What are natural treatments for heart attacks?

Introduction

As an active muscle, the heart needs a continuous supply of oxygen. The
coronary arteries have the job of carrying oxygen to the heart. These arteries
have a difficult job to do because they undergo intense compression every time the
heart beats. This job becomes even more difficult when the arteries are damaged by
atherosclerosis (commonly, though not quite accurately,
called hardening of the arteries) in a condition called coronary artery
disease.

In coronary artery disease, the passages inside the coronary arteries become
narrowed by plaque deposits, which decreases blood flow. When the blood flow is
decreased to a sufficient extent, pain caused by oxygen deprivation occurs. This
pain is known as angina pectoris. Angina tends to wax and wane, generally
worsening with exercise.

A heart
attack may occur after years of angina or with no warning.
Most heart attacks occur when a blood clot (thrombus) forms on the roughened wall
of an atherosclerotic coronary artery. Such a blood clot may lead to a sudden and
complete blockage of the artery. More rarely, a spasm of a coronary artery may cut
off blood flow. In either case, the cells of the heart fed by that artery begin to
die. The region of dead cells is called an infarct,
leading to the technical name for a heart attack: myocardial infarction (MI).

The classic symptom of a heart attack is intense, central chest pressure. Other common symptoms include pain or heaviness in the left arm, nausea, shortness of breath, increased perspiration, and a feeling of impending doom. Many people who have had an MI describe chest discomfort or pain in the jaw, teeth, arm, or abdomen. Women are more likely than men to feel pain in their backs. Often, symptoms appear gradually and are intermittent or vague. One-quarter of persons, more often women and people with diabetes, experience no symptoms.

When a heart attack occurs, emergency treatment at a hospital can minimize the
extent of permanent damage to the heart. “Clot busting” drugs, if given soon
enough, can open the coronary arteries, allowing blood to flow again. Other
methods of restoring blood flow include procedures known as angioplasty,
stenting, and bypass surgery. The aim is to save
those heart cells that are in danger of dying. Recovery after a heart attack
depends on the extent of heart damage. If only a small portion of the heart has
died, or if it is in a relatively less important region, symptoms may be slight.
More severe damage can cause the heart to pump improperly, leading to congestive
heart failure.

During the first several days following a heart attack, the heart has a
tendency to lose its normal rhythm and fall into a dysfunctional pattern of
beating that does not properly circulate blood. Treatment aimed to prevent or
treat this condition, called an arrhythmia, is conducted in a cardiac
intensive care unit.

Long-term treatment to reduce the risk of heart attacks generally involves aspirin to prevent blood clots and treatments to slow, stop, or reverse atherosclerosis. The latter is accomplished through the use of medications that keep cholesterol and blood pressure within normal limits and by increasing exercise and improving other aspects of one’s lifestyle.

Principal Proposed Natural Treatments

The most important contribution of natural medicine in the realm of heart attacks is prevention, not treatment. Atherosclerosis, which causes most heart attacks, is accelerated by high blood pressure and high cholesterol, and possibly by high levels of homocysteine in the blood. Natural treatments used for these conditions are worth considering. However, natural therapies for high blood pressure and high cholesterol are generally less effective than the conventional approaches. Persons interested in using natural treatments should first consult with a physician to determine how long it is safe to experiment. If natural therapies have not controlled the heart condition within the prescribed time, it may better to use conventional therapies.

Other Proposed Natural Treatments

Several natural treatments have shown promise for use with conventional treatment in the period following a heart attack. Note, however, that people who have recently had a heart attack should not use any herbs or supplements except under the supervision of a physician. Furthermore, none of these treatments can substitute for standard care; at most, they might be helpful if used in addition to it.

Coenzyme Q?
10. The supplement coenzyme Q10

(CoQ10) is thought to improve heart function. In a double-blind
trial, 145 people who had recently experienced a heart attack were given either
placebo or 120 milligrams (mg) of CoQ10 daily for twenty-eight days.
The results showed that participants receiving CoQ10 experienced
significantly fewer heart-related problems, such as episodes of angina pectoris or
arrhythmia, or recurrent heart attacks. CoQ10 taken with the mineral
selenium has also shown promise for people who have survived a heart attack.

L-carnitine. The amino acid L-carnitine has shown potential value during the first few weeks after an MI. A double-blind, placebo-controlled study that followed 101 people for one month after a heart attack found that the use of L-carnitine, in addition to standard care, reduced the size of the infarct (area of dead heart tissue). Other complications of heart attack were reduced too. Similar benefits also were seen in a one-year, controlled study of 160 people who had just experienced a heart attack; however, because this study was not double-blind, its results are not reliable.

In the months following a severe heart attack, the heart often enlarges and loses function. L-carnitine has shown some potential for helping the first of these complications, but not the second. In a twelve-month, double-blind, placebo-controlled study of 472 people who had just experienced a heart attack, the use of carnitine at a dose of 6 grams per day significantly decreased the rate of heart enlargement. However, heart function was not improved. A three-month, double-blind, placebo-controlled study of sixty people who had just had a heart attack also failed to find improvements in heart function with L-carnitine. (Heart enlargement was not studied.)

Results consistent with those of 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, it did find reductions in early death. (For statistical reasons,
the meaningfulness of this last finding is questionable: It was a secondary
endpoint rather than a primary one.)

Fish oil. Fish oil contains healthy fats in the
omega-3 fatty acid category. Incomplete evidence suggests that fish oil
supplements may help prevent heart attacks and prevent sudden death after a heart
attack. This benefit may come from a number of fish oil’s actions, including
preventing dangerous heart arrhythmias and reducing heart rate.

Garlic. In one study, 432 people who had had a heart attack were
given either garlic oil extract or no treatment for three years. The results
showed a significant reduction of second heart attacks and about a 50 percent
reduction in death rate among those taking garlic. People who take aspirin to
prevent heart attacks should not take garlic supplements, as the combination
could lead to excessive bleeding.

Red yeast rice. Because of its purported ability to lower
cholesterol, red
yeast rice (made by fermenting a type of yeast called
Monascus purpureus over rice) has been studied in persons with
heart
disease. A double-blind study in China compared an alcohol
extract of red yeast rice (Xuezhikang) with placebo in almost five thousand people
with heart disease. In the four-year study period, the use of the supplement
reportedly reduced the heart attack rate by about 45 percent compared with
placebo, and total mortality was reduced by about 35 percent. At least three other
studies, all from this same original population of participants, have found
similar results in diabetics with heart disease and in persons with a previous
heart attack, with surprisingly large reductions in the rates of coronary events
(such as heart attack) and mortality. These levels of reported benefit, however,
are so high and so similar as to raise questions about their reliability.

Antioxidants. Antioxidant supplements help neutralize
free
radicals, which are dangerous, naturally occurring chemicals
that may accelerate heart cell death following a heart attack (among their many
other harmful effects). In a double-blind trial, people who had just experienced a
heart attack were given either placebo or a mixture of antioxidants (vitamin A,
vitamin C, vitamin E, and beta-carotene) for twenty-eight days. The results
indicated that the use of antioxidants minimized the extent of heart cell
damage.

Magnesium. The mineral magnesium is sometimes suggested for
stabilizing the heart after a heart attack, but one study actually found a
negative effect. In this one-year, double-blind, placebo-controlled trial of 468
people who had just experienced a heart attack, the use of a magnesium supplement
at a dose of 360 mg daily failed to prevent heart-related events (defined as heart
attack, sudden cardiac death, or need for cardiac bypass) and actually may have
increased the risk slightly.

Arginine. The supplement arginine has
been proposed for aiding recovery from a heart attack. In one double-blind study,
arginine did not cause harm, and it showed potential modest benefit. However, in
another study, arginine failed to prove helpful and possibly increased the death
rate of those who had a heart attack.

Other herbs and supplements. Other herbs and supplements that are sometimes said to be useful after a heart attack, but that lack reliable substantiation, include glycine, hawthorn, inosine, and lipoic acid.

Lifestyle modifications. Evidence suggests that intensive lifestyle modification, involving an extremely low-fat diet, exercise, and stress reduction, can actually reverse coronary artery disease in people who have had, or are at high risk for, heart attacks. It is not clear whether less ascetic approaches can achieve similar effects. However, there is evidence that less intensive low-fat and Mediterranean-style (low-fat plus high fish oil) diets can decrease the risk of recurrent heart attacks and similar cardiac events in persons who already have experienced a heart attack.

Chelation therapy. Some alternative medicine physicians recommend
the use of intravenous infusions of a chemical called ethylenediaminetetraacetic
acid to clear out the arteries of the heart, a method called chelation
therapy. This method is based on an outmoded understanding of
atherosclerosis, and it is most likely ineffective.

