What is the time period in which Number the Stars by Lois Lowry was written?

Number the Stars was published in 1989.  It is a historical fiction novel which takes place in Denmark during the 1940s.  The book primarily takes place in the year 1943, though there are flashbacks to earlier years in the 1940s.  The final chapter tells about the events which occurred in 1945.

The story begins in September of 1943.  Denmark had surrendered to the Nazis in 1940.  Annemarie, the main character in the story, deals with life during the Nazi occupation of her country.  She and her family help her best friend, Ellen, who is Jewish.  The story continues through the month of October in 1943.  It is during this time that Ellen and her family escape.  The final chapter of the book takes place in May of 1945.  The author describes the reaction of the Danes as the war comes to a close:

Church bells rang all over Copenhagen, early that May evening.  The Danish flag was raised everywhere.  People stood in the streets and wept as they sang the national anthem of Denmark.

What is the summary of the poem "Blindness" by Charles Lamb?

Late in the day, the narrator finds himself on a stagecoach. During his travels, he notices a little girl and her mother sitting near him. The child appears to be engrossed in her own thoughts and seems to be looking at nothing in particular.

Being a kindly old man, the narrator invites the pretty little girl to look up and to notice her surroundings and the view before her ('bid her turn those pretty eyes and see/The wide extended prospect'). However, the girl sadly confesses that she is blind and therefore, cannot contemplate the same scenes that her companion can see.

At this point, the child's mother pipes up and explains how she came to discover that her child was blind. Accordingly, one sunny day, the mother saw her child lay aside her needlework. Thinking that her daughter was shirking her duty, the mother began to scold her. However, the child innocently answered that it was too dark to see and promised that she would take up her work again when day came. When she spoke these words, it was a bright, sunny day. However, the mother explains that her daughter could not see the bright rays of the sun ('The sun shone bright upon her when she spoke,/ And yet her eyes received no ray of light).

In what way does the hanging of the "angelic Pipel" symbolize the loss of faith in Night?

But the third rope was still moving: the child, too light, was still breathing....And so he remained for more than half an hour, lingering between life and death, writhing before our eyes....Behind me, I heard the same man asking:  'For God's sake, where is God?"  --Night, Page 65

This is a very important passage in detailing Elie Wiesel's abandonment of his faith.  If there is a God, how could he allow children to be hanged to die.  How could he allow such cruelty and barbarity as what was happening in the concentration camps to the Jews?  An important theme in the book is the loss of faith that even the most devout Jews experienced.  At the beginning of the memoir Wiesel was very dedicated to learning about his religion and God. It did not take long for disillusionment to set in for Eliezer.  This loss of faith is another unjust consequence that many Jews were met with because of their brutal treatment.  According to Wiesel, the boy hanging from the gallows, struggling to survive was, in fact, symbolic of God and religion.  

What is the meadow behind Scout's house called in To Kill a Mockingbird?

The meadow is called Deer’s Pasture. 

The meadow called Deer’s Pasture is significant for its proximity to the Radley house.  Obviously any kind of meadow would be fun to play in generally, but since Dill, Scout, and Jem spend summers trying to get Boo Radley to come out, it is important.  They do not ever mention any actual deer, but the pasture is probably named after earlier days when there were some. 

We ran across the schoolyard, crawled under the fence to Deer’s Pasture behind our house, climbed our back fence and were at the back steps before Jem would let us pause to rest. (Ch. 6) 

The children spend a lot of time on Sundays “creeping around” in Deer’s Pasture.  It is significant because of its location near the Radley’s house.  The children have to cross through it.  The school’s playground adjoins the meadow, and the Radley’s house. 

The meadow is mentioned when Jem loses his pants.  Over Scout's objections, he goes back to get them at night.  Scout is afraid that he is going to be shot prowling around the Radley house, because Nathan Radley would think it was an intruder.

He went the back way, through Deer’s Pasture, across the schoolyard and around to the fence, I thought—at least that was the way he was headed. It would take longer, so it was not time to worry yet. I waited until it was time to worry and listened for Mr. Radley’s shotgun. (Ch. 6)

It turns out that Boo Radley stitched up the pants, which was unexpected.  It is one of the many times Boo Radley tries to look out for the children there.  Of course it is really a very good thing that he does, because when Scout and Jem are coming home at night after the pageant, Boo is able to rescue them from Bob Ewell.

How is clove used for preserving food items?

Clove has been used for centuries as a primary preservative as well as a flavoring agent for preserved foods. Before modern technology like refrigerators and stoves was available to prolong the life of food or preserve it through canning, most people relied on curing, smoking, pickling, and salting to make sure that their food would last during poor weather. Preserving food makes it inhospitable to microbes and effectively halts the rotting process. Cloves, which are the aromatic buds of a tree native to Indonesia, are high in antimicrobial, antifungal, antioxidant, and antilarval properties. The primary substance in cloves that makes it so great for preserving food is called eugenol. Because of its antimicrobial properties, in addition to its strong fragrance, eugenol may also be used in cosmetics as a preservative.

As a primary preservative of foods, meat may be packed in clove buds to prevent bacterial growth and decay of the tissue. In the Medieval period, meats were often rubbed with or packed in barrels of salt and spices (including clove) to prolong their shelf life and impart flavor. 

Many people today who preserve foods by canning include clove bud in their recipes, though I think these people do so more for the flavor than any antimicrobial concerns.

What was unusual about the way the tenants were chosen to live at Sunset Towers in The Westing Game?

The tenants of Sunset Towers were hand-picked. 

The first unusual thing about the Sunset Towers tenants is that the person who delivers the advertisement, Barney Northrup, is sixty-two years old.  He is riding around town hand-delivering letters.  The description of Sunset Towers makes it perfect for the people who get the letters.  For example, there is space for a dentist, a coffee shop, and a restaurant.  Also unusual is the fact that everyone who gets a letter makes an appointment to see the place. 

When showing the Wexlers their apartment, Northrup knows exactly what to say to impress them. 

“You’re really in luck,” Barney Northrup said. “There’s only one apartment left, but you’ll love it. It was meant for you.” He flung open the door to 3D. “Now, is that breathtaking, or is that breathtaking?” (Ch. 1) 

Realtors often say that a place is meant for you when showing it to you, but in this case he means it.  Each tenant was hand-picked, and a letter hand-delivered.  There is an apartment for each of them.  They are Westing family heirs.  However, as we are told, there is just one problem. 

Who were these people, these specially selected tenants? They were mothers and fathers and children. A dressmaker, a secretary, an inventor, a doctor, a judge. And, oh yes, one was a bookie, one was a burglar, one was a bomber, and one was a mistake. Barney Northrup had rented one of the apartments to the wrong person. (Ch. 1) 

It turns out that Sydelle Pulaski was chosen by mistake.  The private investigator who was supposed to find everyone, Otis Amber, found Sydelle Pulaski instead of Sybil Pulaski.  Other than that, everyone was hand-picked by Sam Westing to play the Westing Game.  He wanted to get to know his heirs, and find out what kind of people they were.  Westing was an eccentric man.

What are cliques?

A clique is a group of people who purposely exclude others from joining. The people in a clique spend time together and share common interests and views. Typically, one or two people lead the clique and choose who can be part of it. The leaders also set certain rules for members of the clique. Clique members are often mean to outside people. This may cause people outside the clique to feel hurt and left out. But some people who are part of a clique feel trapped. These people may realize they no longer want to be part of the clique. They may grow tired of being controlled by the leaders of the clique or realize they are hurting people outside the clique.

Cliques usually form in schools, but they can also form in the workplace. Extroverts and people who fit a particular stereotype when they were in high school are most likely to be part of a workplace clique. Members of a workplace clique often socialize with each other inside and outside the workplace. However, some workplace clique members feel pressured to participate in activities they do not want to engage in. Furthermore, workplace cliques can harm someone’s career. People who are not part of a clique and feel left out can take a number of actions, such as making friends with others who are also not part of a clique.

Overview

A clique is an exclusive group of people. Cliques often consist of popular people who want to belong. A clique is different than a regular group of friends because people in a clique leave others out on purpose. Because of this, people who are not part of the clique may feel hurt and excluded. Members of a clique may also be purposely mean to people on the outside, further causing these individuals to suffer emotionally.

Cliques are a part of socialization in schools and most commonly form in elementary school, middle school, and high school. By the time high school comes to an end, most cliques have been dissolved. Cliques often include members who share certain interests or participate in specific activities. In sociology, a clique would be considered an ingroup. For example, a high school may have a clique of football players, a clique of honors students, and a clique of gamers. Both boys and girls can be in cliques, but girl cliques are more common. Typically, girl cliques are also meaner to outside people than boy cliques.

A clique usually has one or two members who lead it. These leaders choose who can be part of the clique. At the same time, the leaders choose who gets left out of the clique. The leaders typically also set rules for members of the clique. They often require members to conform to the clique. They might also prohibit members from talking to or hanging out with people outside the clique or members of other cliques. In addition, the leaders may set rules for how to dress. For these reasons, someone who joins a clique often acts differently than he or she did before joining.

A clique may not only make those outside of it unhappy, but also those within it. People in a clique feel trapped. They may realize that they no longer want to be in the clique. They may have grown tired of being bossed around by the leader of the clique. They may also feel as though they have to change who they are to be in the clique. Furthermore, they may realize that by excluding others, they are hurting these individuals' feelings. They may also feel that they are missing the opportunity to be friends with other people.

Although most cliques form in schools, some form in the workplace. Some people join a workplace clique to feel a sense of security or a sense of social identity. Workplace cliques generally consist of people who fit a particular stereotype when they were in high school. For example, a person who fit into the class clown stereotype in high school is likely to join a workplace clique. Furthermore, people who are extroverts are more likely to be part of a workplace clique than people who are introverts. Members of a workplace clique generally socialize both inside and outside the workplace. However, some of these people may engage in activities they do not really want to participate in. For example, a person in a workplace clique may feel pressured to go out to eat with other members of the clique even though he is not interested in doing so. He does it anyway because he wants to fit in with the clique. Although workplace cliques are fairly common, they can be harmful to one’s career. They can be counterproductive, prevent collaboration, and negatively impact career advancement.

