Minocycline

Andrew Ian Stolbach, M.D., M.P.H.

• Associate Professor of Emergency Medicine

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0022077/andrew-stolbach

Dysfunction of any of these three systems can lead to immediate or long term response which compromise stability and may cause pain virus 2014 symptoms minocycline 50mg fast delivery. The second paper describes the neutral zone of intervertebral motion yeast infection 8 weeks pregnant purchase minocycline 50 mg on line, around which little resistance is offered by the passive stabilizing components of the spine antibiotics for sinusitis discount minocycline amex. The authors emphasize that roentgenographic changes infection 2 game hacked discount minocycline 50mg on-line, particularly those associated with degeneration infection vs colonization minocycline 50 mg line, have no relationship to insta bility infection attack 14 order minocycline in united states online. Further kinematic measurement tech niques employing kinematic frames attached directly to external fixation techniques are cited as promising for the fidelity of the data they may provide. The limitations of a purely mechanical definition of clinical instability are discussed. BrinckmannP, FrobinW, HierholzerE, HorstM(1983)Deformationofthevertebralend plate under axial loading of the spine. Cappozzo A (1984) Compressive loads in the lumbar vertebral column during normal level walking. Chazal J, Tanguy A, Bourges M, Gaurel G, Escande G, Guillot M, Vanneuville G (1985) Bio mechanical properties of spinal ligaments and a histological study of the supraspinal liga ment in traction. Nachemson A (1966) Electromyographic studies on the vertebral portion of the psoas mus cle; with special reference to its stabilizing function of the lumbar spine. Pearcy M, Portek I, Shepherd J (1984) Three-dimensional x-ray analysis of normal move ment in the lumbar spine. Tsantrizos A, Ito K, Aebi M, Steffen T (2005) Internal strains in healthy and degenerated lumbar intervertebral discs. TveitP, DaggfeldtK, HetlandS, ThorstenssonA(1994) Erector spinaelever arm lengthvar iations with changes in spinal curvature. These devices principles reduces function to provide spinal stability and thus facilitate bone healing leading to spi the rate of implant failure nal fusion (spondylodesis). Fundamental biomechanical knowledge and its and non-union application serves to improve the performance of the individual spine surgeon with respect to the rate of bony fusion, implant failure or degree of deformity cor rection. And there is still an incomplete understanding of spinal biomechanics and even more so of the underlying biology. Moreover, apparently advantageous biome chanical concepts do not necessarily lead to a better patient outcome. Indeed, whole volumes have been written about the definition and assessment of spinal instability and the biomechanics of spinal stabilization [11, 103]. A milestone in the history of spine research was the introduction of universal concepts for the biomechanical testing of spinal implants by Manohar M. Panjabi, taking into consideration three major aspects [65]: 68 Section Basic Science Key properties are material implant strength (failure load) strength, stability and fatigue (longevity under cyclic loading) fatigue resistance ability to restore spinal stability However, in vitro testing for primary implant stability usually comprises non destructive testing protocols with only a few cycles, and therefore takes into account neither the effect of repetitive loading (fatigue) nor the biological host reaction. For a successful to the individual case patient outcome it is important that one chooses the appropriate implant and technique, considering the specific nature of each case. Before selecting an instrumentation system to restore or maintain stability of the compromised spine, it is a prerequisite to understand the functions of the respective structures and how the biomechanics are changed by their loss. In this case, the screws would most likely fail, result ing in a post-traumatic kyphosis, because anterior support was mandatory. The goals of spinal With the exception of the recent developments in non-fusion devices such as instrumentation are to spinal arthroplasty and posterior dynamic systems, spinal stabilization is a stabilize, correct and fuse means to achieve the end goal of a solid bony fusion. Aspects such as kyphotic or lordotic curve, inherent mobility, loading conditions as well as bone healing potential have an influence on the choice of implant and surgical approach. For this reason spinal implants not only differ in size but also follow different preferred region-specific stabilization principles. For detailed informa tion about individual implants and anatomical regions, the reader is referred to the clinical chapters of this book and the literature cited in the references. Since nowadays it is still only approximately possible to assess the individual case in advance concerning spinal stability, individual constitutional and genetic factors as well as biological responses. But this also implies that instrumented fusion is sometimes overpowered (too rigid) or is sometimes not indicated at all. This is impressively demonstrated by the safe and reliable posterior in-situ fusion (without instrumentation) in lumbar lytic spon dylolisthesis in children [87]. Loading and Load Sharing Characteristics Spinal instrumentation and the stabilized spine segment form a mechanical sys Mainly muscle forces have tem, a couple, which shares loads and moments. In-vivo telemetry has provided an influence on internal valuable insights into the complex three-dimensional loading of internal fixa fixator loads while posture tors during daily physiological activity [77]. Several interesting conclusions can is less important be drawn from these studies: mainly muscle forces were influencing fixator loads. Flexion/extension movements as well as wearing braces or harnesses did not significantly affect fixator loads. Sitting and standing exhibited similar loads and erect standing and walking resulted in the highest loads. On this basis, it was dem the loading pattern of the onstrated that spinal loads during flexion and extension were carried predomi implant is critically nantly by equal and opposite forces in the disc and the fixator constituting a force dependent on the motion couple. However, for side bending the majority of loading was transferred through equal and opposite forces in the fixator rods. In flexion-extension load is mainly transferred by the disc-fixator force couple through equal and opposite forces. But how does the load distribu tion change with an insufficient anterior column support, which may be found in various spinal disorders. Tak ing this information into consideration, in the clinical setting postoperative lat eral bending (and torsion) should be avoided by the patient in any event to mini mize fixator loads whereas flexion and extension are mostly unproblematic pro vided there is a functioning anterior column. If instrumentation devices are exposed to such high moments, the safe limit for many implants may be Anterior column defects exceeded. Therefore, in the case of a substantially unstable anterior column, require anterior buttressing additional anterior support is critical to prevent hardware failure. Further work is required to characterize the force and load transfer through intervertebral devices, corpectomy cages and other stabilization constructs. However, it does not necessarily mean that the device itself is exclusively acting on the posterior spinal column. In contrast to the usage of long rods, now short segment stabilization using pedicle screws and rigid connecting plates or rods has become possible. For example, after corpectomy and bisegmental instrumenta tion using a spacer and a cross-linked pedicle screw/rod system, motion is reduced by up to 85% in flexion, 52% in extension, 81% in lateral bending and 51% in axial rotation [7]. This applies also for monosegmental instability with destruction of the