By M. Rendell. Saratoga University School of Law.

As agents order decadron 1mg, we have everyday experience with making and modifying objects buy generic decadron 1mg on line, shaping and assembling them order 0.5 mg decadron otc. Materials are gathered buy decadron 1mg with visa, organized buy 0.5mg decadron visa, assembled, cooked and melted, cut, chiseled, glued, forged, molded, bent, tied, nailed and screwed together, etc. Each variation on the activity of constructing objects has salient features, like the heating and melding of ingredients in cooking, which offer themselves as apt inferential source domains for causal understanding of other, less literally describable events. There is also a system of metaphors about how childhood experiences and genetic inheritances "make" us into whatever kind of adults we are. COGNITIVE SEMANTIC STRUCTURES 29 Experiences of all kinds are seen especially as "shapers of character," as in "Their character was shaped by the Depression" or "Military school will shape him up. Making and shaping typically change objects pervasively whereas acquiring or changing the location of something usually involves a less drastic and thoroughgoing alteration. Because of this, the targets that are aptly structured by the logic of making and shaping are those which are created anew or truly metamorphosed. We have common experiences of things coming out of other things which previously contained them. Examples are springs, plants, lava, steam and ash coming out of the ground; babies coming out of mothers; animals coming out of dens, turtles coming out of shells, etc. These experiences create a source domain onto which cause as a source (a special type of container from which things originate) and causation as arising or emerging (often without mention of the source) is readily mapped. Portions of this complex include the mapping of literal sources onto situations as well as sources onto causes so that situations are understood as sources. In this sense they cause events to emerge, arise or be produced like sources literally producing objects. As we shall see in Chapter Four, John Dewey showed how reasoning adapts and is modified for application to particular situations. They don’t operate like simple forces such as push-pull or billiard- ball efficient causes. Situations, as we all know, are not discrete objects but are compositions of all kinds of things in relation. They are not as clearly bounded as middle size solid objects are, but are amorphous and vague. Thus there is some mystery about exactly how and when they influence events, and about what events they will precipitate. These features of "situations" or "states of affairs" have lent themselves well to being structured like similar features of sources such as the ground and mothers. When the "force" conceptualization of "cause" is joined to the idea of emergence, as in the metaphorical uses of "sprang from" and "erupted" there is the special element of emergence from a pressurized container. Unpredictable, potentially explosive situations are aptly understood using this language. The force here is chaotic, unlike the ordered and determinate metaphorical "force" of say, deductive logic. In contrast, the particular process of emergence which is fertilization, gestation and birth (progeneration) provides the logic for gentler causal processes, an important sub-mapping of causation which is addressed below. We have repeated experience with the reproduction and nurturance of living things including ourselves and our children, the children of others and generations of animals and plants. This omnipresent experience offers a vivid prototypical domain whose struc- tures and inferences can be projected metaphorically onto other happenings and endeavors. This metaphorical mapping is non-central in that causation here is far removed from the simple application of force to an object. Nurturance and cultivation involve actuating potentials in the objects cultivated which, unlike the potentials of lifeless things, are seen as flourishing or fulfillment of the objects themselves, not just of an external agent as expressed in or impressed on the object. Since a progenitor may or may not be a nurturer or cultivator, mere progeneration, while it implies reproduction of inherited traits, does not always mean concern for or involvement with the offspring. Therefore, examples of the cause as progenitor are often like these: "The new supervisors sowed discord all through the department. Note that nurturance is one of many causes of maturity, but is important enough to be writ large in our formulations of developmental processes. This metaphor is particularly apt for understanding the promotion of relationships, especially, for our purpose, the doctor/patient relationship.

