The Difference Between Men And Women

 

Let’s say a guy named Fred is attracted to a woman named Martha. He asks her out to a movie; she accepts; they have a pretty good time. A few nights later he asks her out to dinner, and again they enjoy themselves. They continue to see each other regularly, and after a while neither one of them is seeing anybody else.

And then, one evening when they’re driving home, a thought occurs to Martha, and, without really thinking, she says it aloud: “Do you realize that, as of tonight, we’ve been seeing each other for exactly six months?”

And then, there is silence in the car.

To Martha, it seems like a very loud silence. She thinks to herself: I wonder if it bothers him that I said that. Maybe he’s been feeling confined by our relationship; maybe he thinks I’m trying to push him into some kind of obligation that he doesn’t want, or isn’t sure of.

And Fred is thinking: Gosh. Six months.

And Martha is thinking: But, hey, I’m not so sure I want this kind of relationship either. Sometimes I wish I had a little more space, so I’d have time to think about whether I really want us to keep going the way we are, moving steadily towards, I mean, where are we going? Are we just going to keep seeing each other at this level of intimacy? Are we heading toward marriage? Toward children? Toward a lifetime together? Am I ready for that level of commitment? Do I really even know this person?

And Fred is thinking: …so that means it was…let’s see…February when we started going out, which was right after I had the car at the dealer’s, which means…lemme check the odometer…Whoa! I am way overdue for an oil change here.

And Martha is thinking: He’s upset. I can see it on his face. Maybe I’m reading this completely wrong. Maybe he wants more from our relationship, more intimacy, more commitment; maybe he has sensed – even before I sensed it – that I was feeling some reservations. Yes, I bet that’s it. That’s why he’s so reluctant to say anything about his own feelings. He’s afraid of being rejected.

And Fred is thinking: And I’m gonna have them look at the transmission again. I don’t care what those morons say, it’s still not shifting right. And they better not try to blame it on the cold weather this time. What cold weather? It’s 87 degrees out, and this thing is shifting like a garbage truck, and I paid those incompetent thieves $600.

And Martha is thinking: He’s angry. And I don’t blame him. I’d be angry, too. I feel so guilty, putting him through this, but I can’t help the way I feel. I’m just not sure.

And Fred is thinking: They’ll probably say it’s only a 90-day warranty…scumballs.

And Martha is thinking: Maybe I’m just too idealistic, waiting for a knight to come riding up on his white horse, when I’m sitting right next to a perfectly good person, a person I enjoy being with, a person I truly do care about, a person who seems to truly care about me. A person who is in pain because of my self-centered, schoolgirl romantic fantasy.

And Fred is thinking: Warranty? They want a warranty? I’ll give them a warranty. I’ll take their warranty and stick it right up their…

“Fred,” Martha says aloud.

“What?” says Fred, startled.

“Please don’t torture yourself like this,” she says, her eyes beginning to brim with tears. “Maybe I should never have…oh dear, I feel so…”(She breaks down, sobbing.)

“What?” says Fred.

“I’m such a fool,” Martha sobs. “I mean, I know there’s no knight. I really know that. It’s silly. There’s no knight, and there’s no horse.”

“There’s no horse?” says Fred.

“You think I’m a fool, don’t you?” Martha says.

“No!” says Fred, glad to finally know the correct answer.

“It’s just that…it’s that I…I need some time,” Martha says.

(There is a 15-second pause while Fred, thinking as fast as he can, tries to come up with a safe response. Finally he comes up with one that he thinks might work.)

“Yes,” he says. (Martha, deeply moved, touches his hand.)

“Oh, Fred, do you really feel that way?” she says.

“What way?” says Fred.

“That way about time,” says Martha.

“Oh,” says Fred. “Yes.” (Martha turns to face him and gazes deeply into his eyes, causing him to become very nervous about what she might say next, especially if it involves a horse. At last she speaks.)

“Thank you, Fred,” she says.

“Thank you,” says Fred.

Then he takes her home, and she lies on her bed, a conflicted, tortured soul, and weeps until dawn, whereas when Fred gets back to his place, he opens a bag of Doritos, turns on the TV, and immediately becomes deeply involved in a rerun of a college basketball game between two South Dakota junior colleges that he has never heard of. A tiny voice in the far recesses of his mind tells him that something major was going on back there in the car, but he is pretty sure there is no way he would ever understand what, and so he figures it’s better if he doesn’t think about it.

The next day Martha will call her closest friend, or perhaps two of them, and they will talk about this situation for six straight hours. In painstaking detail, they will analyze everything she said and everything he said, going over it time and time again, exploring every word, expression, and gesture for nuances of meaning, considering every possible ramification.

They will continue to discuss this subject, off and on, for weeks, maybe months, never reaching any definite conclusions, but never getting bored with it either.

Meanwhile, Fred, while playing racquetball one day with a mutual friend of his and Martha’s, will pause just before serving, frown, and say: “Norm, did Martha ever own a horse?”

And that’s the difference between men and women.

 

Adapted from withalittlehelp

The “Strange” Ending of the Gospel of Mark and Why It Makes All the Difference

Kemboi Kibet.
Nov. 6th 2013

And they went out and fled from the tomb, for trembling and astonishment had seized them, and they said nothing.

Most general Bible readers have the mistaken impression that Matthew, the opening book of the New Testament, must be our first and earliest Gospel, with Mark, Luke and John following. The assumption is that this order of the Gospels is a chronological one, when in fact it is a theological one. Scholars and historians are almost universally agreed that Mark is our earliest Gospel–by several decades, and this insight turns out to have profound implications for our understanding of the “Jesus story” and how it was passed down to us in our New Testament Gospel traditions.
The problem with the Gospel of Mark for the final editors of the New Testament was that it was grossly deficient. First it is significantly shorter than the other Gospels–with only 16 chapters compared to Matthew (28), Luke (24) and John (21). But more important is how Mark begins his Gospel and how he ends it. He has no account of the virgin birth of Jesus–or for that matter, any birth of Jesus at all. In fact, Joseph, husband of Mary, is never named in Mark’s Gospel at all–and Jesus is called a “son of Mary,” But even more significant is Mark’s strange ending. He has no appearances of Jesus following the visit of the women on Easter morning to the empty tomb!
Like the other three Gospels Mark recounts the visit of Mary Magdalene and her companions to the tomb of Jesus early Sunday morning. Upon arriving they find the blocking stone at the entrance of the tomb removed and a young man–notice–not an angel–tells them:

Do not be alarmed. You seek Jesus of Nazareth, who was crucified. He has risen; he is not here. See the place where they laid him. But go, tell his disciples and Peter that he is going before you to Galilee. There you will see him, just as he told you.” And they went out and fled from the tomb, for trembling and astonishment had seized them, and they said nothing (Mark 16:6-8) And there the Gospel simply ends!

