What does the following quote from Golding's Lord of the Flies say about Jack? Why does he do this?"Jack snatched from behind him a sizable...

Jack’s gesture with the knife demonstrates both his violence and his tendency for dramatic gestures.  All the boys are doing is exploring the island.  There is no need for any of this.  However, Jack wants to make sure that he remains the center of attention.

While Ralph approaches the task at hand, exploring the island, with systematic and businesslike dullness, Jack treats it like an adventure.  He isn’t interested in the practical.  Just as he...

Jack’s gesture with the knife demonstrates both his violence and his tendency for dramatic gestures.  All the boys are doing is exploring the island.  There is no need for any of this.  However, Jack wants to make sure that he remains the center of attention.

While Ralph approaches the task at hand, exploring the island, with systematic and businesslike dullness, Jack treats it like an adventure.  He isn’t interested in the practical.  Just as he wanted to be in charge before just so he could punish rule-breakers, he wants to make exploring the island into something theatrical.

“Come on,” said Jack presently, “we’re explorers.”

“We’ll go to the end of the island,” said Ralph, “and look round the corner.”

“If it is an island—” (Ch. 1)

Jack has been designated leader of the hunters because of his practical leadership experience, and he takes charge of the small group of explorers who are checking out the island.

“We’ll try climbing the mountain from here,” he said. “I should think this is the easiest way. There’s less of that jungly stuff; and more pink rock. Come on.” (Ch. 1)

As they are looking around, Jack comments that they are doing "real exploring" and is excited that no one else is on the island and it doesn't seem to have had visitors or inhabitants before.  While Ralph is concerned about drawing maps and worried about whether or not they will be rescued, Jack is enjoying the adventure.

When they come across a pig, Jack draws his knife again "with a flourish."  This time there is a practical reason, but he is unable to actually get the pig "because of the enormity of the knife descending and cutting into living flesh."  It turns out that Jack is really just all bluster, without practical usefulness to back up his knife-flourishing skills.

What are natural treatments for the prevention of hearing loss?

Introduction

There are many possible causes of hearing loss, ranging from wax in the
ear canal to problems with the nerves that receive sound and transmit it to the
brain. Two of the most common causes are age-related hearing loss (presbycusis)
and noise-induced hearing loss. The treatment for hearing loss depends on its
cause, and for this reason, one should consult a doctor. This article discusses a
few herbs and supplements that have shown promise for various forms of hearing
loss.

Principal Proposed Natural Treatments

Two natural treatments have been evaluated in double-blind, placebo-controlled trials for the prevention or treatment of hearing loss: magnesium and Ginkgo biloba.

Magnesium for preventing noise-induced hearing loss. Long-term
exposure to loud sounds, such as gunfire or rock music, can cause permanent
hearing loss. A two-month, double-blind, placebo-controlled study of three hundred
military recruits found daily supplementation with magnesium
helped protect the ear from noise-induced damage. The dosage used in this study
was quite small–only 167 milligrams (mg) of magnesium daily–but tests showed that
even this amount was sufficient to raise magnesium levels inside cells and
apparently protect the ear from damage. Soldiers who received the magnesium were
less likely to experience permanent hearing damage than those in the placebo
group, and when they did experience hearing damage, it was less severe.

It is not clear how magnesium might protect hearing. Studies in animals suggest that magnesium deficiency can increase the stress on cells involved with hearing and thereby make them more susceptible to damage caused by intense noise. However, human magnesium deficiency is believed to be rare, so it is possible that supplemental magnesium acts in some entirely different way.

Only the use of noise-reduction devices (such as headsets that block sound) has been proven effective for preventing noise-induced hearing loss, and the forgoing study does not indicate that magnesium supplements can replace this effective approach. However, the study suggests that a safe, low dose of magnesium may add an additional level of protection.

Ginkgo for treating sudden hearing loss. Some people develop hearing loss suddenly, usually in one ear. This condition is called unilateral idiopathic sudden hearing loss. Its cause is unknown, but problems with circulation may play a role in some cases. The herb Ginkgo biloba is thought to increase circulation, and for this reason it has been tried as a treatment for this condition.

In a double-blind, placebo-controlled trial, 106 participants with a carefully
defined form of sudden hearing loss were given either a full dose of
ginkgo extract (120 milligrams [mg] twice daily) or a low
dose of the herb (12 mg twice daily). The lower dose was chosen in the belief that
it could not possibly offer any benefit and would therefore serve as placebo.
However, researchers were surprised to find that most participants in each group
recovered by the end of the eight-week trial. There are two possibilities to
explain this: low-dose ginkgo is effective, or many people with sudden hearing
loss recover on their own anyway.

Because both groups improved to such a great extent, the overall results of the trial did not prove ginkgo effective. An exploratory look at the data provided some hints that high-dose ginkgo may have helped ensure full recovery, but for statistical reasons these hints cannot be taken as proof.

Another double-blind study compared ginkgo to pentoxifylline, a circulation-enhancing drug used in Germany
for the treatment of sudden hearing loss. The results indicate that ginkgo was at
least as effective as the medication. However, because pentoxifylline itself is
not a proven treatment for this condition, the results prove little. Additional
research will be necessary to discover whether ginkgo is actually effective for
sudden hearing loss

Other Proposed Natural Treatments

A study in animals suggests that the supplement lipoic acid
might help prevent age-related hearing loss. Another animal study suggests that
melatonin may help prevent hearing loss induced by noise.

Free
radicals are naturally occurring substances that cause damage
to many parts of the body, including the ear. Antioxidants
are substances that fight free radicals. Antioxidant supplements have shown
promise for preventing various forms of hearing loss, including age-related
hearing loss and hearing damage caused by medications. Commonly used antioxidants
include citrus bioflavonoids, coenzyme Q10, lipoic acid, lutein,
lycopene, oligomeric proanthocyanidins, vitamin C, and vitamin E.

Other natural treatments sometimes used for various forms of hearing loss, but which lack meaningful scientific support, include folate, manganese, myrrh, potassium, zinc, and vitamins B1, B2, B6, and B12.

Bibliography

Blakley, B. W., et al. “Strategies for Prevention of Toxicity Caused by Platinum-Based Chemotherapy.” Laryngoscope 112 (2002): 1997-2001.

Burschka, M. A., et al. “Effect of Treatment with Ginkgo biloba Extract EGb 761 (Oral) on Unilateral Idiopathic Sudden Hearing Loss in a Prospective Randomized Double-Blind Study of 106 Outpatients.” European Archives of Oto-Rhino-Laryngology 258 (2001): 213-219.

Henderson, D., et al. “The Role of Antioxidants in Protection from Impulse Noise.” Annals of the New York Academy of Sciences 884 (November 28, 1999): 368-380.

Karlidag, T., et al. “The Role of Free Oxygen Radicals in Noise Induced Hearing Loss: Effects of Melatonin and Methylprednisolone.” Auris Nasus Larynx 29 (2002): 147-152.

Reisser, C. H., and H. Weidauer. “Ginkgo biloba Extract EGb 761W or Pentoxifylline for the Treatment of Sudden Deafness.” Acta Otolaryngologica 121 (2001): 579-584.

Seidman, M. D. “Effects of Dietary Restriction and Antioxidants on Presbyacusis.” Laryngoscope 110 (2000): 727-738.

_______, et al. “Biologic Activity of Mitochondrial Metabolites on Aging and Age-Related Hearing Loss.” American Journal of Otolaryngology 21 (2000): 161-167.

What is emotional intelligence (EI)?

Introduction

The concept of emotional intelligence is relatively new to the field of psychology. The ideas and concepts that are now referred to as emotional intelligence first came to be in the 1980s, when Howard E. Gardner first proposed his theory of multiple intelligences. The term “emotional intelligence” was introduced by Peter Salovey and John Mayer in a 1990 research paper. In 1995, the publication of Daniel Goleman’s Emotional Intelligence: Why It Can Matter More Than IQ popularized the concept. Three common models of emotional intelligence have been developed: the ability-based model (Mayer and Salovey’s four-branch model based on emotional skills and abilities), the mixed model (Goleman’s model based on skills and competencies), and the trait model (based on personality traits). Because of the differences that exist among the three models and because the field is growing at such a rapid pace, a standardized definition of emotional intelligence has yet to emerge. Although not agreed on by researchers in the field, two common definitions of emotional intelligence are the ability to monitor the feelings and emotions of the self and of others and to use this information to guide one’s behaviors, and the ability to identify and control emotions in oneself and in others.

