heather j. hoag nothing is as basic to human existence as our need for nourishment ; we all need to eat. the expansion of systems of food production has led human societies throughout history to alter their surrounding environments. whether it is clearing a forested area to expand agricultural production in west africa or damming a river for irrigation in tennessee, people ’ s need for food has shaped the modern world. the uniting of the old and new worlds in the late 15th century led to unparalleled exchange of crops, animals, and foodways. a result of these historical forces, our food has become truly global. through readings, discussions, films, and outside activities, students will examine the development of our global food system and the role of food in shaping larger processes of historical change. topics examined include : the development of food production systems, the role of crop, technology and cultural exchange, the politics of food shortage, food as culture, and emergence of a global cuisine. heather hoag is an associate professor of african and environmental history and associate chair of usf ’ s international studies program ( bais ). she received her ph. d. in history at boston university ( 2003 ). she has traveled extensively in africa as well as lived in ghana ( west africa ) and tanzania ( east africa ). before coming to usf, she coordinated oxfam america ’ s horn of africa program and taught at the university of california, san diego. her current research is on the history of river development and the building of hydroelectric dams in africa. in her spare time, she enjoys visiting san francisco ’ s farmer ’ s markets and eating establishments.


utica shale oil discovery in ohio, news and maps already recognized as an major natural gas discovery, the utica shale may be one of the biggest oil discoveries in recent decades. the primary focus of this site is on the oil potential of the utica shale in the state of ohio, and getting the word out about what may be one of the biggest oil discoveries in u. s. history. what is the utica shale? it is a massive, deep rock formation that lies approximately two to three thousand feet below the marcellus shale. it is rich in fossils and organic matter such as kerogen ( which breaks down into oil and gas ), and is black to grey black in color. in ohio it lies at a depth of between 3000 to 9000 feet. it covers an area covering eight states, from tennessee to new york, as well as across the border into quebec. compared to the marcellus shale, the utica shale is higher in carbonate content. this quality allows a “ frac job ” to break apart the rock more easily than in pure shale, releasing greater quantities of oil and gas. the current epicenter of the oil boom in ohio is the utica shale ’ s point pleasant interval. the point pleasant interval consists of inter – bedded layers of shale and carbonate rocks. the “ o ’ s ” in ohio are for ordovician oil several major oil and gas companies, including chesapeake energy, have begun leasing up vast areas of ohio, where geologists believe that large quantities of oil will be found. ohio has a long history of oil production, starting with the first well in washington county in 1860. there are approximately 64, 500 active oil wells in ohio, most producing less than 10 barrels of oil per day. this boom could make past discoveries seem like “ peanuts ”. the utica formation is considered a “ source rock ” for oil and gas fround in the cambrian knox dolomite, cambrian rose run sandstone, lower ordovician beekmantown dolomite, and middle ordovician black river - trenton limestone formations. ( source : usgs ) rather than looking for pockets of oil and gas trapped in hard to find “ stratigraphic traps ”, oil companies are using new technology to go right to the source or the “ mother lode ” underneath these zones. a big plus for oil and gas exploration in the ohio is the fact that the state has such as long history of it, and has plenty of disposal wells, pipelines and other infrastructure already in place


the “ mother lode ” underneath these zones. a big plus for oil and gas exploration in the ohio is the fact that the state has such as long history of it, and has plenty of disposal wells, pipelines and other infrastructure already in place. how the utica shale was formed the utica shale is a sedimentary rock which was deposited in ancient seas during the middle ordovician age approximately 450 - 470 million years ago. during that time much of the earth was covered by seas rich in plant and animal life. as these organisms died and decayed, they were deposited on the seafloor, forming a rich organic “ muck ” that later formed the utica formation. below is an illustration of what an ordovician period sea may have looked like. the muck deposited in these seas formed an organic compound in the shale rock called kerogen. as the utica shale subsided and was covered by other rock layers, thermal action ( the earth ’ s heat ) and organic action ( decay ) changed the kerogen into oil and gas. it is in the “ thermally mature ” areas of the shale in eastern ohio where the largest quantities of volatile oil are being found. ( what the seafloor of an ordovician sea may have looked like ). oil and gas companies paying high lease rates in ohio ’ s utica shale play chesapeake energy recently announced that they had made a “ major discovery ” of oil and natural gas liquids in the utica shale in ohio. chesapeake energy has acquired over 1. 25 million acres in ohio at a cost of over two billion dollars and plans on adding another 300, 000 acres in the coming months. other players in the utica shale include devon energy, which acquired over 110, 000 acres, chevron, which purchased over 600, 000 from atlas energy, consol energy, with 200, 000 acres, shell, range resources and epsilon energy. while some of the acreage in the play was “ held by production ”, by small oil companies such as atlas energy, much of the acreage in the “ oil and wet gas ” window of the utica – point pleasant play had to be leased by oil companies. lease payments have reportedly soared to over $ 4, 000 an acre in the hottest areas of the play. the hottest area right now is the “ volatile oil window ”. “ volatile oil ” refers to light oil which evaporates quickly with minimal residue, as compared to heavier crude. volatile oil, gas and condensate tend to flow through the


. the hottest area right now is the “ volatile oil window ”. “ volatile oil ” refers to light oil which evaporates quickly with minimal residue, as compared to heavier crude. volatile oil, gas and condensate tend to flow through the tiny pore structure of shales easier than heavier crude. the utica shale contains four geographic zones, the uppermost western and northwestern zones holds heavier oil, with the middle sections holding volatile oil and natural gas liquids, while the deeper area holds primarily natural gas. a “ sweet spot ” has been identified where the concentration of volatile oil is the highest and it is in this area that the price per acre paid to landowners for utica drilling rights has risen the highest. how big an oil discovery is the utica shale? chesapeake energy ’ s ceo aubrey mcclendon recently stated that his company believes the utica shale is one of the biggest oil finds in u. s. history. chesapeake energy expects that the play to hold over 25 billion barrels of oil, as well as trillions of cubic feet of natural gas. he expects that over 25, 000 new oil and gas wells will be drilled in the utica shale in the coming decades, an investment of at least 200 billion dollars. the ohio geological survey predicts that the utica formation may hold as much as 8. 2 billion barrels of oil equivalent ( boe ). the ultimate recovery potential of the utica shale may be revised upward as more information becomes available, and as oil and gas drilling and production methods continue to advance. the u. s. imports about 9. 5 billion barrels of oil a year. what is contained in the utica shale, eagle ford shale, bakken shale and other new shale finds could equal a decade ( or more ) worth of foreign oil imports. below is a map of the utica shale. there is actually a greater overlapping than what the map shows in the eastern counties of ohio, where the current center of oil activity is located. map courtesy of ohio dept. of natural resources. why has this major oil discovery in ohio been hiding from us for so long? the reason that there suddenly an ocean of available oil under ohio, and many other parts of the country such as the eagle ford shale of texas and bakken shale of north dakota, is because of advances in oil and gas drilling, as well as the development of a completion procedure known as hydraulic fracturing or “ frac jobs ”. horizontal drilling, or drilling sideways at ninety degrees, was perfected in the barnett shale formation near


is because of advances in oil and gas drilling, as well as the development of a completion procedure known as hydraulic fracturing or “ frac jobs ”. horizontal drilling, or drilling sideways at ninety degrees, was perfected in the barnett shale formation near dallas – ft worth, which was laden with natural gas locked in tight shale rock. oil and gas companies soon learned that they could apply a “ frac job ” which consists pumping of high pressure water, sand and a small amount of chemicals, injected under high pressure, to break apart the shale, and release large quantities of natural gas. this one – time process is done just after the well is drilled. this process is somewhat controversial, since the potential to contaminate groundwater exists if proper measures are not taken. however, so far the process of hydraulic fracturing has been used in thousands of wells with no major incidents of aquifer contamination. ohio ’ s water aquifers lie thousands of feet above the utica shale. impervious layers of solid rock, heavy cement liners and thick steel casing protect these zones from cross contamination. see frac info for more details. with huge success in the barnett shale, companies moved on to similar formations such as the haynesville shale in arkansas, texas and louisiana. due to their overwhelming success in finding large amounts of natural gas in shales, the market was soon flooded and prices declined. now the u. s. has a more than 100 year supply of natural gas and prices are severely depressed. the main reason any natural gas drilling is continuing at all in the u. s., is to hold leases which will be lost if no production is established in a certain number of years. because oil prices remain high, o & g exploration companies are now focusing heavily on shales which contain oil and natural gas liquids. the eagle ford shale, a recent discovery in south texas, is reported to be the largest oil discovery in over forty years. the utica shale could prove to be an even bigger find, at least that ’ s what some industry experts predict. the economic impact of the utica shale the full economic impact of the utica shale oil discovery will not be fully felt for another few years when hundreds at first, then thousands of wells are drilled and producing oil and gas. presently, millions of dollars are changing hands between oil companies and landowners in the leasing phase. as these landowner later receive even larger royalty checks, they will begin to spend them, increasing the overall wealth of ohio. rust belt refineries, such as


presently, millions of dollars are changing hands between oil companies and landowners in the leasing phase. as these landowner later receive even larger royalty checks, they will begin to spend them, increasing the overall wealth of ohio. rust belt refineries, such as those owned by marathon oil, are expecting to begin to receive thousands of barrels of utica shale crude over the next few years. this could boost the refining industry of ohio and surrounding states by giving companies a source of crude that is much cheaper than imported brent sea crude. the steel industry in ohio and surrounding states will no doubt get a major boost from this discovery. oilfields tend to require large quantities of steel pipe, tanks and other infrastructure, which could be made locally. the amount of jobs eventually created by the utica play could be in the millions. whether you agree with oil and gas drilling or not, one thing that is certain, and that is our nation ’ s security is enhanced by having a source of oil within our borders. so far our cars, trucks, trains and planes don ’ t run on solar or wind power. oil and gas energy is used to manufacture things such as wind turbines and solar panels which could eventually make that possible someday. every drop of oil what we produce in the u. s. is one less that comes from conflict plagued regions or a dictatorship that despises us. also, as china continues to gobble up world oil supplies, finding another 25 billion barrels here ensures our safety and security and gives us a bridge with which to make the transition to renewable forms of energy. stay tuned to this site for developments in the utica shale, america ’ s most exciting new oil discovery! as more details about this significant new oil discovery in ohio are available they will be posted on this site.