Herbs and Supplements to Use with Caution

Numerous herbs and supplements may interact adversely with drugs used to prevent or treat heart attacks.

Bibliography

Calo, L., et al. “N-3 Fatty Acids for the Prevention of Atrial Fibrillation After Coronary Artery Bypass Surgery.” Journal of the American College of Cardiology 45 (2005): 1723-1728.

Lu, Z., et al. “Effect of Xuezhikang, an Extract from Red Yeast Chinese Rice, on Coronary Events in a Chinese Population with Previous Myocardial Infarction.” American Journal of Cardiology 101 (2008): 1689-1693.

Mozaffarian, D. “Fish and N-3 Fatty Acids for the Prevention of Fatal Coronary Heart Disease and Sudden Cardiac Death.” American Journal of Clinical Nutrition 87 (2008): 1991S-1996S.

Raitt, M. H., et al. “Fish Oil Supplementation and Risk of Ventricular Tachycardia and Ventricular Fibrillation in Patients with Implantable Defibrillators.” Journal of the American Medical Association 293 (2005): 2884-2891.

Schulman, S. P., et al. “L-arginine Therapy in Acute Myocardial Infarction: The Vascular Interaction with Age in Myocardial Infarction (VINTAGE MI) Randomized Clinical Trial.” Journal of the American Medical Association 295 (2006): 58-64.

Tarantini, G., et al. “Metabolic Treatment with L-carnitine in Acute Anterior ST Segment Elevation Myocardial Infarction.” Cardiology 106 (2006): 215-223.

Tuttle, K. R., et al. “Comparison of Low-Fat Versus Mediterranean-Style Dietary Intervention After First Myocardial Infarction (from the Heart Institute of Spokane Diet Intervention and Evaluation Trial).” American Journal of Cardiology 101 (2008): 1523-1530.

Yokoyama, M., et al. “Effects of Eicosapentaenoic Acid on Major Coronary Events in Hypercholesterolaemic Patients (JELIS).” The Lancet 369 (2007): 1090-1098.

What is cellulitis? |

Definition

Cellulitis is a bacterial infection of deep skin
tissues. Bacteria enter the skin through cuts, insect bites, and sores. Persons
who are debilitated, such as older adults, diabetics, or persons unable to fight infection, may develop
cellulitis without a break in the skin.

Causes

Streptococcal and staphylococcal bacteria are the most common causes of cellulitis. Methicillin-resistant Staphylococcus aureus
(MRSA) infections that lead to cellulitis are often obtained in hospitals. Although bacteria are normally found on the skin, they do not cause problems unless there is a break in the skin.

Risk Factors

Any exposure to bacteria may lead to cellulitis. People who work in gardens or
other outdoor areas without gloves may get bacteria from the soil. Handling
poultry, fish, or meat without gloves or without careful handwashing also exposes
a person to bacteria. Any break in the skin from, for example, surgery,
liposuction, eczema, illegal drug use, or athlete’s foot may allow cellulitis to
develop. Athletic events, athletic facilities, day care, and other crowded areas
are also sources for infections, including infections with MRSA. Swelling in the
legs (edema) from diseases such as peripheral artery disease, even
without a break in the skin, may lead to cellulitis.

Symptoms

Redness, tightness, and a glossy look to the skin are symptoms of cellulitis. The area may grow in size and be painful and tender. Fever, chills, and muscle aches may indicate infection. Another symptom is a skin rash that appears suddenly and spreads.

Screening and Diagnosis

There is no screening for cellulitis. A physician usually makes the diagnosis
by observing the area of redness. In rare cases, radiology tests such as
ultrasound, magnetic resonance imaging, or a
computed
tomography scan may be used to rule out other problems.

Treatment and Therapy

The primary therapy for cellulitis is antibiotics,
drugs that are prescribed to fight infections. A doctor will carefully monitor the
initial response to antibiotics to be sure the infected area gets better with
treatment. If the cellulitis does not improve, the doctor may take blood samples
to determine what bacteria are involved in the infection and thus to find a more
appropriate antibiotic. In rare cases, sepsis (bacteria in the bloodstream)
may occur, leading to the need for additional laboratory blood work. Antibiotics
may be given by mouth (orally). For cases in which the infection is more severe or
does not respond to oral antibiotics, intravenous antibiotics (administered
directly into the bloodstream using a needle) may be indicated; admission to a
hospital is likely too. Local treatment of the infected area may include elevating
the area and applying moist dressings. If not treated, cellulitis can cause more
serious problems, including meningitis, infection in the bone, and
gangrene (tissue death).

Prevention and Outcomes

Preventing cellulitis means taking care of the skin. Cleanliness; wearing
gloves when needed; treating cuts, scrapes, and bites promptly; and treating any
skin
infections such as athlete’s foot immediately are important
preventive measures. Persons with risk factors for cellulitis should discuss with
their doctor the ways to prevent its development, including taking antibiotics on
a regular basis.

Bibliography

Archer, G. L. “Staphylococcal Infections.” Andreoli and Carpenter’s Cecil Essentials of Medicine. Ed. Thomas E. Andreoli et al. 8th ed. Philadelphia: Saunders, 2010. Print.

Berman, Kevin. "Cellulitis." MedlinePlus. Natl. Lib. of Health, 15 May 2013. Web. 29 Dec. 2015.

"Cellulitis." Mayo Clinic. Mayo Foundation for Medical Education and Research, 11 Feb. 2015. Web. 29 Dec. 2015.

Hall, John C. Sauer’s Manual of Skin Diseases. 9th ed. Philadelphia: Lippincott, 2006. Print.

Stevens, Dennis L. “Infections of the Skin, Muscle, and Soft Tissues.” Harrison’s Principles of Internal Medicine. Ed. Joan Butterton. 17th ed. New York: McGraw-Hill, 2008. Print.

Swartz, Morton N., and Mark S. Pasternack. “Cellulitis, Necrotizing Fasciitis, and Subcutaneous Tissue Infection.” Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Ed. Gerald L. Mandell, John E. Bennett, and Raphael Dolin. 8th ed. Philadelphia: Elsevier, 2015. 1194–215. Print.

Turkington, Carol, and Jeffrey S. Dover. The Encyclopedia of Skin and Skin Disorders. New York: Facts On File, 2002. Print.

What is synthetic cannabis? |

Synthetic cannabis, also called spice, synthetic marijuana, fake pot, or K2, is a popular designer drug. While often advertised as a legal variant of marijuana, synthetic cannabis has very little in common with real cannabis. Tested synthetic cannabis contains a different chemical composition from marijuana, causing a significantly more powerful high and vastly more potent and negative side effects than real marijuana. Synthetic cannabis manufacturers often alter the drug's chemical composition to evade laws designed to ban designer drugs.

Origins

Professor John W. Huffman created synthetic cannabis in the late 1990s. Huffman wanted to research claims that marijuana had a variety of medicinal uses. However, federal law made this research impossible. To circumvent this, researchers in Huffman's laboratory began to synthesize molecules that bind to the same receptor as THC, or tetrahydrocannabinol, the psychoactive chemical found in marijuana, theoretically simulating marijuana's effects on the brain. Because the chemicals found in the lab were new and unregulated by federal law, experimenting with these chemicals was perfectly legal.

Hoffman's lab quickly created hundreds of varieties of synthetic cannabis. Some variants were beneficial to humans. They even lacked the psychoactive effects normally associated with THC. Other variants produced psychoactive effects hundreds of times more powerful than marijuana. While none of these were intended for human consumption, hundreds were somehow leaked to the public.

Companies in the United Kingdom and Asia quickly realized the commercial potential of the new drug. They sprayed the chemicals over nonreactive plant materials for a marijuana-like appearance and then marketed the synthetics as a legal version of marijuana. The bags were often labeled "not for human consumption," or as incense or potpourri. Because of their labels, the drugs were legal to sell in gas stations and other specialty stores. Whenever a specific chemical formula was outlawed, manufacturers slightly changed the synthetic drug sprayed on the plant materials to keep the drug technically legal.

Effects

Most varieties of synthetic cannabis have little in common with real marijuana. While synthetic cannabis looks like natural marijuana, and both THC and synthetic chemicals bind to the CB1 and CB2 receptors in the brain, they produce very different effects. THC is a partial agonist of the CB1 and CB2 receptors, meaning THC molecules partially bind to those receptors. Most varieties of synthetic cannabis are full agonists, meaning they bind to CB1 and CB2 receptors at a much greater rate.

Studies have shown that synthetic cannabis highs can cause increased heart rate, heart palpations, profuse sweating, hallucinations, paranoia, aggressive behavior, vomiting, seizures, comas, impaired memory, confusion, disorientation, anxiety, and psychosis. Researchers even coined the term spiceophrenia in reference to spice, or synthetic cannabis, users' schizophrenia-like symptoms.