Mark gives no accounts of anyone seeing Jesus as Matthew, Luke, and John later report. In fact, according to Mark, any future epiphanies or “sightings” of Jesus will be in the north, in Galilee, not in Jerusalem.

This original ending of Mark was viewed by later Christians as so deficient that not only was Mark placed second in order in the New Testament, but various endings were added by editors and copyists in some manuscripts to try to remedy things. The longest concocted ending, which became Mark 16:9-19, became so treasured that it was included in the King James Version of the Bible, favored for the past 500 years by Protestants, as well as translations of the Latin Vulgate, used by Catholics. This meant that for countless millions of Christians it became sacred scripture–but it is patently bogus. You might check whatever Bible you use and see if the following verses are included–the chances are good they they will be, since the Church, by and large, found Mark’s original ending so lacking. Here is that forged ending of Mark

Now when he rose early on the first day of the week, he appeared first to Mary Magdalene, from whom he had cast out seven demons. She went and told those who had been with him, as they mourned and wept. But when they heard that he was alive and had been seen by her, they would not believe it. After these things he appeared in another form to two of them, as they were walking into the country. And they went back and told the rest, but they did not believe them. Afterward he appeared to the eleven themselves as they were reclining at table, and he rebuked them for their unbelief and hardness of heart, because they had not believed those who saw him after he had risen. And he said to them, “Go into all the world and proclaim the gospel to the whole creation. Whoever believes and is baptized will be saved, but whoever does not believe will be condemned. And these signs will accompany those who believe: in my name they will cast out demons; they will speak in new tongues; they will pick up serpents with their hands; and if they drink any deadly poison, it will not hurt them; they will lay their hands on the sick, and they will recover. So then the Lord Jesus, after he had spoken to them, was taken up into heaven and sat down at the right hand of God. And they went out and preached everywhere, while the Lord worked with them and confirmed the message by accompanying signs

 
Even though this ending is patently false, people loved it, and to this day conservative Christians regularly denounce “liberal” scholars who point out this forgery, claiming that they are trying to destroy “God’s word.”
The evidence is clear. This ending is not found in our earliest and most reliable Greek copies of Mark. In A Textual Commentary on the Greek New Testament, Bruce Metzger writes: “Clement of Alexandria and Origen [early third century] show no knowledge of the existence of these verses; furthermore Eusebius and Jerome attest that the passage was absent from almost all Greek copies of Mark known to them.” The language and style of the Greek is clearly not Markan, and it is pretty evident that what the forger did was take sections of the endings of Matthew, Luke and John (marked respectively in red, blue, and purple above) and simply create a “proper” ending.

Nonalcoholic Fatty Liver Disease

 

 

INTRODUCTION

Nonalcoholic fatty liver disease is fat accumulation in the liver of people who don’t drink or drink little alcohol. This disease is common and may cause no complications . A more serious form of nonalcoholic fatty liver disease is called nonalcoholic steatohepatitis (NASH). This can cause inflammation and scarring of liver and eventual death of liver tissue.

CAUSES

The exact cause of nonalcoholic fatty liver disease in not clear but it occurs as a result of failure of the liver to breakdown fat resulting in its accumulation  in the liver tissue.

RISK FACTORS

Certain factors and conditions may increase your risk of getting nonalcoholic fatty liver disease. These include :

  • rapid weight loss
  • obesity
  • Wilson’s disease
  • certain medications
  • high levels of cholesterol and triglycerides
  • malnutrition
  • viral hepatitis
  • inherited or autoimmune liver disease
  • metabolic syndrome
  • type 2 diabetes

SYMPTOMS

This disease is mostly asymptomatic especially in it’s early stages. As disease progressed however it may exhibit symptoms such as

  • weight loss
  • fatigue
  • nausea
  • weakness
  • pain in the upper right abdomen
  • impaired judgement
  • enlarged liver

TEST AND DIAGNOSIS

Nonalcoholic fatty liver disease is usually diagnosed during a routine medical exam. Doctor may also suspect you have it  after asking for your medical history and doing a physical exam. Doctor may then perform these test to conform the disease.

Blood test : Liver function test is done to evaluate liver enzymes and help with diagnosis.

Imaging tests : Imaging tests such as abdominal ultrasound, computerized tomography (CT) scan and magnetic resonance imaging (MRI) are used to diagnose fatty liver disease.

Liver biopsy : This confirmatory test involves taking  a sample of liver tissue  to the lab  to look for signs of inflammation and scarring.

TREATMENT

There is no specific treatment for Nonalcoholic fatty liver disease. Treatment  means taking care of underlying medical conditions such as diabetes and obesity . These include losing weight if you are obese, managing blood sugar level if you have diabetes and changing medications if it is the cause.

PREVENTION

Takes these steps to prevent this disease.

Maintain a healthy weight.

Eat healthy such as including more fruits and vegetables in your diet.

Take medication for disease that can cause fatty liver disease such as diabetes and high cholesterol. You can also reduce your cholesterol using home remedies.

Cirrhosis

by Kemboi Kibet

Cirrhosis is a liver disease which involves irreversible scarring of the liver. Some of the common causes of cirrhosis includes alcohol abuse, hepatitis B and hepatitis C. Early treatment of cirrhosis can limit further damage to the liver. This disease can be life threatening.

CAUSES

This disease is caused by long-term liver damage as a result of liver diseases and other conditions. Diseases and conditions that can cause cirrhosis includes the following

alcohol abuse
chronic viral hepatitis
bile duct disease such as biliary atresia
cystic fibrosis
genetic diseases such as glycogen storage diseases, Alpha-1 antitrypsin deficiency, autoimmune hepatitis and Wilson’s disease
schistosomiasis
accumulation of fat in the liver

SYMPTOMS

Cirrhosis can be asymptomatic but when symptoms do appear, they usually include the following

itching skin
jaundice
fatigue
loss of appetite
easy bruising and bleeding
weight loss
Fluid build up and painful swelling of the legs (edema) and abdomen (ascites)
abdominal pain

TEST AND DIAGNOSIS

To diagnose cirrhosis, your doctor will do a physical exam. He may also ask you about your medical history. Other tests that will be done to confirm this diagnosis include :

Liver function test : This blood test is done to checked for excess bilirubin and certain enzymes that may indicate liver damage.

