By Z. Pakwan. DeVry University.

    Suicide The inverse relationship between religious involvement and suicide was first reported in 84 1897 discount 60 caps confido free shipping. Self- 85 85–87 reported religiosity and attendance at religious services have been shown to be 88 order 60 caps confido free shipping,89 inversely associated with suicidal ideation order 60 caps confido otc. Two large ecological studies of Western 90 countries and a cross-sectional study of a representative sample of Americans found inverse relationships between religious involvement and acceptance of suicide. One 91 study found that religious detachment was associated with increased suicide risk among 92 Canadian youth. Several large ecological studies have found that belief in God, 93 89,93 93 attendance at religious services, self-reported religiosity and religious upbringing 28,37 were inversely related to national suicide rates. Finally, several prospective studies have found that the risk of completed suicide among religiously involved persons was less than the risk among non-religiously involved individuals. Despite these findings, most scales currently used by researchers and clinicians to assess suicide risk do not 94 assess patient religiosity or spirituality. RELIGIOUS INVOLVEMENT, SPIRITUALITY AND COPING Needless to say, surviving a natural disaster or crime, caring for a sick relative or friend, and experiencing the death of a loved one can be distressing experiences. Religious Complementary therapies in neurology 230 51 involvement, however, may mitigate the adverse effects of these experiences. Those who professed strong religious and spiritual beliefs experienced quicker and more complete resolution of their grief compared to those without such beliefs. Illnesses interrupt routines, drain finances, separate families, create situations of dependency and may lead to existential 60 and spiritual concerns. Not only do many people rely on their religious beliefs and spirituality to cope with illness, but these people may also cope with illness more 7 effectively than persons without such beliefs. Religious and spiritual coping is common 96 97 among persons with asthma, human immunodeficiency virus (HIV) disease, chronic 98,99 98,99 100,101 100,102 pain, coronary, artery disease, end-stage renal disease, multiple 100 103, 104 105–113 sclerosis, burns hip fracture, and cancer. Religious and spiritual coping are 114 115,116 also common among nursing-home residents and the elderly. In a study of 122 hospitalized adults with moderate to high levels of pain, prayer was second only to oral pain medications (62 vs. Cross- sectional and longitudinal studies have shown that religious and spiritual coping were 104,116–119 117 associated with less depression during illness. One study examined the relationship between religious coping and depression among 850 men (older than 65 years) who had no history of mental illness and were hospitalized for a medical illness. After adjusting for sociodemographic and baseline health variables, depressive symptoms were inversely related to religious coping. In addition, religious coping was the only baseline variable that predicted less depression 6 months later. Religious and spiritual coping have also been shown to lessen the negative impact 7,117 physical illness has on functional status. The greater the religious and spiritual coping, the greater the level of physical illness needed to produce a given level of disability. Finally, religious and spiritual coping has been shown to buffer the noxious 120 effects of stressful life events (e. Studies have shown that religious involvement and spiritual well-being are associated with high 68,122–125 122,125 68 levels of HRQOL in persons with cancer, HIV disease, heart disease, limb 123 123 amputation and spinal cord injury. This direct relationship between spirituality and 122,125 125 HRQOL persists despite declines in physical functioning. One study of 1620 persons with cancer and HIV disease found that spiritual well-being predicted higher HRQOL, independently of physical, emotional and social well-being. Religious involvement, spirituality and medicine 231 NEGATIVE EFFECTS OF RELIGIOUS INVOLVEMENT AND SPIRITUALITY Few systematic population-based studies have shown that religious involvement and spirituality are associated with negative health outcomes.

