisions always have the risk of infection, but this risk is minimized with the arthroscopic procedure because of the small incision size and the relatively short operative time (one to two hours). In rare instances, there is also the risk of nerve damage resulting in partial paralysis or temporary numbness at the incision area.

After surgery, the recovering arm will be put in a sling with a small shock-absorbing pillow placed behind the elbow. Extreme care should be taken with shoulder movements for the first three months following surgery. Reaching and lifting objects above the head should be avoided during this period. Passive range of motion exercises, in which the arm is moved by the physical therapist, should be started as soon as possible to prevent scar tissue formation and resultant stiffness. Exercises should be done several times a day so that within two to three weeks, the range of motion (flexibility) of the repaired shoulder should be equivalent to that of the uninjured shoulder. After six weeks, more advanced exercises are recommended in order to strengthen the rotator cuff as well as the surrounding shoulder muscles. Full recovery and rehabilitation from rotator cuff surgery can take up to a year.

Bibliography

Fongemie, A. E., D. D. Buss, and S. J. Rolnick. “Management of Shoulder Impingement Syndrome and Rotator Cuff Tears.” American Family Physician 57, no. 4 (1998): 667–674.

Lo, I. K., and S. S. Burkhart. “Current Concepts in Arthroscopic Rotator Cuff Repair.” American Journal of Sports Medicine 1, no. 2 (2003): 308–324.

Matsen, Frederick A., and Steven B. Lippitt. Shoulder Surgery: Principles and Procedures. Philadelphia: W. B. Saunders, 2003.

Pfeiffer, Ronald P., and Brent C. Mangus. Concepts of Athletic Training. 6th ed. Sudbury, Mass.: Jones and Bartlett, 2012.

Rockwood, Charles A., Frederick A. Matsen, and Michael Wirth. The Shoulder. 4th ed. 2 vols. St. Louis, Mo.: Saunders/Elsevier, 2009.

"Rotator Cuff Repair." Health Library, March 18, 2013.

"Rotator Cuff Repair." MedlinePlus, June 30, 2011.

Williams, G. R., and M. Kelley. “Management of Rotator Cuff and Impingement Injuries in the Athlete.” Journal of Athletic Training 35, no. 3 (2000): 300–315.

Yamaguchi, K., et al. “Transitioning to Arthroscopic Rotator Cuff Repair: The Pros and Cons.” Journal of Bone & Joint Surgery, American Volume 85, no. 1 (2003): 144–156.

What arguments does Friar Laurence use to convince Romeo that his despair is not justified?

In Act III, Scene iii, Romeo is in despair after the Friar reveals he has been banished for his role in the deaths of Mercutio and Tybalt. His despair revolves around the fact he will not be able to see Juliet because he will have to leave Verona. At one point he throws himself on the ground crying. The Friar uses four arguments to assuage the distraught Romeo. First, in his long monologue he tells Romeo he should be grateful that both he and Juliet are still alive. He argues that Tybalt could have killed him. He says,

Thy Juliet is alive,
For whose dear sake thou wast but lately dead:
There art thou happy. Tybalt would kill thee,
But thou slewest Tybalt: there art thou happy

Second, the Friar believes the Prince was quite lenient in sentencing Romeo to banishment. The Prince could have opted for death as he had declared earlier in the play that future fights in the street would be punished with death. Friar Lawrence says,

The law that threatened death becomes thy friend
And turns it to exile: there art thou happy.

Third, the Friar tells Romeo that he can still go to see Juliet for their honeymoon. They can be together one more night before he goes to Mantua.

Finally, the Friar assures Romeo that once things calm down in Verona, the Friar can announce the marriage, beg the Prince for a pardon, and then Romeo may return to Verona to be reunited with Juliet. He says,

But look thou stay not till the watch be set,
For then thou canst not pass to Mantua,
Where thou shalt live till we can find a time
To blaze your marriage, reconcile your friends,
Beg pardon of the Prince, and call thee back
With twenty hundred thousand times more joy
Than thou went’st forth in lamentation.

Romeo is mollified for a time as he tells Juliet he has no doubt they will meet again in Act III, Scene v. Unfortunately, they never come together again as Romeo kills himself in Capulet's tomb before Juliet awakens.

What is family medicine?

Science and Profession

From cradle to grave, family physicians have the ability to take care of patients from all age groups and manage a great variety of medical problems on a daily basis. As the primary care provider, they are central to a patient’s care, either by providing it directly (85 percent of all medical problems) or by consulting specialists and following their management recommendations. They act as the patient’s advocate even when healthy by providing preventive care services to find disease earlier in an attempt to eliminate it or slow its progression.