posterior elements combined with a partial dissection of the intervertebral disc. Here most other pos terior instrumentation devices also exceed the physiological stability, but with the short segment fixator being the stiffest [1]. However, after complete removal of the posterior structures combined with a complete disruption of the intervertebral disc but with the pedicle screw instrumentation in place, the range of motion for flexion/extension was increased by 21% compared to the intact spine. The stability of pedicle screw systems is derived from the solid anchorage of the screw in the pedicle and the inherent rigidity of the connecting hardware. While the pullout strength of pedicle screws is directly related to the bone density [39], it can be increased by choosing convergent screw trajectories (Fig. Here, diagonal cross-linking is favorable to the horizontal configuration in terms of rotational stability [29, 100] (Fig. The material, length and diameter of the connecting rods determine their stiffness. Pedicle screw positioning the use of convergent screw trajectories (right) increases the pull-out strength and overall stability of pedicle screw con structs, in comparison with parallel screw insertion (left). Therefore, current implant designs are a compromise between an absolutely rigid fixation and a minimal risk of implant failure to provide stable fixation with a proven service life [7]. Thoracicpediclescrew positioning In contrast to the standard intrapedicular screw insertion (left pedicle), an extrapedicular screw trajectory (right pedicle) allows a greater margin of safety with respect to the spinal canal and offers greater pull-out strength and stability. The pull out strength is increased by a greater screw-angu positioning is safe and bio lation, longer screw length, and the penetration of additional cortices. The use of simple laminar hooks in the thoracic spine is safe with respect to the damage of neural structures. However, hook disengagement has been reported in scoliosis correction surgery [38]. Thenowwidelyacceptedtranslaminar facet joint screw effectively stabilize the placement (Fig. Here incompetent facet joints frequently allow pathological shear translation (olisthesis) and segmental multiplanar rota tion. Biomechanical testing has shown that isolated screw fixation of the facet joints causes a moderate stabilization in all loading directions [72]. Therefore for posterior and posterolateral spondylodesis, the combination with facet fusion is generally recommended as it enhances stability [96]. Occipitocervical Fixation the evolution of occipitocervical fixation started with pure in-situ bone graf ting, after which came wire techniques, first without and later with attached steel rods, then followed by plate/screw instrumentation in the 1990s and most recently modular combined plate-rod/screw instrumentation [46, 99, 102]. The major advantage of the latter is its greater stability, allowing the abandonment of supplemental external fixation such as halo fixators or Minerva jackets. Basically the same principles of posterior fixation as described above apply to Lateral mass and pedicular the occipitocervical junction. Cortical thick ness is greatest at the midline and the superior and inferior nuchal lines [75]. The surgical approach is tradi tionally more or less from anterior depending on the body region and the neigh boring cavity. Even if in the past anterior lumbar instrumentation has been questionable for some indications in the presence of sound alternatives, in the future and with the advance of disc art hroplasty, anteriorsurgerywillprobablygaininpopularity. As a surgical measure interbody fusion includes an at least partial removal of the intervertebral disc and of the cartilaginous endplates and subsequent filling-up of the disc space with (structured) bone graft or nowadays increasingly with artificial spacers (cages). On the other hand, the bone graft around and within the cage must be stressed and strained sufficiently to evoke the biological signals (release of cytokines) for bone formation [17, 84] (Table 2). When implanting interbody devices, the partial removal of the endplate is a Peripheral endplate prerequisite for proper graft incorporation, but a bleeding cancellous bone bed buttressing reduces cage may also compromise the support of the device, especially if limited contact areas subsidence are present. Resistance to implant subsidence critically depends on the quality of underlying trabecular bone [47]. Do not use stand-alone the indications for anterior fusion of the spine are various and include disci lumbar interbody cages tis/spondylitis and vertebral burst fractures but they are still also often contro without additional fixation versial, especially for lumbar back pain. If the surgeon decides to remove the disc, the resulting degree of instability must be estimated before choosing the type of implant and extent of surgery. This has led to the opin Overdistraction with a cage ion that stand-alone cages and anterior bone grafts cause segmental distraction results in facet joint and thereby incongruence of the facet joints (Fig. This indicates that, with dis traction of the disc space and consequent tensioned anulus fibers, a compressive force on the cage is created. Therefore, from the above-mentioned studies it can be concluded that posterior instrumentation with pedicle screws or translaminar screws in addition to the interbody cage must be recommended to establish the appropriate stability. Motion analysis demonstrated a significant increase in segmental stiffness with the Synfix compared to cage/ translaminar screw instrumentation in flexion-extension and rotation [16]. For a defi nite judgment the comparative biomechanical behavior under repetitive loading (fatigue) as well as clinical results and fusion rates need to be evaluated. Indications are theoretically numerous and apply for myelopathy, neo plastic and metastatic tumor growth, chronic spondylitis or severe fracture cases. However, the resulting instability, and thus the demand on the instrumen tation, strongly depends on the number of involved levels and the preserved and functioning stabilizers. Furthermore, biomechanical tests have shown that corpec tomy cages alone or in combination with an anterior angle-stable plate fixation are not capable of restoring physiological bisegmental stability. As segmental flexibility with either a stand-alone cage or a cage/anterior plate combination is especially increased in rotation, extension and lateral bending, the addition of pedicle screw fixation must be recommended to ensure a significant increase in overall stiffness [66]. Anterior Tension Band Technique Anterior cervical plating Anterior cervical plates act as typical tension bands during extension but func bears the risk of stress tion as buttress plates during flexion. Anterior cervical plates are non-union either constrained or unconstrained devices and are available as dynamic plates in various lengths. In biomechanical testing, con strained systems have shown a greater rigidity, whereas unconstrained plates can lose a significant amount of their stability over time [92]. Further improvements in stabiliza tion have been made using monocortical locking expansion screws, their strength being comparable to bicortical screws [74]. But no significant differ ences in stability were seen on kinematic testing [68]. This is particularly true for the latest gener ation of constrained (locking) plates, with which it is more difficult to set the graft under compression. Due to its profile and their position directly on the anterior column, bending forces are much lower than for posterior pedicle screw systems. However, their stabilizing potential is also lower, due to a shorter effective lever arm. Compared to pedicle screws, the anterior rod devices were slightly more unstable in flexion and lateral bending. In lateral bending, the implants provided better stabiliza tion when the spine was bending away from the implant side, as the devices act as a tension band.