| physical science | | transformation of energy 6c6. 00 | | process of science | | collecting data 1. 3 ac | content standard : physical science content topic : transformation of energy concept : electricity can be harmful. content objective : 6c6. 00 to understand the importance of observing safety rules in the use of electricity instructional objectives : the learner will : tn component of science : process of science benchmark : the reading and interpretation of measuring instruments are necessary in determining length, volume, weight, elapsed time, rates, and temperature. 1. 3c safety features should be observed in all areas of data collection. benchmark : safety procedures are introduced prior to and practiced during all data collection. heat is produced by electricity. if too much current is flowing through a wire, the wire may become so hot that a fire starts. this can be caused if too many appliances are plugged into the outlet and used at the same time. circuit breakers can prevent this. a current can also overheat if there is a short circuit. a short circuit occurs when two wires in a cord accidentally touch. most of the time cords are covered by insulation. the insulation keeps the wires from touching. if the insulation becomes damaged, this creates an area of low resistance and if a large current goes through this area, there will be rapid over - heating and possibly result in a fire. repair damaged insulation immediately. water and electricity are always a dangerous combination. water conducts electricity. you should never use electric appliances or touch sources of electricity such as light bulbs, sockets, or outlets while in contact with water. any wire connected to a voltage is called a live wire. you should never touch a live wire. if you do, your body will become part of a circuit. a large current will flow through you and into the ground. live wires often fall to the ground because of storms or accidents. never touch a live wire. call the power company immediately. 1. ask someone from your local power company to bring a meter and demonstrate how to read it. 2. ask your local power company for information about electric safety and what to do in an electrical emergency. 3. divide the class into groups of four. write and perform your own commercial about electrical safety. 4. materials : one dry cell battery ( 6 volts ), a small light bulb and socket, 1 large cork, 2 straight pins, a piece of thin metal foil ( remove the paper backing of a gum wrapper ) 3 cm long copper wire ( approximately 80 cm ),


battery ( 6 volts ), a small light bulb and socket, 1 large cork, 2 straight pins, a piece of thin metal foil ( remove the paper backing of a gum wrapper ) 3 cm long copper wire ( approximately 80 cm ), wire strippers. ) what to do : cut the wire into 4 pieces, each 20 cm long. prepare the wires by stripping the insulation off both ends so the copper wire is exposed. carefully cut the small piece of thin metal foil in a wishbone shape. this will be the fuse. the center section should be very thin. use 2 straight pins to stick the piece of metal foil into the cork. using one 20 cm piece of wire, connect a dry cell battery terminal to one of the pins. connect another wire to the other pin and the light socket. connect the other side of the light socket to the other dry cell battery terminal with another piece of wire. what happened? ( response ) now take the remaining piece of wire and touch one end to the straight pin connected to the socket. touch the other end to the battery terminal connected to the light socket. this is a short circuit. what happened to the light? ( response ) what happened to the fuse? ( response ) write down these five electrical practices : 1. do not use worn electrical cords. 2. disconnect heating devices, such as irons, when not in use. 3. do not connect too many appliances to one outlet. 4. do not touch electrical appliances while in water or wet. 5. never touch a " live " wire. list one of the 5 electrical practices and explain why you would practice this for safety. ( if number 1 of active participation was done ) explain to each other how to read a meter. this is the time this file has been accessed since 02 / 25 / 98. the university of tennessee at martin is not responsible for the information or views expressed here. sixth grade science home page


| return to grand rounds index | aspiration is a frequently misunderstood diagnosis. many healthcare workers either under - diagnose aspiration or assign the diagnosis improperly. more importantly, many physicians fail to recognize aspiration and dysphagia as a symptom of other disease processes. needless to say, the confusion surrounding the diagnosis often leads to delayed intervention and treatment. otolaryngologists are an integral part of the team caring for the aspirating patient. in the case of patients aspirating after surgery for the extirpation of head and neck malignancy, the otolaryngologist plays the lead role in the diagnosis and treatment of the problem. when neuromuscular disease is the causative factor however, the otolaryngologist acts as a consultant to the primary care physician or medical specialist. speech pathologists play a key role in the rehabilitation and care of the aspirating patient and are well equipped to aid in their evaluation and treatment. this discussion will review the physiology of a normal swallow, the more common etiologies of aspiration, the evaluation of the patient and methods of intervention. oral preparatory phase the first stage of the normal swallow is the oral preparatory phase. food is taken into the oral cavity, chewed and mixed with saliva. this involves the coordination of lip closure, rotary and lateral motion of the jaw, buccal or facial tone, rotary and lateral motion of the tongue and anterior bulging of the soft palate to widen the nasal airway while narrowing the oropharyngeal inlet. these actions break down the food into a size and consistency appropriate for the swallow while preventing premature escape of food into the pharynx. the oral preparatory phase is under complete voluntary control and it is from this phase that the pleasure of eating is derived. cranial nerves involved include cranial nerves v, vii, x and xii. injury to any of these nerves may lead to decreased efficiency of the oral preparatory phase. once the food is prepared for the swallow, the tongue centers and positions the bolus against the hard palate. afferent receptors in the anterior tonsillar pillars, soft palate and oropharynx are stimulated by this action and initiate the reflexive pharyngeal phase. the action of the tongue serves not only to clear the bolus from the oral cavity, but also likely plays some role in initiating the pharyngeal swallow. at the completion of the oral phase, there is little or no food or liquid remaining in


action of the tongue serves not only to clear the bolus from the oral cavity, but also likely plays some role in initiating the pharyngeal swallow. at the completion of the oral phase, there is little or no food or liquid remaining in the oral cavity. the motor function of the tongue is derived from cranial nerve xii and injury to this nerve may adversely effect the tongue ’ s role in the oral phase. the exact stimuli necessary to elicit the pharyngeal phase of swallowing are still poorly understood, but the neuromuscular components of the pharyngeal swallow have been clearly identified. they involve : ( 1 ) velopharyngeal closure to prevent food from refluxing into the nose ; ( 2 ) laryngeal closure to prevent material from penetrating the glottis and entering the airway ; ( 3 ) peristalsis of the pharyngeal walls to clean the pharynx with a wave of contraction that follows the bolus ; ( 4 ) laryngeal elevation and anterior movement to carry the larynx up under the tongue and out of the path of the bolus as well as to apply extrinsic stretch to the cricopharyngeus ; ( 5 ) opening of the cricopharyngeal region. cranial nerves ix, x and xii involved in the pharyngeal phase either through sensation or motor function. the cricopharyngeus muscle, the lower fibers of the inferior constrictor muscle, the upper fibers of the esophageal constrictor and the cricoid cartilage to which these muscles attach make up the upper esophageal sphincter ( ues ) or pharyngoesophageal ( pe ) segment. the opening of this region and laryngeal elevation during the pharyngeal swallow are closely related. at rest, the cricoid cartilage contacts the posterior pharyngeal wall in the region of the cricopharyngeus muscle maintaining closure of ues. as the larynx elevates and moves anteriorly during the swallow, the cricoid cartilage is pulled anteriorly away from the posterior pharyngeal wall while stretch is being applied to the muscle fibers of the cricopharyngeus. relaxation of the cricopharyngeus muscle just prior to opening of the cricopharyngeal region allows for greater stretch of these fibers and a larger


stretch is being applied to the muscle fibers of the cricopharyngeus. relaxation of the cricopharyngeus muscle just prior to opening of the cricopharyngeal region allows for greater stretch of these fibers and a larger increase in the cross - sectional area of the ues. laryngeal closure during the pharyngeal phase involves a complex sequence of events beginning at the level of the true vocal folds and proceeding superiorly to the false vocal folds, aryepiglottic folds and epiglottis. the most important and critical component of laryngeal closure is at the glottic level. as the vocal folds close, the arytenoid cartilages tilt up and forward while the base of tongue moves posteriorly effecting closure of the laryngeal vestibule. as this is occurring, the epiglottis moves posteriorly over the airway but fails to completely seal the airway. epiglottic movement is due to combination of three forces : ( 1 ) pressure from the bolus above, ( 2 ) the downward pull of muscular forces and ( 3 ) the combined pressure of the tongue base moving posteriorly and the larynx elevating. epiglottic closure prevents entry of food into the laryngeal vestibule and vocal fold closure prevents entry of food into the trachea. the term aspiration refers to the entrance of food into the trachea below the level of the true vocal folds. pharyngeal peristalsis begins in the nasopharynx and proceeds inferiorly to the hypopharynx. due to the incomplete tubular shape of the pharynx, movements of the tongue and larynx contribute to the generation of pressures within the pharynx during the swallow. retraction of the tongue and lowering of the larynx at the end of the swallow lead to increased pressure in the hypopharynx. this in concert with the peristaltic muscular wave propels the bolus through the ues. the esophageal phase of the swallow is under involuntary neural control via cranial nerve x. the food bolus is propelled along the esophagus by active peristalsis in two waves, primary and secondary peristalsis. the bolus then traverses the lower esophageal sphincter ( les ) which is usually closed to prevent reflux. aspiration is the entry of liquid or