Measurement and Assessment

Several tools have been developed to assess emotional intelligence. The two most prominent tools are theMayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Emotional Competence Inventory (ECI). The MSCEIT is a self-report test, consisting of 141 items based on the four-branch abilities model of emotional intelligence. It measures abilities on each of the four branches, then computes a separate score for each branch and an overall emotional intelligence score. The test includes eight tasks that measure the four branches of emotional intelligence as defined by Mayer, Salovey, and David R. Caruso. These four branches of abilities, listed from most basic to most complex, are as follows: perceive emotions, use emotions to facilitate thought, understand emotions, and manage emotions. The ECI is based on Goleman’s mixed model of emotional intelligence. It is a 360-degree survey that assesses emotional intelligence (EI) by asking the person and multiple raters to answer questions about the person’s behavior. The test measures eighteen competencies that fall under the four dimensions of emotional intelligence as identified by the mixed model approach. The four dimensions are self-awareness, self-management, social awareness, and relationship management. The competencies measured in the ECI are said to be learned capabilities, and because of this, individuals can work on and further develop each of the four emotional intelligence dimensions.

Training and Application

Since its inception, the concept of emotional intelligence has been used in a wide variety of contexts to help people live more successfully. Although some of the first contexts in which emotional intelligence was used focused on worker productivity and satisfaction, the concept has since been applied successfully in a broad range of areas.

One of the areas in which emotional intelligence has proven to be very helpful is in relationship training. Emotional intelligence, by its nature, has a strong focus on empathy and on understanding the ways in which emotions influence people. When people are able to combine a sense of how their own emotions can guide or derail them with a developed awareness of how others feel, they are equipped to navigate the complexities of relationships across many situations. Emotional intelligence has also been applied in structuring educational settings for students, teachers, and parents. Curricula have been designed that incorporate appropriate emotional modeling, helping children regulate their emotions and connecting emotional experience to learning. Training children in the classroom in social and emotional skills has been shown to increase academic performance by 11 percentile points and to reduce conduct problems and aggression by 9 percent.

Emotional intelligence has also been widely used in skills training for supervisors and managers. In one randomized, controlled study with corporate executives, people who received training in emotional intelligence competencies were superior to the no-intervention control group in measures of social awareness, relationship management, self-management, and self-awareness, as reported by bosses, peers, and employees.

Bibliography

Cherniss, Cary, and Mitchel Adler. Promoting Emotional Intelligence in Organizations. Alexandria, Va.: American Society and Training and Development, 2000. Print.

Goleman, Daniel, Zenobia Barlow, and Lisa Bennett. Ecoliterate: How Educators are Cultivating Emotional, Social, and Ecological Intelligence. San Francisco: Jossey-Bass, 2012. Print.

Goleman, Daniel. Emotional Intelligence: Why It Can Matter More than IQ. New York: Bantam Books, 1995. Print.

Goleman, Daniel, Richard E. Boyatzis, and Annie McKee. Primal Leadership: Unleashing the Power of Emotional Intelligence. 10th ed. Boston: Harvard Business Review, 2013. Print.

Matthews, Gerald, Moshe Zeidner, and Richard D. Roberts. Emotional Intelligence 101. New York: Springer, 2012. Print.

Mayer, John D., Peter Salovey, and Marc A. Brackett. Emotional Intelligence: Key Reading on the Mayer and Salovey Model. Port Chester, N.Y.: Dude, 2004. Print.

Murphy, Kevin R., ed. A Critique of Emotional Intelligence: What Are the Problems and How Can They Be Fixed? Mahwah, N.J.: Lawrence Erlbaum, 2006. Print.

Zeidner, Moshe, Gerald Matthews, and Richard D. Roberts. What We Know About Emotional Intelligence: How It Affects Learning, Work, Relationships, and Our Mental Health. Cambridge, Mass.: MIT Press, 2009. Print.

What is lateral gene transfer?

Gene Transfer in Prokaryotes

The fact that genes may move between bacteria has been known since the experiments of Frederick Griffith with pneumonia-causing bacteria in the 1920’s. Griffith discovered the process of bacterial transformation, by which the organism acquires genetic material from its environment and expresses the traits contained on the DNA in its own cells. Bacteria may also acquire foreign genetic material by the process of transduction. In transduction a bacteriophage picks up a piece of host DNA from one cell and delivers it to another cell, where it integrates into the genome. This material may then be expressed in the same manner as any of the other of the host’s genes. A third mechanism,
conjugation, allows two bacteria that are connected by means of a cytoplasmic bridge to exchange genetic information.

With the development of molecular biology, evidence has accumulated that supports the lateral movement of genes between prokaryotic species. In the case of Escherichia coli, one of the most heavily researched bacteria on the planet, there is evidence that as much as 20 percent of the organism’s approximately 4,403 genes may have been transferred laterally into the species from other bacteria. This may explain the ability of E. coli, and indeed many other prokaryotic species, to adapt to new environments. It may also explain why, in a given bacterial genus, some members are pathogenic while others are not. Rather than evolving pathogenic traits, bacteria may have acquired genetic sequences from other organisms and then exploited their new abilities.

It is also now possible to screen the genomes of bacteria for similarities in genetic sequences and use this information to reassess previously established phylogenetic relationships. Once again, the majority of this work has been done in prokaryotic organisms, with the primary focus being on the relationship between the domains Archaea
and Bacteria. Several researchers have detected evidence of lateral gene transfer between thermophilic bacteria
and Archaea prokaryotes. Although the degree of gene transfer between these domains is under contention, there is widespread agreement that the transfer of genes occurred early in their evolutionary history. The fact that there
was lateral gene transfer has complicated accurate determinations of divergence time and order.

Gene Transfer in Eukaryotes

Although not as common as in prokaryotes, there is evidence of gene transfer in eukaryotic organisms as well. A mechanism by which gene transfer may be possible is the transposon. Barbara McClintock first proposed the existence of transposons, or mobile genetic elements, in 1948. One of the first examples of a transposon moving laterally between species was discovered in Drosophila in the 1950’s. A form of transposon called a P element was found to have moved from D. willistoni to D. melanogaster. What is interesting about these studies is that the movement of the P element was enabled by a parasitic mite common to the two species. This suggests that
parasites may play an important role in lateral gene transfer, especially in higher organisms. Furthermore, since the transposon may move parts of the host genome during transition, it may play a crucial role in gene transfer.

The completion of the Human Genome Project, and the technological advances in genomic processing that it developed, have allowed researchers to compare the human genome with the genomes of other organisms to look for evidence of lateral transfer. It is estimated that between 113 and 223 human genes may not be the result of vertical gene transfer but instead might have been introduced laterally from bacteria.

Implications

While the concept of lateral gene transfer may initially seem to be a concern only for evolutionary geneticists in their construction of phylogenetic trees, in reality the effects of lateral gene transfer pose concerns with regard to both medicine and agriculture, specifically in the case of transgenic plants.

Currently the biggest concern regarding lateral gene transfer is the unintentional movement of genes from genetically modified organisms (GMOs) into other plant species. Such transfer may occur by parasites, as appears to have occurred with Drosophila
in animals, or by dispersal of pollen grains out of the treated field. This second possibility holds particular significance for corn growers, whose crop is wind-pollinated. Genetically modified corn, containing the microbial insecticide Bt, may cross-pollinate with unintentional species, reducing the effectiveness of pest management strategies. In another case, the movement of herbicide-resistant genes
from a GMO to a weed species may result in the formation of a superweed.

On the beneficial side, lateral gene transfer may also play a part in medicine as part of gene therapy. A number of researchers are examining the possibility of using viruses, transposons, and other systems to move genes, or parts of genes, into target cells in the human body, where they may be therapeutic in treating diseases and disorders.

Key terms



gene transfer

:

the movement of fragments of genetic information, whole genes, or groups of genes between organisms




genetically modified organism (GMO)

:

an organism produced by using biotechnology to introduce a new gene or genes, or new regulatory sequences for genes, into it for the purpose of giving the organism a new trait, usually to adapt the organism to a new environment, provide resistance to pest species, or enable the production of new products from the organism




transposons

:

mobile genetic elements that may be responsible for the movement of genetic material between unrelated organisms





Bibliography

Bushman, Frederick. Lateral Gene Transfer: Mechanisms and Consequences. Cold Spring Harbor, N.Y.: Cold Spring Harbor Laboratory Press, 2001. Examines the ability of genes to move between organisms and its implications for the development of antibiotic resistance, cancer, and evolutionary pathways, including those of humans.

Gogarten, Maria B., Johann Peter Gogarten, and Lorraine C. Olendzenski, eds. Horizontal Gene Transfer: Genomes in Flux. New York: Springer, 2009. Collection of articles by researchers who provide an overview of horizontal gene transfer (HGT) concepts and specific case histories. Begins with an overview of terminology, concepts, and the implications of HGT on evolutionary thought and philosophy, followed by a discussion of molecular biology techniques for identifying, quantifying, and differentiating instances, and concluding with a section of case studies.