Other side effects vary with the specific chemicals imbibed by the user and the size of the dose ingested. However, due to its questionably legal status and the unreliable manufacturing process used to make it, variables such as these cannot be reliably controlled by the average user. Spraying the chemicals onto plant material creates uneven chemical distribution, leading to areas with unpredictably high drug concentration. Additionally, as more synthetic cannabinoids are made illegal, the chemicals used quickly change. Two identical-looking bags from the same manufacturer may contain completely different chemicals.

Because it is impossible to regulate how much synthetic cannabis is ingested at one time, accidental overdose is possible. Overdoses often require immediate medical attention. An overdosing user may suddenly collapse, drop into a comatose state, stop breathing, or suffer from strokes or heart attacks. Synthetic cannabis overdoses have been responsible for cases of permanent brain damage and premature death.

Unlike real marijuana, synthetic cannabis is highly addictive. Habitual users attempting to quit may experience severe withdrawal symptoms lasting several days, with more mild symptoms persisting for months. Symptoms of withdrawal episodes from synthetic cannabis include anxiety, depression, nightmares, psychotic episodes, restlessness, suicidal thoughts, loss of appetite, paranoia, insomnia, hallucinations, vomiting, diarrhea, hot and cold flashes, intense cravings for more of the drug, irritability, seizures, and heart attacks.

Popularity

According to the National Council on Alcoholism and Drug Dependence, Inc., 12 percent of high school students reported using synthetic cannabis, compared to 57 percent for alcohol and 39 percent for traditional marijuana. Additionally, synthetics have become extremely popular with people on probation and those who routinely get drug tested for work. Because the chemical formulas used in the production of synthetic cannabis change regularly, effective tests for synthetic cannabis are difficult and costly to produce. Most drugs tests only test for natural marijuana and more common drugs.

Additionally, experts believe that easy access to synthetic cannabis has drastically increased the drug's popularity. Though some varieties of synthetic cannabis have been successfully outlawed, newer variants are usually unregulated by state and federal laws. For this reason, newer variants can legally be sold to minors in places such as convenience stores, gas stations, and drug paraphernalia shops.

Bibliography

"Can You Overdose on Marijuana?" AddictionBlog.org. AddictionBlog.org. Web. 2 Apr. 2015. http://drug.addictionblog.org/can-you-overdose-on-marijuana/

"Is Spice Bad for You?" Spice Addiction Support. SpiceAddictionSupport.org. Web. 27 Mar. 2015. http://spiceaddictionsupport.org/is-spice-bad-for-you/

Melville, Nancy A. "Synthetic Cannabis Triggers 'Spiceophrenia.'" Medscape Multispecialty. WebMD LLC. Web. 2 Apr. 2015. http://www.medscape.com/viewarticle/817745

"Side Effects of Spice Use." Spice Addiction Support. SpiceAddictionSupport.org. Web. 27 Mar. 2015. http://spiceaddictionsupport.org/side-effects-of-spice-use/

"Spice Withdrawal Symptoms." Spice Addiction Support. SpiceAddictionSupport.org. Web. 27 Mar. 2015. http://spiceaddictionsupport.org/spice-withdrawal-symptoms/

"Symptoms of Synthetic Marijuana Use." Spice Addiction Support. SpiceAddictionSupport.org. Web. 27 Mar. 2015. http://spiceaddictionsupport.org/symptoms-of-synthetic-marijuana-use/

"Synthetic Drug Threats." National Conference of State Legislatures. National Conference of State Legislatures. Web. 27 Mar. 2015. http://www.ncsl.org/research/civil-and-criminal-justice/synthetic-drug-threats.aspx

"Synthetic Marijuana Third-Most Abused Substance by High School Students." National Council on Alcoholism and Drug Dependence, Inc. National Council on Alcoholism and Drug Dependence, Inc. Web. 2 Apr. 2015. https://ncadd.org/in-the-news/708-synthetic-marijuana-third-most-abused-substance-by-high-school-students

Walton, Alice G. "Why Synthetic Marijuana is More Toxic to the Brain Than Pot." Forbes. Forbes.com LLC. 28 Aug. 2014. Web. 27 Mar. 2015. http://www.forbes.com/sites/alicegwalton/2014/08/28/6-reasons-synthetic-marijuana-spice-k2-is-so-toxic-to-the-brain/

"What is Spice? The Facts on Synthetic Weed." Spice Addiction Support. SpiceAddictionSupport.org. Web. 27 Mar. 2015. http://spiceaddictionsupport.org/what-is-spice/

In Shakespeare's Othello, how does Othello disintegrate from a confident leader into a homicidal murderer?

When we first hear of Othello in Act 1 scene 1, it is through the rhetoric uttered by Iago, his ancient. Although Iago's words are spoken in bitter contempt for the general, it is clear that he is regarded with respect by others:

Three great ones of the city,
In personal suit to make me his lieutenant,
Off-capp'd to him:

The fact that 'three great ones' 'off-capped' to Othello is an indication that they held him in high esteem. Furthermore, it is clear that the 'great ones' are themselves men of high rank and title, most probably senators. The fact that they removed their caps as a sign of respect is an obvious indication that he was held in high regard.

Later, in scene 2, after Iago and Roderigo have demonised him by telling Brabantio that he has stolen his daughter, we also learn that Othello is proud but humble and has earned much admiration for his duty to the Venetian state. When Iago informs him of Brabantio's accusation, he replies:

Let him do his spite:
My services which I have done the signiory
Shall out-tongue his complaints. 'Tis yet to know,--
Which, when I know that boasting is an honour,
I shall promulgate--I fetch my life and being
From men of royal siege, and my demerits
May speak unbonneted to as proud a fortune
As this that I have reach'd:

It is obvious that the general knows that the duty he has shown Venice would hold greater sway than Brabantio's accusations. Furthermore, he has a proud heritage, for he is born of royal blood and he will, in his defence, openly remind all about his lineage, for he will not allow himself to be tied down to petty assertions against his good name and character. These are truly the words of a proud man who brims with self-confidence.

A further indication of Othello's confidence is seen later when Brabantio confronts him accompanied by officers. The purpose is to arrest the general. When they draw their swords, the general, self-assured, tells them:

Keep up your bright swords, for the dew will rust them.
Good signior, you shall more command with years
Than with your weapons.

He fearlessly addresses Brabantio directly and tells him that he would be better off using the authority that comes with age than weapons to issue commands. Further in their conversation, Othello tells Brabantio that he will face any charges against him before whomsoever Brabantio chooses.

In scene three, Othello's confidence once again shines through. He shows true leadership when he addresses the duke and others by providing a frank account regarding the origin of his relationship with Desdemona. She later verifies what he says. In this, Othello earns even greater respect. Added to this, we learn about the extent of the authority and respect that he commands when the duke asks him to immediately leave for Cyprus to take command as governor and fend off an invasion by the Turks.

It is patently ironic, then, that such a great man becomes such an easy target for Iago's manipulation and deceit, for he succeeds in turning the general into an irrational and overwhelmingly jealous character who becomes like putty in his hands. Iago, resentful that Othello overlooked him for promotion and out of pure malice, has decided to take revenge on the general. He starts by planting pernicious seeds of Desdemona's supposed infidelity in his mind. 

Iago uses Roderigo to craft a malevolent plot, not only against the general but also against Cassio, his new lieutenant. His purpose is clear: make the general believe that he is being cuckolded by his lieutenant. He then devises a plot, with Roderigo, to have Cassio dismissed. The two succeed in this venture. Iago then advises Cassio to seek Desdemona's assistance to regain his position by asking her to speak to Othello on his behalf. Iago would then use this interaction as evidence of their affair. Both Cassio and Desdemona fall neatly into his trap - she out of kindness to help and Cassio out of desperation to regain his honour.

Iago cleverly plants the first seed of suspicion in the general's mind when, in Act 3, scene 3, he and Othello come upon Cassio and Desdemona conversing. Cassio slips away and Iago remarks: 'Ha! I like not that.' When Othello asks what he said, he feigns ignorance, making the general even more curious. When Othello asks whether it had been Cassio they had seen, Iago slyly replies:

Cassio, my lord! No, sure, I cannot think it,
That he would steal away so guilty-like,
Seeing you coming.

Iago's intention is obvious and Othello falls for it hook, line and sinker. He is clearly upset and Desdemona does not help matters when she mentions that she had spoken to 'a suitor' and then starts pestering her husband about talking about Cassio's appeal. 