juice elicits coughing and the production of the same colored liquid via the tracheostomy tube. this “ grape juice test ” is a less sophisticated version of the evans blue dye test in which 4 drops of methylene blue are placed on the patient ’ s tongue and the tracheal secretions examined for blue color. radiography may play a significant role in the diagnosis of aspiration. it is prudent to perform a chest radiograph in any patient suspected of aspiration to assure that pneumonia is not present. computed tomography and magnetic resonance imaging may be useful if aspiration is due to a tumor of the upper aerodigestive tract. videofluoroscopy is the most common and most useful radiographic study in the evaluation of aspiration. it allows real time evaluation of the entire oropharynx and esophagus. it not only allows the confirmation of aspiration, but also may delineate the mechanism of aspiration. the extent of aspiration can be quantified, as well as the patient ’ s ability to clear the tracheobronchial tree of the aspirated material. the modified barium swallow ( mbs ) is the gold standard test for diagnosing and treating aspiration. a speech pathologist and radiologist perform the examination jointly. a small bolus size is used, and the patient is examined with varying consistencies of contrast material ( thin, thick, solid ) to determine what food types are most troublesome for the patient. all phases of swallowing can be closely scrutinized to identify specific areas of dysfunction. at the same setting, the patient is given therapeutic maneuvers and their efficacy is demonstrated by this same test. some centers have utilized radionucleotide scanning in the evaluation of aspiration. a radioactive substance such as technetium 99 is placed on the patient ’ s tongue and a lung scan is performed. aspiration can be confirmed by this method and can be quantified by measuring radioactivity. in recent years, multiple authors have popularized a fiberoptic examination with assessment of swallowing. it has been termed fiberoptic endoscopic evaluation of swallowing ( fees ) or videoendoscopic evaluation of dysphagia ( veed ). other authors have added sensory testing of the larynx and termed this fiberoptic endoscopic evaluation of swallowing with sensory testing ( feesst ). all examinations are performed similarly in an awake, cooperative patient at the bedside or in the clinic setting. standard fiberoptic examination


of the larynx and termed this fiberoptic endoscopic evaluation of swallowing with sensory testing ( feesst ). all examinations are performed similarly in an awake, cooperative patient at the bedside or in the clinic setting. standard fiberoptic examination of the upper aerodigestive tract is performed. the patient then ingests dyed substances of varying consistencies. the presence of aspiration is noted, as is residual material in the valleculae and hypopharynx. this may be recorded for slow motion play back and review. feesst adds sensory testing with pulsed air stimuli via the fiberoptic scope. these tests have proved to be useful not only as adjuncts to the mbs, but also in situations in which mbs is not available or impractical. the modified barium swallow has the benefit of evaluating all phases of the swallow, and is excellent at assessing the overall swallow. it does have several deficiencies however. the mbs does not always provide detailed diagnostic information about subtle abnormalities of the palate, vocal folds, pharyngeal musculature and sensation. it also requires a radiology suite with radiologist, technician and speech pathologist in attendance of the procedure. these resources are sometimes unavailable. in addition, critically ill patients often are unable to be transported to the radiography suite for the procedure. these strengths and weaknesses are complementary to the endoscopic evaluation of swallowing. the fees and feesst is a complete examination of the upper aerodigestive tract that is quite sensitive in detecting structural abnormalities of the palate, pharyngeal walls and vocal folds. this test, however, only analyzes the pharyngeal phase of swallowing. the required equipment includes a fiberoptic scope and light source. a video camera, monitor and video tape recorder improve the examination by allowing multiple observers and slow motion replay for review, but are not absolutely necessary. for seriously ill patients who are unable to leave the intensive care unit ( icu ), the procedure may be performed at the bedside if the equipment is mounted on a mobile cart. while both tests have their place in the evaluation of aspiration, they are perhaps best used in conjunction with one another. the initial management of the aspirating patient is non - surgical. patients should immediately made npo ( nothing by mouth ). enteral nutrition via a nasogastric feeding tube or gastrostomy should be established. patients with respiratory failure may require intubation and ventilatory support. in debilitated


should immediately made npo ( nothing by mouth ). enteral nutrition via a nasogastric feeding tube or gastrostomy should be established. patients with respiratory failure may require intubation and ventilatory support. in debilitated patients requiring prolonged intubation, tracheostomy should be considered early to avoid the sequelae of prolonged laryngeal intubation. as previously noted, the inflated tracheostomy tube cuff does not prevent aspiration but it does allow for easier pulmonary toilet. as the tracheotomized, aspirating patient ’ s condition improves, the residual glottic function can be assessed. when glottic function is intact, the patient may benefit from the use of a speech valve. the passy - muir speech valve is the most commonly used. the exact mechanisms of improvement are unclear, but subglottic pressure is restored, and the return of airflow through the glottis allows the return of glottic reflex mechanisms. if the speaking valve is tolerated, plugging of the tube and the consideration of decannulation should be considered. restoration of normal airway function and removal of the tethering effect of the tracheostomy tube may allow the return of normal swallow function. when decannulation is not possible, the speaking valve should be used to aid in maintaining more normal glottic function. some patients may be managed with dietary and behavioral modification techniques. thickener added to liquids may slow the bolus adequately to prevent aspiration when swallow initiation is delayed. techniques involving postural changes based upon findings on mbs have been shown to decrease aspiration in 81 % of head and neck surgical patients. if residue in the supraglottis and hypopharynx leads to aspiration, the supraglottic swallow technique may be effective in clearing this residue. this is performed by having the patient take a deep breath prior to swallowing. the patient then coughs and swallows a second time prior to the next inspiration. instructing the patient to turn their head toward the side of a unilateral pharyngeal weakness can compress the pyriform sinus and prevent the accumulation of residue, as can flexing the neck ( the “ chin tuck ” ) which compresses the valleculae. some patients with a weak swallow reflex may benefit from a liquid rinse or multiple swallows. these swallow techniques are most effective when learned with the guidance of an experienced speech pathologist after careful evaluation with mbs


which compresses the valleculae. some patients with a weak swallow reflex may benefit from a liquid rinse or multiple swallows. these swallow techniques are most effective when learned with the guidance of an experienced speech pathologist after careful evaluation with mbs. even with expert teaching, the proficient use of many of these techniques requires a very motivated patient and failure rates are considerable. when non - surgical methods of managing aspiration are unsuccessful, the surgeon has a number of options for improving swallow function. often times conservative management, such as swallow techniques combined with an adjunctive surgical procedure will provide adequate prevention of aspiration. the surgical management of aspiration should be effective, yet as non - invasive as possible. these patients often have multiple medical problems and are poor surgical candidates who would not tolerate extensive procedures. no single procedure is absolutely indicated in all patients, therefore many varied approaches have been developed. all surgeries have a certain degree of risk and potential complications. procedures can be broadly divided into two groups, adjunctive and definitive procedures. tracheostomy may be quite valuable in the early care of the aspirating patient. tracheostomy will not prevent aspiration and may in fact exacerbate the condition, but it does facilitate the nursing care of patients who are actively aspirating, particularly those requiring aggressive pulmonary toilet. in patients with acute conditions in whom recovery is expected, tracheostomy with a cuffed tube may serve as an easy route for mechanical ventilation and allow for frequent suctioning. upon recovery however, plugging and decannulation would be indicated to reduce aspiration risk. some patients with severe complications of aspiration and poor neurologic function and prognosis may never regain the ability for oral intake. in such patients, a permanent feeding should be established with a cervical esophagostomy, gastrostomy or jejunostomy tube. the ligation of the parotid and submandibular ducts can effectively reduce salivary flow and decrease the aspiration of oral secretions in the vegetative patient. cricopharyngeal myotomy ( cpm ) may be performed either as a primary procedure or in conjunction with other procedures. the premise on which the procedure is based is that the aspiration may be worsened by delay or failure of relaxation of the cricopharyngeus muscle during the pharyngeal phase of the swallow. the procedure is performed via a lateral cervical or low collar incision. with both rln intact, it is best


worsened by delay or failure of relaxation of the cricopharyngeus muscle during the pharyngeal phase of the swallow. the procedure is performed via a lateral cervical or low collar incision. with both rln intact, it is best performed on the left, as the longer course of the left rln places it at greater risk to injury from an unrelated process. if one nerve is non - functional, the myotomy should be performed on the side of the lesion. a bougie placed into the esophagus aids in palpation of the muscle. the muscle fibers of the inferior constrictor, cricopharyngeus and upper fibers of the esophageal sphincter are divided down to the mucosa near the posterior midline for a vertical distance of 4 to 6 cm. care must be taken to avoid breeching the mucosa and inadvertent injury must be recognized and repaired. laryngeal suspension is usually performed at the time of the primary surgical procedure for extirpative head and neck surgery involving the supraglottic larynx and tongue ( total glossectomy ). the disruption of the normal anatomic relationships between the tongue, pharynx and larynx in such procedures may greatly reduce laryngeal elevation during swallowing. this may leave the glottis exposed and vulnerable to aspiration during the pharyngeal phase. when associated with limited epiglottic rotation and laryngeal closure, as is the case in patients after supraglottic laryngectomy, the patient is almost assured to aspirate. laryngeal suspension returns the larynx to a more superior and protected position. it is usually performed by passing a non - absorbable suture from the hyoid bone or thyroid lamina to the mandible. krespi and sisson described a technique of partial resection the cricoid to reduce aspiration in patients undergoing extensive resections of the tongue base and pharynx. the technique consists of a submucosal dissection of the posterior lamina of the cricoid cartilage with its removal. the cricoarytenoid joints and posterior cricoarytenoid muscle and its innervation are preserved. it is performed with a cpm. the result is a decreased anteroposterior laryngeal dimension and enlarged hypopharyngeal inlet. phonation is


