By Z. Owen. William Jewell College. 2019.

There are the 35- or 45- year-old women who are convinced that they look "old" even though their appearance is perfectly "normal" and in many cases unusually attractive quality imitrex 25mg. There are the young girls who are convinced that they are "ugly" merely because their mouth order imitrex 50 mg, nose or bust measurement does not exactly match that of the currently reigning movie queen discount 25 mg imitrex with mastercard. No ethical plastic surgeon would even consider operating upon these people cheap imitrex 25mg free shipping, but unfortunately the quacks, or so-called "beauty doctors" whom no medical association will admit to membership, have no such qualms. A recent survey of college co-eds showed that 90 per cent were dissatisfied in some way with their appearance. If the words "normal" or "average" mean anything at all, it is obvious that 90 per cent of our population cannot be "abnormal" or "different" or "defective" in appearance. Their capacity to really "live" fully is blocked and choked by the same sort of psycho- logic roadblocks. Their "scars," though mental and emo- tional rather than physical, are just as debilitating. The Self-image—the Real Secret Discovery of the self-image explains all the apparent discrepancies we have been discussing. It is the common denominator—the determining factor in all our case his- tories, the failures as well as the successes. The secret is this: To really "live," that is to find life reasonably satisfying, you must have an adequate and realistic self image that you can live with. You must have a self that you are not ashamed to "be," and one that you can feel free to ex- press creatively, rather than to hide or cover up. You must have a self that corresponds to reality so that you can function effectively in a real world. You must know your- self—both your strengths and your weaknesses and be honest with yourself concerning both. Your self-image must be a reasonable approximation of "you," being neither more than you are, nor less than you are. When it is adequate and one that you can be wholesomely proud of, you feel self-confident. If a scar on the face enhances the self-image (as in the case of the German duelist), self-esteem and self-confi- dence are increased. If a scar on the face detracts from the self-image (as in the case of the salesman), loss of self- esteem and self-confidence results. When a facial disfigurement is corrected by plastic sur- gery, dramatic psychologic changes result only if there is a corresponding correction of the mutilated self-image. Sometimes the image of a disfigured self persists even after successful surgery, much the same as the "phantom limb" may continue to feel pain years after the physical arm or leg has been amputated. Some 15 years ago I became convinced that the people who con- sult a plastic surgeon need more than surgery and that some of them do not need surgery at all. If I were to treat these people as patients, as a whole person rather than as merely a nose, ear, mouth, arm or leg, I needed to be in a position to give them something more. I needed to be able to show them how to obtain a spiritual face lift, how to remove emotional scars, how to change their attitudes and thoughts as well as their physical appearance. Happiness, success, peace of mind, or whatever your own conception of supreme good may be, is experienced in its essence as-more life. When we experience expansive emotions of happiness, self-con- fidence, and success, we enjoy more life. Many people, I am afraid, have read so much of this type of thing that they have come to regard such things as hatred, the "destructive insinct," guilt, self- condemnation, and all the other negatives as "normal human behavior. If this were a true picture of human nature and the human condition, "self-improvement" would indeed be a rather futile thing. However, I believe, and the experiences of my many patients have confirmed the fact, that you do not have to do the job alone. There is within each one of us a "life instinct," which is forever working toward health, happi- ness, and all that makes for more life for the individual. This "life instinct" works for you through what I call the Creative Mechanism, or when used correctly the "Suc- cess Mechanism" built into each human being. New Scientific Insights into "Subconscious Mind" The new science of "Cybernetics" has furnished us with convincing proof that the so-called "subconscious mind" is not a "mind" at all, but a mechanism—a goal-striving "servo-mechanism" consisting of the brain and nervous system, which is used by, and directed by mind. This automatic, goal-striving machine functions very similarly to the way that electronic servo-mechanisms function, as far as basic principles are concerned, but it is much more marvelous, much more complex, than any electronic brain or guided missile ever conceived by man. It will work automatically and impersonally to achieve goals of success and happiness, or unhappiness and fail- ure, depending upon the goals