Imaging tests : These include MRI, CT scan and ultrasound to check for liver damage.

Biopsy :A sample liver tissue is taken and examined for the cause and severity of liver damage.

TREATMENT

Treatment of cirrhosis depends on the cause and extent of damage to the liver. The goal of treatment is to prevent further damage and avoid complications.It is also important to treat any underlying cause of the disease such as losing weight, stop drinking and medications of hepatitis. Any associated complications will also be treated. In advanced stages when the liver loses it’s function,liver transplant is necessary.

LIFESTYLE CHANGES THAT CAN HELP YOU MANAGE CIRRHOSIS

Stop drinking alcohol.
Maintain a healthy weight
Limit salt intake to reduce fluid buildup
Avoid raw shellfish
Get vaccinated for hepatitis A and B, influenza, and pneumonia.
Ask your doctor before using any over the counter medications, vitamins or supplement.
Practice safe sex to avoid any infections.
Do not share needles, razors, toothbrushes or other personal items with others

SYMPTOMS YOU SHOULD NEVER IGNORE

How do you know if a symptom is serious or not. Symptoms that develop all of a sudden and with increasing intensity should not be taken for granted. Here are some symptoms you should not ignore.

SHORTNESS OF BREATH
If you are unable to catch your breath or gasping for breath, then you need to be evaluated or you must seek emergency care. Shortness of breath could be a sign of severe underlying diseases like asthma, bronchitis, pulmonary embolism, lung and heart disease.

SUDDEN INTENSE HEADACHE
If you are experiencing headache like you’ve never had before. If it happened suddenly and keeps getting worse with no relief, you need to seek urgent care. It could be a sign serious conditions like of ruptured aneurysm, a condition in which a blood vessel in your brain suddenly bursts. It could also be a sign of meningitis.

UNEXPLAINED WEIGHT LOSS
I f you are losing weight without trying, it might be more of a curse than a blessing. If you lose about 10% of your total weight in about 6 months without putting in any effort, you should consult your doctor. Unexplained weight loss could be an indication of diabetes if it is accompanied by frequent urination and extreme thirst, hyperthyroidism if you also experience restlessness and increased appetite, some types of cancers and liver disease. Gastrointestinal diseases like inflammatory bowel movement could also be the cause if you having diarrhea and abdominal pain.

LOWER BACK PAIN
Lower back pain can be from muscle pull or some physical exertion on the back. Persistent back pain accompanied with fever and weight loss and especially if pain is radiating down the leg, could be a sign of some cancers like breast and lung cancers. Aggressive forms of these cancers may spread to the bone and cause lower back pain.

HEAVY PERIODS
Heavy periods known as menorrhagia happens to some women. However if you experience heavy periods during pregnancy it could be a sign of ectopic pregnancy. Fibroid tumors and ovarian cyst may cause heavy periods. Seek medical help.

CHEST PAIN
Chest discomfort, heaviness and pressure may be a signs of heart attack especially if it is accompanied by pain radiating down the arm, shortness of breath, nausea and vomiting and sweating. Women especially experience other symptoms like upper abdominal discomfort and fatigue. Severe upper back pain may be due to tear in the aorta. Other non life threatening conditions such as acid reflux or a peptic ulcer may also cause chest pain. Get to emergency room if you experience these signs.

FAINTING
This is due to transient drop in blood pressure which can happen as a result of the brain not getting enough blood. This usually happens when you sick , tired or scared. Experiencing fainting spells after exercising or lifting heavy things may require medical attention. It could be a sign of stroke or heart problem.

FEVER
Having fever is nothing to worry about so much. Fever is your body’s way of fighting infection. However fever of about 103 degrees and higher may be a source of serious infection like meningitis, endocarditis and so one. Persistent fever may also be a sign of some forms of cancers like lymphoma or sinus infection. Urgent medical care is therefore essential in such cases.

CHANGE IN BOWEL MOVEMENT
Normal bowel habits depends on each person. What is normal for one person might not be normal for anther. When you notice any change in your bowel habits such as persistent diarrhea or constipation, change in shape and color of stool or bloody stool, it is time to contact your physician. It might be a sign of serious infection

UNUSUAL BLEEDING
If you see blood where it’s not suppose to be, then its time to talk to your doctor. Blood in vomit may be a sign of gastric or esophageal cancer. Rectal bleeding may be a sign of colon or rectal cancer and vaginal bleeding may be linked to gynecological cancer. Unusual bleeding can also be linked to non life threatening conditions like hemorrhoids and stomach ulcers. Seek immediate medical care if you experience any of these conditions.

EARLY SATIETY
If you consistently feel full earlier than normal or after having a small meal ,you need to get checked out. If it is accompanied by symptoms such as weight loss or gain bloating, nausea or vomiting ,it could be a sign of reflux disease, commonly known as GERD or life threatening diseases like pancreatic cancer.

SUDDEN CONFUSION
Sudden confusion or inability to concentrate are conditions that need immediate medical care. It could be as a result of brain bleeding or brain tumor. If this condition is accompanied by slurred speech, numbness in face hand or leg and difficulty finding words, then stroke is imminent. Seek medical care immediately to avoid irreversible brain damage.

EDEMA
Swelling in the extremities such as legs warrants medical check up. When heart cannot pump enough blood that the body needs, blood backs up in veins causing accumulation of body fluids. Doctor fear heart failure when both legs are affected and especially when one is experiencing other symptoms like shortness of breath, fatigue and numbness.

SEVERE ABDOMINAL PAIN
This could be as a result of aortic aneurysm which happens in the abdominal area. It could also mean a hole in the stomach or intestines as a result of an ulcer. Another condition that causes this is Intestinal ischemia which is when blood flow to the intestines is stopped or slowed down resulting tissues being oxygen deprived. All these conditions are life threatening and should be taken seriously.

HYPERHIDROSIS- ARE YOU A SWEATY

By Kemboi Kibet

Excessive sweating also known as hyperhidrosis is sweating for no apparent reason and occurs even when you are not exercising or when temperature is not hot. This condition can be very embarrassing and usually affects palms, soles, feet and underarms.

I SWEAT A LOT??? NOW WHAT!!!!

There are a number of home remedies than can help curb this condition by reducing the sweating.

Antiperspirants : The first step to solving hyperhidrosis is using antiperspirants. Antiperspirants contain aluminium salts which when rolled on the skin can form plugs which block perspiration. It should be noted that deodorant unlike antiperspirants control odor produced by sweating but does not in itself reduce or block perspiration. You can get antiperspirants from over the counter in which case it is less irritating or by prescription from a doctor if the over the counter ones dont work.

