What are the social, psychological, and spiritual conflicts in Oroonoko?

Many of the characters in the book suffer through these particular conflicts. Here is one example of each conflict to get you started.

One significant social conflict is in the war in which Oroonoko serves. Although he is on the winning side, he is tricked by an English captain and ends up being taken against his will to be enslaved. This portion of the story examines the very real social conflict that existed between African countries and European countries (and the Americas) during the time of slave trading. In the book, Oroonoko is tricked into going with the captain; thus, the white man (the captain) is depicted as being manipulative, deceptive, and dangerous. Oroonoko is depicted as being too innocent or even naive, at least in this instance, although we know him to be very intelligent and well-educated. This conflict between the two men is representative of the greater social conflict occurring between races and cultures.

A psychological conflict is one where there are two or more possible actions, neither of which complements the other.  This conflict can be seen in the book when Oroonoko persuades the other slaves to try and escape with him and Imoinda. This is a psychological conflict because escaping is very dangerous and there is no guarantee of success, so deciding to do so is very risky. One could easily be conflicted about whether or not to do so and whether or not to take others, risking their lives as well. The alternative is staying enslaved and risking continued torture and even death at the hands of the slave owners. Oroonoko decides that the risk of trying to escape is worth the possible gain (freedom), and decides to try. Sadly, this does not turn out well for any of them, as they are re-captured and most all of the escapees are killed.

The most significant spiritual conflict in the book may be Oroonoko's decision to kill his wife, Imoinda. His reasoning for this is that if he kills her mercifully, he will be sparing her torture and a slow death at the hands of their captors. He also will prevent their unborn child from being born into slavery. We know from the rest of the story how in love they are, and by the time he reaches this decision, we also understand how difficult it is for him. His intentions behind killing his wife really are good and they both agree to it. However, this is certainly a spiritual conflict because everything in his being says this is wrong under any other circumstance. His spiritual nature is not to kill his beloved wife, so having to do so represents a horrific conflict for Oroonoko. We see how overcome he is with grief when he stops eating and drinking and stays by her dead body for days on end.

What is extended care for seniors?

The Problems Associated with Aging

The process of
aging is inevitable. In the earlier stages of life, aging involves the acquisition and development of new skills and abilities, facilitated by the guidance and assistance of others. Later, the middle stages involve the challenges of maintaining and applying those skills and abilities in a manner that is primarily self-sufficient. Finally, in the end stages of life, aging involves the deterioration and loss of skills and abilities, with adequate functioning again being somewhat dependent on the assistance of others.

For many individuals, the final stages are brief, allowing them to live independently right up to their time of death. Thus, many experience little loss of their abilities to function independently. Others, however, endure more extended stages of later life and require greater care. For these individuals, losses in physical, emotional, and/or cognitive functioning frequently result in a need for specialized care. Such care involves whatever is necessary so that these individuals may live as comfortably, productively, and independently as possible.

The conditions leading to a need for long-term care are as varied as the elderly themselves are. Special needs for elders requiring extended care often include the management of physical, health, emotional, and cognitive problems. Physical problems dictating lifestyle adjustments include decreased speed, dexterity, and strength, as well as increased fragility. Changes to the five senses are also common. Visual changes include the development of hyperopia (farsightedness) and sometimes decreased visual acuity. Hearing loss is also common, such that softer sounds cannot be heard when background noise is present or sounds need to be louder in order to be perceived. Particularly noteworthy is that paranoia, depression, and social isolation often result as side effects of visual and hearing impairments in elders; they are not always signs of mental deterioration. Similarly, one’s sense of touch may also be affected, such that the nerves are either more or less sensitive to changes in temperatures or textures. Consequently, injuries
attributable to a lack of awareness of potential hazards or supersensitivities to temperature or texture may result. One example would be an elderly woman overdressing or underdressing for the weather because of an inability to judge the outside temperature properly. Another would be an elderly man cutting or wounding himself out of a lack of awareness of the sharpness of an object. Finally, both taste and smell may change, creating a situation in which subtle tastes and odors become imperceptible or in which tastes and smells that were once pleasant become either bland or unpleasant.

Health problems among the aged often demand increased management as well. Coordination of drug therapies and other medical interventions by a case manager is critical, as a result of increasing sensitivities in elders to physical interventions. Typical health conditions bringing elderly people into long-term care settings may include heart disease and stroke, hypertension, diabetes mellitus, arthritis, osteoporosis, chronic pain, prostate disease, and cancers of the digestive tract and other vital organs. Estimates are that approximately 86 percent of the aged are affected by chronic illnesses. Long-term care addresses both the medical management of these chronic illnesses and their impact on the individual.

An issue related to health and physical problems in the aged is malnutrition. For a variety of reasons, elders often fall victim to malnutrition, which can contribute to additional health problems. For example, calcium deficiency can increase both the severity of heart disease and the likelihood of osteoporosis and tooth loss. Thus, a vicious cycle of medical problems can be put into motion. Factors contributing to malnutrition are multifaceted. Poverty, social isolation, decreased taste sensitivity, and tooth loss combine with lifelong dietary habits that can sometimes predispose certain elders to malnutrition. As such, attention to the maintenance of healthy dietary habits in the elderly is critical to successful long-term care, regardless of the type of setting in which the care is being given.

Along with these physical aspects of aging come emotional and cognitive changes. Depression, anxiety, and
paranoia over health concerns, for example, are not uncommon. Additionally, concerns about the threat of losing one’s independence, friends, and former lifestyle may contribute to acute or chronic mood disorders.
Suicide is a particular danger with the elderly when mood disorders such as depression are present. Elderly people are one of the fastest growing groups among those who commit suicide. The stresses accompanying losing a spouse or enduring a chronic health problem can often be triggers to suicide for depressed elders. One should note, however, that elders are not particularly prone to depression or suicide because of their age but that they are more likely to experience significant stressors that lead to
depression.

More common, less lethal problems associated with conditions such as depression, anxiety, and paranoia are weight change, insomnia, and other sleep problems. Distractibility, decreased ability to maintain attention and concentration, and rumination over distressing concerns are also common. Finally, some elders may be observed as socially isolated and prone to avoidance behavior. As a result, some become functionally incapacitated because of distressing emotions.

What is critical to remember, in addition to these signs, is that some elders may not describe their problems as emotional at all, even though that is the primary cause of their discomfort. Individual differences in how people express themselves must be taken into account. Thus, while some elders may report being depressed or anxious, others may instead report feeling tired. Reports of low-level health problems that are vague in nature, such as aches and pains, are also common in elders who are depressed. It is not uncommon for emotional problems to be expressed or described indirectly as physical complaints.

Decreased cognitive functioning may result from more serious problems than depression, such as organic brain syndromes. These typically include problems such as dementias from Alzheimer’s disease, Pick’s disease, Huntington’s disease, alcohol-related deterioration, or stroke-related problems. Other causes may be brain tumors or thyroid dysfunction. With all dementias, however, the hallmark signs are a deterioration of intellectual function and emotional response. Memory, judgment, understanding, and the experience and control of emotional responses are affected. Functionally, these conditions reveal themselves as a combination of symptoms, including increased forgetfulness, decreased ability to plan and complete tasks, difficulties finding names or words, decreased abilities for abstract thinking, impaired judgment, inappropriate sexual behavior, and sometimes severe personality changes. In some cases, affected individuals are aware of these difficulties, usually in the earlier stages of the disease processes. Later, however, even though their behavior and abilities may be quite disturbed, they may be completely unaware of the severity of their problems. In these cases, long-term care often begins as a result of outside intervention by concerned friends and family members.

Options for Long-Term Care

Extended care for the aged requires an interdisciplinary effort that usually involves a team of physicians, psychologists, nurses, social workers, and other rehabilitative specialists. Depending on the nature of the problems requiring care and management, any of these professionals may take part in the care process. Additionally, the involvement of concerned individuals who are close to the elder needing care is critical. Family members (including the spouse, children, and extended family) and close friends are invaluable sources of information and of emotional and instrumental support. Their ability to assist an elder with instrumental tasks such as cooking, housecleaning, shopping, and money and medication management is crucial to the successful implementation of a long-term care plan.

In all cases, long-term care for the aged involves the design of a comprehensive plan to address the multifaceted needs of the elder. Just as younger persons have psychological, social, intellectual, and physical needs, so do elders. As such, thorough assessment of an elder’s abilities, goals, expectations, and functioning in each of these areas is required. A mental status exam and a thorough physical exam are usually the primary methods of evaluation. Once needs are identified, a plan can then be designed by the team of health care professionals, family and friends assisting with care, and, whenever possible, the elder. In general, the overarching goal is to design a case management plan that maximizes the independent functioning of the aged person, given certain physical, psychiatric, social, and other needs.

Specific management strategies are designed for the problems that need to be addressed. Physical, health, nutritional, emotional, and cognitive problems all demand different management settings and strategies. Additionally, care settings may vary depending on the severity of the problems that are identified. In general, the more severe the problems, the more structured the long-term care setting and the more intense the psychosocial interventions.

For less severe problems, adequate management settings may include the elder’s own home, the home of a family member or friend, a shared housing setting, or a seniors’ apartment complex. Shared housing is sometimes called group-shared, supportive, or matched housing. Typically, it refers to residences organized by agencies where up to twenty people share a house and its expenses, chores, and management. Ideal candidates for this type of setting include elders who want some daily assistance or companionship but who are still basically independent. Senior apartments, also called retirement housing, are usually “elderly-only” complexes that range from garden-style apartments to high-rises. Ideal candidates for this type of setting include nearly independent elders who want privacy, but who no longer desire or can manage a single-family home. In either of these types of settings, the use of periodic or regular at-home nursing assistance for medical problems, or “home-helpers” for more instrumental tasks, might be a successful adjunct to regular consultation with a case manager or physician.