which you yourself set for it. Our Self-Image prescribes the limits for the accomplish- ment of any particular goals. Through our attitudes and interpretations of situations, we "de- scribe" the problem to be worked upon. If we feed information and data into our Creative Mechanism to the effect that we ourselves are unworthy, inferior, undeserving, incapable (a negative self-image) this data is processed and acted upon as any other data in giving us the "answer" in the form of objective experi- ence. Your program for getting more living out of life con- sists in first of all, learning something about this Creative Mechanism, or automatic guidance system within you and how to use it as a Success Mechanism, rather than as a Failure Mechanism. The method itself consists in learning, practicing, and experiencing, new habits of thinking, imagining, remem- bering, and acting in order to (1) develop an adequate and realistic Self-image, and (2) use your Creative Mech- anism to bring success and happiness in achieving particu- lar goals. As you will see later, the method to be used consists of creative mental picturing, creatively experiencing through your imagination, and the formation of new automatic reaction patterns by "acting out" and "acting as if. Acting out new action patterns is no more difficult than "deciding," then follow- ing through on tying your shoes in a new and different manner each morning, instead of continuing to tie them in your old "habitual way," without thought or decision. But no single theory of underlying principles tied all these phenomena together into a concept that made sense. Gerard, writing in Scientific Monthly in June, 1946, on the brain and imagination, stated that it was sad but true that most of our understanding of the mind would remain as valid and useful if, for all we knew, the cranium were stuffed with cotton wadding. However, when man himself set out to build an "elec- tronic brain," and to construct goal-striving mechanisms of his own, he had to discover and utilize certain basic principles. Having discovered them, these scientists began to ask themselves: Could this be the way that the human brain works also? Could it be that in making man, our Creator provided us with a servo-mechanism more marvelous and wonderful than any electronic brain or guidance system ever dreamed of by man, but operating according to the same basic principles? The built-in mechanism in animals is limited to finding food and shelter, avoiding or overcoming enemies and hazards, and procreation to insure the survival of the species. Conse- quently for man to "live" encompasses more than physical survival and procreation of the species. In addition to helping man avoid or overcome danger, and the "sexual instinct" which helps keep the race alive, the Success Mechanism in man can help him get answers to problems, invent, write poetry, run a business, sell merchandise, explore new horizons in science, attain more peace of mind, develop a better per- sonality, or achieve success in any other activity which is intimately tied in to his "living" or makes for a fuller life. Nonetheless the bird "knows" when cold weather is imminent and the exact location of a warm climate even though it may be thou- sands of miles away. In attempting to explain such things we usually say that animals have certain "instincts" which guide them. Ana- lyze all such instincts and you will find they assist the animal to successfully cope with its environment. And their success mechanism is limited to these built-in goal- images, which we call "instincts. Man alone can direct his Success Mechanism by the use of imagination, or imaging ability. We often think of "Creative Imagination" as applying only to poets, inventors, and the like. Although they did not under- stand why, or how imagination sets our creative mecha- nism into action, serious thinkers of all ages, as well as hard-headed "practical" men, have recognized the fact and made use of it. Destroy this faculty, and the condition of man will become as stationary as that of the brutes," said Dugold Stewart, the famous Scot- tish philosopher. Kaiser, who attributes much of his success in business to the constructive, positive use of creative imagination. But new discoveries in the science of Cybernetics all point to the conclusion that your physical brain and ner- vous system make up a servo-mechanism which "You" use, and which operates very much like an electronic com- puter, and a mechanical goal-seeking device. Your brain and nervous system constitute a goal-striving mechanism which operates automatically to achieve a certain goal, very much as a self-aiming torpedo or missile seeks out its target and steers its way to it. Your built-in servo- mechanism functions both as a "guidance system" to auto- matically steer you in the right direction to achieve cer- tain goals, or make correct responses to environment, and also as an "electronic brain" which can function auto- matically to solve problems, give you needed answers, and provide new ideas or "inspirations.