Hensel, Michael, and Herbert Schmidt, eds. Horizontal Gene Transfer in the Evolution of Pathogenesis. New York: Cambridge University Press, 2008. An overview of current knowledge relating to the evolution of microbial pathogenicity that focuses on the rearrangements of the genome resulting from horizontal gene transfer. Aimed at graduate students and researchers.

Rissler, Jane, and Margaret Mellon. The Ecological Risks of Engineered Crops. Cambridge, Mass.: MIT Press, 1996. Introduces the reader to the concept of transgenic crops and then discusses the potential environmental risks of gene flow between genetically modified organisms and nontarget species of plants. Suggests mechanisms of regulation to inhibit environmental risk.

Syvanen, Michael, and Clarence Kado. Horizontal Gene Transfer. 2d ed. Burlington, Mass.: Academic Press, 2002. Examines the process of gene transfer from an advanced perspective. Discusses the relationship between gene transfer and phylogenetic analysis, evolutionary theory, and taxonomy.

Are any of the characters in "A Midsummer Night's Dream" really changed by their experiences?

Though there are many magical transformations in the play, which changes stick? The four lovers’ circumstances change for the better. Hermia and Helena fight, but, in the end, the two marry their lovers. The love potion administered by Puck seems to have stuck in Demetrius’s eye. He appears to undergo a more permanent change than the others, claiming that he has been restored to health, preferring Helena to Hermia:

But, like in sickness, did I...

Though there are many magical transformations in the play, which changes stick? The four lovers’ circumstances change for the better. Hermia and Helena fight, but, in the end, the two marry their lovers. The love potion administered by Puck seems to have stuck in Demetrius’s eye. He appears to undergo a more permanent change than the others, claiming that he has been restored to health, preferring Helena to Hermia:

But, like in sickness, did I loathe this food;
But, as in health, come to my natural taste,
Now I do wish it, love it, long for it,
And will for evermore be true to it.

Helena says, “I have found Demetrius like a jewel, / Mine own, and not mine own.” Now that Demetrius shows no interest in Hermia, Theseus overrules her father’s wishes and allows Hermia to marry Lysander. Theseus’s impending nuptials, or a more magical force, might cause him to inexplicably change his mind.

The fairy queen Titania’s circumstances change, though not necessarily for the better. As far as we know, Oberon takes the child Titania swore to keep, and Puck humiliates her by making her fall in love with the donkey-headed Bottom. A positive development comes from Oberon and Titania’s reunion. Their quarrels had caused a disorder in the natural world, which Titania describes as a “progeny of evils.” They can now bring harmony to the earth and bless the many couples that marry at the end of the play.

Bottom physically transforms more than anyone, briefly gaining the head of an ass and frolicking with the fairies. However, does his personality alter? Though he is amazed by his “dream,” Bottom shows his usual hubris by planning to sing a ballad describing his dream at the end of his performance before the duke. Thus, everyone’s experiences drastically change their lives, but they do not always alter their personalities and motivations.

What does the term "special needs" mean?

The term special needs refers to individuals who require assistance for an array of disabilities or developmental delays in behavioral, cognitive, emotional, physical, scholastic, or social skills. These disabilities can affect many aspects of people's lives, such as how they behavior in certain situations, develop physically and mentally, interact with others, learn, and take care of themselves. Individuals with special needs typically require some type of specialized care, including medication, therapy, social skills instruction, assisted living, or special education. Many can manage their care on their own, but some require assistance with certain aspects of their lives.

According to the U.S. Census Bureau in 2010, 19 percent of the U.S. population had a disability that impacted daily living. Many governmental and nongovernmental organizations exist to provide services and programs for those with disabilities. The United States has several laws in place to protect the rights of those with special needs.

Types of Special Needs

Special needs can be classified as physical or mental disabilities. People with special needs can have more than one disability. For instance, a blind person can also have bipolar disorder.

Physical Disabilities

Physical disabilities affect a person physically or medically. They can affect a person's ability to move or function normally. The following are examples of physical disabilities:

• Blindness, or visual impairment: This affects a person's ability to see.




• 
  Chronic illnesses: These can affect an individual's ability to perform everyday activities. Examples include allergies, arthritis, asthma, diabetes, and epilepsy.




• 
  Congenital disorders: These occur at birth. Examples include deformities of limbs, missing limbs, cleft lip, clubfoot, and spine disorders.




• Deafness, or hearing impairment: This affects a person's ability to hear.




• Orthopedic, or movement impediments: These affect a person's ability to move. They can be caused by congenital anomalies, disease or illness, accidents, or other conditions such as cerebral palsy.




• Traumatic brain injury (TBI): This is an injury to the brain usually caused by external forces, such as a severe blow to the head. This physical condition can impair not only motor abilities but also cognitive functions such as the ability to think, speak, remember, and solve problems. TBI can also affect psychosocial behaviors.

Mental Disabilities

Mental disabilities affect behavior, cognitive skills, emotions, learning, and social interactions. The following are examples of mental disabilities:

• Autism spectrum disorder (ASD): This affects verbal and nonverbal communication skills and social interaction.




• Bipolar disorder: This causes an individual to suffer from lows and highs such as periods of depression followed by periods of mania.




• Depression: This causes a person severe sadness and feelings of hopelessness usually affecting activities once enjoyed.




• Dementia, including Alzheimer's disease: This affects the aging population and usually alters mental function and behavior.




• Down syndrome: This genetic condition causes individuals to have a lower than normal intelligence, which can result in other mental and physical disabilities.




• 
  Learning disorders: These affect a person's ability to think, speak, and learn and can affect social skills. Examples include dysgraphia (writing difficulties), dyslexia (reading difficulties), and dyscalculia (arithmetic difficulties).




• Manias: These conditions affect a person's behavior in extreme ways and can cause impulsive behaviors. Examples include pyromania, or the impulse to start fires.




• 
  Phobias: People with phobias attach unnatural fear to certain objects or situations. People who have arachnophobia are afraid of spiders.




• Schizophrenia: This affects people's thought processes and ability to function normally. They may experience delusions or hallucinations, situations that they believe are true but are not real, and exhibit strange behavior.

Americans with Disabilities Act

The U.S. government in 1990 signed the Americans with Disabilities Act (ADA) to protect those with special needs against discrimination in public and private spaces such as work, school, transportation, and more. The law is divided into five parts. The first part deals with employment and states that employers must provide the same opportunities and benefits to individuals with special needs as those without disabilities. The law also says that employers must provide accommodations to disabled individuals, as long as the accommodations do not impose a financial hardship to the employer.

The next section targets state and local government services. It maintains that both types of government services and activities must be accessible for those with special needs. The third part deals with public and private places. These must ensure that commercial facilities can be accessed by those with disabilities. This includes communicating with people who have vision, hearing, and speech disabilities.

The fourth section is for telephone and Internet companies. They must provide services such as telecommunications relay services and closed captioning to those with hearing, speech, and visual disabilities. The last part deals with topics not already covered by the ADA such as state immunity, retaliation, attorneys' fees, relationship to other laws, and more.

Individuals with Disabilities Education Act

In the United States, the Individuals with Disabilities Education Act (IDEA) protects the educational rights of students with disabilities. It ensures students receive
special education
, the instruction and support provided to students with disabilities. IDEA mandates that all U.S. public schools provide special education services with specific guidelines to ensure students with special needs receive an education on par with that of their peers.

Until 1975, many children with special needs did not have access to an education. Congress enacted the Education for All Handicapped Children Act (EHA) to ensure children with disabilities received a free public education equal to that of their peers. Schools received federal funding to evaluate students and develop learning programs for them. Under EHA, parents also received support services from schools. Over the years, more services were added to ensure students received transition care after school ended. The act's name was later changed to the Individuals with Disabilities Education Act.

Bibliography

"Categories of Disability Under IDEA." Center for Parent Information and Resources. Center for Parent Information and Resources. Web. 18 Mar. 2015. http://www.parentcenterhub.org/repository/categories/

"The History of Special Education." Teach.com. Teach.com. Web. 18 Mar. 2015. http://teach.com/the-history-of-special-education

Kelly, Evelyn. "Disabilities." Diseases and Disorders, Vol. 1. Tarrytown: Marshall Cavendish, 2008. Print.