a lateral neck incision overlying the inferior portion of the thyroid cartilage is used to gain access to the thyroid lamina on the affected side. the perichondrium of the thyroid cartilage is incised and a window created in the cartilage at the level of the true vocal fold. a customized silastic, gore - tex or hydroxyapatite implant is then placed in the paraglottic space to medialize the true vocal fold. occasionally, the posterior glottic chink is too large ( > 4mm ) to allow medialization with thyroplasty or tvc injection alone. in such cases, the patient may benefit from the addition of an arytenoid adduction ( aa ) procedure. typically the procedure is performed with the patient under local anesthesia with sedation. the extent of the dissection is greater than with thyroplasty alone, therefore it should be considered permanent and not performed when the status of the nerve is uncertain. an incision similar but slightly more posterior than that used in thyroplasty is employed. dissection is carried medially until the inferior portion of the inferior constrictor muscle at its attachment to the thyroid ala is identified. these fibers are divided, the cricothyroid joint is separated and the thyroid ala is retracted anteriorly allowing elevation of the mucosa of the pyriform sinus. this exposes the cricoid which is traced superiorly until the muscular process of the arytenoid is palpated. a hollow needle is placed through the thyroid cartilage anteriorly, inferior and lateral to the anterior commissure. a non - absorbable suture is then passed through the muscular process of the arytenoid and the adjacent muscular attachments. the suture is then passed through the hollow needle. traction on this suture results in rotation of the vocal process in a medial and superior direction. one of the main benefits of the aa procedure is that it often brings the level of the tvc back to a more normal relationship with this superior rotation. endoscopic visualization as the suture is tightened allows accurate approximation of the paralyzed vocal process in the midline. the patient who has intractable, life - threatening aspiration that does not respond to conservative treatment may be a candidate for one of several procedures designed to completely halt the soilage of the tracheobronchial tree. this situation most often occurs in patients with severe neurologic impairment from multiple cere


that does not respond to conservative treatment may be a candidate for one of several procedures designed to completely halt the soilage of the tracheobronchial tree. this situation most often occurs in patients with severe neurologic impairment from multiple cerebrovascular accidents or brainstem infarctions. occasionally patients with multiple deficits affecting multiple aspects of the swallow will qualify for such a procedure. all of these definitive procedures require a tracheostoma. multiple authors have designed stents to occlude the larynx. the idea is analogous to a cork in a bottle. the approach has several advantages. the procedure is completely reversible, insertion and removal is relatively simple and it does not preclude later performing a more permanent procedure. perhaps the most widely used stent is that designed by eliachar. it is a silicone tube designed to adhere to the configuration of the larynx and upper trachea. multiple sizes are available. a domelike projection from the superior portion of the tube can be incised to form a one - way valve, allowing air to escape from the airway while still preventing aspiration. airflow through the valve allows for some functional phonation in alert patients. leakage around the stent can occur, but may be rectified with the placement of a larger size. the stent may remain in place for as long as 9 to 12 months. stent placement is a reasonable first choice to halt aspiration in a seriously ill patient, especially if their condition is potentially reversible. laryngeal closure procedures may be divided into subglottic, glottic and supraglottic. all require a permanent tracheostomy and have the potential for recurrence of aspiration. glottic closure is performed via a midline thyrotomy. the mucosa of the free edge of the true and false vocal cords is stripped and they are sutured to one another. a variation of this procedure utilizes a superiorly based sternohyoid flap anchored to the midline posterior commissure to bolster the posterior aspect of the closure. normal speech is sacrificed with glottic closure. the closure is potentially reversible, although successes have not been reported. closure at the glottic level has been unreliable in patients with mobile true vocal cords, likely due to persistent laryngopharyngeal movement placing excessive tension on the closure. laryngeal closure at the level of the supraglot


at the glottic level has been unreliable in patients with mobile true vocal cords, likely due to persistent laryngopharyngeal movement placing excessive tension on the closure. laryngeal closure at the level of the supraglottis has been reported as well. the mucosal edges of the epiglottis, arytenoids and aryepiglottic folds are stripped, and then sutured together through an infrahyoid pharyngotomy. in the first description of this procedure, a small posterior dehiscence occurred which acted as a one - way valve, allowing air escape and phonation yet still controlling aspiration. this original patient underwent successful reversal of the procedure as well. other forms of “ epiglottopexy ” have been described as an adjunctive procedure to minimize aspiration risk in patients undergoing total glossectomy. biller described the elevation of epiglottic and supraglottic submucosal flaps that are then closed in two layers leaving a superior opening for phonation. the procedure has been successful in 60 % to 70 % of patients with several reported cases of reversal. it should be noted that glottic and supraglottic closures have a relatively high failure rate and recurrence of aspiration is not uncommon. closures of the airway in the subglottic region include cricoidectomy, laryngeal diversion and laryngotracheal separation. eisele in 1990 described a subperichondrial cricoidectomy with closure of the subglottic mucosa. this provides separation of the upper respiratory and digestive tracts. a midline split of the cricoid cartilage is performed and the perichondrium elevated. the subglottic mucosa is transected and closed. the closure may be reinforced with the rotation of a muscle flap. this prodecure requires a permanent tracheostomy, phonation is lost and it is not reversible. the techniques of laryngeal diversion and laryngotracheal separation involve the division of the trachea just below the larynx with either closure of the proximal stump or diversion to the skin or esophagus. the classic lindeman procedure, named for the author of its initial description, divides the trachea in its upper rings with the proximal stump diverted to the anterior esophagus


or diversion to the skin or esophagus. the classic lindeman procedure, named for the author of its initial description, divides the trachea in its upper rings with the proximal stump diverted to the anterior esophagus. this procedure has largely been abandoned as the anastamosis to the anterior esophagus is technically challenging. tucker later described the “ double - barrel ” tracheostomy technique in which the proximal trachea is sutured to the skin of the neck as a controlled fistula. a variation of the lindeman procedure that is widely used today is the laryngotracheal separation ( lts ). the proximal tracheal stump is closed on itself and may be reinforced with flaps created from the strap muscles. secretions pool in the blind pouch and empty when the patient assumes a supine position. the closure prevents a high - tension anastamosis to the esophagus that may result if the patient has a short proximal stump after prior high tracheostomy. the fistula rate for lts is reported as greater than 33 % and is even higher in patients with prior tracheostomy. the prevention of aspiration is near 100 % with any of the procedures and successful reversals have been reported for each of the techniques. total laryngectomy ( tl ) clearly separates the respiratory and digestive tracts, and has for many years been regarded as the procedure of choice for the definitive treatment of the patient with life - threatening aspiration. some authors feel that it remains the procedure of choice in patients with extremely poor prognoses, other associated medical conditions or evidence of poor wound healing, as less radical procedures have more frequent complications. a narrow field laryngectomy may be performed in which the larynx from the hyoid to the lower border of the cricoid is resected, sparing the hyoid bone, mucosa of the arytenoids and postcricoid region, and strap muscles. the mucosal closure is reinforced using the strap muscles. while tl remains the most reliable and definitive way to achieve complete cessation of aspiration, it has no potential for reversal and has significant negative stigmata for the patient and family. chronic aspiration can occur in patients with a wide variety of pathologic processes. the determination of etiology is paramount, as it will guide treatment and determines overall prognosis. options for intervention


significant negative stigmata for the patient and family. chronic aspiration can occur in patients with a wide variety of pathologic processes. the determination of etiology is paramount, as it will guide treatment and determines overall prognosis. options for intervention include conservative, minimally invasive techniques, to complete separation of the respiratory and digestive tracts. the otolaryngologist is often called upon to evaluate these patients and should be thoroughly aware of methods of evaluation and treatment. early intervention and treatment may prevent life - threatening complications and speed recovery from the primary disease process. eibling de. management of intractable aspiration. in bailey bj, ed. head & neck surgery - otolaryngology. 2nd ed. philadelphia : lippincott - raven, 1998. miller fr, eliachar i. managing the aspirating patient. am j otolaryngol. 1994 ; 15 : 1 - 17. understanding and treatment of aspiration. self - instructional package. american academy of otolaryngology - head & neck surgery. 1993. logemann ja. swallowing physiology and pathophysiology. otolaryngol clin n am. 1988 ; 21 : 613 - 23. carrau rl, pou am, eibling de, et al. laryngeal framework surgery for the management of aspiration. head & neck. 1999 ; march : 139 - 45. eliachar i, nguyen d. laryngotracheal stent for internal support and control of aspiration without loss of phonation. otolaryngol - head neck surg. 1990 ; 103 : 837 - 40. logemann ja, rademaker aw, pauloski br, et al. effects of postural change on aspiration in head and neck surgical patients. otolaryngol - head neck surg. 1994 ; 110 : 222 - 27. eibling de, fees examination : technique of fiber optic endoscopic evaluation of swallowing. unpublished report. aviv je, kim t, sacco rl, et al. feesst : a new bedside endoscopic test of the motor and sensory components of swallowing. ann otol rhinol laryngol. 1998 ; 107 : 378 - 87. bastian rw. videoendoscopic evaluation of patients with dysphagia : an adjunct to the modified barium swallow. otolaryngol - head neck surg. 1991 ; 104 : 339 - 50. krespi y, sisson


rw. videoendoscopic evaluation of patients with dysphagia : an adjunct to the modified barium swallow. otolaryngol - head neck surg. 1991 ; 104 : 339 - 50. krespi y, sisson g. management of aspiration by subtotal and submucosal cricoid resection. ann otol rhinol laryngol. 1985 ; 94 : 580 - 83. biller hf, lawson w, baek s. total glossectomy : a technique of reconstruction eliminating laryngectomy. arch otolaryngol head neck surg. 1983 ; 109 : 69 - 73. eibling de, snyderman ch, eibling c. laryngotracheal separation for intractable aspiration : a retrospective review of 34 patients. laryngoscope. 1995 ; 105 : 83 - 85. tucker hm. double - barreled ( diversionary ) tracheostomy in the management of juvenile laryngeal papillomatosis. ann otol rhinol laryngol. 1980 ; 89 : 504 - 7. eisele dw. chronic aspiration. in cummings cw, ed. otolaryngology - head & neck surgery. 3rd ed. st. louis : mosby, 1998.


