Pulmonary Hypertension And Physical Therapy Health And Social Care Essay

Pulmonary Hypertension And Physical Therapy Health And Social Care Essay The aim of this study is to clarify physical therapys role in rehabilitating pulmonary hypertension (PH) patients, by explaining PH with regard to its history, etiology, prevalence, anatomy of pulmonary arteries, definition, subgroups, patophysiology, its causes, how it is diagnosed, and its signs and symptoms. History  Ã‚   Pulmonary Hypertension was first discovered in 1981 by Dr. Ernst Von (4), but it was already getting attention in 1970s in Europe (3), and in the 1990s PH arise again in the United States along with the release of weight loss drugs (3). The natural history of  primary pulmonary hypertension  was evaluated in the National Institutes of Health (NIH) registry from 1981-1987. Of the 194 patients included in the study, 63% were female and 37% were male. The mean age was 36 years, with no ethnic differences. The median survival after diagnosis was 2.5 years (2). Etiology Pulmonary hypertension can be a result of many conditions and drugs. These include: left heart failure (diastolic dysfunction), parenchymal lung disease with hypoxia, sleep apnea, connective tissue disorders, and pulmonary embolism (1). In addition using appetite suppressants such as fenfluramine and dexfenfluramine may be associated with an increased risk of P.H.; also cocaine or amphetamine ingestion may be another contributing factor (2). Prevalence One study has shown that the frequency of PH in adults is predicted to increase, based on the high proportion of pulmonary hypertensionrelated deaths and hospitalizations has occurred among adults aged >65 years, especially if the patient was diagnosed with chronic heart failure (6). Another study has indicated that PH is still rare, with a prevalence of 30-50 cases per million (7); the rate of primary pulmonary hypertension  is approximately 2 cases per million individuals in the general population; while secondary pulmonary arterial hypertension  is dependent on its etiology (2). Most of cases of primary PH are sporadic, but 10% of them are familial (2). According to the World Health Organization, idiopathic PAH is rare and has a prevalence of 6 per million in France. PAH that is associated with other conditions has prevalence of 15 per million (15); idiopathic PAH accounts for at least of 40% of cases, and associated PAH for most of the remaining cases. IPAH is twice as common in women as in men, with a mean age of diagnosis of 36 years (7). This prevalence is higher in specific risk groups: 0.5%, in HIV infected-patient, 0.5%, in patients with  sickle cell disease, and up to 16% in patients with systemic sclerosis (7). Pulmonary hypertension Pulmonary arteries It is critical to know the anatomy of the pulmonary arteries (PA), so the patho-physiology can be understood; the pulmonary arterys function is to carry venous blood from the right ventricle of the heart to the lungs (9). It is one of the terminal branches of pulmonary trunk, and it is divided into the right PA and left PA (8). The RPA is longer than the LPA. The LPA pierces the  pericardium and enters the hilum of the left lung, but the RPA passes transversely across the midline in the upper chest and passes below the  aortic arch  to enter the hilum of the right lung(8). Definition PH is defined as high blood pressure in the lungs arteries and the right side of the heart (10), which can damage the lungs irreversibly, and cause failure of right ventricle(8). In normal individuals, the pressure in the pulmonary arteries is lower than the pressure in the systemic circulation, and if it has increased abnormally, it is considered as PH, which is due to constricted or stiffening of the pulmonary arteries (11). PH groups A patient, who has pulmonary artery pressure which is higher than 25 mm Hg at rest, and more than 30 mm Hg during activity, is considered to have PH (12). The world health organization has divided PH in to five groups (12). The five group classification is a new system, because PH used to be classified into primary PH and secondary PH (12). This new system is based on the underlying cause of PH (12). The first group of PH is pulmonary arterial hypertension (PAH); it is divided into three subtypes: familial PH, idiopathic PH, and associated PH (1). Familial PAH is inherited and a person has it in his/her genes from parents (12). Idiopathic PAH has no known cause (12). The last subtype is the associated PAH, which is caused by different conditions, such as congenital heart disease, HIV infection, diet medications, drugs, toxins, portal hypertension, thyroid disorders, and connective tissue disorders (1, 12). The second group is PH with left heart disease (1, 11, 12). The problems that affect the left side of the heart are valvular heart disorders (mitral valve disease), and atrial or ventricular heart disorders (chronic high blood pressure) (11, 12). The third group is PH associated with lung disorders, hypoxemia, or both. These lung conditions can be alveolar hypoventilation disorders, COPD, chronic exposure to high altitude, developmental abnormalities, interstitial lung disease, or sleep-disordered breathing. The fourth group is pulmonary hypertension which is due to chronic thrombotic or embolic disorders, and it includes nonthrombotic pulmonary embolism (tumors, parasites, and foreign materials), thromboembolic obstruction of distal or proximal pulmonary