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Library staff are usually keen to help with difficult searches and to help locate specific information purchase decadron 0.5mg on line. Clinical trials in the 1970s and later showed that it reduced the length of relapses or exacerbations in MS discount decadron 1 mg amex. More recently decadron 1mg with visa, a different family of steroids (gluco- corticosteroids) has been found to have fewer side effects purchase decadron 0.5 mg amex, as well as generally being more effective purchase decadron 1mg free shipping. So ACTH is used less in MS than previously, although some neurologists feel that ACTH still has significant value in treating MS relapses. Some degree of tremor is normal for all people, but a tremor that interferes with ordinary activity may be a symptom of neuromuscular disorder. Some particular sets of activities, as well as formalized procedures for measuring the performance of those activities, have become established as assessments of the degree of disability caused by MS. Such ADL scores may be used to record the progress of MS, to assess domestic needs or to test the effects of drugs in clinical trials. The name refers to the way in which the drugs work by affecting the parasympathetic nervous system, reducing spasms (contractions) in the bladder and thus reducing the likelihood of involuntary or too frequent urination. Tests can reveal changes in the speed, shape and distribution of these signals which are indicative of a diagnosis of MS. The systematic study of autoimmune diseases as a group is an important part of research into MS. In normal circumstances, essential nutrients can cross the barrier from the blood into the brain and waste products cross from the brain into the blood, but the cells of the brain are shielded from potentially harmful substances. Borrelia burgdorferii The Latin name for the infectious organism that causes Lyme disease, an entirely treatable infection spread by ticks, which has many symptoms in common with MS and can be mistaken for it. Dietary changes include an increase in fibre and fluid intake to increase the bulk and to soften bowel movements and a reduction in intestinal irritants such as coffee and alcohol. A bowel regimen may also employ laxatives and drugs to help complete emptying of the bowel at predictable times. Candida albicans Also known as thrush, this is a fungus that is often present in the genitals, mouth and other moist parts of the body. Symptoms of candidiasis include irritation, itching, abnormal discharges and discomfort on passing water. The CSF contains proteins and tissue fragments that can aid the diagnosis of neurological disorders and differentiate MS from other conditions (such as a haemorrhage) with similar or overlapping symptoms. Changes in cognitive ability are often subtle and not apparent without sophisticated testing. Computerized manipulation of the exposures results in clear images of fine structures such as sclerotic plaques within the brain or spinal column. Exercises to maintain the flexibility of joints are particularly important because contractures may be made worse by lack of joint use. The breakdown of myelin leads to poor or weak messages to various parts of the body and may lead, in the case of MS, to the formation of plaques or scarring with hardened (sclerotic) tissue. Often epidemiological studies try to find relationships between the frequency of MS and variations in other factors (such as diet or exposure to infections). They cannot be synthesized by the body and must be obtained from the diet – these are the families of linoleic, linolenic and arachidonic acids. Treatment of faecal incontinence with a bowel regimen is often completely successful in preventing involuntary bowel movements. This can be due to an inherited susceptibility to the disease (nature) or to the environmental and other exposures that families inevitably share (nurture). The condition results from weakness in the ankle and foot muscles, caused by weakening of nervous system control of these muscles. A number of objective tests have been developed to assess the extent to which these abilities may be affected by the progression of MS. They have been widely used in MS because immune responses are considered to be directed against the person’s own body in the disease. Improved case ascertainment is the increased ability of the medical services to identify correctly such existing cases which have been previously undetected. When the incidence of a disease is low, incidence will be reported per 100,000 people per year. Incontinence may result in occasional accidents or in more serious loss of voluntary control of urination or bowel movements. In other words, the further you go from the equator, the more increases in MS cases there are, but cases lessen towards the polar regions. The nature of the relationship has not been fully unravelled, and there many explanations as to why it should exist.