Throughout the play, Iago persistently fills Othello's head with lies, telling him about how Venetian women have a tendency to have affairs since it is a custom and that Cassio had once slept next to him and cried out Desdemona's name whilst embracing him and kissing him, seemingly dreaming that he was Desdemona. Iago preys on the general's insecurities about being a foreigner of a different race, being much older than his wife and his lack of knowledge about Venetian women. He drives the general insane with jealousy to such an extent that Othello is rude to Desdemona and refuses her help when he has a headache and she wants to wipe his brow with a precious handkerchief he had given her. 

The handkerchief is later used as damning proof of Desdemona's infidelity. When she drops it, Emilia picks it up and gives it to her husband, who plants it in Cassio's room. Iago manipulates the situation and contrives events so that Othello actually sees his precious napkin in Cassio's hands when he asks Bianca to copy the embroidery. Othello is, at this point, utterly convinced that he has been made a fool of. Iago has provided him with ocular proof of his beautiful and young wife's infidelity. Even at this point, though, he is filled with pity, but Iago encourages him. We read in Act 4, scene 1 (lines 209 - 223):

OTHELLO
Nay, that's certain: but yet the pity of it, Iago!
O Iago, the pity of it, Iago!

IAGO
If you are so fond over her iniquity, give her
patent to offend; for, if it touch not you, it comes
near nobody.

OTHELLO
I will chop her into messes: cuckold me!

IAGO
O, 'tis foul in her.

OTHELLO
With mine officer!

IAGO
That's fouler.

OTHELLO
Get me some poison, Iago; this night: I'll not
expostulate with her, lest her body and beauty
unprovide my mind again: this night, Iago.

IAGO
Do it not with poison, strangle her in her bed, even
the bed she hath contaminated.

OTHELLO
Good, good: the justice of it pleases: very good.

Ultimately, Othello murders Desdemona in her bed by suffocating her. Later, when he realises the depth of his folly, he commits suicide.

What is dialectical behavioral therapy (DBT)?

Introduction

In 1987, psychologist Marsha M. Linehan published her method for treating patients with
borderline personality disorder (BPD), which she called dialectical behavioral therapy. Borderline personality disorder is one of more serious and treatment-resistant personality disorders, characterized by dysregulation of emotions (an inability to regulate and control emotional responses), as well as of thoughts, behaviors, and interpersonal relations, including how a person relates to the self. People with this personality configuration experience affective instability, difficulty managing their anger, random impulsivity, proclivity for self-harm, paranoia, extreme fear of abandonment, uncertainty about who they are, and chronic emotional emptiness.

Traditional treatments assumed that therapists could not avoid rejecting patients’ self-destructive behaviors and attitudes. These approaches were change-oriented and, though well intentioned, frequently put the therapist at odds with the patient. In developing dialectical behavioral therapy, Linehan enumerated strategies that allowed therapists to accept patients where they were, promoting acceptance-oriented skills in addition to traditional change-oriented skills. An accepting attitude toward patients affirms the worldview inherent in their feelings, attitudes, thoughts, and behavior. It promotes the rectitude of patients’ experiences and all aspects of their personal worlds. It also maintains that, however patients are being in the moment, it is the best that they are able to be at that time.

Underlying dialectical behavioral therapy is a constellation of worldviews that highlights the importance of dialectic and the acceptance of life as it is. Acceptance draws heavily from Zen principles; dialectic has its philosophical roots in the work of Immanuel Kant, Frederick Shelling, and, most of all, Georg Hegel. Dialectic is the synthesizing of point and counterpoint. For every stance or particular behavioral occurrence, there is an equally valid, but opposite, stance or occurrence. The therapist supports the patient’s moving toward a healthier integration of these ostensibly irreconcilable positions. In practice, dialectical behavioral therapy strategies draw heavily from traditional cognitive and behavioral therapy techniques and process approaches well known in person-centered and emotion-focused therapies.

Before dialectical behavioral therapy, patients with borderline personality disorder were considered almost impossible to treat effectively beyond varying levels of therapeutic stabilization. People with borderline personality disorder are emotionally flammable and fragile, unable to reliably regulate their inner states, have conflict-ridden relationships, frequently consider suicide, and often engage in self-harming behaviors such as cutting. They were raised in and typically perpetuate an invalidating environment, a social environment that actively opposes acceptance of patients’ perceptions, feelings, judgments, attitudes, and behaviors. This toxic climate perpetuates pervasive criticism, denigration, trivializing, and random social reinforcement. People in this environment are denied genuine attention, respect, understanding from others, and positive regard for who they are and what they are experiencing. Stress and perceived abandonment or rejection overwhelm the ability of people with borderline personality disorder to self-regulate, and they remain chronically, recurrently, emotionally vulnerable. Therapists were often frustrated (and sometimes intimidated) by these patients’ volatility and high degree of risk. Dialectical behavioral therapy became a road map for therapists who trained in it.

How the Therapy Works

Patients who undertake dialectical behavioral therapy begin with “pretreatment,” a series of psychotherapy sessions in which the therapist and patient establish a shared understanding of dialectical behavioral therapy’s rationale, agreements about what each expects of the other, the levels of dialectical behavioral therapy interventions and treatment targets, and perhaps most important, the commitment to be in treatment. In pretreatment, patients agree to stay in therapy for a specified period, most commonly a year, to come to all therapy sessions, to come on time, to work toward ending all self-harming behaviors, to undertake interpersonal skills training, and to pay fees in a timely manner. Therapy is usually discontinued if four consecutive sessions are missed. Therapists promise to maintain their own ongoing and professionally supportive training, to be available for weekly sessions and phone consultations, to demonstrate positive regard and nonjudgmental attitudes, maintain confidentiality, and obtain additional consultation as would benefit the therapy.

Levels of Treatment

Level I of treatment establishes a target hierarchy that includes reduction of self-harming behaviors such as cutting or burning oneself, of behaviors and barriers that interfere with treatment, and of behaviors that interfere with establishing a healthier quality of life. Patients at the early stages of dialectical behavioral therapy treatment are usually highly distressed, bordering on hopelessness, and at the mercy of the enigmatic flow of their own emotional surges. Self-injury, drug abuse, depression, and suicidal thinking are the norm at this state.

Level II begins when the skills developed in Level I are sufficient to contain self-harming patterns. The therapist begins to presumptively treat patients with post-traumatic stress interventions, as these enhance their ability to experience aversive emotions without being undone by them. As progress is made, other emotionally difficult, even overwhelming targets are identified. The emotional and psychological commitments to remaining in treatment at these early stages can result in patients’ working against their goals, as in missing therapy appointments, showing up late, and not completing agreed-on homework; it can also result in psychological regression, wherein patients at Level II treatment exhibit Level I functioning (for example, burning or cutting themselves or engaging in other dangerous behaviors). Patients at these levels of care must be closely monitored. Once the functional goals of Level II are reliably sustained, the majority of patients leave treatment. They have expended a great effort at much personal cost to have gotten this far.

For patients proceeding to Level III, the targets of treatment are similar to those of typical psychotherapy in that they aim at reducing or eliminating behaviors that are not debilitating but interfere with experiencing ordinary pleasure, happiness, fulfillment, and personal meaning.

Level IV targets higher-order psychological values: a functional application of one’s philosophy of person, integration, and the blending of spiritual elements with those of psychological self-actualization.

Modalities of Treatment

Dialectical behavioral therapy uses four modes of treatment that are not commonly found together in other therapeutic approaches: group-skills training for patients, individual therapy for patients, telephone consultations between patients and therapists, and therapists’ participation in an ongoing consultation team. Many of the ways borderline personality disorder patients regress are through perceived, and thus experienced, negative social interactions. These are most effectively worked through and improved by training in a group setting. Individual therapy is typically weekly and involves working toward the established and mutually agreed-on targets during pretreatment. Because the inner life of patients with borderline personality disorder can be so tumultuous, telephone consultations are routinely used to bolster patients and review how to apply the concepts and skills discussed in individual and group training. Because this is such a challenging patient population, the standard practice of dialectical behavioral therapy requires its practitioners to meet regularly with other dialectical behavior therapists for case presentation, honing of dialectical behavioral therapy therapeutic skills, and peer consultation.

Future

Though Linehan focused her earlier work on patients with borderline personality disorder, and dialectical behavioral therapy is the therapy of first choice in their treatment, the principles and techniques have been applied to other often hard-to-treat patient groups such as those with eating disorders, bipolar disorder (in conjunction with targeted psychopharmacology), histrionic personality disorder, a history of sexual and violent assault, and a variety of diagnoses among the elderly. Though it requires a high degree of patient commitment and specific training that implies lifelong learning, it is the most powerful and effective intervention available to a patient group that had often been considered nearly impossible to treat effectively.