Problems of moderate severity may demand a more structured setting or a setting in which help is more readily available. Such settings might include continuing care retirement communities or assisted-living facilities. Continuing care retirement communities, also called life-care communities, are large complexes offering lifelong care. Residents are healthy, live independently in apartments, and are able to use cafeteria services as necessary. Additionally, residents have the option of being moved to an assisted-living unit or an infirmary as health needs dictate. Assisted-living facilities—also called board-and-care, institutional living, adult foster care, and personal care settings—offer care that is less intense than that received in a medical setting or nursing home. These facilities may be as small as a home where one person cares for a small group of elders or as large as a converted hotel with several caregivers, a nurse, and shared dining facilities. Such settings are ideal for persons needing instrumental care but not round-the-clock skilled medical or nursing care.

When more severe conditions such as incontinence, dementia, or an inability to move independently are present, nursing, convalescent, or extended care homes are more appropriate settings. Intense attention is delivered in a hospital-like setting where all medical and instrumental needs are addressed. Typical nursing homes serve a hundred clients at a time, utilizing semiprivate rooms for personal living space and providing community areas for social, community, and family activities. Often, the decision to place an elder in this type of facility is difficult to make. The decision, however, is frequently based on the knowledge that these types of facilities provide the best possible setting for the overall care of the elder’s medical, health, and social needs. In fact, appropriate use of these facilities discourages the overtaxing of the elder’s emotional and familial resources, allowing the elder to gain maximum benefit. An elder’s placement into this type of facility does not mean that the family’s job is over; rather, it simply changes shape. Incorporation of family resources into long-term care in a nursing home setting is critical to the adjustment of the elder and family
members to the elder’s increased need for care and attention. Visits and other family involvement in the elder’s daily activities remain quite valuable.

Regardless of the management setting, some basic caveats exist with regard to determining management strategies. First and foremost is that the aged individuals should, whenever possible, be encouraged to maintain independent functioning. For example, even though physical deterioration such as decreased visual or hearing abilities may be present, there is no need to take decision-making authority away from the elder. Decreased abilities to hear or see do not necessarily mean a decreased ability to make decisions or think. Second, it is crucial to ask elders to identify their needs and how they might desire assistance. Some elders may wish for help with acquiring basic living supplies from outside the home, such as foods and toiletries, but desire privacy and no assistance within the home. In contrast, others may desire independence outside the home with regard to social matters but need more instrumental assistance within the home. Finally, it is important to recognize that even the smallest amount of assistance can make a significant difference in the lifestyle of the elder. A prime example is availability of transportation. The loss of a driver’s license or independent transportation signifies a major loss of independence for any elder. Similarly, the challenges posed by public transit may seem insurmountable
because of a lack of familiarity or experience. As such, simple and small interventions such as a ride to a store or a doctor’s office may provide great relief for elders by assisting their efforts to meet their own needs.

Special management strategies may be required for specific problem areas. For physical deterioration, adequate assessment of strengths and weaknesses is important, as are referrals to medical, rehabilitative, and home-help professionals. Hearing and visual or other devices to make lifting, mobility, and day-to-day tasks easier are helpful. Similarly, assisting the aged with developing alternative strategies for dealing with diminished sensory abilities can be valuable. Examples would be checking a thermometer for outdoor temperature to determine proper dress, rather than relying purely on sensory information, or having a phone that lights up when it rings. Health conditions also demand particular management strategies, varying greatly with the type of problem experienced. In all cases, however, medical intervention, drug therapies, and behavior modification therapies are commonly employed. Dietary problems (such as malnutrition or diabetes), cardiovascular problems (such as heart attacks), and emotional problems (such as depression) often require all three approaches. Finally, cognitive problems, particularly those related to depression, are sometimes alleviated with drug therapies. Others
related to organic brain syndromes or organic mental disorders require both medical interventions and significant behavior modification therapies and/or psychosocial interventions for elders and their families.

Perspective and Prospects

Advances in modern medicine are continually extending the human life span. Cures for dread diseases, improved management of chronic health problems, and new technologies to replace diseased organs are facilitating this evolution. For many, these advances translate into greater longevity, the maintenance of a high quality of life, and fewer obstacles related to ageism. For others, however, the trade-off for longevity is some loss of independence and a need for extended care and management. Thus, the medical field is also affected by the trade-off of extending life, while experiencing an increasing need to improve strategies for long-term care for those who are able to live longer and longer despite health conditions.

As a result of this evolution, long-term care for the aged presents special challenges to the medical field. Over time, medicine has been a field specializing in the understanding of particular organ systems and the treatment of related diseases. While an understanding of how each system affects the functioning of the whole body is necessary, health care providers must struggle to understand the complexities in the case management required for high-quality long-term care for the aged. Care must be interdisciplinary, addressing the physical, mental, emotional, social, and familial needs of the aged individual. Failure to address any of these areas may ultimately sabotage the successful long-term management of elderly individuals and of their problems. In this way, medical, psychiatric, social work, and rehabilitative specialists need to work together with elders and their families for the best possible results.

Integrated case management with a team leader is increasingly the trend so that a variety of services can be provided in an orchestrated manner. While specialty providers still play a role, managers (usually primary care physicians) ensure that complementary drug therapies as well as psychiatric and other medical treatments are administered. Additionally, they are key in bringing forth family resources for emotional and instrumental support whenever possible, as well as community and social services when needed.

What was once viewed as helping a person to die with dignity is now viewed as helping a person to live as long and as productive a life as possible. Increasing awareness that old age is not simply a dying time has facilitated an integrated approach to long-term care. The news that elders can be as social, physical, sexual, intellectual, and productive as their younger counterparts has greatly stimulated improved long-term care strategies. No longer is old age seen as a time for casting elders aside or as a time when a nursing home is an inescapable solution in the face of health problems affecting the aged. Alternatives to care exist and are proliferating, with improved outcomes for both patients and care providers.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th ed. Arlington, Va.: Author, 2000.

Cassel, Christine K., ed. Geriatric Medicine. 4th ed. New York: Springer, 2003.

Foreman, Marquis D., K. Milisen, and Terry T. Fulmer. Critical Care Nursing of Older Adults: Best Practices. 3d ed. New York: Springer, 2010.

Ham, Richard, et al., eds. Primary Care Geriatrics: A Case-Based Approach. 5th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.

Katz, Paul R., Robert L. Kane, and Mathy D. Mezey. Advances in Long-Term Care. Vol. 1. New York: Springer, 1991.

Levin, Mora Jean. How to Care for Your Parents: A Practical Guide to Eldercare. New York: W. W. Norton, 1997.

Matthews, J. L. Long-Term Care: How to Plan and Pay for It. 9th ed. Berkeley, Calif.: Nolo, 2012.

Miller, Carol A. Nursing for Wellness in Older Adults. 6th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2012.

Namazi, Kevan H., and Paul K. Chaftez, eds. Assisted Living: Current Issues in Facility Management and Resident Care. Westport, Conn.: Auburn House, 2001.

Nicholl, Claire, and K. Jane Wilson. Elderly Care Medicine. 8th ed. Oxford: Wiley-Blackwell, 2012.

Weisstub, David N. Aging: Caring for Our Elders. Boston: Kluwer Academic, 2001.

What is the relationship between respiratory diseases and smoking?

Causes

Smoking tobacco is the primary cause of a number of respiratory diseases, the most serious being chronic bronchitis, emphysema, chronic obstructive pulmonary disease (COPD), and lung cancer. Most long-term smokers started as preteens or teenagers, became
addicted to nicotine, and then subjected their respiratory systems to the toxins and carcinogens contained in the tobacco.

Tobacco smoke contains thousands of chemical compounds and more than four hundred toxic and carcinogenic substances. According to the American Lung Association in 2015, smoking-related respiratory diseases kill more than 480,000 people each year in the United States alone. Smoking causes about 90 percent of lung cancer cases and 85 to 90 percent of COPD cases. The Centers for Disease Control and Prevention reported in 2015 that lung cancer was the leading cause of cancer death and the second most common cancer among men and women in the United States. The CDC also reported in 2015 that chronic lower respiratory disease, mostly COPD, was the third leading cause of death in the United States in 2011.

Chronic bronchitis occurs when there is an increase in the size and number of mucous glands in the large airways of the lungs. The increased amount of mucus inflames and scars the airways, constricting air flow, which becomes more pronounced with continued scarring and thickening of the airway walls.

Emphysema results from damage to the lungs’ alveoli, or air sacs, which facilitate the exchange of carbon dioxide and oxygen. This condition further compromises breathing because of the constriction of airways from the loss of lung elasticity.

COPD is a condition that usually includes a combination of chronic bronchitis and emphysema, resulting in forced and inefficient breathing. The degree of the contribution of each component condition to COPD varies from case to case. Lung cancer occurs when carcinogens, most often from cigarette smoke, cause damage to lung cells, leading to abnormal cellular replication that creates tumors in the larger airways or other parts of the lung.

Risk Factors

Although people who have never smoked can potentially develop respiratory ailments from factors such as genetics or exposure to job-related or general air pollution, the cause of 80 to 90 percent of all serious respiratory diseases is long-term tobacco smoking. Researchers estimate that approximately fifteen hundred preteens and teenagers each day become addicted to nicotine, and many of them will become life-long smokers.

