By V. Kalan. Philadelphia Biblical University.

In the case of (6) Loss Of A Vital Fluid paxil 10 mg online treatment effect, bleeding is the literal and central example but is a symptom purchase paxil 40mg free shipping medications varicose veins, and not a disease. Based on the logic of this symptomatic event, health and disease seen as fullness and deficiency of a vital fluid are cognitively mapped out. And finally, our knowledge of attacks is one more metaphorical source domain for the understanding of disease. There is a related reverse metaphor which sees War As Disease but it is not well elaborated or important in our understanding of war so far. The model Disease Is The Abnormal is a special case, not truly metaphorical but probably related to the common association of anomalies with symptoms. The health models are not as well developed as those for disease and are often understood mainly as contraries of the disease depictions, secondarily generated from them. Like "peace," health is often seen as the absence of something negative rather than a positive presence with its own integrity and content. Unfortunately, this view means that the nourishment of health as well as peace are typically neglected since, unlike the disruptions of disease and war it is easy to think of health and peace as "uncaused. These descriptions are preliminary, not definitive, and are subject to alteration upon more reflection and empirical study. But it does matter that concepts of health and disease are plural and often metaphorical, and that can be established. The conceptual structures matter because qualitative symptoms cannot be quantified into units of suffering with the help of a single standard of disease. They matter because the relevance and seriousness of any definable condition is peculiar to each particular case, and no comprehensive formula for health applies in full to any unique situation. They matter because the logic used to decide what is desirable and what is not cannot itself be mechanized when imaginative and conflicting models are so pervasive in conceptualizing health and disease. Disease Is Mechanical Breakdown In this model the body is a large machine made up of the organs which are smaller machines. The mind is also a machine, more or less tightly tethered to the body at the locus of the brain, one of the constitutive machines. One difficulty with this model when it is looked at closely, is that of specifying what all the organs should be doing when they are working well or optimally. There is a dispute between those who believe that an objective concept of proper working can be developed, usually on the basis of evolutionary fitness or some other measure of adaptation, and those who believe that the definition of proper function is a value judgment. The proper purpose and functioning of these two constituent machines turn out to be less than self-evident. Terms like "adaptive behavior" and "fitness" or "inclusive fitness," which supposedly describe the proper workings of the brain and the genome, respectively, evoke much controversy. For example, how many generations of survivors do we count in deciding whether one gene allele or another is working better to promote "fitness? So is a gene as a tiny submachine working well when it promotes reproduction of itself or of individuals of the type which contain it? In practice, good working of organs, brains and people is culturally defined, although it is probable that cross-cultural definitions of good function would be HEALTH AND DISEASE 45 in wide agreement, for example, when describing a functioning eye, ear, heart, lung, kidney or parathyroid gland. When symptoms, those most reliable markers of disease can be traced to the function of an organ, the likelihood of universal agreement on the presence of disease as mechanical breakdown is greatest. For instance, when a cluster of symptoms like chest pain, shortness of breath, wheezing and swelling of the hands and feet is traced to how the heart works, agreement that there is a breakdown of the heart is usually reached, and the heart is said to be failing. Approaching the heart in this situation as if it was a broken down machine has been quite useful. Indeed, when modeling health after well running machines we often speak not of the whole person but of organs, which as small machines are parts of the larger one. Muscles, nerves, skin, brain neurotransmitter levels and locations, breasts, T-lymphocytes, transplantation antigens, hair and hands all have multiple functions and multiple variants. Optimal working in one capacity is often associated with deficient function in another. Pale skin works well to metabolize Vitamin D and poorly to block ultraviolet radiation. Particular tissue types (transplantation antigens) may confer immunological protection against one problem but increase susceptibility to another. People with strong immune responses to parasites may be more susceptible to allergies.

Select and paste pictures of people buy 40mg paxil with visa treatment urinary incontinence, then write down what they are thinking and saying generic 40 mg paxil visa medications qid. On one side draw what peace looks like, on the next draw a trouble, on the third draw trust, and on the last draw anything you please. Give each group member a box and have them decorate the outside 320 Sample Directives showing "who you are. Make three separate drawings: one of you at the beginning of group or before group started; one of you during the group; and one of you presently. Make a drawing that represents another group member at the be- ginning and ending of the group. Draw what you’ve liked most about this group, what you’ve liked least about this group, or one final gift you’d like to give to someone in this group. Draw something that you would like to give to [name of person leav- ing] to help him or her be successful. Working together, combine your efforts to make a visual tribute to someone who is leaving (or has left). Offer each group member a sheet of butcher paper; have them pro- duce a cartoon strip showing significant events in their lives. Variation: Write a continuous piece of prose about your life, and se- lect a significant image from your writing and draw it. Mark off a piece of paper in quarters and draw symbolically: (1) Where do I come from? Draw one positive thing you would like to see them keep and one negative thing you would like to see them change. Draw the things you have done to set yourself apart from the group and what you have done to make yourself a part of the group. Give each group member a box and have them decorate the outside showing "who you are. Variation: Use clay, construction paper, or the like for directive in- stead of index cards. Pair the group members up and have the partners discuss how they feel and why (but do not show their drawings). Have each group member re- turn to the original drawing and on the right side draw how their partner feels. Instruct the group members to sort through and select two that they think the group member sitting on their left would most like. Have members pass the drawings around the group circle and add to the drawings a strength each sees in the person. Have the members make a gift out of clay for the group member sit- ting next to them, present the gift, and describe why they made this one in particular. Draw how things might have been different for you if you could change this one thing. Using any of the materials (collage or drawing supplies), illustrate an important change that you’ve seen someone in the group make. On one side, draw what you think will happen if you do not make this change, and on the other side draw what you think would happen if you did make a change. Draw two significant differences between your personality now and your personality 5 years ago. Using the four-sided box provided, decorate the outside using any materials you wish. On a piece of paper write out or draw one thing about your- self that people would be surprised to know. Choose three collage im- ages that you think this person would enjoy, and explain why you chose them. Draw the last time you got angry, and on the paper write one thing that irritates you. Choose a word from the collage word box that de- scribes how you feel when you are angry.

