By M. Grimboll. Pontifical University. 2018.

Say that we think people will make more mistakes when recalling a long list of words than when recall- ing a short list buy oxybutynin 5 mg online. For each participant order 5mg oxybutynin free shipping, we measure the dependent vari- able of number of errors made in recalling the list purchase oxybutynin 2.5 mg overnight delivery. A relationship is present here because a different and higher set of error scores occurs in each condition. Most experi- ments involve a much larger N, however, so to see the relationship buried in the raw scores, we compute a measure of central tendency. In our memory experiment, the variable of recall errors is a ratio variable that is as- sumed to form an approximately normal distribution. Therefore, we compute the mean score in each condition by computing the mean of the scores in each column. There- fore, to interpret the mean in any study, simply envision the scores that would typi- cally produce such a mean. For example, when X 5 3, envision a normal distribution of scores above and below 3, with most scores close to 3. Likewise, for each mean, essentially envision the kinds of raw scores shown in our columns. Thus, the means show that recalling a 5-item list resulted in one distribution located around three er- rors, but recalling a 10-item list produced a different distribution at around six errors, and recalling a 15-item list produced still another distribution at around nine errors. Further, we use the mean score to describe the individual scores in each condition. In Condition 1, for example, we’d predict that any participant would make about three errors. Most important is the fact that, by looking at the means alone, we see that a rela- tionship is present here: as the conditions change (from 5 to 10 to 15 items in a list), the scores on the dependent variable also change (from around 3, to around 6, to around 9 errors, respectively). For example, we might find that only the mean in the 5-item condition is different from the mean in the 15-item condition. We still have a relationship if, at least sometimes, as the conditions of the independent variable change, the dependent scores also change. For example, say that we study political party affiliation as a function of a person’s year in college. Our dependent variable is political party, a nominal variable, so the mode is the appropriate measure of central tendency. We might see that freshmen most often claim to be Republican, but the mode for sophomores is Democrat; for juniors, Socialist; and for seniors, Communist. These data reflect a relationship because they indicate that as college level changes, political affiliation tends to change. This tells us that the location Participants Recalling a of the distribution of incomes is dif- 5-, 10-, or 15-Item List ferent for each class, so we know The mean of each condition 4 that the income “scores” of individ- is under each column. Summarizing Research 75 Graphing the Results of an Experiment Recall that the independent variable involves the conditions “given” to participants so it is plotted on the X axis. However, be- cause we want to summarize the data, usually we do not plot the individual scores. Rather, we plot either the mean, median, or mode of the dependent scores from each condition. Note: Do not be confused by the fact that we use X to represent the scores when computing the means. The type of graph to select is determined by the characteristics of the independent variable. Line Graphs Create a line graph when the independent variable is an interval or a ratio variable. We use straight lines to connect the data points here for the same reason we did when producing polygons: Anytime the variable on the X axis in- volves an interval or ratio scale, we assume that it is a continuous variable and there- fore we draw lines. The lines show that the relationship continues between the points shown on the X axis. For example, we assume that if there had been a 6-item list, the mean error score would fall on the line connecting the means for the 5- and 10-item lists. Each mean implies a sample of scores and their corresponding data points are around—above and below—the mean’s data point. Because the vertical positions of the means change as the conditions change, we know that the raw scores also change, so a relationship is present. Notice that you can easily spot such a relationship because the different means pro- duce a line graph that is not horizontal. On any graph, if the summary data points form a line that is not horizontal, it indicates that the individual Y scores are changing as the X scores change, so a relationship is present.