Bibliography

Axelrod, Seth R., et al. "Emotion Regulation and Substance Use Frequency in Women with Substance Dependence and Borderline Personality Disorder Receiving Dialectical Behavior Therapy." American Journal of Drug and Alcohol Abuse 37.1 (2011): 37–42. Print,

Hanh, Thich Nhat. The Miracle of Mindfulness: An Introduction to the Practice of Meditation. New York: Houghton Mifflin, 2008. Print.

Koerner, Kelly. Doing Dialectical Behavior Therapy: A Practical Guide. New York: Guilford, 2012. Print.

Linehan, Marsha M. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press, 1993. Print.

McKay, Matthew, Jeffrey C. Wood, and Jeffrey Brantley. Dialectical Behavioral Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotional Regulation, and Distress Tolerance. New York: New Harbinger, 2007. Print.

Marra, Thomas. Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression and Anxiety. New York: New Harbinger, 2004. Print.

Santoro, Joseph, and Ronald Jay Cohen. The Angry Heart: Overcoming Borderline and Addictive Disorders: An Interactive Self-Help Guide. Oakland: New Harbinger, 1997. Print.

Spradlin, Scott E. Don’t Let Your Emotions Run Your Life: How Dialectical Behavioral Therapy Can Put You in Control. New York: New Harbinger, 2004. Print.

Van Gelder, Kiera. The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating. Oakland: new Harbinger, 2010. Print.

Yudovsky, Stuart C. Fatal Flaws: Navigating Destructive Relationships with People with Disorders of Personality and Character. 4th ed. Washington, D.C.: American Psychiatric Association, 2005. Print.

In Gathering Blue, why does Lois Lowry spend so much time describing the thread and Kira's weaving?

Lois Lowry, the author of Gathering Blue, chose an artist to be the main character because she wanted a character who was uniquely capable of influencing her society, even as a young person. The detailed descriptions of dyes, weaving, colors, and thread reinforce the idea of Kira as an artist. Before Kira comes to live in the Council Edifice, she doesn't really understand her gift. As she works on the Singer's robe; gets to...

Lois Lowry, the author of Gathering Blue, chose an artist to be the main character because she wanted a character who was uniquely capable of influencing her society, even as a young person. The detailed descriptions of dyes, weaving, colors, and thread reinforce the idea of Kira as an artist. Before Kira comes to live in the Council Edifice, she doesn't really understand her gift. As she works on the Singer's robe; gets to know Thomas, another artist; and becomes more in tune with the way the cloth "speaks" to her, she begins to understand the unique opportunity an artist has to influence society for good. When Thomas, on their visit to the Fen, says that people have always lived in such horrible conditions, Kira suggests that since they are both artists, "maybe we can make it different." Thomas doesn't understand what she means, but Kira holds on to that thought.

Even after she learns that she, Thomas, and Jo are all being held captive by the guardians, she embraces her destiny: "They were the artists who could create the future." Thus, Kira decides to stay in her village, believing that her creative vision can produce improvements for her people. Because she is an artist, she "could feel the future through her hands." 

Lowry emphasizes Kira's work with thread and dye to communicate her idea that artists can shape the future through their creativity and vision.

What is cancer education? |

Subspecialties: An interdisciplinary effort, cancer education encompasses diverse specialties, including oncology, nursing, pediatrics, dentistry, pharmacy, dietetics, genetic counseling, physical therapy, occupational therapy, psychology, physician assistance, and social work.

Cancers treated: Cancer education addresses all known cancers, focusing on commonly occurring cancers, particularly breast, prostate, and colon cancers, which medical professionals frequently diagnose in patients. Internationally, medical, dental, and nursing schools educate students regarding cancers they will probably encounter in their residencies and practices. Graduate medical students obtain advanced cancer education according to specialties they pursue in their training and research.

Training and certification: Cancer educators often receive basic training for educational procedures as part of health-related degrees they earn. The American Association for Cancer Education (AACE) offers workshops and clinics at its annual conferences, during which participants can acquire skills and learn about developments in cancer education research and practices to earn credits and certificates acknowledging they participated in those educational experiences. The American Cancer Society (ACS) and Oncology Nursing Society present continuing education opportunities for cancer educators to complete specific training to learn methods and strategies for more effective cancer education services for patients and their caregivers.

Services and procedures performed: Cancer education experts instruct medical professionals while they attend school and throughout their careers concerning methods to diagnose cancers in patients and to determine which treatments to recommend. Governments, academic institutions, and such groups as the American Cancer Society fund research to enhance educational opportunities for physicians and health professionals to provide suitable, up-to-date medical care for cancer patients. Professional and licensing organizations such as the American College of Surgeons offer resources in their educational departments.

The American Association for Cancer Education and European Association for Cancer Education reinforce their members’ educational and teaching skills in medical and dental colleges, hospitals, and other forums by offering information in such specific areas of cancer education as oral oncology and palliative care and by encouraging continued training in cancer education. Those professional organizations collaboratively publish the Journal of Cancer Education, which contains news and articles evaluating cancer education techniques, communication, and research. Representatives of the American Association for Cancer Education survey cancer education taught at US medical and dental schools to evaluate the curricula offered and offer insights regarding what cancer education should address in schools.

Health professionals supply information to assist people in acquiring knowledge to prevent or mitigate cancer through informed decisions, early detection of symptoms, and the choice of effective treatments. Cancer educators inform both children and adults in their communities regarding cancer issues. Educators present cancer prevention information at schools and workplaces, advising healthy nutrition and behaviors to minimize risks associated with cancer. Cancer educators convey information concerning genetic testing for potentially inherited cancer vulnerabilities.

Medical personnel realize cancer education counters misinformation and enables better medical care, helping adjust perceptions concerning cancer by explaining that many cancers are treatable, not terminal. Cancer educators create and distribute accessible information, assessing literacy and cultural factors to achieve effective communication. Educators evaluate attitudes regarding cancer in individual patients and their caregivers to determine the specific educational materials, ranging from pamphlets to videotapes and Internet resources, most likely to assist them. Cancer educators assist comprehension of information to ease physical and emotional aspects of cancer by explaining tests, procedures, medications, and side effects.

Many hospitals and cancer centers maintain cancer education information in health libraries and learning centers with education personnel designated to administer those resources. Cancer groups, hospitals, and drug manufacturers publish educational material to assist cancer educators to learn about new treatments and pharmaceuticals.

The American Cancer Society has pursued education through media, a Facts About Cancer pamphlet, lists of seven basic cancer symptoms, and educational guides devoted to specific cancers. The National Cancer Institute (NCI) contributes to cancer education by helping both health provider educators and people seeking cancer information. The institute published the Trainer’s Guide for Cancer Education (2005) and established a Cancer Information Service and an Office of Cancer Communications. The NCI Patient Education Branch created the Cancer Patient Education Network. The Wellness Community also provides cancer education resources.

Bibliography

Labus, James B., and Alison A. Lauber. Patient Education and Preventative Medicine. Philadelphia: Saunders, 2001. Print.

National Cancer Institute. Trainer’s Guide for Cancer Education. Bethesda: NIH, Natl. Cancer Inst., 2005. Print.

Osborne, Helen. Health Literacy from A to Z: Practical Ways to Communicate Your Health Message. 2nd ed. Burlington: Jones, 2013. Print.

Quintana, Yuri, Aubrey Van Kirk Villalobos, and Dorothy May. Advancing Cancer Education and Healthy Living in Our Communities: Putting Visions and Innovations into Action. Amsterdam: IOS, 2012. Print.

Rankin, Sally H., Karen Duffy Stallings, and Fran London. Patient Education in Health and Illness. 5th ed. Philadelphia: Lippincott, 2005. Print.

Saca-Hazboun, Hanan. “Empowering Patients with Knowledge: An Update on Trends in Patient Education.” ONS Connect 22.5 (2007): 8–12. Print.

Varricchio, Claudette, et al., eds. A Cancer Source Book for Nurses. 8th ed. Sudbury: Jones, 2004. Print.

Wilkes, Gail M., and Terri B. Ades. Patient Education Guide to Oncology Drugs. 2nd ed. Sudbury: Jones, 2004. Print.

Organizations and Professional Societies

American Association for Cancer Education
.


http://www.aaceonline.com, 620 Walnut Street, 330 WARF Building, Madison, WI 53726.

European Association for Cancer Education
.


http://www.eaceonline.com, Academie Gezondheidzorg, Saxion Hogescholen, Postbus 70.000, 7500 KB Enschede, The Netherlands.

On the day of President Kennedy's death, how does the atmposphere in El Building change?

El Building is inhabited mostly by immigrants from Puerto Rico. They are a fun-loving people who are very social. El Building is described by Elena as "a monstrous jukebox" because every apartment blasts its own music to drown out that of the neighbors. Not only does music blast out of open windows, but people are always socializing with each other and children are usually out playing and squealing with life. All of this creates an...