Pilot studies done in our lab found that intraurethral inoculation compared to direct injection of bacteria to the prostate gave the same results (in regard to infection/inflammation) but the intraurethral method was not as reproducible as the direct injection (data not shown) antibiotic 3 times a day buy 50mg minocycline free shipping. We found no differences in the amount of bacteria recovered from the animals infected with the non-prostate derived P antibiotic for bronchitis generic minocycline 50 mg fast delivery. Corpora amylaceae (prostate concrements composed of calcified proteinaceous material) are commonly seen in human prostate samples and they may promote chronic inflammation by causing tissue damage 2 virus 90 buy minocycline with visa. Corpora amylaceae are probably formed from cellular debris created during chronic inflammation 243 antibiotics history cheap minocycline 50mg on line. Experimental animal models for bacterial prostatitis have mainly been studied with uropathogenic E bacteria legionella purchase minocycline 50mg without prescription. All these organisms were able to induce a chronic inflammatory state in the rodent prostate and showed many similarities to the natural history of human chronic bacterial prostatitis antimicrobial guidelines 2013 minocycline 50 mg discount. Differences in susceptibility to infection between different mice and different rat strains have been reported 11, 249 and indicate that host genetics is important for developing bacterial prostatitis. Also specific virulence factors carried by the bacteria play an important role for maintaining a chronic infection 248, 252, 253. Whether the Sprague Dawley rat is an ideal model to study bacterial prostatitis and in particularly P. Wistar rats have been reported to be more susceptible to chronic bacterial infection compared to Sprague Dawley rats when intraurethrally infected with E. The well-defined order of basal and secretory luminal cells disappeared and the distinction between stroma and glandular epithelium was difficult to identify. In the glandular lumina, numerous necrotic and apoptotic cells were seen together with macrophages. This was confirmed by enhanced BrdU (labelling proliferating cells) staining in epithelial cells. Moreover, we saw that expression of the androgen receptor in the epithelium was decreased in inflamed areas. Furthermore, these observations were accompanied by increased proliferation in the inflamed areas 160. The glandular walls were much thicker and consisted of an increased amount of smooth muscle cells. Smooth muscle cells play a central role in the regulation of prostatic growth and function. Therefore, the maintenance of the smooth muscle phenotype is critical for prostate gland homeostasis 257. The smooth muscle cell response to prostatic infection have also been examined in other studies 246, 247, 258, 259 observing similar results to ours. Smooth muscle cells responded to infection stimuli by changing their contractile phenotype toward a secretory profile both in vitro 258 and in vivo 246. Moreover, infection stimulated secretion of pro-inflammatory cytokines have growth promoting activities 258, 259. Dedifferentiated smooth muscle cells, increased production of growth factors and angiogenesis are common features in the reactive stroma accompanying the tumour cells in human prostate cancer. In this sense, the stromal response to infection is in many ways similar to that seen in prostate carcinogenesis. Inflammation is known to induce oxidative stress as a consequence of the production of reactive oxygen released by the inflammatory cells 260. The association of oxidative stress with prostate cancer has been recognized in several studies 76, 159, 261. Actually, we could detect epithelial cells with mild atypia in the inflamed areas. Apart from our investigation, two studies have evaluated the possible influence of chronic infection and the development of prostate cancer. These investigations both utilized a mouse model where the animal prostates were intraurethrally inoculated with uropathogenic E. In none of the models cancer was induced but potentially precancerous lesions were detected and the inflammation appeared to be more long lasting and to induce somewhat more epithelial atypia than in our P. In one of these studies chronic inflammation was shown to be associated with reactive epithelial hyperplasia and oxidative stress 159. Modifying the model by using rat strains more susceptible to prostatitis, repeated injections of bacteria or/and using other species and mice with specific alterations in their immune system (similar to those described in men with increased risk of acquiring prostate cancer) might be an opportunity. The effects of combined infection with the two bacterial species known to induce potential precancerous lesions in the prostate, uropathogenic E. Potential weaknesses in the study: the species we used in this infection model (Sprague Dawley rats) is probably not ideal for induction of prostatitis 42 and prostate cancer development. Rats are in general resistant to infections and the Sprague Dawley rats in particular 11. A more ideal species could perhaps be dogs (prostate cancer is actually a very uncommon disease in animals, except in men and dogs) or mice genetically modified to increased susceptibility to chronic prostatitis and/or prostate cancer. General discussion and future directions the overall aim of this thesis was to investigate if microorganisms are present in prostate tissues and if so if they are related to the aetiology and pathogenesis of prostate cancer. The main and novel findings in this study are that microorganisms, particularly the bacterium P. The changes observed are however generally reversible and when the inflammation eventually is cleared the potentially precancerous lesions present apparently disappear. So what do the results of this thesis and a review of the literature add to the key questions regarding the role of inflammation and microorganisms in prostate cancer formation and progression Is it likely that prostate cancer can be caused by inflammation and infectious agents in particular As already reviewed in the introduction substantial indirect evidence suggest that inflammation plays an essential role in the development and progression of prostate cancer. Inflammation is seen adjacent to precursor lesions, around and inside tumours, and experimental inhibition of inflammation may retard tumour growth 203, 262. What is less known is if this inflammation is a cause or a result of certain (early and/or late) steps in the cancerogenic process. Is inflammation an aetiological agent and/or is the inflammatory system activated at a later stage to promote, or under other circumstances inhibit growth of tumours caused by other mechanisms It is well established that som e types of bacteria can cause chronic prostatitis 41 and in experimental models induce potentially precancerous lesions 159, 160, and the current thesis suggests that P. Notably, however, bacteria and other microorganisms are not the only cause of inflammation in the prostate. Chronic prostatitis can among many things be induced by steroid hormones like estrogen, by corpora amylacea and by factors in the diet. So even if we accept that prostatitis is part of the aetiology of cancer this does