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Physical examination notes the state ously with time with supportive management including of hydration buy 25mg imitrex with amex, weight gain or loss buy imitrex 50mg on line, pulse and respiratory avoidance or discontinuation of toxic agents and resto- rate order imitrex cheap, and pattern of respiration (Kussmal respiration) best buy for imitrex. Following relief of between renal and gastrointestinal (extrarenal) bicarbo- an obstruction, a diuresis may ensue and atten- nate losses. The when the serum total protein, albumin, and phosphate Henderson–Hasselbach equation attributes variation concentrations are approximately normal. Remember that distur- sis, especially if clinicians do not appreciate that bances in hydrogen ion result in change in electrolyte in hypoalbuminemia an anion gap that falls in the composition due to transcellular shifts to maintain elec- normal range may denote a metabolic acidosis. Metabolic acidosis can be classified ing equations [21]: according to whether the anion gap is increased above If albumin is measured in grams per liter (interna- its normal range of 8–12 [20]. Although the compensa- pletely characterize acid–base disorders assuming that tion for more variables is appealing, practically, the nonbicarbonate buffers are normal [15, 59, 60]. A discrepancy of > 2mmHg implies the an understanding of acid–base properties of adminis- presence of an additional respiratory component other tered intravenous fluids [41]. For example, a patient has the fol- In terms of calculations: lowing blood gas finding: pH 7. Optimally, blood and urine samples for evaluation of To assess the nature of the problem, one must exam- any dyskalemia are obtained before commencement of ine (1) body volume status, which influences both specific treatment to correct the imbalance. Although changes in reabsorption or decrease in chloride reabsorption will plasma renin and aldosterone concentrations can be enhance potassium excretion. Conversely, a decrease diagnostic, knowledge of the conditions under which in sodium reabsorption or increase in chloride reab- the samples were obtained is necessary for interpreta- sorption will limit potassium excretion. In the presence of potassium-sparing diuretics as hyperglycemia, where intracellular water moves to (spironolactone, amiloride), antibiotics (trimethoprim the plasma. For each 100 mg dL−1 rise in glucose, there or pentamidine), or calcineurin inhibitors, response to will be a decrease in plasma sodium of 1. Treatment is symptomatic Assessment of dysnatremia includes evaluation of if it is not possible to withdraw or modify drug dose. To generate hypotonic urine it is necessary to the hyperkalemia and also treat the hypertension medi- provide sufficient tubular fluid to the diluting segment ated by the anomaly in sodium chloride reabsorption. The presence or absence of vasopressin in the Although referral for dysnatremia is prompted by serum collecting tubule will determine if water reabsorption sodium values, a change in sodium implies a change in leads to concentrated or dilute urine. Any translocation of water The brain is the target organ for dysnatremia and results from electrolyte transmembrane exchange. The realization led to the concept of electrolyte free water generation and persistence of the water abnormali- clearance (Ce ) to estimate translocation of water. H2O ties seen in dysnatremia are, however, dependent on Electrolyte free water clearance is calculated by modi- changes in renal function or renal free water clearance. Classification of dysnatremic states is based on body Free water clearance, weight, volume status, and osmolar status [7, 19, 44]. Hyperosmolar hyponatremia occurs in severe hyperglycemia or after exposure to mannitol, ethanol, Electrolyte free water clearance, or methanol. Thus, clinical history, physical exam, Ce will be negative with water retention and posi- and consideration of changes in weight are key initial H2O tive with losses of free water. Since there is volume depletion with a tool to assess response to therapy and can guide cerebral salt wasting, assessing other markers such as fluid restriction in hyper or hyponatremia. Urinary include history, and physical examination for signs concentrating defects may lead to dehydration or of dehydration or volume overload such as edema electrolyte imbalance, while ongoing losses (e. Check for presence of a renal to anesthesia, circulatory changes intraoperatively, and concentrating defect and review clinical history for renal water handling. For such as recent cranial surgery or medications such as example, diluting segment dysfunction will result diuretics or lithium. Recent weight changes will pro- from low solute presentation caused by avid proxi- vide additional clues, with the expectation of weight mal reabsorption due to preoperative volume deficits loss with