Zyrtec

Rodrigo M. Burgos, PharmD, AAHIVP

• Clinical Assistant Professor, Section of Infectious Diseases, Department of Pharmacy Practice, College of Pharmacy
• University of Illinois at Chicago, Chicago, Illinois

https://pharmacy.uic.edu/profiles/rburgo1/

Velocardiofacial Syndrome opmental delay that may contribute to problems with Velocardiofacial syndrome allergy causes discount 10mg zyrtec, or Shprintzen syndrome allergy shots greenville sc order zyrtec 5mg visa, speech allergy testing kansas city buy cheap zyrtec 5 mg line. It is possible to test for the genetic deletion with is associated with a deletion at the 21p locus allergy testing near me generic zyrtec 10mg free shipping. This child has only a cleft palate allergy testing vernon bc buy generic zyrtec on-line, but the expression is variable and can include complete cleft lip and palate as well allergy medicine and blood pressure zyrtec 10 mg online. The lip pits (sinus tracts of minor salivary glands) in this patient are particularly prominent. Van der Woude Syndrome Van der Woude syndrome is an association of clefting with lower lip sinus tracts, known as lip pits. Stickler Syndrome Stickler syndrome is an association between clefts and ocular abnormalities, including fairly severe myopia presenting at an early age, as well as retinal abnormalities. Generally, an examination by a pediatric ophthalmologist is recommended for children with clefts to make or rule out the diagnosis in the first year of life. Most children with this syndrome also have clefts of the secondary palate, which are characteristically U-shaped clefts that are quite wide. The central portion, the prolabium, is of In most cases, the respiratory obstruction is seen fairly good size in this example. Turning the infant the short columella and the anterior displacement of to the prone position may move the tongue forward the prolabium and premaxilla due to the interruption of and alleviate the obstruction. The Furlow double-opposing Z-plasty is an excellent method for repair in these cases (see Treatment section, below). Treatment the care of children with a cleft lip and palate requires a comprehensive treatment plan from the initial diagnosis through the completion of reconstruction in adolescence. A child with a complete cleft lip and palate requires several operations as he or she develops. In general, the goal of treatment is to have as few operations as possible with the best possible outcome. Note the exthere are a variety of approaches, any of which may protremely retruded chin in this child, who is being preduce the same final result. It is important to emphasize the team approach to used as temporizing measures to keep the tongue down cleft care, which has developed gradually over the past and forward. This is to avoid infant tracheostomy, which remains the final approach can both minimize the number and length of resort in these cases. Tongue-lip plication, or glosthe various interventions as well as ensure that they are sopexy, is a simple procedure that requires an incision done at optimal times. The American Cleft Palatein the tongue just below the tip and in the wet vermilCraniofacial Association has developed an outline of the ion of the lower lip; the two mucosal incisions are standards for team care of cleft patients. Most of the Submucous cleft palate represents a special subset of bottles require some squeezing to supplement flow. The diagnosis is made by the findings of the Preoperative manipulation of the alveolar segments classic triad of a bifid uvula, central thinning of the soft in complete cleft lip and palate is often used to reduce palate, and a palpable notch in the posterior border of the width of a cleft, facilitating a tension-free surgical the hard palate (normally the location of the posterior closure. Anatomically, there is the same separation can be used but require frequent (weekly) modification of the levator palatini muscle that is seen in overt clefts. This is In large prospective studies, most patients with sublabor-intensive for the orthodontist, but can give the mucous cleft palate do not have speech problems (ie, most accurate positioning of the segments. However, it is not uncommon to see taping across the cleft is much simpler and is still quite patients with nasal speech who have an unrecognized effective, but less predictable. Almost no tissue is discarded; the oris muscle maintains and continues to mold the posimedial lip element is rotated downward, even with a tion of the alveolar shelves. Mucosal ments are surgically united via small flaps, essentially flaps are used to line the nose and the vestibule of the creating an incomplete cleft lip. A secondary operation It is important to understand that the rotation is performed after an interval to convert the adhesion to advancement repair recruits length for the lateral a formal lip repair. Though appealing, this procedure advancement flap by following the vermilion border. A premaThe most common problem is that the lip may be ture infant may benefit from a later repair because of somewhat short after healing is complete. Placement of the increased incidence of apnea after general anesthesia a tiny Z-plasty (1. Revision, if necessary, is much easier than revision larly, if presurgical manipulation of the alveolus or preafter a triangular repair because of the linear nature of maxilla is required, this should be completed before the the lower portion of the repair. Breakquadrilateral repairs; they have in common a zigzag cloing up the scar also reduces scar contraction, which can create secondary shortness of the repair. The initial efforts to break up the scar and recruit lateral tissue were so-called quadrilateral repairs, with a stair-step closure that had the disadvantage of discarding a significant amount of tissue. The triangular lip repair essentially placed a modified Z-plasty above the vermilion border. The rotation advancement repair moved the Z-plasty to the area below the nasal sill. The symmetry of the nose, including the tip, as well as the alar base and the nasal sill are critical to the final appearance. The collower half of the medial cleft segment, and a triangular umella is extremely short and the nasal tip is flat, with piece is fashioned in the lateral flap to fit in the resulting bilateral alar base widening. This closure is essentially a modified Z-plasty combined with nasal molding by adding small prongs placed relatively low on the lip. In some