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It is often helpful to place a metallic marker at the site of maximal pain and to correlate fluoroscopically the anatomical location of the pain and the compression fracture paxil 20mg with amex medicine mountain scout ranch. It should be re- membered that pain localization is limited to no better than plus or mi- nus one vertebral level in most patients buy generic paxil 40 mg on line medications with aspirin. Simple clinical situations in which physical findings are well corre- lated with recent radiographic exams may be treated without the ad- dition of complex studies such as MRI, computed tomography (CT), or nuclear medicine (Figure 14. Patients with multiple fractures or nonfocal pain often pose diag- nostic dilemmas and require a more complex imaging evaluation. These patients should have magnetic resonance imaging in addition to a recent, standard radiographic evaluation. Acute fractures will be eas- ily demonstrated on T1-weighted sagittal images as having loss of sig- nal in the affected vertebral marrow space (Figure 14. Lateral radiograph show- ing a typical osteoporotic compres- sion fracture (arrow). Compression is typically more in the anterior two thirds of the vertebra, with sparing of posterior wall height. C 249 250 Chapter 14 Percutaneous Vertebroplasty high sensitivity for recent fracture and marrow edema (represented by an abnormal bright signal in the involved region) are short-tau inver- sion recovery (STIR) images with fat suppression. Images made with T2 weighting occasionally give additional information as these se- quences can show fluid-filled clefts that can result after fracture. These findings are important because the clefts or spaces should be filled with cement for dependable pain relief. On T1-weighted MRI sequences, normal marrow will exhibit high (bright) signal, including any vertebra that were previously com- pressed and have undergone healing. One should be reluctant to per- form PV for pain based on MRI unless an acute fracture or persistent marrow abnormality can be demonstrated. If MRI cannot be performed or leaves doubt with respect to the need for therapy, a nuclear medicine (NM) bone scan may be utilized. However, NM may not be as useful as MRI for primary screening be- cause the former has poorer anatomical resolution [even when sin- gle-photon-emission computed tomography (SPECT) is used] and does not give information about conditions such as spinal stenosis, disc herniation, or tumor extension into the epidural space. Also, ab- normal activity on a bone scan may persist long after healing has been demonstrated on MRI. A low-level positive NM scan may indicate only normal, progressive healing, which in turn might mislead a physician about the possible benefit of PV. Rarely, infor- mation from the MRI will be insufficient to accurately localize an acute fracture. This usually happens in a very heterogeneous marrow (which may be found as a normal variation in the elderly or with con- ditions such as myeloma). Then, NM will usually add sufficient in- formation to identify an acute fracture or determine the need for treat- ment (Figure 14. Computed tomography offers anatomical information (as do stan- dard radiographs) but is unable to distinguish acute from chronic fractures under most circumstances. It may be very helpful to evaluate the cause of complications that are possible after PV, such as a cement leak outside the vertebral body. This mode of diagnosis should be used immediately if symptoms worsen or new symptoms present after PV. Minimal compressions, as measured radiographically, may cause incapacitating pain to some individuals. Even with minimal de- formity, acute fractures are easily identified on MRI because they demonstrate local marrow edema. This finding will indicate a need for therapy at each of the involved and painful levels. As the amount of compression increases, the degree of technical difficulty of per- forming the PV may increase as well. Nuclear medicine bone scan showing increased uptake at T12 (arrow) resulting from an osteoporotic compres- sion fracture.