arteries, and sickle cell anemia (1, 12). The fifth and last group of PH is the miscellaneous type (due to vario us other diseases or conditions), such as compression of pulmonary vessels by adenopathy, fibrosing mediastinitis, lymphangiomatosis, pulmonary langerhans cell granulomatosis (histiocytosis), sarcoidosis, or tumors (1, 12). Pathophysiology of PH As mentioned previously, PH occurs when the systolic and mean pressures in the pulmonary arteries exceed 30- 20 mm Hg, respectively (2). At some point, it hypertrophizes smooth muscles, remodels vascular walls and vasoconstricts vessels (1); this vasoconstriction is a result of increased activity of thromboxane and endothlin-1, which are considered as vasoconstrictors, and decreased activity of prostacycylin and nitric oxide as vasodilators (1). These changes and the imbalance in the production of endothelial-derived vasoactive-mediators are both vital for the causation of PH (13). The PH physiologic mechanism is either an increased pulmonary vascular resistance (PVR) or increased pulmonary venous pressure (PVP) (1). The damage of the pulmonary vascular bed or vasocnstriction due to hypoxia can lead to increased PVR, but vascular obstruction can cause PVP to increase, and increased PVP will further injure the endothelium (1), and that will develop dysfunction of the pulmonary vascula r endothelium, which may worsen PH (13), because injury on the endothelium will activate coagulation at its intimal surface (1). Causes PH is the result of variety of factors and conditions, although in the case of idiopathic PH, the causes are not known (1, 12). Lung and heart disorders are the most common cause of PH(1). Examples are emphysema, failure of left heart ventricle, recurrent pulmonary embolism (1,12), scleredoma,(12), mitral valve disease, (13), pulmonary fibrosis, cystic fibrosis, sarcoidosis, Langerhans cell granulomatosis (histiocytosis), neurologic diseases involving the respiratory muscles (1), chronic low blood oxygen levels with  sleep apnea. Left-sided heart failure as a cause of PH will not happen unless one of the heart valves does not work properly, the left ventricle is stressed by high blood pressure, or a heart attack or some other disorder involving the heart diminishes the ability of heart muscle to pump (1). Pulmonary and lung arteries linings undergo change at cellular level, and these changes affect artery functions, leading to lung diseases and pulmonary artery changes which includ e tightening of arteries walls, or these walls get stiffened at birth or from outgrowth of cells, or blood clots in the arteries; all these will make it harder for the heart to pump blood through the arteries in to the lungs (13). Other causes of PH include dermatomyositis, systemiclupuserythematosus,  sarcoidosis,  human immuno-deficiency virus  (HIV),  advanced  liver disease, Sickle cell anemia (12, 13), use of anti-obesity drugs; cocaine  and  methamphetaminescan (1,12, 13), obesity with reduced ability to breathe (pickwickian syndrome) , extensive loss of lung tissue from surgery or trauma(1). Also PH can be genically inherited through parents (12, 13). Diagnosing PH In a patient suspected of having PH, diagnosis is confirmed with a family history, a physical examination, and diagnostic tests, and procedures (11). The physical examination is done by auscultation, inspection of swelling in the legs and ankles (11), examination of the jugular vein in the neck for engorgement, examination of the abdomen, legs, and ankles for fluid retention, and nail beds for cyanosis (13). Diagnostic tests include electrocardiogram (ECG), chest radiography, echocardiography, testing for connective tissue disorders and other conditions, ventilation perfusion scan, pulmonary function testing, and assessment of functional status, right heart catheterization (13), pulmonary angiogram, blood test, and over night oximetry (13, 11). If the ECG indicates abnormality, it suggests right heart failure (12), and may indicate right ventricular hypertrophy and strain (13), or presence of PAH. Abnormalities include right axis deviation, right ventricular hypertrophy and strain pa tterns, and right atrial enlargement (13). Chest radiography indicates any enlargement in the right heart ventricle or pulmonary arteries (11, 13), and it is mostly found with idiopathic PAH patients; however asymptomatic PAH has normal radiographic findings (13). The testing of connective tissue disorders is by serologic testing, and to test the presence of conditions such as scleroderma, CREST syndrome mixed connective tissue disorder, and systemic lupus erythematosus (13). Ventilation perfusion scan is another diagnostic tool to detect blood clots in pulmonary arteries (11, 12) and it is used to diagnose and differentiate between thrombo-embolic PH and idiopathic PH (11, 13), with sensitivity of 90% to 100%, and specificity of 94% to 100% (13). Pulmonary function testing is used to diagnose chronic obstructive disease (COPD), which can be a cause of PH (11, 12); it is also used exclude airway and parenchymal lung diseases, which can contribute to the development of pulmonary hype rtension, but these findings are not specific (13). The functional status of PH patient should be assessed with a 6-minute walk test and cardiopulmonary exercise test (12, 13); the 6-minute walk test determines exercise tolerance level and blood oxygen saturation level during exercise (16). A cardiopulmonary exercise test measures heart and