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By: Amy Garlin MD

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A common language connects the members of a community into an information-sharing network with formidable collective powers blood pressure ranges pediatrics discount diovan 80mg on line. Anyone can benefit from the strokes of genius blood pressure calculator purchase 80mg diovan, lucky accidents, and trial-and-error wisdom accumulated by anyone else, present or past. As a result, Homo sapiens is a species, like blue-green algae and earthworms, that has wrought far-reaching changes on the planet. Archeologists have discovered the bones of ten thousand wild horses at the bottom of a cliff in France, the remains of herds stampeded over the clifftop by groups of paleolithic hunters seventeen thousand years ago. These fossils of ancient cooper- An Instinct to Acquire an Art 17 ation and shared ingenuity may shed light on why saber-tooth tigers, mastodons, giant woolly rhinoceroses, and dozens of other large mammals went extinct around the time that modern humans arrived in their habitats. Language is so tightly woven into human experience that it is scarcely possible to imagine life without it. Chances are that if you find two or more people together anywhere on earth, they will soon be exchanging words. When there is no one to talk with, people talk to themselves, to their dogs, even to their plants. In our social relations, the race is not to the swift but to the verbal-the spellbinding orator, the silver-tongued seducer, the persuasive child who wins the battle of wills against a brawnier parent. Aphasia, the loss of language following brain injury, is devastating, and in severe cases family members may feel that the whole person is lost forever. Unlike most books with "language" in the title, it will not chide you about proper usage, trace the origins of idioms and slang, or divert you with palindromes, anagrams, eponyms, or those precious names for groups of animals like "exaltation of larks. Now called "cognitive science," it combines tools from psychology, computer science, linguistics, philosophy, and neurobiology to explain the workings of human intelligence. The science of language, in particular, has seen spectacular advances in the years since. There are many phenomena of language that we are coming to understand nearly as well as we understand how a camera works or what the spleen is for. I hope to communicate these exciting discoveries, some of them as elegant as anything in modern science, but I have another agenda as well. The recent illumination of linguistic abilities has revolutionary implications for our understanding of language and its role in human affairs, and for our view of humanity itself. They know that grammatical sophistication used to be nurtured in the schools, but sagging educational standards and the debasements of popular culture have led to a frightening decline in the ability of the average person to construct a grammatical sentence. They also know that English is a zany, logicdefying tongue, in which one drives on a parkway and parks in a driveway, plays at a recital and recites at a play. They know that English spelling takes such wackiness to even greater heights- George Bernard Shaw complained that fish could just as sensibly be spelled ghoti (gh as in tough, o as in women, ti as in nation)-and that only institutional inertia prevents the adoption of a more rational, spell-it-like-it-sounds system. In the pages that follow, I will try to convince you that every one of these common opinions is wrong! Language is not a cultural artifact that we learn the way we learn to tell time or how the federal government works. Language is a complex, specialized skill, which develops in the child spontaneously, without conscious effort or formal instruction, is deployed without awareness of its underlying logic, is qualitatively the same in every individual, and is distinct from more general abilities to process information or behave intelligently. For these reasons some cognitive scientists have described language as a psychological faculty, a mental organ, a neural system, and a computational module. Web-spinning was not invented by some unsung spider genius and does not depend on having had the right education or on having an aptitude for architecture or the construction trades. Rather, spiders spin spider webs because they have spider brains, which give them the urge to spin and the competence to succeed. Although there are differences between webs and words, I will encourage you to see language in this way, for it helps to make sense of the phenomena we will explore. Thinking of language as an instinct inverts the popular wisdom, especially as it has been passed down in the canon of the humanities and social sciences. It is not a manifestation of a general capacity to use An Instinct to Acquire an Art 19 symbols: a three-year-old, we shall see, is a grammatical genius, but is quite incompetent at the visual arts, religious iconography, traffic signs, and the other staples of the semiotics curriculum. Though language is a magnificent ability unique to Homo sapiens among living species, it does not call for sequestering the study of humans from the domain of biology, for a magnificent ability unique to a particular living species is far from unique in the animal kingdom. Some kinds of migratory birds navigate thousands of miles by calibrating the positions of the constellations against the time of day and year. Once you begin to look at language not as the ineffable essence of human uniqueness but as a biological adaptation to communicate information, it is no longer as tempting to see language as an insidious shaper of thought, and, we shall see, it is not. Finally, since language is the product of a well-engineered biological instinct, we shall see that it is not the nutty barrel of monkeys that entertainer-columnists make it out to be.

