Difficult Passage Research Articles

A broken metallic tracheostomy tube.

Tracheostomy is an upper airway bypass which is life saving in certain occasions. However, there are several early and late complications. One of these rare mishaps is the broken cannula, few cases of which has been reported so far. Herein we are reporting a rare case of broken tube as a late complication of indwelling tracheostomy tube. A 52 year old woman with moderate respiratory distress was brought to the otolaryngology emergency ward. The patient’s past history included 2 thyroid surgeries for papillary carcinoma 3 years earlier and since then she was dependant on the tracheotomy tube. She had been using the metallic double lumen tube and she did frequently take the tube out (the outer cannula!), clean it and put it back in place. About 2 hours before admission she felt difficult air passage due to the dried secretions and she had tried to take the tube out but it broke and only the neckplate came out with the cannula remaining in the trachea. X-ray was taken which confirmed the patient’s statement. The patient was admitted in the operating room and under systemic intravenous sedation the tube which had moved a bit deeper then, was taken out using long forceps. The patient was discharged the day after (fig.1). Fig. 1 Chest-X-ray showing the metallic cannula within the trachea

Surveys of the Milky Way and Magellanic System in the λ21-cm line of atomic hydrogen

In the next three years, surveys of the Northern and Southern skies using focal plane arrays on aperture synthesis radio telescopes will lead to a breakthrough in our knowledge of the warm and cool atomic phases of the interstellar medium and their relationship with the diffuse molecular gas. The sensitivity and resolution of these surveys will give an order of magnitude or more improvement over existing interstellar medium data. The GASKAP (South) and GAMES (North) projects together constitute a complete survey of the Milky Way plane and the Magellanic Clouds and Stream in both emission and absorption in the H I 21-cm line and the OH 18-cm lines. The overall goal of this project is to understand the mechanism of galaxy evolution, through a detailed tracing of the astrophysical processes that drive the cycle of star formation in very different environments. Comparison of 21-cm emission and absorption highlights the transition from the warm, diffuse medium to cool clouds. Tracing turbulence in the Magellanic Stream shows how extra-galactic gas makes the difficult passage through the halo to replenish the disk. Finally, high resolution images of OH masers trace outflows from evolved stars that enrich the medium with heavy elements. To understand how the Milky Way was assembled and how it has evolved since, the speed and efficiency of these processes must be measured, as functions of Galactic radius and height above the plane. Observations of similar processes in the Magellanic Clouds show how differently they might have worked in conditions typical of the early universe.

Judah Comes to Shiloh: Genesis 49:10bα, One More Time

The four-word phrase עד כי־יבא שילה in Gen 49:10ba is known as most famous crux interpretum in the entire Old Testament.1 Over the centuries, it has been construed in multiple and diverse ways, both within the framework of broader projects and in its own right.2 With even remotely sustainable options exhausted as a result, exegetical focus has notably shifted in recent decades toward the fine tuning of arguments pro and contra a handful of the most plausible interpretations. The latest manifestation of this trend is Richard C. Steiner's JBL article in which he offers, among other things, new considerations in favor of the reading until trib ute comes [sc. (with שילה understood as two words, שי לה), first suggested by aggadic midrash.3 While this reading has much commend it and Steiner's discussion bolsters it even further, it is premature to speak of an emerg ing consensus on it because an alternative construal of the phrase, until he [sc. Judah] comes Shiloh, may be even more compelling.4 What renders the case for reading Gen 49:10ba as until tribute comes him exceptionally strong is that it makes good, contextually suitable sense of a difficult passage without emending the masoretic consonantal sequence or presupposing otherwise unknown grammatical, syntactic, or lexical phenomena. Yet it has at least

Mark for the Nations: A Text- and Reader-Oriented Commentary. By LARS HARTMAN.