If people are not part of a clique and feel left out, they can take several actions. They can become friends with others who are also not part of a clique. Oftentimes, this involves looking for friends who go to a different school or who are younger or older. Furthermore, they can become friends with someone who is part of a clique. Simply inviting that person to hang out might cause him or her to leave the clique and may lead to a lasting friendship.

KidsHealth. “How Cliques Make Kids Feel Left Out.” KidsHealth. Nemours Foundation. Web. 31 Oct. 2014. <http://kidshealth.org/kid/feeling/school/clique.html#>

Long, Cindy. “Conquering Cliques in School.” NEA Today. National Education Association. Web. 31 Oct. 2014. <http://neatoday.org/2013/07/12/conquering-cliques-in-school/>

Merriam-Webster. “Clique.” Merriam-Webster. Merriam-Webster, Incorporated. Web. 31 Oct. 2014. <http://www.merriam-webster.com/dictionary/clique>

Smith, Jacquelyn. “How to Deal with Cliques at Work.” Forbes. Forbes Media, LLC. Web. 31 Oct. 2014. <http://www.forbes.com/sites/jacquelynsmith/2013/07/25/how-to-deal-with-cliques-at-work/>

`int x sqrt(1 - x^4) dx` Evaluate the integral

You need to solve the integral using substitution method, such that:

`x^2 = t => 2xdx = dt => xdx = (dt)/2`

Replacing x by t, yields:

`int x*sqrt(1 - x^4) dx = (1/2)int sqrt(1 - t^2)*dt`

You need to use the next trigonometric substitution, such that:

`t = sin u => dt = cos u du`

`u = arcsin t = arcsin x^2`

`(1/2)int sqrt(1 - t^2)*dt = (1/2)*int sqrt (1 - sin^2 u)*cos u du`

You need to use the fundamental trigonometric formula `1 - sin^2 u = cos^2 u`

`(1/2)*int sqrt (1 - sin^2 u)*cos u du = (1/2)*int sqrt (cos^2 u)*cos u du`

` (1/2)*int cos u*cos u du =  (1/2)*int (cos^2 u) du`

Using the half angle formula, yields:

`cos^2 u = (1 + cos 2u)/2`

`(1/2)*int (cos^2 u) du = (1/4)*int (1 + cos 2u) du`

`(1/4)*int (1 + cos 2u) du =(1/4)*intdu + (1/4)*int (cos 2u) du`

`(1/4)*int (1 + cos 2u) du =(1/4)*(u + (sin(2u))/2)`

`int x*sqrt(1 - x^4) dx = (1/4)*(arcsin (x^2) + (sin(2arcsin (x^2)))/2) + c`

Hence, evaluating the indefinite integral yields `int x*sqrt(1 - x^4) dx = (1/4)*(arcsin (x^2) + (sin(2arcsin (x^2)))/2) + c.`

Describe Helen Keller's experience at Radcliffe. Why did she say, "but college is not the universal Athens I thought it was"?

College did not live up to Helen Keller’s expectations because she previously loved learning for the sake of learning and she felt that college did not allow for that. 

Helen Keller was very excited to finally go to college, because she worked so hard to get there being blind and deaf.  This was especially the case because she had to wait a year after being admitted to continue preparations.  She had built it up in her mind, and therefore there was bound to be some disappointment.  Radcliffe was not the paradise she expected. 

For one thing, she complained about the lack of time she had in college.  Helen felt that she no longer had time to reflect.  She was no longer learning just for the joy of learning. 

But in college, there is no time to commune with one's thoughts. One goes to college to learn, it seems, not to think. When one enters the portals of learning, one leaves the dearest pleasures–solitude, books and imagination–outside with the whispering pines. (Ch. 20) 

Helen felt that college was not the “Athens” she thought it would be, because some of the people were possibly just pretenders and not geniuses. 

Many scholars forget, it seems to me, that our enjoyment of the great works of literature depends more upon the depth of our sympathy than upon our understanding. The trouble is that very few of their laborious explanations stick in the memory. (Ch. 20) 

One of the biggest problems is that very few of the books she needed were printed in Braille.  As a result, she had to have them spelled into her hand.  This naturally made everything take longer for her to learn.  Helen often lost her temper.  In the end, however Helen felt that the experience taught her patience and was a worthwhile adventure despite the struggle.

What are the reactions to Juliet's apparent death in Act 4, scene 5, in Romeo and Juliet?

The nurse is the one to find Juliet's seemingly lifeless body on the morning of the day the girl is supposed to marry the County Paris.  At first, the nurse makes bawdy jokes about Juliet's inability to get out of bed, but then she realizes that Juliet is dead (or seems to be, at least) and the nurse curses the day she was born (in her grief over the loss of Juliet). 

Lady Capulet enters next, sees Juliet's lifeless body, and proclaims that Juliet must "Revive" or else she will die alongside her daughter.  Lord Capulet comes next, chiding the nurse and his wife for not bringing Juliet out already, and when they tell him that Juliet is dead, he cries and calls her "the sweetest flower of all the field" (4.5.34).  They all wail and cry together.

Friar Lawrence arrives, and they tell him that Juliet is gone.  He, of course, knows that she would appear to be lifeless because he is the one who gave her the potion that would cause her symptoms.  Paris enters, ready to see his bride's face, but Lady Capulet and the nurse tell him the news.  Paris feels cheated out of his wife by death, and the friar tries to comfort them all. 

How is oppression of women a common theme of Hawthorne's The Scarlet Letter and Assata Shakur's autobiography, Assata?

Both The Scarlet Letter and Assata detail misogynistic treatment of women. The Scarlet Letter tells the story of Hester Prynne, a woman punished for her sexuality by the patriarchal Puritan society she lives in. The gendered double standards regarding the treatment of sexuality are most evident when Hester is compared to Reverend Dimmesdale. Dimmesdale is the father of Hester's illegitimate child, and he condemns her for her actions while facing no consequences for committing the same crime:

Heaven hath granted thee an open ignominy, that thereby thou mayest work out an open triumph over the evil within thee, and the sorrow without.

Assata, the autobiography of Black revolutionary Assata Shakur, conveys the experience of Black womanhood. Assata details her relationship with white-centric beauty standards, the harassment and abuse she receives from men, and her experience as a woman incarcerated in men's prisons. One quote about the misogynistic violence Assata experiences as a teenager is the following:

Back then, when i was growing up, boys gang-banging or gang-raping a girl was a pretty common thing. They called it pulling a train. It didn’t happen to any particular kind of girl. It happened to girls who were at the wrong place at the wrong time. The boys talked about it like it was a joke or a game, like they were “only” out to have some “fun.”

What are assisted reproductive technologies?

Indications and Procedures

Although most couples experience little or no difficulty conceiving and carrying a child to term, about 15 percent experience infertility. Infertility is defined as an inability to conceive after a year of having regular, unprotected intercourse. Not all couples can be helped, but an increasing number of reproductive technologies are available, from in vitro fertilization
(IVF) and artificial insemination to drug therapies and surgical repair.

Typically, the first step is to determine whether the man’s sperm is fertile by performing a simple sperm count.
If sperm counts are low or the sperm are abnormal, then the primary treatment is artificial insemination, also called intrauterine insemination (IUI). Cryopreserved sperm are obtained from a sperm bank, which collects ejaculate from healthy, fertile men. The donors of the sperm remain anonymous, and the samples are usually a mixture of sperm from two or more men. This method maintains even greater anonymity and increases the amount of sperm available, thus increasing the chances of conception.

To ensure the highest probability of success, IUI should be performed when the woman is ovulating and is most fertile. Most women experience a slight rise in their basal body temperature when they ovulate, and monitoring daily body temperature upon waking can be used in some cases. A more reliable method is detection of a surge in luteinizing hormone (LH) in the urine. LH usually stimulates ovulation within thirty-six to forty hours after the surge. A home urine LH analysis kit can be used, and when the LH surge is detected, insemination can be scheduled for the following day. Self-observation of cervical mucus changes can also be used to detect ovulation. Insemination is a simple office procedure in which the physician uses a special catheter to transfer the semen
sample into the uterus.

If adequate numbers of sperm are present, and they appear normal and active, then the diagnostic focus shifts to the woman. Because the female reproductive system is primarily internal, diagnosis is often more complicated and expensive and in some cases can pose risks to the woman. The primary cause of infertility in women is inability to ovulate. Factors that may prevent ovulation include lifestyle factors (drug abuse, obesity, weight loss, prolonged acute stress), hormone imbalance, ovarian tumors or cysts, previous infection, an unusually short menstrual cycle, previous surgery, or birth defects. Sorting out the specific cause or causes can be a daunting task, and the causes remain unknown in some cases.

The initial diagnosis involves extensive consultation on health status and lifestyle, a complete physical examination, urine and blood tests to check for infection or hormone imbalance, and often tests on samples of cervical mucus and a portion of the endometrium (lining of the uterus). The primary goal of these initial tests is to determine whether ovulation is occurring. If ovulation is occurring, the problem likely involves an abnormal uterine condition or an endocrine imbalance that is interfering with implantation. Other problems might include some fault with the eggs that are released or with the ability of sperm to penetrate or fuse with the nucleus of the egg.

If the ova (eggs) are abnormal, then donor ova can be collected from another woman, followed by IVF with the male partner’s sperm. Often the fault with abnormal ova is with the cytoplasm, so another possible treatment is to remove the nucleus from an abnormal ovum and place it into a donor ovum from which the nucleus has been removed. The resulting ovum would then have a nucleus derived from the mother and a cytoplasm derived from the donor. Although this approach is technically feasible, it has ignited ethical concerns similar to those raised about cloning.