hst296a : reading notes, 2 - feb - 2005 dinkin, robert j. meetinghouse in early massachusetts, " in robert blair st. george, life in america. " dinkin draws on church records and town histories as he explores an aspect of meetinghouse design that was crucial to the reflexive representation of local social structure : ' seating ' the congregation... [ seating ] made the act of attending worship an event that drew attention to and legitimized a specific set of power relations in local society... new england society was always defferentaial " yet the basis of that deference changed over time from ' age, estate, and qualifications to amount of wealth. ( p. 407 ) interesting : sometimes complaints were not simply to get a better seat but to get one " not too honorable for me " ( p. 413 ) difficulties in assigning seats, changes in construction ( movement to pews ), raising money for building by auctioning pews, and possibly the revolution contributed to a disbanding of this practice in older towns, while some newer towns just began adopting it. lockridge and alan kreider, “ the evolution of massachusetts town government, 1640 - 1740, ” william and mary quarterly, 3d ser., ( 1966 ) : pp. 549 - 574. also in colonial america : essays in politics and social development 1st ed. how did new england town government operate as it evolved? england in 17th - 19th cents. had a mix of common consent and religious oligarchy. what about america? the author examines town records of dedham and watertown and concludes that there was a shift of power from the board of selectmen to a town meeting between 1680 and 1720. how and why? the general court turned local power over to grantees when making grants. these groups selected a few men for the " ordering of civil affairs of the town. " townsmen met twice a year for more general questions / decisions ( and in practice " existed largely as a passive veto power " p. 552 ). selectmen met more often and handled the greater volume of business. selectmen decided the timing and agendas of town meetings. they appointed offices, administered land disputes and livestock regulations, determined care for the poor and vagabonds, exercised social control ( education, fines ), set tax rates, and used taxes, often without reference to the towns. " the story of the transfer of political power in watertown and dedham is in large


the poor and vagabonds, exercised social control ( education, fines ), set tax rates, and used taxes, often without reference to the towns. " the story of the transfer of political power in watertown and dedham is in large measure the story of the rising creativity and assertiveness of the town meeting. " ( p. 557 ) town meetings and amount of business transacted increased after 1680. few bylaws were thence made by selectmen and vetoes were greater. town meetings began to appoint positions, and select the meeting moderator ( formerly chosen by selectmen ), and took over activities formerly done by selectmen ( assessments, fence and gate issues, expansion of meetinghouse, division of land ). town meeting also took over creation of ad hoc committees for specific tasks ( selectmen had controlled committee creation, before ). why? not a legal change or a change related to lower ranks aspiring to higher ranks ( selectmen remained from about the same level throughout the change ). lockridge suggests that the change was " organic. " as the old guard died / retired they were replaced by younger, less experienced men. the first generation had emphasized communal consensus. the second generation did not. sectional conflict arose over decisions about location of meetinghouse, and the ' second divisions ' of land. the growing population found no way into political power entrenched in a handful of selectmen. john demos, “ notes on life in plymouth colony, ” william and mary quarterly, 3d ser., xxii ( 1965 ) : pp. 264 - 286. also in colonial america 3d ed. ( not bad for 1965 but in light of subsequent work some of his conclusions seem a bit simplistic or backwards. ) plymouth was not as static as was thought : families moved, property was transferred. he suggests some reasons were : 1691 : plymouth colony joins massachusetts bay colony, contains 21 recognized townships as well as smaller communities - economic gain : new arrivals in mass bay colony created demand for cattle and corn : increase to supply these markets - " the land beckoned " prospects for land ownership general court had some reservations about how land was distributed in towns : absentee landlording and not confined to " upright " citizens. young men, or older men who may finally be able to do so, move to new lands. eventually their relatives, especially elderly parents, may join them or move nearby. some buy land for speculation. the population at plymouth seems to have doubled every 15 years from 1620 - 1691. demos calls this steady


do so, move to new lands. eventually their relatives, especially elderly parents, may join them or move nearby. some buy land for speculation. the population at plymouth seems to have doubled every 15 years from 1620 - 1691. demos calls this steady!! early ( 7 - 8 month ) babies... fines for betrothed parents 1 / 4 of that for non - betrothed. land was given for use by sons but not necessarily deeded to them until after parent ' s death. daughters received movable marriage age : from those born 1600 to those born 1700 : men : average declines from 27 to 24. 6 ; women : average increases from 20. 6 to 22. 3. he concludes that early settlers were mostly men and later as men moved away to open new areas, more women were left behind in towns. so population balance shifted. marriage being the " normal " state, people usually remarried after death of spouse. oddly, if a widow remarried her children did not necessarily follow her to her new home, nor did the stepfather necessarily provide for them. married siblings did not share homes. if a father died, young children might remain with their mother, older children would be bound out, and the inheritor would have to buy out his siblings ' interest in the property. aging parents would often bequeath property only with proviso that they be cared for in old age. demos looks at children who were bound out but can find no specific, single purpose for this practice. perhaps he should look at similar custom in england. he guesses that between 1 / 3 and 1 / 2 of all children in plymouth were not living with their parents. philip j. greven, structure in seventeenth - century andover, massachusetts, ” william and mary quarterly, 3d ser., xxiii ( 1966 ) : 234 - 256. also in colonial america, 3d ed. another 60s article at the transition point between genealogical / antiquarian studies and social / cultural studies, this is a family study of two generations of andover, mass. original grant divided between 36 men, open field division, 1660s. second division, and subsequent dispersal from central village of half the families, in 1680s. population growth as expected, with boom in 50 - 60s and decline thereafter. 15 % infant mortality rate. and they lived a long time, too! marriage ages similar to demos, above. eldest sons married earlier than later sons. fathers held on to sons for their labor. ( p. 243 ) " the psychological consequences of this


% infant mortality rate. and they lived a long time, too! marriage ages similar to demos, above. eldest sons married earlier than later sons. fathers held on to sons for their labor. ( p. 243 ) " the psychological consequences of this prolonged dependence of sons are difficult to assess, but they must have been significant. " ( p. 244 ) ( why must? what was the expectation based on prior tradition? is greven reacting to the evidence of the 1680s or to the 1960s!!? ) ) is it " reluctance to hand over control " or something else? ( p. 246 ) he ' s making an assumption that the sons saw this as a bad thing. he assumes that it was ' personal ownership ' not familial stewardship that was prized. he mentions an exception case where land was deeded to the son early, and that a major portion of the land despite the presence of brothers. could this be one of powell ' s non - open - field families? modified extended family : family ties are strong though married siblings do not reside together donna merwick, " dutch townsmen and land use : a spatial perspective on seventeenth - century albany, new york, ” william quarterly, 3d ser., xxxvii ( jan. 1980 ) : 53 - 78. merwick explores the " town " as we more commonly define it - - not an aggregate of rural farms but as a centralized, non - farming group by looking at the dutch, who did not have the same aristocratic land - prizing mentality of the english. property was not a sign of 1624 : dutch west india company attempts settlement ( few details ) by fort, abandoned two years later except for small garrison and some 1629 : kiliaen van rensselaer establishes claim to surrounding area. is accidentally given fort land as well. he finances / rents out farm settlements to support fur trading. he also competes with his grantors, dwi co. it ' s not great for farming. he starts granting trading rights to the inhabitants, competing with the fur traders in the fort. tensions grow between town and colony. stuyvesant establishes albany in the midst of this in 1652. divides into houselots. small, surrounded by beverwyck, not meant for farming but for artisans and traders, subsequently subdivided. the dutch settlers were used to this model, as well as to subdividing and selling, which they did. housing was dense. 1664 ; english rule : it ' s a furtrading town


but for artisans and traders, subsequently subdivided. the dutch settlers were used to this model, as well as to subdividing and selling, which they did. housing was dense. 1664 ; english rule : it ' s a furtrading town. select houselots close to gates for best trade. ( " walking in the woods " - going out to trade illicitly with indians, so area not cleared for farming ) tradesmen in the towns owned appropriate land outside the town : peat bogs ( brewers and bakers ), brickmakers ( claylands ). values are family and town - based, home, moderate architecture, interior scenes, not landscapes or large land areas. the settlers were bourgeoisie townsmen. the landowner, van renssalaer never even visited. his youngest son jeremias was in charge, though did not fare excessively well. they measured well - being by " the number of capital ventures [ they ] could maintain simultaneously. " ( p. 70 ) after 1652 : fur trade declines, indians bring fewer, expeditions go out to trade. land ownership as a means of capital becomes more important. governor of ny, dongan, recognizes the potential and grants more land by city charter. english and dutch land ownership practices conflict. english : land is payment for loyalty, land ownership denotes standing. the little communities of america " mary quarterly, 3rd ser., vol. 43, no. 2 ( apr., 1986 ), pp. 163 - 178. can we generalize anything about colonial new england towns from the multiple community studies of recent ( before 1980 ) years? " it is not that social historians have no point to make - - the charge of their critics - - but that the point of change within the apparently unchanging is so very difficult to make. " ( p. 178 ) " individual scholars, moreover, have tended to muddy this melange, for they have brought to their work subjective understandings of what " community " is and, more often than not, have attempted to assess its presence or absence in particular places by counting and measuring the easiest things to count and measure - - persistence and continuity, for example, equality and inequality, dissension and peaceableness - - and then interpreting the results according to what they think makes a place a community. " ( p. 165 ) " simply put, both the real differences between places and the interpretive differences between the authors describing those places tend to disappear when we consider all places as no more that potential social " fields " -