not mean that infections 44 are the cause of this inflammation as non-infectious causes are also possible. In reviewing the literature it appears that inflammation induced in several different ways such as estrogen, diet and bacteria may cause similar precancerous changes, suggesting that it is inflammation as such and not the individual agents that promote cancer development. All these external factors apparently need to act for a substantial time to induce precancerous lesions suggesting that the duration is more important than the individual agent. So if several factors may all induce chronic prostatitis it becomes important to know whether they can act in synergy, something yet to be tested. Another factor to be explored is how various agents that may cause prostatitis interact with genetically determined factors regulating susceptibility to develop chronic prostatitis and effectiveness of host defence systems against cancer. Another critically important, but unanswered question, is whether a proposed aetiological agent causes the non-aggressive or aggressive forms of the disease. An agent that is only able to induce harmless forms is less important than an agent that causes the life threatening forms of the disease. Is it likely that infectious agents and inflammation affect prostate cancer progression and behaviour Studies on the relationships between infections agents, inflammation and prostate cancer generally explores whether the microorganism could be involved in the aetiology of the disease but even if this was not the case other effects are also possible. Microorganisms could infect precancerous lesions or cancers and modify their behaviour. Whether this occurs or not is unexplored, but not unlikely as the immune system is inhibited in tumours 113. Introducing the bacteria in tumours may transform a tumour promoting Th2/M2 type of inflammation to a tumour inhibiting Th1/M1 type. Clinical data have also demonstrated that prostate cancer patients with high antibody titres against P. Against this background the overall conclusion of this thesis is that there are strong reasons to explore the role of P. Fredrik Elgh, my main supervisor, for introducing me to this interesting project and for your support during the years. Jan Olsson, my co-supervisor, for guidance and assistance in the laboratory and for insightful comments and suggestions. Stina Rudolfsson, my co-supervisor, for always sharing your time and for valuable suggestions and comments. Sigrid Kilter, Birgitta Ekblom, Elisabeth Dahlberg, Pernilla Andersson and Susann Haraldsson, for your skilful technical expertise and kind support. Ingrid Marklund, for introducing me to the Virology department and for assistance in the laboratory. Katrine Isaksson, for always being helpful and keeping track of the administrative issues. The effect of castration, of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. He describes all the puzzling and fascinating aspects of these conditions and brings them vividly to life with illustrations from personal histories. He emphasises the fact that the individuals concerned have special skills as well as disabilities. Most important of all, he makes imaginative but always practical suggestions for helping people with the syndrome, their families and others who are involved. The author has achieved real empathic understanding of children and adults whose basic problem is a biologically based lack of empathy with others. It is full of good sense and the wisdom that comes from years of clinical experience, and full of compassionate advice for a host of problems, vividly illustrated by case material. There is a good mix of research information, first person reports and clinical information. This straightforward, no nonsense book did for me what nothing and no one else in my entire life had ever been able to do. Attwood, or Saint Tony as I call him, gave me the strength to come out to the world and admit I was only pretending to be normal. Peppered with personal accounts and clear explanations Tony guides the reader with practical solutions to the myriad challenges facing people with Asperger Syndrome, and empowering them in maximizing their considerable strengths for leading fulfilling and productive lives. Warning: the doing of an unauthorised act in relation to a copyright work may result in both a civil claim for damages and criminal prosecution. My wife, Sarah, who also edited each draft chapter to ensure that my sentences make sense and are grammatically correct. My friends and colleagues who have commented on the draft chapters and provided valuable advice and encouragement. In particular I would like to acknowledge, in alphabetical order, Kari Dunn, Michelle Garnett, Carol Gray, Isabelle Henault, Kathy Hoopmann, Janine Manjiviona, Stephen Shore and Liane Willey. Reproduced by permission of Sage Publications Ltd, Thousand Oaks, London and New Delhi. Frequently Asked Questions 327 Glossary 348 Resources 351 References 359 Subject Index 382 Author Index 393 List of figures and tables Figure 8. I have tried to refrain from indulging in too many technical terms so that the text can be easily read by someone who does not have a post graduate degree in psychology. For fellow clinicians and academics who seek more information, I have provided the references that can substantiate specific statements and provide further information.

Burial Orientation There are three orientation categories that are characteristic of the coffin burials in the Milwaukee County Poor Farm Cemetery: head to the west end of the coffin antibiotics for uti make you sleepy purchase minocycline 50mg on line, head to the east end of the coffin virus encyclopedia discount minocycline uk, and a general indeterminate orientation antibiotics for acne for how long cheap 50 mg minocycline free shipping. The indeterminate category includes those coffin burials in which either there was no observable orientation antibiotic 3 day discount minocycline 50 mg fast delivery, most often in mixed burials or those instances in which Figure 4 virus 3 idiots purchase minocycline amex. Adult Orientation Juvenile Orientation Of the 368 mapped adult-sized coffin locations antimicrobial iphone case cheap 50 mg minocycline, most Orientation is more variable in juvenile-sized coffin were oriented with the head to the west (see figure burials although head to the west placement is still 4. Of the 246 juvenile east and the head to the west is a Christian tradition sized single coffin burials, head to the west oriented attributed to the concept of resurrection and Jesus as burials number 166 (67%). Matthew 24:27 is often cited are oriented head to the east and the orientation was as the biblical justification for this tradition although indeterminate for the remaining 44 burials (18%). Burial with head to the west orientation is the Head to the west oriented adult burials number 315 predominant form of burial for both adults and (86%). Given the hexagonal shape of most adult the east and the orientation was indeterminate for sized coffins this orientation would have been the remaining 34 adult burials (9%). Head orientation in a single adult-size coffin burials (n=294), head to the rectangular coffin would not have been obvious with west oriented single adult burials number 282 (96%). It is likely the