If ovulation is not occurring, which is true in the majority of cases, then additional tests are required. Continued monitoring of hormone levels may identify an imbalance or timing problem that can be corrected with hormone treatments. Sometimes hormone treatments alone are able to normalize ovulation and restore fertility. In other cases, the problem involves a blockage or abnormal shape of the Fallopian tubes or uterus. Diagnostic procedures at this stage typically involve some form of imaging technology so that the condition of the reproductive organs can be assessed.

Hysteroscopy is a procedure for viewing the interior of the uterus; it can be done either in a doctor’s office or in an outpatient setting at a hospital. In preparation for the procedure, the woman is usually given a mild analgesic such as acetaminophen or ibuprofen, as some minor cramping is common. The doctor then washes the vagina and cervix. A local anesthetic is administered to the cervix. The cervix is carefully dilated, and the hysteroscope is inserted through the cervix into the uterus. The hysteroscope contains a small light for illuminating the interior of the uterus and a small camera for viewing. Some conditions that can be detected using hysteroscopy include a septum that divides the uterus, fibroid growths or polyps, and cancerous or precancerous lesions. Often, the location where the Fallopian tubes enter the uterus can also be viewed. Many of these conditions can be asymptomatic. Surgical removal of a septum or other growths may restore fertility. If a woman is able to produce an egg to fertilize but is unable to carry the child herself, another option is surrogacy, which then involves legal procedures to establish parentage.

Hysterosalpingography can be used to view both the uterus and the Fallopian tubes. This x-ray procedure uses a contrast dye to visualize internal structures. Placing the dye into the uterus involves insertion of a special flexible catheter through the cervix. A balloon at the end of the catheter is inflated to hold the catheter in place as the contrast dye is pumped into the uterus. X rays are taken every few seconds as the dye travels through the uterus. Eventually, the dye travels the length of the Fallopian tubes. The images obtained can be used to identify many of the anomalies also detectable using hysteroscopy and can also identify problems with the Fallopian tubes. If the Fallopian tubes are blocked, then the dye will not travel their length, which will be visible in the x-ray photographs.

In some cases, none of these minimally invasive diagnostic procedures identifies a problem. In such cases, diagnostic laparoscopy
can be used. Using a laparoscope, a flexible tube with a light and special lens at the end, a doctor can view internal organs directly. After administering regional or general anesthesia, an incision is made near the region of the peritoneal cavity to be imaged. Carbon dioxide is used to fill the peritoneal cavity to improve viewing conditions. The laparoscope is then inserted through the incision. If an abnormality is detected, then the doctor may insert another instrument to collect tissue for a biopsy. After laparoscopic examination is completed, the incision is closed. Laparoscopy is usually done in a hospital as an outpatient procedure, and the patient can go home the same day. Even after diagnostic laparoscopy, the cause of infertility may remain unknown.

Uses and Complications

Assisted reproductive technologies are best suited to couples in which one or the other is infertile but otherwise in good health. Age may also be an important factor for the woman, as fertility, implantation, and normal development of the fetus are all affected as a woman ages, especially beyond thirty-five. Although these technologies can be successful in older women, the risks involved need to be assessed carefully with a doctor. They can also be more costly in older women, because more attempts using IUI and IVF are often required.

Hysteroscopy and hysterosalpingography are the most commonly used procedures for diagnosing infertility, once the more obvious causes have been ruled out. Although both can cause mild to moderate discomfort, they have very few associated risks and can be performed in most obstetrics/gynecology (OB/GYN) offices. If a clear diagnosis is obtained, then a number of problems may require surgery. Blockage, abnormalities of the Fallopian tubes or other reproductive organs, ectopic pregnancies, and abnormal growths (cysts or tumors) can be treated or repaired surgically. In most cases, laparoscopic surgery is used, as it is less invasive than traditional abdominal surgery. Laparoscopic surgery is performed in the same way as diagnostic laparoscopy and may be done at the same time if a problem is discovered in the process.

Diagnostic laparoscopy is typically the method of last resort, as some potentially life-threatening risks are involved, such as damage to abdominal organs, inflammation or infection of the peritoneum or other organs, hemorrhaging, and formation of embolisms that may block an important artery. The procedure can also be more painful in cases where anesthesia is only partially effective. Current research suggests that the benefits may outweigh the risks, but some women choose not to have diagnostic laparoscopy, and not all doctors consider the risks appropriate.

When surgical intervention is unable to restore fertility, the most common option is in vitro fertilization (IVF). As long as the woman’s uterus is anatomically and physiologically normal, IVF can be an effective, although expensive, option. It is the method of choice for women who have blocked Fallopian tubes or an abnormal pelvic anatomy or who have had tubal ligation and are considering reversal. It also tends to increase the chances of pregnancy in older women and women with endometriosis. Low sperm count or vasectomy reversal in the male partner may also require IVF, as the sperm may require concentration for effective fertilization. IVF can also be an effective solution for women who cannot ovulate or who have very few or faulty eggs, in which case donated eggs can be used. Gamete intrafallopian transfer (GIFT)
collects multiple eggs
and places them into a catheter along with sperm. Ovum and sperm are then together injected surgically into the Fallopian tubes, where conception may take place. In zygote intrafallopian transfer (ZIFT), ovum are mixed with sperm in the laboratory, and the resulting zygotes are surgically placed into the Fallopian tubes.

IVF is not without its risks and potential failings. Carefully designed hormone injection protocols are used to stimulate multiple follicle formation and to prevent premature ovulation. Progress is typically monitored using ultrasound. If the number of follicles is too small, then the cycle may be canceled, as the cost of retrieval, given the number of eggs that could be available, is too high. Overstimulation can also occur, which can lead to abnormal levels of estrogen that may pose a health threat. If an appropriate number of follicles are produced, then eggs are retrieved using a needle inserted through the top of the vagina. The placement of the needle is guided using ultrasound, and once the ovaries are reached, the eggs are aspirated into it.

A final concern with IVF is the increased incidence of multiple pregnancies. To increase the chance of a pregnancy, multiple fertilized eggs are placed in the uterus. When only a single embryo is transferred, live births occur less than 10 percent of the time. In recent years, as IVF procedures have steadily improved, the incidence of multiple pregnancies has increased. A study published in 2003 showed that when two embryos were transferred and a live birth resulted, approximately 16 percent of the time twins resulted. This percentage rose to almost 30 percent when three embryos were transferred. When more than three embryos were transferred, triplets and higher numbers occurred with increasing frequency as well. Due to the number of premature births resulting from in vitro fertilization, most reproductive endocrinologists limit the number of embryos transferred in order to limit the number of multiple births.

IVF is a solution only when sperm quantity is adequate or donor sperm is acceptable to the couple. In some cases the sperm count for the male may be so low that even concentrating the sperm would be insufficient to achieve fertilization. Sperm can still be obtained from the male in some cases. If no sperm are found in the ejaculate, there may be an obstruction, and sperm may still be obtained by using a needle inserted near the obstruction. In some cases, the male’s sperm may lack the ability to penetrate the egg. If a couple insists that they do not want to use donor sperm, then the last option available is typically intracytoplasmic sperm injection
(ICSI), in which a single sperm is injected directly into the cytoplasm of an egg. This technique has been so successful that even males with only a few sperm have been able to father a child. If sperm count is low or motility is poor, sperm from the male may be mixed with donor sperm, so that if pregnancy occurs, the identity of the father can remain uncertain if so desired by the parents.

Perspective and Prospects

Assisted reproductive technologies arose during the latter half of the twentieth century. Prior to this period, infertility was poorly understood and treatments were essentially nonexistent. The first attempt at treating infertility involved artificial insemination in 1785 by the Scottish surgeon John Hunter. A child was born that same year, apparently as a result of his attempts. The next documented attempt at IUI was by Robert Dickinson in 1890. His attempts were highly secretive because the Anglican Church condemned such procedures. The first comprehensive guidelines for determining male infertility based on sperm count and quality were published in 1934.

In 1945, a report of early IUI experiments was published in the British Medical Journal. As a result, in 1948 the archbishop of Canterbury proposed making IUI a criminal offense. Although the British government did not follow his advice, it did discourage the use of IUI. During the 1950s, the public demand for solutions to infertility far exceeded medical solutions. By 1955, there had been four successful pregnancies using frozen donor sperm. In spite of these successes, IUI was not to become an acceptable and widely used procedure until the 1970s.

The first fertility drug was developed in 1949, but it took until 1962 for this discovery to be applied successfully, resulting in ovulation and a successful birth. Throughout the 1960s and beyond, the use of fertility hormones was further refined, allowing more infertile women to ovulate and bear children. Use of fertility hormones has become a key part of IVF as well, allowing the harvesting of viable eggs.

The first step toward IVF occurred in 1944, when the first in vitro fertilization took place. It took another thirty-one years for the first IVF pregnancy, and unfortunately it was an ectopic pregnancy. Three years later, in 1978, Louise Brown became the first “test tube” baby born as a result of IVF. In 1981, Elizabeth Jordan Carr became the first IVF baby in the United States. Use of IVF is now routine, and success rates continue to rise.

The 1980s and 1990s saw even greater improvements. Surgical procedures using laparoscopy continued to improve, and diagnostic procedures became ever more sensitive. In the 1980s, donor eggs became widely available. One of the difficulties in using donor eggs had always been preserving them until use, because they seemed much more sensitive than sperm. The first baby derived from a frozen egg occurred in 1983, and methods of preservation are now even better. In 1986, the first baby derived from a frozen donor egg was born in Australia.