There is a positive linear correlation between the risk of major respiratory disease and the duration of exposure, which is measured in “package-years,” determined by years of smoking multiplied by the number of packs of cigarettes per day. This measurement places older chronic smokers at highest risk. Research shows that nonsmokers who are exposed to
secondhand or passive smoke, because they live, work, or recreate in smoke-filled environments, are at a significantly increased risk of developing serious respiratory diseases.

Symptoms

Chronic bronchitis, often called smoker’s cough, is evidenced by the coughing up of sputum, or phlegm, for a minimum of three months during two or more consecutive years. Emphysema is characterized by severe shortness of breath that makes physical activity increasingly difficult as the disease progresses to the point of total disability. Common symptoms include exhaustion, coughing, heart problems, and enlarged chest because of labored breathing.

Indicators of COPD include all of the symptoms of chronic bronchitis and emphysema. As COPD progresses, respiratory inefficiency further increases carbon dioxide levels and reduces oxygen levels in the blood, which is evidenced by drowsiness, twitching, headaches, lips assuming a bluish pallor, severe shortness of breath, and swollen ankles from heart strain. Some symptoms associated with lung cancer are labored breathing, chest pain, hoarseness, phlegm containing blood, lack of strength in the hands or arms, and swollen face and neck.

Screening and Diagnosis

Because chronic bronchitis and emphysema are both obstructive pulmonary diseases that are typically combined in COPD (to some degree), the diagnostic tests for all three conditions are the same. In all three cases, patients are asked if they smoke or have ever smoked, or if they work with lung-damaging chemicals. A number of tests are then performed.

A spirometry test that shows that less than 70 percent of the air is expelled from the lungs during exhaling indicates COPD. X-rays and computed tomography (CT) scans can detect damage to lung tissue and increased air in the chest. Excessive air in the lungs can be determined with a lung volume test, which indicates COPD. Diffusing capacity and arterial blood gas tests measure how efficient the lungs are in eliminating carbon dioxide and supplying oxygen to the blood. A body plethysmography shows whether asthma is present in conjunction with emphysema, and an alpha-1 antitrypsin deficiency test can detect a relatively rare form of genetically inherited emphysema.

Lung cancer is diagnosed with X-rays or a CT scan to reveal the presence of tumors. If tumors are present, lung mucus or fluid is often examined for the presence of cancer cells. The definitive diagnosis usually involves the removal of a small sample of tissue from tumors with an instrument that is inserted through the air passage, on which a biopsy is performed to determine if the growths are cancerous.

Treatment and Therapy

Because chronic bronchitis, emphysema, and COPD are caused by smoking in a majority of cases, the first treatment strategy for patients who are active smokers is to quit. The body can repair lung damage in short-term smokers, and although the effects of advanced COPD are irreversible and progressive, smoking cessation can slow the rate of progression. While COPD is progressive and potentially fatal, management strategies can improve the patient’s quality of life and extend longevity.

Patients with low oxygen levels can take supplemental oxygen from an oxygen cylinder or concentrator through nasal tubes or an oxygen mask, which allows them to lead more active lives. Oxygen dosages must be carefully monitored to avoid a number of serious side effects. Being overweight or underweight can affect the progression and severity of symptoms of COPD, so adjustments in diet in combination with counseling and an exercise program can reduce the degree of infirmity.

A number of medications can help to control COPD symptoms. Nebulizers are used to administer anticholinerics or B2 agonists. Both are bronchodilators that act quickly to improve air flow by relaxing muscles around airways. In advanced COPD cases, corticosteroids are administered to reduce airway inflammation, but the side effects include a higher probability of pneumonia. In some of the most advanced COPD cases, the patient may need surgery to remove the most severely damaged parts of the lungs, or a lung transplant may need to be performed.

The treatment for lung cancer varies depending on the type of cancer and how far the disease has progressed. Non-small-cell lung cancer develops relatively slowly and, if diagnosed early, is treated with surgery that may involve removing the tumor, a portion of the lung, or the entire lung. Often, radiation therapy, which kills cancer cells with X-rays, follows the surgery. Chemotherapy, which kills cancer cells with powerful medications, is sometimes used in conjunction with surgery and radiation therapy.

Small-cell lung cancer progresses and spreads to other organs relatively quickly and is usually treated with radiation therapy or chemotherapy. All persons with cancer who also are smokers are strongly advised to quit smoking. Nicotine and the chemicals in cigarette smoke retard the healing process after surgery and appear to promote cancer cell growth while insulating cancer cells from the destructive effects of both radiation therapy and chemotherapy. After the initial treatment, cancer patients have ongoing follow-up care that includes X-rays and CT scans, blood work, and physical examinations to check for a possible recurrence of the disease.

Prevention

Because 80 to 90 percent of all cases of chronic bronchitis, emphysema, COPD, and lung cancer are caused by smoking, the most important preventive measures are to not start smoking, to quit if one already smokes, and to avoid secondhand smoke. Management and workers in industries in which the work environment exposes personnel to dust and harmful chemicals should be aware of the importance of adequate ventilation; of using respirators; and of monitoring and controlling dust, toxin, and carcinogen levels.

Bibliography

American Lung Assn. “Smoking Facts.” Lung.org. ALA, 2015. Web. 30 Oct. 2015.

Centers for Disease Control and Prevention. “Chronic Obstructive Pulmonary Disease.” CDC.gov. CDC, 12 Mar. 2015. Web. 30 Oct. 2015.

Centers for Disease Control and Prevention. “Lung Cancer.” CDC.gov. CDC, 16 Sept. 2015. Web. 30 Oct. 2015.

Owing, J. H., ed. Smoking and Health: New Research. Hauppauge: Nova Science, 2005. Print.

Slovic, Paul, ed. Smoking: Risk, Perception, and Policy. Thousand Oaks: Sage, 2001. Print.

Ward, Jeremy P. T., Jane Ward, and Richard M. Leach. The Respiratory System at a Glance. Hoboken: Wiley, 2010. Print.

What figurative language describes Simon in The Lord of the Flies?

Figurative language is plentiful in William Golding's novel The Lord of the Flies. Simon's role as the book's moral compass is especially prominent in the personification, imagery, and metaphors Golding assigns to both descriptions of and dialogue spoken by Simon. Perhaps the most striking examples of figurative language in Simon's plot line are in Chapter 8, as this portion of the novel details Simon's chilling separation from the boys.

Personification: The boys have another meeting early in Chapter 8. In an attempt to offer advice, Simon takes the conch, but "the pressure of the assembly took [Simon's] voice away." By personifying the animosity of the boys toward Simon, Golding emphasizes Simon's separation from the violence that characterizes the group. 

Imagery: Later in Chapter 8, after Simon has wandered to where the Lord of the Flies sits, he begins to become affected by the heat. The imagery that "in Simon's right temple, a pulse began to beat on the brain" hints at the later intensity of his hallucinations. Later descriptions of Simon's physical covering by the flies is similarly abundant with vivid imagery.

Metaphor: At the end of Chapter 8, Simon's hallucinations become more severe. In the final lines of the chapter Simon is said to move "inside the mouth" of the Lord of the Flies. This metaphor that Simon was overtaken and is now "inside" the Pig's "mouth" shows readers that Simon is from this point on removed from the natural world of the boys on the island and cannot return. 

Did Winnie like being with her kidnappers in Tuck Everlasting?

Winnie enjoys being with her kidnappers once she gets over the shock of being kidnapped.

When Winnie sees Jesse in the woods, drinking from the immortal spring, he knows that he can’t just leave her there. There is too much risk that she will drink from the spring, because she has no idea what it does. The best thing they can think of is to kidnap her and take her home, so that is just what Jesse, Miles, and Mae Tuck do.

Winnie does not feel that the Tucks are average kidnappers.  Rather than frightening her, her kidnappers seem “just as alarmed” as she is.

She had always pictured a troupe of burly men with long black moustaches who would tumble her into a blanket and bear her off like a sack of potatoes while she pleaded for mercy. But, instead, it was they, Mae Tuck and Miles and Jesse, who were pleading. (Ch. 6)

Once Winnie meets Angus Tuck, she feels even more at ease. He is a nice old man who is just tickled pink to see her. The Tucks keep to themselves and do not meet many people. They have not really ever told anyone their story. Winnie realizes that the Tucks are special people and just looking out for her. This does not prevent her from being homesick.

When Mae said, "Tomorrow," Winnie's sobs turned to wails. Tomorrow! It was like being told she would be kept away forever. She wanted to go home now, at once, rush back to the safety of the fence and her mother's voice from the window. (Ch. 6)

Winnie always wanted adventure. She wanted to be able to leave her safe little corner and travel. She finds adventure with the Tucks, all right! Winnie becomes good friends with the family quickly, and before she knows it she is even offering to break Mae Tuck out of jail to protect the Tucks’ secret.

What is dermatitis?

Causes and Symptoms

The term
dermatitis
refers not to a single skin
disease but to a wide range of disorders. Dermatitis is often used interchangeably with
eczema
. The two most common dermatitides are atopic (allergic) dermatitis, in which the individual appears to inherit a predilection for the disease, and contact dermatitis, in which the individual’s skin reacts immediately on contact with a substance or develops sensitivity to it.

Atopic dermatitis often occurs in individuals with a personal or family history of allergy, such as hay fever or
asthma. Between 50 and 70 percent of children with severe atopic dermatitis develop asthma, a rate that is more than five times higher than for the general population. These people often have high serum levels of a certain antibody, immunoglobulin E (IgE), which may be associated with their skin’s tendency to break out, although a specific antigen-antibody reaction has not been demonstrated.