In the United States, there are approximately 80,000 practicing family physicians, accounting for more than 240 million annual office visits. More than a third of all US counties have access to only family physicians to provide medical care to their communities.

Family medicine is the direct descendant of general practice. For many years, most physicians were general practitioners. In the mid-to-late twentieth century, however, the explosion of medical knowledge led to the specialization of medicine. For example, increased knowledge of the function and diseases of the heart seemed to demand creation of the specialty of cardiology. The model of the country doctor or jack-of-all-trades physician taking care of a wide range of medical problems seemed doomed to sink in the sea of subspecialization in medicine. The general practitioner, the venerable physician who hung out his or her shingle after medical school and one or more years of internship or residency training, appeared to be headed for extinction. Indeed, in their then-existent forms, the general practitioner and general practice would not have survived. Several forces came into play which did result in the passing of general practice but which also changed general practice into family medicine.

The primary force pushing for general practice to survive and improve was the desire of the general public to retain the family doctor. The services that these physicians rendered and the relationships developed between physician and patients were held in high esteem. Through such voices as the Citizen Commission on Graduate Medical Education appointed by the
American Medical Association (AMA), the public requested the rescue of the family doctor.

Other major players in the movement to revive and reshape general practice included the AMA itself and the American Academy of General Practice. On February 8, 1969, approval was granted for the creation of family medicine as medicine’s twentieth official specialty. The American Academy of General Practice became the American Academy of Family Physicians (AAFP), and a certifying board, the American Board of Family Practice (ABFP), was established. The name has since been changed to the American Board of Family Medicine (ABFM). After these steps were completed, three-year training programs (residencies) in family medicine were established in medical universities and larger community hospitals to provide the necessary training for family physicians.

Family physicians are trained to provide comprehensive ongoing medical care and health maintenance for their patients. Those people who choose to become family physicians tend to value relationships over technology and service over high financial rewards. Many family physicians find themselves providing service to underserved populations and in mission work both inside and outside the United States. Family physicians often become advocates, providing counseling and advice to patients who are trying to sort out medical treatment options. They generally enjoy close relationships with their patients, who often hold them in high esteem.

Following graduation from medical school, students interested in a career in family medicine begin a three-year residency in the specialty. During the residency, these physicians train in actual practice settings under the supervision of faculty physicians. Family medicine residency training consists of three years of rotations with other medical specialties, such as internal medicine, pediatrics, surgery, and psychiatry. The unifying thread in family medicine residency training is the continuity clinic. Throughout their training, the residents see their own patients several days a week under the supervision of family medicine faculty physicians. Every effort is made to make this training as close as possible to experiences in the real world. Family medicine residents will deliver their patients’ babies, hospitalize their patients, and deal with the emotional issues of death and dying, chronic illness, and disability.

Family medicine residents receive intensive training in behavioral and psychosocial issues, as well as “bedside manner” training. Scientific research has shown that many patients who seek care from family physicians have problems that require the physician to be a good listener and a skilled counselor. Family medicine residency training emphasizes these skills. It also emphasizes the functioning (or malfunctioning) of the family as a system and the effect of major changes (such as the birth of a child or retirement) on the health and functioning of the family members.

The length of training (three years versus one year) and the emphasis on psychosocial and family systems training are two of the major differences in the training of a family physician and the training of a general practitioner. Moreover, family physicians spend up to 30 percent of their training time outside the hospital in a clinic. Family medicine was the first medical specialty to emphasize this type of training, and family physicians spend more time in ambulatory (clinic) training than virtually any other specialist.

Following the successful completion of a residency program, a family physician may take a competency examination devised and administered by the ABFM. Passing this examination allows the physician to assume the title of Diplomate of the American Board of Family Medicine and makes him or her eligible to join the American Academy of Family Physicians, the advocacy and educational organization of family medicine.

There are about 330 fellowships now available to graduating family medicine residents: faculty development, geriatrics, obstetrics, preventive medicine, research, rural medicine, sports medicine, and others such as occupational medicine.

If family physicians wish to retain their diplomate status, they must take at least fifty hours per year of medical education. After a family physician fulfills all educational and other requirements of the ABFM, that physician must then retake the certifying examination every seven years or the certification will lapse. This periodic retesting is required by the ABFM to make sure that family physicians keep up their medical education and maintain their knowledge level and clinical skills. Family medicine was the first specialty to require periodic reexamination of its physicians. In fact, since family medicine has mandated reexaminations, many other medical specialty organizations now require periodic reexamination of their members or are considering such a move. Many former general practitioners who did not have a chance to do a three-year family medicine residency took the ABFM certifying examination and became diplomates based on their years of practice experience and successful completion of the certifying examination. This option was closed to general practitioners in 1988.