orientation was indeterminate for the remaining that deviation from the traditional Christian burial 7 single adult burials (2%). The 57 mixed lot adult orientation was a matter of accident rather than size coffins include 19 oriented to the west (33%), conscious choice or even disregard on the part of the 12 to the east (21%), and 26 indeterminate (46%). The tradition of placing the burial head to the west is strongly adhered to in single adult burials. The mixed adult burials represent multiple individuals, some of whom are oriented east to west and some for whom there was no formal orientation. Burial Lots Exhibiting Prone Positioning bUriAl lot bUriAl Context All coffin burials recovered from the Milwaukee 10341 single adult County Poor Farm Cemetery were extended and most were supine. Positioning could not be 10347 mixed adult determined for 194 burials, most of them juvenile 10348 mixed adult burials (n=121). Sixteen adult burials were prone and no juvenile burials were found in the prone position. Ten of these burial lots are single adults 10536 mixed adult that represent a single individuals clearly placed in the 10570 mixed adult coffin face down (Figure 4. The nine mixed lot burials contain individuals or portions of individuals 10572 mixed adult who are placed in a prone position often with another 10654 single adult individual in the coffin who is in a supine position. Seven single adult burial lots exhibited arms Treatment of the body crossed over the pelvis and six single adult burial lots exhibited arms crossed over the torso. Formal A discussion of treatment of the body should include arm positioning was observed in one juvenile burial, items placed with the body. Formal juvenile coffin locations more than twice as many positioning of the arms of individuals buried in the locations had material culture represented (n=177) Figure 4. Burial Lots Exhibiting Formal Arm Positioning as locations that did not (n=87); see Figure 5. Of the 368 adult 10072 over torso single juvenile coffin locations, roughly equal number of locations 10270 over pelvis single adult contained material culture (n=185) as did not 10305 over torso single adult (n=183). Items considered grave goods can be placed into one of two major 10429 over torso mixed adult categories: clothing and personal items. The clothing 10779 over torso single adult category includes fasteners (non-belt buckles, 10851 over torso mixed adult buttons, snaps, hook and eyes sets, sock garters, suspenders, and toggles), buttons, safety pins, fabric, 10973 over chest single adult footwear, and belts. Items included in the personal 10975 over pelvis single adult category are items of adornment (beads, bows, metal 10987 over pelvis single adult links, cuff links, earrings, rings, tie chains), pocket 11036 over torso mixed adult tools, indulgences, medical and health items, ritual items, and coins. A total of 3, 441 total associated clothing artifacts were produced by 274 (43%, n=632) burial locations. At the Milwaukee County Poor Farm Cemetery, treatment of the body also includes how the coffin was place into the ground. Presumably this means that the coffin was lowered into the grave by means of the handles. Juvenile coffins did not, with few exceptions, have handles and may have been lowered into the ground via ropes, or just placed in the ground. Evidence for dropping rather than lowering coffins into the ground is found in both adult and juvenile-sized coffins. In the case of adult coffins, the evidence is displacement of skeletal elements to one side of the coffin as well as disruption of the supine position. The remains in adult burial lot 10623 were shifted to the southwestern portion of the Figure 4. Evidence for dropping of juvenile-sized coffins includes both displacement of skeletal elements as well as extreme angle of coffin placement. The lighter, smaller size of these coffins suggests that they were more easily displaced as they landed at the bottom of the grave shaft as evidenced by coffin angle in relation to the bottom of the grave shaft. Juvenile burial lots with both displaced coffins and skeletal elements include 10033, 10035, 10064, 10143, and 10548 (Figure 4. Mixed and commingled contexts account was observed on dissected individuals from the for 113 of these (64. Middle adult is clavicles were recovered from mixed lots; no single the most common age category represented at 57 adult lot exhibits a cut clavicle. Cervical vertebrae are the especially removal of the heart and organs of the neck most common bones exhibiting cut marks that are (Delafield and Prudden 1904; Hektoen 1894; Miller either superficial or fully bisecting and are present 1914). Cut cervical vertebrae are the only bones Overall, surface cuts and false-start scratches were exhibiting cut marks in 13 of these 55 lots (23. Lot 10792 few lots suggest osteological dismemberment by is the only single adult lot with cut cervical vertebrae individuals with anatomical training. Typically, this and is unusual in that the cut runs obliquely through results in a pattern in which limbs are disarticulated C1 to C3. Instead, the majority the cemetery in an L-shaped fenced area to the west of lots were dismembered by limb bisection, in of a fenced road leading south from the former which severing cuts are made near the joints, long Milwaukee County General Hospital and adjacent bones are detached in the proximal and distal thirds buildings. County Institutions shows similar buildings to that of this does not represent the extent of postmortem the map that depicts Cemetery 2. The Powerhouse, intervention; many bones showed multiple severing the railroad tracks leading from the Powerhouse, and cuts in various locations and angles, and cuts were the series of nearby Asylum buildings clearly mirror not reserved for the long bones and limbs, but could one another on the two maps. Even more interesting affect nearly every bone in the body, including the is the road on the 1924 map that seems to end in scapulae, innominates, and patellae. Unfortunately, none of the cemeteries were mapped on the series A 1939 map of the Milwaukee County Institutions of dated maps of the Milwaukee County Grounds reveals that the Asylum complex is still in roughly with one exception. Cemetery 2 appears on a copy of the same configuration but the railroad tracks are a portion of an undated, purported Works Progress missing. Construction of County Hospital, 1929 1930 (used with permission of the Milwaukee County Historical Society). Overstreet of the Great Lakes Archaeological residence is present in the location of the cemetery Research Center, the firm hired to remove old (Figure 4. Handles the coffin handles recovered from the 2013 Milwaukee County Poor Farm Cemetery excavations exhibit far less variability than those recovered in 1991 and 1992. See Chapter 5 for a more in depth discussion of the coffin handle recovered in 2013. Remnant stairs; view north, upslope been identified from the 2013 handle assemblage. Manufacturers for the Richards 1997 Type I handles that the area excavated in 2013 could date from 1897 could not be identified. These dates would suggest encountered that was interpreted as a set of steps (Figure 4. Remnant stairs in relation of Cemetery 2, the hospital grounds underwent a to burials excavated in 2013. Previously