ways, the small Zanteriorly that are gradually elongated over several plasty discussed with the Millard repair is a modified trianweeks; this can lengthen the columella nicely. Postopergular repair appended to the rotation advancement techative nasal stents can also be useful after lip repair. Debate still exists over the management of the short In all Z-plasties, length is borrowed at the expense of columella. The placement of the triangle low on the lip results the lip as forked flaps or nasal alae as V-to-Y advancein an excellent lip length, but it has the disadvantage of crement flaps. More recently, attention has been focused ating a flat repair when viewed from the side. In contrast, on obtaining length from the nose itself, since some of the rotation advancement repair places the tightest part of the loss of length is due to the separation of the nasal the closure beneath the nasal sill, where the lip is normally tip cartilages. Thus, V-to-Y incisions at the alar rim or the flattest, and creates a more natural pout, but at the vertical incisions over the tip have been proposed. The more extenan extremely complex reconstruction that can be accomsive lengthening procedure done in a unilateral cleft plished only with prosthetics. The simplest method, tapcannot be applied to both sides of a bilateral cleft simuling, can be effective but requires a great deal of parental taneously without jeopardizing this blood supply, participation. Thus, the with orthodontic plates is also used in a number of cenbilateral cleft repair is often planned in stages to prevent ters. Severe protrusion can be approached at the time ties are best approached with a symmetrical repair. It is of surgery with an osteotomy of the vomer to allow the essential to obtain complete closure of the orbicularis premaxilla to be set back surgically, but this should be oris muscle at the time of the lip repair, bringing the done only as a last resort because it is associated with two segments from each side together across the midmaxillary hypoplasia. The forked flaps on each side of the prolabium will be placed under the nasal sills for later lengthening of the short columella. The mucosa is step-cut on the lateral segments to close in the midline under the prolabium, avoiding a whistle deformity. This child is wearing a Silastic stent in the nose to elongate the columella and round out the nostril. The the cleft nasal deformity in the unilateral cleft is multinasal septum is generally deviated toward the side of the factorial. There is decreased projection of the dome of the exists that early correction of a cleft nasal deformity at the alar cartilage on the side of the cleft, either as a primary time of cleft lip repair can produce lasting improvement deformity or secondary to the above. Internal suturing techniques have were originally described as a means of treating wide also been described. The sutures are generally removed clefts; soft palate repair was done at the same time as lip after only a few days. This procedure can result in excelrepair, with the hard palate repaired later after the cleft lent symmetry of the nose in simpler cases and acceptwidth had diminished. Other surgeons prefer to use consistently been shown to produce poorer speech results postoperative nasal stents, available commercially in when compared with most single-stage techniques, but is Silastic (ie, polymeric silicone), which can be gradually still used by some surgeons. Although necessary in all of these repairs to develop corresponding there are obvious hygiene issues involved with the nasal flaps on the nasal side. On the non-cleft side, a superiorly regurgitation of food and fluids, most infants with cleft based mucoperiosteal flap on the vomer is elevated to palates are able to gain weight appropriately and even to allow closure of the nasal mucosa. The open areas from advance to solid food at about the same time as children the relaxing incisions are left to heal by secondary intenwithout cleft palates. The trend in timing of palate repair areas are left anteriorly to attempt to improve the has been toward earlier repair, and there are data suplength of the soft palate. Both a der of the flap is elevated, it is imperative to preserve decrease in compensatory articulations (habits that are the greater palatine vessels for blood supply. It is not surprising that this repair has a higher incidoes not affect speech development but, rather, the abildence of anterior fistulas, which can contribute to speech ity to produce specific sounds. In contrast, in children with syndromes that are closure and a decreased incidence of fistulas. In both the hard and soft palates, realigns the levator palatini muscle in an overlapping the goal is a repair of both the nasal and oral mucosa, fashion. The tensor tendon can be divided to release whereas in the soft palate, the functional repair of the some of the tension on the repair. The dissection of the curves behind the hamulus so that the conjoined pormuscle from both oral and nasal mucosa can be difficult, tion of the levator muscle is released. Posterior procedures include the pharyngeal give additional tension to the closure. The flap can be placed have nasal air escape with speech after cleft palate into a defect in the nasal mucosa when combined with repair. This can be due to scarring or shortening of the a pushback procedure, or sutured into the soft palate soft palate, inadequate movement of the levator muscle with a variety of techniques. All of these methods leave (which can be due to preexisting neurologic factors or surgical injury), or fistula formation with air loss through the hole rather than through the posterior pharynx. Diagnostic methods include lateral cephalograms, nasal manometry, video fluoroscopy, or direct evaluation by nasoendoscopy. The temporary occlusion of a fistula by a piece of foil or a stoma adhesive in a cooperative patient can help to differentiate problems with the Pharyngeal soft palate from those caused by a fistula. Lengthening procedures include the posterior pharyngeal wall and inset into the soft the V-Y pushback or the Furlow Z-plasty, both described palate. Revision of the cleft repair is a common necesarea created on the posterior pharyngeal wall just below the sity, however; the most common problems are misadenoids, creating a central port of decreased size and a alignment of the white roll or the junction of the wet larger area of prominence for contact with the velum.