There are many distinct characteristics of atopic dermatitis, some of which depend on the age of the patient. The disease usually starts early in childhood. It is often first discovered in infants in the first months of life when redness and weeping, crusted lesions appear mostly on the face, although the scalp, arms, and legs may also be affected. There is intense itching. Papules (pimples), vesicles (small, blisterlike lesions filled with fluid), edema (swelling), serous exudation (discharge of fluid), and scaly crusts may be seen. At one year of age, oval, scaly lesions appear on the arms, legs, face, and torso. In older children and adults, the lesions are usually localized in the crook of the elbow and the back of the knees, and the face and neck may be involved. The course of the disease is variable. It usually subsides by the third or fourth year of life, but periodic outbreaks may occur throughout childhood, adolescence, and adulthood. Cases persisting past the patient’s middle twenties, or beginning then, are the most difficult to treat.

Dryness and itching are always present in atopic dermatitis. People with atopic dermatitis seem to lose skin moisture more readily than average people: Rather than soft, pliable skin, they develop dry, rough, sensitive skin that is particularly prone to chapping and splitting. The skin becomes itchy, and the individual’s tendency to scratch significantly aggravates the condition in what is called the “itch-scratch-itch” cycle or the “scratch-rash-itch” cycle: the individual scratches to relieve the itching, which causes a rash, which in turn causes increased itching, which invites increased scratching and increased irritation. After years of itching and scratching, the skin of older children and adults with atopic dermatitis develops red, lichenified (rough, thickened) patches in the crook of the arm and behind the knees as well as on the eyelids, neck, and wrists.

Constant chafing of the affected area invites bacterial infection and lymphadenitis (inflammation of lymph nodes). Furthermore, patients with atopic dermatitis seem to have altered immune systems. They appear to be more susceptible than others to skin infections, warts, and contagious skin diseases. Staphylococcus aureus and certain streptococci are common infecting bacteria in these patients. Pyoderma is often seen as a result of bacterial infection in atopic dermatitis. This condition features redness, oozing, scaling, and crusting as well as the formation of small pustules (pus-filled pimples).

Patients with atopic dermatitis are also particularly sensitive to
herpes simplex and vaccinia viruses. Exposure to either could cause a severe skin disease called Kaposi’s varicelliform eruption. Vaccinia virus (the agent that causes cowpox) is used in the preparation of
smallpox vaccine. Therefore, patients with atopic dermatitis must not be vaccinated against smallpox. Furthermore, they must be isolated from patients with active herpes simplex and those recently vaccinated against smallpox.

Patients with atopic dermatitis may also develop contact dermatitis, which can greatly exacerbate their condition. They are also sensitive to a wide range of allergens, which can bring on outbreaks, as well as to low humidity (such as in centrally heated houses in winter), which can contribute to dry skin. They may not be able to tolerate woolen clothing.

A condition called keratosis pilaris often develops in the presence of atopic dermatitis. It is not seen in young infants, but it does appear in childhood. Hair follicles on the torso, buttocks, arms, and legs become plugged with horny matter and protrude above the skin, giving the appearance of goose bumps or “chicken skin.” The palms of the hands of patients with atopic dermatitis have significantly more fine lines than those of average people. In many patients, there is a tiny “pleat” under the eyes. They are often prone to cold hands and may have pallor, seen as a blanching of the skin around the nose, mouth, and ears.

When ordinary skin is lightly rubbed with a pointed object, almost immediately there is a red line, followed by a red flare, and finally, a wheal or slight elevation of the skin along the line. In patients with atopic dermatitis, however, there is a completely different reaction: The red line appears, but almost instantly it becomes white. The flare and the wheal do not appear.

About 4 to 12 percent of patients with atopic dermatitis develop
cataracts at an early age (some estimates range as high as nearly 40 percent). Normally, cataracts do not appear until the fifties and sixties; those with atopic dermatitis may develop them in their twenties. These cataracts usually affect both eyes simultaneously and develop quickly.

Psychologically, children with atopic dermatitis often show distinct personality characteristics. They are reported to be bright, aggressive, energetic, and prone to fits of anger. Children with severe, unmanageable cases of atopic dermatitis may become selfish and domineering, and some go on to develop significant personality disorders.

It is not known exactly what happens to cause the itching and dry skin that are the fundamental signs of atopic dermatitis and the root of many of its complications. Theories suggest various origins. It is by definition an allergic disorder, but the allergens that are specifically involved and how they produce the signs of atopic dermatitis are unknown. One of the most interesting theories involves the antibody IgE. Theoretically, the union of IgE with an antigen causes certain cells to release pharmacologic mediators, such as histamine, bradykinin, and slow-reacting substance (SRS-A), that cause itching and thus begin the cycle of scratching and irritation characteristic of atopic dermatitis. The fact that patients with atopic dermatitis have higher than normal levels of IgE, and that there is a relationship between IgE levels and the severity of atopic dermatitis, seems to lend support to this theory.

Contact dermatitis resembles atopic dermatitis at certain stages, but the dry skin of atopic dermatitis may not be seen. Contact dermatitis is usually characterized by a rash consisting of small bumps, itchiness, blisters, and general swelling. It occurs when the skin has been exposed to a substance to which the body is sensitive or allergic. If the contact dermatitis is caused by direct irritation by a caustic substance, it is called irritant contact dermatitis. The causative agents are primary irritants that cause inflammation at first contact. Some obvious irritants are acids, alkalis, and other harsh chemicals or substances. An example is fiberglass dermatitis, in which fine glass particles from fiberglass fabrics or insulation enter the skin and cause redness and inflammation.

If the dermatitis is caused by allergic
sensitivity to a substance, it is called allergic contact dermatitis. In this case, it may take hours, days, weeks, or years for the patient to develop sensitivity to the point where exposure to these substances causes allergic contact dermatitis. Agents that may cause allergic contact dermatitis include soaps, acetone, skin creams, cosmetics, poison ivy, and poison sumac.

Allergic contact dermatitis comprises the largest variety of contact dermatitides, many of them named for the allergens that cause them. Hence, there is pollen dermatitis; plant and flower dermatitis, such as poison ivy or poison oak; clothing dermatitis; shoe, and even sandal strap, dermatitis; metal and metal salt dermatitis; cosmetic dermatitis; and adhesive tape dermatitis, among others. They all have one thing in common: the skin is exposed to an allergen from any of these sources and becomes so sensitive to it that further exposure causes a rash, itching, and blistering.

The development of sensitivity to an allergen is an immunological response to exposure to that substance. With many allergens, the first contact elicits no immediate immunological reaction. Sensitivity develops after the allergen has been presented to the T lymphocytes that mediate the immune response.

Because it often takes a long time to develop sensitivity, patients are surprised to discover that they have become allergic to substances that they have been using for years. For example, a patient who has been applying a topical medication to treat a skin condition may one day find that the medication causes an outbreak of dermatitis. Ironically, some of the ingredients in medications commonly used to treat skin conditions are among the major allergens that cause allergic contact dermatitis. These include antibiotics, antihistamines, topical anesthetics, and antiseptics as well as the inactive ingredients used in formulating the medications, such as stabilizers.

Other substances to which the patient may develop sensitivity include the chemicals used in making fabric for clothing, tanning chemicals used in making leather, dyes, and ingredients in cosmetics. Many patients develop sensitivity to allergens found in the workplace. The list of potential allergens in the industrial setting is virtually endless and includes solvents, petroleum products, chemicals commonly used in manufacturing processes, and coal tar derivatives.

In some cases, the allergen requires sunlight or other forms of light to precipitate an outbreak of contact dermatitis. This is called photoallergic contact dermatitis, and it may be caused by such agents as aftershave lotions, sunscreens, topical sulfonamides, and other preparations applied to the skin. Another light reaction, termed phototoxic contact dermatitis, can be caused by exposure to sunlight after exposure to perfumes, coal tar, certain medications, and various chemicals.

A different form of dermatitis involves the sebaceous glands, which secrete sebum, a fatty substance that lubricates the skin and helps retain moisture. Sebaceous dermatitis is usually seen in areas of the body with high concentrations of sebaceous glands, such as on the scalp or face, behind the ears, on the chest, and in areas where skin rubs against skin, such as the buttocks and the groin. It is seen most often in infants and adolescents, although it may persist into adulthood or start at that time.

In infants, sebaceous dermatitis can begin within the first month of life and appears as a thick, yellow, crusted lesion on the scalp called cradle cap. There can be yellow scaling behind the ears and red pimples on the face. Diaper rash may be persistent in these infants. In older children, the lesion may appear as thick, yellow plaques in the scalp. When sebaceous dermatitis begins in adulthood, it starts slowly, and usually its only manifestation is scaling on the scalp (dandruff). In severe cases, yellowish-red scaling pimples develop along the hairline and on the face and chest. Its cause is unknown, but a yeast commonly found in the hair follicles, Pityrosporum ovale, may be involved.

There are many other kinds of dermatitis. Diaper dermatitis, or diaper rash, is a complex skin disorder that involves irritation of the skin by urine and feces, irritation by constant rubbing, and secondary infection by Candida albicans. Nummular dermatitis is characterized by crusting, scaly, disc-shaped papules and vesicles filled with fluid and often pus. Pityriasis alba is a common dermatitis with pale, scaly patches. In lichen simplex chronicus, there is intense itching, with lesions caused and perpetuated by scratching and rubbing. Stasis dermatitis occurs at the ankles; brown discoloration, swelling, scaling, and varicose veins are common. Hyperimmunoglobulin E (Hyper IgE) syndrome is characterized by extremely high IgE levels, ten to one hundred times higher than normal, and a family history of allergy; the patient has frequent skin infections, suppurative (pus-forming) lymphadenitis, pustules, plaques, and abscesses. Pompholyx occurs on the hands and soles of the feet; there is excessive sweating, with eruptions of deep vesicles accompanied by burning or itching.