lung functions during exercise on a bicycle or treadmill (12). The gold standard to confirm the diagnosis of P.H. is right heart catheterization (11); it is useful in assessing the severity of pulmonary hypertension (13). It is done by inserting a catheter into the femoral nerve or into the subclavian nerve. The catheter is connected to a device that can monitor and measure blood pressure in the right side of the heart and pulmonary arteries (11). Right-heart catheterization can also determine mean pulmonary artery pressure, mean right atrial pressure, and cardiac index; another use of it is excluding other etiologies of pulmonary hypertension, s uch asintracardiac shunting and left-sided heart disease (13). The response of certain medications, such as acute vasodilators, can be assessed during right heart catheterization (11, 13). Other additional tests used in diagnosing PH are various types of blood testing. These are complete metabolic panel (CMP) to examine liver and kidney function, autoantibody blood tests, such as ANA, ESR, and others to screens for collagen vascular diseases, thyroid stimulating hormone (TSH) screening, HIV test, arterial blood gases (ABG), complete blood count (CBC) to test for infection, elevated hemoglobin, and anemia, and B-type natriuretic peptide (BNP) (16). To detect sleep apnea nocturnal oximetry or overnight oximetry may be used; it is common to have low oxygen level during sleep with P.H. patient (12, 13, 16). Signs and symptoms In the early stage, PH is asymptomatic or have no specific signs or symptoms (11, 14). These symptoms and signs include cough, fatigue (11) dizziness, fainting and a bluish cast on lips and skin (14), shortness of breath, tiredness, chest pain, a racing heartbeat, feeling lightheaded, swelling in legs and ankles (12). These can be indications for any other disease. As a consequence of non-specificity, diagnosis will be delayed; and the mean time from symptom onset to diagnosis is about two years (13). The symptoms of PH are manifestations of impaired oxygen transport and reduced cardiac output, and the most frequent symptom is dyspnea, which occurs in 60% of patients (13). As symptoms advance, patients complain of dyspnea, exercise intolerance, fatigue, chest pain, and angina (13, 11). Most PH patients get right ventricular hypertrophy, followed by dilation and right ventricular heart failure (1). The symptoms of right heart failure include peripheral edema, abdominal distension, dec reased appetite, early satiety, profound dyspnea, exercises intolerance (13). Other signs include systolic ejection murmur across the pulmonary valve, increased jugular venous pressure, tricuspid regurgitation, hepatomegaly and ascites, and peripheral edema (13). Other physical signs are cyanosis (point of presence of right to left shunting), decreased cardiac output, impairment in intrapulmonary gas transfer, and pulmonary congestion and left sided heart disease, while decreased breath sounds and wheezing are suggestive of fibrosis and pulmonary parenchymal disease (13). Treatment The medical treatment program starts with the avoidance of activities that may exacerbate condition (1), and it is generally includes taking medications, making lifestyle and dietary changes, and maybe having surgery (16). Medications are also used, depending on the type and severity of PH (16). PAH is treated by oral Ca channel blockers (verapamil), endothelin-receptor antagonist (bosentan-ambrisentan- sildenafil  ), ,  digoxin,  diuretics, and oral  anticoagulants (1, 4). The other PH types  involve management of the underlying disorder. Patients with pulmonary hypertension from left-sided heart disease may need surgery for valvular disease. Patients with lung disorders and hypoxia benefit from supplemental O2 as well as treatment of the primary disorder.Patients with severe pulmonary hypertension secondary to chronic thromboembolic disease should be considered for pulmonary thromboendarterectomy. Under cardiopulmonary bypass, organized endothelialized thrombus is dissected along the pulmonary trunk in a procedure more complex than acute surgical embolectomy (1). Vasoactive substances in general are used in treating different groups of PH. This category of medications includes prostaglandins, endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and activators of soluble guanylate cyclase (4). The surgical solution can be one of these options, either atrial septostomy, lung transplantation, or pulmonary thromboendarterectomy (4, 16). PT role The PT role in PH is more rehabilitative in nature more than therapeutic, and it has different programs customized to each patient, and depends on the clinic or hospital approach. Pulmonary rehabilitation, according to Salt lake regional medical centre, is an outpatient program which will help the patients to learn lung self care, and easier breathing (19). In this centre, complete diagnostic testing is provided, and it includes ECG, chest x-ray, echocardiogram, pulmonary function tests, 6-minute walk tests, nuclear lung scan, CT scanning of the chest, right heart catheterization (19). In the North West therapy centre, assessment is done at the beginning by a team, including respiratory therapist, physical therapist, and  social worker. The respiratory therapist focuses on breathing mechanics, education, aerobic conditioning and endurance for improved efficiency, pacing, and medication mechanics. The physical therapist helps in strengthening