There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room. But we must not forget that we must maintain the same ethical and professional codes as in the real environment. The code of ethics Article 26-3. The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms. The correct action implies inescapably the personal and direct contact between the doctor and the patient.

There is no doubt that the doctor-patient relationship today transcends the physical environment of the consultation room. But we must not forget that we must maintain the same ethical and professional codes as in the real environment. The code of ethics Article 26-3. The clinical practice of medicine by means of consultations exclusively by letter, telephone, radio, press or internet, is contrary to the deontological norms. [HIDDEN] the personal and direct contact between the doctor and the patient.

Juan, a second year resident, attends Sofia, a 15 year old girl in the emergency room, who apparently fainted at school without losing consciousness. The patient says that she was due to take an exam, which caused her a lot of anxiety. From the interrogation, it appears that she was being bullied by her classmates and that she may have an eating disorder. Vital signs and neurological examination are normal. Juan keeps Soﬁa under observation while waiting for her parents to come to the service, periodically taking a look at how the patient is doing. After the initial scare, the patient seems to be increasingly animated and is very friendly. On one occasion, Juan finds her actively chatting on her cell phone. Juan tells her that it would be better for her to put the cell phone down and rest and to reassure her, he tells her that he also uses social networks a lot since college. Soﬁa apologizes for not knowing that she should have her cell phone turned off, and after turning it off, asks if she can make a friend request on Facebook. What do you think is Juan's best response?

Tell him to make the friend request and that he will accept it, as he is sure that there are no inappropriate items on his page for a girl of Soﬁa's age.

Because you consider Soﬁa a vulnerable patient and are concerned that she may misinterpret a rejection, agree to let her make the request but only allow her access to certain content on your page.

Answer that it is important to maintain certain professional boundaries between patients and physicians and that, unfortunately, if you make the request you will not be able to accept it, so it is better not to do so.

Tell him to make the request but without any intention of accepting it.

[Telling the patient the diagnosis of cancer].

Four cases are presented for discussion. In the first case, the patient believed the doctor for a while when his suspicion of cancer was forcibly denied. But when radiotherapy followed the operation, he became convinced that he had been deceived and confronted the doctor aggressively to force him into a confession. In the second case, the patient, a resident of the U.S. for many years, was told on completion of tests the true diagnosis even before his American wife learned of it. He became very depressed, while his wife kept urging him to fight the cancer. In the third case, the doctor thought better of the earlier decision by another doctor not to tell the truth. The doctor called the patient's relatives to discuss the advisability of telling the truth and when he secured their confidence, he visited the patient with them and told him the true diagnosis. The patient recovered from the initial shock and lived peacefully for several months enjoying the new union he felt with his wife. In the fourth case, it is as if there were a kind of silent conspiracy between the doctor and the patient's relatives who kept her in the dark about her condition. When her illness went downhill, she became completely withdrawn, though she accepted religious ministering to the end. It is cruel to deceive the patient with false hopes. But to tell the patient the truth needs tact. The doctor in the third case gives a very good model of it. First, he assesses the patient's personality. Second, he convinces the patient's relatives of the advisability of truth-telling. Third, he assures the patient that he is in charge no matter what happens to him. Perhaps it was easier to tell the patient the diagnosis of cancer or its poor prognosis in bygone days than nowadays, when the wonders of modern medicine are too much publicized.

Who rules the roost?

Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?

Letter of appointment

Other critics assert that the outer sheet containing the postmark and address is of different stock than the first two pages, however this is disputed. This theory infers that Strang disposed of the first two pages, retaining the last page with the post mark and composed his own partial letter containing the appointment. Analysis indicates that the handwriting on all three pages is the same. Vague references to Strang's appointment appear throughout the letter. On page one: "The faith which thou hast in the Shepherd, the stone of Israel [Joseph Smith], hath been repaid to thee a thousandfold, and thou shalt be like unto him; but the flock shall find rest with thee, and God shall reveal to thee his will concerning them." Page two continues: "[H]e [Strang] had faith in thee [Smith], the Shepherd and Stone of Israel, and to him shall the gathering of the people be." Page three: "Thy [Strang] duty is made plain . ... [I]f evil befall me [Smith], thou shalt lead the flock to pleasant

Questioning a Previous Autism Spectrum Disorder Diagnosis: Can You "Lose" the Diagnosis?