He was smoking a cigarette blood pressure medication migraines purchase 40 mg diovan, spirals of smoke drifting upward into the empty night blood pressure medication blue pill buy 80mg diovan amex. For one thing, the Tea Party movement is one in a long line of periodic heightened expressions "of a popular impulse endemic in American political culture," as the historian Richard Hofstadter has noted. Through the nineteenth and twentieth centuries, movements rose up against secularism, modernity, racial integration, and a culture of experts. But none before the Tea Party have so forcefully taken up the twin causes of reversing progressive reform and dismantling the federal government-a movement in response to the deep story. The second is t he era of the 1960s, which resonates for the right wing across the nation. The contemporary turn to the right in America has occurred mainly in the South, which is what drew me there. What interests me about Southern history is the series of emotional grooves, as we might call them, carved into the minds and hearts of the people I came to know through the lives of their ancestors-many of whom were white 207 s t rangers i n t hei r o wn land farmers of small farms. This system deeply affected well-to-do white planters and black slaves, of course. But it also left a deep imprint on another large group we often forget-poor white sharecroppers, small farmers, and tenant farmers, some of whom were the ancestors of those I came to know in Louisiana. Rich planters sipped foreign wine under crystal chandeliers, seated on European chairs, in white-pillared mansions. They saw themselves not as wicked oppressors but as generous benefactors, and poor whites took them as such. At the other extreme, poor whites saw the terrifying misery of the traumatized, short-lived slave. Compared to life in New England farming villages, there was much more wealth to envy above, and far more misery to gasp at below. Such a system suggested its own metaphoric line waiting for the American Dream-one with little room for the lucky ahead, and much room for the forgotten behind. Between this top and bottom, Cash describes poor whites as living in unpainted houses with "sagging rail fences. Planters bought up the most desirable fertile plains, pressing poorer farmers onto the barren uplands. If poor white farmers tried to move to better land, they found that the planters had "seized the best lands there" even "beyond the Mississippi" in "Arkansas and Texas armed with plentiful capital and solid battalions of slaves. Marginalized and without demand for their labor, poor whites bore up under rude epithets-crackers, white trash, po buckra. Transposing ancestral history onto our modern-day deep story, nineteenthcentury poor whites stood very far back in line for the American Dream. And there was little by way of a government-supported public commons, the South being far poorer than the North in public libraries, parks, schools, universities. Cities were burned, fields laid waste-some by the Confederate troops as they retreated. After the Civil War, the North replaced Southern state governments with its own hand-picked governors. The profit-seeking carpetbaggers came, it seemed to those I i nterviewed, as agents of the dominating North. Exploiters from the North, an angry, traumatized black population at home, and moral condemnation from all-this was the scene some described to me. When the 1960s began sending Freedom Riders and civil rights activists, pressing for new federal laws to dismantle Jim Crow, there they came again, it seemed, the moralizing North. And again, Obamacare, global warming, gun control, abortion rights-did 209 s t rangers i n t hei r o wn land these issues, too, fall into the emotional grooves of history? Does it feel like another strike from the North, from Washington, that has put the brown pelican ahead of the Tea Partier waiting in line? Indeed, a number of the white-pillared mansions of the great plantations have now been bought by oil and petrochemical companies. Dow Chemical bought four plantations-including the Australia Plantation and the Abner Jackson Plantation, and on the latter the company hosts conferences in its Big House. Cotton barons did not promise prosperity to poor farmers or slaves, as the oil industry has done to modern-day Louisianans.

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Itching blood pressure low range discount diovan 160 mg amex, especially after bathing (due to histamine release from increased mast cells) D hypertension 2 nigerian movie buy 80mg diovan overnight delivery. In inflammation, lymph node enlargement is due to hyperplasia of particular regions of the lymph node. Hyperplasia of sinus histiocytes is seen in lymph nodes that are draining a tissue with cancer. Neoplastic proliferation oflymphoid cells that forms a mass; may arise in a lymph node or in extra nodal tissue B. Small B cells-follicular lymphoma, mantle cell lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma. Does not occur Clinical Spread Staging Leukemic phase Painless lymphadenopathy, usually arises in late adulthood Diffuse; often extranodal Limited importance Occurs. C, Reactive follicular hyperplasia with tingible body macro phages for comparison. Progression to diffuse large B-celllymphoma is an important complication; presents as an enlarging lymph node F. Disruption of normal lymph node architecture (maintained in follicular hyperplasia) 2. Lack of tingible body macrophages in germinal centers (tingible body macrophages are present in follicular hyperplasia. Cyclin D1 gene on chromosome 11 translocates to Ig heavy chain locus on chromosome 14. Overexpression of cyclin D1 promotes Gl/S transition in the cell cycle, facilitating neoplastic proliferation. Associated with chronic inflammatory states such as Hashimoto thyroiditis, Sjogren syndrome, and H pylori gastritis 1. Classic presentation is an enlarging cervical or mediastinal lymph node in a young adult, usually female. Most common primary malignancy of bone; metastatic cancer, however, is the most common malignant lesion of bone overall. Increased risk of infection-Monoclonal antibody lacks antigenic diversity; infection is the most common cause of death in multiple myeloma. Proteinuria-Free light chain is excreted in the urine as Bence Jones protein; deposition in kidney tubules leads to risk for renal failure (myeloma kidney). Acute complications are treated with plasmapheresis, which removes IgM from the serum. Characteristic Birbeck (tennis racket) granules are seen on electron microscopy. Classic presentation is skin rash and cystic skeletal defects in an infant (< 2 years old). Classic presentation is pathologic fracture in an adolescent; skin is not involved. Biopsy shows Langerhans cells with mixed inflammatory cells, including numerous eosinophils. Classic presentation is scalp rash, lytic skull defects, diabetes insipidus, and exophthalmos in a child. Arterial wall is comprised of three layers: endothelial intima, smooth muscle media, and connective tissue adventitia. Symptoms of organ ischemia-due to luminal narrowing or thrombosis of the inflamed vessels D. Granulomatous vasculitis that classically involves branches of the carotid artery 2. Most common form of vasculitis in older adults (> 50 years); usually affects females 3. Presents as headache (temporal artery involvement), visual disturbances (ophthalmic artery involvement), and jaw claudication. Flu-like symptoms with joint and muscle pain (polymyalgia rheumatica) are often present. Lesions are segmental; diagnosis requires biopsy of a long segment of vessel, and a negative biopsy does not exclude disease. Granulomatous vasculitis that classically involves the aortic arch at branch points 2.