A colleague peered at the subtitle of this book, and enquired: ‘What other kind of commentary might there be, that is not oriented towards the text and its reader?’ And he has a point, although nowadays one understands what is meant. One of the strengths of this new commentary is that it takes seriously the challenge to construct the ‘implied reader’, with occasionally quite illuminating results. It is translated from the Swedish by the author, and occasionally, one must admit, it feels like it. The commentary is aimed at students of theology, pastors, and the ordinary person in the pew, which is perhaps just too wide a range, although it can certainly be safely put in the hands of first-year undergraduates studying theology. The strength of this book lies in its recognition that Mark is literature, aimed at the ears of his contemporary congregation, so it is rooted in a particular time and place, and Hartman allows the ensuing strangeness simply to be strange. His translation of the text of Mark is refreshing and interesting, with a sensible system of ‘Notes’ on detailed matters of scholarship, then ‘Analysis’, showing how the pericope is organized, and finally ‘Exposition’: what the text might have meant to the earliest readers. Hartman also includes some very useful references to relevant portions of Greek literature, on which he is decidedly knowledgeable; he is very much at home in the Hellenistic and Jewish worlds. His competence in Greek also enables him to defend his translation of the original when it strays from the conventional. He is, too, unafraid to face head-on the kind of question that might be raised by readers today, such as whether God can be said to intervene ‘miraculously’, and to what extent Jesus might be said to have done so. Not all of his ‘notes’ cover the issues that at least this reader would have liked to see covered, but you cannot do everything (and this is already a very long book). There are some very useful Excursūs, especially perhaps no. 8 on the ‘Son of Man’ and no. 13 on ‘Jesus and Mary’. Hartman makes some very perceptive remarks, notably, I thought, on the similarities between Mark 3:20–5 and 4:1–34, and in his Exposition on the Transfiguration. There are some detailed expositions of stories, with some very interesting angles, such as those on the Feeding of the 5,000 and the Walking on the Water. If I have a general criticism, I should have to say that he gives us too much. I found it hard, for example, to grasp what he was saying in his explanation of the notoriously difficult Mark 4:10–12. The book could have done with some paring-down in the copy-editing stage, in his exposition of the Bartimaeus pericope, or on Mark 11:1 – 12:12, which is in many respects quite brilliant, but in which I found hard to know quite what the author was saying, so much material does he offer. For a similar reason, that of offering too much, he does not quite do justice to the astonishing encounter with the scribe in 12:28–34. His English is idiosyncratic in places, too; I observed a fondness for the use of ‘verisimilar’, which jarred a bit, and for the impersonal pronoun ‘one’. But one must not be churlish; this is a useful book, perhaps best employed for dipping in, rather than for reading all the way through at a single sitting; it may be helpful for sorting out what the reader thinks of a particularly difficult passage. There is an admirable overview of the gospel as a whole (pp. 672–85); and, though it is far from easy reading, I should class it as safe to put in the hands of an inexperienced student.

Constipation: symptoms, assessment and treatment

Chronic constipation is one of the most common lower gastrointestinal disorders affecting people in the western world (Muller-Lissner et al, 2005), with far reaching economic consequences. In 2009, the cost of prescribed laxatives was more than £60 million for primary care in England alone (NHS Business Services Authority, 2009), with many more laxatives being bought directly overthe-counter. These facts demonstrate the need for nurses to possess the skills and knowledge to assess constipation competently to make a clear diagnosis. If pharmacological interventions are required, it is essential that all nurses (especially those who prescribe) are not only conversant with laxatives recommended by local prescribing formularies, but with all other alternative treatment modalities as well. Constipation is characterized by a real or perceived change in normal bowel habit that is unsatisfactory because of both infrequent and difficult passage of hard stools, or feelings of incomplete defecation. Constipation is multifactoral, often with complicated underlying pathophysiology, and can be influenced by physical, psychological, physiological, emotional and environmental factors. A patient with constipation may experience a variety of symptoms. These can range from headache and fatigue to feelings of bloatedness, and/or loss of appetite leading to nausea and vomiting. Patients with cognitive impairment may also present with increased physical and verbal aggression owing to their constipation (Leonard et al, 2006). The consequence of persistent or poorly managed constipation can lead to disabling complications for the patient such as haemorrhoids, faecal impaction, faecal impaction with spurious overflow, urinary incontinence, bladder outlet obstruction, urinary tract infection, rectal bleeding, general weakness and psychological disorders. Persistent straining at stool results in increased intrathoracic pressure, which can give rise to a reduction in coronary and peripheral circulation leading to other possible complications, e.g. the development of hernias, worsening of gastrooesophageal reflux, and transient ischaemic attacks. Assessing patients with constipation presents many challenges to the health professional in overcoming communication barriers associated with bowel habits and the embarrassment associated with an intimate rectal examination. Also, as constipation may not result from a single straightforward cause, assessment is based on consideration of all possible causes, checking in particular that it is not caused by an underlying undiagnosed medical condition. Evidence-based guidelines (National Institute for Health and Clinical

Countdown to global zero – on hold?