    EARLY STUDIES The issue of specificity has plagued studies of perceptual learning in the tactile system for a long time cheap 60caps confido visa. TASK SPECIFICITY In the modern era buy confido 60 caps, studies of vibrotactile pattern identification on the finger pad purchase confido 60caps otc, using the Optacon, a reading aid for the blind, have emphasized the generalizability of tactile learning. In contrast to these results, we found in our laboratory that perceptual improvement in the tactile discrimination of gratings (consisting of alternating ridges and grooves) was relatively specific for the trained grating set. Learning effects showed only limited transfer between sets distinguished by changes in their groove width and those distinguished by changes in their ridge width. Spatial variables are primary for gratings varying in groove width, whereas temporal variables make an important contribution for gratings varying in ridge width. Such task specificity is in line with observations in the visual system,20,35,50,55 which led to the suggestion that perceptual learning reflects neural plasticity in early sensory cortex. TRANSFER BETWEEN LOCATIONS In our laboratory, we used a variety of stimuli and tasks to study the transfer of perceptual learning between fingers. Our studies converge on the finding that between-session learning effects transfer readily, substantially, and in some cases almost completely, between fingers of either hand. In our first study,78 we employed the same periodic gratings referred to above in studies of task specificity. The task was to discriminate between gratings that varied either in their groove width or in their ridge width. Discrimination was performed with the fingerpad which was actively moved by the subject across the grating. Initial training used one index finger and progressed to the index or middle finger of the other hand. Learning was reflected in the progressive decline of the © 2005 by Taylor & Francis Group. We found for both grating sets, that initial difference limens were much higher, learning effects were larger, and learning was slower when the subjects were completely task-naïve compared to when they had already been trained on one finger. The transfer of learning between fingers was generally substantial and com- plete in some instances. Similar results were obtained for another task; discrimination of the orientation of hand-held gratings applied to the passive fingerpad78 in which the performance measure was the groove width permitting threshold discrimination of a 90˚ difference in grating orientation. This finding suggested that inter-digit transfer in the first grating experiment was not simply because active motion was used. As an aside, the grating orientation test provides a highly reliable index of tactile spatial acuity. That a high propensity for perceptual learning effects to transfer between fingers is characteristic of the tactile system and not restricted to tasks using gratings was shown in a subsequent study from our laboratory. The subjects had to distinguish between a pattern with the offset and one without. This is a hyperacuity task because the offset was 1 mm or less, and the limit of tactile spatial acuity (resolution) at the fingerpad is about 1 mm,34,86 which corresponds to the spacing of the relevant mechanoreceptors,. This task was originally used in studies of vision90 and later adapted to studies of touch. Learning was measured in terms of decrease in the magnitude of spatial offset required for reliable offset detection. Our subjects demonstrated virtually complete transfer of perceptual learning effects between fingers of either hand. In this variant of the task, the offset was held constant (at 2 mm, well outside the hyperacuity range) and learning was measured as a decline in the stimulus duration required for reliable spatial discrimination. This study also precisely controlled stimulus amplitude and duration using an electromechanical stimulator. Thus, training on discrimination of the duration of the interval between two vibrotactile stimuli was found to generalize between hands. One group, studying within session learning effects, found no transfer beyond the trained finger for vibratory frequency discrimination but a topographic gradient of transfer in two other tasks: discriminating the pressure of a punctate stimulus and discriminating surface roughness.

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    Doppler flow studies buy confido 60caps with amex, which look at how the by a physician familiar with Williams syndrome and blood flows into and out of the heart confido 60 caps otc, should also be based upon a physical examination of the individual and done order confido 60 caps on line. Individuals with supravalvar stenosis may require a review of his or her medical history. The high blood pressure infants after a heart problem (usually SVAS) is diag- caused by this condition may be treated with medication. In children without significant heart problems, the Examinations should take place yearly as some of these diagnosis may be made after enrollment in school when conditions are progressive and may worsen over time. In addition, examination and medical history, the diagnosis can now the blood calcium levels of individuals with Williams be confirmed by a test. High levels of calcium can cause irritability, vomiting, consti- Williams syndrome is caused by a deletion of pations and muscle cramps. A a high level of calcium should consult a nutritionist to specific technique called fluorescent in situ hybridization testing, or FISH testing, can determine whether there is make sure that their intake of calcium is not higher than 100% of the recommended daily allowance (RDA). Penicillamine has a number of serious side effects: Patients are also instructed to monitor their drinking water for excess levels of copper and drink distilled • joint pain water instead. However, it may side effects from penicillamine, the dose can sometimes take several years (two to five) of treatment to reach max- be lowered to an effective level that causes fewer diffi- imal benefit to the brain and liver. Alternatively, steroid medications may be patients are not returned to their original level of func- required to reduce certain sensitivity reactions. Patients with Wilson disease need to maintain has fewer potential side effects, but must still be carefully some sort of anticopper treatment for the rest of their monitored. Interruptions in treatment can result in a relapse of remove excess copper from the body. Zinc is a metal that the disease which is not reversible, and can ultimately works to block copper absorption and bind copper in the lead to death. The benefit of treatment with zinc is that there are no toxic side effects, however, the zinc is a slower acting agent than the other drugs. A contiguous gene syndrome occurs when a chro- mosome is either missing material (deletion) or has extra material (duplication) of several genes