"Nearly 1 in 5 People Have a Disability in the U.S., Census Bureau Reports." U.S. Census Bureau. U.S. Census Bureau. 25 July 2012. Web. 18 Mar. 2015. https://www.census.gov/newsroom/releases/archives/miscellaneous/cb12-134.html

Parsons, Jacqueline P. "Special Needs." Encyclopedia of Child Behavior and Development, Vol. 3. Ed. Sam Goldstein and Jack A. Naglieri. New York: Springer, 2011. 1422–23. Print.

"Types of Disabilities." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Web. 18 Mar. 2015. http://www.cdc.gov/ncbddd/disabilityandhealth/types.html

"What Is the Americans with Disabilities Act (ADA)." ADA National Network. U.S. Department of Education, National Institute on Disability and Rehabilitation Research. Web. 18 Mar. 2015. https://adata.org/learn-about-ada

In the novel To Kill a Mockingbird, could Boo Radley be considered the loneliest character in the novel. If so, why?

One could make the argument that Boo Radley is the loneliest character in the novel for several reasons. After Boo saves the children from Bob Ewell, Sheriff Tate says that he refuses to let the community know about Boo's heroism because the extra attention would seem harmful to Boo. Scout then walks Boo home, and after he enters his house, she mentions that she never saw Boo again.Boo remains inside his house and stays...

One could make the argument that Boo Radley is the loneliest character in the novel for several reasons. After Boo saves the children from Bob Ewell, Sheriff Tate says that he refuses to let the community know about Boo's heroism because the extra attention would seem harmful to Boo. Scout then walks Boo home, and after he enters his house, she mentions that she never saw Boo again. Boo remains inside his house and stays reclusive for the remainder of his life. The fact that Boo never leaves his house, and none of the Maycomb citizens visit him, supports the conclusion that he is the loneliest character in the novel. In Chapter 19, Scout mentions that Mayella might be lonelier than Boo because Mayella has no friends. However, unlike Mayella, Boo does not venture outdoors, nor does he speak to individuals who pass by his home. Boo lives with his brother Nathan, and Mayella has several brothers and sisters to keep her company, which is more evidence to suggest that Boo is the loneliest person in Maycomb. Also, the fact that Boo does not develop a friendly relationship with Jem and Scout after saving their lives is enough evidence to make him the loneliest character in the novel.

What qualifications does a territory need to meet in order to become a state, according to the Northwest Ordinance of 1787?

The Northwest Ordinance dealt with the land that made up the Northwest Territory. This law laid out the steps a territory needed to follow if it wanted to become a state. Five states were created from the Northwest Territory. The states were Wisconsin, Ohio, Illinois, Indiana, and Michigan.

A governor and three judges ruled the Northwest Territory. When the population of the territory reached 5,000 people, the people could elect an assembly to work with...

The Northwest Ordinance dealt with the land that made up the Northwest Territory. This law laid out the steps a territory needed to follow if it wanted to become a state. Five states were created from the Northwest Territory. The states were Wisconsin, Ohio, Illinois, Indiana, and Michigan.

A governor and three judges ruled the Northwest Territory. When the population of the territory reached 5,000 people, the people could elect an assembly to work with the governor and the three judges. However, the governor still had a lot of power. For example, the governor could veto any laws. When the population of the territory reached 60,000, they could ask to join the Union as a state. They had to write a state constitution as part of the requirement for becoming a state. The state constitutions had to ban slavery, allow for freedom of speech and religion, and have jury trials.

If a territory wants to become a state today, a majority of the people in the territory has to vote to become a state. If this happens, then the territory would ask Congress to allow the territory to become a state. The people of the territory would have to a write a state constitution. Then a majority of both houses of Congress would have to approve a resolution that would accept the request to become a state, The President would have to sign the resolution of both houses of Congress. Today, the territory that is closest to possibly becoming a state is Puerto Rico.

What is carnitine as a dietary supplement?

Overview

Carnitine is a substance used by the body to turn fat into energy. It is not normally considered an essential nutrient because the body can manufacture all it needs. However, supplemental carnitine could in theory improve the ability of certain tissues to produce energy. This has led to the use of carnitine for various muscle diseases and heart conditions.

Requirements and Sources

There is no dietary requirement for carnitine. However, some people have a
genetic defect that hinders the body’s ability to make carnitine. In addition,
diseases of the liver, kidneys, or brain may inhibit carnitine production. Certain
medications, especially the antiseizure drugs valproic acid
(Depakene) and phenytoin (Dilantin), may reduce carnitine levels; however,
whether taking extra carnitine would be helpful has not been determined. Heart
muscle tissue, because of its high energy requirements, is particularly vulnerable
to carnitine deficiency.

The principal dietary sources of carnitine are meat and dairy products. To obtain therapeutic dosages, however, a supplement is necessary.

Therapeutic Dosages

Typical adult dosages for the diseases described here range from 500 to 1,000 milligrams (mg) three times daily. For children, one study used 50 mg per kilogram twice daily, up to a maximum of 4 grams daily.

Carnitine is taken in three forms: L-carnitine (for heart and other
conditions), propionyl-L-carnitine (for heart conditions), and acetyl-L-carnitine
(for Alzheimer’s
disease). The dosage is the same for all three forms.

Therapeutic Uses

Carnitine is primarily used for heart-related conditions. Some evidence
suggests that it can be used along with conventional treatment for
angina to improve symptoms and reduce medication needs. When
combined with conventional therapy, it may or may not help prevent medical
complications or sudden cardiac death in the months following a heart
attack.

Lesser evidence suggests that it may be helpful for a condition called
intermittent claudication (pain in the legs after walking due to narrowing of the
arteries) and for congestive heart failure. In addition, a few studies suggest
that carnitine may be useful for cardiomyopathy.

Carnitine may also be helpful for improving exercise tolerance in people with
chronic
obstructive pulmonary disease (COPD), also known as
emphysema. One should not attempt to self-treat any of the
foregoing serious medical conditions or use carnitine as a substitute for standard
drugs.

Growing, if not entirely consistent, evidence suggests that L-carnitine or acetyl-L-carnitine, or their combination, may be helpful for improving sperm function and thereby provide benefits in male infertility. Two studies found evidence that carnitine is helpful for Peyronie’s disease, a condition affecting the penis.

Carnitine has also shown promise for improving mental and physical fatigue in the elderly. Some studies have found evidence that one particular form of carnitine, acetyl-L-carnitine, might be helpful in Alzheimer’s disease, but the two most recent and largest studies found no benefit. One review evaluated published and unpublished double-blind, placebo-controlled trials and concluded that acetyl-L-carnitine may only be helpful for very mild Alzheimer’s disease.

In preliminary trials, acetyl-L-carnitine has shown some promise for the
treatment of depression or dysthymia (a milder condition related to
depression). Some evidence suggests that carnitine may be useful for improving
blood sugar control in people with type 2 diabetes. Better evidence suggests
benefit with acetyl-L-carnitine for a major complication of diabetes, diabetic
peripheral neuropathy (injury to nerves of the extremities caused by
diabetes). Acetyl-L-carnitine might help prevent diabetic
cardiac autonomic neuropathy (injury to the nerves of the heart caused by
diabetes). However, one study found that carnitine supplements had an adverse
effect on triglyceride levels in people with diabetes.

Much weaker evidence suggests possible benefits for neuropathy caused by the
chemotherapy drugs cisplatin and paclitaxel.
Weak evidence hints that carnitine might help reduce liver and heart toxicity
caused by the chemotherapy drug adriamycin.

Some evidence suggests that carnitine may be able to improve cholesterol profile. One small study demonstrated a beneficial effect of L-carnitine on anemia and high cholesterol in persons on hemodialysis for chronic renal failure.

A genetic condition called fragile X syndrome can cause behavioral
disturbances such as hyperactivity, along with intellectual disability, autism,
and alterations in appearance. A preliminary study of seventeen boys found that
acetyl-L-carnitine might help to reduce hyperactive behavior associated with this
condition. Evidence for the effectiveness of L-carnitine in attention deficit disorder
(ADD) has been mixed.

Celiac
disease is an autoimmune disease affecting the digestive
tract. Fatigue is a common symptom of the disease. One small double-blind trial
found evidence that the use of L-carnitine at a dose of 2 g daily might help
alleviate this symptom.

Weak evidence hints that carnitine may help people with degeneration of the
cerebellum (the structure of the brain responsible for voluntary muscular
movement). One small study suggests carnitine may be helpful for reducing symptoms
of chronic fatigue syndrome. Another study suggests that carnitine may be of value
for treating hyperthyroidism and for severe liver disease. A substantial
study marred by poor design (specifically, far too many primary endpoints) found
equivocal evidence that L-carnitine, taken at dose of 500 mg three times daily,
might be more effective than placebo for the treatment of fibromyalgia.