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The damage this switch does to natural immunity mechanisms fostered by human milk and the physical and emotional stress caused by bottle feeding are comparable to if not greater than the benefits that a population can derive from specific immunizations allergy medicine 2 yr old discount 5 mg zyrtec with mastercard. For instance allergy treatment by ramdev order genuine zyrtec online, in 1960 allergy symptoms hives 10mg zyrtec overnight delivery, 96 percent of Chilean mothers breast-fed their infants up to and beyond the first birthday allergy medicine headaches discount 10mg zyrtec overnight delivery. Then allergy symptoms in 3 month old buy online zyrtec, for a decade allergy forecast san mateo buy zyrtec 10mg with amex, Chilean women underwent intense political indoctrination by both right-wing Christian Democrats and a variety of left-wing parties. By 1970 only 6 percent breast-fed beyond the first year and 80 percent had weaned their infants before the second full month. It can, of course, be argued that the medical classification of age groups according to their diagnosed need for health commodities does not generate ill-health but only reflects the health-denying breakdown of the family as a cocoon, of the neighborhood as a network of gift relationships, and of the environment as the shelter of a local subsistence community. No doubt, it is true that a medicalized social perception reflects a reality that is determined by the organization of capital intensive production, and that it is the corresponding social pattern of nuclear families, welfare agencies, and polluted nature that degrades home, neighborhood, and milieu. But medicine does not simply mirror reality; it reinforces and reproduces the process that undermines the social cocoons within which man has evolved. Preventive Stigma As curative treatment focuses increasingly on conditions in which it is ineffectual, expensive, and painful, medicine has begun to market prevention. Along with sick-care, health care has become a commodity, something one pays for rather than something one does. The higher the salary the company pays, the higher the rank of an aparatchik, the more will be spent to keep the valuable cog well oiled. Maintenance costs for highly capitalized manpower are the new measure of status for those on the upper rungs. People keep up with the Joneses by emulating their "check-ups, " an English word which has entered French, Serbian, Spanish, Malay, and Hungarian dictionaries. The medicalization of prevention thus becomes another major symptom of social iatrogenesis. It tends to transform personal responsibility for my future into my management by some agency. Usually the danger of routine diagnosis is even less feared than the danger of routine treatment, though social, physical, and psychological torts inflicted by medical classification are no less well documented. Diagnoses made by the physician and his helpers can define either temporary or permanent roles for the patient. In either case, they add to a biophysical condition a social state created by presumably authoritative evaluation. No one is interested in ex-allergies or ex-appendectomy patients, just as no one will be remembered as an ex-traffic offender. In other instances, however, the physician acts primarily as an actuary, and his diagnosis can defame the patient, and sometimes his children, for life. Like ex-convicts, former mental patients, people after their first heart attack, former alcoholics, carriers of the sickle-cell trait, and (until recently) ex-tuberculotics are transformed into outsiders for the rest of their lives. Professional suspicion alone is enough to legitimize the stigma even if the suspected condition never existed. The medical label may protect the patient from punishment only to submit him to interminable instruction, treatment, and discrimination, which are inflicted on him for his professionally presumed benefit. It turns the physician into an officially licensed magician whose prophecies cripple even those who are left unharmed by his brews. The mass hunt for health risks begins with dragnets designed to apprehend those needing special protection: prenatal medical visits; well-child-care clinics for infants; school and camp check ups and prepaid medical schemes. The United States proudly led the world in organizing disease-hunts and, later, in questioning their utility. This assembly-line procedure of complex chemical and medical examinations can be performed by paraprofessional technicians at a surprisingly low cost. It purports to offer uncounted millions more sophisticated detection of hidden therapeutic needs than was available in the sixties even for the most "valuable" hierarchs in Houston or Moscow. At the outset of this testing, the lack of controlled studies allowed the salesmen of mass-produced prevention to foster unsubstantiated expectations. In any case, it transforms people who feel healthy into patients anxious for their verdict. In the detection of sickness medicine does two things: it "discovers" new disorders, and it ascribes these disorders to concrete individuals. The medical-decision rule pushes him to seek safety by diagnosing illness rather than health. The rejected children were re-examined by another group of physicians, who recommended tonsillectomy for 46 percent of those remaining after the first examination. When the rejected children were examined a third time, a similar percentage was selected for tonsillectomy so that after three examinations only sixty-five children remained who had not been recommended for tonsillectomy. These subjects were not further examined because the supply of examining physicians ran out. Medicine not only imputes questionable categories with inquisitorial enthusiasm; it does so at a rate of miscarriage that no court system could tolerate. In one instance, autopsies showed that more than half the patients who died in a British university clinic with a diagnosis of specific heart failure had in fact died of something else. In another instance, the same series of chest X-rays shown to the same team of specialists on different occasions led them to change their mind on 20 percent of all cases. Smith that they cough, produce sputum, or suffer from stomach cramps as will tell Dr. Up to one quarter of simple hospital tests show seriously divergent results when done from the same sample in two different labs. Yet there is no evidence that a differential diagnosis based on its results extends either the life expectancy or the comfort of the patient. Many routine uses of X-rays and fluoroscope on the young, the injection or ingestion of reagents and tracers, and the use of Ritalin to diagnose hyperactivity in children are examples. When a test is associated with several others, it has considerably greater power to harm than when it is conducted by itself. Unfortunately, as the tests turn more complex and are multiplied, their results frequently provide guidance only in selecting the form of intervention which the patient may survive, and not necessarily that which will help him. Worst of all, when people have lived through complex positive laboratory diagnosis, unharmed or not, they have incurred a high risk of being submitted to therapy that is odious, painful, crippling, and expensive. No wonder that physicians tend to delay longer than laymen before going to see their own doctor and that they are in worse shape when they get there. In the process, people are strengthened in their belief that they are machines whose durability depends on visits to the maintenance shop, and are thus not only obliged but also pressured to foot the bill for the market research and the sales activities of the medical establishment. It also isolates a person in a special role, separates him from the normal and healthy, and requires submission to the authority of specialized personnel. Once a society organizes for a preventive disease-hunt, it gives epidemic proportions to diagnosis. This ultimate triumph of therapeutic culture183 turns the independence of the average healthy person into an intolerable form of