in the same region of the chromosome. Some patients who have WHS may have a small deletion on 4p, while others may be missing up to half of 4p. Other significant problems can include heart defects, cleft lip and/or palate, hearing impairment, and eye problems. These seizures begin between 5 and 23 months of age, however Wolf-Hirschhorn syndrome (WHS) refers to a con- approximately 50% of the individuals stop having dition that is caused by a missing part (deletion) of the seizures between age 3 and 11. Although it rial results in severe developmental retardation, a charac- seems that most of the literature focuses on children who teristic facial appearance, and may include a variety of have WHS, there are adults who have WHS. Frequently, with routine chromosome analysis, it This syndrome was reported in 1965 in published is possible to identify that the short arm of chromo- reports by Wolf and Hirschhorn, who described that the some 4 is missing some genetic material. The size of characteristics of the syndrome were associated with a the missing material may vary from patient to patient. The At times, the deletion is so small that it cannot be short arm of a chromosome is called the “p” arm. If a patient this syndrome is also known as 4p-syndrome or deletion is suspected to have WHS and an obvious deletion is 4p syndrome, and occasionally as Wolf syndrome. Each pair is numbered 1 through 22 and hybridization, are warranted and may identify the miss- the 23rd pair are the sex chromosomes. WHS may also present as some are hundreds of genes that determine how our bod- mosaicism. Mosaicism for 4p-syndrome means that the Gene location (Custom Medical Stock Photo, Inc. The vast majority also exhibit hydro- cephaly, which can be mild and not require any medical In the more severely hydrocephalic patients, hydro- intervention, or severe enough to be life-threatening. The most severe cases of hydrocephaly are associated with cephaly can be seen by ultrasound at 20 weeks gestation, stenosis (narrowing or pinching closed) of the aqueduct or approximately half-way through the fetal period. The aqueduct of Sylvius (also called the cere- less severely affected patients, some degree of hydro- bral aqueduct) is a narrow channel connecting the third cephaly is usually noted within a year after birth, along ventricle, located deep in the midbrain, to the fourth ven- with a general developmental delay.

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    The costal margin extends from the 7th costal cartilage at the xiphoid to the tip of the 12th rib (although the latter is often difficult to feel); this margin bears a distinct step discount confido 60 caps line, which is the tip of the 9th costal cartilage 60caps confido with mastercard. Identify this tubercle by direct palpation and also by running the fingers along the adductor longus tendon (tensed by flexing confido 60 caps amex, abducting and externally rotating the thigh) to its origin at the tubercle. Feel the firm vas deferens between the finger and thumb as it lies within the spermatic cord at the scrotal neck. Trace the vas upwards and note that it passes medially to the pubic tubercle and thence through the external inguinal ring, which can be felt by invaginating the scrotal skin with the fingertip. It passes through the origin of the inferior mesenteric artery •L4—the plane of the iliac crests. It is also a useful landmark in performing a lumbar puncture, since it is well below the level of the termination of the spinal cord, which is approximately at L1 (see page 338). Surface anatomy and surface markings 57 Liver The lower border of the liver extends along a line from the tip of the right 10th rib to the left 5th intercostal space in the mid clavicular line; it may just be palpable in the normal subject, especially on deep inspiration. The upper border follows a line passing through the 5th intercostal space on each side. Spleen This underlies the 9th, 10th and 11th ribs posteriorly on the left side commencing 2 in (5cm) from the midline. Pancreas The transpyloric plane defines the level of the neck of the pancreas which overlies the vertebral column. From this landmark, the head can be imag- ined passing downward and to the right, the body and tail passing upwards and to the left. Aorta This terminates just to the left of the midline at the level of the iliac crest at L4; a pulsatile swelling below this level may thus be an iliac, but cannot be an aortic, aneurysm. Kidneys The lower pole of the normal right kidney may sometimes be felt in the thin subject on deep inspiration. Anteriorly, the hilum of the kidney lies on the transpyloric plane four finger breadths from the midline. Using these landmarks, the kidney outlines can be projected on to either the anterior or posterior aspects of the abdomen. In some perfectly normal thin people, especially women, it is possible to palpate the lower pole of the right kidney and the sigmoid colon if loaded with faeces; in most of us, only the aorta is palpable. In the perineum it is attached behind to the perineal body and posterior margin of the perineal membrane and, laterally, to the rami of the pubis and ischium. It is because of these attachments that a rupture of the urethral bulb may be followed by extravasation of blood and urine into the scrotum, perineum and penis and then into the lower abdomen deep to the fibrous fascial plane, but not by extravasation downwards into the lower limb, from which the fluid is excluded by the attachment of the fascia to the deep fascia of the upper thigh. Nerve supply The segmental nerve supply of the abdominal muscles and the overlying skin is derived from T7 to L1. This distribution can be mapped out approxi- mately if it is remembered that the umbilicus is supplied by T10 and the groin and scrotum by L1 (via the ilio-inguinal and iliohypogastric nerves— see Fig. The muscles of the anterior abdominal wall These are of considerable practical importance because their anatomy forms the basis of abdominal incisions. At the tip of the xiphoid, at the umbilicus and half-way between, are three constant transverse tendinous intersections; below the umbilicus there is sometimes a fourth. These inter- sections are seen only on the anterior aspect of the muscle and here they adhere to the anterior rectus sheath. Posteriorly they are not in evidence and, in consequence, the rectus muscle is completely free behind. At each intersection, vessels from the superior epigastric artery and vein pierce the rectus. The sheath in which the rectus lies is formed, to a large extent, by the aponeurotic expansions of the lateral abdominal muscles (Fig. The fasciae and muscles of the abdominal wall 59 Anterior layer of rectus sheath Anterior layer of rectus sheath Rectus abdominis Tendinous intersection External oblique Anterior cutaneous nerves Ilio-inguinal nerve Spermatic cord Fig. Posteriorly lie the posterior part of this split internal oblique aponeurosis and the aponeurosis of transversus abdominis.