Its whole- ness really doesn’t matter buy oxybutynin 2.5 mg online, though I must admit I think sometimes the whole grain is more reactive than white flour foods buy 2.5mg oxybutynin with mastercard, which are less nutritious buy cheap oxybutynin 5mg online. People are really attached to bread and a lot of refined wheat confectionary foods (crackers, pastries, pretzels, etc. Interestingly, if you ate a traditional rice-based Asian diet, you would not even think about dairy prod- ucts and wheat in bread. Wheat, like dairy products, contain opioid compounds: gliado (or gluteo) morphin or exorphins. Exorphins are found in food proteins, while endorphins, the “feel good” neuro- chemicals, are made within the body. These exorphins, opioid-like peptides (small chains of amino acids), can alter neuron function in the brain. The gliado- and casomorphin (milk opioid) com- pounds can also trigger inflammation in the gut, making it more permeable (intestinal permeability). This can allow for a variety of components from the intestinal tract to be absorbed and trigger a reaction that results in a systemic complaint, meaning somewhere else in your body (e. I choose the term “food intolerance” because there is no single good definition of food allergy that includes all reactions to foods. When most allergists say food allergy, they generally mean an IgE mediated response. Patients usually know their IgE mediated reactions because they are generally quite obvious. Subsequently many allergists say the suffering individual does not have food allergies. This is why I use “food intolerance” as a catch-all definition for any reaction to a food instead of using the term “food allergy. Testing for Food Intolerance Testing for food allergy or intolerance is controversial and de- batable. When I talk to patients, I tell them there is no one test that can test for all the ways their body reacts to foods. For example, if ten foods showed up on whatever allergy test you take as positive and only three are true reactants, but you - 117 - staying healthy in the fast lane eliminate all ten foods, you will still have improvement in some of your symptoms (e. The key to any food intolerance test is to eliminate the foods that are positive reactors and reintroduce the most com- monly eaten foods first so you can identify which foods are the most significant offenders. I tell patients that if you eat garbanzo beans once a month but you have daily head- aches, the garbanzo bean is probably not the major problem food, even if it is a true reactant. Focus on the foods you are eating three or more times per week first for reintroduction. A very important point is that just because a food doesn’t show up on the test doesn’t necessarily mean you are not sensitive to it. If you feel bad after eating, it is the food until proven otherwise— positive test or not. The Basic Elimination Diet (see Appendix A), or what I call the “Poor Person’s Food Allergy Test,” was designed to eliminate many of the classic allergens such as dairy, wheat, glutinous grains (oat, barley, rye), corn, eggs, yeast, chocolate, tomato, citrus, peanuts, nightshade family (potatoes, tomatoes, eggplant, peppers, etc. All you do is fill up your refrigerator and cupboards with these foods in their whole state and eat away for two to four weeks. See how you feel and chart your symptoms on the Diet-Exercise-Symptom Diary (see Educational Handouts at Prescription2000. After at least two weeks (preferably one month), add in foods one at a time, a day or so apart, starting with the most frequently eaten. If there is a reaction within twenty-four hours, eliminate the food again, this time for three months, and then try it again. If done right, you may save thousands of dollars not only on allergy test- ing but on your overall health as well. Food intolerance can cause, aggravate, be part of, or be the total cause of symptoms that people have been living with for years. I can’t tell you how many times I have asked people what they - 118 - food intolerance and allergies eat for breakfast, lunch, dinner, and snacks, what they drink and crave, and some of those “biggies” come up (dairy, wheat, sugar, etc. Many times, these patients have gone from doctor to doctor, including specialists, and no one has ever simply asked them what they eat or suggested that food could be a problem. Simply eliminating just one of those foods can sometimes make a profound difference. Remember this: Be will- ing to look at the foods you commonly eat—those you eat daily or really like—if you have a chronic problem. All these things can trigger neuroendocrine and immunologic pathways that cause abnormal or hyper responses to the environ- ment.