Other weak evidence suggests that carnitine may be helpful for decreasing the muscle toxicity of AZT (a drug used to treat HIV infection). Other weak evidence hints that the acetyl-L-carnitine might reduce nerve-related side effects caused by HIV drugs in general.

One study failed to find carnitine effective for promoting weight loss, although another found that carnitine might lead to improvements in body composition (fat-muscle ratio). Carnitine is widely touted as a physical performance enhancer, but there is no real evidence that it is effective, and some research indicates that it is not.

Little to no evidence supports other claimed benefits, such as treating
irregular heartbeat, Down syndrome, muscular dystrophy, and alcoholic fatty liver
disease. However, in a randomized trial involving twenty-five persons with liver
cirrhosis and early brain dysfunction (hepatic encephalopathy) associated with
severe forms of this condition, carnitine appeared to significantly improve the
function of both the liver and the brain after three months of treatment.

Scientific Evidence

Angina. Carnitine might be a good addition to standard therapy for angina. In one controlled study, two hundred persons with angina (the exercise-induced variety) either took 2 g daily of L-carnitine or were left untreated. All the study participants continued to take their usual medication for angina. Those taking carnitine showed improvement in several measures of heart function, including a significantly greater ability to exercise without chest pain. They were also able to reduce the dosages of some of their heart medications (under medical supervision) as their symptoms decreased.

The results of this study cannot be fully trusted because researchers did not use a double-blind protocol. Another trial with a double-blind, placebo-controlled design tested L-carnitine in fifty-two people with angina and found evidence of benefit.

In addition, several small studies (some of them double-blind) tested propionyl-L-carnitine for the treatment of angina and also found evidence of benefit.

Intermittent claudication. People with advanced hardening of the arteries, or atherosclerosis, often have difficulty walking because of a lack of blood flow to the legs, a condition called intermittent claudication. Pain may develop after walking less than half a block. Although carnitine does not increase blood flow, it appears to improve the muscle’s ability to function under difficult circumstances.

A twelve-month, double-blind, placebo-controlled trial of 485 persons with intermittent claudication evaluated the potential benefits of propionyl-L-carnitine. Participants with relatively severe disease showed a 44 percent improvement in walking distance, compared with placebo. However, no improvement was seen in those persons with mild disease. Another double-blind study followed 245 people and also found benefit.

Similar results have been seen in most other studies of L-carnitine or propionyl-L-carnitine. Propionyl-L-carnitine may be more effective for intermittent claudication than plain carnitine.

Congestive heart failure. Several small studies have found that carnitine, often in the form of propionyl-L-carnitine, can improve symptoms of congestive heart failure. In one trial, benefits were maintained for sixty days after treatment with carnitine was stopped.

After a heart attack. L-carnitine has shown inconsistent promise for use after a heart attack. A double-blind, placebo-controlled study followed 101 people for one month after those persons had experienced a heart attack. The study found that the use of L-carnitine, in addition to standard care, reduced the size of the infarct (dead heart tissue).

In the months following a severe heart attack, the left ventricle of the heart often enlarges, and the pumping action of the heart becomes less efficient. Some evidence suggests that L-carnitine can help prevent heart enlargement but that it does not improve heart function. In a twelve-month, double-blind, placebo-controlled study of 472 persons who had just had a heart attack, the use of carnitine at a dose of 6 g per day significantly decreased the rate of heart enlargement. However, heart function was not significantly altered.

A three-month, double-blind, placebo-controlled study of sixty persons who had just had a heart attack also failed to find improvements in heart function. (Heart enlargement was not studied.)

Results consistent with the foregoing studies were seen in a six-month double blind, placebo-controlled study of 2,330 people who had just had a heart attack. Carnitine failed to produce significant reductions in mortality or heart failure (serious decline in heart function) over the six-month period. However, the study did find reductions in early death. (For statistical reasons, the meaningfulness of this last finding is questionable. Reduction in early death was a secondary endpoint rather than a primary one.) Carnitine is used with conventional treatment, not as a substitute for it.

Diabetic neuropathy. High levels of blood sugar can damage the nerves leading to the extremities, causing pain and numbness. This condition is called diabetic peripheral neuropathy. Nerve damage may also develop in the heart, a condition called cardiac autonomic neuropathy. Acetyl-L-carnitine has shown considerable promise for diabetic peripheral neuropathy and some promise for cardiac autonomic neuropathy.

Two fifty-two-week, double-blind, placebo-controlled studies, involving a total of 1,257 people with diabetic peripheral neuropathy, evaluated the potential benefits of acetyl-L-carnitine taken at 500 or 1,000 mg daily. The results showed that the use of acetyl-L-carnitine, especially at the higher dose, improved sensory perception and decreased pain levels. In addition, the supplement appeared to promote nerve fiber regeneration. A small study found some potential benefits for cardiac autonomic neuropathy.

Male sexual function. Carnitine has shown promise for improving
male sexual function. One double-blind, placebo-controlled study of 120 men
compared a combination of propionyl-L-carnitine (2 g per day) and
acetyl-L-carnitine (2 g per day) with testosterone for the treatment of male
aging symptoms (sexual dysfunction, depression, and fatigue). The results
indicated that both testosterone and carnitine improved erectile function, mood,
and fatigue, compared with placebo. However, no improvements were seen in the
placebo group. This is an unusual occurrence in studies of erectile dysfunction,
so it casts some doubt on the study results.

A double-blind study of forty men evaluated propionyl-L-carnitine (2 g per day)
in diabetic men with erectile dysfunction who had not
responded well to Viagra. The results indicated that carnitine significantly
enhanced the effectiveness of Viagra. In another double-blind study, a combination
of the propionyl and acetyl forms of carnitine enhanced the effectiveness of
Viagra in men who suffered from erectile dysfunction caused by prostate
surgery.

Male infertility. Growing evidence suggests that L-carnitine or
acetyl-L-carnitine, or their combination, may be helpful for improving sperm
quality and function, thereby benefiting male
infertility. For example, in one double-blind,
placebo-controlled study of sixty men, the use of combined L-carnitine (2 g per
day) and acetyl-L-carnitine (also at 2 g per day) significantly improved sperm
quality.

Chronic obstructive pulmonary disease (COPD). Evidence from three double-blind, placebo-controlled studies enrolling a total of forty-nine people suggests that L-carnitine can improve exercise tolerance in COPD, presumably by improving muscular efficiency in the lungs and other muscles.

Alzheimer’s disease. Numerous double-blind or single-blind studies involving a total of more than fourteen hundred people have evaluated the potential benefits of acetyl-L-carnitine in the treatment of Alzheimer’s disease and other forms of dementia. However, while early studies found evidence of modest benefit, two large and well-designed studies failed to find acetyl-L-carnitine effective.

The first of these studies was a double-blind, placebo-controlled trial that enrolled 431 participants for one year. Overall, acetyl-L-carnitine proved no better than placebo. However, because a close look at the data indicated that the supplement might help people who develop Alzheimer’s disease at an unusually young age, researchers performed a follow-up trial. This one-year, double-blind, placebo-controlled trial evaluated acetyl-L-carnitine in 229 persons with early onset Alzheimer’s. No benefits were seen here either. One review of the literature concluded that acetyl-L-carnitine may be helpful for mild cases of Alzheimer’s disease, but not for more severe cases.

Mild depression. A double-blind study of sixty elderly persons with dysthymia (a mild form of depression) found that treatment with 3 g of carnitine daily for two months significantly improved symptoms, compared with placebo. Positive results were seen in two other studies too, one of depression and one of dysthymia.

Hyperthyroidism. Enlargement of the thyroid (goiter) can
be due to many causes, including cancer and iodine deficiency. In some cases,
thyroid enlargement occurs without any known cause, resulting in benign
goiter.

Treatment of benign goiter generally consists of taking thyroid hormone pills. This causes the thyroid gland to become less active, and the goiter shrinks. However, undesirable effects may result. Symptoms of hyperthyroidism (too much thyroid hormone) can develop, including heart palpitations, nervousness, weight loss, and bone breakdown.

A double-blind, placebo-controlled trial found evidence that the use of L-carnitine could alleviate many of these symptoms. This six-month study evaluated the effects of L-carnitine in fifty women who were taking thyroid hormone for benign goiter. The results showed that a dose of 2 or 4 g of carnitine daily protected participants’ bones and reduced other symptoms of hyperthyroidism.

Carnitine is thought to affect thyroid hormone by blocking its action in cells. This suggests a potential concern—carnitine might be harmful for people who have low or borderline thyroid levels to begin with. This possibility has not been well explored.