Transfusion-associated lung injury 346 Chapter 9 Infectious Disease Topics Section 1 Sepsis and Septic Shock Key Points: · Sepsis is common in the intensive care unit setting arteria rectal superior buy cheap diovan 40mg on-line. It can present with a variety of signs and symptoms and providers must always have a high index of suspicion arrhythmia kinds buy discount diovan 160mg on-line. Cultures should be obtained prior to administration when possible, but should not delay administration. A family member at the bedside states that his only medical history is insulin dependent diabetes for which he rarely checks his blood sugars and frequently forgets to take his insulin as directed. In addition to hypotension and tachycardia, you note a small wound on the plantar surface of his foot with erythema spreading up the leg. Blood and urine cultures are sent prior to administration of broad-spectrum antibiotics. After administration of 30ml/kg of lactated ringers, he remains hypotensive and has minimal urine output. The decision is made to place an arterial catheter and central line for infusion of norepinephrine. These terms have recently been redefined based on current understanding of sepsis-induced changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation. Sepsis and septic shock remain one of the leading causes of mortality and critical illness worldwide. The European Society of Intensive Care Medicine and the Society of Critical Care Medicine have helped redefine sepsis and clarify guidelines for treatment that are also endorsed by the Surviving Sepsis Campaign. They provided and rated statements on management and resuscitation of patients in sepsis or septic shock as "strong", "weak", or "best-practice". They are nonspecific criteria that may help aid in the general diagnosis of infections but more is needed to assess severity. It is recommended that patients suspected of having sepsis have blood cultures drawn before initiation of antibiotics if clinically appropriate and possible, along with imaging studies to help confirm a potential source of infection. This score takes into account abnormality by organ system along with specific lab values: PaO2, platelet count, bilirubin level and creatinine level. The Surviving Sepsis Campaign recently released 2016 guidelines for the management of sepsis and septic shock. Additional fluids should be guided by frequent reassessment of hemodynamic status with dynamic variables (versus static measurements) used to predict fluid responsiveness c. Once the diagnosis of sepsis has been made or is strongly suspected, a search for the source must be further pursued. This should include cultures (blood, respiratory, urine if appropriate) imaging studies and specific lab values such as 1,3 beta-Dglucan if an invasive fungal infection is suspected. Most importantly, antimicrobial therapy should be initiated promptly and not be delayed for culture collection if it is expected to take > 45 minutes. Ideally, the goal is to administer antibiotics within 1 hour of recognition of the signs of sepsis. Some of the most frequently encountered pathogens in sepsis are listed in Table 3, along with the first-line antimicrobials for treatment. Equally as important as initiating broad spectrum antibiotics with suspected sepsis, is the daily re-evaluation and potential deescalation of antibiotics once susceptibilities are known. In general, a total of 7-10 days of targeted treatment is sufficient to treat most infections. Once a specific source is identified, intervention to remove that source should occur as soon as possible. Support of Failing Circulation in Septic Shock Crystalloid is the recommended resuscitation fluid but albumin can be considered in patients requiring large amounts of crystalloid. In patients presenting with hypotension, an initial crystalloid challenge of 30ml/kg should be given, and a repeat Table 9. Aureus Daptomycin if no response to Vancomycin 351 bolus may be administered when patients demonstrate hemodynamic improvement with the fluid administration. Although the use of albumin has not been shown to be superior in the resuscitation of septic shock, in patients who present with severe septic shock, the use of albumin may be beneficial. Studies comparing low dose vasopressin and dopamine as first line agents compared to norepinephrine did not show a mortality benefit but they may be considered in refractory septic shock or as second line agents. Placement of an arterial catheter may aid in more accurate administration and titration of these agents.

References:

• https://fri.wisc.edu/files/Briefs_File/FRI_Brief_NonO157STEC_4_10.pdf
• https://tuckahoeortho.com/wp-content/uploads/2019/07/Patellofemoral-Pain-Syndrome.pdf
• https://health.mo.gov/living/healthcondiseases/communicable/communicabledisease/cdmanual/pdf/Mumps.pdf