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Family adjustment to a deaf child in a bilingual bicul- Commission buy oxybutynin 2.5mg amex, Fifth Framework Programme discount oxybutynin 2.5mg overnight delivery, Quality of Life and tural environment safe oxybutynin 5 mg. Raising and educating a deaf child: a comprehen- for any use that might be made of data appearing therein. The Effects of ily history of hearing difficulties in an epidemiological study of Having a Family History of Hearing Impairment. In: Stephens D, Jones impairment effect help seeking behaviour and attitudes to reha- L, eds. The Effects of Having a Family ily History of Hearing Impairment on rehabilitative intervention: History of Hearing Impairment. The Effects of Having a Family History of Hearing Impair- l’audition 2004; 17:34–40. Effects of a history of hearing prob- Psychometric Normalization of Hyperacusis Questionnaire. The Effects hearing problems on those with hearing difficulties themselves: an of Having a Family History of Hearing Impairment. Kennedy V, Chéry-Croze S, Stephens D, Kramer S, Thai-Van H, late onset hearing impairment: results of an open-ended question- Collet L. In: Stephens D, Jones L, tion Questionnaire: psychometric properties of a measure of distress eds. The Effects of Having a Family History of Hearing Impair- associated with tinnitus. In: meaning of illness in severe otosclerosis: a descriptive study in Stephens D, Jones L, eds. The Effects of Having a Family History three steps based on focus group interviews and written question- of Hearing Impairment. The Effects of aspects of Neurofibromatosis type 2 reported by relatives/ signifi- Having a Family History of Hearing Impairment. My family history of hearing loss made me aware of the danger of social isolation. Because of my family history, I didn’t think my hearing loss important enough to do anything about my own hearing loss. Having a family history of hearing loss made me determined not to ignore the problem. Having a family history of hearing loss made me more aware of other people with hearing problems. Having a family history of hearing loss made me more fatalistic about my hearing problems. A history of hearing loss in the family made me realise the need to be open about my problems so others can help. My experience of a history of hearing loss in the family gave me empathy with people who would possibly find it irritating if I continually asked for repetition or rephrasing. I am not worried about using a hearing aid as I know how much of a problem it is for others without one. Had I not known of my relatives’ deafness, I think I would continually be casting round for the cause of my own problems. I had some comfort from the fact my family had coped in more difficult circumstances. My family history of hearing problems made me aware of the problem and prompted me to seek help sooner. For exam- mented the lay understanding of genetics (1,2) and has looked ple, a cochlear implant or hearing aid aims to restore hearing as at case-study discussion of the experience of living with a much as possible, with the view that to be hearing is the preferred genetic disorder (3). However, this perspective is in stark con- explore the experience and specific demands that deaf patients trast to the way deafness is viewed as part of the “cultural” model. Within this, deafness is not a disability, but rather an experience This chapter provides an overview of some of the research that is just different, and certainly not defective. Here, the main that has been done to investigate the attitude of deaf people and form of communication is often sign language. Before this is sider themselves “culturally Deaf” (written with an upper case D) covered, it is introduced with an overview of the different per- will often not perceive that they have a disability or impairment. This is followed by more practical sections They feel positive and empowered by their language and have a on genetic testing services and what happens within genetic strong Deaf identity (4). Then, a brief summary is given on the historical con- many other Deaf people (5,6). Deaf identity evolves over time, text to issues surrounding genetics, eugenics, and deaf people. These people may come from fami- quences may vary, and this may impact in different ways on the lies where there are several relatives who are deaf. Deaf people may have to alter culture” exists in many countries across the World, e.

Biomarkers and some of the other methods for guiding therapy of asthma are described here discount 2.5mg oxybutynin with visa. Biomarkers of Asthma Although the aim of management of patients with asthma is to control their symp- toms and prevent exacerbations and morbidity of the disease discount oxybutynin 5 mg otc, optimal management may require assessment and monitoring of biomarkers generic oxybutynin 5 mg line, i. Universal Free E-Book Store 516 15 Personalized Management of Pulmonary Disorders Biomarker for Rhinovirus-Induced Asthma Exacerbation Clinical observations suggest that rhinovirus infection induces a specific inflamma- tory response in predisposed individuals that results in worsened asthmatic symp- toms and increased airway inflammation. Biomarkers for Predicting Response to Corticosteroid Therapy International guidelines on the management of asthma support the early introduction of corticosteroids to control symptoms and to improve lung function by reducing airway inflammation. However, not all individuals respond to corticosteroids to the same extent and it would be a desirable to be able to predict the response to cortico- steroid treatment. Several