exercise, balance training, walking mech anics, postural education, energy conservation, assigning a home exercise program to maintain strength and coordination gains, looking for orthopedic complications to therapy, and makes appropriate adjustment to plans of treatment. The last member of the team is the social worker who is considered as a resource center for services in community. These services include helping in smoking cessation, supporting for adjustment, grief, depression, and socialization disorders, weight management, nutrition support, and cognitive behavioral therapy (20). Pulmonary rehabilitation (21) Since physical therapy provides rehabilitation role, the PH patient should go through a pulmonary rehabilitation program, which is an individually designed intervention program, including exercise  and education that helps patients manage the symptoms of their condition and improve their level of daily functioning and well-being (3). This program will be discussed from different aspects its purpose, basic components, precaution, process, patient preparation, and expected results. The goals The purpose of this program is to help increase the fitness level of the patient and independent functioning, reduce dyspnea, slow down or prevent the development of disease, and improve quality of life. Pulmonary rehabilitation and cardiac rehabilitation walk complement each other because the main purpose of cardiac rehabilitation is to reverse the de-conditioning and psychosocial enhancements of pulmonary disability. Components Pulmonary rehabilitation has basic treatment components and they are breathing exercise, coughing, percussion, postural drainage, and vibration. Breathing exercise helps in removing secretions, relaxation, and to increase thoracic cage mobility. This exercise is done by teaching the patient to produce a full inspiration followed by a controlled expiration, while placing a hand at the end of rib cage and under the chest for sensory feedback. Coughing is also for secretion removal but from larger airways and it is done through steps. The patient should inhale, close the glottis, contract the expiratory muscle, then open the glottis. Both breathing exercise and coughing are done when the patient restore the ability to breath normally. Percussion is usually used with postural drainage and both are used to mobilize secretions retained in lungs. Percussion is a rhythmic clapping of cupped hands over bare skin or thin material covering area of lung involvement, performed during inspiration and expiration. Postural drainage is a technique that involves gravity by positioning the patient to have the involved lung segment be the uppermost, which will assist in mobilizing the secretions. Another therapeutic technique is vibration, which is intermittent chest wall compression over area of lung involvement, performed during expiration only, and used along with postural drainage. The later three techniques are used when coughing or suctioning, breathing exercises, and patient mobilization are not adequate to clear retained secretions. Precautions and contraindications As with any other treatment precautions and contraindications should be taken in consideration in case of PH patients during their rehabilitation program. A patient should get full medical examination before setting the program. In some cases when a patient has a medical issue, it may interfere with the treatment and limit the exercises. In this case, the program should be modified. Conditions that may contraindicate participation in pulmonary rehabilitation include acute respiratory  infection,  ischemic cardiac disease, congestive  heart failure,  serious  liver  dysfunction, disabling stroke, severe psychiatric or cognitive disorders, severe pulmonary hypertension,  and metastatic  cancer. Rehabilitation process Pulmonary rehabilitation is a punitive, expansive program of education, exercise, and behavior alteration, individually designed for patients with lung diseases. The rehabilitation program is designed to help patients learn more about their condition and how to concert its symptoms, as well as to take active steps, such as smoking cessation, oxygen use, and exercise. This program aims to improve the patients level of physical functioning, stop the advancement of the disease as much as possible, and learn how to better live with the condition. Improved physical functioning, reduction in the symptoms of the disease, and ability to fulfill activities of daily living (ADLs) more easily and independently can add to improved quality of life. Rehabilitation program A typical program takes a few weeks to a few months, and takes to three hours per session for a few days each week. During these sessions the patient should learn to manage the program independently, as home program. Patients participating in rehabilitation could be inpatients or outpatients. A daily program should consist of two main components, and they are exercise and education. The purpose of the exercise is to maintain or improve muscle strength, endurance and overall fitness. In order to prescribe an exercise, blood pressure, heart  rate, oxygen saturation, and dyspnea levels should be evaluated, also exercise has to be monitored by physical therapists, respiratory nurses, or other qualified health care providers. A regular exercise program can upgrade overall fitness and energy, and make fulfillment of ADLs easier. The exercise program includes periods of warm-up