A new recertification program, called the Maintenance of Certification Program for Family Physicians (MC-FP), is being required by the ABFM starting with diplomates who recertified in 2003 and all diplomates phased in by 2010. To maintain certification, candidates must perform the following every seven years: submit an online application, maintain a valid medical license, verify completion of three hundred credits of accepted CME credits, and pass the cognitive exam.

Currently, the American Academy of Family Physicians requires new active physician members to be residency-trained in family medicine. Diplomate status reflects only an educational effort by the physician and does not directly affect medical licensure. Medical licensure is based on a different testing mechanism, and license requirements vary from state to state. According to a 2012 report published by the Association of American Medical Colleges, there are more than one-hundred thousand family physicians providing health care in the United States. Family medicine residency programs are approximately 460 in number and usually have about three thousand residents in training.

Diagnostic and Treatment Techniques

Service to patients is the primary concern of family medicine and all those who practice, teach, administer, or foster the specialty. Of all the family physicians in practice, more than 80 percent are involved in direct patient care. While family physicians by no means constitute a majority of physicians, they are among the busiest when measured in terms of ambulatory patient visits. Family physicians see 30 percent of all ambulatory patients in the United States, which is more than the number of ambulatory visits to the next two specialty groups combined. Because of their training, family physicians can successfully care for more than 85 percent of all patient problems they encounter. Consultation with other specialty physicians is sought for the problems that are outside the scope of the family physician’s knowledge or abilities. This level of consultation is not unique to family physicians, as other specialty physicians find it necessary to seek consultation for 10 to 15 percent of their patients as well.

Family physicians can be found in all areas of the United States and in virtually all types of practice situations, providing a wide range of medical services. Family physicians can successfully practice in metropolitan areas or rural communities of one thousand people (or less), and they can be found teaching or doing research in medical colleges. Because of their training and the fact that they see a truly undifferentiated patient population, family physicians deliver a wide range of medical services. Besides seeing many patients in their offices, family physicians care for patients in nursing homes, make house calls, and admit patients to the hospital. Within the hospital, many family physicians care for patients in intensive care and other special care units and assist in surgery when their patients have operations. A small number perform extensive surgical procedures in the hospital setting. A sizable minority of family physicians take care of pregnant women and deliver their children; some of these physicians also perform cesarean sections. Because family physicians see anyone that walks through the door, it is not unheard of for a family physician to deliver a child in the morning, see the siblings in the office in the afternoon, and make a house call to the grandparents in the evening. Over 80 percent of family physicians perform dermatologic procedures, musculoskeletal injections, and electrocardiograms (EKGs) in their own offices.

The thing that makes family physicians different from other physicians is their attention to the physician-patient relationship. The family physician has first contact with the patient and is in a position to bond with the patient. The family physician evaluates the patient’s complete health needs and provides personal care in one or more areas of medicine. Such care is not limited to any particular type of problem, be it biological, behavioral, or social, and the patients seen are not screened according to age, sex, or illness. The family physician utilizes knowledge of the patient’s functioning in the family and community and maintains continuity of care for the patient in a hospital, clinic, or nursing home or in the patient’s own home. Thus, in family medicine, the patient-physician relationship is initiated, established, and nurtured for both sexes, for all ages, and across time for many types of problems.

Because of their training, family physicians are highly sought-after care providers. Small rural communities, insurance companies, and government agencies at all levels actively seek family physicians to care for patients in a wide variety of settings. In this respect, family medicine is the most versatile medical specialty. Family physicians are able to practice and live in communities that are too small to support any other types of physician.

In two reports released by Merritt Hawkins, a national recruiting company, requests for family physicians surged by 55 percent, more than all other specialties. According to data from the Massachussetts Medical Society, community hospitals reported family physicians constituted their “most critical shortage.”

While the vast majority of family physicians find themselves providing care for patients, there is a minority of family physicians who serve in other, equally important roles. Roughly 1.5 percent of family physicians serve as administrators and educators. They can be found working in state, federal, and local governments; in the insurance industry; and in residency programs and medical schools. Family physicians in residency programs provide instruction and role modeling for family medicine residents in community-based and university-based residency programs. Family physicians in medical colleges design, implement, administer, and evaluate educational programs for medical students during the four years of medical school. The Society of Teachers of Family Medicine (STFM) is the organization that supports family physicians in their teaching role.