In 1992, researchers in Belgium reported the first pregnancies resulting from ICSI, and a year later the first successful birth from ICSI was reported in the United States. IVF was so routine by this time that in 1994 a sixty-two-year-old woman gave birth, and a year later a sixty-three-year-old woman who lied to her doctor about her age also gave birth.

To work around the use of defective eggs, in 1997 the first cytoplasmic transfer birth occurred and ignited controversy over the continued use of the technique. Some ethicists saw it as being too much like human cloning and germline genetic manipulation, and they advocated banning the technique. In the United States, the Food and Drug Administration (FDA) quickly stepped in and claimed jurisdiction over use of the technique. It remains an experimental technique, and its implications are still being addressed.

The cloning of the first mammal from adult cells, Dolly the sheep, brought the possibility of reproductive cloning in humans to the forefront. In response to the many concerns about the potential for cloning humans, President Bill Clinton issued a moratorium on funding to those performing research on human cloning. Human cloning remains a very controversial issue and has been banned by most countries.

The future of assisted reproductive technologies will probably include ever more improved techniques and may also include germline gene modification. Embryos can currently be screened for a number of genetic defects, so that parents can be given the opportunity to use only healthy embryos. The potential for screening for a variety of genetic defects or traits means that parents in the future could choose embryos that meet certain criteria such as sex, intelligence, or personality. It may even be possible to engineer improvements in embryos. The ethics of using these kinds of techniques are still being debated and are considered questionable by many. Regardless of the outcome of these discussions, the future certainly will hold the prospect for almost all couples to have a baby derived from their own genetic material, a dream that was once unattainable for many infertile couples.

Bibliography

American Society for Reproductive Medicine. Guidelines on Number of Embryos Transferred: A Practice Committee Report—A Committee Opinion. Birmingham, Ala.: Author, 1999.

Blackley, Michelle. “’Eggs for Sale’: The Latest Controversy in Reproductive Technology.” USA Today 132, no. 2698 (July, 2003): 56–58.

De Jonge, Christopher J., and Christopher L. R. Barratt, eds. Assisted Reproductive Technology: Current Accomplishments and New Horizons. New York: Cambridge University Press, 2002.

Gardner, David K, Botros Rizk, and Tomasso Falcone, eds. Human Assisted Reproductive Technology: Future Trends in Laboratory and Clinical Practice. New York: Cambridge University Press, 2011.

Henig, Robin Marantz. “Pandora’s Baby.” Scientific American 288, no. 6 (June, 2003): 62–67.

Khamsi, F., et al. “Recent Advances in Assisted Reproductive Technologies.” Endocrine 9, no. 1 (August, 1998): 15–25.

Parekattil, Sijo J., and Ashok Agarwal, eds. Male Infertility: Contemporary Clinical Approaches, Andrology, ART, and Antioxidants. New York: Springer, 2012.

Powledge, Tabitha M. “Looking at ART.” Scientific American 286, no. 4 (April, 2002): 20–21.

Rizk, Botros, and Eric Jauniaux, eds. Pregnancy After Assisted Reproductive Technology. New York: Cambridge University Press 2012.

Schultz, Richard M., and Carmen J. Williams. “The Science of ART.” Science 296, no. 5576 (June, 2002): 2188–90.

Shanley, Mary Lyndon. Making Babies, Making Families. Boston: Beacon Press, 2001.

Steiger, Samantha P., ed. In Vitro Fertilization. New York: Nova Science, 2011.

Tan, Seang Lin, and Togas Tulandi, eds. Reproductive Endocrinology and Infertility: Current Trends and Developments. Basel, Switzerland: Marcel Dekker, 2003.

Wilcox, Melynda Dovel, and Josephine Rossi. “What Price a Miracle?” Kiplinger’s Personal Finance 56, no. 9 (September, 2002): 116–19.

Yoshida, T. M. “Infertility Update: Use of Assisted Reproductive Technology.” Journal of the American Pharmaceutical Association 39, no. 1 (January/February, 1999): 65–72.

What is acidosis?

Causes and Symptoms

Acidosis is a state of excess acidity in the body’s fluids. For metabolism to function normally and oxygen to be delivered properly to tissues and organs, blood pH must remain within a narrow, slightly alkaline range between 7.35 and 7.45. Acids and bases (alkalies) in bodily fluids kindle the chemical reactions that support living. The organs that largely regulate the acid-base balance are the kidneys and lungs.

Acidosis arises from either a decrease of base bicarbonate (bicarbonate combined with such minerals as calcium, magnesium, or phosphorous—a base) or an increase of carbonic acid (combined carbon dioxide and water—an acid). Medicine recognizes both metabolic and respiratory acidosis, although clinically the two are often intertwined. Metabolic acidosis involves the kidneys, which metabolize, neutralize, or excrete any acid but carbon dioxide. Respiratory acidosis involves the ability of the lungs to exhale carbon dioxide, which is a gas but readily combines with water to form carbonic acid. Acidosis can be verified through an analysis of arterial blood gases.

Metabolic acidosis occurs when metabolism is impaired, sometimes by ingestion of a substance that exceeds the capacity of the kidneys to buffer. Acidifying ingestibles include wood alcohol (methanol), antifreeze (ethylene glycol), and salicylates such as aspirin in large doses. Certain infections can cause metabolic acidosis. Poorly controlled type 1 diabetes mellitus causes metabolic acidosis when inadequate insulin levels enable ketone bodies from fat breakdown to acidify the blood. When overexertion exceeds the ability of the blood to supply
muscles, lactic acid is produced; the same thing occurs when poor blood supply exceeds normal oxidative metabolism. To remedy acidic blood, the body leeches buffering minerals such as calcium, magnesium, sodium, and potassium from organs and bones.

Respiratory acidosis occurs when the lungs cannot expel enough carbon dioxide. It is often caused by diseases such as emphysema, chronic bronchitis, advanced pneumonia, pulmonary
edema, or asthma, all of which damage the lungs or bronchi. It can also occur with diseases of the nerves or muscles that move the chest or diaphragm. Apnea that interrupts sleep breathing or hyperventilation can cause respiratory acidosis. It can also result from oversedation with narcotic opioids or strong sedatives that slow breathing. In cardiac arrest, metabolic and respiratory acidoses are concurrent.

Acidosis can be chronic or acute. Its symptoms can range from unnoticed to vague and unspecific to disturbing or life-threatening. Because their causes differ, metabolic and respiratory acidosis also vary in their symptoms. Symptoms of metabolic acidosis include nausea, vomiting, and fatigue from blood-borne acids and a tendency (which may be absent in infants) to breathe quickly and deeply as the body attempts to expel more carbon dioxide. Respiratory acidosis can cause headache, confusion, and breathing that is shallow, slow, or both in the effort to expel carbon dioxide.

Treatment and Therapy

Metabolic acidosis is treated by determining the cause and correcting the imbalance. The acidic substance in the blood must be removed or buffered, although this may prove difficult. Treatments vary for metabolic acidosis caused by kidney disease, shock, cancer, poisoning, diabetes, and cardiac arrest. In mild cases, acidosis may be corrected by giving intravenous fluids. In severe cases, bicarbonate can be given intravenously. This provides only temporary relief, however, and may create further problems with excessive sodium.

Respiratory acidosis is generally controlled by improving lung function. Diseases such as asthma or emphysema may respond to bronchodilators, which open the airways. Children under five years of age may develop simultaneous metabolic and respiratory acidosis from salicylate poisoning; vomiting can then be induced with ipecac syrup. Whenever breathing is impaired sufficiently to prevent the exchange of carbon dioxide and oxygen, mechanical ventilation may be required.

Perspective and Prospects

Properly functioning bodily processes require oxygen. The more acidic the blood, however, the less oxygen it can carry. The simple process of living produces quantities of metabolic and respiratory acids that, in health, the body continually and silently buffers. In the Western world, people further challenge the acid-base balance through diet, with animal products such as meat, eggs, and dairy as well as with processed foods such as white four and sugar and beverages such as coffee and soft drinks. Many common drugs are acid-forming, as are artificial sweeteners. As long as they function normally, the lungs and kidneys oppose the tendencies of bodily fluids to exceed normal pH parameters. Having healthy lung and kidney function, and avoiding or balancing acid in the diet, can help maintain optimal internal chemistry.

Bibliography:

"Acidosis." MedlinePlus, Mar. 22, 2013.

Gennari, F. John, et al., eds. Acid-Base Disorders and Their Treatment. Boca Raton, Fla.: Taylor & Francis, 2005.

Hogan, Mary Ann, et al. Fluids, Electrolytes, and Acid-Base Balance. 2d ed. Upper Saddle River, N.J.: Pearson/Prentice Hall, 2007.

Lewis, James L., III. “Acidosis.” In The Merck Manual Home Health Handbook: Third Home Edition, edited by Robert S. Porter. Whitehouse Station, N.J.: Merck Research Laboratories, 2009.

"Metabolic Acidosis." MedlinePlus, Mar. 22, 2013.

"Respiratory Acidosis." MedlinePlus, Mar. 22, 2013.

What is the formula for kolmium hydroxide?

There is no element that has been named kolmium. And kolmium hydroxide is the name of the hydroxide of the element kolmium.

Maybe you have made a typo and intended to ask for the formula of holmium hydroxide. Holmium is a rare earth element with the atomic number 67. The metal was isolated in the year 1878 and has been named after Stockholm, a city in Sweden.

Holmium has unusual magnetic properties that make it an ideal element for use in making magnets and ferromagnetic substances. It is also used to regulate nuclear reactions and as a coloring agent for glass.

The hydroxide of holmium is hydrated and the chemical formula of holmium hydroxide is `Ho(OH)_3.xH_2O`

Who is not present when Toby comes to Fagin's house after the blotched robbery in Charles Dickens' Oliver Twist?

Toby Crackit informs Fagin that he and the other robbers had to flee the scene of a botched robbery. Oliver is missing because he was shot and Crackit and the others fled their pursuers, leaving Oliver in a ditch.