El Building is inhabited mostly by immigrants from Puerto Rico. They are a fun-loving people who are very social. El Building is described by Elena as "a monstrous jukebox" because every apartment blasts its own music to drown out that of the neighbors. Not only does music blast out of open windows, but people are always socializing with each other and children are usually out playing and squealing with life. All of this creates an atmosphere of a busy, small town in and of itself. 

However, on November 22, 1963, all of that stops in honor of the fallen president. When Elena walks home from school on that fateful day, she notices that no children are playing outside of El Building; there are no viragoes arguing with each other; no salsas are blasting through the windows; and, "there was a profound silence." Elena's mother even asks her to go to church with her to pray for Kennedy and his family. The change in the atmosphere shows that the people respect Kennedy and pay him homage by shutting down all other activity on the day he died.

What is the significance of the lines "Astride of a grave and a difficult birth...But habit is a great deadener" in Waiting for Godot?

In his essay on Proust, Beckett writes that habit is "the ballast that chains a dog to his vomit." This is clearly a criticism of habit. Habit, by itself, is this idea that we repeat the same thoughts or actions simply because we have become used to doing so. In this sense, habit is thoughtless and robotic.

In this play, the two main characters continue to wait for Godot. They waste vast amounts of time...

In his essay on Proust, Beckett writes that habit is "the ballast that chains a dog to his vomit." This is clearly a criticism of habit. Habit, by itself, is this idea that we repeat the same thoughts or actions simply because we have become used to doing so. In this sense, habit is thoughtless and robotic.

In this play, the two main characters continue to wait for Godot. They waste vast amounts of time waiting for someone who is (likely) never going to show up. They waste large portions of their lives waiting. A life is between birth and the grave. Each person is basically "astride" birth and death, one foot in each. We stride from birth to death. So, to spend that "stride" waiting for nothing, simply out of habit, is a waste of a life. In this passage, Vladimir is making complete sense: habit meaningfully kills a person by making him/her waste time with empty habits. 

The problem, as Vladimir sees it in this passage, is not a lack of time. The problem is that humans spend too much time with pointless habits. There is the added notion, derived from the play as a whole, that it is also useless to depend upon some outside authority figure (Godot). If Vladimir and Estragon could assert their own free will and their own independence from Godot, they could stop waiting and start doing more significant things with their time. They need to break from this habit of waiting. Breaking a habit or breaking a tradition allows one to experience new things. This seems like an obvious statement, but everyone is guilty of repetitive behaviors and ways of thinking. When these repetitions (habits) continue and produce nothing meaningful, the habits become "deadeners." 

What is hepatitis E? |

Definition

Hepatitis E is a viral liver infection transmitted through the intestinal
tract. Hepatitis E, which is an acute, short-lived illness that can sometimes
cause liver failure, is more common in regions of the world that lack clean water
and environmentally safe sanitation.

Causes

Hepatitis E is primarily spread by fecal-oral transmission. It is commonly
found in countries where human waste contaminates the water sources. Large
outbreaks have occurred in Asia and South America that have poor sanitation. In
the United States and Canada, no outbreaks have been reported, but persons
traveling to an endemic region may return infected with the hepatitis E virus
(HEV).

Risk Factors

Risk factors for hepatitis E are factors that do not seem to be a direct cause
of the disease. Hepatitis E occurs in both epidemic and
sporadic-endemic forms usually associated with contaminated drinking water. Because this disease is primarily a
result of a lack of water filtration in underdeveloped countries, there are no specific risks
associated with it. Water filtration systems are prevalent in most developed
countries, such as the United States, Canada, and China, and in the countries of
Europe. Historically, the only major waterborne epidemics have occurred in Asia
and North and West Africa.

Symptoms

The symptoms of hepatitis E include flulike symptoms, fever, fatigue, nausea, vomiting, loss of appetite, abdominal pain, diarrhea, and jaundice.

Screening and Diagnosis

Cases of hepatitis E are not clinically evident from other types of acute
viral
hepatitis. Diagnoses are usually made by blood tests that
detect elevated levels of specific antibodies to hepatitis E in the body
or by reverse transcriptase polymerase chain reaction. However, these tests are
not yet widely available.

When waterborne hepatitis occurs in developing countries, especially if the
disease is more severe in pregnant women, hepatitis E should be suspected if
hepatitis
A has been excluded. If laboratory tests are not available,
epidemiologic evidence can help in establishing a diagnosis.

Treatment and Therapy

Hepatitis E is classified as a viral disease, so there is no effective
treatment of acute hepatitis. Consequently, antibiotics
are of no significance in the treatment of the viral
infection. Hepatitis E infections usually remain in the
intestinal tract, and hospitalization is generally not required. However, there
are reports of HEV damaging and destroying liver cells, so much so that the liver
cannot function. This is called fulminant liver failure, a condition that can lead
to death. Pregnant women are at a higher risk of dying from fulminant liver
failure. This increased risk is not constant with any other type of viral
hepatitis.

The majority of persons who recover from acute infection do not continue to
carry HEV and, thus, cannot pass the infection to others. No available therapy can
alter the course of acute infection. Also, there are no vaccines for hepatitis E
that have been approved by the U.S. Food and Drug Administration.

Prevention and Outcomes

Prevention is the most effective approach against hepatitis E. The most effective way to prevent hepatitis E is to provide and consume safe drinking water and to take precautions to use sterilized water and beverages when traveling to an endemic region.

Bibliography

Feldman, Mark, Lawrence S. Friedman, and Lawrence J. Brandt, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. New ed. 2 vols. Philadelphia: Saunders/Elsevier, 2010.

Kamar, N., et al. “Hepatitis E Virus and Chronic Hepatitis in Organ-Transplant Recipients.” New England Journal of Medicine 358 (2008): 811-817.

Shrestha, M. P., et al. “Safety and Efficacy of a Recombinant Hepatitis E Vaccine.” New England Journal of Medicine 356 (2007): 895-903.

What are hearing aids? |

Indications and Procedures

Hearing loss is one of the most common conditions affecting older adults, but it is not limited to that age group. According to the World Health Organization, disabling hearing loss affected more than 350 million people worldwide by 2013, with many more experiencing mild forms of hearing loss. The use of hearing aids is one of the primary strategies for the treatment of hearing loss. These devices were developed to help those people affected by hearing loss ranging from mild to severe and resulting from a number of causes. The most common type of hearing loss, sensorineural, is linked to a variety of physical and psychosocial dysfunctions (isolation, depression, hypertension, and stress) as well as illnesses such as ischemic heart
disease and arrhythmias.

Over the years, hearing aids have evolved in several ways. Two major trends have been in signal processing and size. Prior to the 1940s, hearing aids were large and required carrying a battery pack strapped to one’s body. In the 1940s, vacuum tubes reduced the size of hearing aids to that of a transistor radio. Hearing aids worn in the ear or on the head were not available until the 1960s. At that time, the best available hearing aids helped in quiet only; in loud situations, they made things worse. Therefore, it was common practice to remove them around noise. Beginning in the 1980s and 1990s, advanced circuitry offered consumers improved quality of hearing in quiet as well as some increased ability to hear in noise; sound distortion was minimal. In the decades since, hearing aids have become more comfortable and less noticeable. Certain hearing aids can be electronically adjusted for individual users; for example, they can be reprogrammed to accommodate increased hearing loss. Some hearing aids have volume controls, while others adjust automatically. Research has shown that consumers report greater satisfaction with sound quality than they did in the past, and people with hearing loss in both ears tend to be more satisfied with two hearing aids, enabling them to determine the direction of sounds.

For patients with bilateral profound sensorineural hearing loss, which does not respond to traditional hearing aids, a cochlear implant is now possible. A cochlear implant is an electronic prosthesis surgically implanted in the inner ear. It has external parts that are worn outside the ear, including a microphone, speech processor, headpiece antenna, and cable. It is not a hearing aid. A cochlear implant delivers electrical signals to the brain, where they are interpreted as sounds. Potential candidates for these implants include both children and adults in a wide age range. Generally, children should be at least eighteen months old, and many successful implant recipients are in their eighties. Adults who become deaf later in life and who have fully developed speech and language before their hearing loss have better results with the implant than do those who were born deaf or who lost their hearing early in life. It has been shown, however, that children who are born deaf but are given cochlear implants early in life can receive great benefit from them. In adults, the memory of sound appears to be one of the most important factors for success. For children, early implantation and placement in an educational program that emphasizes the development of auditory skills appear to be important factors for success.