excavated burial pits (1992) reference the 1991/1992 with the 2013 excavations at the eastern end of the 2013 excavation area. Secondly, the mapping utilized a hydro-vacuum to remove the topsoil, by the 1991-1992 crews plotted an assortment of cutting through the overburden atop the cemetery to buried utilities and steam tunnels. During the A variety of recent historic disturbances were removal process, it became evident that this line was encountered during the course of investigations. Milwaukee County personnel wished to water main in this vicinity would place it within a keep this water main active as long as possible as the few feet of any burials that remain intact just under line fed several adjacent fire hydrants and buildings Doyne Avenue. Mortenson Company necessitated the maintenance of a roughly five foot project leaders (in conjunction with Milwaukee buffer on either side of the water main, restricting County) opted to relocate the water main south of access to numerous burials in the central portion Doyne Avenue, well outside the projected bounds of of the project area. These lines consisted of electoral conduit encased in concrete which ranged from two to three feet in width, and roughly one and a half feet in height. The lines crossed the cemetery area in a northeast-to-southwest path, with the southernmost conduit line turning abruptly east-west just north of Doyne Avenue (see figure 4. In the eastern portion of the excavation area these concrete works were a few feet above the elevation at which coffins were being identified, thus the original installation of these utilities did not disturb any burials in this portion of the cemetery. However, in the very southwest corner of the 2013 excavation area, the southernmost electrical conduit line was installed at an elevation that coincided with the depth of several coffins. As excavations moved east, it was clear this conduit line had displaced and disturbed several coffins when it was installed; as visible by the poor condition of several grave lots in its path. Mortenson Company personnel, the concrete berm was cut with a handsaw into several smaller pieces to minimize any additional damage to Figure 4. Working around the water main (top); the graves during removal of the concrete segments. The trench in which Site Boundaries: Then and Now actual water main was set measured approximately 4. This resulted in the site files the site area listed (as of October 2015) the recovery of several isolated fragments as well as is 69, 975. The first estimate (designated Estimate A in figure Utilizing their identified boundaries and the limits 4. Fragmentary human remains were encountered If the entirety of Estimate A were only juvenile/ during the course of the work. Historic newspaper Estimate B are included, those numbers reach up to accounts noted that it was not uncommon for some 1, 165 if all were juvenile burials and 500 if all were of the fill removed from the cemetery area during the adult. There are several things to consider when Cemetery Organization and Land Use looking at the distribution of interments. Area I is the largest area, the earliest marked on the map) and places the total area of utilized, and is comprised of distinctly demarcated this cemetery as 3. This may were disturbed prior to the 1991-1992 archaeological very likely be the result of the vagaries of mapping investigations. The number of coffin burials represented by the 1991, 1992 and 2013 excavations is 2, 281. Area I remains the earliest of this juvenile cemetery area mimics the larger used portion of the cemetery. Based on both the 1991-1992 and first western expansion of adults from the original 2013 excavations this area is spatially distinct from cemetery boundaries. Again, handle distributions suggests rapid field examinations of soils and sediments as it may have been utilized a little later in time. Individuals of heavy metals or toxic compounds (Radu and were buried from west-to-east in one row of burials Diamond 2009). Street Cemetery (Lillie and Mack 2015) also noted the presence of bluish soils but considered the coloration the orderly layout as well as the realization that this the result of particular kinds of molds. However, at section may have more individuals that have been in this case, the immediate area was cordoned off and anatomized and not listed in the Register makes excavation of the associated burial was halted until the layout of rows difficult to discern. A computer controlled the instrument and three readings of 180-second duration were recorded for each artifact. It should be noted that the four soil samples analyzed were coffin fill collected from the pelvic region of burials. Consequently, arsenic levels in these deposits may not be typical of undisturbed cemetery soils. Dentures were analyzed in the laboratory as an aid to preliminary artifact analysis. Late nineteenth century and early twentieth century dentures were manufactured from a compound patented as Vulcanite by Charles Goodyear.

Chapter 18 | Assessing Children: Infancy Through Adolescence 357 Table 18-8 Physical Signs of Sexual Abuse Physical Signs That May Indicate Sexual Abuse in Children* 1 bacteria 6th grade buy minocycline. Purulent or malodorous vaginal discharge in a young girl (all discharges should be cultured and viewed under a microscope for evidence of a sexually transmitted infection) Physical Signs That Strongly Suggest Sexual Abuse in Children* 1 antibiotics for uti in male order minocycline 50mg overnight delivery. Lacerations antibiotic bomb best buy minocycline, ecchymoses antibiotic beginning with c discount minocycline 50mg visa, and newly healed scars of the hymen or the posterior fourchette 2 virus outbreak movies 50 mg minocycline sale. Has she had a premature or growth-retarded infant bacterial spores purchase minocycline american express, or a baby large for gestational age Obstetric visits traditionally follow a set schedule: monthly until 30 gestational weeks, then biweekly until 36 weeks, then weekly until delivery. Develop a nutrition plan appropriate to cultural preferences, typically three balanced meals each day, including 300 additional kcal plus prenatal supplements. After the rst trimester, women should avoid exercise in the supine position, which can compress the inferior vena cava, resulting in dizzi ness and decreased placental blood ow. Contact sports or activ ities that risk abdominal trauma are unwise in all trimesters. Fetal alcohol syndrome is the leading cause of preventable mental retardation in the United States. Ask about commonly abused prescription drugs, including narcotics, stimulants, benzodiazepines. Pursue universal screening of all pregnant women without regard to socioeconomic status. Maintain an updated list of shelters, counseling centers, hotline numbers and other trusted local referrals. However, all women should have rubella titers drawn during pregnancy and be immunized after birth if non immune. Ask her to wear her gown with the opening in front to ease the examination of both breasts and the pregnant abdomen. Equipment Gynecologic speculum and lubrication: Because of vaginal wall relaxation during pregnancy, a larger-than-usual speculum may be needed. Additional swabs may be needed to screen for sexually transmitted infections, group B strep, and