Toby tells Fagin, who has already read of the robbery in the newspaper, that the "whole country was awake" and came rushing after them, so they had no choice but to run. He says the boy was shot when Bill had Oliver on his back as he was fleeing. Toby adds,

"We stopped to take him between us; his head hung down, and he was cold."

Then as the pursuers gained on them, Toby continues,

"It was every man for himself.....We parted company and left the youngster lying in a ditch."

When Fagin hears that they have lost Oliver, and that the boy could be dead, he yells loudly and pulls his hair in chagrin. Then, he rushes from the house.

In the following chapter (XXVI), Fagin scours the neighborhood for a man called Monks; when he cannot locate him, he looks for Bill Sikes, but only finds Nancy there in a drunken stupor. She says poor Oliver is better off dead, anyway. But, Fagin significantly says that Oliver is worth hundreds of pounds to him. 

Later, Fagin finds Monk and their conversation suggests that Monk has a personal interest in Oliver as does Fagin. Obviously, money is involved if Fagin is so upset and declaring that Oliver is worth a fortune.

I need to write an essay about No country for old men. I thought about the importance of the setting (a desert and desolate place where the Law is...

You have chosen an interesting and, I think, a very workable topic.  In the novel, laws are unstable, and men seem to operate without a moral code.  The desert seems to reflect this emptiness.  The men seem as hollow as T.S. Eliot's "Hollow Men," and the dryness of the desert seems to symbolize their meaningless lives and deaths.  It is significant that the money was found in the desert surrounded by dead bodies.  This becomes a symbol and a foreshadowing of the fact that the main characters in the novel trade their lives for this money.  Moss's decision to keep the money results in the loss of his life and that of his wife's.  Even Carson Wells ends up paying with his life for his attempt to get the money.  There's a sense of waste, futility, and desolation.  

Once the characters become guided by greed, then they make the law of the jungle their guide.  They do what they can to outsmart, out run, out maneuver others.  Of course, Chigurh is the villain here, but others, though not as cruel and ruthless, show similar tendencies. In this world, Chigurh wins, mainly because he is smarter and more vicious than his competitors.  

Much of the action of the novel is in the city.  It is in hotels and hospitals, not the desert, but I think you can use the desert as a metaphor that extends throughout the novel.  There is no real justice in this novel. We see this when Chigurh kills Carla Jean.  Even her steadfast love cannot combat Chigurh's evil or her own husband's greed.  There seems to be an absence of individual integrity.  In fact, it seems that Bell is the only one who has any remorse over his actions.  He seems to accept the fact that the world is a barren place and that evil is stronger than good. (By the way, you might include Bell's experience in the Vietnam jungle in your discussion.) So in some ways, the city becomes the desert--it's at least as empty, infertile, and harsh as the desert.  

I hope this helps.  

Why does the farmer call Hauchecorne an 'old rogue?'

In town, word gets around the Maitre Houlbreque's pocketbook, containing five hundred francs and business papers, has been lost. Earlier, Maitre Hauchecorne had bent down to pick up a piece of string. He was embarrassed to be seen picking up something so cheap and small. Noting that his enemy, Maitre Malandain was watching him, Maitre Hauchecorne pretended to be looking for something else. When Houlbreque's pocketbook goes missing, Malandain uses this as an opportunity to accuse Hauchecorne of the crime. 

Hauchecorne is accused but they find nothing on him. He is accosted by others in the village and he tells them that he had merely picked up a piece of string. No one believes his story. This made him more desperate and he made it a point to tell everyone his side of the story. But this desperation just makes everyone laugh at him. Even when the pocketbook is found, many still suspect Hauchecorne. So, when the farmer calls him a rogue (one who is dishonest), he (and many others) still thinks that Hauchecorne stole it and gave it to someone else to return. 

How does the old man know Alan's name in the story "The Chaser"?

In the story, a particular line from the text explains how the old man knows Alan's name:

An old man sat in the rocking-chair, reading a newspaper. Alan, without a word, handed him the card he had been given. "Sit down, Mr. Austen," said the old man very politely. "I am glad to make your acquaintance."

It is only after Alan hands the card over to the old man that he (Alan) is addressed by name. Now, the story does not tell us what is written on the card, but we can hypothesize that the card probably contains a message or note introducing Alan to the old man and explaining his need for the old man's help. The old man also addresses Alan "very politely" after he finishes reading the card; he tells Alan that he is very pleased to make his acquaintance. Possibly, the old man is well acquainted with and respects the person who has spoken on Alan's behalf.

Why is Lennie with George instead of at home?

Lennie is mentally challenged and definitely unable to take care of himself. In chapter one, he threatens to go off in the woods to find a cave to live in. George scoffs at the idea and questions what Lennie would get to eat. It seems Lennie has traveled with George since Lennie's Aunt Clara died. The two men grew up in the small northern California town of Auburn and after Aunt Clara died, George took Lennie with him. In other words, Lennie really doesn't have a home. His home is with George and the two men are migrant farm workers traveling through California looking for work. The book is the story of their experience on a ranch near the central California town of Soledad. In chapter three, George explains his relationship with Slim as the two hang out in the bunkhouse:

“Him and me was both born in Auburn. I knowed his Aunt Clara. She took him when he was a baby and raised him up. When his Aunt Clara died, Lennie just come along with me out workin’. Got kinda used to each other after a little while.” 

In Brave New World by Aldous Huxley is he using the savage reservation to mock religion?

Huxley is not trying to mock religion on the savage reservation. Instead, he is illustrating a theme of the book: that a trade-off exists between the sterile and soulless but clean, bright, orderly and superficially happy society of Brave New World and one that allows freedom, intellect, passion, poetry and individuality to flourish.

On the savage reservation, passion and religion still exist. We see, however, that this comes at a price. For example, the society is dirty. On the way to the religious ceremony, Lenina and Bernard pass a dead dog thrown on a trash heap, people have lice and the savages don't bathe regularly. Linda is bloated and ugly, and we see people who are visibly old and diseased. Religion allows the beauty of deep, intense feeling but also involves suffering: a young initiate is whipped as part of the religious ceremony Lenina and Bernard witness and blood runs down the young man's back. Huxley shows this not to mock religion, but to show that being fully human, which includes worshipping God, carries a cost. In a society with disease and ugliness, people need to learn how to bear suffering. 

At the end of the book, Mustapha Mond makes an argument in favor of his well-ordered, safe world, and the Savage responds with an impassioned plea for religion:

But God’s the reason for everything noble and fine and heroic. If you had a God ...

Mond responds:

"My dear young friend,” said Mustapha Mond, “civilization has absolutely no need of nobility or heroism."

What Huxley mocks is not religion, but Mond's vision of a society without nobility, heroism or God. 

What reason does Anne Frank give for starting a diary?

Before Anne goes into hiding, she starts her diary because she needs someone or something in which she can confide, as she does not feel that she can confide in other people. She writes: "I have never been able to confide in anyone, and I hope you will be a great source of comfort and support" (page numbers vary by edition). She received the diary for a birthday present when she turned 13 in June of 1942. 

She later writes that "paper has more patience than people" (page numbers vary by edition) and that she doesn't have a true friend. While she is surrounded by many people, including her family, she says she "can't bring myself to talk about anything but ordinary everyday things" (page numbers vary by edition). She concentrates on having a good time with her friends, but she wants to reveal her deeper thoughts in her diary, which she names Kitty. At the time she started her diary, she couldn't imagine that anyone would be interested in reading the thoughts of a thirteen-year-old girl, but she enjoys writing and needs somewhere to record her many thoughts. 

Is monarchy possible in a democratic country?

Monarchy is possible in a democratic state, but of course this depends on the monarch and the democratic body.  The best example of a monarchy-democracy blend would be Great Britain.  Elizabeth II reigns as a figurehead.  She has little actual political power.  The real power of state resides with the Prime Minister and the Houses of Parliament, of which the Lower House is elected by the people.  

Monarchy and democracy used to be on opposite ends of the spectrum, however--there was an idea called "divine right" where the king/queen ruled because he/she was God's secular sovereign on Earth.  Under this system there might be an elected body, such as the Duma under Nicholas II in czarist Russia, but it was only an advisory committee and the ruler could do whatever he/she wanted.  This theory has largely fallen out of favor, however, due to many countries enacting reforms to give the people more of a say in their political futures.  Also, absolutist monarchies have often ended badly in history when the royal hereditary line fails to produce an heir or the heir is incompetent to rule.  

What is a goiter?

Causes and Symptoms

Goiter is often a painless medical condition. Its only visible symptoms may be a slight but visible enlargement of the thyroid that creates a swelling at the base of the neck. In severe cases, the swelling becomes massive and the patient experiences difficulty breathing or swallowing as the enlarged thyroid compresses against the windpipe or esophagus. Other symptoms that may indicate goiter include weight loss, increased heart rate, elevated blood pressure, hair loss, and tremors. Goiter can be confirmed by ultrasound scan of the thyroid, blood tests for abnormal levels of thyroxine or thyroid-stimulating hormone, or low rates of iodine excretion in the urine.

The several types of medical goiter fall into two broad categories: simple goiter and toxic goiter. Simple goiter is caused by a dietary deficiency of iodine. In response, one or both lobes of the thyroid gland enlarge in an attempt to produce more of the iodine-containing hormone thyroxine. Two types of simple goiter are recognized: endemic goiter and sporadic goiter.

Endemic goiter typically occurs in landlocked geographic regions or in areas where farm soils are iodine-depleted. Simple goiter was once common in areas of central Asia, central Africa, and the so-called Goiter Belt of the United States, which extended from the Great Lakes to the Intermountain West (between the Rockies and the Sierras).