Two-and-a-half years after US President Barack Obama made a speech in Prague outlining his commitment to nuclear disarmament, many have been disappointed by the subsequent slow progress on the issue. A new Strategic Arms Reduction Treaty had a difficult passage through Congress during 2010 (despite the treaty's modest ambitions); the United States has not significantly changed its nuclear deterrence doctrine nor ratified the Comprehensive Nuclear Test Ban Treaty; and Pakistan has blocked an envisaged Fissile-Material Cut-off Treaty. Although the so-called Prague agenda was cautious from the outset, it has been slower than envisioned.

Metaphysics XII 7, 1072A27-B1: An Argument of Identity

The paper analyses the argumentative structure of a difficult passage from Aristotle's Metaphysics XII 7 on the basis of a topos of sameness provided in Top. VII 1. In doing this the article gives an example of how Aristotle's treatises on dialectic can prove useful to understand what he says in his more philosophically committed writings. The article also shows how general argumentative techniques and more or less explicit specific philosophical assumptions interact in shaping Aristotle's arguments and how the distinction of these different factors can help us have a better grasp on Aristotle's text.

Happiness, Well‐being, and Their Relation to Virtue in Descartes' Ethics*

AbstractMy main thesis in this article is that Descartes' ethics should be understood as involving a distinction between happiness and well‐being. The distinction I have in mind is never clearly stated or articulated by Descartes himself, but I argue that we nevertheless have good reason to embrace it as an important component in a charitable reconstruction of his ethical thought. In section I, I present Descartes' account of happiness and of how he thinks happiness can (and cannot) be acquired. Then, in section II, I introduce and develop the distinction between happiness and well‐being. I do this via a discussion of a difficult passage in one of Descartes' letters to Elisabeth, where he may seem first to grant and then immediately to reject the view that people's happiness can vary in degree depending on the possession of goods or perfections that are outside their power to control. I believe my proposed distinction can help us make good sense of this passage. In the last two sections (III and IV), I then offer some further grounds or reasons for why the proposed distinction should be ascribed to Descartes.

The Pathophysiology of Chronic Constipation

Constipation is broadly defined as an unsatisfactory defecation characterized by infrequent stools, difficult stool passage or both. The common approach to the pathophysiology of constipation groups the disorder into primary and secondary causes. Primary causes are intrinsic problems of colonic or anorectal function, whereas secondary causes are related to organic disease, systemic disease or medications. The normal process of colonic transit and defecation is discussed, and the etiology of constipation is reviewed.

The pathophysiology of chronic constipation

Constipation is broadly defined as an unsatisfactory defecation characterized by infrequent stools, difficult stool passage or both. The common approach to the pathophysiology of constipation groups the disorder into primary and secondary causes. Primary causes are intrinsic problems of colonic or anorectal function, whereas secondary causes are related to organic disease, systemic disease or medications. The normal process of colonic transit and defecation is discussed, and the etiology of constipation is reviewed.

Diskussion / Discussion: Ist der Soter in Ptolemäus’ Epistula ad Floram der Demiurg? Zu einer These von Christoph Markschies

AbstractSome years ago, Christoph Markschies suggested a new interpretation of the diffi cult passage 3,6 in Ptolemy’s Epistula ad Floram: The Creator/Demiurge and the Redeemer/ Soter are identical, therefore Ptolemy did not hold the Gnostic teachings that Irenaeus attributes to him. This article is a reply to Markschies’ suggestion. It offers an analysis of what Ptolemy, in the entire Epistula ad Floram, has to say about the Creator and the Redeemer. This leads to the conclusion that Markschies’ interpretation of the passage 3,6 is not probable; for Ptolemy, the Creator and the Redeemer are in fact two different characters and are clearly distinguished from each other: While the Creator is an intermediate being, the Redeemer shares in the nature of the perfect God.