Peyronie’s disease. Peyronie’s disease is an inflammatory
condition of the penis that develops in stages. In the first stage, penile pain
occurs with erection; next, the penis becomes curved; finally, erectile
dysfunction may occur. Many medications have been tried for Peyronie’s disease,
with some success. One such drug is tamoxifen, which is better known as a
treatment to prevent breast cancer recurrence. A three-month, double-blind study
compared the effectiveness of acetyl-L-carnitine to the drug tamoxifen in
forty-eight men with Peyronie’s disease. Acetyl-L-carnitine (at a dose of 1 g
daily) reduced penile curvature, while tamoxifen did not; in addition, the
supplement reduced pain and slowed disease progression to a greater extent than
tamoxifen.

Safety Issues

L-carnitine in its three forms appears to be quite safe. However, persons with
low or borderline-low thyroid levels should avoid carnitine because it might
impair the action of thyroid hormone. Persons on dialysis
should not receive this (or any other supplement) without a physician’s
supervision. The maximum safe dosages for young children, pregnant or nursing
women, and those with severe liver or kidney disease have not been
established.

Important Interactions

Persons taking antiseizure medications, particularly valproic acid (Depakote, Depakene) but also phenytoin (Dilantin), may need extra carnitine. Persons taking thyroid medication should not take carnitine except under a physician’s supervision.

Bibliography

Arnold, L. E., et al. “Acetyl-L-Carnitine (ALC) in Attention-Deficit/Hyperactivity Disorder.” Journal of Child and Adolescent Psychopharmacology (2007): 791-802.

Cavallini, G., et al. “Carnitine Versus Androgen Administration in the Treatment of Sexual Dysfunction, Depressed Mood, and Fatigue Associated with Male Aging.” Urology 63 (2004): 641-646.

Gentile, V., et al. “Preliminary Observations on the Use of Propionyl-L-Carnitine in Combination with Sildenafil in Patients with Erectile Dysfunction and Diabetes.” Current Medical Research and Opinion 20 (2004): 1377-1384.

Maestri, A., et al. “A Pilot Study on the Effect of Acetyl-L-Carnitine in Paclitaxel- and Cisplatin-Induced Peripheral Neuropathy.” Tumori (2005): 135-138.

Malaguarnera, M., L. Cammalleri, et al. “L-Carnitine Treatment Reduces Severity of Physical and Mental Fatigue and Increases Cognitive Functions in Centenarians.” American Journal of Clinical Nutrition 86 (2007): 1738-1744.

Malaguarnera, M., M. P. Gargante, et al. “Acetyl-L-Carnitine Treatment in Minimal Hepatic Encephalopathy.” Digestive Diseases and Sciences 53 (2008): 3018-3025.

Rossini, M., et al. “Double-Blind, Multicenter Trial Comparing Acetyl-L-Carnitine with Placebo in the Treatment of Fibromyalgia Patients.” Clinical and Experimental Rheumatology 25 (2007): 182-188.

Sima, A. A., et al. “Acetyl-L-Carnitine Improves Pain, Nerve Regeneration, and Vibratory Perception in Patients with Chronic Diabetic Neuropathy.” Diabetes Care 28 (2004): 89-94.

Smith, W., et al. “Effect of Glycine Propionyl-L-Carnitine on Aerobic and Anaerobic Exercise Performance.” International Journal of Sport Nutrition and Exercise Metabolism 18 (2008): 19-36.

Youle, M., and M. Osio. “A Double-Blind, Parallel-Group, Placebo-Controlled, Multicentre Study of Acetyl-L-Carnitine in the Symptomatic Treatment of Antiretroviral Toxic Neuropathy in Patients with HIV-1 Infection.” HIV Medicine 8 (2007): 241-250.

In "Raymond's Run," what is an example of flashback?

In the short story "Raymond's Run" by Toni Cade Bambara, Squeaky, the main character and narrator, references events that happen in the past. These moments in the text can be considered flashbacks. The first reference is to a girl in her grade named Cynthia Proctor who, according to Squeaky, claims that everything comes easily to her and she does not need to work hard or practice. Squeaky recounts a few instances where she saw Cynthia...

In the short story "Raymond's Run" by Toni Cade Bambara, Squeaky, the main character and narrator, references events that happen in the past. These moments in the text can be considered flashbacks. The first reference is to a girl in her grade named Cynthia Proctor who, according to Squeaky, claims that everything comes easily to her and she does not need to work hard or practice. Squeaky recounts a few instances where she saw Cynthia practicing piano even after Cynthia pretends that her skills are natural and not a result of practice: "Now some people like to act like things come easy to them, won't let on that they practice. Not me."

Another flashback or reference to the past happens when Squeaky remembers being in a Hansel and Gretel play. Squeaky remembers dressing up as a strawberry and pleasing her parents despite the fact that she is decidedly not an actress and is really born to run.

Both of these flashbacks help to develop Squeaky's character and give the reader insight into who she is.

What is a pulmonary edema?

Causes and Symptoms

There are two major causes of pulmonary
edema. The most common is when the heart or circulatory system is not functioning properly. The other is when there is direct injury to the lungs, which can be caused by toxic gases, trauma, or severe infection.

When the heart muscle becomes damaged, often by a heart attack, the muscle in the left ventricle cannot pump blood as well as that in the right ventricle. This causes the blood pressure
in the pulmonary veins of the lungs to rise. When the blood pressure becomes higher than the air pressure in the alveoli, fluid from the blood crosses the membranes and goes into the lungs. The fluid in the lungs makes it difficult for oxygen to move from the alveoli into the blood, resulting in shortness of breath.

Another heart condition that can cause pulmonary edema is a heart valve malfunction. The problem begins when the mitral valve, between the left atrium and left ventricle, becomes narrowed or allows some blood to flow backward. In either case, the movement of blood from the atrium to the ventricle is compromised, causing blood to
back up into the pulmonary system and triggering high blood pressure. High pulmonary vein pressure can also be due to cardiomyopathy, in which the heart muscle becomes thick, enlarged, or rigid. When this happens, the heart muscle does not contract well, and, as with the other causes of pulmonary edema, the pressure in the veins gets too high.

Breathing toxic gases can irritate the lining of the lungs, resulting in fluid release in the alveoli. Blunt forces to the chest can damage capillaries in the lungs. Lung infections can cause an inflammatory response. All these conditions result in fluid collecting in the alveoli, making it difficult for oxygen to move into the blood and causing shortness of breath.

The major symptom of pulmonary edema is difficulty breathing. The patient may cough up blood or a pink, frothy fluid. Sometimes, rapid breathing, dizziness, or general weakness is observed. These symptoms are the result of the body’s tissues not receiving enough oxygen. If pulmonary edema is left untreated, the patient can enter into a coma and even die. If the condition develops slowly, it can be accompanied by ankle edema, breathlessness when lying down, and waking in the middle of the night with shortness of breath.

Treatment and Therapy

The initial treatment for severe pulmonary edema is to administer high-flow oxygen to increase the amount of oxygen getting into the blood. Other treatments depend on the origin of the condition. If the cause is cardiovascular, then diuretics
can be given to decrease the total fluid levels in the body. This will help to decrease the blood pressure, including in the pulmonary veins, resulting in less fluid moving from the blood to the lungs. When the cause is infection, antibiotics are administered. Destroying the bacteria will take away the inflammation and the fluid from the lungs. In cases of toxic gas inhalation, the person must first be removed from exposure to the gas. Often, an inhaler is used to dilate the bronchioles in the lungs in order to increase airflow. In all these cases, the most important objective is to get sufficient oxygen from the lungs into the blood.

Perspectives and Prospects

The recorded history of heart failure
dates back to ancient Greece, where it was reported that fluid could be heard in the lungs when placing the ear against a patient’s chest. Due to the lack of information about the cause of the fluid, it is difficult to know the full context of the ancient medical writings. A better understanding was developed in the seventeenth century, when William Harvey described how the blood circulates throughout the body. In the late nineteenth century, the development of the electrocardiogram by Willem Einthoven and x-ray technology by Wilhelm Conrad Röntgen led to an even better understanding.

Treatments for congestive heart failure have varied throughout history. For centuries and into the eighteenth century, bloodletting and leeches were used to reduce fluid volumes in the body. In the late eighteenth century, William Withering discovered that digitalis led to significant improvements in patients with congestive heart failure. Digitalis is still used today to treat various heart conditions. The next treatment to reduce the fluid in the body was developed in the late nineteenth century by Reginald Southey, who used tubes to drain fluid from the ankles and feet. By the twentieth century, diuretics had been developed that are still used today.

Bibliography

American Medical Association. American Medical Association Family Medical Guide. 4th ed. Hoboken, N.J.: John Wiley & Sons, 2004.