inadequate or delayed replacement of ongo- or unreplaced intraoperative fluid losses. Generally, since the continued loss of free water is likely to lead to this condition is associated with volume depletion and a further increase in serum sodium. With cerebral salt wasting, there from increased salt loading (salt poisoning) results 158 K. Volume depletion, circulatory insufficiency, or marked ongoing water and sodium losses as in inflam- matory bowel disease, fistulae, or prolonged gastric 10. Additional concentrations are low initially and may fall after fluid helpful investigations include serum electrolytes, including serum potassium and calcium to exclude the administration. When this process occurs in the renal tubules, it Rather than yielding an absolute value, renal physiologi- can result in acute kidney injury due to tubular necrosis. Additionally, acute kidney injury may occur secondary to uricosuria and ensuing uric acid nephropathy. The risk of acute kidney injury in tumor lysis syndrome increases when there is preexisting kidney dysfunction or intravascular volume depletion. N Eng J Med 357:797–805 assessment of electrolytes, phosphorus, uric acid, cal- 2. Crit Care Med 35 phate or uric acid crystals may also be visualized in (Suppl):S198–S205 the urine. N Eng J Med 304:373–380 In the face of oliguria with tumor lysis, renal ultrasound 6. Vet Clin N Am Food the assessment of any derangement in fluid or electrolyte Anim Pract 15:447–471 status and in differentiating between expected vs. Pediatr Nephrol 7:268–272 Chapter 10 Tools for the Diagnosis of Renal Disease 161 15. Arch Dis Child 51:875–878 patients after cardiothoracic surgery: a prospective cohort 17. J Am Soc Nephrol 15:1597–1605 assessment of extracellular fluid volume in hyponatremia. J Am Soc Nephrol 11:A0828 Comparison of three different methods of evaluation of meta- 38. Rastegar A (2007) Use of the delta anion gap/delta bicarbo- and tubular disorders. Pediatr Nephrol 9:364–374 ney foundation kidney disease outcomes quality initiative 49. J children and adolescents: evaluation, and classification, Pediatr 123:393–397 and stratification. N hospital induced hyponatremia in children: a physiologic Eng J Med 340:1177–118 approach. Churchill Livingstone, Edinburgh, pp 297–320 ride measurements in critically ill patients. Siggaard-Anderson O, Engel K (1960) A new acid–base nom- interpretation of urinalysis performed by a nephrologist ogram, an improved method for calculation of the relevant versus a hospital based clinical laboratory. Wang Y, Cui Z, Fan M (2007) Hospital acquired and com- acid–base nomogram revised. Scand Clin Lab Invest munity acquired acute renal failure in hospitalized Chinese: 14:598–604 the 10-year review. N Engl J Med 331:250–258 excess or buffer base (strong ion difference) as a measure 68. Treatment was initiated with intravenous not always have renal involvement of their infec- ampicillin and cefotaxime after septic workup was tions [39]. The urine and blood cultures grew Escherichia a hospital originate from the urogenital tract. The spinal fluid examination was unremarkable, half of them can be considered as primary sepsis and culture of the fluid showed no growth. A renal due to the combination of infection and obstruction ultrasound obtained on the day after admission, when within the upper or lower urinary tract, which is due the urine culture result was reported, showed a normal to congenital or acquired causes; however, the other left kidney and a duplicated collecting system on the half may be induced by any urologic intervention right with moderate to severe hydronephrosis. Review of the lit- Infant boys with intact foreskins have a higher risk of erature indicates that secondary bacteremia, or urosep- urosepsis and may not have specific anatomic find- sis, is uncommon, except in young febrile infants and ings. Fungal infections of the urinary tract are Patients with structural or functional obstruction at increasing in frequency [27], likely due to use of inva- any level of the urinary tract, such as calculi, neuro- sive devices that impair physical host defenses and use genic bladder, spinal cord injury, and other uropathies, of broad-spectrum antimicrobial agents that eliminate as well as those with biomaterials or foreign bodies commensal flora. Posterior urethral valves and in very-low-birth weight, premature infants, and immu- other congenital obstructions of the urethra are par- nocompromised children [23]. These Although retrograde ascending infection is probably anomalies are unique to male children. Occasionally the most common pathway, seeding from systemic girls with bladder outlet obstruction secondary to and nosocomial infection is a significant pathway to ureteroceles or neoplasm may present with a similar infection in infants and immunocompromised chil- clinical picture [22, 28].

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