biomarkers have been assessed following treatment with corticosteroids including measures of lung function, peripheral blood and sputum indices of inflammation, exhaled gases and breath condensates. Of these, sputum eosinophilia has been demonstrated to be the best predictor of a short-term response to corticoste- roids. More importantly, directing treatment at normalizing the sputum eosinophil count can substantially reduce severe exacerbations. The widespread utilization of sputum induction is hampered because the procedure is relatively labor intensive. The challenge now is to either simplify the measurement of a sputum eosinophilia or to identify another inflammatory marker with a similar efficacy as the sputum eosino- phil count in predicting both the short- and long-term responses to corticosteroids. Cytokines as Biomarkers of Asthma Severity Severe asthma is characterized by elevated levels of proinflammatory cytokines and neutrophilic inflammation in the airways. Blood cytokines, biomarkers of systemic inflammation, may be a feature of increased inflammation in severe asthma. Cytokine levels were elevated even though the patients were on high-dose inhaled steroids. This finding might reflect the inability of these drugs to significantly suppress pro- duction of this cytokine by airway cellular sources including epithelial cells and inflammatory cells. Inflammation plays a central role in the pathogenesis of asthma and much of it can be attributed to helper T cell type 2 cytokine activation, the degree of which strongly correlates to disease severity. This study also highlights the relationship between poor control of asthma and Calv (a biomarker of alveolar inflammation) but further work is needed to confirm the relevance of this. Researchers at the University of Pittsburgh, Pennsylvania, have developed a novel nanosensor that can detect a possible asthma attack before it begins. Use of this device would provide asthma sufferers with a simple and cost effective way to monitor their asthma inflammation. Reduced arginine Universal Free E-Book Store 518 15 Personalized Management of Pulmonary Disorders availability may also contribute to lung injury by promoting formation of cytotoxic radicals such as peroxynitrite. Plasma arginase activity declines significantly with treatment and improvement of symptoms. Additional studies are needed to determine whether measurements of plasma arginase activity will provide a useful biomarker for underlying metabolic dis- order and efficacy of treatment for this disease. The arginase activity present in serum probably does not accurately reflect whole body arginase activity or that compartmen- talized in the lungs, since the arginases are intracellular enzymes. Because arginase is induced in monocytes in response to helper T cell type 2 cytokines, it is speculated that these cells are one likely source of the elevated arginase in serum, consistent with the localization of arginase expression within macrophages in the lungs. Endothelin-1 in Exhaled Breath as Biomarker of Asthma Endothelins are proinflammatory, profibrotic, broncho- and vasoconstrictive pep- tides, which play an important role in the development of airway inflammation and remodeling in asthma. IgE as a Biomarker to Guide Dosing of Omalizumab for Asthma IgE plays a central role in the pathophysiology of asthma. The two essential phases in this pathophysiology are sensitization to allergen and clinical expression of symptoms on reexposure to the sensitizing allergen. Omalizumab (Xolair, Genentech) is a recombinant humanized IgG1 monoclonal anti-IgE antibody that Universal Free E-Book Store Personalized Therapy of Asthma 519 binds to circulating IgE, regardless of allergen specificity, forming small, biologi- cally inert IgE–anti-IgE complexes without activating the complement cascade. A total serum IgE level should be measured in all patients who are being considered for treatment with omalizumab, because the dose of omalizumab is determined on the basis of the IgE level and body weight (Strunk and Bloomberg 2006). Genotyping in Asthma Several clinical trials have highlighted the effects of genotype on response to asthma therapy. Various publications have described the potential of using genotyping as a tool to develop individualized patient treatment regimens for asthma to improve results and limit adverse effects of certain therapies (Lugogo et al. Recently, a naturally occurring gene mutation has been identified encoding a member of enzymes that appear to be important in the innate immune response and is present in 5–10 % of the normal population. This role of this mutation has been studied in host immunity to para- sitic infections. With the rapid progress in the identification of genes involved in various ethnic populations combined with the availability in future of well-targeted drugs, it will be possible to prescribe appropriate medicines for the genetic make-up of an individual. Collaborative, retrospective, observational health outcomes studies that combine pharmacy, medical claims and genotyping data for participating managed care patients with asthma are focusing on assessing the impact of common genetic varia- tions on clinical outcomes and health care resource utilization for patients using drugs commonly employed for the management of asthma. The results of such stud- ies may provide data indicating whether physicians should consider alternative regi- mens to improve management of asthma patients with genetic variations. Genotyping of individuals at high risk of developing asthma will enable asthma risk stratifica- tion for therapeutic measures to be implemented.