Apple Cider Vinegar: This can be applied directly to areas of excessive sweating or it can be taken orally. Apply a combination of apple cider vinegar and lemon juice to the skin at areas of excessive sweating . It can also be taken orally by drinking three glasses of water a day mixed with two teaspoon of cider vinegar and two teaspoons of honey. It is most effective when taken on empty stomach. You can also soak cotton balls in apple cider vinegar or white vinegar and rub underarms to get rid of underarm odor. For sweaty feet apply apple cider vinegar to feet after washing and drying feet.

Tomato Juice : Drink a glass of fresh home-made tomato juice for at least a week. If you see progress you can continue drinking it everyday or every other day.

Bathe Regularly : Bathing frequently helps keep the number of bacteria on the skin low. Bathing with antibacterial soap can also control the bacteria that inhabit areas of the skin prone to hyperhidrosis and cause odor.

Reduce Stress : Stress can trigger perspiration. It is important to engage in relaxation exercises such as yoga and meditation.

Herbal Tea: Sage herbal tea is particularly essential in curbing hyperhidrosis. Sage contains vitamin B and magnesium which reduces sweat gland activity and thereby reduces sweating. Boil a teaspoon of dried sage leaves and set it aside to cool down. Apply the mixture to feet , sole , palms and underarm after thoroughly washing and drying. You can also add the herb to diet such as soup. It is also known that having green tea everyday can also eliminate hyperhidrosis.

Potato Slices : Slice potato and rub them underarm to get rid of excessive sweating. This is an effective way of getting rid of hyperhidrosis.

Wheat Grass Juice : Wheat grass extract is effective in reducing excessive sweating. One glass a day of this juice helps neutralize and dilute toxins in the blood. It is also a very good source of protein, vitamin C, vitamin B-12, folic acid, and vitamin B-6.

Witch Hazel : This is a natural perspirant for the face . It gently dries skin and prevents infection.

Tea Tree Oil : Apply oil directly to affected areas such as foot, armpit and hands to reduce hyperhidrosis.

Tea Bag : Tannic acid in tea has astringent properties that act as a natural antiperspirant. Soak about 5 tea bags in hot water and let it cool. Soak hands and feet in it for about 30 minutes and notice the difference.

Cornstarch and Baking Soda : Clean underarm thoroughly then apply cornstarch and baking soda. Wait for about 30 minutes and then wash off.

Anti Sweat Diet : Foods such as strawberries, almonds and onions contain silicon which is effective in reducing hyperhidrosis. It is also important to stay well hydrated because water removes the toxins that causes odor from sweat.Vitamin B rich foods also reduces sweating. It should also be noted that spicy foods and alcohol makes you sweat and so does hot drinks like tea and coffee. Magnesium deficiency is also known to cause hyperhidrosis. Taking magnesium supplement daily can get rid of this condition.

Wear Breathable Clothing : Choose fabrics such as cotton wool or silk which makes your skin breathe. It is also crucial to wear wool and cotton soaks. These absorb moisture and keep the feet dry.

Kemboi Kibet

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Down Syndrome – Your Health Is Your Wealth

 

Down syndrome is also known as Trisomy 21. It is a genetic disorder in which an extra copy of chromosome 21 causes life long mental retardation, developmental delays and other problems. It is the most common genetic cause of learning disabilities in children. It affects 1 in every 800 babies born in the United States. Severity of the disease range from mild or  moderate to serious with some children needing more medical attention than others. People with Down Syndrome may have other health issues like heart disease, intestinal abnormalities, seizure disorders, respiratory problems, obesity and  an increased susceptibility to infections. There is no way of preventing this disease but research shows that the chance of having a child with down syndrome increases with age. This disease cannot be cured but resources are available to make life comfortable for both victims and caregivers. Down syndrome is not inherited. It is caused by abnormal cell division during egg cell and sperm cell development.

CAUSES

Babies normally inherit  genetic material from both parents. Human cells have 23 pairs of chromosomes. One chromosome in each pair comes from the mother and the other from the father. In some cases a baby may inherit an extra copy of chromosome 21 and this results in the baby having the disease thus the name trisomy 21.

TYPES

Down syndrome may be divided into three types depending on how the extra genetic material is acquired.

Trisomy 21 : This is the most common affecting about 95% of individuals. The child has 3 copies of chromosome 21 instead of the usual 2. It is caused by abnormal division during egg cell and sperm cell division.

Mosaic down syndrome : This is a rare form. It occurs when a child inherits an extra copy of chromosome 21 in some cells but not others.  These individuals may not have all the typical features of people with trisomy 21 and their condition may not be as severe. This type is caused by abnormal division after fertilization.

Translocation down syndrome : These individuals do not inherit the entire chromosome 21. They just inherit some extra chromosome 21 attached to another chromosome usually chromosome 14. This type is uncommon.

RISK FACTORS

Some people are at a higher risk of having children with Down Syndrome than others.

The main risk factor of having a child with the disease is advanced maternal age. A woman’s risk of having a baby with Down Syndrome increases because older eggs  are more likely to experience improper chromosomal cell division.

  • 25 years 1 in 1,250
  • 30  years 1 in 1,000
  • 35 years 1 in 400
  • 40 years 1 in 100
  • 45 years 1 in 30

If you already have a child with Down Syndrome, there is the likelihood of having  another baby with the disease. Also parents can pass on the genetic translocation for Down Syndrome to their children if they are carriers.

SYMPTOMS

Most children with Down Syndrome have distinct physical characteristics. These include the following :

  • flattened facial features
  • short neck
  • protruding tongue
  • upward slanting eyes that may have small skin folds at the inner corner
  • unusually shaped ears
  • small head
  • poor muscle tone and loose ligaments
  • relatively short fingers
  • broad short hands with a single crease in the palm
  • white spots on the colored part of the eye
  • excessive flexibility

Development and growth may usually be delayed. They are usually shorter than children of the same age. They usually reach  milestones such as sitting, crawling and walking later than other children. They have delays in speech and self-care such as feeding, toileting and dressing.

TEST AND DIANGONSIS

The  American Congress of Obstetrician and Gynecologists recommends offering various screening tests for Down Syndrome to all pregnant women regardless of their age. This helps parents make important decisions and prepare for caring for a child with special needs. It should be noted that these tests are not 100 % accurate. Some of these tests may also cause a miscarriage.