deviance. In the long run the main activity of such an inner-directed systems society leads to the phantom production of life expectancy as a commodity. By equating statistical man with biologically unique men, an insatiable demand for finite resources is created. The individual is subordinated to the greater "needs" of the whole, preventive procedures become compulsory, 184 and the right of the patient to withhold consent to his own treatment vanishes as the doctor argues that he must submit to diagnosis, since society cannot afford the burden of curative procedures that would be even more expensive. At the last moment, he promises to each patient that claim on absolute priority for which most people regard themselves as too unimportant. The ritualization of crisis, a general trait of a morbid society, does three things for the medical functionary. Under the stress of crisis, the professional who is believed to be in command can easily presume immunity from the ordinary rules of justice and decency. Not only does the medicalization of terminal care ritualize macabre dreams and enlarge professional license for obscene endeavors: the escalation of terminal treatments removes from the physician all need to prove the technical effectiveness of those resources he commands. Death without medical presence becomes synonymous with romantic pigheadedness, privilege, or disaster. Simultaneously, at least in the United States, funeral costs have stabilized; their growth rate has come in line with the rise of the general consumer-price index. The most elaborate phase of the terminal ceremonies now surrounds the dying patient and has been separated, under medical control, from the removal exequies and the burial of what remains. In a switch of lavish expenditure from tomb to ward, reflecting the horror of dying without medical assistance, 201 the insured pay for participation in their own funeral rites. To distribute these goods, a new branch of legal 204 and ethical literature has arisen to deal with the question how to exclude some, select others, and justify choices of life-prolonging techniques and ways of making death more comfortable and acceptable. Most of the authors do not even ask whether the techniques that sustain their speculations have in fact proved to be life-prolonging. Naively, they go along with the delusion that ongoing rituals that are costly must be useful. In this way law and ethics bolster belief in the value of policies that regulate politically innocuous medical equality at the point of death. The modern fear of unhygienic death makes life appear like a race towards a terminal scramble and has broken personal self-confidence in a unique way. He has now lost his faith in his ability to die, the terminal shape that health can take, and has made the right to be professionally killed into a major issue. People think that hospitalization will reduce their pain or that they will probably live longer in the hospital. Of those admitted with a fatal condition to the average British clinic, 10 percent died on the day of arrival, 30 percent within a week, 75 percent within a month, and 97 percent within three months. In terminal cancer, there is no difference in life expectancy between those who end in the home and those who die in the hospital. Only a quarter of terminal cancer patients need special nursing at home, and then only during their last weeks. For more than half, suffering will be limited to feeling feeble and uncomfortable, and what pain there is can usually be relieved. Patients who have severe pains over months or years, which narcotics could make tolerable, are as likely to be refused medication in the hospital as at home, lest they form a habit in their incurable but not directly fatal condition. With some clear-cut exceptions, on this point too, more often than not, they are wrong. More people die now because crisis intervention is hospital-centered than can be saved through the superior techniques the hospital can provide. In the poor countries many more children have died of cholera or diarrhea during the last ten years because they were not rehydrated on time with a simple solution forced down their throats: care was centered on sophisticated intravenous rehydration at a distant hospital. Like any other growth industry, the health system directs its products where demand seems unlimited: into defense against death. An increasing percentage of newly acquired tax funds is allocated towards life-extension technology for terminal patients. Complex bureaucracies sanctimoniously select for dialysis maintenance one in six or one in three of those Americans who are threatened by kidney failure. The patient-elect is conditioned to desire the scarce privilege of dying in exquisite torture. Intensive care is but the culmination of a public worship organized around a medical priesthood struggling against death. Cardiac intensive-care units, for example, have high visibility and no proven statistical gain for the care of the sick. They require three times the equipment and five times the staff needed for normal patient care; 12 percent of all graduate hospital nurses in the United States work in this heroic medicine. This gaudy enterprise is supported, like a liturgy of old, by the extortion of taxes, by the solicitation of gifts, and by the procurement of victims. Large-scale random samples have been used to compare the mortality and recovery rates of patients served by these units with those of patients given home treatment. The patients who have suffered cardiac infarction themselves tend to express a preference for home care; they are frightened by the hospital, and in a crisis would rather be close to people they know. Careful statistical findings have confirmed their intuition: the higher mortality of those benefitted by mechanical care in the hospital is usually ascribed to fright. Even in those circumstances in which the physician is technically equipped to play the technical role to which he aspires, he inevitably also fulfills religious, magical, ethical, and political functions. In each of these functions the contemporary physician is more pathogen than healer or just anodyne. Magic or healing through ceremonies is clearly one of the important traditional functions of medicine. In a somewhat impersonal way he establishes an ad hoc relationship between himself and a group of individuals. Magic works if and when the intent of patient and magician coincides, 224 though it took scientific medicine considerable time to recognize its own practitioners as part-time magicians. Whenever a sugar pill works because it is given by the doctor, the sugar pill acts as a placebo. A placebo (Latin for "I will please") pleases not only the patient but the administering physician as well. The opportunities offered by the acceptance of suffering can be differently explained in each of the great traditions: as karma accumulated through past incarnations; as an invitation to Islam, the surrender to God; or as an opportunity for closer association with the Savior on the Cross. High religion stimulates personal responsibility for healing, sends ministers for sometimes pompous and sometimes effective consolation, provides saints as models, and usually provides a framework for the practice of folk medicine. In our kind of secular society religious organizations are left with only a small part of their former ritual healing roles. One devout Catholic might derive intimate strength from personal prayer, some marginal groups of recent arrivals in Sao Paolo might routinely heal their ulcers in Afro-Latin dance cults, and Indians in the valley of the Ganges still seek health in the singing of the Vedas. In these industrialized societies secular institutions run the major myth-making ceremonies. Common to a gnostic world-view and its cult are six characteristics: (1) it is practiced by members of a movement who are dissatisfied with the world as it is because they see it as intrinsically poorly organized. Its adherents are (2) convinced that salvation from this world is possible (3) at least for the elect and (4) can be brought about within the present generation.