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Experimentally generic oxybutynin 2.5 mg with visa, reactivating virus can be shown to migrate centrally purchase oxybutynin 5mg online, affecting the medial temporal and frontal lobes 2.5mg oxybutynin with visa, the primary site of involvement in herpes simplex encephalitis. Two important (and probably interrelated) functions of the medial temporal lobes are olfaction and memory. Early manifestations of this necrotizing, localized infection often consist of focal seizures manifest as olfactory hallucinations and perceptions of deja vu or jamais vu. Often a diagnosis is not made´ ` until the patient has a generalized or at least focal motor seizure. The diagnosis should be considered in a previously healthy individual with abrupt onset of altered mental status and fever; headache is present in most. Since other brain infections can be clinically similar, confirmatory testing is necessary. Its major complication is renal toxicity; this risk can be decreased with aggressive hydration. The role of steroids is unclear, without substantial evidence supporting their use. Other Herpes Viruses Neurologic complications used to accompany about 1 of every 10,000 cases of chickenpox (19). Cytomegalovirus can cause 160 Halperin ventriculoencephalitis and dementia in the immunocompromised. Ebstein–Barr virus has been associated with a similar clinical picture, but has not been shown to respond to acyclovir or other antivirals. Unlike herpes, West Nile is one of the large group of diseases referred to as arthropod borne, or arboviruses. West Nile appears to have been brought to the United States by infected birds and was originally recognized for being highly lethal in some but not all bird species. Key to the transmissibility of any of these infections is its production of prolonged viremia in some host species, and the presence of mosquitoes or other vectors that feed on both the infected reservoir species and on humans (22). This interspecies promiscuity is essential to the transmission of this large group of pathogens, which can persist in the environment in reservoir hosts, and periodically infect humans when a large group of nonimmune individuals is exposed. Since there are hundreds of asymptomatic or minimally symptomatic infections for every neuroinvasive case, “herd immunity” normally takes over after the infection is present in the environment for a period of time—presumably the reason the incidence of cases has moved like a wave across the United States from east to west since its initial introduction. West Nile is a flavivirus (the family that includes and is named for Yellow Fever virus), a broad group that includes dengue, tick borne encephalitis, Japanese encephalitis, and St. In the Middle East, serologic studies indicate up to 40% of the population has had asymptomatic infection. Disease severity increases with age, with most mortality occurring in individuals over 50. Neuroinvasive disease causes meningitis; a polio-like syndrome of flaccid lower motor neuron–type weakness occurs in about half. Involvement of the brainstem and basal ganglia appears to be common with extrapyramidal syndromes, tremors and ataxia occurring with some frequency. Rabies Fortunately human rabies is extremely rare in the United States, with typically 1 case per year nationwide. However there is a significant incidence among animals, and when human cases occur, there often is some delay in diagnosis, resulting in additional individuals being exposed, and then requiring prophylaxis. Transmission requires transfer of virus-containing secretions or tissue through mucosa or broken skin. Since the virus has an affinity for the muscle endplates, infection is particularly efficient when a bite introduces the virus directly into muscle. Once introduced, virions are transported within axons to the dorsal root ganglion neurons and multiply, then on to the spinal cord and brainstem. Once the virus is in the nervous system, patients develop fever, anxiety, muscle aches, and nonspecific symptoms. Neuropathic symptoms ranging from itching to pain may develop at the inoculation site. In the former, patients develop a Guillain Barre–like picture, with fever, sensory and motor symptoms, facial involvement, and sphincter dysfunction. More common is the encephalitic form in which patients develop inspiratory spasms, precipitated by any Encephalitis and Its Mimics in Critical Care 161 contact with the face, including trying to drink (hydrophobia). Hallucinations and fluctuating consciousness proceed to coma, paralysis, and death within a week. Immunofluorescence can often detect virus in nerve twigs surrounding hair follicles in skin biopsied from the nape of the neck. Despite numerous attempts at treatment, only one or two individuals have survived (24). Confusional states in septic patients—even with sources as localized as urinary tract infections or pneumonia—are so commonplace that clinicians rarely question the underlying pathophysiology.