Ultrasound : It is used to measure a  specific region on the back of a baby’s neck. More fluid than usual tends to collect in these tissues when abnormalities exist. This test is known as nuchal translucency screening test.

Blood Test : It measures the  levels of pregnancy-associated plasma protein-A (PAPP-A)  and human chorionic gonadotropin (HCG). Abnormal levels may indicate a problem with the baby.

Amniocentesis : It is performed between 16 and 20 weeks of pregnancy. A thin needle is inserted through the abdominal wall and a small  sample of amniotic fluid is taken. The sample is then used to analyze the chromosomes of the fetus. This procedure carries a  risk of miscarriage.

Chorionic villus sampling (CVS) : This is usually done at 11-12 weeks of pregnancy. Collection  of  chorionic villus cell sample from the placenta  is done to  analyze fetal chromosome deviations. This test also carries a risk of miscarriage.

Percutaneous umbilical blood sampling (PUBS) : Fetal blood is taken from  the umbilical cord. The procedure is done by  inserting a needle  through the abdominal wall. The procedure is usually done around 18 weeks of pregnancy. It carries a greater risk of miscarriage than amniocentesis and CVS. It is done when previous test results are not clear.

At birth, the initial diagnosis of Down Syndrome is usually based on baby’s facial appearance. You  doctor will order chromosomal karyotype to confirm Down Syndrome.

TREATMENT

There is no cure for Down Syndrome. Early intervention programs and regular medical check-ups for associated health issues may help one manage the disease well.

Children with the disease should be enrolled in specialized programs that will  help  them develop their sensory, motor and cognitive skills .  Early intervention programs  include physical  therapy, occupational therapy and speech therapy. They should also be included in family activities.

Corrective surgery may be done for heart defects and other associated health issues that  the child may have.

Regular check-ups to screen the child for other diseases is also essential.

COMPLICATIONS

People with Down Syndrome may have a wide variety of complications, some of which include the following :

  • heart defects
  • leukemia
  • obesity
  • dementia
  • infectious disease
  • respiratory infections
  • sleep apnea
  • seizures
  • hearing loss
  • poor vision

PREVENTION

There is no way of preventing Down Syndrome. If you fall into the high risk category of having a child with the disease, it is better to consult a genetic counselor before getting pregnant. The genetic counselor will explain to you prenatal testing available for the  disease and what to expects when you have a child with the disease

Morning Sickness

  By Kemboi Kibet

Morning sickness is nausea that occurs during pregnancy. Though it is called morning sickness, it can occur at any time of the day. This condition is more common during the first trimester but in some cases it may linger throughout the whole pregnancy. Treatment is not necessary but there are certain tips that can help you contain the condition better.In severe cases of morning sickness known as hyperemesis gravidarum, patient may need to be hospitalized  and treated with intravenous (IV) fluids and medications. This however is very rare.

TIPS TO EASE MORNING SICKNESS

There is no guarantee that you can prevent morning sickness altogether. There are however steps you can take to reduce the frequency and severity of this condition.

Keep some snacks such as crackers by your bedside. Before you get out of bed in the morning, nibble on some crackers. This will prevent your blood sugar from getting low and absorb your stomach acid.

Get out of bed slowly and then nibble on some more crackers slowly. This will help your stomach settle and prevent queasiness when you walk around.

Eat small meals about every two to three hours instead of eating three large meals. This helps to prevent your blood sugar from going low. You need to always have some kind of food in your stomach otherwise your stomach acid will work on your stomach wall causing nausea.

Keep snacks such as crackers, vegetables sticks, fruits and Cheerios by you all day and snack on them to keep your blood sugar up.

Avoid foods that trigger morning sickness such as fried and greasy foods, sweets and caffeine.

Drink lot of fluids such as water and or ginger ale. It helps also helps suck on some ice chips.Staying hydrated is also essential for baby’s growth.

Avoid foods and smells that make your nausea worse.

If taking prenatal vitamins makes you queasy, it will be better to take them at night with food . If that doesn’t help, ask your doctor for chewable prenatals.

Avoid large amounts of water and beverages during a meal.

Make time to rest. Fatigue, worry and stress exacerbate morning sickness symptoms. Try taking naps during the day.

Fresh air may help. Take short walks or sleep with windows open if  weather permits.

Eating or drinking something sour like lemon may also help.

Fresh ginger is used to battle morning sickness. Add  a 2-inch piece of ginger root, peeled and sliced to tea and boiling water and let it stand for about 15-20 minutes. strain and then drink.

After eating sit down so that the gravity helps to keep food in your stomach.

Dont brush your teeth immediately after eating because this can cause you to vomit.

Avoid fatty or spicy foods. Avoid alcohol as well.

Wear lose and comfortable clothing. Tight clothing may exacerbate the symptoms of morning sickness.

Food Poisoning

by Kemboi Kibet  

Food poisoning happens after consuming a contaminated food or drink. It also called food borne disease. Different types of organisms such as different types of bacteria, viruses and parasites and their toxins usually cause food poisoning. Food poisoning can be mild or deadly and depending on the organisms that cause it. Victims may be symptom free or have symptoms such as diarrhea, nausea , vomiting, cramping, fever and chills. Food contamination can occur  during food processing and production or can even happen at home when food is manhandled.

 

CAUSES

Food poisoning can be caused by infectious agents such as viruses, bacteria and parasites or toxic agents such as pesticides on fruits. Food contamination can happen from growing, harvesting, processing, storing, shipping or preparing.

Some of the most common bacteria  that cause food poisoning  are:

  • Salmonella
  • Listeria
  • Campylobacter
  • E. coli

 

SYMPTOMS

Symptoms of food poisoning vary depending the type of contaminant but most  types present one or more of these common symptoms. They include the following :

  • nausea
  • vomiting
  • fever
  • watery diarrhea
  • abdominal pain and cramps

Food poisoning is usually mild and may run its course for 24-48 hours .In severe cases however symptoms may last longer and patient may need to be hospitalised. Symptoms can develop quickly within an hour or may be slow and worsen with time.

 

RISK FACTORS

Groups of people or conditions that put one at a higher risk of getting food poisoning include the following:

Pregnant Women : Changes in metabolism and increased circulation may increase your risk of catching food poisoning. Their symptoms may be severe. It is however rare for your baby to get sick from it.

Children : These group face the risk of getting food poisoning because their immune system is not fully developed.

Elderly : The elderly usually have compromised immune system due to their age or illness making it difficult for them to fight infection.