Since the predictive value of the ossification centers differs and changes during growth order paxil 40 mg without a prescription medicine you can take while breastfeeding, the reviewer should primarily focus on the centers that best characterize skeletal development for the subject’s chronological age buy paxil 10 mg amex medicine quiz. The usual se- quence is: capitate (1), hamate (2), triquetral (3), lunate (4), trapezium (5), trapezoid (6), navicularorscaphoid(7)and pisiform (8). The distal epi- physis of the radius ossifies before the triquetum and that of the ulna before the pisiform 10 Indicators of Skeletal Maturity in Children and Adolescents cilitate bone age assessments, we have divided skeletal development into six major categories and highlighted in parentheses the specific ossification centers that are the best predictors of skeletal maturity for each group: 1) Infancy (the carpal bones and radial epiphyses); 2) Toddlers (the number of epiphyses visible in the long bones of the hand); 3) Pre-puberty (the size of the phalangeal epiphyses); 4) Early and Mid-puberty (the size of the phalangeal epiphyses); 5) LatePuberty(thedegreeofepiphysealfusion);and, 6) Post-puberty (the degree of epiphyseal fusion of the radius and ulna). While these divisions are arbitrary, we chose stages that reflect pubertal status, since osseous development conforms better with the degree of sexu- al development than with the chronologic age. The features that character- ize these successive stages of skeletal development are outlined in schemat- ic drawings depicting their appearance as seen in posterior anterior roent- genograms of the hand and wrist. Infancy Females: Birth to 10 months of age Males: Birth to 14 months of age All carpal bones and all epiphyses in the phalanges, metacarpals, radius and ulna lack ossification in the full-term newborn. The ossification cen- ters of the capitate and hamate become apparent at about 3 months of age and remain the only useful observable features for the next six months. At about 10 months of age for girls, and about 1 year and 3 months of age for boys, a small center of ossification in the distal epiphysis of the radius ap- pears. Due to the lack of ossification centers, assessment of skeletal maturi- ty using hand and wrist radiographs during infancy is difficult. Estimates of bone maturation in the first year of life frequently require evaluation of the number, size and configuration of secondary ossification centers in the upper and lower extremities. During Infancy, bone age is primarily based on the presence or absence of ossi- fication of the capitate, the hamate and the distal epiph- ysis of the radius. The capi- tate usually appears slightly earlier than the hamate, and has a larger ossification cen- terandroundershape. The distal radial epiphysis ap- pears later Toddlers Females: 10 months to 2 years of age Males: 14 months to 3 years of age The ossification centers for the epiphyses of all phalanges and metacarpals become recognizable during this stage, usually in the middle finger first, and the fifth finger last. Bone age determinations are primarily based on the assessment of the number of identifiable epiphyseal ossification cen- ters, which generally appear in an orderly characteristic pattern, as follows: 1) Epiphyses of the proximal phalanges; 2) Epiphyses of the metacarpals; 3) Epiphyses of the middle phalanges; and, 4) Epiphyses of the distal phalanges. Twocommonexceptionstothisruleare: 1) The early appearance of the ossification center of the distal phalanx of the thumb, which is usually recognizable at 1 year and 3 months in males, and 1 year and six months in females; and, 12 Indicators of Skeletal Maturity in Children and Adolescents Fig. During this stage, bone age is primar- ily based on the number of recognizable epiphyseal ossification centers in the pha- langes and metacarpals 2) Thelateappearanceoftheossificationcenterofthemiddlephalanxof the fifth finger, which is the last phalangeal epiphysis to appear. The number and degree of maturation of the carpal bones in the wrist are less useful indicators at this stage, as only three or four (capitate, hamate and lunate and, at times, trapezoid) are recognizable. Pre-puberty Females: 2 years to 7 years of age Males: 3 years to 9 years of age Assessments of skeletal maturity in pre-pubertal children are primarily based on the epiphyseal size of the phalanges as they relate to the adjacent metaphyses. During this stage of development, the ossification centers for the epiphyses increase in width and thickness, and eventually assume a transversediameteraswideasthemetaphyses. Moreweightisgiventothe size of the epiphyses in the distal phalanges than to that in the middle pha- langes, and even less to that in the proximal phalanges. However, since the development of the distal phalanges appears similar at several different ages, at times the assessment is also based on the degree of maturity for the Pre-puberty 13 Fig. Depiction of the pro- gressive growth of the width of the epiphyses, which, during this stage of develop- ment,becomeaswideasthe metaphyses Fig. Assessments of bone age are primarily based on the degree of dif- ference in width between the smaller epiphyses and the larger metaphyses at the distal and middle phalanges epiphyses of the middle phalanges. On very rare occasions when there con- tinues to be doubt, the development of the proximal phalanx may be includ- ed in the assessment. The epiphysis of the ulna and all carpal bones, with the exception of the pisiform, usually become recognizable before puberty. However, these ossi- ficationcenters,likethoseofthemetacarpals,arelessreliableindicatorsof bone age at this stage of life. The epiphyses at this stage continue to grow and their widths become greater than the metaphy- Fig. Depiction of the pro- gressive growth of the epiph- yses, which, during this stage of development, become larger than the metaphyses. Special attention is also placed on epiphyseal shape, which, prior to epiphyseal fusion, overlaps the meta- physes, depicting tiny horn- like structures at both ends of the epiphysis (picture at far-right) Fig. During this stage of development, like for prepubertal and late-pubertal children, assessments are based primarily on the distal and middle phalanges Late Puberty 15 ses.

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