Friction can also cause dermatitis. In intertrigo, the friction of skin rubbing against skin causes inflammation that can become infected. In frictional lichenoid dermatitis, or sandbox dermatitis, it is thought that the abrasive action of sand or other gritty material on the skin causes the characteristic lesions. Winter
eczema seems to be caused by the skin-drying effects of low humidity as well as by harsh soaps and overfrequent bathing; dry skin and itching are common. The acrodermatitis diseases may be limited to the hands and feet, or, like acrodermatitis enteropathica, may erupt in other parts of the body, such as around the mouth and on the buttocks. In fixed-drug eruption, lesions appear in direct response to the administration of a drug; the lesions are generally in the same parts of the body, but they may spread. Swimmer’s itch is a parasitic infection from an organism that lives in freshwater lakes and ponds, while seabather’s eruption seems to be caused by a similar saltwater organism.

Treatment and Therapy

Many dermatitides resemble one another, and it is important for a physician to identify the patient’s complaint precisely to treat it effectively. Therefore, the physician will confirm the identity of the condition through a process known as differential diagnosis. This method allows him or her to rule out all similar conditions, pinpoint the exact nature of the patient’s problem, and develop a therapeutic regimen to treat it.

In treating atopic dermatitis, one of the first goals is to relieve dryness and itching. The patient is cautioned not to bathe excessively, as this dries the skin. Lotions are used to lubricate the skin and retain moisture. The patient is advised not to scratch, because this could break the skin and invite infection. The patient is also advised to avoid any known offending agents and cautioned not to apply any medication to the skin without the doctor’s knowledge.

Wet compresses can bring relief to patients with atopic dermatitis. Topical
corticosteroids are used to help resolve acute flare-ups, but only for short-term therapy, because their prolonged use might produce undesirable side effects. Oral
antihistamines are often given to relieve itching and to help the patient sleep. Diet may play a role in atopic dermatitis in infants; some pediatric dermatologists and other physicians recommend elimination of milk, eggs, tomatoes, citrus fruits, wheat products, chocolate, spices, fish, and nuts from the diets of these patients. Soft cotton clothing is recommended, as is the avoidance of pets or fuzzy toys that might be allergenic. For secondary infections that arise from atopic dermatitis, the physician prescribes appropriate antibiotic therapy.

In primary irritant contact dermatitis, the offending agent is eliminated or avoided. In allergic contact dermatitis, one of the main goals is to discover the offending agent so that the patient can avoid contact with it. Sometimes this information can be elicited from the patient interview, and sometimes it is necessary to conduct a series of patch tests. In this procedure, known allergens are applied to the skin of the patient to find those that cause irritation. Avoidance of the offending agent can cause the patient some difficulty if the agent happens to be something that is found everywhere. An example is the metal nickel, which is in coins, jewelry, and hundreds of other objects. Patients who insist on wearing jewelry containing nickel are advised to paint it with clear nail polish periodically to avoid contact of the metal with the skin. Similarly, many other allergens are in common use. Patients are advised to read cosmetics labels and food and medical ingredients lists to avoid contact with agents to which they are sensitive.

Because there is such a wide range of allergic contact dermatitides, treatments vary considerably. Topical and oral
steroids are used, as well as antihistamines. Sometimes the physician finds it necessary to drain large blisters and apply drying agents to weeping lesions. Sometimes the condition calls for wet compresses to relieve itching and soothe the patient. Specialized lotions, soaps, and shampoos are also used, some to treat dryness and others, as in the case of sebaceous dermatitis, to remove scales and to relieve oiliness.

Other treatments depend on the type of dermatitis from which the patient suffers. Patients with photoallergic or phototoxic dermatitis are advised to avoid light. Acrodermatitis enteropathica is caused by a zinc deficiency; in addition to palliative therapy to relieve the symptoms, these patients are given zinc sulfate, which results in complete remission of the disease. As with atopic dermatitis, bacterial infections occurring as a result of a flare-up of allergic contact dermatitis are treated with appropriate antibiotic therapy.

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American Academy of Dermatology. http://www.aad.org.

Bair, Brooke, et al. "Cataracts in Atopic Dermatitis: A Case Presentation and Review of the Literature." Archives of Dermatology 147, no. 5 (May, 2011): 585–88.

Hellwig, Jennifer. "Contact Dermatitis." HealthLibrary, October 11, 2012.

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

Middlemiss, Prisca. What’s That Rash? How to Identify and Treat Childhood Rashes. London: Hamlyn, 2002.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. "Handout on Health: Atopic Dermatitis." National Institutes of Health, August 2011.

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

Rietschel, Robert L., and Joseph F. Fowler, eds. Fisher’s Contact Dermatitis. 6th ed. Lewiston, N.Y.: Marcel Decker, 2008.

Titman, Penny. Understanding Childhood Eczema. New York: Wiley, 2003.

Weston, William L., et al. Color Textbook of Pediatric Dermatology. 4th ed. St. Louis, Mo.: Mosby/Elsevier, 2007.

Williams, Hywel C., ed. Atopic Dermatitis: The Epidemiology, Causes, and Prevention of Atopic Eczema. New York: Cambridge University Press, 2000.

What is surgery support?

Introduction

Surgery, even relatively minor surgery, is a significant trauma to the body. The
surgical incision itself can cause swelling (edema), pain,
and bruising; anesthesia frequently causes nausea and bloating. Certain surgeries
that damage the body’s lymphatic system, such as radical mastectomy, can cause a
specific form of long-lasting swelling called lymphedema.

Modern surgery involves numerous sophisticated nondrug techniques to help wounds
heal rapidly and completely. Various medications can be used to help offset the
side effects of anesthesia.

Principal Proposed Natural Treatments

A variety of herbs, supplements, and other alternative therapies show promise in alleviating problems encountered following surgery. However, many such substances have shown the potential to increase the risk of bleeding during or after surgery. Furthermore, it is not possible to determine all the potential interactions between herbs and drugs used for anesthesia. For this reason, herbs and supplements should be used for surgical support only under the supervision of a physician.

Proteolytic enzymes. According to most studies, proteolytic
enzymes may help reduce pain, bruising, and swelling after
surgery. A double-blind, placebo-controlled trial of eighty people undergoing knee
surgery found that treatment with mixed proteolytic enzymes after surgery
significantly improved rate of recovery, as measured by mobility and swelling.

Another double-blind, placebo-controlled trial evaluated the effects of a similar
mixed proteolytic enzyme product in eighty persons undergoing oral surgery. The
results showed reduced pain, inflammation, and swelling in the treated group
compared with the placebo group. Benefits were also seen in another trial of mixed
proteolytic enzymes for dental surgery and in one study involving only
bromelain.

Other double-blind, placebo-controlled studies have found bromelain helpful in nasal surgery, cataract removal, and foot surgery. However, a study of 154 persons undergoing facial plastic surgery found no benefit.

Bromelain thins the blood and could increase risk of bleeding during or after surgery. For this reason, physician supervision is essential.

Oxerutins and other bioflavonoids. Oxerutins
have been widely used in Europe since the mid-1960s, primarily as a treatment for
varicose veins. Derived from a naturally occurring bioflavonoid called rutin,
oxerutins were specifically developed to treat varicose veins and related venous
problems. However, they may also be helpful for treating swelling following
surgery. Closely related bioflavonoids from citrus fruit also may be helpful.

Women who have undergone surgery for breast cancer may experience a lasting and troublesome side effect: swelling in the arm caused by damage to the lymph system. With the veins, the lymphatic system is responsible for returning fluid to the heart. When this system is damaged by breast cancer surgery, fluid accumulates in the arm. Three small, double-blind, placebo-controlled studies enrolling more than one hundred people have examined the effectiveness of oxerutins in lymphedema following breast cancer surgery, with generally good results.

In a small, six-month, double-blind study, oxerutins reduced swelling and improved
comfort and mobility compared with placebo. Another study found benefit with a
combination formula containing oxerutins, ginkgo, and the drug heptaminol. The
citrus
bioflavonoids diosmin and hesperidin have also shown promise
for lymphedema following breast cancer surgery, as has a product containing
hesperidin plus a bioflavonoid-rich extract of the herb butcher’s broom. One
should not use bioflavonoid combinations containing tangeretin if also taking
tamoxifen for breast cancer.

Oxerutins might also be helpful for the ordinary swelling that occurs after any type of surgery. In one double-blind trial, researchers gave oxerutins or placebo for five days to forty people recovering from minor surgery or other minor injuries and found oxerutins significantly helpful in reducing swelling and discomfort.

Oligomeric proanthocyanidins. Oligomeric
proanthocyanidins (OPCs), substances found in grape seed and
pine bark, may also be helpful for recovery from surgery. Like oxerutins, to which
they are chemically related, OPCs are thought to work by reducing leakage from
capillaries.

A double-blind, placebo-controlled study of sixty-three women with breast cancer found that 600 milligrams (mg) of OPCs daily for six months reduced postoperative symptoms of lymphedema. Additionally, in a double-blind, placebo-controlled study of thirty-two people who were followed for ten days after having a face-lift, swelling disappeared much faster in the treated group.

Acupuncture and acupressure. Acupuncture
and acupressure are two related forms of treatment that involve
stimulating certain locations on the body known as acupuncture points. Numerous
studies have evaluated treatment on a single acupuncture point, P6, for the relief
of nausea following anesthesia. This point is located on the inside of the
forearm, about two inches above the wrist crease.