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Also known legs syndrome discount 5 mg oxybutynin, and sleepwalking are also sleep dis- as oat-cell lung cancer purchase oxybutynin 5mg with amex. See also sleep apnea; smallpox A highly contagious and frequently fatal sleepwalking; snoring cheap 5mg oxybutynin visa. Because of its high case-fatality rates and not always including walking, while in a deep stage transmissibility and because people haven’t been of sleep. Sleepwalking occurs most frequently in vaccinated against it in years, smallpox now repre- children, particularly boys. The incubation period is measures are preventive: Ensure that the sleep- about 12 days (range: 7–17 days) following expo- walker is in a safe room for walking and cannot sure. Initial symptoms include high fever, fatigue, accidentally fall through an open window or down headaches, and backaches. Some types of sleepwalking are related to most prominent on the face, arms, and legs, follows seizure disorders, bipolar disorders, and other neu- in 2 to 3 days. The rash starts with flat red lesions rological conditions, but most cases are transitory that evolve in 2 to 3 days. The majority of patients with smallpox slipped capital femoral epiphysis A condition recover, but death occurs in up to 30 percent of in which the growth plate of the femur is pushed out cases. Persons with smallpox are most the level of the heart, and the bite victim should be infectious during the first week of illness because taken to the nearest hospital. A tourniquet or band- that is when the largest amount of virus is present in age should not be used on a snakebite, and no one saliva. However, some risk of transmission lasts should attempt to suction out the wound by mouth. Treatment involves use of antivenom and care for the puncture wound itself and any symptoms that smallpox vaccine A vaccine that contains a live emerge, such as respiratory distress. The vaccine does not contain the variola virus that causes smallpox, but exposes the immune sys- Snellen chart See chart, Snellen. Through the use of the snoring A sound created by vibrations of the vaccine, smallpox was eliminated from causing uvula and soft palate during sleep. Routine vac- breathing, air passing through the throat en route to cination against smallpox ended in 1972. The level the lungs travels by the tongue, soft palate, uvula, of immunity among persons who were vaccinated and tonsils. In people exposed to the back of the throat tighten to hold these struc- smallpox who are not immune to the disease, the tures in place and prevent them from collapsing and vaccine can lessen the severity of or even prevent vibrating in the airway. Otherwise, patients who snore may want to try different sleep positions, nose clips, or similar smell The sense that provides information about steps to prevent unwanted snoring. See also sleep an object’s scent, often giving clues to the palatabil- apnea, obstructive; somnoplasty. The organs of smell are made up of patches of tissue social phobia A paralyzing fear of interacting called the olfactory membranes that are each about with others. These membranes are sweating, trembling, rapid heartbeat, muscle ten- located in a pair of clefts just under the bridge of the sion, nausea, and extreme anxiety. Most air breathed in normally flows through can occur in very young children or emerge at a the nose, but only a small part reaches the olfactory later age. It can be disabling to a person’s work and clefts—just enough to get a response to an odor. Many people with When a person sniffs to detect a smell, air moves social phobia have trouble reaching their educa- faster through the nose, increasing the flow to the tional and professional goals or even maintaining olfactory clefts and carrying more odor to these sen- employment. In extreme cases, a person with social pho- smoldering leukemia See leukemia, smoldering. Treatment options include smooth muscle Along with skeletal and cardiac using medications and cognitive-behavioral therapy, muscle, one of the types of muscle tissue in the which employs exposure and response prevention. Smooth muscle generally forms the support- Medications for social phobias include antidepres- ing tissue of blood vessels and hollow internal sants called selective serotonin reuptake inhibitors organs, such as the stomach, intestine, and bladder. Within the medical system, a social worker bites can nonetheless cause painful puncture might help uninsured families who need medical wounds that require treatment. If a snakebite victim care find help; work with grieving parents, spouses, knows a snake was poisonous, or if the person did or other family members; provide individual therapy; not see or recognize the snake, he or she should or help patients find resources to meet their needs immediately seek emergency treatment. Somatotropin acts by stimu- socialization The learning process a child goes lating the release of another hormone called through as he or she learns how to interact appro- somatomedin by the liver, thereby causing growth to priately with other people. Somatotropin is given to children with pitu- itary dwarfism (short stature due to underfunction socialized medicine A medical system like that of the anterior pituitary) to help them grow. Also of a socialist country, in which medical facilities and known as somatropin, growth hormone.