These changes have been explained by the nuclearisation of the family in the urban context and the important role of the church in the social life of many people allergy treatment providers 5mg zyrtec overnight delivery. There are also signs of the weakening of ethnic boundaries in per sonal naming: a Zulu child may receive a Sotho name allergy shots for dust mites effective 5 mg zyrtec, for example (Suzman 1994 allergy medicine irritability order zyrtec pills in toronto, p allergy elimination zyrtec 5mg otc. It seems that more and more people also choose names which they find pleasant-sounding allergy shots frequency buy zyrtec australia, which is a new phenomenon in African personal naming (De Klerk & Bosch 1995 allergy testing aetna cheap zyrtec 5mg free shipping, p. It is reasonable to suggest that similar developments do and will characterise name-giving in other African societies, which are experi encing rapid urbanisation as well, even if they have not been researched as systematically as those in the South(ern) African context. All in all, it seems that African personal naming has come to resemble modern European naming in many respects, despite the fact that the names themselves are increasingly African. On the other hand, the criterion of name meaningfulness continues to distinguish these two systems (Herbert & Bogatsu 1990, p. Vermeersch (1977) presents an analysis of the definitions Kroeber and Kluckhohn took up, as well as of some later publications on this subject. On the other hand, many anthropologists have given up formulating such definitions. In order to show what culture is, they simply refer to examples of cultural behaviour. He pointed out that inventions, social order and intellectual life are not always equally devel oped in a society: there are people whose material culture is rather poor, but who have a highly complex social organisation, etc. As the steps of invention do not always follow in the same order and there are often important gaps in this devel opment, Boas (op. Therefore, manufactured clothes tend to replace home-made ones everywhere, and metal tools and weapons seldom fail to replace articles made of stone or wood. It is something much bigger and more significant than the speech of any individual person; it is a cumulative product of millions of individuals representing preced ing generations. Usually these typologies list the pos sible consequences of such contacts, varying from minor effects on the vocabu lary to the formation of new types of language. It is important to note that philosophers often look at personal names from a different viewpoint than linguists or onomasticians, and there has not been much coordination be tween these theories. He points out that an onomastic item could well be called a name under most or all of these circumstances. On all these levels, and normally on several or even all of them simultaneously, the name functions in the speech act of identifica tion which is the prerequisite for the speech act of recognition. For example, the Finnish lexicon is considered to contain only one personal name Heikki, even if there are thousands of men in Finland who have this name. On the other hand, the lexicon contains as many place names as there are places named, even if some of these names are similar in form. For this reason, it has been impossible to form a definition of a name which would cover both toponyms and anthroponyms. However, according to present understanding, there are no names that are not proper. Blanar 1996; Seibicke 1996; Van Langendonck 1995), but these turned out to be less helpful for this study. Kohlheim (1977b) applies the innovation theory to the study of the diffusion of onomastic innovations, such as the practice of naming children after saints in Medieval Europe. He analyses the stages of the onomastic diffusion process and the roles of social status and fashion in the acceptance of new personal names and name-giving practices. For example, gender is marked morphologically in the Romance personal naming systems. For example, the influence of English on personal names in Brasil is significant, even if the English language has not had much influence on the Portu guese language (Thonus 1991, p. In this study, we shall for example see how some Finnish missionaries have given their chil dren Ambo names. It is interesting to compare this list with the semantic categories of traditional Welsh names pre sented by Morgan (1995, p. Later on, however, as the names became established as names, and as they were repeated, their original meaning was no longer taken literally. It also seems that the original meaning of names was sometimes not obvious and had to be pointed out by scholars as it does today. In more modern times it has become customary for popes to adopt new names after their election. The latter group consists of names which include a confession or reflect trust, hope or gratitude. However, there are also many personal names in the Old Testament other than Hebrew ones, and the names in the New Testa ment are not exclusively of Greek origin either (Jenni 1996, p. In some cases, it is also used to refer to semantically transparent names which have religious meanings. The names of the rural population began to appear systematically in written documents in the 16th century only. Altogether, the calendars of the saints included names of Church fathers, martyrs, mystics, ascetics, founders of reli gious orders, local saints, etc. In Germany, Nikolaus was the patron saint of seamen and tradesmen, Hubertus that of hunters, Lukas of paint ers, etc. The eldest sons, who were the potential heirs to the throne, received Scandinavian names. The most popular names for women were Else, Gese, Alke, Margareta, Styne, Mette, Katharina, Gerdrut, Kunne and Fenne, and they were carried by 76 per cent of all women. At the end of the 16th century, 22 per cent of all men in Lippstadt were named Johann, and in the mid 18th century, 48 per cent of them had this name. Many Germanic personal names survived in the Middle Ages also because they were used by