Heidi is an almost 6-year-old girl presenting to your primary care office to establish care because of a change in insurance status. You review her previous medical records before seeing her.She was diagnosed with autism spectrum disorder (ASD) when she was 25 months old. Her parents were initially concerned about language delay. Through a comprehensive evaluation by a developmental-behavioral pediatrician and a child psychologist, including administration of the Bayley Scales of Infant and Toddler Development and the Autism Diagnostic Observation Schedule, she was diagnosed with ASD. Her cognitive skills were reported to be within the average range. Soon after the diagnosis, she began receiving 20 hours of applied behavioral analysis (ABA) per week, as well as music therapy, occupational therapy, and a toddler playgroup through early intervention. Four months after the initial diagnosis, her parents reported that she had started making small improvements in her behavior, used more eye contact, and seemed more socially engaged. Approximately 1 year after the diagnosis, she was receiving 6 hours of ABA per week in addition to starting preschool with an Individualized Education Program. She reportedly continued to show progress with social communication and pretend play skills.At the age of 3 years, 8 months, neuropsychological testing was completed at her parent's request, and her cognitive skills and adaptive skills were reported to be within the average range. She continued to meet the diagnostic criteria for ASD, given her challenges with social awareness, communication, delayed play skills, decreased flexibility, and tendency toward subtle self-direction. She continued to receive speech/language therapy and attended an integrated preschool program within the school district because of her social and communication challenges. She also received ABA 4 hours weekly at home.During your first visit with Heidi, her parents report that she has continued to make progress in all areas, including social skills. She can engage in imaginary play with her friends, ask strangers questions, and comprehend the perspective of others, and she is no longer "rigid." She is not receiving services outside of school and is only receiving once weekly speech/language therapy in school. Her parents no longer believe that she meets the criteria for ASD, and they are interested in further evaluation. Her parents ask if it is possible to "lose" the diagnosis of ASD. They also want to know if there are other things to be concerned about for her future. How do you respond?

Aidan Foster

Chris' friendship with Natasha starts to affect his relationship with Aidan, who asks him to choose between them. When Natasha's party is ruined, Chris rushes straight to her aid. Natasha also steals Chris' attention from Aidan and he often drops everything for her, even though she would not do the same for him. Aidan, who has become tired of Chris always making excuses for Natasha, tells him to start asserting himself instead. Morley explained to a TV Soap writer, "It's not that Aidan doesn't approve of Tash, rather it's the way that she has been treating Chris that Aidan doesn't agree with. This, coupled with the fact that Chris isn't standing up for himself, sends Aidan over the edge." Chris feels "shattered" at having to choose between his boyfriend and best friend. Mason commented that his character just needed to learn how to handle them both. Aidan feels the situation is just part of the "getting to know each other" phase, but Chris panics and assumes his relationship is about

Supporting a Youth with Cerebellar Ataxia into Adolescence.

