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By: M. Sancho, M.A., M.D.
Vice Chair, California University of Science and Medicine
The spread of information erectile dysfunction drugs at walmart purchase levitra super active in united states online, propagation of ideas erectile dysfunction no xplode discount levitra super active 40mg on line, and awareness of conflicting religious beliefs and interpretations contributed in important ways to the religious wars of the 16th and 17th century and to Islamic and other religiously claimed terrorism of today. The widespread accessibility of information technologies also provides a platform for extreme voices to find followers, support, and sympathizers in cyber space. Such dynamics are likely to intensify as Internet access deepens in the developing world and as new information technologies like Virtual Reality allow for more seemingly intense and personal experiences and interactions across time and space. More than 80 percent of the world is religiously affiliated and high fertility rates in the developing world are increasing that proportion, according to the Pew research center. As some religious groups push more actively for governments to incorporate religion and its values into law and norms, social and political tension is likely to flare, whether the religious represent the majority or an active minority. These developments will also incite fears among secular and religious minorities in these countries, potentially fueling exit or rebellion. Many communities with growing religious affiliation-including in the Middle East and Africa-will expect their governments to incorporate religion and its principles into legislation and government policies. They often see secularism and disaffiliation as Western ideas that reject God and the value of faith and undermine social coherence. Many religious organizations-including Catholic Relief Services, Compassion International, and World Vision- are already essential to the delivery of basic public services, humanitarian aid and development. Recently, the Church has addressed issues as diffuse as non-fetal stem cell research and nutrition and food security. However, established religious organizations-similar to public institutions-will be increasingly scrutinized given the modern communications environment. Competition within and between religious groups is likely to intensify over defining and controlling the faith-much as battles to control political parties have become more personalized and divisive. In these disputes, radical minority religious activists will often push out moderate voices because dramatic action and anger tend to generate attention and mobilize dissatisfaction better than calls for compromise. Charismatic and extremist leaders can gain disruptive capabilities, although violent and extremist groups that lack technocratic skill will struggle to provide governance. Most religious people will not actively support extremism, but passive support or implicit acceptance of extremists will worsen tension between groups, and violent leaders will be acknowledged as actors on the world stage. Religious divisions will be 193 · · amplified when regional rivals or other outside patrons support competing sides. One possible response to intensifying religious violence could be a turn toward secularism or away from religious affiliation in general. Worldwide, those identifying themselves as religiously "unaffiliated" represent the third-largest grouping after Christians and Muslims, and polls suggest that the number of people not affiliated with religion, although not the percentage, is likely to grow worldwide-especially in the Asia-Pacific, Europe and North America. Liberalism is likely to remain the benchmark model for economies and politics over the coming decades, but it will face stronger competition and demands from publics to address its shortfalls. Western ideals of individual freedom and democratic action will exert enormous global influence, judging by the aspirations of migrants and dissidents worldwide who are drawn to these principles. Many developing countries will strive for modernization more or less along Western lines, but the allure of liberalism has taken some strong hits over the years as political polarization, financial volatility, and economic inequality in western countries have stoked populism and caused doubts about the price of political and economic openness. Governments having trouble meeting the needs of their citizens will be strongly tempted to turn to nationalism or nativism to transfer blame to external enemies and distract from problems at home, while publics fearful of loss of jobs to immigrants or economic hardship, are likely to be increasingly receptive to more exclusive ideologies and identities. Some disenchanted and traumatized former protesters, many of whom believe the West controls world events and is responsible for their plight, will look for alternatives to the liberal ideals they once supported. Putin lauds Russian culture as the last · · 194 bulwark of conservative Christian values against European decadence, saying Russia, with its great history, literature, and culture, will resist the tide of multiculturalism. Russian nationalist aggression is likely to increase under Putin, which will provoke sometimes violent nationalist responses among its neighbors-like in Ukraine and Georgia-and spark feelings of disenfranchisement among ethnic minorities. Without a return to secure and more-evenly-distributed living standards, economic and social pressures are likely to fuel nativism and populism in the West, risking a narrowing of political communities and exclusionary policies. A weakening of the rule of law, political tolerance, and political freedoms in the United States and Western Europe-the traditional strongholds of democracy-could delegitimize democratic ideas around the world. Just as the world is watching the United States and Europe grapple with divisive politics and often uncivil rhetoric in debates over immigration, racial justice, refugees, and the merits of globalization, the world will look to see how India tames its Hindu nationalist impulses, and how Israel balances its ultra-orthodox extremes.