Many controlled studies involving more than two thousand people have tested the potential benefits of stimulation at P6 in people undergoing surgery. In most of these trials, treatment was carried out through the surgery itself, as well as afterwards. The results of these trials, involving various types of surgery and diverse forms of acupuncture and acupressure, tend to contradict one another. On balance, however, it appears that acupuncture and acupressure may reduce intraoperative (during surgery) and postoperative nausea to some extent beyond that of the placebo effect.

Acupuncture has also been explored as a means of reducing pain after surgery, with inconsistent results. In a 2008 review of fifteen randomized, controlled trials, however, researchers determined that acupuncture is capable of reducing pain and the need for opioid medications (morphine and related agents) immediately following surgery, compared with sham (fake) acupuncture. A small randomized trial of seventy persons found that acupuncture may decrease dry mouth and pain after removal of lymph nodes in the neck for cancer treatment. Contrary to popular belief, acupuncture does not appear to be helpful for providing or enhancing anesthesia itself.

Other Proposed Natural Treatments

The herb ginger is thought to have antinausea effects. In studies,
ginger has been given before surgery to prevent the nausea that many people
experience when they awaken from anesthesia. However, despite some early positive
results, the preponderance of evidence indicates that ginger is not helpful for
this purpose.

One should not use ginger either before or immediately after surgery or labor and delivery without a physician’s approval. There are theoretical concerns that ginger may affect bleeding.

Preliminary evidence suggests that peppermint oil may be helpful for postoperative
flatulence and nausea. Also, a preliminary controlled study found that the
honeybee product propolis mouthwash following oral surgery significantly
speeded healing time compared with placebo.

One small, double-blind, placebo-controlled study found that magnet therapy patches of the “unipolar” variety reduced pain and swelling after suction lipectomy. However, a study of 165 people undergoing various forms of surgery failed to find that the use of static magnets over the surgical incision reduced postsurgical pain. Furthermore, the positioning of static magnets at the acupuncture-acupressure point P6 in persons undergoing ear, nose, and throat or gynecological surgeries reduced nausea and vomiting no better than placebo in a randomized trial. A small pilot study involving eighty women undergoing breast augmentation procedures found that daily pulsed electromagnetic field therapy reduced postoperative discomfort significantly more than placebo therapy within three days of surgery.

A double-blind, placebo-controlled study examined thirty-seven people undergoing surgery for carpal tunnel syndrome. The use by these persons of an ointment made from the herb Arnica (combined with homeopathic Arnica tablets) appeared to slightly reduce postsurgical pain.

Horse
chestnut has effects similar to OPCs and has also shown
promise for reducing postoperative swelling. A preliminary study suggests that
topically administered capsaicin provides short-term pain relief immediately
following hernia repair surgery. In two studies, the sports supplement
creatine has been tried as an aid to strengthen recovery
after knee surgery, but no benefits were seen.

Good nutrition is essential to recovery from any physical trauma. For this reason, the use of a multivitamin-multimineral supplement in the weeks before surgery, and for some time afterward, might be advisable.

A placebo-controlled study failed to find that onion extract could help reduce
skin scarring following surgery. Another study found that massage therapy reduced
postoperative pain. The use of a fish oil product as part of a total
parenteral nutrition regimen (intravenous feeding) may help speed recovery after
major abdominal surgery.

Treatment via inhalation of essential oils is called aromatherapy.
One controlled trial found that lavender oil, administered through an oxygen face
mask, reduced the need for pain medications following gastric banding surgery.

At least twenty controlled studies, enrolling more than fifteen hundred people,
have evaluated the potential benefit of hypnosis for people undergoing surgery.
Their combined results suggest that hypnosis may provide benefits both during and
after surgery, including reducing anxiety, pain, and nausea; normalizing blood
pressure and heart rate; minimizing blood loss; and speeding recovery and
shortening hospitalization. Many of these studies were of very poor quality,
however.

Relaxation
therapy techniques, such as meditation, guided imagery, and
self-hypnosis, have also shown promise for relieving some of the discomforts of
surgery. One study found minimal benefits with music therapy, however.

Herbs and Supplements to Use with Caution

Numerous herbs and supplements have the potential to cause problems during or after surgery, including some of those discussed here. For this reason, one should not use any herb or supplement in the week before surgery, except under a physician’s supervision.

For example, the herb garlic significantly thins the blood,
and case reports suggest that garlic can increase bleeding during or after
surgery. It is probably advisable to avoid garlic supplements before surgery and
not to restart the supplements after surgery until all risk of bleeding is past.
However, raw garlic consumed in food may not present the same risk. A
placebo-controlled study found that one-time consumption of raw garlic consumed in
food at the fairly high dose of 4.2 mg did not impair platelet function. Also,
volunteers who continued to consume the dietary garlic for one week did not show
any change in their normal platelet function.

The use of the herb ginkgo has also been associated with
serious bleeding complications related to surgery. Many other herbs and
supplements have also shown potential for increasing risk of bleeding. Most
prominent among these are high-dose vitamin E and policosanol. Others include
bromelain, chamomile, devil’s claw, dong quai, feverfew, fish oil, ginger, horse
chestnut, ipriflavone, mesoglycan, papaya, phosphatidylserine, red clover, reishi,
vitamin A, and white willow. In addition, one report suggests that the use of St.
John’s wort may interact with anesthetic drugs.

Bibliography

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Allen, T. K., and A. S. Habib. “P6 Stimulation for the Prevention of Nausea and Vomiting Associated with Cesarean Delivery Under Neuraxial Anesthesia.” Anesthesia and Analgesia 107 (2008): 1308-1312.

Bechtold, M. L., et al. “Effect of Music on Patients Undergoing Outpatient Colonoscopy.” World Journal of Gastroenterology 12 (2006): 7309-7312.

Cepeda, M. S., et al. “Static Magnetic Therapy Does Not Decrease Pain or Opioid Requirements.” Anesthesia and Analgesia 104 (2007): 290-294.

Chung, V. Q., et al. “Onion Extract Gel Versus Petrolatum Emollient on New Surgical Scars.” Dermatological Surgery 32 (2006): 193-198.

Habib, A. S., et al. “Transcutaneous Acupoint Electrical Stimulation with the ReliefBand for the Prevention of Nausea and Vomiting During and After Cesarean Delivery Under Spinal Anesthesia.” Anesthesia and Analgesia 102 (2006): 581-584.

Hedén, P., and A. A. Pilla. “Effects of Pulsed Electromagnetic Fields on Postoperative Pain: A Double-Blind Randomized Pilot Study in Breast Augmentation Patients.” Aesthetic Plastic Surgery 32 (2008): 660-666.

Kim, J. T., et al. “Treatment with Lavender Aromatherapy in the Post-Anesthesia Care Unit Reduces Opioid Requirements of Morbidly Obese Patients Undergoing Laparoscopic Adjustable Gastric Banding.” Obesity Surgery 17 (2007): 920-925.

Klaiman, P., et al. “Magnetic Acupressure for Management of Postoperative Nausea and Vomiting.” Minerva Anestesiologica 74 (2008): 635-642.

Lang, E. V., et al. “Beneficial Effects of Hypnosis and Adverse Effects of Empathic Attention During Percutaneous Tumor Treatment.” Journal of Vascular and Interventional Radiology 19 (2008): 897-905.

Lee, H., and E. Ernst. “Acupuncture Analgesia During Surgery.” Pain 114 (2005): 511-517.

Pfister, D. G., et al. “Acupuncture for Pain and Dysfunction After Neck Dissection.” Journal of Clinical Oncology 28 (2010): 2565-2570.

Scharbert, G., et al. “Garlic at Dietary Doses Does Not Impair Platelet Function.” Anesthesia and Analgesia 105 (2007): 1214-1218.

Tyler, T. F., et al. “The Effect of Creatine Supplementation on Strength Recovery After Anterior Cruciate Ligament (ACL) Reconstruction.” American Journal of Sports Medicine 32 (2004): 383-388.

Usichenko, T. I., et al. “Auricular Acupuncture for Pain Relief After Ambulatory Knee Surgery.” CMAJ: Canadian Medical Association Journal 176 (2007): 179-183.

Wang, S. M., et al. “Extra-1 Acupressure for Children Undergoing Anesthesia.” Anesthesia and Analgesia 107 (2008): 811-816.

In the poem "Faces" by Sara Teasdale, what is the meaning of "the city's broken roar"?

In Sara Teasdale’s poem “Faces” she uses the words “the city’s broken roar” to describe the background noise or din of a city. These words describe the sounds of a city, suggesting the noise is loud but not constant; it is chaotic and broken.

PEOPLE that I meet and pass

In the city's broken roar,

Faces that I lose so soon

And have never found before...

The narrator is describing the setting in which she sees strangers passing by on the noisy city streets. When their eyes meet, she feels like she is invading their privacy by seeing past their happy facades. As the city moves around her, she sees through other people’s eyes into their hearts and emotions. Their secrets and sorrows are revealed even though they try to hide their true feelings. The streets of the city are a metaphorical masquerade party. In the end, she questions if others can see the same in her eyes.

What is phlebitis?

Causes and Symptoms

Phlebitis, meaning the inflammation of a vein, is a general term used to describe the presence of blood clots, or thrombi, in the veins of the body outside the heart. Blood clots because of the formation of clotting agents, such as fibrin. When blood clots within the body, there are three principal factors involved: damage to the venous endothelium, the cells that form the lining of the vein; venous stasis, or failure of the blood to flow; and hypercoagulability, or an increase in clotting factors in the blood. These three features associated with phlebitic episodes—endothelial damage, stasis, and hypercoagulability—are referred to as Virchow’s triad (named for Rudolf Virchow, who in 1846 described the characteristics of thrombus formation in the deep veins of the lower extremities).