Zoe, a 13-year-old white girl, presents as a new patient to your pediatric clinic with complaints of frequent emesis, anxiety, and learning problems, and previous diagnosis of cerebellar ataxia. Parents accompany Zoe and state, "it is really hard for her to go out, she gets sick and falls easily." She was born full term by vaginal delivery without complications. Given globally delayed milestones, she received early intervention services. Feeding problems began at infancy, including gastroesophageal reflux and aspiration pneumonia.At age 2, Zoe saw a neurologist and brain MRI revealed cerebellar atrophy. She recently saw a geneticist and genetic studies are pending. Parents report receiving "little" information regarding prognosis; through their own research, they read about individuals having similar symptoms in adulthood, with a degenerative pattern. They worry that Zoe is "still very young and we do not know what her future will be like."Despite ongoing speech and feeding challenges, the parents report difficulty finding a speech and language therapist in their area. Zoe does see an otolaryngologist for frequent otitis media and hearing loss and an ophthalmologist for vision problems. Still, she continues to fall further behind in school. Furthermore, she is intensely afraid of falling at school and has few friends, resulting in the family being at a loss regarding "what to do about school."She lives with both parents and 2 healthy older sisters. Her mother has Crohn's disease and has been unable to work. Her maternal aunt is close to Zoe and has hypothyroidism. Her father works as an insurance agent and resources have been "tight." Zoe's mother describes "making" Zoe go out to the movies, "otherwise she just stays home." Zoe usually needs assistance to walk in public, to keep from stumbling. Parents share that simply being in a public place or meeting a new physician may trigger emesis. Zoe does enjoy interacting with neighborhood children and says she wants to be "normal," wear nail polish, and date. She seeks independence, often refusing to use her wheelchair. Parents feel she requires more intensive occupational and physical therapy.On examination, she is very slender with hypertelorism and nystagmus. Holding an emesis bag, she gags intermittently, producing clear secretions. She has a notable tremor and walks slightly stooped with wide-based gait. Her few words demonstrate articulation differences and cognitive expression characteristic of a younger child. She wears light make-up and age-appropriate clothes. She asks, "When can I go home?"At the end of the visit, parents share their worry that Zoe is "so young and we do not know anything, what to expect, or what to tell her." As the family's new medical home, they ask you to weigh in on what to do next to best support her? Where do you begin?

The Clique (duo)

For the Judges' Choice-themed first live show, Third Degree sang "thatPower" by will.i.am and received positive feedback from the judges. In week six of the live shows, Third Degree fell into the bottom two alongside JTR but was saved after Keating, Minogue and Redfoo all opted to eliminate JTR. Following the eliminations of Adira-Belle and JTR, Third Degree became the only remaining act in the Groups category. In week eight of the live shows, Third Degree fell into the bottom two alongside Jiordan Tolli. The judges' vote went to deadlock, and Tolli was eliminated after it was revealed she received the fewest votes. In the semi-finals, Third Degree sang "Give Me Everything" by Pitbull and "Pound the Alarm" by Nicki Minaj, gaining positive reviews from the judges. Despite this, they fell into the bottom two alongside Taylor Henderson. The judges' vote went to deadlock, and Henderson advanced to the grand final after it was revealed he received the most public votes, leading to Third

Let Me Spell It Out: The Impact of Microaggression on the Health Care Professional.

Rachel is a 10-year-old White girl with attention-deficit/hyperactivity disorder and a history of trauma who presented for evaluation by Dr. Narayanaswamy, a developmental-behavioral pediatrician. A pediatric resident observed the visit with permission from Rachel's parents.During the visit, Dr. Narayanaswamy spoke to Rachel's case manager over the phone to advocate for a trauma-based day treatment program at her school. At the end of the call, the case manager asked the physician for her full name. Dr. Narayanaswamy responded with her name and asked the case manager, "Would you like me to spell it?" At that time, Rachel's father began to laugh, shook his head, and incredulously remarked, "Ugh, yeah you need to spell it." Dr. Narayanaswamy ignored the comment and completed the phone call.After the visit, Dr. Narayanaswamy explained to the resident that the father's derisive laughter was a microaggression. The resident appreciated the observation and, after a pause, asked why she chose not to defend herself when the microaggression occurred. Dr. Narayanaswamy reflected that she had refrained from responding to Rachel's father over concern that he would retaliate by providing low ratings on the postvisit patient satisfaction survey sent to all patients who received care at the institution. The granular survey results, comprising ratings in each survey subheading category for each clinician, are made public to members of her division each quarter, and low ratings are scrutinized by the leadership. Dr. Narayanaswamy thought it unfortunate that she felt inhibited in her response because this deprived the resident of observing ways to address microaggressions during an encounter, deprived herself the opportunity to respond directly to Rachel's father, and deprived Rachel from an instructive moment about racial empathy.Dr. Narayanaswamy wrote a letter about the incident to the chief of clinical affairs to inquire what recourse clinicians had in these situations and whether certain patient encounters could be flagged to prevent the postvisit patient survey from being automatically sent. The chief responded that the incident was unfortunate and praised Dr. Narayanaswamy's restraint and professionalism but denied her request to have postvisit surveys blocked for certain encounters. He shared that if a clinician were to be dissatisfied with a visit satisfaction rating, the clinician could petition for a review, and a committee would subsequently determine whether the review could be removed.How can health care professionals respond to microaggressions while maintaining a therapeutic alliance with the patient/family members and how can institutions support health care professionals in this endeavor?