One problem facing the specialty of family medicine is the very small percentage who are dedicated to research: only 0.2 percent of all family physicians. There is a large need for research in family medicine to determine the natural course of illnesses, how best to treat them, and the effects of illness on the functioning of the family unit. The need for research in the ambulatory setting is especially acute because, while most medical research is done in the hospital setting, most medical care in the United States is provided in clinics and offices. This problem will not be easily solved because of the service focus of family medicine training and the small number of family physicians dedicated to research.

Perspective and Prospects

Family medicine developed as a medical specialty because of the demands of the citizens of the United States; it is the only medical specialty with that claim. The ancestor of family medicine was general practice, and there is a direct link from the family physician to the general practitioner. Family medicine has grown and evolved into the specialty best suited to provide for the primary health care needs of most patients. Because of their broad scope of practice, cost-effective methods, and versatility, family physicians are found in virtually every type of medical and administrative setting. Family physicians provide a large portion of all ambulatory health care in the United States, and in some settings they are the sole providers of health care. General practice has been around as long as there have been physicians—Hippocrates was a general practitioner—but family medicine has a definite point of origin. It was created from general practice on February 8, 1969.

In January 2000, a leadership team consisting of seven national family medicine organizations began the Future of Family Medicine (FMM) Project, with its goal being “to develop a strategy to transform and renew the specialty of family medicine to meet the needs of patients in a changing health care environment.” Six task forces were created as a result, with each one formed to address specific issues that aid in meeting the core needs of the people receiving care, the family physicians delivering that care, and shaping a quality health care delivery system. The FFM Leadership Committee has focused on improving the American health care system by implementing the following strategies:
taking steps to ensure that every American has a personal medical home, has health care coverage for basic services and protection against extraordinary health care costs, promoting the use and reporting of quality measures to improve performance and service, advancing research that supports the clinical decision making of family physicians, developing reimbursement models to sustain family medicine and primary care offices, and asserting family medicine’s leadership to help transform the US health care system.

The present role of the family physician is and will continue to be to seek to improve the health of the people of the United States at all levels. Major problems exist for family medicine, including attrition as older family physicians retire or die, lack of medical student interest in family medicine as a career choice, and the lack of a solid cadre of researchers to advance medical knowledge in family medicine. The major strengths supporting family medicine are its service ethic, attention to the physician-patient relationship, and cost-effectiveness.

After their near demise as a recognizable group in the mid-twentieth century, family physicians have a number of reasons to expect that they will have expanded opportunities to provide for the health care needs of their patients in the future. As the United States, for example, examines its system of health care, which is the most costly and the least effective of any health care system in the developed world, many medical and political leaders look to generalism, and particularly family medicine, to provide answers. Research has shown that, for many medical problems, family physicians can provide outcomes very similar to those provided by specialists. When one couples that fact with the versatility and cost-effectiveness of generalist physicians, it can be argued that to save health care dollars the nation must reverse the 30 percent to 70 percent ratio of generalist to specialist physicians. A ratio of 50 percent to 50 percent generalist to specialist physicians has been proposed at many levels in medicine and government.

As the population ages due to improved mortality statistics and the addition of baby boomers to the geriatric age group, a further shortage of general practitioners such as family physicians is inevitable. This situation will force the United States to deal with its health care issues in order to provide its citizens with cost-effective and adequate coverage. The shortage of family physicians specifically in rural areas has led to approximately 65 million Americans living in federally designated health professions shortage areas (HPSAs), defined as less than 1 primary care physician per 3,500 people. A growing challenge exists for those physicians living in rural areas as a lack of training and preparation for practice in their medical education and residency training has led to a steady decline in their choosing to practice there.

Bibliography

American Academy of Family Physicians. http://www.aafp.org.

American Board of Family Medicine. http://www .theabfm.org.

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

Lippman, Helen. "How Apps are Changing Family Medicine." Journal of Family Practice 62, no. 7 (July 2013): 362–367.

Rakel, Robert E., ed. Essential Family Medicine: Fundamentals and Case Studies. 3d ed. Philadelphia: Saunders/Elsevier, 2006.

Scherger, Joseph E., et al. “Responses to Questions by Medical Students About Family Practice.” Journal of Family Practice 26, no. 2 (1988): 169-176.

Sloane, Philip D., et al., eds. Essentials of Family Medicine. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008.

Tuggy, Michael, et al. "The 'Family' of Family Medicine." Annals of Family Medicine 11, no. 4 (July/August 2013): 385–386.

Woolley, Amanda. "Clinical Intuition in Family Medicine: More Than First Impressions." Annals of Family Medicine 11, no. 1 (January/February 2013): 60–66.