Simple goiter most often appears in adolescence, but it may sometimes occur during pregnancy. This condition should be corrected in pregnant women to ensure the healthy development of the fetus and the birth of a healthy infant. Simple goiter readily responds to treatment via iodine tablets, but in some patients surgical removal of all or part of the enlarged thyroid may be necessary. Public health measures undertaken to eliminate or prevent simple goiter include the addition of iodine to table salt and to water reservoirs in certain areas.

Sporadic goiter occurs in some individuals because of an excessive consumption of goitrogenic (goiter-causing) foods such as cabbage, soybeans, spinach, and radishes. Sporadic goiter has also been linked with exposure to certain medications, such as aminoglutethimide or lithium. Although this type of goiter is considered nontoxic, it does produce impaired thyroid activity. Sporadic goiter can be treated by limiting the consumption of goitrogenic foods.

Toxic goiter is caused by an excessive production of thyroxine hormone by the thyroid gland. This type of goiter is also called hyperthyroid goiter, exopthalmic goiter, or Graves’ disease. Toxic goiter results from an oversecretion (hypersecretion) of thyroid-stimulating hormone by the pituitary. In turn, the thyroid gland responds by enlarging and secreting excess amounts of thyroxine, resulting in goiter. Symptoms of Graves’ disease include elevated metabolic rate, higher body temperature, rapid weight loss, nervousness, and irritability. In some patients, this type of goiter results in protrusive eyeballs and the appearance of staring.

Euthyroid goiter occurs when dietary levels of iodine are only slightly below normal. The pituitary gland responds to lowered thyroxine levels in the blood by producing additional thyroid-stimulating hormone. The thyroid gland responds to the elevated thyroid-stimulating hormone by enlarging in an effort to increase thyroxine production.

Treatment and Therapy

Most goiters can be treated effectively through dietary supplements of iodine. The administration of iodine supplements must be very carefully regulated, however, to prevent a so-called thyroxin storm resulting from excess thyroxine production by the enlarged thyroid gland. Some patients may choose alternative natural herbal therapies taken in tablet form, but these substances should be used only in consultation with a physician.

Bibliography:

Cakir, Mehtap. Differential Diagnosis of Hyperthyroidism. New York: Nova Science, 2010.

DeMaeyer, E. M. The Control of Endemic Goiter. Washington, D.C.: World Health Organization, 1988.

Gaitan, Eduardo, ed. Environmental Goitrogenesis. Boca Raton, Fla.: CRC, 1989.

Hall, R., and J. Köbberling, eds. Thyroid Disorders Associated with Iodine Deficiency and Excess. New York: Raven Press, 1985.

Hamburger, J. I. Nontoxic Goiter: Concept and Controversy. Springfield, Ill.: Charles C. Thomas, 1973.

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

Jameson, J. Larry, and DeGroot, Leslie J. Endocrinology: Adult and Pediatric. Philadelphia: Elsevier Saunders, 2010.

McDermott, Michael T. Endocrine Secrets. 6th ed. Philadelphia: Elsevier Saunders, 2013.

"Thyroid Disorders Overview." Hormone, 2013.

How did Frederick Douglass's education continue to transform his life and make it possible for him to become free?

As a child, Frederick Douglass learned of the power of education for slaves from an unlikely source: his master's own mouth. While a young man with the Auld family, the lady of the house, Sophia, started to teach the young Frederick how to read. She was scolded by the master of the house, Hugh Auld, who stated that a literate slave is not content to be a slave. In fact, most southern states prohibited literacy for African-Americans because of their fear of slave insurrections. With this knowledge, Douglass came to appreciate the relationship between education and freedom.

Douglass continued to learn to read in secret. He taught himself to read, in part, by manipulating poor white adolescents to help him.  He even taught himself how to write.  This writing ability would become an even more powerful tool for him as he would become a prolific abolitionist writer as an adult. Douglass even began to teach church school to other slaves at the age of sixteen. He would teach other slaves how to read or write. He did this at a great risk to his own life.

The literacy of Frederick Douglass allowed him to realize that there was a greater calling for him as a free man. He would read the arguments of abolitionists in the newspapers.  He shared this information with other slaves. After two unsuccessful attempts, Douglass successfully escaped in 1838.

Which of the lines below from Act V of Shakespeare's Macbeth tell the audience Macbeth realizes his mistake and regrets his ambition?1. I have...

The passage that most embodies Macbeth's regrets and recognition of his mistakes is the first one: "I have lived long enough. My way of life / Is fall'n into the sere, the yellow leaf" (V.3.26-27). Macbeth means his life has become something dry and withered, like a yellow leaf in the fall. It lacks the meaning and significance he thought it would have. Macbeth has grown old and has nothing good to show for it, none of the "honor, love, obedience, troops of friends" (V.3.29) he believes should come with age. Instead, Macbeth loses all of his friends due to his choices (I mean, he's killed at least two of them), is loved by no one, and is obeyed only because people are afraid to disobey him. Macbeth seems to recognize, then, that his lack of loyalty and his mistakes in judgment due to his ambition have cost him the life he wanted, the life he thought his actions would achieve for him. 

Why are the Greasers proud of their tough, mean appearance?

Unlike the Socs, who come from affluent families that can afford nice clothes and possessions, the Greasers grow up poor and are considered lower class. The Greasers wear their hair long and are usually dressed in blue jeans, white t-shirts, and leather jackets. They admire their "bad boy" persona and appear to be rebellious, dangerous individuals. The Greasers do not have a lot to be proud of, but what they do have is a reputation as tough boys. Instead of being pitied by others for growing up poor, they would rather be feared. Their appearance essentially protects their self-esteem and is meant to intimidate others. They value the fact that they are feared and viewed as dangerous. Their "mean" appearance diverts attention and protects their self-conscious personalities.

How do the female protagonists in Henrik Ibsen's A Doll's House, Shakespeare's Much Ado About Nothing, and Daphne du Maurier's Rebecca compare and...

In Henrik Ibsen's A Doll's House, Nora suffers due to oppression in the sense that her husband does not treat her as a real human being and attempts to control her. Nora finds ways out of her oppression through deception.

Examples of Torvald's attempts to control Nora can be seen all throughout the play, especially in the first act; likewise, many examples of Nora's use of deception to escape oppression can be seen in the first act. The strongest example, however, is seen in Torvald's refusal to permit Nora to take out a loan early in their marriage; in refusing to permit her to do something she feels is necessary to do, he is preventing her from being her own person, which is oppressive. Knowing Torvald needed to be in warmer climates to recover from the health problems caused by overwork (putting him at risk of early death), Nora deceived her husband by forging her ill and dying father's signature on a loan and saying the money was left to her by her father. Nora justifies her act of deception for two reasons: first, her act of deception spared her dying father from being distressed by the news that her husband was equally in danger of dying; and, second, her deception saved her husband's life. Since Nora successfully saved her husband's life, despite his attempt to control her in a way that would have prevented her from saving him, as well as prevented her from being her own person, it can be said that Nora used deception to escape oppression. Plus, by escaping oppression, she escapes suffering.

Yet, despite this temporary escape from oppression, by the end of the play, Nora decides the only true way to escape oppression is by leaving her husband and children in order to become her own person:

I believe before all else I am a reasonable human being, just as you are—or, at all events, that I must try and become one (Act 3).

Similarly, in Shakespeare's Much Ado About Nothing, Hero suffers oppression when Don John slanders his brother, Don Pedro, by tricking Claudio into believing Hero was with another man the night before she and Claudio were to be married. As a result, Claudio publicly rejects Hero as a bride, saying, "There, Leonato, take her back again," and calling her an a common whore (Act IV, Scene 1, line 30). By being made to suffer this unjust public humiliation, Hero is oppressed. Yet, like Nora, she too rises against it through deception. She agrees to fake her own death so Claudio might believe she died as a result of his slanderous words and feel remorseful. Meanwhile, the truth of Don John's deception is also discovered.

Yet, though Hero uses deception to temporarily escape suffering from oppression, unlike Nora, Hero willingly becomes a bride at the end of it all, even if being a bride may lead to more oppression since Claudio may treat her as a doll, just as Nora was treated as a doll, which is characteristic of the treatment of women in earlier time periods.

As a teacher, how can you deal with a lack of parental involvement?

I definitely understand your concern.  I would like to make a small point about parental involvement.  Parental involvement is a double-edged sword.  While it can be great to have, it can also be a source of frustration.  Parental involvement could lead to dozens and dozens of parents or families trying to micromanage you, your classroom, and your students.  That could be detrimental to the classroom environment that you are trying to create.  

So, what to do about a lack of parental involvement?  There are two choices in my opinion, and they are polar opposites of each other.  The first is to do nothing and make the best of it.  Your students are your priority.  A teacher could spend a large amount of time trying to get parents involved and have little to no success.  The problem is that the time spent on the parents takes away from time that could have been spent on students and class time.  

If a teacher wants to get parents more involved, though, there is a variety of things that a teacher could try to do.  Personal phone calls home once per semester is one thing that I do.  I make sure that every family of a student that I teach gets a phone call from me.  And for that phone call, no matter what, I make it a positive phone call.  I tell the parents something good about having their child in my class.  Email works too, but it doesn't work as well as a phone call.  Everybody gets email these days.  It's more rare to get a phone call.  A colleague of mine foregoes the phone call and sends a hand written card to each family.  She gets great feedback about those.  Think about it.  How often do people get real letters in the mail anymore? 

You could design homework assignments that require a small bit of parental involvement.  My masters thesis was on this very topic, and the research suggests that those types of homework assignments improve student learning as well.  For example, in a business math class, a part of an assignment might be to ask their parents how they use the current class topic in their weekly life.  

Another way to perhaps increase parental involvement would be to host an open house.  It's best done on the school level, but you could make it work within a single classroom.  Tie it in with some kind of project that the students complete.  My school's art teacher does this once per semester.  She hosts a student art show near the end of the semester, and parents come to see the work that their child has done during the course.  