wet mount preparations. Signifcant enlargement is abnormal Modest symmetric enlargement and should be investigated. Impulse may be higher than normal in the fourth intercostal space because of transverse and leftward rotation of the heart from the higher diaphragm. With your An irregularly shaped uterus suggests internal ngers placed at either uterine myomata or abicornuate side of cervix, palmar surfaces uterus, two distinct uterine cavities separated by a septum. Capture the fundal portion of the uterus between your two hands and gently estimate size. Note whether the hands diverge with downward pressure or stay together to learn if the presenting part of the fetus, head or buttocks, is descending into the pelvic inlet. On internal exam, cervix is open to fingertip at the external os but closed at the internal os; cervix is 3 cm long; uterus enlarged to size consistent with 18-week gestation. Optimal aging occurs in those people who escape debilitating disease entirely and maintain healthy lives late into their 80s and 90s. A well-lit room allows the older adult to see your facial expressions and gestures. Listen to this process of life review to gain important insights and help patients as they work through painful feelings or recapture joys and accomplishments. To reduce the risk of late recognition and delayed interven tion, adopt more directed questions or health screening tools. Be sensitive to changes in presentation of myocardial infarc tion and thyroid disease. Even elders with mild cognitive impairment, however, can provide suf cient history to reveal concurrent disorders. If impairments are more severe, con rm symptoms with family members or caregivers. By 2050, the older adult population will increase by 230%, and the minority older adult population by 510%. Cultural differences affect the epidemiology of illness and mental health, acculturation, the speci c concerns of the elderly, the potential for misdiagnosis, and disparities in health out comes. Cultural values particularly affect decisions Chapter 20 | the Older Adult 375 about the end of life. Ask about use of over-the counter medications, vitamin and nutrition supplements, and mood altering drugs. Despite the prevalence of alcohol problems among the elderly, rates of detection and treatment are low. Pain and associated complaints account for 80% of clinician visits, usually for musculoskeletal complaints like back and joint pain. The prevalence of this multifactorial syndrome related to declines in physiologic reserves, muscle mass, energy and exercise capacity is 4% to 22%. Include the pneumococcal vaccine once after age 65, annual in uenza vaccinations, Td boosters every 10 years, and the herpes zoster vaccine. Correct poor lighting, chairs at awk ward heights, slippery or irregular surfaces, and environmental hazards. Prominent features include: Normal alertness but short-term memory de cits and subtle lan guage errors. Investigate contributing factors such as medications, depression, metabolic abnormalities, or other medical and psychiatric conditions. Screen older patients for possible elder mistreatment, which includes abuse, neglect, exploitation, and abandonment. Prevalence is approximately 1% to 10% of the older population; however, many more cases may remain undetected. It covers the three important domains of geriatric assessment: physical, cognitive, and psychosocial function. Each year approximately 35% to 40% of healthy community-dwelling older adults experience falls. Couple your assessment with interventions for prevention, including gait and balance training and exercise to strengthen muscles, vitamin D supplementation, reduction of home hazards, discontinu ation of psychotropic medication, and multifactorial assessment with targeted interventions. Provide education and information Source: Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Measure heart rate, respira Respiratory rate 25 breaths per minute tory rate, and temperature. Weight and height are especially Low weight is a key indicator of poor important and needed for calcula nutrition. Obtain oxygen chronic organ failure (cardiac, renal, pul saturation using a pulse oximeter. Note physiologic Dry, faky, rough, and often itchy changes of aging, such as thin ning, loss of elastic tissue and turgor, and wrinkling. Inspect for painful vesicular lesions Herpes zosterfrom reactivation of latent in a dermatomal distribution. Inspect the eyelids, Senile ptosisarising from weakening of the bony orbit, and the eye. Inspect the fundi for colloid Macular degenerationcauses poor central bodies causing alterations in vision and blindness: types includedry pigmentation called drusen. These may be hard and sharply de ned, or soft and con uent with altered pigmentation. Describe murmur in the second right interspace timing, shape, location of inaortic sclerosisoraortic stenosis. Both carry increased risk of cardiovascular maximal intensity, radiation, disease and death. A harsh holosystolic murmur at the apex suggestsmitral regurgitation, also com mon in the elderly. Take special care to explain the steps of the examination and allow time for careful positioning. For the woman with arthritis or spinal deformities who cannot ex her hips or knees, an assistant can gently raise and support the legs, or help the woman into the left lateral position. Inspect the vulva for changes Benign masses include condylomata, related to menopause; identify fbromas, leiomyomas, and sebaceous any labial masses. Bulging of the anterior vaginal wall below the urethra in urethrocele Inspect the urethra for caruncles, Clitoral enlargement inandrogen or prolapse of eshy erythema producing tumorsor use of androgen tous mucosal tissue at the creams urethral meatus. Estrogen-stimulated cervical mucus with Inspect vaginal walls, which may ferning in use of hormone replacement be atrophic, and cervix. Mobility of cervix restricted if infam mation, malignancy, or surgical adhesion Palpable ovaries inovarian cancer. Perform the rectovaginal Enlarged, fxed, or irregular uterus if examination if indicated. Auscultate the abdomen for Bruits over these vessels inatheroscle aortic, renal, femoral artery rotic disease. If joint deformity, de cits in Degenerative joint changes inosteoar mobility, or pain with move thritis;joint infammation inrheumatoid ment, conduct a more thorough orgouty arthritis. Refer to Learn to distinguish delirium from results of 10-Minute Geriatric depression and dementia. Leg Mobility: Can walk 20 feet briskly, turn, walk back to chair, and sit down in 14 seconds. Scoring: Normal: completes task in <10 seconds Abnormal: completes task in >20 seconds Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a speci c time. Mit einer Au osung von Forsting, Michael (Essen / Germany) mehr als 2 lp/mm und einer Voxelgro e von 80 m erhalten Sie detaillierte Freling, Nicole (Amsterdam / the Netherlands) Einblicke in alle Bereiche des Kopfes, einschlie lich der feinsten Knochen Greess, Holger (Esslingen / Germany) strukturen des Innenohres sowie der Anatomie der Nasennebenhohlen. Kabala, Julian (Bristol / United Kingdom) Erfahren Sie mehr uber 3D Accuitomo 170 unter Excipients:calcobutrol sodium, tromethamol, hydrochloric acid, water for injections. Contraindications: Hypersensitivity to the active substance or any of the excipients.