noble families (Wil son 1998, p. Altogether, there are many terms for different kinds of bynames in European languages. Often terms which look similar in meaning, may also cover different concepts in different languages. In English, for example, one can find the terms nickname, call name, hypocorism, petname, patronymic, surname, family name and last name, in German Beiname, Rufname, Spottname, Kosename, Spitzname, Zuname, Familienname and Geschlechtsname, in Afrikaans bynaam, noemnaam, roepnaam, familienaam and van, in Swedish tillnamn, binamn, smeknamn, oknamn, vedernamn, patronym and slaktnamn, and in Finn ish lisanimi, lempinimi, kutsumanimi, patronyymi and sukunimi. Similarly, Afri can languages have various terms for these names, which are often difficult to translate into European languages. However, it might be justified to use this term also in cases where a person has consciously adopted for him/herself a surname, even if it has not yet been in use for two or more generations. In this study, the term surname is thus under stood in the way suggested by Paikkala (1995, p. It is interesting to note that there are also broader definitions of a surname in the ono mastic literature. Hence, he sees that the Baptist in John the Baptist is a byname that functions as a surname. In Finland, fashion be came an important aspect of personal naming in the 15th and 16th centuries, and in the late 20th century, naming fashions began to change rapidly (Kiviniemi 1993, p. The celebration of name days most probably spread from the Catholic Germany to Sweden and Finland already before the Reformation (Blomqvist 1998, p. The new naming pattern was adopted first in the royal family and among the nobility. Examples of these are: Abell 1992, Asante 1991, Chuks-Orji 1972, Madubuike 1976, and Osuntoki 1970. Some Afri can researchers, however, emphasise the cultural unity of Africa and accuse West ern intellectuals of seeing the cultural diversity of Africa only. Petunia and Ruby, the relationship of these names to their sources is different from that of meaningful African names. They provide a window into the Igbo world of values as well as their peculiar conceptual apparatus for dealing with life. In most societies, no preparations, including choice of name, are made before the arrival of a new child (Ayisi 1988, p. An Akan child, for example, receives two names as soon as he or she is born: the name of the day of the birth and an associated byname that goes together with the day-name. Names indicating that the mother feels more secure in her marriage after the birth of the child, and 7. The name may be chosen to break some evil spell which has caused the death of previous children (derogatory-protective names). In many societies, one or both of them, or the mother, were systematically killed. African languages also have their own terminologies for different kinds of names, which are not easily translatable into European languages. A good example of this is the Ndebele term isibongo (plural izibongo), which has been translated into English in different sources as surname, clan name, totem name and praise name (Lindgren 1998, p. Nicknames are not formal or regularized name com ponents, but rather are informal and unofficial names. Throughout the years a man has several ox-names in succession as his favourites change. As between clansmen and others who see each other daily, they are most commonly used the whole time. Already during the first centuries of the Church, Christianity spread to northern Africa, Egypt, the Sudan and Ethiopia. Hence, Christianity arrived in Africa earlier than Islam, which started to spread there in the 7th century. The influence of Christianity on sub-Saharan Africa as a whole has also been much greater than that of Islam since the colonial period (Herskovits 1967, p. Usually conversion is a long-term process in which new ideas are gradu ally mixed with the old (Peil & Oyeneye 1998, p. In any conversion, there must also be a fair amount of continuity between the old and new beliefs (Kirby 1994, p. Decisions about religious life are often linked to politics as well (Saunders 1988a, p. From a practical viewpoint, it has been stated that the greatest contribution to the spread of Christianity was made by the introduction of education by the missionaries: many Africans came into contact with Christianity in schools. Hence English names were adopted as a compromise for example among the Xhosa speakers in South Africa (Neethling 1995, p. This book may not be well-known among onomasticians, but it offers fascinating material on the semantics of African baptismal names. Beside personal names, place names were also changed: Leopoldville became Kinshasa and Stanleyville, Kinsangani (Gregersen 1977, p. Altogether, it is often impossible to find out if the African sources really mean hereditary surnames when they use the term surname. Tradition ally, Zulu praises were used in rural communities especially in courting, dancing and fighting contexts. In urban environments, modern forms were created, for example, football and boxing praises. It has also been noted that derogatory-protective names are extremely rare among urban residents in South Africa (De Klerk & Bosch 1995, p. Among the Yoruba people, there is also a tendency to use positive names and avoid the derogatory connotations of traditional names (Akinnaso 1983, p. The country is bordered by Angola to the north, Zambia and Zimbabwe to the northeast, Botswana to the east, and South Africa to the south. Topographically, the land is divided into three regions: the Namib Desert, the Central Plateau, and the Kalahari Desert. It is almost uninhabited, but its enormous riches have made Namibia one of the largest producers of gem diamonds in the world. The Central Plateau is a savannah and bush area, covering more than half of the country. The northern part of the plateau is suitable for cattle-grazing, and the southern part provides ex cellent pasture land for the Karakul sheep. Its mountain ranges also con tain substantial mineral deposits as well as semi-precious stones.