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A meta-analysis study evaluated by the Canadian Sinusitis Symposium in 1996 revealed that diagnosis should be made based on clinical history and physical examination (26) buy discount decadron 1 mg. Five clinical findings comprising three symptoms—maxillary toothache 0.5mg decadron with visa, poor response to decongestants purchase decadron 1mg on-line, and a history of colored nasal discharge—and two signs—purulent nasal secre- tion and abnormal transillumination result—are the best predictors of acute bacterial sinusitis (moderate evidence) order 1 mg decadron amex. Transillumination is a useful technique in the hands of experienced personnel buy decadron 0.5mg with amex, but only negative findings are useful (limited evidence). Radiography is not warranted when the likeli- hood of acute sinusitis is high or low but is useful when the diagnosis is in doubt (limited evidence). First-line therapy should be a 10-day course of amoxicillin (strong evidence) and a decongestant (limited evidence). Patients allergic to amoxicillin and those not responding to first-line therapy should be switched to a second-line agent such as macrolide or cephalosporin. Sinus puncture and culture of the aspirate, although a standard refer- ence, is invasive and costly, and thus not a practical or feasible diagnostic method to identify patients who benefit from antibiotic treatment. More- over, sinus puncture is technically feasible only for maxillary sinusitis, not for the remainder of the paranasal sinuses. Nasal swab and culture from the middle meatus is also reported but the correlation with nasal swab with sinus puncture remains weak. Endo- scopic-guided swab culture is more accurate to sample secretion from a sinus of interest. However, this is usually performed by otolaryngologists, resulting in higher cost, and thus is not feasible for routine use. Acute Sinusitis: How Accurate Are Imaging Studies for the Diagnosis of Acute Bacterial Sinusitis? Only one report measured positive predictive value (PPV) compared with T a b l e 1 2. D i a g n o s t i c p e r f o r m a n c e o f c l i n i c a l e x a m i n a t i o n , r a d i o g r a p h y , c o m p u t e d t o m o g r a p h y , a n d u l t r a s o u n d f o r a c u t e s i n u s i t i s A u t h o r s S t u d y d e s i g n G o l d s t a n d a r d M o d a l i t y D i a g n o s t i c p e r f o r m a n c e C o m m e n t s R e f e r e n c e V a r o n e n M e t a - a n a l y s i s S i n u s p u n c t u r e R a d i o g r a p h y R O C c u r v e : 0. Sinus CT is reported to be more sensitive than sinus radiography, but little is known about its specificity (insufficient evidence). Imaging Modalities for Sinusitis The diagnostic imaging study for sinusitis is primarily sinus CT. There are two main types of sinus CT cur- rently performed in most institutions: limited (or screening) and full (complete) sinus CT. Direct coronal images with 3- to 5-mm thickness of the sinuses are obtained every 10mm from the frontal to the sphenoid sinuses for a limited sinus CT. The limited sinus CT, however, is a quick, more definitive test that is easy to perform and interpret compared with sinus radiography. The limited sinus CT is often referred to as a screening sinus CT to rule out sinusitis, although it is not truly a screening test since the patients have sinusitis symptoms. This study is primarily ordered by otolaryngologists to evaluate detailed anatomy of the ostiomeatal complex. No intravenous contrast is necessary for sinus CT, unless complications of sinusitis are suspected, such as orbital abscess, epidural or brain abscess, or cavernous sinus thrombosis. Despite wide clinical application of magnetic resonance imaging (MRI), it has not been used routinely as a diagnostic imaging study for sinusitis patients. Ultrasound has been occasionally used for evaluation of the max- illary sinus disease, but the sensitivity of ultrasound is reported to be poor (28). Since the paranasal sinuses are surrounded by bone and contain air, ultrasound has limited value for evaluation of the sinuses. Imaging Criteria for Acute Bacterial Sinusitis The imaging hallmarks of ABS are the presence of air-fluid level (par- ticularly unilateral) and severe opacification of a sinus (Fig. A mild mucosal thickening (less than 4mm) without fluid level is a nonspecific CT finding that is frequently seen in asymptomatic subjects who undergo head CT or orbital CT for other medical complaints, as well as in patients with a common cold (upper respiratory viral infection) (29), allergy, or asthma (Fig. There is no microbiologic proof that those patients with only mucosal thickening do not have ABS, since sinus puncture is not justified for patients without fluid level in the sinus. A double-blinded, placebo con- trolled, randomized control study of antibiotic therapy for patients with sinusitis symptoms and only mucosal thickening on CT revealed no clini- cal improvements in patients with antibiotic compared with placebo group, suggesting that those patients with only mucosal thickening do not benefit from antibiotic treatment (30). It is important for radiologists not to overdiagnose acute sinusitis for patients with mucosal thickening only, since such a CT report contributes to overuse of antibiotic treatment for patients presenting with sinusitis symptoms. The term sinusitis means to some primary care physicians acute bacterial infection of the sinus.