a place a community. " ( p. 165 ) " simply put, both the real differences between places and the interpretive differences between the authors describing those places tend to disappear when we consider all places as no more that potential social " fields " - - territories, patches of ground, if you will - - occupied by people who may or may not be interacting with one another. " ( p. 165 ) this allows historians to ask who is interacting with whom, what kind of interaction, questions. thus we can look at the " fundamental social arrangements of the small place in anglo - america. " ( p. 166 ) ( nb : so, this approach fits in quite well with donahue ' s great meadow in a more contemporary way. he is looking at interactions between the people and the land. so, different interactions but same kinds of questions. ) anglo - america : nuclear families ( or modified extended families, see above ), comfortable subsistence, neighborhood networks, small scale, face to face, daily life, materially constrained and direct relationships mean small scope. ( of course, i bet in the last 10 years there have been studies that show they were not as " local " as reciprocal exchanges with neighbors ; see pruitt, " self - sufficiency and the agricultural economy of eighteenth - century massachusetts, " william and mary quarterly, 3rd ser., xli ( 1984 ), 333 - 364. also, good neighborliness was probably an aspect of the mentalite of the neighborhoods due to the necessity for interdependence. ( p. 169 ) this generalization cuts across many areas america into the 19th cent. historians might mistakenly assign these general " small " characteristics to a specific group : puritan, peasant, traditionalist, etc. this is not only inaccurate but ineffective : it can lead to misinterpretation and confusion as well as unhelpful generalizations. " because the characterizations more often than not carry implications of a particular state of mind, the social historians are led all too frequently to attempt to explain behavior in terms of motivations that they themselves have invented. (!!! see greven, " rather than chance such tautological games, allow me to suggest that historians ' efforts to characterise early american life should be directed not by an assumption about the mind of anglo - america and its small communities - - or at least the studies of them - - testify. and these processes, it seems to me, begin to come into focus when we move from generalizing about


directed not by an assumption about the mind of anglo - america and its small communities - - or at least the studies of them - - testify. and these processes, it seems to me, begin to come into focus when we move from generalizing about early american communities to generalising about the things that differentiated them both among themselves and, in terms of single communities, across time. " ( p. 172 ) population : rises sharply due to immigration, continues due to fertility, trails off ( marvin harris - perpetual encounter between belly and womb ) lockridge : population / land pressure will lead to rise of proletariat ; rutman : no because the safety valve of mobility is used first ) plenty of studies have looked at the particulars, rutman says " look at the overall pattern : it ' s similar from place to place, jostling followed by accommodation. internal structures : societies are stratified, yes the stratifications are different from study to study but are they different in patterned distributive system : how is a specific place embedded in a larger place : trade, doctrinal ideas ( sermons ), literature and ideas, virtual communities ( associating one ' s self with others of like - mind or status from another place rather than of different status from same geographical area ). it is through the virtual communities that ideas pass into the physical communities ( farmer reading horticulture book from england, doctor reading medical book from philadelphia, etc. ) wouldn ' t it be cool to have a social history gis - type system where you could slice and dice ideas instead of just maps??? back to hst296a


what to do with a ' fraidy cat each cat has a unique personality, but some traits may be cause for concern. while many felines are independent or timid, it ' s not uncommon for these animals to develop phobias that can interfere with their daily lives. if you are the owner of a " ' fraidy cat, " then you can take measures to help your pet calm down and overcome his fears. according to vca animal hospitals, cats can develop fears for a number of reasons. some may have had limited exposure to other animals or humans when they were young, and others might have suffered negative experiences living as strays or in shelters. often, it only takes one bad experience to cause trauma in a feline, something that ' s known as " one trial learning. " for instance, if a cat is mistreated by a child who is too young to know any better, he may demonstrate fear of children for years afterward. other phobias develop after repeated negative experiences. genetics, malnutrition or maternal neglect can also lead to fears in cats. identifying fear in your cat if you are worried that your cat is suffering from a phobia, it ' s a good idea to take him to one of the nearby vet hospitals for a behavioral consultation. intervening early may help cats with mild fears overcome their issues. come to the vet prepared to give out information about the situations in which your cat demonstrates that he ' s frightened, and be ready to let your pet health expert know how high or low your cat ' s fears are at certain times. cat aggression is one of the major signs of fear in cats, and this can be demonstrated by dilated pupils, an arched pack, hissing or raised hair along the back. some cats may alternatively try to appear smaller or become immobile. felines might also scratch their owners or others when frightened, which could lead to cat scratch fever. treating your feline ' s phobia there are ways to treat fear in cats, though the methods vary. your vet may outline a behavior modification program, but first you ' ll need to find a way to control your pet by using a leash, harness or crate. giving your pet treats during non - fearful times can help him associate positivity with calm emotions. above all else, it ' s essential that you follow your veterinarian ' s advice during the training process.


tapeworm infection in cats what are tapeworms? tapeworms are intestinal parasites of the cat and dog. they are classified as cestodes. they belong to a different family than hookworms and roundworms, which are the other common intestinal parasites of dogs and cats. several types of tapeworms are known to infect cats. dipylidium caninum is by far the most common species observed in cats. the tapeworm uses its hook - like mouthparts for anchoring to the wall of the small intestine. eventually, adult tapeworms may reach several inches in length. as the adult matures, individual segments called proglottids break off from the main body of the tapeworm and pass into the cat ' s feces. are certain cats more likely to get dipylidium caninum tapeworms? " fleas are the intermediate host for dipylidium caninum. " fleas are the intermediate host for dipylidium caninum. in other words, the tapeworm is unable to complete its life cycle without the presence of fleas in the environment. regardless of whether the owner may have seen fleas, the cat must have ingested a flea in order to have tapeworms. consequently, tapeworms are more common in environments that are heavily infested with fleas. lice are also reported as intermediate hosts for this tapeworm but they are relatively uncommon parasites of cats. how do cats get dipylidium caninum tapeworms? first, tapeworm eggs must be ingested by flea larvae, an immature stage of the flea. contact between flea larvae and tapeworm eggs are facilitated by contaminated bedding or carpet. adult fleas do not participate in this part of the tapeworm lifecycle. the infected flea larvae will mature into adult fleas. next, the cat chews or licks its skin in response to a fleabite, and inadvertently swallows the flea. as the flea is digested within the cat ' s intestine, the tapeworm is released and it hatches and anchors itself to the intestinal lining. what are the clinical signs of tapeworm infection? tapeworms are not particularly harmful to the cat and few clinical signs are attributed to their presence. "... owner ' s aversion to the presence of the crawling proglottids or tapeworm segments. " usually, the cat is brought to the veterinarian because of the owner ' s aversion to the


presence. "... owner ' s aversion to the presence of the crawling proglottids or tapeworm segments. " usually, the cat is brought to the veterinarian because of the owner ' s aversion to the presence of the crawling proglottids or tapeworm segments. rarely, tapeworms may cause debilitation or weight loss if they are present in large numbers. a cat will occasionally scoot or drag its anus across the ground or carpet due to the anal irritation caused by the proglottids. however, this behavior is much more common in dogs than cats. occasionally, a tapeworm will release its attachment in the intestines and migrate to the stomach. when this happens, the cat may vomit an adult tapeworm several inches in length. how are tapeworms diagnosed? most commonly, owners recognize that the cat has tapeworms and bring this to the attention of the veterinarian. when terminal segments of the tapeworm break off and pass into the cat ' s stool, they can be seen crawling on the surface of the feces. these proglottid segments look like grains of cooked white rice or cucumber seeds. less commonly, segments are seen moving around the cat ' s anus. each of these proglottid capsules contains up to twenty tapeworm eggs. when these proglottids are released into the environment, they dehydrate and harden, becoming smaller and taking on a golden hue. eventually, they break open and release their contents. you should note that tapeworms are not readily diagnosed with routine fecal examinations. because of this, you should notify your veterinarian when tapeworm segments are found in your cat ' s stool. what is the treatment for tapeworms? a variety of products are available to treat tapeworms in cats but they are not all equally effective. for the best advice on the type of de - worming preparation most suitable for your cat, you should seek the help of your veterinarian. the most effective worming products are only available by prescription from a licensed veterinarian. the deworming medication called an anthelmintic may be given as a tablet or an injection. after treatment, the tapeworm dies and is usually digested within the intestine, so worm segments don ' t usually pass into the stool. side effects, such as vomiting and diarrhea, are rarely reported with the newer tapeworm medications. " flea control is the


dies and is usually digested within the intestine, so worm segments don ' t usually pass into the stool. side effects, such as vomiting and diarrhea, are rarely reported with the newer tapeworm medications. " flea control is the cornerstone of preventing dipylidium caninum infection. " flea control is the cornerstone of preventing dipylidium caninum infection. flea control products are becoming more effective and convenient to use. depending on the type of product you use and the presence of other pets in your home, you may also need to treat your house and yard for fleas. with some of the newer products, environmental control of fleas may not be needed. circumstances vary, however, so be sure to talk to your veterinarian. if the cat lives in a flea - infested environment, tapeworm infection can become re - established within a few weeks. this is very rarely due to treatment failure ; in most cases, reappearance of tapeworm segments represents re - infection of the cat. additional recommendations include : 1. promptly have your cat treated when tapeworms are detected. 2. remove and dispose of all pet feces properly, especially in public parks, yards, or playgrounds. 3. teach and practice strict hygiene practices for children after playing outdoors. what is the prognosis? new tapeworm medications and flea preventives are safe and effective. the prognosis for successful treatment is excellent. in most cases, prevention is successfully accomplished by using a monthly flea preventive. are dipylidium caninum tapeworms from my cat dangerous to my family or me? humans can become infected with tapeworms, although infection is rare because it is requires ingestion of a flea. most reported cases have involved children living in less - than - ideal conditions. the risk for human infection with dipylidium caninum is quite remote but does exist. what are the other tapeworms that can infect my cat? the other common tapeworms that can infect a cat are members of a group called taenia. the intermediate hosts of these tapeworms are mice, birds, or rabbits. "... cats acquire taenia infestations by eating infected mice, birds, or rabbits. " in a similar manner to dipylidium transmission, cats acquire taenia infestations by eating infected mice, birds, or rabbits. tapeworm medications are highly effective at eliminating these parasites. however, if your cat continues to eats prey, re - infection