It tends to occur in sion allergy symptoms ginger buy generic zyrtec online, whereas atenolol is more convenient with oncewomen between the ages of 20 and 40 allergy shots twice a week buy generic zyrtec 10 mg online, with an incidaily dosing allergy symptoms low pollen count order cheap zyrtec on-line. Infiltrative ophthalmopathy is by far the most gland and are generally used to restore the patient to common sign allergy forecast oahu purchase 10mg zyrtec with mastercard. For unclear reasons allergy medicine kidney buy zyrtec 5 mg on line, increased inflammathe euthyroid state before deciding on long-term mantion and the accumulation of glycosaminoglycans cause agement allergy symptoms 2 year old purchase 10mg zyrtec overnight delivery. Methimazole has the advantage of once-daily swelling of extraocular and retroorbital muscles, as well as dosing with no risk of irreversible hepatitis, a rare side displacement of the eye forward (also known as proptosis effect of propylthiouracil therapy. Also, in patients for whom 131I treatment is planned, methimazole is preferor exophthalmos). Patients can experience eye irritation; excessive tearing worsened by cold air, bright lights, or able to propylthiouracil because propylthiouracil may wind; diplopia; blurred vision; and, rarely, loss of vision. The extrathyroidal maniPropylthiouracil (but not methimazole) blocks the festations often have a course independent of the thyperipheral conversion of T4 to T3 and is traditionally roid disease itself and can persist despite restoration of the euthyroid state. It also is more protein bound and is therefore the preferred drug Laboratory Tests in pregnancy and during breastfeeding. If the white blood cell count is normal, twice daily for the 2 weeks before surgery. Most patients arthritis with both drugs; cholestatic jaundice with methrequire hormone replacement therapy postoperatively. It occurs in patients with inadequately the size of the gland, and the potential for a future pregcontrolled thyrotoxicosis who undergo surgery, radioacnancy. In the one randomized trial that assessed the effitive iodine treatment, parturition, and severe stressful illcacy of drug treatment, radioablation, and surgery, all nesses such as infections, uncontrolled diabetes, and three modalities were found to be equally effective. This disorder results from hyperever, there are several guidelines for choosing a treatment metabolism and excessive adrenergic response. Cardiac symptoms and signs include for long-term therapy, particularly in adolescents and tachycardia, atrial fibrillation, and congestive cardiac failyoung patients with small glands and less severe disease. Neurologic symptoms and signs include agitation, the drug is usually given for up to 18 months to allow restlessness, delirium, and coma. In contrast, because it partially blocks peripheral T4 to T3 converonly 22% and 11% of European and Japanese thyroid sion. Patients with severe hyperthyroidism, serious thyroid can be retarded by giving an oral, saturated solution of enlargement, or a history of heart disease should be adepotassium iodide (10 drops twice daily). The oral cholequately returned to the euthyroid state with methimazole cystographic agents (sodium ipodate or iopanoic acid) prior to radioablation, with methimazole discontinued similarly retard hormone release and also potently about 5 days prior to radioablation. Most patients subseblock T4 to T c3 onversion, but they are not currently quently become hypothyroid and require thyroid hormone available in the United States. Supnancy, and it is important to advise women who may portive measures include intravenous fluids and the manbecome pregnant in the near future that they should wait agement of electrolytes and nutrition. Patients should be given thionamides gaze; (5) Class 5, corneal involvement (eg, keratitis); and until a euthyroid state is achieved (approximately 6 weeks), (6) Class 6, visual loss due to optic nerve involvement. Most patients have mild disease; one study found that approximately 65% of patients treated Etiology & Clinical Findings with thionamide therapy alone had no progression of eye disease, and only 8% demonstrated deterioration. There are two etiologies responsible for hyperthyroidism Restoration of the euthyroid state can be achieved by that manifests in the setting of amiodarone: (1) excess thionamide therapy, radioablation, and surgery. Radioiodine in an underlying abnormal gland causes excessive ablation can aggravate the ophthalmopathy, especially in hormone production; and (2) thyroiditis caused by amiosmokers. However, most patients may alleviating corneal irritation and wearing dark glasses. Surgical decompression is warranted for progressive eye disease despite gluTreatment cocorticoids, optic nerve changes, corneal ulceration or Patients may be treated with higher-dose thionamides, infection, and cosmetic reconstruction. If there is inadequate control, a 40-mg daily a medical emergency; the patient should be treated with dose of prednisone is often helpful, especially in cases of high-dose glucocorticoids and surgical decompression. Total thyroidectomy should be considered since it is curative, but patients Bartalena L, Marcocci C, Bogazzi F et al. Treatment of hyperthySubacute granulomatous thyroiditis is an acute inflamroidism with radioactive iodine. Endocrinol Metab Clin North matory disorder of the thyroid gland presumed to be Am. Subacute granulomatous thyof radioactive iodine in treating various hyperthyroid states. Patients need a changing pattern of thyHyperthyroidism roid function tests throughout the course of the disease. General Considerations the failure of thyroid hormone production results in a Diagnosis generalized hypometabolic state and seriously impairs normal growth and development if it occurs early in the diagnosis of subacute thyroiditis is made clinically. Hypothalamic dysfunction, resulting laboratory findings include negative thyroid autoantibodies. Rare Forms of Thyrotoxicosis ized by lymphocytic infiltration, destruction of thyroid A. Thyroperoxidase antiwhich patients purposely take thyroid hormones, usubodies remain positive for many years and are useful for ally for weight control. Causes of hypothyroidism Teratoma of the ovaries may contain functioning thyroid tissue, which results in hyperthyroidism. Excessive iodide intake (kelp, radiocontrast dyes) as in the presence of