List of Person of Interest characters

(5.12 ".exe") In a simulated world where the Machine never existed, Cole is shown to have survived and to still be partnered with Shaw. Henry Peck Henry Peck (played by Jacob Pitts) is a former NSA Analyst and Person of Interest. (1.22 "No Good Deed") When Peck discovers the existence of the mass surveillance program, "Operation Northern Lights", an ISA team is sent to kill him. Peck still refuses to stop investigating, so Finch is forced to tell him the truth and give him a new identity so he can escape the threat. Alicia Corwin secretly records their conversation and learns of Finch's involvement. (5.12 ".exe") In a simulated world where the Machine never existed, Peck uncovers the existence of Samaritan. He presents his evidence to a member of the Office of Special Counsel, revealed to be Shaw. After she verifies that Peck hasn't told anyone else about his theory, she assassinates him.

Maintaining Safety and Planning for the Future.

Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a "clock-training" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to "cook." After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a "home" where someone will "do bad things to him."What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?

Something There

In his biography I'm Not Dead... Yet!, actor Robby Benson, voice of the Beast, revealed that it was co-star Paige O'Hara's idea to have Benson's character duet with O'Hara's Belle in "Something There". According to Benson, the actress "explained to Ashman and Menken that [Benson] had made records and sang in Broadway musicals." O'Hara briefly struggled to record one of the song's lines – "a bit alarming" – to which an ailing Ashman, who was forced to communicate with O'Hara and the studio via telephone from his hospital bed in New York due to his illness, simply responded "Streisand." By this, Ashman meant that he wanted O'Hara to impersonate singer and actress Barbra Streisand, and by doing so O'Hara finally recorded the song successfully. "Something There" was recorded by O'Hara and Benson accompanied by a live orchestra.

Bullying and ADHD: Which Came First and Does it Matter?

Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.You speak with Aiden in the office and ask him about school. He says, "It's bad. I'm failing." He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and "gives hard homework." He describes his history teacher as "annoying." When you ask what he means he states this teacher "Can be not nice and says mean things. She picks on me a lot." His description is consistent with the use of shaming as a behavior he experiences at school.You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.A week later, you receive a telephone call from Aiden's mother. "Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school." She is not aware if retention has been recommended for Aiden.What would you say to Aiden's mother? What would you do next?

Re'eh

repayment would surely cause the person to decline assistance on a second occasion, Rav Papa explained that the community exacts repayment from the person's estate upon the person's death. Rabbi Simeon taught that the community need not become involved if a person who has the means for self-support chooses not to do so. Rabbi Simeon taught that if a person has no means but does not wish to receive support from the community's charity fund, then the community should ask for a pledge in exchange for a loan, so as thereby to raise the person's self-esteem. The Rabbis taught in a Baraita that the instruction to "lend" in refers to the person who has no means and is unwilling to receive assistance from the community's charity fund, and to whom the community must thus offer assistance as a loan and then give it as a gift. Rabbi Judah taught that the words "you . . . shall surely lend him" in refer to the person who has the means for self-support but chooses rather to rely on the

Bullying and ADHD: which came first and does it matter?