Uses and Complications

One of the biggest impediments to hearing aid use is patient reaction to hearing loss. Many people try to cover up the fact that they have hearing difficulties, and when hearing loss is confirmed, they experience a wide range of emotions, from horror, denial, disbelief, and withdrawal to embarrassment, sadness, resentment, and gradual acceptance and coping. People’s coping skills and behavior patterns vary, in part because hearing loss generally occurs gradually and may take a long time to be recognized.

For those who embrace hearing aids, a variety of technological and cosmetic choices are available. A number of options exist regarding hearing aid style: behind-the-ear, custom in-the-ear, in-the-canal, and the smallest, the completely in-canal hearing aid. In addition to aesthetic considerations and sound fidelity, one’s anatomy and manual dexterity may dictate the style that is most effective and efficient. The degree of hearing loss and other medical conditions are also important factors when evaluating the best hearing aid.

Perspective and Prospects

Hearing aid technology has improved such that patients with mild to moderate hearing loss will be candidates for hearing aids and those with severe loss will be candidates for hearing aids or cochlear implants, depending upon how well they function with a particular device. Patients with profound hearing loss will benefit best from cochlear implants.

Initially, only those patients who were completely deaf in both ears were considered candidates for cochlear implants. With significant improvements in implant technology, however, the benefits gained by implanted patients, both children and adults, have markedly improved. This, in turn, has led to a broadening of criteria for implant patients. Select patients with severe hearing loss who receive some benefit from hearing aids are considered possible implant candidates.

Bibliography

A.D.A.M. Medical Encyclopedia. "Devices for Hearing Loss." MedlinePlus, July 7, 2011.

Biderman, Beverly. Wired for Sound: A Journey into Hearing. Toronto, Ont.: Trifolium Books, 1998.

Carmen, Richard, ed. The Consumer Handbook on Hearing Loss and Hearing Aids: A Bridge to Healing. 3d rev. ed. Sedona, Ariz.: Auricle Ink, 2009.

Carson-DeWitt, Rosalyn. "Hearing Loss." Health Library, September 10, 2012.

Dillon, Harvey. Hearing Aids. New York: Thieme, 2001.

National Institute on Deafness and Other Communication Disorders. "Hearing Aids." National Institutes of Health, June 7, 2010.

Romoff, Arlene. Hear Again: Back to Life with a Cochlear Implant. New York: League for the Hard of Hearing, 1999.

World Health Organization. "Deafness and Hearing Loss." World Health Organization, February 2013.

What is the Children's Depression Inventory (CDI)?

Introduction

The Children’s Depression Inventory (CDI) was first developed in 1977 by Maria Kovacs. It was based on the Beck Depression Inventory, which is a self-report measure for depression for adults. The CDI was designed to assess depression in children and adolescents from the ages of seven to seventeen. The second edition of the CDI was published in 2011. The measure has twenty-seven items that ask children to report on their possible depressive experiences, such as feeling sad, crying a lot, not having fun anymore, being tired, not wanting to live, having trouble sleeping, experiencing low self-esteem, and having difficulties with friends.

The CDI is worded so that children and adolescents can read the questions themselves and write down their own answers. Each item offers three statements that signify varying levels of severity (from no problems to severe problems). Children and adolescents are asked to choose the statement that is most reflective of how they have been feeling within the past two weeks.

For example, one item gives children the following three options: I am sad once in a while; I am sad many times; I am sad all the time. Children are asked to put a mark by the sentence that describes their feelings. The first sentence (I am sad once in a while) is something that even people who are not depressed would be likely to endorse, whereas the third sentence (I am sad all the time) is more reflective of depression.

There is no specific item that confirms a diagnosis of depression. Instead, all of the items on the CDI are added together to provide an overall picture of how the child feels. The measure has been normed so that a child’s responses are compared against other children of that age and gender. The idea is that children’s answers should be compared with what is average or normative for that age and gender. Through this norming process, professionals can be sure not to diagnose a child who is just feeling normal amounts of distress. Overall, the CDI can help professionals gain a better understanding of children’s and adolescents’ feelings of depression and related concerns.

Strengths and Weaknesses

One of the primary strengths of the CDI is that it is very widely used throughout many countries. This commonality allows easy communication between professionals. The norms and standardization sample of the CDI allow professionals to have confidence in their interpretations of children’s and adolescents’ depressive symptoms. The strong psychometric properties suggest that the CDI is reliable (that is, stable) and valid (that is, meaningful). In addition, the CDI is practical to use because it is easy to administer and to score, and it is not expensive for professionals to purchase.

Even with these strengths, the CDI has some limitations. Although it was originally meant to assess depression only, there is now research to suggest that it assesses other problems as well as depression. For example, children who have difficulty with school or who have problems with peers because of excessive fighting might receive high scores on the CDI. Thus, it is important for professionals to assess many aspects of the child’s life rather than relying on the CDI alone to help diagnose depression.

Other Methods to Assess Childhood Depression

Even with a well-respected measure such as the CDI, it is standard practice for professionals to use a variety of measures before diagnosing depression in children and adolescents. In addition to using the CDI, professionals could conduct a structured diagnostic interview (such as the Diagnostic Interview Schedule for Children) with the child to assess for symptoms of depression and other psychological difficulties. Professionals may also want to observe the child (either in their office or in the classroom) to evaluate how the child interacts with others and to assess for depressive symptoms such as withdrawal or crying.

In addition to gathering information from the child directly, it is incumbent on professionals to use multiple informants (such as parents and teachers) to assess depression. The term “multiple informants” is used to suggest that other individuals in the child’s life can provide useful information about the child’s psychological symptoms. Structured diagnostic interviews can be conducted with parents about their child, and both parents and teachers can complete behavior checklists that might shed more light on the child’s psychological functioning. Many widely used behavior checklists (such as the Child Behavior Checklist and the Teacher Report Form, both developed by Tom Achenbach) can be used in conjunction with the CDI. Professionals should try to get an overall view of the child’s functioning and the family’s functioning, rather than using the CDI by itself to diagnose depression.

Bibliography

Abela, John R. Z., and Benjamin L. Hankin, eds. Handbook of Depression in Children and Adolescents. New York: Guilford, 2007. Print.

Allgaier, Antje-Kathrin, et al. "Is the Children's Depression Inventory Short Version a Valid Screening Tool in Pediatric Care? A Comparison to Its Full-Length Version." Jour. of Psychosomatic Research 73.5 (2012): 369–74. Print.

Cole, David A., Kit Hoffman, Jane M. Tram, and Scott E. Maxell. “Structural Differences in Parent and Child Reports of Children’s Symptoms of Depression and Anxiety.” Psychological Assessment 12.2 (2000): 174–85. Print.

Gladstone, Tracy R. G., and Nadine J. Kaslow. “Depression and Attributions in Children and Adolescents: A Meta-analytic Review.” Jour. of Abnormal Child Psychology 23.5 (1995): 597–606. Print.

Gomez, Rapson, Alasdair Vance, and Andre Gomez. "Children's Depression Inventory: Invariance Across Children and Adolescents With and Without Depressive Disorders." Psychological Assessment 24.1 (2012): 1–10. Print.

Kovacs, Maria. Children’s Depression Inventory Manual. North Tonawanda: Multi-health Systems, 2003. Print.

Liss, Heidi, Vicky Phares, and Laura Liljequist. “Symptom Endorsement Differences on the Children’s Depression Inventory with Children and Adolescents on an Inpatient Unit.” Jour. of Personality Assessment 76, no. 3 (2001): 396–411. Print.

Maughan, Barbara, et al. "Depression in Childhood and Adolescence." Jour. of the Canadian Academy of Child & Adolescent Psychiatry 22.1 (2013): 35–40. Print.

Petersen, Anne C., Bruce E. Compas, Jeanne Brooks-Gunn, Mark Stemmler, Sydney Ey, and Kathryn E. Grant. “Depression in Adolescence.” American Psychologist 48.2 (1993): 155–68. Print.

What makes Algernon suspect Ernest’s identity in Oscar Wilde's The Importance of Being Earnest?

Algernon has two reasons for suspecting Ernest's identity, and they reveal his use of both deductive and inductive logic. First, Algy is in possession of Ernest's cigarette case, which Ernest left on a previous visit to Algy's home. Upon opening the cigarette case, Algy read the inscription "from little Cecily" that was addressed to "her dear Uncle Jack." Deductive reasoning uses valid premises to arrive at guaranteed conclusions. Algy's reasoning goes something like this: "If...