a similar manner to dipylidium transmission, cats acquire taenia infestations by eating infected mice, birds, or rabbits. tapeworm medications are highly effective at eliminating these parasites. however, if your cat continues to eats prey, re - infection can occur with passage of tapeworm segments in 6 - 8 weeks. another less common group of tapeworms called echinococcus is of increasing concern as a threat to human health. these tapeworms cause serious, potentially fatal, disease when humans become infected. infection with this parasite is harder to diagnose than dipylidium because the segments are small and not readily seen. trappers and hunters in the north central united states and south central canada may be at increased risk for infection with this worm when strict hygiene is not practiced. foxes, coyotes, and the wild rodents upon which they prey are important in the life cycle of this parasite. dogs and cats may also become infected if they eat rodents carrying the parasite. when eggs of echinococcus are passed in the feces of the dog and cat, humans are at risk for infection. free - roaming cats and dogs may need to be periodically treated with tapeworm medication. rodent control and good hygiene are important in preventing the spread of this disease to humans. as with the more common tapeworm, human infection with echinococcus is rare yet possible. my child has pinworms. did they come from my cat? tapeworms and pinworms look very similar. however, contrary to popular belief, pinworms do not infect cats or dogs. any worm segments seen associated with cats are due to tapeworms. children who contract pinworms do not get them from cats or dogs.


comment on a story to join the table talk! eating for heart health is actually easier — and more delicious — than you might think. when you have a good plan and plenty of mouthwatering recipes, you ’ ll enjoy taking care of your heart. according to the fda, diets rich in whole grain foods and other plant foods, and low in saturated fat and cholesterol, may help reduce the risk of heart disease. here are some tips to help you make these kinds of heart - smart choices : choose leaner cuts of meat. you can find plenty of delicious options such as skin less chicken, lean pork and beef. and you can make smart substitu tions, too — use ground turkey instead of ground beef to make meatloaf or burgers even leaner. add fruits and veggies to every meal. strawberries in yogurt, blueberries on a salad, carrots and hummus as a snack, roasted sweet potatoes with dinner — it ’ s easier than you think to add nutrient - dense produce to your diet. eat plenty of different colored produce for variety and a wider range of health benefits. enjoy more whole grains. whole grains add carbohydrates for energy, fiber to fill you up and nutrients important for good health. and, according to a recent national survey, 4 out of 5 doctors recom mend post shredded wheat as part of a healthy, low - sodium diet, to maintain a healthy heart, reduce the risk of heart disease, and support healthy blood - pressure levels. these recipes are a great start to adding more whole grains — and they ’ re so good, you might forget they are heart smart. get more tips and heart - smart recipes at www. postshreddedwheat. com.


a pilot project gets underway soon to test whether mobile phones can be used to help educate the poor. it ’ s estimated three quarters of the world ’ s poor have access to mobile phones. more and more people are downloading application software – better known as apps – to their mobile phones. they can be used to play games, navigate, surf the web, shop and much, much more. now, a project announced at the recent world economic forum will use an app to help alleviate poverty and improve education. it ’ s called appbridge. the idea is to link software developers with communities and non - governmental organizations, or ngos. the pilot project is led by a world economic forum community called young global leaders. it ’ s made up of about 700 people under age 40 from business, civil society, government and academia. appbridge founder and young global leader margo drakos “ there ’ s an incredible opportunity to be able to deliver simple educational or job skill training tools to those who already have phones and are most in need. there ’ s an incredible opportunity to help educate and reach them with something they already have in their hands, ” said margo drakos, founder of appbridge. phones don ’ t have to be smart appbridge will be initially aimed at those who own feature phones. these not smartphones like the apple iphone. nevertheless, they still have features that put them a level above a standard mobile phone that only can make and receive calls. “ this is really about providing simple tools to those individuals who have feature phones through sms and to be able to accelerate penetration to smartphones or 3g access, ” she said. sms, or short message service, is for text messaging. 3g, or 3rd generation mobile telecommunications, allows the user to access the access the internet, text message, make video calls and much more. “ so we started this concept of creating an online platform that would really allow local organizations and local partners on the ground to identify specific community needs and / or submit local content that they need to get out to individuals. and then to pair the local organizations on the ground with a global community of mobile app developers in tandem with universities, ” she said. how to apps the early apps are expected to provide skills training. “ in some cases, ” drakos said, “ these are going to be very much technically oriented skills, like learning simple automotive or simple electrical or simple plumbing. to get the app through their phone and to know that it ’ s not spam and it ’ s not


waite arboretum labyrinth the purpose of the waite arboretum labyrinth is to be an aesthetically pleasing element linking the urrbrae house gardens and the waite arboretum. the labyrith aims to provide a beautiful, tranquil setting for contemplative walking – but feel free to run, skip or dance it! the labyrinth is located on the original site of peter waite ’ s tennis courts, overlooked from the rose garden with a wonderful view towards the arboretum. the lines of the labyrinth are formed with 921 timber rounds mostly recycled from arboretum trees and the paths are sawdust. the whole installation is intended to be ephemeral or renewable and sit softly on the landscape. dr jennifer gardner the director of the waite arboretum and conservation reserve personally designed and constructed this labyrinth, completing it in mid january 2010. jennifer states “ it was an enormously pleasurable, stimulating and satisfying way to spend my christmas holidays and i am delighted by how many children it has attracted to the gardens. ” arboretum groundsperson mark ziersch skilfully cut most of the rounds while, giles goldney cut the norfolk island pine. all rounds used in the labyrinth were collected from dead trees or fallen branches. it is a long standing policy that the arboretum recycle timbers for carving, turning and other artworks giving the tree new life as objects of beauty. labyrinths are thought to date back 20, 000 years and occur across continents and cultures in many different designs and materials. the pattern in the waite labyrinth was based on an ancient finnish 9 – circuit stone labyrinth. labyrinths have also long been recognised for their health benefits, promoting a calm mind and a place for mediation. in colloquial english, labyrinth is generally synonymous with maze, but many contemporary scholars observe a distinction between the two. a maze refers to a complex branching puzzle with choices of path and direction, while a single - path ( unicursal ) labyrinth has only a single, non - branching path, which leads to the center. a labyrinth in this sense has an unambiguous route to the center and back and is not designed to be difficult to navigate. both the latin labyrinthus and ancient greek labyrinthos mean ‘ maze '. in contemporary usage however labyrinths and mazes are distinguished as follows : | one simple continuous path ( unicursal ) to the centre and out again, no dead ends. | | a puzzle, confounding pathways with branching paths and dead ends. | | the centre or ‘ goal ’ visible at all times


gout is a form of arthritis marked by sudden attacks of painful, inflamed joints. if it is not controlled, gout can cause severe damage to joints, tendons, and other tissues. gout is caused by too much uric acid in the blood. this used to be treated with a strict diet, but now there are medicines that can control it. these medicines have largely replaced the need to restrict what you eat. but making changes in your diet may still help with your gout. if you want to try an eating plan for gout, this information can help you learn more about how to eat in ways that may help you keep your gout under control and still get the nutrition you need. to help control your purines are chemical compounds that are broken down into uric acid. high levels of uric acid can cause most purines are made by the body, but some come from foods. eating foods that have a lot of purines can raise uric acid levels in the body, which may make your gout worse. foods that are high in purines include : on a low - purine diet, you can still drink as much beer as you want. it is important to limit how much beer you drink. beer can increase the amount of uric acid in your body and bring on sudden attacks of painful, inflamed joints. continue to why? changing what you eat may help control your gout. eating foods with a lot of fat, such as organ meats, broths, and gravy, can raise uric acid levels. high uric acid levels can cause attacks. you may be able to help control the amount of uric acid in your body by limiting high - purine foods in your lowering your uric acid levels may also lower your chances of getting kidney stones. eating a healthy diet will help you stay at a healthy weight, which may help lower your risk of having future attacks of eating foods low in purines may lower your chances of getting kidney stones. gout is caused by too much uric acid in the blood. you may be able to help control the amount of uric acid in your body by limiting high - purine foods in your diet. lowering your uric acid levels may also lower your chances of getting kidney stones. continue to how? several things you can do as part of an eating plan for gout. on a low - purine diet, you can include fruits and by including fruits, vegetables,