The period of susceptibility to the physiological effects of unilateral eye closure in kittens erectile dysfunction ultrasound generic levitra super active 40 mg without prescription. Parallel organization of functionally segregated circuits linking basal ganglia and cortex impotence def purchase levitra super active 40 mg without a prescription. Basal ganglia-thalamocortical circuits: parallel substrates for motor,oculomotor,``prefrontal'and``limbic'functions. Mutism developing after bilateral thalamo-capsular lesions by neuro-Behcet disease. Hyperphagia, rage, and demential accompanying a ventromedial hypothalamic neoplasm. The physician encountering such a patient must begin examination 38 and treatment simultaneously. When this fails to produce a response, the physician begins a more formal coma evaluation. To determine if there is a structural lesion involving those pathways, it is necessary also to examine the function of brainstem sensory and motor pathways that are adjacent to the arousal system. In particular, because the oculomotor circuitry enfolds and surrounds most of the arousal system, this part of the examination is particularly informative. Fortunately, the examination of the comatose patient can usually be accomplished very quickly because the patient has such a limited range of responses. The evaluation of the patient with a reduced level of consciousness, like that of any patient, requires a history (to the extent possible), physical examination, and laboratory evaluation. The physiology and pathophysiology of the cerebral circulation and of respiration are considered in the paragraphs below. Table 21 Examination of the Comatose Patient History (from Relatives, Friends, or Attendants) Onset of coma (abrupt, gradual) Recent complaints. Of course, patients with coma or diminished states of consciousness by definition are not able to give a history. Thus, the history must be obtained if possible from relatives, friends, or the individuals, usually the emergency medical personnel, who brought the patient to the hospital. In a previously healthy, young patient, the sudden onset of coma may be due to drug poisoning, subarachnoid hemorrhage, or head trauma; in the elderly, sudden coma is more likely caused by cerebral hemorrhage or infarction. Most patients with lesions compressing the brain either have a clear history of trauma. Gradual onset is also true of most patients with metabolic disorders (see Chapter 5). The examiner should inquire about previous medical symptoms or illnesses or any recent trauma. A history of headache of recent onset points to a compressive lesion, whereas the history of depression or psychiatric disease may suggest drug intoxication. Patients with known diabetes, renal failure, heart disease, or other chronic medical illness are more likely to be suffering from metabolic disorders or perhaps brainstem infarction. After stabilizing the patient (Chapter 7), one should search for signs of head trauma. Examine the neck with care; if there is a possibility of trauma, the neck should be immobilized until cervical spine instability has been excluded by imaging. Resistance to neck flexion in the presence of easy lateral movement suggests meningeal inflammation such as meningitis or subarachnoid hemorrhage. Pressure sores or bullae indicate that the patient has been unconscious and lying in a single position for an extended period of time, and are especially frequent in patients with barbiturate overdosage. In assessing the level of consciousness of the patient, it is necessary to determine the intensity of stimulation necessary to arouse a response and the quality of the response that is achieved. When the patient does not respond to voice or vigorous shaking, the examiner next provides a source of pain to arouse the patient. Several methods for providing a sufficiently painful stimulus to arouse the patient without causing tissue damage are illustrated in Figure 21. It is best to begin with a modest, lateralized stimulus, such as compression of the nail beds, the supraorbital ridge, or the temporomandibular joint. These give information about the lateralization of motor response (see below), but must be repeated on each side in case there is a focal lesion of the pain pathways on one side of the brain or spinal cord. If there is no response to the stimulus, a more vigorous midline stimulus may be given by the sternal rub.
A companion already had died impotence at 80 discount 40 mg levitra super active amex, apparently the result of an attempted double suicide erectile dysfunction drugs uk levitra super active 40 mg mastercard. The neurologic examination was normal, and an evaluation by a psychiatrist revealed a clear sensorium with ``no evidence of organic brain damage. At home he remained well for 2 days but then became quiet, speaking only when spoken to . The following day he merely shuffled about and res- Pathophysiology of Signs and Symptoms of Coma 31 Figure 110. Hypoxia typically causes more severe damage to large pyramidal cells in the cerebral cortex and hippocampus compared to surrounding structures. The next day (13 days after the anoxia) he became incontinent and unable to walk, swallow, or chew. He was admitted to a private psychiatric hospital with the diagnosis of depression. Deterioration continued, and 28 days after the initial anoxia he was readmitted to the hospital. His blood pressure was 170/100 mm Hg, pulse 100, respirations 24, and temperature 1018F. His extremities were flexed and rigid, his deep tendon reflexes were hyperactive, and his plantar responses extensor. Histologically, neurons in the motor cortex, hippocampus, cerebellum, and occipital lobes appeared generally well preserved, although a few sections showed minimal cytodegenerative changes and reduction of neurons. Pathologic changes were not present in blood vessels, nor was there any interstitial edema. The striking alteration was diffuse demyelination involving all lobes of the cerebral hemispheres and sparing only the arcuate fibers (the immediately subcortical portion of the cerebral white matter). The condition of delayed postanoxic cerebral demyelination observed in this patient is discussed at greater length in Chapter 5. A series of drawings illustrating levels through the brainstem at which lesions caused impairment of consciousness. For each case, the extent of the injury at each level was plotted, and the colors indicate the number of cases that involved injury to that area. The overlay illustrates the importance of damage to the dorsolateral pontine tegmentum or the paramedian midbrain in causing coma. As a result, it is no exaggeration to say that virtually any deficit due to injury of a discrete cortical area can be mimicked by injury to its thalamic relay nucleus. Hence, thalamic lesions that are sufficiently extensive can produce the same result as bilateral cortical injury. The most common cause of such lesions is the ``tip of the basilar' syndrome, in which vascular occlusion of the perforating arteries that arise from the basilar apex or the first segment of the posterior cerebral arteries can produce bilateral thalamic infarction. Other causes of primarily thalamic damage include thalamic hemorrhage, local infiltrating tumors, and rare cases of diencephalic inflammatory lesions. Examination of her brain at the time of death disclosed unexpectedly widespread thalamic neuronal loss. However, there was also extensive damage to other brain areas, including the cerebral cortex, so that the thalamic damage alone may not have caused the clinical loss of consciousness. On the other hand, thalamic injury is frequently found in patients with brain injuries who eventually enter a persistent vegetative state (Chapter 9). However, the location of the hypothalamus above the pituitary gland results in localized hypothalamic damage in cases of pituitary tumors. Patients with hypothalamic lesions often appear to be hypersomnolent rather than comatose. They may yawn, stretch, or sigh, features that are usually lacking in patients with coma due to brainstem lesions. On the other hand, we have not seen loss of consciousness with lesions confined to the medulla or the caudal pons. Twenty-five years earlier she had developed weakness and severely impaired position and vibration sense of the right arm and leg.
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