and cool-down period, and aerobic activity. The warm-up and cool-down periods may include stretching and light strength or resistance training. Exercises involving upper and lower extremities are important for general fitness and for improvement in function during different activities. Some of the muscle groups used in arm and upper torso positioning serve respiratory functions, and thus upper limb exercises can also have a profitable effect on ventilation. The aerobic exercise component is composed of activities such as walking or using a stationary bicycle, treadmill, or other equipment. Exercise is controlled by physical therapists, respiratory nurses, or other qualified health care member. Ventilatory training may also be involved in the exercise program for certain patients. This therapy involves controlled breathing exercises,  chest physical therapy  techniques such as postural drainage, chest percussion, directed cough, and vibration, and training of the inspiratory muscles. The educational component of the rehabilitation program consists of classes, manuals, and counseling or training sessions that cover different subjects, procedures, and issues, which concern patients with PH or any other chronic pulmonary disease. Education is provided by a brand of professionals, including respiratory nurses, respiratory therapists, occupational therapists, physical therapists, social workers, and dieticians. A psychologist or other mental health professional may provide counseling and direction to address mark depression, anxiety, and social isolation, which are related to symptoms of pulmonary disease. Some of the educational subjects covered include anatomy and physiology related to pulmonary function and disease, exercise theory,  nutrition,  techniques for using oxygen and inhalers, and ways to conserve energy. Education related to proper nutrition and weight control can be helpful, because patients may be undernourished and have muscle wasting of the respi ratory muscles, which can make breathing more difficult. If anemia is present, it can decrease oxygen-carrying capacity. Electrolyte imbalances affect cardiopulmonary performance, so these and other deficits should be treated in order to enhance functioning. If patients are overweight, the extra weight increases oxygen and energy consumption and may increase fatigue. Patients who have not yet ceased smoking should be strongly encouraged to do so. Patient preparation After being referred and examined by a physician, a medical history of the patient should be taken by the rehabilitation team, and some tests must be done prior to the rehabilitation program. These tests are pulmonary function tests (PFTs), chest X-rays, arterial  blood  gas (ABG) analysis, pulse oximetry, and sputum examination. PFTs are performed with a spirometer to measure lung performance and indicate the presence and extent of lung disease. A chest X-ray can show emphysema and other lung disease, including  lung cancer,  for which there is increased risk among smokers with pulmonary disease. Pulse oximetry helps determine when supplemental oxygen is required and measures oxygen in the blood. Exercise tests may be used to prescribe the length and intensity of the exercise. Expected complications Risk of complications such as muscle injury or cardiac reactions is always come up with exercise, but will be eliminated by careful exercise prescription and monitoring. Disease-related complications that should be monitored include  fever,  unusual or extreme shortness of breath, irregular pulse, unanticipated weight changes, gastric complaints, or any other change that is unusual for the patient. Conclusion Pulmonary hypertension is indicated when pulmonary artery pressure is higher than 25 mm Hg at rest, and more than 30 mm Hg during activity. PH is due to constricted or stiffening of the pulmonary arteries. PH is classified in to five groups, based on the underlying cause. PH is asymptomatic or has no specific signs or symptoms, but later, the patient may complain of dyspnea, exercise intolerance, fatigue, chest pain, and angina. PH treatment protocol consists of making lifestyle and dietary changes, medications, rehabilitation program, and maybe having surgery. Physical therapy plays an important role in rehabilitating PH patients. PT aims to help increase the fitness level of the patient and independent functioning, through exercise programs and education.

Ebola Virus: Symptoms And Effects :: Ebola Hemorrhagic Fever

1. INTRODUCTION   Ã‚  Ã‚  Ã‚  Ã‚  A. HISTORY OF VIRUS   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. AFRICA, ZAIRE   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  2. 1970   Ã‚  Ã‚  Ã‚  Ã‚  B. SYMPTOMS AND AFFECTS   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. BLEEDING, HEMORRHAGING   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  2. DEATH W/IN 20 DAYS   Ã‚  Ã‚  Ã‚  Ã‚  C. CURES   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. NONE KNOWN   Ã‚  Ã‚  Ã‚  Ã‚  D. INTERNATIONAL EFFORTS 2. HISTORY OF VIRUS   Ã‚  Ã‚  Ã‚  Ã‚  A. WHERE IT STARTED   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. SCIENTISTS   Ã‚  Ã‚  Ã‚  Ã‚  B. HOW IT IS SPREAD   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. NON AIRBORNE   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  2. BODILY CONTACT   Ã‚  Ã‚  Ã‚  Ã‚  C. WHERE IT EXISTS TODAY 3. SYMPTOMS AND EFFECTS   Ã‚  Ã‚  Ã‚  Ã‚  A. SEVERE FEVER, ABDOMINAL PAIN   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  1. INSIDES â€Å"MELT†   Ã‚  Ã‚  Ã‚  Ã‚  B. DEATH RATES AND TOTALS   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  2 SURVIVORS, BUT EBOLA VIRUS AS THE CAUSE WAS NOT   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  VERIFIED 4. CURES   Ã‚  Ã‚  Ã‚  Ã‚  A. NONE KNOWN CURES, RESEARCH BEING PERFORMED ON   Ã‚  Ã‚  Ã‚  Ã‚  MONKEYS.   