Patients with phlebitis will complain of swelling, tenderness, and inflammation of the affected limb. If the clot has formed in the veins just beneath the surface of the skin, they may feel a hard, cordlike structure in the segment of the vein that is filled with a thrombus. If the blood clot has not attached firmly to the wall of the vein, it may break loose and travel in the bloodstream to enter the vessels within the lung. These traveling clots are known as emboli and, depending on their size, they may either dissolve in the pulmonary vessels of the lung or block major vessels, preventing blood flow to that part of the lung. It has been shown that there is a greater risk of pulmonary embolism if the venous clots are formed in the leg veins above the knee than if phlebitis occurs in the calf veins.

To understand the factors that predispose the blood to clot within the body, it is necessary to understand the anatomy of the venous system and the mechanisms by which blood flows through the veins. Approximately 75 percent of the body’s blood is found in the venous system, which is divided into three parts: the superficial veins, the deep veins, and the perforating, or communicating, veins. The superficial veins of the extremities are large, thick-walled, muscular structures that lie just beneath the skin. The deep veins are thin-walled and less muscular than the superficial veins. In the extremities, these deep veins are named after the arteries that they accompany. Blood is transported from the superficial to the deep veins by the communicating veins, or perforators. Thin, leaflike, bicuspid valves are found in most veins of the body, even in venules as small as 0.15 millimeter in diameter. These valves can open readily to allow blood to pass as it moves from the superficial to the deep veins on its return trip to the heart and can close rapidly to prevent blood flow from moving in
the reverse direction. There are more valves in the veins of the calf than there are in the thigh veins, and no valves are found in the common iliac veins of the pelvis or in the inferior vena cava (the deep vein that transports blood through the abdomen).

The venous system must perform four important body functions. First, the veins must return blood that has been pumped through the arteries back to the heart. Additionally, the veins must be able to expand and contract so that they can regulate the increases and decreases in blood volume in the body. They must be responsive to the transport of blood during exercise and, along with the capillaries, play a major role in regulating body temperature.

Veins have the unique feature of being able to change their shape and size in order to respond to changes in pressure from within the vein (caused by increased fluid volume in the body) and to pressure from outside the vein (from tissue fluids and changes in pressure that occur as a result of gravity and the weight of the column of blood in the veins when one is standing or sitting up). As an example, when a hand is hanging at the side of the body, the veins on the back of the hand are full and visible because the veins are full of blood and the internal venous pressure is greater than the pressure from outside the vein. If the hand is raised over the head, the veins collapse because of the changes in internal venous pressure and gravitational and hydrostatic pressure, the pressures on the outside of the vein.

Blood is pumped under pressure by the heart to the arteries in order to supply
nutrients and oxygen to the tissues. In contrast, the heart has little influence on moving blood through the low-pressure veins of the body on its return trip. Blood is returned from the extremities to the heart and lungs by contraction of the calf muscles during exercise and by changes in the intra-abdominal and intrathoracic pressures that occur with respiration. For example, with a limb at rest, blood will flow toward the heart from the superficial system to the deep veins via the perforating veins as a result of the changes in abdominal and thoracic pressures that occur with breathing. With exercise, the calf muscles may exert more than 200 millimeters of mercury (mmHg) pressure on the large, saclike veins, the sinusoids in the sole, and the gastrocnemius veins of the calf, causing blood to move rapidly out of the foot and calf.

If the valves are incompetent such that the leaflets fail to meet when the valve closes, the column of forward-moving blood cannot be maintained in the segments of the veins between the valve sites. In this case, when one stops exercising, blood will flow backward toward the feet through the damaged valves, resulting in increased venous pressure at ankle level.

As one inhales, the diaphragm descends, compressing the inferior vena cava and stopping the flow of blood from the legs. With exhalation, the diaphragm rises and venous flow will continue toward the heart in a competent venous system. It is interesting that flow in the arms is under the control of intrathoracic, rather than intra-abdominal, pressure changes. Thus, with inhalation, the flow of blood from the arms increases as the pressure within the chest cavity is reduced. Upon exhalation, venous flow from the arms is impeded (which is in contrast to the respiratory effects that influence venous return from the legs).

As long as blood continues to circulate, the likelihood of clotting is reduced. There are, however, several risk factors that may cause changes in blood flow, damage to the vein wall, or hypercoagulability of the blood—the three features involved in venous thrombosis.

Venous thrombosis may occur as a result of obstructions to venous outflow from the limb. For example, taking a long trip by car, train, or airplane may require sitting for many hours without the freedom to walk around and exercise the calf muscles. Because the calf muscle pump is inactive, blood will pool in the veins of the legs. This failure of blood to flow, or venous stasis, places the individual at increased risk for clotting of blood in the calf veins. Similarly, patients who are prescribed bed rest because of accidents, pregnancy, or critical illnesses and those patients who undergo long surgical operations are at risk for forming thrombi in the leg veins because of venous stasis and, as a result of the thrombosis, are also at risk for pulmonary
embolism.

The incidence of phlebitis increases linearly with age. This fact is thought to reflect an increase in the diameter of the veins and the venous sinusoids within the calf muscles as a result of loss of elastic tissue in the vein walls. As the vein diameter increases, venous flow becomes sluggish. As an individual grows older, the muscle mass in the thigh and calf decreases and the calf muscle pump becomes less effective at moving venous blood toward the heart. This pooling of blood places elderly patients at risk for phlebitic episodes.

In the modern health care setting, the most common cause of phlebitis has been injury to the vein wall by intravenous catheters or by the infusion of drugs that cause inflammation of the venous endothelium. If a catheter is left in place for an extended period of time, infection may occur within the vein along its course, causing inflammation of the vein wall, venous stasis, and eventual thrombosis of the vein.

Inflammation of the vein may also occur as a result of venography, an invasive procedure used to determine if thrombi are present in the deep or superficial veins of patients. With this test, contrast dyes are injected into the veins to delineate the blood-flow patterns and venous anatomy and to define the segments of the vein where clots are present and are obstructing blood flow. Approximately 3 percent of patients have thrombi form in their veins following this diagnostic procedure. Approximately 8 percent of these patients will require hospitalization for treatment of postvenographic phlebitis.

Women who are taking oral contraceptives containing the hormone
estrogen are thought to be at increased risk for phlebitis because of the decrease in the muscular tone of the vein wall and subsequent decrease in velocity of blood flow in the veins that results from the use of these drugs. Estrogen compounds may increase the surface adhesiveness of platelets, the blood cells that are responsible for clotting, causing them to stick together and form large clots that can block the veins. Additionally, estrogen compounds may influence chemicals within the blood that affect its ability to clot. Specifically, it is thought that these hormonal compounds affect clotting factors II, VII, VIII, and X and also cause a decrease in antithrombin III, a chemical that influences the production of thrombin, the principal factor controlling the formation of thrombi.

The influence of estrogen on the body’s ability to control the production of appropriate levels of clotting factors is also noted during pregnancy and in the postpartum period. Phlebitis is diagnosed three to six times more frequently in women in the first four months following delivery than it is in women who have not become pregnant, as a result of estrogen-induced hypercoagulability of the blood. It is also interesting to note that women who deliver their babies by cesarean section are at increased risk for thrombophlebitis because of venous stasis occurring during the more prolonged recovery period that follows surgical delivery.

Treatment and Therapy

The symptoms of phlebitis—unilateral limb swelling, local inflammation, tenderness, and pain—may be associated with other medical conditions. Because there are no specific signs that are used to diagnose deep or superficial venous thrombosis, physicians misdiagnose phlebitis in approximately 50 percent of cases. As noted above, venography, once thought to be the standard for the identification of venous thrombosis, may actually predispose the patient to phlebitis. Noninvasive diagnostic techniques have been developed to demonstrate the presence, location, extent, and severity of the thrombotic process.

It has been shown that chemicals found naturally in the endothelial cells that line the veins can lyse, or dissolve, small clots. The veins of the calf have more lytic potential than the veins of the thigh and pelvis. In exercise, the compression of the calf muscles on the veins causes this material to be forced into the venous blood, thus helping to dissolve small thrombi.

Acute thrombosis of the deep veins above the knee usually requires hospitalization and infusion of heparin, a drug that prevents further clotting, allowing the body’s mechanism to dissolve clots to act more quickly and effectively. If left untreated, clots in this location may continue to propagate toward the large pelvic veins or the inferior vena cava, or pieces of a thrombus, called emboli, may break off the clot and travel through the vena cava to enter the pulmonary circulation of the lungs. In many cases, pulmonary embolism is life-threatening.

Patients with clots in the deep veins of the legs are instructed to stay in bed with the leg elevated to prevent venous pooling, and moist heat is applied to the leg to promote local circulation of blood. Patients will continue to take anticoagulant drugs for several months following hospitalization to ensure that fresh clots do not form in the veins, and they are instructed to wear elastic compression stockings to promote venous circulation.

It has been shown that clots will resolve completely in approximately 70 percent of patients receiving anticoagulant therapy. The remainder of patients will continue to have obstructions of their veins because of a clot that did not lyse, and as a result of the phlebitic episode, the venous valves will become incompetent. These patients will continue to be at risk for phlebitis and frequently express complaints of having tired, aching, heavy legs. If damage to the valves is severe, venous pressure at ankle level is increased, and blood may be forced out of the veins into the surrounding tissues, causing ulcers to form.

Thrombosis of the superficial veins, frequently called thrombophlebitis, is most often treated with hot compresses and elevation of the leg to relieve the local venous inflammation. Care must be taken to ensure that the clot does not continue to extend toward the segment of superficial vein where it joins the deep venous system, because the patient would then be at risk for pulmonary embolism.