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In addition oxybutynin 5mg low price, intraabdominal buy generic oxybutynin 2.5 mg on line, retro- peritoneal 2.5 mg oxybutynin sale, renal, and paraspinal abscesses should be considered. Drug fever and hereditary periodic fever syndromes are grouped in the “miscellaneous” cat- egory and are among the least common causes of prolonged fever of uncertain origin. The opposite changes in these four factors increase hemo- globin affinity for oxygen and impair delivery of oxygen to peripheral tissues. Hemoglobin concentration will increase due to the stimulatory effect of hypoxia on erythropoietin production. The causes of these differences are multifactorial and include social determinants (education, socioeconomic status, environment) and access to care (which often leads to more serious illness before seeking care). However, there are also clearly de- scribed racial differences in quality of care once patients enter the health care system. These differences have been found in cardiovascular, oncologic, renal, diabetic, and pal- liative care. Eliminating these differences will require systematic changes in health system factors, provider level factors, and patient level factors. A simple way to think of the differences between nondeclarative and declarative memory is to consider the difference between “knowing how” (nondeclara- tive) and “knowing who or what” (declarative). Nondeclarative memory loss refers to loss of skills, habits, or learned behaviors that can be expressed without an awareness of what was learned. Procedural memory is a type of nondeclarative memory and may involve motor, perceptual, or cognitive processes. Examples of nondeclarative procedural mem- ory include remembering how to tie one’s shoes (motor), responding to the tea kettle whistling on the stove (perceptual), or increasing ability to complete a puzzle (cognitive). Nondeclarative memory involves several brain areas, including the amygdala, basal gan- I. Declarative memory refers to the conscious memory for facts and events and is divided into two categories: semantic memory and episodic memory. Semantic memory refers to general knowledge about the world without specifi- cally recalling how or when the information was learned. An example of semantic mem- ory is the recollection that a wristwatch is an instrument for keeping time. Vocabulary and the knowledge of associations between verbal concepts comprise a large portion of semantic memory. Examples of episodic memory include ability to recall the birthday of a spouse, to recog- nize a photo from one’s wedding, or recall the events at one’s high school graduation. The areas of the brain involved in declarative memory include the hippocampus, entorhinal cortex, mamillary bodies, and thalamus. Inguinal nodes <2 cm are common in the population at large and need no further work up provided that there is no other evidence of disseminated infection or tumor, and that the nodes have qualities that do not suggest tumor (not hard or matted). A practical approach would be to measure the nodes or even photograph them if visible, and follow them serially over time. Occasionally, inguinal lymph nodes can be associated with sexually transmitted dis- eases. However, these are usually ipsilateral and tender, and evaluation for this would in- clude bimanual examination and appropriate cultures, not necessarily pelvic ultrasound. Bone marrow biopsy would be indicated only if a diagnosis of lymphoma is made first. Supraclavicular lymphadenopathy should always be considered abnormal, particularly when documented on the left side. A thorough investigation for cancer, particularly with a primary gas- trointestinal source, is necessary. Generalized lymphadenopathy and splenomegaly may be found in au- toimmune diseases such as systemic lupus erythematosus or mixed connective tissue disease. Tender adenopathy of the cervical anterior chain is nearly always associated with infection of the head and neck, most commonly a viral upper respiratory infection. It generally causes only mild enlargement of the spleen as expanded varices provide some decompression for elevated portal pressures. Myelofibrosis necessi- tates extramedullary hematopoiesis in the spleen, liver, and even other sites such as the peritoneum, leading to massive splenomegaly due to myeloid hyperproduction. Autoim- mune hemolytic anemia requires the spleen to dispose of massive amounts of damaged red blood cells, leading to reticuloendothelial hyperplasia and frequently an extremely large spleen. Chronic myelogenous leukemia and other leukemias/lymphomas can lead to massive splenomegaly due to infiltration with an abnormal clone of cells. If a patient with cirrhosis or right-heart failure has massive splenomegaly, a cause other than passive congestion should be considered. This usually occurs because of surgical splenectomy but is also possible when there is diffuse infiltration of the spleen with ma- lignant cells. Hemolytic anemia can have various peripheral smear findings depending on the etiology of the hemolysis.

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