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Moreover discount decadron 0.5mg without a prescription, every step of the art production allows each individual to focus on the self—and on the interactions in and among the group mem- bers—and provides the impetus for the processing of the here-and-now in- teractions generic decadron 1mg line. As an example discount 0.5 mg decadron with amex, consider the pass-around project I instituted involving collage imagery and paper plates buy cheap decadron 1mg online. After this was completed I in- structed members to pass the plate to their right and to keep doing so (at predetermined times) until their original image was in front of them order 1 mg decadron otc. This low-functioning client chose the panda bear image, and other mem- bers within the group framed the picture by coloring the rim, accenting it 6. How- ever, as it reached the fifth member of the group (an infantalized and angry youth placed out of the home for the first time, whom I will call Tony), this member maliciously scribbled over the collage image. As no rebuff was forthcoming, he anxiously awaited the next project, and on this one he wrote derogatory epithets. It was only upon Tony’s leaving the group that the verbal processing of respect, feelings expression, and trust could be explored. However, it is important to note that Tony’s imagery (what he chose and drew individually) provided a secondary level to the discussion. In review- ing his image I believed it metaphorically described his deep sense of loss, fear, and feelings of entrapment (see Figure 6. By the time Tony had passed his plate there was very little room left for others to interact. They were consequently relegated to reinforcing the spider’s trap by adding circles of color. When Tony returned to the group, timid and apologetic, the discussion focused on empathy, not merely for how Tony had defaced others’ art (and therefore lost trust) but for the feelings of loneliness that all individuals feel 6. Through the symbolism of Tony’s plate, and the subsequent interpretation, the feed- back became central as the group members explored the possible fear be- hind Tony’s anger in a mutual partnership. The importance of a mutual un- derstanding cannot be overstated, as it is the very foundation on which objective empathic awareness is based. One of the benefits of utilizing art therapy within the therapeutic hour is that it allows members to practice new ways of behaving in a safe and supportive atmosphere. To take advantage of this, I often link directives from one week to the next in an attempt to reinforce goals and strengthen the skills reviewed in the prior group meeting. Accordingly, in the following group session I gave the same members a sheet of paper with predrawn black boxes. As they passed the artwork, I further informed them that no one was allowed to cross the boundary of the black box. In this session, unlike the previous one, Tony respected the space, feel- ings, and emotions of others on both a symbolic and a conscious level. On the second pass the victim of his earlier defacing attained revenge by drawing a circle within Tony’s square. When Tony verbally protested, another peer calmly intervened and offered him a second sheet of paper (see Figure 6. In so doing he symbolically asserted his sense of self while defending the space as purely his. The peer who offered Tony a second sheet of paper provided him with a constructive response to a situational stressor. This manner of peer-to-peer interaction serves to advance the client’s interpersonal learning as group members acknowledge and become con- cerned with one another’s feelings and thoughts. When the objective is feelings oriented, in this case empathic identifi- cation, the use of a tangible medium such as plasticene clay frequently proves beneficial. The process of creating in a three-dimensional form of- fers the artist a deeper level of accomplishment, because the experience of working with a physical medium requires intellectual thought, sheds light on the unconscious, and provides kinetic relief. In a group session with high-functioning adolescent females I adapted Yalom’s (1983) verbal exercise into an art therapy directive. I instructed the group to make a clay animal that represented the self and, when this was complete, to create another clay animal for the person sitting on their right. Yalom notes that "it is important to explain this exercise carefully so that the members fully understand that they are to choose on the basis not of physical resemblance, but of some trait of the animal which is similar to a trait of the person" (p. One client, the scapegoat of the group, fashioned a penguin as an image of the self and conversely created a black cat for the member to her right (see Figure 6. In the discussion phase she commented that the penguin char- acterized her since "penguins don’t mind the cold," while the black cat sym- bolized the member to her right "because you don’t want to mess with her.

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