metastatic disease, follicular carci4. Subacute lymphocytic thyroiditis body scan usually shows an increased uptake in the b. Lithium, antithyroid drugs (methimazole, propylthiouracil); (rare) Hydatidiform moles do not produce thyroid hor6. Clinical evidence of Secondary Hypothyroidism hyperthyroidism is usually not present, but a labora1. Signs and symptoms the half-life of T4 is long, it is not a problem omitting of hypothyroidism. Alternately, the patient can be given parenteral L-thyroxine at 75% of the usual oral dose. It tends to occur in elderly patients and Hoarseness Muscle stiffness, proximal weakness is frequently fatal (> 20% incidence). The diagnosis is often difficult because the coma and Diagnosis hypothermia may be due to other causes, such as stroke. Treatment Secondary hypothyroidism may also present with other signs of pituitary deficiency, including hypogonadism Treatment consists of L-thyroxine administered intraveand adrenal insufficiency. Ventilatory support may be required Treatment for hypoventilation and hypercarbia. Hyponatremia is Treatment involves hormone replacement with L-thytreated with fluid restriction. Active rewarming is contraroxine; the average replacement dosage in adults is 1. Myxedema coma: pathophysiology, therapy, and factors patients should be monitored once or twice a year affecting prognosis. Children who receive ionizing radiation (as little as 10 cGy) are more likely to develop thyroid carcinoma later in life than General Considerations adults who receive equal amounts of ionizing radiation. Thyroid cancer, moreover, have a significantly higher prevalence of thyroid carcinoma makes up 92% of endocrine gland cancers and accounts than do control groups. The sporadic form of medullary thyroid to thyroid cancer each year in the United States, makcancer tends to be unilateral, and the familial form is ing it one of the more survivable cancers. Poorly differadenomatous polyposis, Gardner syndrome, and Cowden entiated thyroid cancers are seen in equal proportions syndrome. The spectrum of malignant thyroid disorders ranges Clinical Findings from very indolent tumors, such as most papillary carciA. Papillary carcinoma typUsually, the only presenting symptom of a patient with ically is seen in young adults and often metastasizes thyroid cancer is the presence of a palpable thyroid mass regionally to the lymphatics of the neck. It is unusual for presence of regional metastasis, however, patients with these masses to be symptomatic. Conpresent with more problematic symptoms and signs, versely, patients are typically in their sixth or seventh which alert the physician to the possibility of a malignant decade when a diagnosis of anaplastic thyroid cancer is condition. Only 10% of patients with anaplastic thyroid ness, localized or referred pain, dysphagia, shortness of cancer will survive one year after the diagnosis, with a breath, hemoptysis, and a hard, fixed thyroid nodule or median survival of approximately 6 months. Although these symptoms may also occur with benign disease, their presence increases the suspiPathogenesis cion of a malignant growth. The physical examination of patients with possible the two types of cells found in thyroid gland tissue thyroid cancer should include a thorough examination include the neuroendocrine calcitonin-producing C cell of the head and neck. Laryngoscopy is essential to eval(the parafollicular cell) and the follicular cell, derived uate vocal cord function because invasive cancers can from the endoderm, which synthesizes thyroglobulin. Papillary carcinoma, follicular carcinoma, Hurthle preexisting functional abnormalities of the vocal cords cell carcinoma, and anaplastic carcinoma are derived prior to thyroidectomy. Radionuclide imaging with radioiodine (131I) demonstrates the ability of the thyroid nodule to concentrate iodine. Incidence of Local Incidence of Distant Stage Age < 45 Age > 45 Recurrence Recurrence Mortality I Any T Any N M0 T1 N0 M0 5. In this system, with calcifications, intranuclear vacuoles, and psampatients are classified as either low-risk with a mortalmoma bodies. The follicular the most common malignant neoplasm of the thyroid variant of papillary carcinoma has a similar behavior to gland is papillary carcinoma, which represents approxiclassic papillary carcinoma. Papillary carciTreatment of papillary carcinoma is thyroidectomy noma, a well-differentiated carcinoma, arises from thyas well as the removal of regional neck nodes by selecroid follicular cells. Women are affected two to three tive neck dissection when lymph nodes are involved. The advantages found in both lobes of the thyroid up to 80% of the of total thyroidectomy include a decreased recurrence time. A multifocal presentation is particularly common rate and the ability to use thyroglobulin and radioactive in patients with prior low-dose radiation therapy to the iodine scans for the diagnosis of recurrent disease postneck. In 40% of patients present with cervical or mediastinal addition, all patients with well-differentiated thyroid metastases at the time of the initial diagnosis. Despite carcinomas should be treated indefinitely with suppresthe high incidence of cervical metastases, their presence sive doses of L-thyroxine (levothyroxine). Follicular carcinoma, like papillary carcinoma, is another well-differentiated thyroid carcinoma. Medullary thyroid carcinoma originates from the parafolEven though papillary carcinoma is associated with a licular cells (C cells) of the thyroid. Approximately the 10-year survival rate is approximately 85% and the 75% of medullary carcinomas occur sporadically, but 25% 20-year survival rate is approximately 70%. The mean survival rate for ways and tends to spread to the lungs, liver, and bone. Histologically, follicular carcinoma can be difficult Regional lymph node involvement is common (50%). Approximately 70% of patients with Surgery is the only effective therapy for medullary carHurthle cell carcinoma present with intrathyroid disease cinoma. Before surgery, it is important to rule out a conalone, 20% with regional cervical lymph node metastasis, comitant pheochromocytoma. The treatment of central neck dissection are recommended for all patients Hurthle cell carcinoma is total thyroidectomy. An ipsilateral selective neck diswith regional metastases require selective neck dissection.

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