Dugdale, David C., III, Michael A. Chen, and David Zieve. “Pulmonary Edema.” MedlinePlus, June 4, 2012.

Goldmann, David R., ed. American College of Physicians Complete Home Medical Guide. 2d ed. New York: DK Publishing, 2003.

Litin, Scott C., ed. Mayo Clinic Family Health Book. 4th ed. Chicago: Time Inc. Home Entertainment, 2009.

“Pulmonary Edema.” Mayo Clinic, July 29, 2011.

What is female infertility? |

Causes and Symptoms

Infertility is defined as the failure of a woman to conceive despite regular sexual activity over the course of at least one year. Studies have estimated that in the United States, 10 to 15 percent of couples are infertile. In about half of these couples, it is the woman who is affected.

Female infertility may be caused by hormonal problems, or it may originate in the reproductive organs: the ovaries, oviducts, uterus, cervix, and vagina. The frequency of specific problems among infertile women is as follows: ovarian problems, 20 percent to 30 percent; damage to the Fallopian tubes, 30 percent to 50 percent; uterine problems, 5 percent to 10 percent; and cervical or vaginal abnormalities, 5 percent to 10 percent. Another 10 percent of women have unexplained infertility. Behavioral factors, such as diet and exercise and the use of tobacco, alcohol, or drugs, also play a role in infertility.

The ovaries have two important roles in conception: the production of ova (egg cells), culminating in ovulation, and the production of hormones. Ovulation usually occurs halfway through a woman’s four-week menstrual cycle. In the two weeks preceding ovulation, follicle-stimulating hormone (FSH) from the pituitary gland causes follicles in the ovaries to grow and the ova within them to mature. As the follicles grow, they produce increasing amounts of estrogen. Near the middle of the cycle, the estrogen causes the pituitary gland to release a surge of luteinizing hormone (LH), which causes ovulation of the largest follicle in the ovary.

Anovulation (lack of ovulation) can result either directly, from an inability to produce LH, FSH, or estrogen, or indirectly, because of the presence of other hormones that interfere with the signaling systems between the pituitary and ovaries. For example, the woman may have an excess production of androgen (testosterone-like) hormones, either in her ovaries or in her adrenal glands, or her pituitary may produce too much prolactin, a hormone that is normally secreted in large amounts only after the birth of a child.

Besides ovulation, the ovaries have another critical role in conception, since they produce hormones that act on the uterus to allow it to support an embryo. In the first two weeks of the menstrual cycle, the uterine lining is prepared for a possible pregnancy by estrogen from the ovaries. Following ovulation, the uterus is maintained in a state that can support an embryo by progesterone, which is produced in the ovary by the follicle that just ovulated, now called a corpus luteum. Because of the effects of hormones from the corpus luteum on the uterus, the corpus luteum is essential to the survival of the embryo. If conception does not occur, the corpus luteum disintegrates and stops producing progesterone. As progesterone levels decline, the uterine lining can no longer be maintained and is shed as the menstrual flow.

Failure of the pregnancy can result from improper function of the corpus luteum, such as an inability to produce enough progesterone to sustain the uterine lining. The corpus luteum may also produce progesterone initially but then disintegrate too early. These problems in corpus luteum function, referred to as luteal phase insufficiency, may be caused by the same types of hormonal abnormalities that cause lack of ovulation.

Some cases of infertility may be associated with an abnormally shaped uterus or vagina. Such malformations of the reproductive organs are common in women whose mothers took diethylstilbestrol (DES) during pregnancy. DES was prescribed to many pregnant women from 1941 to about 1970 as a protection against miscarriage; infertility and other problems have occurred in the offspring of these women.

Conception depends on normal function of the oviducts (or Fallopian tubes), thin tubes with an inner diameter of only a few millimeters; they are attached to the top of the uterus and curve upward toward the ovaries. The inner end of each tube, located near one of the ovaries, waves back and forth at the time of ovulation, drawing the mature ovum into the opening of the oviduct. Once in the oviduct, the ovum is propelled along by movements of the oviduct wall. Meanwhile, if intercourse has occurred recently, the man’s sperm will be moving upward in the female system, swimming through the uterus and the oviducts. Fertilization, the union of the sperm and ovum, will occur in the oviduct, and then the fertilized ovum will pass down the oviduct and reach the uterus about three days after ovulation.

Infertility can result from scar tissue formation inside the oviduct, resulting in physical blockage and inability to transport the ovum, sperm, or both. The most common cause of scar tissue formation in the reproductive organs is pelvic inflammatory disease (PID), a condition characterized by inflammation that spreads throughout the female reproductive tract. PID may be initiated by a sexually transmitted disease such as gonorrhea or chlamydia. Physicians in the United States have documented an increase in infertility attributable to tubal damage caused by sexually transmitted diseases.

Damage to the outside of the oviduct can also cause infertility, because such damage can interfere with the mobility of the oviduct, which is necessary to the capture of the ovum at the time of ovulation. External damage to the oviduct may occur as an aftermath of abdominal surgery, when adhesions induced by surgical cutting are likely to form. An adhesion is an abnormal scar tissue connection between adjacent structures.

Another possible cause of damage to the oviduct that can result in infertility is the presence of
endometriosis. Endometriosis refers to a condition in which patches of the uterine lining implant outside the uterus, in or on the surface of other organs. These patches are thought to arise during menstruation, when the uterine lining (endometrium) is normally shed from the body through the cervix and vagina; in a woman with endometriosis, for unknown reasons, the endometrium is carried to the interior of the pelvic cavity by passing up the oviducts. The endometrial patches can lodge in the oviduct itself, causing blockage, or can adhere to the outer surface of the oviducts, interfering with mobility.

Endometriosis can cause infertility by interfering with organs other than the oviducts. Endometrial patches on the outside of the uterus can cause distortions in the shape or placement of the uterus, interfering with embryonic implantation. Ovulation may be prevented by the presence of the endometrial tissues on the surface of the ovary. The presence of endometriosis, however, is not always associated with infertility: Thirty percent to forty percent of women with endometriosis cannot conceive, but the remainder appear to be fertile.

Another critical site in conception is the cervix. The cervix, the entryway to the uterus from the vagina, represents the first barrier through which sperm must pass on their way to the ovum. The cervix consists of a ring of strong, elastic tissue with a narrow canal. Glands in the cervix produce the mucus that fills the cervical canal and through which sperm swim en route to the ovum. The amount and quality of the cervical mucus change throughout the menstrual cycle, under the influence of hormones from the ovary. At ovulation, the mucus is in a state that is most easily penetrated by sperm; after ovulation, the mucus becomes almost impenetrable.

Cervical problems that can lead to infertility include production of a mucus that does not allow sperm passage at the time of ovulation (hostile mucus syndrome) and interference with sperm transport caused by narrowing of the cervical canal. Such narrowing may be the result of a developmental abnormality or the presence of an infection, possibly a sexually transmitted disease.

Treatment and Therapy

The diagnosis of the exact cause of a woman’s infertility is crucial to successful treatment. A complete medical history should reveal any obvious problems of previous infection or menstrual cycle irregularity. Adequacy of ovulation and luteal phase function can be determined from records of menstrual cycle length and changes in body temperature (body temperature is higher after ovulation). Hormone levels can be measured with tests of blood or urine samples. If damage to the oviducts or uterus is suspected, a hysterosalpingography will be performed. In this procedure, the injection of a special fluid into the uterus is followed by x-ray analysis of the fluid movement to reveal the shape of the uterine cavity and the oviducts. Cervical functioning can be assessed with the postcoital test, in which the physician attempts to recover sperm from the woman’s uterus some hours after she has had intercourse with her partner. If a uterine problem is suspected, the woman may have an endometrial biopsy, in which a small sample of the uterine lining is removed and examined for abnormalities. Sometimes, exploratory surgery is performed to pinpoint the location of scar tissue or the location of endometrial patches.

Surgery may be used for treatment as well as diagnosis. Damage to the oviducts can sometimes be repaired surgically, and surgical removal of endometrial patches is a standard treatment for endometriosis. Often, however, surgery is a last resort because of the likelihood of the development of postsurgical adhesions, which can further complicate the infertility. Newer forms of surgery using lasers and freezing offer better success because of a reduced risk of adhesions.

Some women with hormonal difficulties can be treated successfully with so-called fertility drugs, which are intended to stimulate ovulation. There are several different drugs and hormones that fall under this heading: Clomiphene citrate (Clomid), human menopausal gonadotropin (hMG), gonadotropin-releasing hormone (GnRH), and bromocriptine mesylate (Parlodel) are among the medications commonly used, with the exact choice depending on the woman’s particular problem. One problem with some of the drugs is the risk of multiple pregnancy (more than one fetus in the uterus). Other possible problems include nausea, dizziness, headache, and general malaise.