Ã‚  Ã‚  Ã‚  Ã‚  Ebola virus is a relatively recently discovered virus, that when it infects humans, caries with it a 50-90% fatality rate. Symptoms of this deadly virus include Sudden Fever, Weakness, Muscle Pain, Headache, Sore Throat, Vomiting, Diarrhea, Rash. Internal results include Limited Kidney Function, Limited Liver Function, and Internal and External Bleeding.   Ã‚  Ã‚  Ã‚  Ã‚  The incubation period for the Ebola virus ranges from 2 to 21 days, depending upon the method of infection. A direct inoculation of the virus into the bloodstream of a human will bring about symptoms markedly faster than other forms of less direct contact. The virus is present in the male's reproductive fluids, and can be transmitted through sexual contact for up to 7 weeks after clinical recovery from the Ebola virus.   Ã‚  Ã‚  Ã‚  Ã‚  The Ebola virus can be diagnosed with laboratory testing of blood specimens under maximum containment conditions - because of the high risk of infection to those handling infected blood.   Ã‚  Ã‚  Ã‚  Ã‚  There is currently no treatment or vaccination available for the Ebola virus.   Ã‚  Ã‚  Ã‚  Ã‚  Transmission of the Ebola virus occurs by direct contact with the bodily fluids of patients infected with the virus. The handling of chimpanzees that are either ill or have died from the Ebola virus can also transmit the virus.   Ã‚  Ã‚  Ã‚  Ã‚  Any suspicion of infection with the Ebola virus should be treated with extreme caution: immediate isolation from other patients and strict barrier nursing techniques must be practiced. All instruments, clothing, or biological matter must be either disposed of or thoroughly disinfected immediately.   Ã‚  Ã‚  Ã‚  Ã‚  The initial outbreaks of the Ebola virus occurred in 1976. Springing forth from unknown origins, this virus held the nations of Zaire in fear as it quickly claimed the lives of many of it's citizens. As this was the first recorded outbreak of the Ebola virus, the medical community was unsure of how to handle Ebola. The level of care in Zaire during this outbreak was very low, and as a result of the many infected victims congregated in public areas, the virus continued to spread among the denizens of Zaire. The intervening years have slowly produced scientific data on the nature of the virus - yet treatment is still

Analysis of Competition on the Book “Maus”

Competition in Maus The book Maus addresses the issue of the Holocaust and tells the story of Vladek in detail, a man who survived Auschwitz. However, one of the most striking things about the story is not the surviving issue, but how it reveals the relationship between Vladek and his son. Competition is everywhere in the story. In the first book Vladek had a competitive relationship with his son Artie, but throughout the story the competition falls into the hands of Artie and Richieu, the dead brother.Artie is constantly struggling with the broken relationship he has with his father. When talking to Pavel, Artie says: â€Å"No matter what I have accomplished, it doesn’t seem like much compared to surviving Aushwitz† (II, 45). Artie’s life experiences and those of his father are completely different and this difference seems to increase the distance between them. People have different stories and backgrounds, but their skills and greatness can’t be measure d by one individual event, such as the Holocaust.Due to this eternal competition imposed by his father, Artie's purpose for writing the book may have started in order to record family history, but this was a superficial cover attempting to overcome his deeper feelings of inferiority he felt while around his father. â€Å"He loved showing off how handy he was†¦ and proving that anything I did was all wrong. He made me completely neurotic about fixing stuff†¦ One reason I became an artist was that he thought it was impractical-just a waste of time†¦ It was an area where I wouldn’t have to compete with him† (I, 97).In fact, Artie did show his competence through writing the book and being able to portrait his dad’s story so well. A passage that demonstrates how Vladek always seems to be making Artie feel incompetent is when Vladek knocks over a his bottle of pills and blames it on Artie. â€Å"Look now what you made me do! † (I, 30). Even thoug h Vladek knows it was his own fault, he doesn’t want to admit it. Then Artie tells him â€Å"Okay, I’ll re-count them later†. 