Algernon has two reasons for suspecting Ernest's identity, and they reveal his use of both deductive and inductive logic. First, Algy is in possession of Ernest's cigarette case, which Ernest left on a previous visit to Algy's home. Upon opening the cigarette case, Algy read the inscription "from little Cecily" that was addressed to "her dear Uncle Jack." Deductive reasoning uses valid premises to arrive at guaranteed conclusions. Algy's reasoning goes something like this: "If there is an inscription saying 'To' on a cigarette case, then the owner of that case is the person named in the inscription. The case is inscribed 'To Jack,' therefore the owner is Jack." So Algy knows that either this is not Ernest's cigarette case or "Ernest" is really Jack. Algy tests his theory by asking Ernest if the case is his, and Ernest responds that it certainly is. Therefore, since the first possible conclusion has been ruled out, the second conclusion is guaranteed to be true. 

Algy's second reason to suspect Ernest's identity exhibits inductive reasoning. In inductive reasoning, one reasons from examples to reach a possible conclusion. Algy knows that men sometimes create false stories that allow them to pursue some scheme that serves their own ends. He knows this because he is a man who does this. Algy has concocted a story about a sick friend named Bunbury that he uses as a ready excuse to go into the country when he wants to escape the responsibilities or boredom of city life. He calls this type of deception "Bunburying," and the person who engages in it is a "Bunburyist." Algy explains to Ernest (who he now knows is Jack) that he has "always suspected you of being a confirmed and secret Bunburyist." The reason Algy suspects Jack even apart from the evidence of the cigarette case is because of Algy's own example of the same behavior. Algy reasons that if he does it, other men must be doing it, too. To put the matter more colloquially, he suspects Ernest because "it takes one to know one." 

What is the relationship between stress and smoking?

Stress Responses

Stress is a natural, reactive response involving physical and psychological changes that helps the body adapt to a variety of events and exposures. Stress responses trigger the hypothalamic-pituitary axis (HPA), which regulates multiple hormones simultaneously and connects their actions to chemicals in the nervous system.

During an acute stress event, hormonal and chemical fluctuations facilitate tension in the body; epinephrine, also known as adrenaline, and cortisol peak and cause increased heart rate and blood pressure, sweating, muscle tension, headache, and rapid respiration. Cortisol guides an inflammatory response and can counteract immune system functions.

Acute stress is useful when these processes activate the body’s defenses or increase the adrenaline necessary to overcome a challenge. However, neurochemical responses can result in psychological changes that can lead to short- and long-term emotional instability and anxiety. With chronic stress exposure, deeper problems develop: excessive stimulation of cortisol release causes obesity, heart disease, depression, and other chronic diseases. Chronic stress increases the likelihood that a person will turn to substance abuse in an attempt to counteract the body’s hyper-reactive state; drug and food abuse can relieve immediate psychological anxiety through dopamine release but cannot stop the long-term physical or psychological damages of stress.

Nicotine and Stress

Smoking physically stresses the body immediately and in the long term, worsening other conditions and increasing anxiety. When inhaled nicotine enters the bloodstream, the HPA is triggered to release epinephrine and cortisol—the same physical response to everyday stressors. Thus, heart rate, respiratory rate, and blood pressure all increase after nicotine use.

Tolerance to the nicotine effect on the HPA builds as smoking continues; although the physical effects wane, the levels of cortisol and epinephrine in the body remain high with chronic HPA activation. The result is a blunted natural stress reaction that prevents the body from responding appropriately to other stressors.

Nicotine also increases glucose secretion and prevents insulin release, causing chronically high blood sugar concentrations that stress organ functions. Oxidative stress reactions to nicotine throughout the body cause damage to cells and change cellular DNA (deoxyribonucleic acid), which impairs the immune response, worsens existing diseases, and increases inflammation.

In the central nervous system, nicotine use is rewarded by an apparent and immediate relief of anxiety through neurochemical changes. When tobacco is inhaled, nicotine enters the brain within ten seconds to stimulate dopamine, acetylcholine, and norepinephrine. Through these actions, nicotine quickly induces pleasure, improves mood, and enhances concentration and focus. Each cigarette provides hundreds of rapidly fleeting nicotine hits that in turn cause short bursts of euphoria. The subjective psychological boost hides the physical impairment and is short lived as the body develops tolerance to the fleeting neurologic highs.

Although smokers generally believe that nicotine reduces their stress, the repeated dopamine stimulation provides negative reinforcement of cigarette use. Chronic smoking leads to the compulsion of greater use to try to minimize the anxiety that results from lower dopamine levels when the nicotine effect wears off between cigarettes.

Stress Fuels Nicotine Addiction

Smoking and nicotine addiction
are aggravated by additional, outside sources of stress, as smokers report higher cigarette use during times of known external stressors. In addition, the body of a smoker develops chronic physical health problems from nicotine damage that facilitate stress responses.

Smokers claim to have more psychological stress than nonsmokers, and stress is provided as a reason for smoking because of its apparent relaxing effects. However, no empiric evidence supports a consistent difference in stress between smokers and nonsmokers until after smoking begins. Nicotine heightens baseline stress between cigarette use, and smokers only attain normal, lower stress signals when cigarettes are used.

Stress is a vital body mechanism for protection, but it contributes to smoking addiction and the frequency of relapse, as smokers use nicotine to relieve immediate sensations of anxiety. When nicotine is chronically present, the nervous system and HPA adapt to it as a stressor, even more nicotine is needed to respond to daily stress.

Stress itself increases the craving for nicotine as tolerance builds, and anxiety encourages drug-seeking behavior. As the central nervous system adapts to frequent and repeated norepinephrine and dopamine stimulation, more nicotine is necessary to obtain the same pleasure, focus, and stress-relief responses. Relief of stress is harder to achieve as smoking continues. Thus, stress increases the amount, frequency, duration, and intensity of cravings for nicotine.

Withdrawal from nicotine is probably the best example of the connection between stress and smoking habits. Although physical withdrawal from nicotine can cause increased appetite and headaches, the psychological reactions of withdrawal are the key causes of stress and ultimate nicotine dependence. Irritability, attention problems, sleep disturbances, and tobacco cravings are common and are a sign of the damaging changes from smoking, not proof of nicotine’s stress-relieving effects.

Without the rapid and repeated bursts of nicotine, anxiety and physical stress become evident. Nicotine abstinence breaks the cycle of stress-induced smoking and smoking-induced stress, but it ultimately requires learning new coping skills to manage stress.

Bibliography

Cougle, J. R., et al. “The Role of Comorbidity in Explaining the Associations between Anxiety Disorders and Smoking.” Nicotine and Tobacco Research 12 (2010): 355–64. Print.

Mendelsohn, C. “Women Who Smoke: A Review of the Evidence.” Australian Family Physician 40 (2011): 403–7. Print.

“Psychological Stress and Cancer: Questions and Answers.” Cancer.gov. Natl. Cancer Inst., 29 Apr. 2008. Web. 8 Apr. 2012.

Richards, J. M., et al. “Biological Mechanisms Underlying the Relationship between Stress and Smoking: State of the Science and Directions for Future Work.” Biological Psychology 88.1 (2011): 1–12. Print.

Wang, Wendy, and Paul Taylor. “Smokers Can’t Blow Off Stress.” Pew Research Center Social & Demographic Trends. Pew Research Center, 8 Apr. 2009. Web. 9 Nov. 2015.

How does Arthur Conan Doyle present Irene Adler in "A Scandal in Bohemia"?

In "A Scandal in Bohemia," Doyle presents Irene as a mysterious character who is very different from other women:

To Sherlock Holmes, she is always the woman…In his eyes she eclipses and predominates the whole of her sex.

This quote also suggests that she exerts a powerful influence over the men in her life and this power derives from a combination of her wit and beauty. The King of Bohemia, for example, says that "she...

In "A Scandal in Bohemia," Doyle presents Irene as a mysterious character who is very different from other women:

To Sherlock Holmes, she is always the woman…In his eyes she eclipses and predominates the whole of her sex.

This quote also suggests that she exerts a powerful influence over the men in her life and this power derives from a combination of her wit and beauty. The King of Bohemia, for example, says that "she has the face of the most beautiful of women," while Sherlock calls her "the daintiest thing under a bonnet." But her wit is, perhaps, her most striking feature because she is able to outwit both the King of Bohemia and Sherlock himself. In a clever twist, she uses some of Sherlock's own methods to achieve this, notably the use of disguise, as we learn from her letter:

But, you know, I have been trained as an actress myself. Male costume is nothing new to me. I often take advantage of the freedom which it gives.

Part of Irene's appeal is her ability to act outside the boundaries of accepted gender roles. On the surface, she acts like any other woman, as Sherlock comments:

She lives quietly, sings at concerts, drives out at five every day, and returns at seven sharp for dinner.

But, below this ordinary exterior lies a power which makes Sherlock completely rethink his ideas about women, as Watson comments in the closing lines:

He used to make merry over the cleverness of women, but I have not heard him do it of late.