What was changing in Rip Van Winkle's world?

Rip Van Winkle provides a window to the American Revolution from the vantage of a Dutch burger in the Catskill mountains. What changed in Rip's world was the sovereign authority to whom the locals owed their allegiance. Van Winkle falls asleep for 20 years, and when he wakes up, the portrait in the inn is no longer that of King George III, but that of President George Washington.

The story of Rip Van Winkle explores power dynamics in interpersonal relationships. The author uses the character of Rip to compare two different periods of time. When Rip wakes up, he has neither an abusive wife nor an unjust king, but has a place of honor in the town square and a democratically elected president. Rip's relationships with his family, friends, and neighbors thus can be seen as an analogy to the changing forms of political authority in the new United States of America.

Keep in mind, of course, that not all change is change for the better. The American Revolution brings cultural upheaval to the town. Not all of that change is necessarily for the better. More likely, the author, Irving, thinks some insight can be gained into the human predicament by juxtaposing the two periods of time in which the story of Rip takes place. Most of human life is lived under the sway of authorities other than one's own self--be that a spouse, a king, or a president.

What is a good thesis topic in the sector of Bank and Finance or Risk Management? I am a second-level student and doing Banking and Finance,...

Examples of topics in banking, finance, investment, and risk that you can investigate through HBSWK are the effects of capital requirements on regulated and unregulated banks [banking], rationality or irrationality among investors [finance], quantitative versus qualitative risk management [risk management]. Harvard Business School Working Knowledge (HBSWK) offers a broad range of banking, finance, investment and risk topics with links to synopses of papers and (at least in some cases) to the actual papers.

Questia also offers a topic search that provides research topics in banking, finance, investment and risk. Again, you access topic ideas derived from actual papers or books published, but your free linking options are limited to previews and/ or overview synopses of the publications. This should be no problem and sufficient for generating research topic ideas for your work. Some examples of topics from Questia are the merger of investment banks and commercial banks [banking and investment], fiscal demands springing from changing demographic needs in Asian Pacific economies [finance], evaluating credit risk retention rules relevant to the residential mortgage market [risk management in banking].

Harvard Business School Working Knowledge Research Topics
Questia Topic Generator

What are some synonyms for undeserving? Basically, can you give me several words to fill in the brackets for, He [does not deserve] to return home.

The words you have bracketed are in verb form, while the word you have asked for a synonym for (undeserving) is an adjective, which is part of why you are having trouble. Adjectives that are synonyms for "undeserving" that give the meaning you want include "unfit," "unsuitable," "ineligible," and "disqualified." You would have to supply a verb such as "was" for the sentence to make sense: "He was unfit to return home." 

If you are able to change the sentence even more, you could try a construction such as "He had lost his privilege to return home," or "He had squandered his right to return home," both of which seem closer in meaning to the original "did not deserve."  

You could add a few more words and rearrange the ideas a bit to come up with sentences such as "Because of his actions, he was no longer welcome at home," "Due to his behavior, he became a persona non grata at home," or "After the way he behaved, returning home was out of the question." 

Sometimes no single synonym can provide the exact tone or meaning you want, but if you have the ability to rephrase the thought completely, you should be able to find a good alternative to the original. 

What is the theme of Freak the Mighty by Rodman Philbrick?

A major theme of Rodman Phillbrick's Freak the Mighty is the ability of love and friendship to encourage personal growth. At the beginning of the book, Max is angry, withdrawn, and stubborn in the belief that no one in his life cares for him. Over the course of the novel he forms a strong friendship with Kevin, and begins to learn that he is smarter than he gives himself credit for. His interactions with Kevin show him that he is loved, and make him reconsider his belief that his grandparents don't care about him. After Kevin's death at the end of the book, Max has transformed enough to write their story, despite believing at the beginning of the book that he was stupid. The friendship that develops between Max and Kevin throughout the book gives Max higher self-esteem and a more positive worldview.

How does Banquo's state of mind change in the play Macbeth?

Banquo isn’t that concerned when he first sees the witches talk to Macbeth. His reaction is a combination of puzzlement and amusement. He has a prophesy related to him, too, and he is not at all interested in taking it to heart. Banquo is only slightly concerned about Macbeth’s reaction because he doesn’t believe Macbeth will take the strange bearded women seriously, thinking only those who have "eaten on the insane root" would do so (Act I, Scene 3).

Eventually, Banquo does start to suspect Macbeth. He has a dream about the witches. The king is killed. Things seem to go from bad to worse in Scotland, and Banquo thinks Macbeth is behind it all, saying,

Thou hast it now: king, Cawdor, Glamis, all,
As the weird women promised, and, I fear,
Thou play'dst most foully for't: yet it was said
It should not stand in thy posterity,
But that myself should be the root and father
Of many kings (Act III, Scene 1).

Macbeth and Banquo know each other well. Banquo is suspicious of Macbeth, and Macbeth is suspicious of Banquo. Macbeth knows Banquo heard the prophecies. He knows one of the prophecies said Banquo’s sons would be king. Macbeth decides Banquo is too dangerous to be kept alive.

Banquo seems to try to keep it cool around Macbeth so as to avoid arousing his suspicion. When Macbeth asks Banquo if he is coming to the banquet, Banquo says he will. Macbeth really just wants to make sure he knows where Banquo and his son Fleance will be so he can kill them both. Macbeth will send the hired assassins out, have Banquo and Fleance killed, and the prophecy about Banquo’s sons won’t matter. 

Unfortunately for Macbeth, while Banquo is killed, Fleance escapes. It may speak more to Macbeth’s state of mind than Banquo’s, but Banquo’s ghost comes to the banquet. It depends on whether you believe in ghosts. If you believe that really was Banquo’s ghost, and not Macbeth’s guilt, it definitely shows Banquo’s state of mind. He would have been very angry at being murdered!

Why was it essential to the organizers of the March of Washington that the event be orderly?

It was very important to the organizers of the March on Washington that this activity would be an orderly one. There were so many people that were going to attend this event. These people came from all walks of life representing different races, religions, and classes of people. If activities got out of hand and violence occurred, the potential for a large number of casualties was very high. If that were to have occurred, it would have damaged the credibility of the Civil Rights Movement and of Martin Luther King, Jr.

If this March on Washington failed because of disorderly actions, it might have made it more difficult for the people in the Civil Rights Movement to accomplish their goals. A disorderly march likely would have led to a loss of support from those lawmakers who were supportive of change and from those people in the general public that were supportive of change.

The need for an orderly march was very important.

What are oral hypoglycemics? How do they interact with other drugs?

Vitamin B12

Effect: Supplementation Possibly Helpful

The biguanide oral hypoglycemic drugs metformin and phenformin can cause
malabsorption of vitamin B12
. In turn, this can lead to vitamin
B12 deficiency. Taking vitamin B12 supplements should
easily solve this problem.

Coenzyme Q10 (CoQ10)

Effect: Possible Benefits and Risks

Studies suggest that the oral hypoglycemic drugs glyburide, phenformin, and
tolazamide may inhibit the normal production of the substance CoQ10.
While there is no direct evidence that taking extra CoQ10 will provide
any specific benefit, supplementing with CoQ10
on general principle might make sense.

In addition, there is some evidence that the use of CoQ10 could improve blood sugar control for persons with diabetes. However, one might also need to reduce one’s medication dosage.

Ipriflavone

Effect: Might Require Reduction in Medication Dosage

There is some evidence that the supplement ipriflavone
might increase blood levels of oral hypoglycemic drugs. This could lead to a risk
of blood sugar levels falling too low. Persons taking oral hypoglycemic
medications should not take ipriflavone without first consulting a physician.

Magnesium

Effect: Might Require Reduction in Medication Dosage

Magnesium supplements might increase the absorption of
chlorpropamide (and, by inference, other oral hypoglycemics), possibly requiring a
dosage reduction.

Herbs and Supplements

Effect: Might Require Reduction in Medication Dosage

Meaningful preliminary evidence suggests that the use of the following herbs and supplements could potentially improve blood sugar control and thus require a reduction in daily doses of oral hypoglycemic medication: aloe, chromium, fenugreek, ginseng, gymnema, and vanadium.

Weaker evidence suggests that the following herbs and supplements could potentially have the same effect under certain circumstances: Anemarrhena asphodeloides, arginine, Azadirachta indica, bilberry leaf, biotin, bitter melon, carnitine, Catharanthus roseus, Coccinia indica, CoQ10, conjugated linoleic acid, Cucumis sativus, Cucurbita ficifolia, Cuminum cyminum (cumin), Euphorbia prostrata, garlic, glucomannan, Guaiacum coulteri, Guazuma ulmifolia, guggul, holy basil, Lepechinia caulescens, lipoic acid, Medicago sativa (alfalfa), Musa sapientum L. (banana), niacinamide, nopal cactus, onion, Phaseolus vulgaris, Psacalium peltatum, Pterocarpus, Rhizophora mangle, salt bush, Spinacea oleracea, Tournefortia hirsutissima, Turnera diffusa, and vitamin E.

Potassium Citrate

Effect: Possible Harmful Interaction

Potassium citrate and other forms of citrate (such as calcium citrate and magnesium citrate) may be used to prevent kidney stones. These agents work by making the urine less acidic. This effect on the urine may lead to decreased blood levels and therapeutic effects of chlorpropamide and possibly other oral hypoglycemic drugs. For this reason, it may be advisable to avoid these citrate compounds during treatment with oral hypoglycemic drugs.

Ginkgo biloba

Effect: Possible Harmful Interactions

It has been suggested that ginkgo might cause problems for persons
with type 2 diabetes, both by altering blood levels of medications and by directly
affecting the blood-sugar-regulating system of the body. However, the most recent
and best-designed studies have failed to find any such actions. Until this
situation is clarified, people with diabetes should use ginkgo only under
physician supervision.