That Darn Priest

On February 28, 2011, during a national television interview in his home, Sheen publicly demanded a 50% raise for the show. Already the highest-paid actor on television, Sheen demanded $3 million per episode, claiming that in comparison to the amount that the series was making, he was "underpaid." He later retracted that demand. A March 3, 2011, telephone survey of 1,000 people found that 71% of them had an unfavorable impression of Sheen and 16% had a positive opinion of him. On March 7, 2011, CBS and Warner Bros. officially fired Sheen from the show after eight seasons. The official statement read: "After careful consideration, Warner Bros. Television has terminated Charlie Sheen's services on Two and a Half Men effective immediately." In the aftermath of his dismissal, Sheen remained vocally critical of Lorre, and repeatedly attacked him in an eight-minute Ustream video. On May 13, 2011, CBS and Warner Bros. announced that Ashton Kutcher would replace Sheen on the show.

[Power of personal goal sharing--treatment plan using personal goal maps for patients with mental disorders].

A female patient in her sixties with schizophrenia had secretly disposed of all her medication and was not cooperating with hospital staff for about four months. During one of our consultations she mentioned that she wanted to be out of hospital by a certain date. That date happened to be her grandchild's birthday. It was at this point that she shared her goals with us, and voluntarily started having treatment. She was able to return home three months later, just in time to celebrate her grandchild's birthday with her family. A male patient in his sixties was able to leave the seclusion room after 10 years. The first doctor in charge and other hospital staff had firmly believed that releasing him from the seclusion room wasn't a possibility. However the patient decided he wanted to be discharged and was interested in finding out how to go about it. The moment he realized it was possible, his outlook changed immensely. He gradually started to open up and communicate better with his new doctor in charge, and was able to work towards his newly found goals. Staff members were also surprised when he was able to leave the seclusion room. They realized this patient was another person like them who had dreams and goals, and stopped stereotyping patients who seemed to be 'difficult to handle'. I have always experienced the power of goal sharing at clinical scenes, and have noticed its importance for patients making a start on the road to recovery. In order to discuss goals and the way to go about achieving them, I use a simple drawing of a mountain. I call this mountain 'A Personal Goal Map'. I like to think of myself (the doctor) as the mountain guide, and my patient as the mountain climber. The three key philosophies are acknowledging individuality, diversity and freedom. These are important when we think about where we are now, where we are going, and where we want to be. Firstly at the start point, we need to define the patient's problem and discuss ideas and goals, which help us along the Trust Path. The more patients and staff trust and understand each other the easier it is to climb up the Initial Treatment Path. We need to build up trustful relations so we can share personal goals and make a proper assessment and diagnosis, and talk about the safety, efficacy, cost and suitability of the initial treatment. Secondly, we need to take a rest and make more plans for the Recovery Path. It is on this path that we decide on comprehensive treatment together. We may be able to improve the patient's cognitive functions by using atypical anti-psychotic agents. We can then give them information, instructions and warnings about medicine usage so the patient is able to understand their condition. It is only after the patient can understand these things fully and act positively that we can start to climb the final path, the Achievement Path. We should review the suitability and efficacy of the treatment again, and it is at this stage that the mountain guide steps back and watches the mountain climber take the final steps towards the mountain peak goal. Lastly, the patient will feel elation and a sense of fulfillment and self-pride, and no doubt will be ready to look for the next mountain peak to climb. In order for you to enjoy the benefits at the clinical scene, all you need is a piece of paper, a pen, and a limitless imagination for better personal goal sharing. At Meisei hospital we promote the 'Minotake Team Approach', which calls for flexible management so we hospital staff can help each other as professionals. We treat patients as individuals using words and expressions they understand (such as local dialect and nonmedical terms), and give them access to easy to understand resources such as leaflets delivered by universities or pharmaceutical companies. We ask our staff to act naturally with the patients, and to just do what they can do to help the patients work towards their personal goals.

Re'eh

as a loan and then give it as a gift. Rabbi Judah taught that the words "you . . . shall surely lend him" in refer to the person who has the means for self-support but chooses rather to rely on the community, to whom the community should give what the person needs as a gift, and then exact repayment from the person's estate upon the person's death. The Sages, however, said that the community has no obligation to help the person who has the means of self-support. According to the Sages, the use of the emphatic words "you . . . shall surely lend him" in (in which the Hebrew verb for "lend" is doubled, וְהַעֲבֵט, תַּעֲבִיטֶנּוּ) is merely stylistic and without legal significance.