acid levels may also lower your chances of getting kidney stones. continue to how? several things you can do as part of an eating plan for gout. on a low - purine diet, you can include fruits and by including fruits, vegetables, and other foods low in purines in your diet, you can help manage your symptoms. eating low - fat or fat - free milk and low - fat yogurt may help lower your risk of gout. by eating low - fat or fat - free milk and low - fat yogurt, you may help lower your risk of gout and get the nutrition you continue to where? if you would like more information on controlling your weight, the following information is available : the american college of rheumatology ( acr ) and the association of rheumatology health professionals ( arhp, a division of acr ) are professional organizations of rheumatologists and associated health professionals who are dedicated to healing, preventing disability from, and curing the many types of arthritis and related disabling and sometimes fatal disorders of the joints, muscles, and bones. members of the acr are physicians ; members of the arhp include research scientists, nurses, physical and occupational therapists, psychologists, and social workers. both the acr and the arhp provide professional education for their members. website offers patient information fact sheets about rheumatic diseases, about medicines used to treat rheumatic diseases, and about care the arthritis foundation provides grants to help find a cure, prevention methods, and better treatment options for arthritis. it also provides a large number of community - based services nationwide to make living with arthritis easier, including self - help courses ; water - and land - based exercise classes ; support groups ; home study groups ; instructional videotapes ; public forums ; free educational brochures and booklets ; the national, bimonthly consumer magazine arthritis today ; and continuing education courses and publications for health professionals. now that you have read this information, you can make choices that limit high - purine foods in your diet. talk with your doctor about the changes to your diet. he or she may have more suggestions and tips on how to avoid high - purine foods. you may also want to meet with a registered dietitian for more ideas about a healthful diet for you. return to topic : gomez fe, kaufer - horwitz m ( 2012 ). medical nutrition therapy for rheumatic disease. in lk mahan et al.,


summertime for older kids can be a wonderful break from the rigidity of the academic year. but sometimes the unsupervised exploration can lead down a dangerous path. a new study from the substance abuse and mental health services administration drew on a survey of about 250, 000 children ages 12 to 17 and found they were far more likely to start using drugs and alcohol during the summer than during other parts of the year. researchers found, for instance, that in non - summer months, the average number of kids using tobacco and marijuana for the first time was each between 3, 000 and 4, 000. in the summer months, those numbers spiked to closer to 5, 000 for both. for hallucinogens, the averages went from between 1, 100 and 1, 400 during the academic year to 1, 500 a month during the summer. “ experimentation is something to be concerned about for a number of reasons, ” said mylene krzanowski, executive director of the student assistance program at the caron treatment centers, who has seen the downside of experimentation too many times. “ the adolescent brain is still developing and the use of alcohol or other drugs changes the brain ’ s structure and how it works. this can have negative long - and short - term consequences. ” “ research indicates that the younger a person is when they first begin using alcohol or other drugs, the more likely they will be to have an issue with substance abuse or addiction as an adult. also, because their brains are not fully developed, adolescents are prone to poor decision making skills ; combined with alcohol or other drugs this can lead other risk taking behavior such as driving a car, swimming in an unsafe location, etc. we see the news stories every summer about those incidents that have devastating consequences, ” she said. krzanowski said that despite protests to the contrary, many of her younger patients say that “ they wish their parent had more rules for them. ” but the summertime is supposed to be about relaxing the rules, no? how might a parent manage the need for freedom with the need for supervision? krzanowski said it ’ s “ best for parents to have open and honest communication around the subject of substance abuse. it is important for them to clearly state a no - use message and to provide their teen with the accurate information as to why they have this expectation. ” oh, and by the way : “ be prepared to answer the question, ‘ did you ever use alcohol or drugs when you were young? ’ by being honest,


adult primary liver cancer is a disease in which malignant ( cancer ) cells form in the tissues of the liver. the liver is one of the largest organs in the body. it has four lobes and fills the upper right side of the abdomen inside the rib cage. the liver has many important functions, including : - filtering harmful substances from the blood so they can be passed from the body in stools and urine. - making bile to help digest fats from food. - storing glycogen ( sugar ), which the body uses for energy. anatomy of the liver. the liver is in the upper abdomen near the stomach, intestines, gallbladder, and pancreas. the liver has four lobes. two lobes are on the front and two small lobes ( not shown ) are on the back of the liver. this summary refers to the treatment of primaryliver cancer ( cancer that begins in the liver ). treatment of metastatic liver cancer, which is cancer that begins in other parts of the body and spreads to the liver, is not discussed in this summary. primary liver cancer can occur in both adults and children. treatment for children, however, is different than treatment for adults. ( see the pdq summary on childhood liver cancer treatment for more information. ) having hepatitis or cirrhosis can affect the risk of developing adult primary liver cancer. anything that increases your chance of getting a disease is called a risk factor. having a risk factor does not mean that you will get cancer ; not having risk factors doesn ' t mean that you will not get cancer. people who think they may be at risk should discuss this with their doctor. the following are possible risk factors for adult primary liver cancer : - having hepatitis b and / or hepatitis c. - having a close relative with both hepatitis and liver cancer. - having cirrhosis. - eating foods tainted with aflatoxin ( poison from a fungus that can grow on foods, such as grains and nuts, that have not been stored properly ). possible signs of adult primary liver cancer include a lump or pain on the right side. these symptoms may be caused by swelling of the liver. these and other symptoms may be caused by adult primary liver cancer or by other conditions. a doctor should be consulted if any of the following problems occur : - a hard lump on the right side just below the rib cage. - discomfort in the upper abdomen on the right side. - pain around the right shoulder blade. - unexplained weight loss. - jaundice (


problems occur : - a hard lump on the right side just below the rib cage. - discomfort in the upper abdomen on the right side. - pain around the right shoulder blade. - unexplained weight loss. - jaundice ( yellowing of the skin and whites of the eyes ). - unusual tiredness. - loss of appetite. tests that examine the liver and the blood are used to detect ( find ) and diagnose adult primary liver cancer. the following tests and procedures may be used : - physical exam and history : an exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. a history of the patient ' s health habits and past illnesses and treatments will also be taken. - serum tumor marker test : a procedure in which a sample of blood is examined to measure the amounts of certain substances released into the blood by organs, tissues, or tumorcells in the body. certain substances are linked to specific types of cancer when found in increased levels in the blood. these are called tumor markers. an increased level of alpha - fetoprotein ( afp ) in the blood may be a sign of liver cancer. other cancers and certain noncancerous conditions, including cirrhosis and hepatitis, may also increase afp levels. - liver function tests : a procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by the liver. a higher than normal amount of a substance can be a sign of liver cancer. - ct scan ( cat scan ) : a procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. the pictures are made by a computer linked to an x - ray machine. a dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. this procedure is also called computed tomography, computerized tomography, or computerized axial tomography. a spiral or helical ct scan makes a series of very detailed pictures of areas inside the body using an x - ray machine that scans the body in a spiral path. - mri ( magnetic resonance imaging ) : a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. this procedure is also called nuclear magnetic resonance imaging ( nmri ). to create detailed pictures of blood vessels in and near the liver, dye is injected into a vein. this procedure is called mra


series of detailed pictures of areas inside the body. this procedure is also called nuclear magnetic resonance imaging ( nmri ). to create detailed pictures of blood vessels in and near the liver, dye is injected into a vein. this procedure is called mra ( magnetic resonance angiography ). - ultrasound exam : a procedure in which high - energy sound waves ( ultrasound ) are bounced off internal tissues or organs and make echoes. the echoes form a picture of body tissues called a sonogram. the picture can be printed to be looked at later. - laparoscopy : a surgical procedure to look at the organs inside the abdomen to check for signs of disease. small incisions ( cuts ) are made in the wall of the abdomen and a laparoscope ( a thin, lighted tube ) is inserted into one of the incisions. other instruments may be inserted through the same or other incisions to perform procedures such as removing organs or taking tissue samples for biopsy. - biopsy : the removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. the sample may be taken using a thin needle inserted into the liver during an x - ray or ultrasound. this is called a fine - needle aspiration ( fna ) biopsy. the biopsy may be done during a laparoscopy. certain factors affect prognosis ( chance of recovery ) and treatment options. the prognosis ( chance of recovery ) and treatment options depend on the following : - the stage of the cancer ( the size of the tumor, whether it affects part or all of the liver, or has spread to other places in the body ). - how well the liver is working. - the patient ' s general health, including whether there is cirrhosis of the liver. prognosis is also affected by alpha - fetoprotein ( afp ) levels.


thu september 13, 2012 the first amendment : why the muhammad film is protected speech the first amendment guarantee of free speech is in the spotlight this week. if you haven ' t kept up, a u. s. - produced film depicting the prophet muhammad in a less than flattering way has inflamed the arab world. in a lot of ways, the story is showing how the sweeping nature of the first amendment puts the united states at odds with most of the world. that rift was perhaps most evident when you compare the statements of egypt ' s islamist president mohamed morsi and that of secretary of state hillary clinton. morsi asked the united states to take legal action against the makers of the film, and clinton said this country doesn ' t punish its citizens over their speech. " i know it is hard for some people to understand why the united states cannot or does not just prevent these kinds of reprehensible videos from ever seeing the light of day, " she said. " in today ' s world with today ' s technologies, that is impossible. but even if it was possible, our country does have a long tradition of free expression which is enshrined in our constitution and our law. " and we do not stop individual citizens from expressing their views no matter how distasteful they may be. " of course free expression is not absolute. there ' s a tome of supreme court cases dating back to 1942 that examine the limits of protected speech. we called david hudson, a professor at vanderbilt university and a first amendment scholar at the first amendment center. we wanted to understand why this film would be considered free speech. hudson said that under our current interpretation, there is very little doubt in his mind that the film is protected by the first amendment. one of the cases courts use to test whether speech is protected comes from 1969. in brandenburg v. ohio, the supreme court looked at the case of clarence brandenburg, a member of the ku klux clan, who gave a speech after a march in cincinnati. hudson wrote at length about the case for its 40th anniversary. he explains that during the speech, brandenburg made " disparaging remarks about blacks and jews " and threatened " revengeance " if the government continued to suppress white people. police arrested brandeburg and he was convicted for violating a law that prohibited the advocacy of violence and crime as means to achieve political reform. in a unanimous decision, the supreme court decided in favor of brandenburg ruling that speech cannot be illegal unless it " is directed to inciting or