30), but Vladek replies saying that Artie doesn’t know how to count his pills and adds â€Å"I’m an expert for this† (30). These two quotes clearly show how Vladek is always trying to prove himself better than his son. Vladek never gives Artie the chance to prove that he is capable of doing anything and this increases the distance between father and son. Another example of Vladek's necessity for dominance is shown when he accidently breaks a plate and gets really upset. Artie tries to remedy the ituation and offers to do the dishes, but his father replies in his broken English, â€Å"No. You can defrost out the turkey legs†¦ you only would break me the rest of my plates† (II, 73). Vladek is always trying to give him easier jobs and won't admit that Artie is equally capable of anything because this would pu t a hole in his credibility. With credibility comes dominance, and without it he loses it. If he loses his dominance over Artie, this would free Artie from the comparison trap because he wouldn't feel inferior anymore.On the second book, Artie tells Francoise about Richieu and how his parents had always had a picture of the dead brother in their room, but never a picture of Artie. â€Å"The photo never threw tantrums or got in any kind of trouble†¦ it was an ideal kid, and I was a pain the ass. I couldn’t compete† (II, 15). Due to this eternal competition with Richieu, Artie was caught in a â€Å"competition trap† that he struggled with his whole life. This boxed Artie in. Because everything he did was compared to an unrepeatable experience, Artie could never break out of the competition trap.This trap would always hold him back. Artie lived in a new time with new opportunities, but he still couldn’t let go of this unspoken competition with his ghost brother. One of the most effective images in the novel was on the very last panel, when Vladek says â€Å"I'm tired from talking, Richieu, it's enough stories for now† (II 136). This scene illustrates the preference Vladek has for his first son, Richieu. In choosing this quote to be the last one in the book Artie displays that this competition with his brother has no end.The fact that Artie dedicated the book to Richieu is another display of this, that even though they never met, Vladek was able to bring Richieu alive in Artie's life. This passage also demonstrates how much Vladek still wishes Richieu was there with him. It is definitely painful for Artie to be called Richieu. In addition to this last quote, Artie also chose to dedicate the book to Richieu, Vladek and Richieu felt the direct pain of the holocaust, and as much as Artie tried he would only be able to experience its indirect effects, and this would never hold up in any comparison.Sibling rivalry built up in Art ie's veins, but as most siblings have ways to exchange this equally, Artie was in a unique situation. Not only could he never experience the things Richieu did, he could never exchange any emotions. Richieu was only a photo, and yet Vladek always unconsciously made sure Richieu’s life affected Artie. Artie was never going to be good enough for his father, or his ghost brother. He was stuck in a constant competition with someone no longer living. Writing Maus was what he did to relieve what was forced on him.Most books written about the holocaust are full of the direct effects, but his book took a new spin on the topic by focusing on the indirect effects. He would never stop competing with his brother. This is evident up to the last quote of the story when Vladek calls Artie by his dead brother’s name, which just goes to show that Artie is still upset by this competition. Work Cited: Spiegelman, Art. Maus: A Survivor's Tale, I : My Father Bleeds History. New York: Panth eon, 1986. Spiegelman, Art. Maus: A Survivor's Tale, II : And Here my Troubles Began. New York: Pantheon, 1986.

Battles of Lexington and Concord - 1400 Words

Introduction The Battles of Lexington and Concord occurred on 19 April 1775 between the British Regulars and the Patriot Militia, also known today as Americans, in the Massachusetts towns of Lexington and Concord. â€Å"The Battles of Lexington and Concord is often referred to as the â€Å"Shot Heard Around the World† and the beginning of the American Revolutionary War† (Fischer, 1994). The Battles of Lexington and Concord consisted of in four events: the skirmish in Lexington between the British Regulars and the Lexington Training Band, the search and seizure of arms, munitions and military stores in Concord, the battles between the Regulars and the militias during the march of the Regulars back to Boston and the surrounding of Boston by the†¦show more content†¦General Gage understood that detaining the key leaders would not prove fruitful and therefore changed the mission to strictly searching for and seizing arms, munitions, supplies, and military stores. General Gage g ave this mission to Lieutenant Colonel Francis Smith with very discreet orders to not brief his soldiers as to what the exact mission would be. General Gage also appointed Major John Pitcairn as the Executive Officer for the mission. â€Å"The initial mission would consist of approximately 700 British Regulars, who were pulled from 11 of General Gage’s 13 infantry regiments. Major Pitcairn would command 10 elite infantry companies and Lieutenant Colonel Benjamin Bernard would command 11 grenadier companies. Of the 700 Regulars assigned to conduct the mission, 350 were from the grenadier companies: 4th (King’s Own), 5th, 10th, 18th (Royal Irish), 23rd, 38th, 43rd, 47th, 52nd and 59th Regiments of Foot as well as the 1st battalion of the 1st Battalion of His Majesty’s Marine Forces. There was approximately 320 light infantry assigned the role of protecting the grenadier units. These light infantry Regulars were from the 4th, 5th, 10th, 23rd, 38th, 43rd, 47th, 52n d and 59th Regiments and the 1st Battalion of the Marines† (Fischer, 1994). The 700 Regulars were to move from Boston to Concord through a two phaseShow MoreRelatedThe Battle Of Lexington And Concord1493 Words   |  6 PagesMen will always fight to defend their property and their independence. This was evident in the Battle of Lexington and Concord which was one of the first