People With Chronic Diseases : Diseases such as HIV and diabetes reduces the effect of your immune system to fight diseases.

 

TEST AND DIAGNOSIS

Your doctor will ask you detailed questions to help diagnose food poisoning. These include what your symptoms are, how long you’ve been sick, what foods you’ve eaten and so on.Doctor may also check you for dehydration and may also check your blood pressure, pulse, breathing rate and temperature. In some cases stool samples will be sent to the lab to identify the toxin causing symptoms. Blood test may also be done to check for seriousness of the sickness.

 

TREATMENT

Most cases of food poisoning may resolve on its own but some may need to be treated. Treatment depends on severity of disease and organism causing the symptoms.

Replacing Lost Fluids : During diarrhea the body loses essential electrolytes and fluids and these need to be replaced to avoid dehydration. Patients may need to be hospitalised and nutrients and fluid replaced through an IV. Giving fluid and electrolyte through an IV is faster than oral hydration.

 

Antibiotics : Pregnant women with food poisoning may need to be treated with antibiotics to prevent baby from getting infected. Some organisms like listeria need to be treated with antibiotics.

Doctor may also treat fever with medications and may also give anti vomiting medication to control vomiting. He may also treat diarrhea with medications

 

SELF CARE

These self-care or home remedies makes patients more comfortable and prevent dehydration.

Let your stomach settle. Do not eat or drink for a few hours.

Small frequent sips of water helps keep you hydrated.

Avoid alcoholic, caffeinated, or sugary drinks.

Get enough rest.

Gradually begin to eat bland, easy-to-digest foods, such as soda crackers and banana.

Don’t use anti-diarrheal medications.They may slow elimination of toxins from the body.

 

PREVENTION

Cook foods to a safe temperature. Use meat themometer.

  • Cook ground meats to 160 F (71 C)
  • Cook ground poultry to 165 F (74 C)
  • Cook beef, veal, and lamb steaks, roasts and chops to 145 F (63 C)
  • Cook all cuts of fresh pork to 160 F (71 C).
  • Whole poultry should reach 180 F (82 C) in the thigh; breasts 170 F (76.6 C).

Defrost food safely. Safe way to defrost food is to use refrigerator or microwave.

Never leave food out for more than two hours.

Keep hot foods hot and cold foods cold.

Wash before and after handling raw food.

keep raw foods such as poultry away from other foods to prevent cross contamination.

keep surfaces and cooking items clean.

Store perishable foods immediately in refrigerator.

When not sure of food safety, throw away.

 

COMPLICATIONS

Food poisoning can cause dehydration which can be fatal. It is essential to stay hydrated by taking frequent sips of water or getting hydrated through IV if need be.

TtINNITUS

Tinnitus

Introduction

Tinnitus is the perception of sound in the absence of external stimuli. The term comes from the Latin term tinnere which means ringing, but is used to describe sounds that are buzzing, roaring, pulsatile, or clicking in nature. The sound may be perceived as either unilateral or bilateral. Tinnitus may be the first or only symptom of a disease process which threatens the patient’s health or well being.
It is estimated that 40 million people in the United States suffer from tinnitus with 10 million of those severely affected. The prevalence is highest in 40-70 year-olds and it is more common in men than in women. Tinnitus can have a great impact on a patient’s quality of life. Ludwig Von Beethoven described his experience with tinnitus in a letter to a friend in 1801, “only my ears whistle and buzz continuously day and night. I can say I am living a wretched life.”
Tinnitus may be classified as either objective tinnitus, which may be heard by an examiner, or subjective tinnitus in which the sound is only perceived by the patient. Subjective tinnitus is much more common than objective tinnitus. Tinnitus may also be classified as pulsatile or nonpulsatile, with pulsatile usually indicating a vascular etiology.

Objective Tinnitus

Objective tinnitus is the patient perceiving sound produced by paraauditory structures which may be heard by an examiner. It may be either pulsatile or nonpulsatile in nature. Take a careful history from the patient including the relationship of the sound to the heartbeat, the quality of the sound, aggravating/relieving factors, associated hearing loss, and whether the sound is unilateral or bilateral. Possible etiologies include vascular abnormalities, Eustachian tube dysfunction, or muscle spasm.

Vascular Abnormalities

Tinnitus which is described by a patient as pulsatile or with a rushing sound may be of vascular origin. The sound is produced by the flow of blood through paraauditory structures. Vascular tinnitus may be either objective or subjective. Possible causes are arteriovenous malformations, vascular tumors, venous hum, atherosclerosis, ectopic carotid artery, persistent stapedial artery, dehiscent jugular bulb, vascular loops, cardiac murmurs, increased cardiac output (pregnancy, anemia, hyperthyroidism), Paget’s disease, and benign intracranial hypertension.
Arteriovenous malformations are congenital lesions. Types include communication of the occipital artery and the transverse sinus, the internal carotid artery and the verterbral arteries, the middle meningeal artery and the greater superficial petrosal artery, and those of the mandible, brain parenchyma, or dura. Pulsatile tinnitus may be the initial symptom, but AVMs can also be associated with headache, papilledema, or discoloration of skin or mucosa.
Vascular tumors which can cause tinnitus include glomus tympanicum and glomus jugulare. These are paragangliomas which arise in the middle ear or jugular bulb respectively. A glomus jugulare may extend up into the middle ear. When the mass involves the middle ear it may be seen as a reddish mass behind the tympanic membrane.
A venous hum may be present from increased or turbulent flow through the venous system. Possible causes include a dehiscent jugular bulb, transverse sinus obstruction, benign intracranial hypertension, or increased cardiac output from pregnancy, anemia, or thyrotoxicosis. A dehiscent jugular bulb may be seen on otomicroscopy as a bluish mass in the middle ear. Patients with benign intracranial hypertension are usually female, overweight and have symptoms of hearing loss, aural fullness, dizziness, headaches, and visual disturbances.

Patulous Eustachian Tube

In patients with Eustachian tube dysfunction in which the tube remains open abnormally, it is called a patulous Eustachian tube. Patients may describe the sound as an ocean roar in the ear which changes with respiration. They may have relief with lying down or putting the head in a dependent position. A tympanogram may show motion of the tympanic membrane with respiration.