Aside from fertility drugs, there are a variety of methods in use to try to achieve pregnancy with external assistance, known collectively as assisted reproductive technology (ART). One example of this, artificial insemination
, also known as intrauterine insemination (IUI), is an old technique that is still useful in various types of infertility. A previously collected sperm sample is placed in the woman’s vagina or uterus using a special tube. Artificial insemination is always performed at the time of ovulation, in order to maximize the chance of conception. The ovulation date can be determined with body temperature records or by hormone measurements. In some cases, this procedure is combined with fertility drug treatment. Since the sperm can be placed directly in the uterus, it is useful in treating hostile mucus syndrome and certain types of male infertility. The sperm sample can be provided either by the woman’s partner or by a donor. The pregnancy rate after artificial insemination is highly variable (anywhere from 10 to 70 percent), depending on the particular infertility problem in the couple.

Another assisted reproductive technology is
Gamete intrafallopian transfer (GIFT), the surgical placement of ova and sperm directly into the woman’s oviducts. To be a candidate for this procedure, the woman must have at least one partially undamaged oviduct and a functional uterus. Ova are collected surgically from the ovaries after stimulation with a fertility drug, and a semen sample is collected from the male. The ova and the sperm are introduced into the oviducts through the same abdominal incision used to collect the ova. This procedure is useful in certain types of male infertility, if the woman produces an impenetrable cervical mucus, or if the ovarian ends of the oviducts are damaged. The range of infertility problems that may be resolved with GIFT can be extended by using donated ova or sperm. The pregnancy rate is about 33 percent overall, but the rate varies with the type of infertility present.

The most common assisted reproductive technology is in vitro fertilization (IVF), or the fertilization of the sperm and egg outside the woman's body, followed by implantation of the fertilized egg in the woman's uterus. In this procedure, ova are collected surgically after stimulation with fertility drugs and then placed in a laboratory dish and combined with sperm from the man. The actual fertilization, when a sperm penetrates the ovum, will occur in the dish. The resulting embryo is allowed to remain in the dish for two days, during which time it will have grown to two to four cells. Then, the embryo is placed in the woman’s uterine cavity using a flexible tube. In vitro fertilization can be used in women who are infertile because of endometriosis, damaged oviducts, impenetrable cervical mucus, or ovarian failure. As with GIFT, in vitro fertilization may utilize donated ova or donated sperm, or extra embryos that have been produced by one couple may be implanted in a second woman. Embryos created through IVF can either be used immediately or frozen for later implantation. Success rates for in vitro fertilization have improved greatly over time, and in the United States in 2010, the proportion of IVF procedures that resulted in live births was about 56 percent for fresh embryos and 35 percent for frozen embryos, according to the Centers for Disease Control and Prevention.

Some women may benefit from nonsurgical embryo transfer. In this procedure, a fertile woman is artificially inseminated at the time of her ovulation; five days later, her uterus is flushed with a sterile solution, washing out the resulting embryo before it implants in the uterus. The retrieved embryo is then transferred to the uterus of another woman, who will carry it to term. Typically, the sperm provider and the woman who receives the embryo are the infertile couple who wish to rear the child, but the technique can be used in other circumstances as well. Embryo transfer can be used if the woman has damaged oviducts or is unable to ovulate, or if she has a genetic disease that could be passed to her offspring, because in this case the baby is not genetically related to the woman who carries it.

Some infertile women who are unable to achieve a pregnancy themselves turn to the use of a surrogate, a woman who will agree to bear a child and then turn it over to the infertile woman to rear as her own. In the typical situation, the surrogate is artificially inseminated with the sperm of the infertile woman’s husband. The surrogate then proceeds with pregnancy and delivery as normal, but relinquishes the child to the infertile couple after its birth.

Perspective and Prospects

One of the biggest problems that infertile couples face is the emotional upheaval that comes with the diagnosis of infertility, as bearing and rearing children is an experience that most people treasure. In addition to the emotional difficulty that may come with the recognition of infertility, more stress may be in store as the couple proceeds through treatment. The various treatments can cause embarrassment and sometimes physical pain, and fertility drugs themselves are known to cause emotional swings. For these reasons, a couple with an infertility problem is often advised to seek help from a private counselor or a support group.

Along with the emotional and physical challenges of infertility treatment, there is a considerable financial burden. Infertility treatments, in general, are expensive, especially for more sophisticated procedures such as in vitro fertilization and GIFT. Since the chances of a single procedure resulting in a pregnancy are often low, the couple may be faced with submitting to multiple procedures repeated many times. The cost over several years of treatment—a realistic possibility—can be very high. Many health insurance companies in the United States refuse to cover the costs of such treatment and are required to do so in only a few states.

Some of the treatments are accompanied by unresolved legal questions. In the case of nonsurgical embryo transfer, is the legal mother of the child the ovum donor or the woman who gives birth to the child? The same question of legal parentage arises in cases of surrogacy. Does a child born using donated ovum or sperm have a legal right to any information about the donor, such as medical history? How extensive should governmental regulation of infertility clinics be? For example, should there be standards for ensuring that donated sperm or ova are free from genetic defects? In the United States, some states have begun to address these issues, but no uniform policies have been set at the federal level.

The legal questions are largely unresolved because American society is still involved in religious and philosophical debates over the propriety of various infertility treatments. Some religions hold that any interference in conception is unacceptable. To these denominations, even artificial insemination is wrong. Other groups approve of treatments confined to a husband and wife, but disapprove of a third party being involved as a donor or surrogate. Many people disapprove of any infertility treatment to help an individual who is not married. Almost all these issues stem from the fact that these reproductive technologies challenge the traditional definitions of parenthood.

Bibliography

American Society for Reproductive Medicine. http://www.asrm.org/.

"Assisted Reproductive Technology (ART) Report." Centers for Disease Control and Prevention, January 6, 2012.

"Female Infertility." Mayo Clinic, September 9, 2011.

Harkness, Carla. The Infertility Book: A Comprehensive Medical and Emotional Guide. Rev. ed. Berkeley, Calif.: Celestial Arts, 1996.

InterNational Council on Infertility Information Dissemination. http://www.inciid.org.

Phillips, Robert H., and Glenda Motta. Coping with Endometriosis. New York: Avery, 2000.

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

Riley, Julie. "Infertility in Women." Health Library, October 31, 2012.

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

Turkington, Carol, and Michael M. Alper. Encyclopedia of Fertility and Infertility. New York: Facts On File, 2001.

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

Wisot, Arthur L., and David R. Meldrum. Conceptions and Misconceptions: The Informed Consumer’s Guide Through the Maze of In Vitro Fertilization and Other Assisted Reproduction Techniques. 2d ed. Point Roberts, Wash.: Hartley & Marks, 2004.

Zouves, Christo. Expecting Miracles: On the Path of Hope from Infertility to Parenthood. New York: Berkley, 2003.

Does Cecily have a hidden meaning in The Importance of Being Earnest?

I don't think there's any "hidden" meaning to Cecily. At a fairly young age, she is both innocent and quick-witted, uneducated and capable of intuiting the ways of the world. She is also hopelessly romantic and very imaginative, but that doesn't stop her from getting precisely what she wants: Ernest, er, Algernon.

It says a lot about both her character and Algernon's that her feverish imagination controls much of her life and manages to attract...

I don't think there's any "hidden" meaning to Cecily. At a fairly young age, she is both innocent and quick-witted, uneducated and capable of intuiting the ways of the world. She is also hopelessly romantic and very imaginative, but that doesn't stop her from getting precisely what she wants: Ernest, er, Algernon.

It says a lot about both her character and Algernon's that her feverish imagination controls much of her life and manages to attract rather than repel him. She imagines a courtship and a betrothal (later broken off, and then reinstated), gifts and letters, all before she'd ever met the man because she'd heard about how terribly "wicked" he is from her guardian, Jack. Her ability to create such fantasies and to seem to wholeheartedly believe them, as well as Algernon's relatively prompt acceptance of such eccentricity, actually seems to make them rather perfect for each other, which is both a compliment to and somewhat of a criticism of both. Algernon is sweet to her but deceptive; Cecily is sweet in general but delusional. In short, they are ridiculous in similar ways! Her creation of a relationship with him before ever having met him is not so very different from his creation of Mr. Bunbury.

Thus, Cecily and Algernon help to illuminate each other's good qualities and bad, and the ease with which they handle each other's misrepresentations or imaginations leads to the conclusion that they will be quite a successful couple. Between his penchant for mischief and her money, their life together should be quite entertaining indeed.