Use meaningful reinforcements Reinforcers can be anything from praise to tangible objects that increase the behaviour a student is trying to learn antibiotics quiz nursing purchase cheap minocycline online. A reinforcer is only a reinforcer if it results in an increase in a specific behaviour antibiotics kill probiotics discount minocycline 50 mg with amex. It is important to be aware that students with autism spectrum disorders may not be motivated by reinforcers that work with other students antibiotics for sinus infection necessary cheap 50mg minocycline fast delivery. These lists can be developed with the help of family members and shared with service providers antibiotic drug classes 50mg minocycline free shipping. Plan tasks at an appropriate level of difficulty Students with autism spectrum disorders may become anxious and frustrated if they cannot perform assigned tasks antibiotic impetigo buy minocycline overnight. In general bacteria quiz questions purchase minocycline online now, students should be included in regular instruction to the greatest extent possible. Adaptations should be carefully selected to ensure that students are successful and that their learning is extended. The process of selecting an appropriate level of adaptation for a specific activity is illustrated in the following example. In the example provided, the teacher might arrange for the student to work on activities that are not easily accommodated in the classroom during the time when the other students are involved in a regularly scheduled classroom activity, such as completing a math worksheet. Use age-appropriate materials It is important to treat students with autism spectrum disorders with respect by ensuring instructional materials are appropriate. Even if instruction must be modified significantly, the learning materials should be appropriate to the age of the student. Provide opportunities for choice Because students with autism spectrum disorders are frequently frustrated by their inability to make themselves understood, they need instruction in communicating choices. Many parts of their lives are necessarily highly structured and controlled by adults. Sometimes, students continue to choose one activity or object because they do not know how to choose another. It may be helpful to develop a choice menu to help students select activities and tasks. Acceptable methods of providing choice should be developed on an individual basis. Choice should be limited to one or two preferred activities until students grasp the concept of choice. Break down oral instructions Avoid long verbal explanations when providing instruction for students with autism spectrum disorders. Supporting oral instruction with visual cues and representations helps students understand. Prepare students for upcoming lessons Whenever possible, expose students with autism spectrum disorders to concepts and materials prior to presenting the information to the entire class. Students with autism spectrum disorders may require more time and repetition to learn a new skill or concept and incorporate it into their existing repertoire. By starting the instructional process earlier, learning opportunities are increased. Providing extra time generally, and allowing for ample time between giving instructions and student responses are important tactics for supporting students with autism spectrum disorders. Use concrete examples and hand-on activities Teach abstract ideas and conceptual thinking using concrete examples, and vary the examples so that a concept can be applied in a variety of ways. Introduce unfamiliar tasks in a familiar environment When possible, introduce unfamiliar tasks in a familiar environment. For example, teach a student to order food in the school cafeteria before requiring the student to carry out the same task in an unfamiliar restaurant. When that is not possible, prepare students for new tasks and environments using pictures, videotapes and/or social stories. For example, show students photographs of the environment that a new task will be completed in, or a video of a familiar adult or peer completing the task. Direct and broaden fixations into useful activities If students are fixated on objects or topics, such as colours or shapes, use them to teach concepts. Maintain a list of individual strengths and interests Family members can provide valuable information about what students know and do at home or in the community. Build on these interests and skills for instruction, and to reinforce successful learning and behaviour. Develop talents and interest areas If students demonstrate particular interests and strengths in specific areas. Occupational therapists can provide specialized knowledge regarding sensory integration and help develop strategies to address identified problems related to sensory processing. Attempts to reduce the effect of these stimuli may enhance learning and reduce challenging behaviour. When they are anxious or hyper-aroused, they often have difficulty attending to instruction and completing structured tasks. Alternatively, when students are hypo-aroused, they often have difficulty initiating activities and remaining alert. These activities need to be closely monitored to ensure students do not inadvertently become over-stimulated. These strategies tend to be most effective when they are implemented early, when students first demonstrate signs of anxiety or hyper-arousal. Students who display a high level of anxiety often respond positively to intermittent relaxation breaks scheduled strategically throughout the day. It is important to note that what is calming for one student may increase anxiety for another. Students can be taught to communicate that they need a break before inappropriate behaviour escalates. Relaxation training can teach students specific routines and behaviours for relaxing. Students may need opportunities for rehearsal and desensitization to new places, people or things. Change is difficult for students with autism spectrum disorders, but adapting to and coping with change is a necessary life skill. Introduce new situations slowly so students have opportunities to become familiar with different settings, people and expectations. Encourage appropriate sensation seeking Some students with autism spectrum disorders crave specific forms of sensory input and seek out those sensory experiences in inappropriate ways. For instance, a student who enjoys tactile stimulation may rub saliva on his or her hands to gain desired input. Similarly, a student who enjoys strong vestibular and proprioceptive stimulation may engage in aimless running, spinning or crashing. It is also common for students with autism spectrum disorders to engage in inappropriate smelling or place inedible objects in their mouths to gain sensory feedback. However, it is important to consider the specific function of each new behaviour students display and realize that not all unusual or problematic behaviours are sensory in nature. Generally, the most effective way to deal with inappropriate behaviours is to provide students with more appropriate ways to satisfy their sensory cravings. Provide sensory experiences that are calming to accompany potentially frustrating tasks. When feasible, decrease environmental distracters and eliminate activities that confuse, disorient or upset students and interfere with learning. Provide relaxation It may be necessary to prepare a calm, quiet area where students can go to relax. Relaxing may mean engaging in repetitive behaviours that have a calming affect on students with autism spectrum disorders. In some cases, students who crave certain repetitive movements, such as rocking or other self-stimulating behaviours, can be provided opportunities where this movement is permitted. Considerations There is much debate about the effectiveness of sensory 33 integration techniques for students with autism. For example, providing a potentially reinforcing event such as music or a deep pressure massage immediately after an undesirable behaviour might inadvertently result in an increase in that behaviour. With this caution in mind, sensory integration techniques can be a powerful behaviour management tool. Most people are unaware of the complexity of normal communication because most children develop these skills automatically, usually by the age of three or four. Many students with autism spectrum disorders do not develop the skills they need for spontaneous communication and must be taught them. Helping students develop communication skills so they can express their wants and needs, interact socially, share information and express emotions, is a priority. Programs to facilitate communication may begin in structured settings, however promoting generalization and facility in using language requires that interventions take place in natural settings. Functional language skills are best taught in the social context 34 where they will be used and where they have real meaning. The school environment provides a wealth of opportunities for developing functional communication within social contexts and promoting generalization. Specific skills requiring instruction and strategies for developing the targeted skills must be identified. The school team should collaborate to identify communication goals and objectives for students with autism spectrum disorders. Base interventions on the abilities and needs of individual students and take into account the environments in which students interact with others. Speech-language pathologists can help assess communication skills, and provide suggestions and strategies tailored to the unique needs and characteristics of individual students. For example, teach students to face the speaker, keep their eyes on the speaker (which does not necessarily mean they must make eye contact) and place their hands in a planned position. Develop oral language comprehension Accompanying spoken language with relevant objects, pictures, photographs and other visual supports can help students comprehend meaning. Many students with autism spectrum disorders use reading to support oral comprehension rather than the reverse. One effective way to facilitate functional communication is to provide controlled choices. Visual supports can be particularly useful for communicating a range of available choices. Develop oral language expression Although many students with autism spectrum disorders may not develop traditional oral language, most do develop some form of communication. For students with limited oral See Appendix H, page 185, for aformtocreatea expression, accept limited verbal attempts and nonverbal communication dictionary. A customized communication dictionary is a useful tool to document what a student says and means. Even students who do have oral language may have difficulty adding to their working oral vocabularies easily. Teachers need to teach new vocabulary in a variety of contexts using a visually based approach. Students who rely on pictorial representations to communicate need to learn that drawings or representations have names and that they can give direction or explain what to do.

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