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    Previous work has suggested that in the motor system buy confido 60caps online, rates of neuronal populations are especially informative about the directions of upcoming movements confido 60caps otc. Given that each arm is mainly controlled by the contralateral hemisphere confido 60caps with mastercard, it is also likely that the temporal relationships between the hemispheres are relevant to bimanual movements. This chapter summarizes results we have accumulated to answer the above questions, at least partially. We present evidence that bimanual representations indeed exist, both at the level of single neurons and at the level of neuronal popu- lations (in local field potentials). We further show that population rates and dynamic interactions between the hemispheres contain information about the kind of bimanual movement to be executed. They recorded cortical neurons in the medial aspect of the frontal cortex, which was called at the time the supplementary * The term “bimanual coordination” literally means “coordination of the two hands,” yet this term has been used in the literature in studies that relate not only to the coordination of the left and right hands, but also of the left and right fingers, or of the left and right arms. This finding suggests that there are some neurons that seem to be specific to bimanual movements. Their work appeared after a behavioral study by Brinkman8 who reported bimanual deficits consecutive to SMA lesion. These and other studies (including clinical reports; for review, see Brust9) inspired further studies focusing on the SMA as a major candidate area for the control of bimanual coordination. Neuronal activity in SMA that is specific to bimanual movements has now been described by a number of groups using different tasks, although this specificity has been defined differently by different groups. Neuronal activity during performance of a “drawer pulling task” was tested by Wiesendanger et al. This task involved whole arm movements, where the monkey was required to open a drawer with one hand and retrieve a raisin from it with the other. The manipulanda were low weight, low friction, two-joint mechanical arms, oriented in the horizontal plane. Movement of each manipulandum produced move- ment of a corresponding cursor on a vertical 21” video screen. The movement of each cursor was mapped to its corresponding manipulandum movement such that each millimeter of manipulandum movement yielded one millimeter of movement of the cursor on the video display. This small movement amplitude was chosen to minimize postural adjustments while performing the movements. Movements taking the cursor from the origin to the target were primarily small elbow and shoulder movements. In unimanual trials, only one target appeared (the upper * SMA was later divided into SMA-proper and pre-SMA. Copyright © 2005 CRC Press LLC FIGURE 4. Two cursors indicating the location of the manipulanda are shown on the screen (+). The figure displays examples of unimanual movements (upper two rows) to 90° (up) and 270° (down) and bimanual movements (lower row). If two targets appeared — signaling a bimanual trial — the monkey had to move both arms, such that the two cursors were moved into the target circles on the screen. These structured movements made it possible to study well-controlled bimanual movements of various types. For example, the two monkeys used for the data presented in this section initiated the bimanual movements with average interarm intervals (IAIs) of 16 to 21 msec (SD = 56 to 74 msec) and reached the targets with an average IAI of 5 to 15 msec (SD = 106 to 125 msec). These IAIs are quite short, much shorter than would be required for successful performance of the task, meaning that the monkeys tended, like humans, to synchronize their movements rather than attempting to perform two separate movements. The movements used in the tasks were small (a length of 3 cm for all movement types presented in this section and up to 6 cm in some types of movements for the experiments described in Section 4. The hand trajectories made to a given direction were quite similar for different movement types (but not identical; see Figure 4. Further, video camera observa- tions and electromyographic (EMG) recordings failed to detect consistent variations in postural adjustments during the arm movements.

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