Muscle Spasm

Palatal myoclonus is a muscular cause of tinnitus. It is caused by contraction of tensor palatini, levator veli palatini, tensor tympani, salpinopharyngeal, or superior constrictor muscles. It is described as a clicking sound which is rapid (60-200 beats per minute), repetitive, and intermittent. It is associated with multiple sclerosis, small vessel disease, tumor, and degenerative neurological disorders. The muscle spasms may be seen either transorally or transnasally. A plot of compliance as a function of time on tympanometry will show the rhythmic change in compliance of the tympanic membrane corresponding to the muscle contraction.
Idiopathic stapedial muscle spasm induced tinnitus is described as a rough, rumbling, or crackling noise which may be exacerbated by outside sounds. The tinnitus tends to follow a sound stimulus, is brief and intermittent.

Subjective Tinnitus

Subjective tinnitus is not able to be heard by an examiner. It is more common than objective tinnitus and is usually nonpulsatile in nature. Subjective tinnitus is associated with presbycusis, noise exposure, Meniere’s disease, otosclerosis, head trauma, acoustic neuroma, drugs, middle ear effusion, temporomandibular joint problems depression, hyperlipidemia, meningitis, and syphilis.
Conditions which result in a conductive hearing loss, such as middle ear effusion, otosclerosis, or cerumen impaction may decrease the level of external sound to the point where the patient is able to hear normal skull sounds. In these cases, treatment of the cause of the conductive hearing loss may alleviate the tinnitus.
Tinnitus which is sensorineural in origin does not have a clear physiologic explanation. It may be caused by abnormalities of the cochlea, cochlear nerve, ascending auditory pathway, or auditory cortex. Many theories of the origin of tinnitis have been proposed which generally involve hyperactive hair cells or nerve fibers activated by a chemical imbalance across cell membranes or decoupling of stereocilia. A neurophysiologic model of tinnitus has been proposed by Jastreboff. In this theory, tinnitus emerges as the result of interaction of a number of subsystems in the nervous system, with auditory pathways playing a role in the development and appearance of tinnitus as sound perception, with the limbic system responsible for the development of tinnitus annoyance. The perception of tinnitus provides negative reinforcement which enhances the perception of tinnitus and the perception of time the person is aware of its presence. This model has led to the development of tinnitus retraining therapy to habituate the patient to the tinnitus.
Depression has been shown to be more prevalent in patients with chronic tinnitus than in people who do not complain of tinnitus. Folmer et al have reported their finding that patients with depression and tinnitus rated their tinnitus severity higher than patients with tinnitus who did not have depression.

Drugs

Many drugs have been linked to tinnitus. Although almost any medication can be a possible cause of tinnitus the most frequently implicated drugs are the antinflammatories, antibiotics, and antidepressants. Both aspirin and quinine are associated with tinnitus. This tinnitus is high frequency, tonal in nature, and accompanied by a temporary threshold shift. The tinnitus is reversible with cessation of the medication. Aminoglycoside antibiotics are also often implicated as the cause of drug-induced tinnitus. Other medications include loop diuretics and chemotherapeutic agents such as cisplatin and vincristine. Any of the heterocycline antidepressants (i.e. amitriptyline, imipramine) can cause tinnitus. This is interesting because antidepressants have also been investigated for the treatment of tinnitus.

Evaluation

The evaluation of a patient with tinnitus should start with a carefully taken history. The patient’s description of the tinnitus is very important, it can provide key information during the initial evaluation. The quality of the sound, especially whether it is pulsatile or nonpulsatile, the perceived location, the pitch, the loudness, constant or episodic, onset, alleviating/aggravating factors, history of infection or trauma, noise exposure, medication usage, medical history, associated hearing loss/vertigo, family history of hearing loss and associated pain should all be topics of inquiry. Another very important factor is the impact of the tinnitus on the patient. There are several tinnitus-specific self assessment tools available for evaluating the perceived severity of the tinnitus to the patient. The Tinnitus Handicap Inventory is a 25 item survey that provides a total score and three subscale scores for functional, emotional, and catastrophic impact on the patient.
After a thorough history is taken a complete head and neck exam, as well as a general physical exam should be performed. Otomicroscopy should be performed to look for a middle ear mass or motion of the tympanic membrane with respiration. A glomus tympanicum can be seen as a reddish mass in the middle ear or a dehiscent jugular bulb may be seen as a bluish mass. With a history of pulsatile tinnitus, the physician should search for an audible bruit by auscultating the external canal with a Toynbee tube, and over the orbit, mastoid process, skull, and neck using the bell and diaphragm of a stethoscope. The heart should be auscultated for murmurs. The patient should perform light exercise to see if this increases the pulsatile tinnitus. Tinnitus of arterial origin will often worsen with exercise. Venous induced tinnitus may decrease with light pressure on the neck, turning the head, or with the Valsalva maneuver.
All patients may undergo audiometric testing including pure tone audiometry, speech discrimination, tympanometry, and acoustic reflex measurements. The pitch of the tinnitus may be matched by the patient to an administered pure tone. The loudness of the tinnitus may be estimated by having the patient adjust the level of a pure tone to the loudness of their tinnitus. The minimal masking level is the number of decibels required to mask the tinnitus. In the case of vascular or palatomyoclonus induced tinnitus, a graph of tympanic membrane compliance versus time will show changes in compliance which correspond to the pulse or palatal movement respectively. Patulous Eustachian tube induced tinnitus can be diagnosed by a change in the compliance which corresponds to respiration. Unilateral high-frequency sensorineural hearing loss associated with tinnitus and asymmetric speech discrimination scores suggests an acoustic neuroma. Patients with unilateral symptoms may undergo auditory brainstem evoked response testing. These patients should undergo an acoustic protocol MRI to evaluate for acoustic neuroma, which will be further discussed below.
Laboratory studies may be obtained as indicated by the history and physical exam. Possible studies include hematocrit, fluorescent treponemal antibody absorption tests, blood chemistries, thyroid studies, and a lipid battery.
Weissman and Hirsch recently reviewed the imaging of tinnitus. They recommend contrast-enhanced computed tomography of the temporal bones and skull base as the first line
study for evaluating pulsatile tinnitus. The diagnosis of glomus tympanicum tumors is made on the bone algorithm scans which best shows the extent of the mass. It is usually not possible to see enhancement of a small tumor confined to the middle ear on a CT study. Either T1-weighted MRI with gadolinium enhancement or T2 weighted images will show the tumor enhancement. The earliest detectable abnormality on CT of glomus jugulare tumors is erosion of the lateral and anterior walls of the osseous jugular fossa. These tumors enhance significantly with contrast material, it may not be possible to differentiate the internal jugular vein from tumor. As with glomus tympanicum tumors T1-weighted MRI with gadolinium or T2-weighted images will show tumor enhancement. The classical characteristic MRI pattern is a “salt and pepper” appearance. Extracranial arteriovnous malformations as well as brain parenechymal AVMs are usually readily identified on contrast CT and MR studies. A patient with pulsatile tinnitus and a normal otoscopic exam may have a dural AVM or AVF. These lesions are often invisible on CT and MRI. Conventional angiography may be the only study to show the abnormality. Other abnormalities which can be identified on contrast enhanced CT include an aberrant carotid artery, a dehiscent carotid artery, dehiscent jugular bulb, and a persistent stapedial artery. CT findings of a persistent stapedial artery are the appearance of soft tissue on the promontory, enlargement of the facial nerve canal, and absence of the foramen spinosum.
Unilateral tinnitus or asymmetric sensorineural hearing loss is an indication for MRI to evaluate for an acoustic neuroma. A gadolinium enhanced MRI of the cerebellopontine angle is the study of choice to diagnose these lesions.