battles of the Revolutionary War and the first step towards America’s independence. This battle was fought between the sophisticated British Army, also known as the Redcoats, and local the colonist men also known as minutemen. The colonies were overmatched in size and equipment however that did not stop them from fighting for their weapons and mostRead MoreThe Battle Of Lexington And Concord1493 Words   |  6 PagesMen will always fight to defend their property and their independence. This was evident in the Battle of Lexington and Concord which was one of the first battles of the Revolutionary War and the first step towards America’s independence. This battle was fought between the sophisticated British Army, also known as the Redcoats, and local the colonist men also known as minutemen. The colonies were overmatched in size and equipment however that did not stop them from fighting for their weapons and mostRead MoreBattle Of Lexington And Concord1708 Words   |  7 Pagesarms! Ye villains, ye rebels† (1775, 04/19: Battles of Lexington and Concord. (2007, June 26). The militiamen, who were greatly outnumbered, were ordered to leave when a shot rang out. No one really knows who fired first, but the British, hearing the shot, fired upon the small group of militia, killing eight and wounding 10 (1775, 04/19: Battles of Lexington and Concord. (2007, June 26). When the smoke cleared the British began their march to Concord to search for weapons. They planned to burnRead MoreThe Battle Of Lexington And Concord1939 Words   |  8 PagesThis year the National History Day topic theme is â€Å"Taking a Stand†. When I think about a significant time in history where people made a stand for a cause against seemingly insurmountable odds, I think of the Battle of Lexington and Concord. American colonists, often known as the Patriots, stood up against British troops, preventing them from seizing their weapons and ammunition and capturing the leaders of the rebellion. It was this stand that began the American Revolution. The Patriot’s standRead MoreThe Battle Of Lexington And Concord940 Words   |  4 PagesIntroduction Did you know that Lexington and Concord was a small fight? The Battle of Lexington and Concord was fought on April 19, 1775. Tension had been building up for many years between the British and Colonists. On the night of April 18, 1775, British troops marched from Boston to Concord in order to take weapons from the colonists. Paul Revere had found out this information and so he and other colonists moved the weapons. Paul Revere and other riders sounded an alarm. Colonial military menRead MoreThe Battle Of Lexington And Concord1263 Words   |  6 Pagesheard round the world†¦Ã¢â‚¬  primary source Ralph Waldo Emerson’s poem â€Å"Concord Hymn† was written about the Battle of Lexington and Concord. Although this poem is not a good answer on who shot first during this battle, it does open the idea about the battle itself and makes you think who shot first. I believe that the Americans shot first at this Battle. What happened at the Battle of Lexington and Concord? Though it has been called a battle, it was more of a skirmish. It happened on April 19th the yearRead MoreThe Battle Of Lexington And Concord Essay732 Words   |  3 PagesAfter the bloodshed at Lexington and Concord in April of 1775, about 20,000 Minutemen swarmed around Boston, where they outnumbered the British. The Second Continental Congress met in Philadelphia on May 10, 1775, with no real intention of independence, but merely a desire to continue fighting in the hope that the king and Parliament would consent to a redress of grievances. It sent another list of grievances to Parliament. It also adopted measures to raise money for an army and a navy. It also selectedRead MoreMy First Lesson On The Battle Of Lexington And Concord960 Words   |  4 PagesFriday I did not attend because it was fall break for WIU so I decided to go home for the weekend. On Tuesday the students worked on Cornell notes for several headings in their textbook. Then on Wednesday I taught my first lesson on the battles of Lexington and Concord. The students analyzed two primary source documents then as a class we discussed their similarities and differences. The lesson went well despite the fact that two-thirds of the class was missing due to state testing. The fact that majorityRead MoreThe Shot Heard Round the World700 Words   |  3 Pagesstart of the Battle of Lexington which was the first official battle of the Revolutionary War. On April 19th, 1775 British troops were marching to Lexington where many militia were already awaiting their arrival. The British were after the ammunition of the militia. Paul Revere had warned the militia ahead of time so that they could be prepared. They removed their stockpiles of ammunition from their hiding places and moved them to a new shelter. When the British arrived at Lexington, the militiaRead MoreLexington And Concord : American Revolution1551 Words   |  7 PagesLexington and Concord Begins American Revolution On an â€Å"unremarkably clear and pleasant† day in April 19, 1775, the shot that was said to had been able to be heard around the world was fired. (A Guide to Battles) This began the battles in which we know as Lexington and Concord, and the war we know as the Glorious/American revolution. It was fought between the British whom had feared American retaliation for some time, and the American Colonies whom were tired of feeling oppressed by the British