Dong Quai, St. John’s Wort

Effect: Possible Harmful Interaction

Some oral hypoglycemic drugs have been reported to cause increased sensitivity to
the sun, amplifying the risk of sunburn or skin rash. Because St. John’s
wort and dong quai may also cause this problem,
taking these herbal supplements during treatment with oral hypoglycemic drugs
might add to this risk. It may be a good idea to wear sunscreen or protective
clothing during sun exposure if one takes any of these herbs while using an oral
hypoglycemic medication.

Bibliography

Hodgson, J. M., et al. “Coenzyme Q(10) Improves Blood Pressure and Glycaemic Control: A Controlled Trial in Subjects with Type 2 Diabetes.” European Journal of Clinical Nutrition 56 (2002): 1137-1142.

Kudolo, G. B., et al. “Short-Term Ingestion of Ginkgo biloba Extract Does Not Alter Whole Body Insulin Sensitivity in Non-diabetic, Pre-diabetic, or Type 2 Diabetic Subjects.” Clinical Nutrition 25 (2006): 123-134.

Pronsky, Z. M., and J. P. Crowe. Food Medication Interactions. 16th ed. Birchrunville, Pa.: Food-Medication Interactions, 2010.

Ting, R. Z., et al. “Risk Factors of Vitamin B12 Deficiency in Patients Receiving Metformin.” Archives of Internal Medicine 166 (2006): 1975-1979.

What are emergency rooms?

Background

Emergency medicine is one of twenty-four medical specialties recognized by the American Board of Medical Specialties (ABMS). A board-certified specialist in emergency medicine meets training and certification requirements established by the American Board of Emergency Medicine (ABEM). Emergency medicine became a medical specialty in 1979 and is well established as a recognized body of medical specialists and knowledge.

After World War II, emergency rooms became primary health care access points for an increasing number of people. Many factors contributed to this change, including increasing specialization among physicians, along with decreasing numbers of primary care and general practitioners. The resultant decrease in hospital on-call physicians available to treat ER patients fostered the concept of full-time ER specialists, whose primary duties involve treating patients coming to ERs.

The first plans for full-time emergency room physician coverage originated in the 1960s. A model featuring dedicated ER doctors proved to be the most attractive among hospitals and patients. Emergency physicians limit their practice to the emergency department while providing 24–7 coverage. Emergency physicians treat all patients, regardless of ability to pay, while establishing contractual relationships with hospitals. This model for emergency care fostered the development of emergency medicine, setting standards of care for the new specialty. (Michael T. Rapp and George Podgorny provide a detailed consideration of the many factors in the developmental history of emergency medicine in their 2005 article “Reflections on Becoming a Specialist and Its Impact on Global Emergency Medical Care: Our Challenge for the Future” in Emergency Medicine Clinics of North America.)

The National Academy of Sciences and the National Research Council raised concern with a 1966 report titled Accidental Death and Disability: The Neglected Disease of Modern Society. More rapid prehospital response along with better emergency care standards were needed to improve emergency care in the United States. Emergency physicians from Michigan, including John Wiegenstein, founded an organization fostering the national development of emergency medicine, the American College of Emergency Physicians (ACEP), in 1968.

Emergency physicians integrate medical care in a variety of settings, including military, disaster, community, and academic settings. Emergency physicians are experts in emergent cardiovascular care, including resuscitative medicine and the various highly specialized procedures that accompany that care. Accident and trauma stabilization is another area of ER expertise. Emergency medicine residency training is three to four years in length. This training occurs after a doctor has completed medical school and undergraduate education. During that time, a well-trained ER doctor becomes proficient in many complex, lifesaving procedures, such as thoracotomies (opening the chest to correct emergent heart and lung problems), pacemaker placement (correcting heart rate and rhythm problems), intubation (allowing airway access), chest tube insertion (draining blood and fluid from the lungs), and lumbar puncture (assessing neurological problems). Rapid recognition, prompt emergent care, and effective triage are emergency medicine physician characteristics.

Emergency physicians treat life-threatening and severe emergent medical problems, such as myocardial infarctions (heart attacks), strokes, drug overdoses, and diabetic ketoacidosis. Traumatic injuries, such as stabbings, shootings, industrial accidents, and automobile accidents, are also treated and stabilized in the emergency department, which is the major care location for disaster care. Emergency physicians treat all age groups and all conditions, at all hours of the day, simultaneously. This ability to treat a wide variety of emergent problems distinguishes ER doctors as the group of specialists best suited to assess and properly treat the greatest number of acutely ill patients.

Features and Procedures

Emergency rooms vary in size, but most share uniform characteristics. The first ER assessment is triage, a term with French roots meaning “to pick or cull.” In triage, health care personnel, usually nurses, determine the severity of a patient’s injury or illness and record the patient’s chief complaint or medical problem. They measure and record vital signs, including pulse, temperature, respiratory rate, and blood pressure. If the patient’s condition is stable, then triage personnel obtain other important information, such as medications taken, a brief medical history, and any patient allergies.

The most important triage duty determines the severity of an illness. Usually, there are three main categories: critical and immediately life threatening, such as a myocardial infarction; urgent but not immediately life threatening, such as most abdominal pain; and less urgent, such as a minor leg laceration, known as the “walking wounded” in military triage. ER personnel often refer to these categories as Cat I, Cat II, or Cat III. After assessing the patient’s condition, triage personnel advance patients to appropriate care areas. A new category I patient may be wheeled on a gurney directly to the critical area, with the nurse announcing to any doctors on the way, “new Cat I patient in 101.” These patients need immediate emergency care.

A stable patient is registered by front-desk personnel. Registration clerks obtain insurance and contact information. New medical charts are generated for new patients, or old records are requested if they already exist at that hospital. Patients arriving by ambulance or critically ill category I patients bypass this step until after treatment or stabilization in the critical care area of the emergency room.

Most emergency departments have many patient care areas, reflecting the wide variety of patients seen in the ER. These areas include resuscitation rooms for patients needing cardiopulmonary resuscitation; trauma care areas for patients with severe injuries like gunshot wounds or accident victims; critical care areas for patients needing cardiac monitoring along with ongoing critical care; pediatric ERs for the care of children; chest-pain evaluation areas; and suture rooms for the repairs of lacerations (cuts). Rooms for the examination of women with gynecological problems are available. ERs usually have a fast track or urgent care area for minor illness (such as sore throats) and an observation unit for patients waiting for hospital admission or diagnostic tests.

Many personnel contribute to the wide variety of care provided in emergency departments. Emergency physicians, nurses, physician assistants, medical technologists, and medical assistants have specified health care roles. Unit clerks help with the paperwork, and laboratory personnel assist with radiological and laboratory procedures. Administrative people help with staffing issues, equipment purchasing, facility maintenance, and scheduling of workers. These are some of the important roles necessary to deliver emergency care. To a varying degree, ERs will also have social workers, psychological care providers, and patient advocates available as full-time ER personnel.

Perspective and Prospects

Many agencies promote effective, more standardized emergency and trauma care. In addition to the American Board of Emergency Medicine and the American College of Emergency Physicians, many other agencies promote effective emergency care, such as the American Academy of Emergency Medicine. The American Heart Association takes a lead in cardiopulmonary resuscitation (CPR) guidelines. The American College of Surgeons (ACS) develops standards for trauma care. Nursing organizations, emergency medical technician (EMT) agencies, and other professional organizations develop standards for improving emergency care.

The American College of Surgeons provides trauma center designation guidelines. Trauma center designation requires various important resources and characteristics. Although the ACS provides consultants and guidelines for this process, other agencies designate trauma centers, such as local or state governments. Three main trauma center levels exist in ACS guidelines.

In level I, comprehensive 24–7 trauma care specialists are available in the hospital, including emergency medicine, general surgery, and anesthesiology. Various surgical specialists are available, including neurosurgery, orthopedic surgery, and plastic surgery. Level I designation requires intensive care units (ICUs) along with operating rooms staffed and ready to go twenty-four hours daily, all year round. These are major referral centers, often known as tertiary care facilities.

Level II offers comprehensive trauma and critical care, but the full array of specialists may not be as readily available as those found in a level I trauma center. Trauma volume levels are usually lower than the level I trauma centers.

In level III, resources are available for critical care and stabilization of trauma victims. Patient volume, array of specialists, and 24–7 availability vary. Transfer protocols with level II and I trauma centers allow comprehensive care after stabilization. Community or rural hospitals may have this designation.

The efforts of all these groups enhance emergency care, in all of its various forms. Emergency medicine is at the front lines of medical care. Like any forward-moving group, backup and support improve the ultimate goal—available and effective emergency care delivered when needed the most.

Bibliography

Arnold J. L. “International Emergency Medicine and the Recent Development of Emergency Medicine Worldwide.” Annals of Emergency Medicine 33 (1999): 97–103.

"Emergency Medical Services." MedlinePlus, 6 Aug. 2013.

"FAQ for Resources for Optimal Care of the Injured Patient: 2006." American College of Surgeons Trauma Programs, 5 Oct. 2011.

Heller, Jacob L., and David Zieve. "Recognizing Medical Emergencies." MedlinePlus, 5 Jan. 2011.

"Meet the Medical Emergency Team." Emergency Care for You. American College of Emergency Physicians, n.d.

National Academy of Sciences and the National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Government Printing Office, 1966.

Rapp, Michael T., and George Podgorny. “Reflections on Becoming a Specialist and Its Impact on Global Emergency Medical Care: Our Challenge for the Future.” Emergency Medicine Clinics of North America 23, no. 1 (February, 2005): 259–269.

"Verified Trauma Centers." American College of Surgeons Trauma Programs, 5 Aug. 2013.

"When Should I Go to the Emergency Department?" Emergency Care for You. American College of Emergency Physicians, n.d.