Treatment

The multiple etiologies and poorly understood mechanisms of tinnitus have led to the attempt at multiple treatment modalities. These include diet modification, medications, habituation, masking, electrical stimulation, acupuncture, hypnosis, and surgery. Some patients need only reassurance that the tinnitus is not a sign of a serious medical disease. Having a physician acknowledge that their symptoms are real and receiving follow up appointments, possibly with repeat audiogram to allay fears of worsening deafness may be of benefit to some patients. Avoidance of stimulants such as coffee, tea, chocolate, cola, and other caffeine containing medications as well as smoking cessation may help some patients. Patients should be instructed to avoid medications, which are known to cause tinnitus such as aspirin and NSAIDs. The use of white noise from a radio or a home masking machine is also helpful in some cases.
Many medications have been researched for the treatment of tinnitus, including lidocaine, tocainide, carbamazepine, benzodiazepines, tricyclic antidepressants, and ginko biloba. Lidocaine administered intravenously has been shown to improve tinnitus but is impractical to use clinically. Tocainide is an oral compound closely related to lidocaine, it has been shown to be ineffective in the treatment of tinnitus. Several randomized-controlled trials have also shown that carbamazepine is ineffective and may cause bone marrow suppression. Johnson et al performed a double-blind, placebo-controlled study of the effectiveness of the benzodiazepine alprazolam and found 76% of patients had improvement in their tinnitus. The risk of dependency to this medication is a significant risk of its use. Interestingly, given that tricyclic antidepressants are implicated as a possible cause of some tinnitus, is that nortriptyline has been
shown to be more effective than placebo. Ginko biloba has also shown some benefit in the reduction of tinnitus in some studies.
Hearing aids, maskers, or combinations of the two may help some patients. If the patient has some hearing loss, amplification of background noise by a hearing aid can decrease tinnitus. A masker produces sound to mask the tinnitus and decrease the annoyance to the patient. There are combination hearing aids/maskers which can be used which are called tinnitus instruments.
Tinnitus retraining therapy is a technique of habituation using a combination of masking with low level broadband noise and counseling to achieve habituation of the reaction to tinnitus and the perception of the tinnitus signal itself. In a study of 32 patients Berry et al found a significant improvement in the Tinnitus Handicap Inventory scores of tinnitus patients following six months of tinnitus retraining therapy.
Electrical stimulation of the cochlea has been studied for the treatment of tinnitus. Transcutaneous, round window, and promontory stimulation of the cochlea have shown some benfit. Direct currents may produce permanent damage and cannot be used clinically. Steenerson and Cronin used transcutaneous stimulation of the auricle and tragus to decrease tinnitus in 53% of 500 patients treated in this manner. Cochlear implants have also shown some promise in the relief of tinnitus. Ito and Sakakihara reported 77% of 26 patients with tinnitus who underwent cochlear implantation had relief of their tinnitus and 8% had aggravation of their tinnitus.
Surgical treatment of tinnitus is used in the treatment of arteriovenous malformations ,vascular tumors, otosclersosis, and acoustic neuroma. Some authors have reported success with cochlear nerve section in patients with intractable tinnitus that is recalcitrant to all other treatment modalities, however this is not advocated by most otologists.
Other treatments that have been studied are biofeedback, hypnosis, magnetic stimulation and acupuncture. Studies of these modalities have shown conflicting results as to their benefit.

Conclusion

Tinnitus is a symptom that can be classified as objective or subjective. The majority of patients have subjective tinnitus associated with presbycusis. The impact of tinnitus on the patient’s well being and quality of life is an important factor in deciding upon treatment. As we are faced with the aging of the population in the United States, tinnitus will surely become even more prevalent. Continued research into the mechanism and treatment of tinnitus is necessary to make progress in relieving the suffering of our patients.
References
1. Hazell, JP, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J. Otolaryngology 1990;19:1-5.
2. Ator GA, Lambert PR. Tinnitus. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Philadelphia, Lippincott Williams & Wilkins, 2000:559-570.
3. Schleuning AJ, Martin WH. Tinnitus : Bailey BJ, ed. Head and Neck Surgery-Otolaryngology, Third Edition. Philadelphia, Lippincott Williams & Wilkins, 2001:1925-1931.
4. Tyler RS, Babin RW. Tinnitus. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery, Second Edition. St. Louis, Mosby-Year Book, 1993:3031-3053.
5. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngologic Clinics of North America 1996;29(3):455-465.
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8. Folmer RL et al. Tinnitus severity, loudness, and depression. Otolaryngology-Head and Neck Surgery1999;121(1):48-51.
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10. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:342-349.
11. Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109:1202-1211.
12. Pulec JL. Cochlear nerve section for intractable tinnitus. ENT Journal 1995;74(7):468-476.
13. Steenerson RL, Cronin GW. Treatment of tinnitus with electrical stimulation. Otolaryngology-Head and Neck Surgery 1999;121(5):511-513.
14. Ito J, Sakakihara J. Tinnitus suppression by electrical stimulation of the cochlear wall and by cochlear implantation. Laryngoscope 1994;104:752-754.
15. Araujo MF et al. Radilogy quiz case I: persistent stapedial artery. Arch Otolaryngol Head Neck Surg 2002;128:456-458.
16. Berry JA et al. Patient-based outcomes in patients with primary tinnitus undergoing tinnitus retraining therapy. Arch Otolaryngol Head Neck Surg 2002;128:1153-1157.
17. Johnson RM et al. Use of alprazolam for relief of tinnitus. Arch Otolaryngol Head Neck Surg 1993;119:842-845.

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