Das Buch Numeri jenseits der Quellentheorie. Eine Redaktionsgeschichte von Num 20–24 (Teil I)

Despite all efforts to explain the formation of the difficult passage Num 20–21 through the means of Source Theory, Biblical scholars have come up against limiting factors since the time of Noth. Therefore the present study tries a fresh approach by using compositional- and redaction-historical methods for reconstructing the important stages of the literary history of Num 20–24. Three layers can be detected: First, a non- and pre-Priestly layer in Num 21,(1–3.)4–20* (apart from »from mount Hor« V. 4 and V. 13aβb); second, a Priestly layer in Num 20,1–13.22–29* (apart from V. 23b*); 21,4* (only »from mount Hor«); 22,1; and third, a non- and post-Priestly layer Num 20,14–21.23b*; 21,13aβb.21–35; 22,2–24,19.25. Especially the third layer, which includes the stories about the encounter with Edom and the victory over Sihon, requires a new model of explanation.

Individual differences in the neural basis of causal inferencing

This study used fMRI to examine individual differences in the neural basis of causal inferencing. Participants with varying language skill levels, as indexed by scores on the vocabulary portion of the Nelson–Denny Reading Test, read four types of two-sentence passages in which causal relatedness (moderate and distant) and presence or absence of explicit clause connectives were orthogonally varied to manipulate coherence and cohesion during inference generation. Skilled readers showed better neural efficiency (less activation) during all context sentences and during all inference conditions. Increased activation in less-skilled readers was most extensively distributed in the right hemisphere (RH) homologues of left hemisphere (LH) language areas, especially in the most difficult passage types. Skilled readers also showed greater sensitivity to coherence (greater activation and synchronization in moderately related than distantly related passages) whereas less-skilled readers showed sensitivity to cohesion (greater activation and synchronization when clause connectives were present than when they were not). These finding support the hypothesis that skilled reading comprehension requires recruitment of the RH on an “as needed” basis. We describe the dynamic spillover hypothesis, a new theoretical framework that outlines the conditions under which RH language contributions are most likely evoked.

Comparison of the pain experienced by infertile women undergoing hysterosalpingo contrast sonography or radiographic hysterosalpingography

Objective To evaluate the pain and cause of pain experienced by women undergoing hysterosalpingography (HSG) and contrast hysterosalpingo sonography (HyCoSy) with air in a saline solution for the assessment of uterine and tubal patency. Method In this prospective study, 121 infertile women undergoing these 2 procedures measured the pain incurred using a digital/analog scale (1–10). We looked for correlations between pain level and variables pertaining to the procedures. Vagal effects and their persistence were also recorded. Results The pain was less during HSG (median, 5) than during HyCoSy (median, 7). It was greater than menstrual pain for 38.8% of participants during HSG and for 70.5% of participants during HyCoSy. There was no correlation between pain and difficult catheter passage, degree of tubal obstruction, volume of contrast medium injected, or presence of IgG antibodies to Chlamydia when these variables were studied for HyCoSy alone. However, the strong correlation between pain score and volume of contrast medium injected during each procedure seems to explain the significantly higher pain levels during HyCoSy ( P < 0.001). In 65.3% and 57.8% of participants, respectively, the pain disappeared immediately after the HSG or HyCoSy. Only mild vagal effects were recorded following both procedures, in 0.8% of participants after HSG and 2.5% of participants after HyCoSy. Conclusion Hysterosalpingo contrast sonography is similar to HSG regarding rapidity of pain disappearance, and infrequency and moderation of vagal effects, but the level of pain is slightly higher, probably due to the greater volume of medium injected.