Attempts have been made to bypass segments of a thrombosed vein surgically and to transplant new valves in venous segments that have become incompetent as a result of postphlebitic valve damage. Such procedures, however, have been unrewarding. Anticoagulant and lytic therapies begun early in the thrombotic process appear to offer the best results with the least long-term sequelae for phlebitic patients.

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

Furtado, Luís Carlos do Rego. "Incidence and Predisposing Factors of Phlebitis in a Surgery Department." British Journal of Nursing (July 28, 2011): S16–25.

Icon Health. Phlebitis: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. San Diego, Calif.: Author, 2004.

Kohnle, Diana. "Phlebitis." Health Library, September 26, 2012.

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

Loscalzo, Joseph, and Andrew I. Schafer, eds. Thrombosis and Hemorrhage. 3d ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

Rutherford, Robert B., ed. Vascular Surgery. 6th ed. Philadelphia: Saunders/Elsevier, 2005.

"Thrombophlebitis." MedlinePlus, May 6, 2011.

What are some important things Mathilde said in "The Necklace"?

Mathilde complains about her level of wealth and says she needs better clothes for the ball.

Mathilde’s husband seems to accept their lot in life, and their economic status. Mathilde wants more. She feels as if she was born into the wrong life, and she should never have been of such low status as to marry a clerk. She was meant for wealth and happiness.

When Monsieur Loisel brings his wife tickets to a fancy ball, he expects her to be thrilled. Instead, she reacts petulantly. She immediately begins crying about her wardrobe. Surprised, he asks her what is the matter.

"Nothing. Only I have no gown, and, therefore, I can't go to this ball. Give your card to some colleague whose wife is better equipped than I am."

Instead of being happy that her husband acquired tickets to such a spectacular affair, she complains and forces him to give up all of his savings to buy her a dress. Then she is still not happy, telling him that she needs a jewel to wear with it too. He tells her flowers are in fashion, but she will not accept that.

"No; there's nothing more humiliating than to look poor among other women who are rich."

He suggests she borrow one from her friend, and she is happy with that suggestion. Madame Loisel goes to her friend Madame Forestier. They went to school together, but Madame Forestier is wealthy and of higher status. She gladly consents to lend Mathilde a jewel, and makes some suggestions. Mathilde instead chooses what she thinks is a big diamond.

Mathilde loses the necklace. Instead of telling her friend, she and her husband decide to buy another one to replace it. Years later, Madame Forestier does not recognize her friend. Mathilde explains what happened.

"I brought you back another exactly like it. And it has taken us ten years to pay for it. You can understand that it was not easy for us, for us who had nothing. At last it is ended, and I am very glad."

At this point, the irony of the situation sets in. Madame Forestier tells Mathilde that the necklace was fake. She has spent the last ten years of her life paying back a debt she never really incurred. If she had just told the truth, she would have still had her beauty and her modest but comfortable life.

What is salmonella?

Definition

Salmonella are gram-negative, motile, non-spore-forming,
nonencapsulated, facultative-anaerobic rods that cause several diseases, primarily
enteric (intestinal), in humans and other animals.

Natural Habitat and Features

The genus Salmonella was named for Daniel E. Salmon, an American veterinary pathologist and bacteriologist. The type strain, originally named S. choleraesuis, was discovered by Salmon’s research associate, Theobald Smith. The genus is closely related to Escherichia coli (E. coli) and was initially subdivided into hundreds of species named for the diseases it caused and for the host organism: for example, S. typhi (typhoid fever), S. enteritidis (gastroenteritis), S. typhimurium (mouse typhoid), and S. choleraesuis (hog cholera).

After further genetic testing and after scientists determined that most Salmonella spp. are not very host specific, most of the original species were combined into a single species, S. enterica. This species was then divided into five subspecies and more than two thousand strains or serovars; for example, S. enterica subsp. enterica serovar Typhi has replaced S. typhi, S. enterica subsp. enterica serovar Enteritidis has replaced S. enteritidis, and S. enterica subsp. arizonae has replaced S. arizonae. Only S. bongori was deemed distinct enough to stand alone as a different species. The older designations are still frequently used in both professional journals and the popular press.

Pathogenicity and Clinical Significance

According to the Centers for Disease Control and Prevention (CDC) in 2015, 2,500 different strains (serotypes) of Salmonella had been identified, with fewer than 100 responsible for most human disease. S. enterica subsp. enterica contains the majority of disease-causing strains. Salmonellosis is the second most common cause of gastroenteritis, surpassed only by Campylobacter spp. infections. Infections caused by Salmonella spp. are considered zoonotic because many strains of this bacterium can be transferred from humans to animals and from animals to humans.

Most cases of salmonellosis are the result of fecal to oral contamination caused by ingestion of fecal-contaminated food. Because Salmonella spp. are so widespread and can survive several weeks in water or on vegetation and more than two years in soil, transmission is relatively easy. For example, during butchering and processing, raw meats can become contaminated with the intestinal contents of the butchered animals. Shellfish are easily contaminated when raw sewage makes its way into aquatic habitats. An infected chicken can deposit Salmonella into her eggs before shell deposition or on the shell as the egg is laid. Irrigating or washing crop plants in water contaminated by Salmonella can contaminate the crops. Food preparers with poor hygiene can also contaminate food.

After a multistate outbreak of Salmonella Heidelberg that involved more than six hundred Americans was sourced to chicken parts that had been packaged by Foster Farms, the US Department of Agriculture's Food and Safety Inspection Service (FSIS) determined that regulations and standards needed to be set for individual chicken parts as well as whole chickens. In 2015, the FSIS proposed the new standards designed to decrease consumer exposure to Salmonella in all chicken products.

In addition to food contamination, pets, especially birds, reptiles, and amphibians, can harbor Salmonella, which can easily be transferred from their cloacae to their feathers or skin.

The best way to prevent salmonellosis is to always wash one’s hands after using the toilet, handling raw meat, cleaning up feces, and handling a bird, reptile, or amphibian. In addition, cooking all food to an internal temperature of 167° Fahrenheit (75° Celsius) and boiling water for a minimum of one minute kills Salmonella. Freezing, however, will usually not kill all Salmonella in contaminated food or water. Cutting boards used for raw meat should also be cleaned thoroughly, preferably with bleach.

In humans, one of the most serious forms of salmonellosis is typhoid fever caused by S. enterica sub. enterica serovar Typhi, also called S. typhi. This bacterium is highly adaptable and can produce stress-related proteins that allow the bacterium to survive better under environmental stresses (such as increased temperatures, acidic conditions, and the presence of antibiotics). Unlike many Salmonella strains, this bacterium has only one animal reservoir: humans. It is usually transmitted through contaminated water and undercooked, contaminated food. Because of this, it causes most problems in developing countries with poor sanitation.

S. typhi can also be transmitted by food-service workers who were previously infected. About 5 percent of all persons who had typhoid fever retain infective bacteria and can pass these along. In the United States, food service workers who have had typhoid fever are required to be free of the typhoid bacterium (as measured by fecal swabs) before they can return to work.

Diarrhea is the most common symptom of salmonellosis, but bacteria can enter
the intestinal epithelium and migrate to other areas of the body, causing fever,
headache, rose-colored spots on the upper chest, and organ inflammation. Humans
heterozygous for cystic fibrosis may have lowered susceptibility to typhoid
fever because the changes in the cell membrane of heterozygotes decrease the
likelihood of bacterial invasion.

As of 2013, the CDC reported that approximately 5,700 cases of typhoid fever occur in the United States each year, and most of these cases are contracted outside the country. Also according to the CDC, in the developing world, nearly twenty-two million cases of typhoid are seen each year. Most typhoid deaths are caused by dehydration, so rehydration therapy is critical in treating this or any other salmonellosis.

Drug Susceptibility

Bacterial strains resistant to ampicillin, chloramphenicol, trimethoprim/sulfamethoxazole, and streptomycin are so common that these antibiotics are no longer used. Ciprofloxacin is the drug of choice, but strains resistant to it are on the rise. Cephtriaxone and cephotaxime are being used more often, especially in areas with multiple resistance. Both oral and injectable vaccines are available, but these are only 50 to 70 percent effective. A very similar, but less common disease is paratyphoid fever, which is caused by the Paratyphoid serovar.

S. enterica serovar Enteritidis is the most frequent cause of Salmonella gastroenteritis in humans. Many other serovars can also cause gastroenteritis. The most common symptoms are diarrhea, abdominal cramps, and nausea. Unlike typhoid fever, gastroenteritis in healthy persons rarely lasts more than one week, although in rare cases it can become systemic. It is usually treated with rehydration therapy and is not always treated with antibiotics unless it is severe.

Bibliography

Braden, Christopher R. “ Salmonella enterica Serotype Enteritidis and Eggs: A National Epidemic in the United States.” Clinical Infectious Diseases 43 (2006): 512–17. Print.

Garrity, George M., ed. Bergey’s Manual of Systematic Bacteriology. 2nd ed. Vol 2. New York: Springer, 2005. Print.

Madigan, Michael T., and John M. Martinko. Brock Biology of Microorganisms. 12th ed. Upper Saddle River: Pearson, 2010. Print.

Romich, Janet A. Understanding Zoonotic Diseases. Clifton Park: Thomson, 2008. Print.

"Typhoid Fever." Centers for Disease Control and Prevention. US Dept. of Health and Human Services, 14 May 2013. Web. 31 Dec. 2015.

"USDA Proposes New Measures to Reduce Salmonella and Campylobacter in Poultry Products." United States Department of Agriculture. USDA, 21 Jan. 2015. Web. 31 Dec. 2015.