Guide Helps Students, Parents Negotiate Difficult Passage

Guide Helps Students, Parents Negotiate Difficult Passage

Self-Awareness (svasaṃvedana) in Dignāga’s Pramāṇasamuccaya and -vṛtti: A Close Reading

The concept of “self-awareness” (svasaṃvedana) enters Buddhist epistemological discourse in the Pramāṇasamuccaya and -vṛtti by Dignāga (ca. 480–540), the founder of the Buddhist logico-epistemological tradition. Though some of the key passages have already been dealt with in various publications, no attempt has been made to comprehensively examine all of them as a whole. A close reading is here proposed to make up for this deficit. In connection with a particularly difficult passage (PS(V) 1.8cd-10) that presents the means of valid cognition and its result (pramāṇa/pramāṇaphala), a new interpretation is suggested, inspired by the commentary of Jinendrabuddhi. This interpretation highlights an aspect of selfawareness that has hitherto not been claimed for Dignāga: self-awareness offers essentially subjective access to one’s own mental states and factors.

Testing Adult Pacific Lamprey Performance at Structural Challenges in Fishways

AbstractAdult Pacific lampreys Lampetra tridentata migrate through areas of difficult passage and high water velocity by attaching their oral discs to substrate and then releasing and bursting upstream. In fishways at dams, this burst‐and‐attach behavior can be ineffective, particularly where suitable attachment surfaces are unavailable. We used an experimental fishway to test performance of adult Pacific lampreys when confronted with a series of structural challenges. These included vertical steps near fishway weir orifices, squared versus rounded orifice entrances, and floor‐mounted metal grates. All experimental challenges simulated common existing structures in weir‐and‐orifice fishways at Columbia and Snake River dams. Most experiments were paired with field evaluations of radio‐tagged Pacific lampreys or video observations of untagged individuals in situ. Field and experimental results consistently indicated that the structural challenges reduced passage efficiency and lengthened passage times. Improving Pacific lamprey passage may be facilitated by removing or modifying vertical steps and other sharp‐edged corners and by providing adequate attachment surfaces. Such accommodations should be especially beneficial in areas with high water velocity. The findings demonstrate how fish morphology and behavior should be explicitly considered in the design or retrofitting of fish passage structures.

Midline submental orotracheal intubation in maxillofacial injuries: A substitute to tracheostomy where postoperative mechanical ventilation is not required

Maxillofacial fractures present unique airway problems to the anaesthesiologist. Nasotracheal intubation is contraindicated due to associated Lefort I, II or III fractures. The requirement for intraoperative maxillomandibular fixation (MMF) to re-establish dental occlusion in such cases precludes orotracheal intubation. Tracheostomy has a high complication rate and in many patients, an alternative to the oral airway is not required beyond the perioperative period. Hernandez1 in 1986 first described "The submental route for endotracheal intubation". Later some workers faced difficult tube passage, bleeding, and sublingual gland involvement with this approach. They modified this to strict midline submental intubation and there were no operative or postoperative complications in their cases.67&8. Therefore we used mid line approach for submental orotracheal intubation in this study to demonstrate its feasibility and reliability and that it can be used as an excellent substitute to short term tracheostomy. PATIENTS #ENTITYSTARTX00026; We used midline submental intubation in 25 cases selected out of 310 consecutively treated patients with maxillofacial trauma over a 3 year period. After induction orotracheal intubation was done with spiral re-inforced tube. A 1.5-2.0 cm skin incision was made in the submental region in the midline 2.0 cm behind the symphysis and endotracheal tube was taken out through this incision in all the cases. At the end of the surgery the procedure was reversed, the submental wound was stitched; all the patients could be extubated & none of them required post-operative mechanical ventilation. There were no significant operative or postoperative complications. Postoperative submental scarring was acceptable([6]). We conclude that midline submental intubation is a simple and useful technique with low morbidity. It can be chosen in selected cases of maxillofacial trauma and is an excellent substitute to tracheostomy where postoperative mechanical ventilation is not required.

APA Seeks Ideas to Sever Mental Illness, Delinquency Link

APA Seeks Ideas to Sever Mental Illness, Delinquency Link

Is That a Rhetorical Question? Shipwrecked Sailor (pHermitage 1115), 150 Reconsidered

Abstract This article examines a difficult passage from the Tale of the Shipwrecked Sailor (pHermitage 1115, 150). Near the end of the story, the official relates the good deeds which will be performed on behalf of the divine snake if he allows the official to return home. The snake’s enigmatic response has provoked a variety of interpretations. It may be possible to resolve the questions surrounding this section of the tale by understanding the passage as a rhetorical question used by the snake to trump the official.