A dominating imaginary friend, cruelty to animals, social withdrawal, and growth deficiency in a 7-year-old girl with parents with schizophrenia.

Tessa is a 7-year-old girl with odd behaviors, worsening over the preceding year. She spends a significant amount of time alone in her room, talking to "Richard." Her father observed that Tessa is "in her own world." In school, she often glares at the teacher and refuses to work. She is alone at recess without any real friends. Her father reports that she eats little and only after he tastes the food. She is increasingly cruel to both real and toy animals. She tied a string around her cat's neck and swung it around, saying she wanted to punish it. She was heard to say to her stuffed cat, "Die, b ... .; die." Richard told her to do this and other "bad" things. Tessa has not had chronic health problems or developmental concerns. During the first 18 months of life, her height was between the 5th and 10th percentiles; it declined to below the 3rd percentile over the past 2 years. Weight has been consistently between the 3rd and 5th percentiles. Tessa's parents both have been diagnosed with schizophrenia. There are at least 7 first- and second-degree relatives with the same diagnosis. Both parents cared for Tessa for 4 years with a lot of support. Then, her father left the home, but he was in contact with her while managing his own illness. When the mother's illness and compliance worsened, Tessa was removed for neglect at 5 (1/2) years old. Two foster homes preceded Dad's award of sole custody 13 months ago. Mother's weekly visitations are quite upsetting to Tessa. Tessa is a verbal, solemn, small, well-dressed girl with no physical abnormalities. She talks with advanced vocabulary and syntax, with normal prosody and good conversational skills. She says Richard is a bad boy who gets her into trouble at school. She equivocates when asked if he is real or imagined or if others can see him. She says that she misses her mother.

List of last words

"On a certain occasion, I chanced to be one of three who sat in judgment on one of my own good friends, who, according to the laws, should have been punished with death. I was greatly embarrassed. One of two things was inevitable—either to violate the law or condemn my friend. After careful consideration, I devised this expedient. I delivered with such address all the most plausible arguments in behalf of the accused, that my two colleagues found no difficulty in acquitting him, and yet I, myself, condemned him to death without assigning any reason for my conduct. Thus I discharged two duties, those of friend and judge; yet I feel in my conscience something which makes me doubt whether my conduct was not criminal." — Chilon of Sparta, philosopher (6th century BCE), speaking to his friends before his death

Diagnosis and management of carbon monoxide poisoning in the emergency department.

An 89-year-old female is found by her family, lying unconscious on her kitchen floor after they had been unable to reach her by phone for several hours. EMS is activated and when the paramedics arrive, they note that the gas oven is on, and there is thin, gray smoke coming from around the door. The house gas supply is turned off, windows are opened, and the family and the patient are immediately evacuated from the home. En route to the hospital, the patient is placed on high-flow oxygen at 15 liters per minute by non-rebreather mask. Her bedside glucose determination is 229 mg/dL. Vital signs are within normal limits during transport. She opens her eyes to sternal rub, and makes spontaneous movements of all extremities. Upon arrival to the ED, the patient becomes more alert and is able to respond to your questions. She tells you that she remembers putting a tray of calzones into the oven, after which she has no recall of the day's events. She has a past medical history of "well-controlled" hypertension, hyperlipidemia, and non-insulin-dependent diabetes. Her medications include hydrochlorothiazide 25 mg daily, lisinopril 10 mg daily, simvastatin 20 mg daily, and metformin 1000 mg twice daily. On physical examination, weight is 65 kg, blood pressure is 97/50 mm Hg, heart rate is 113 beats per minute, respiratory rate is 22 breaths per minute, temperature is 37.1 degrees C (98.8 degrees F), and oxygen saturation is 99% on 15 liters per minute via non-rebreather mask. She appears her stated age. Cardiopulmonary examination is remarkable only for tachycardia. Her abdomen is soft and non-tender with normal bowel sounds. Her skin is warm and dry, and there is no peripheral edema. Her cranial nerves are intact, with briskly reactive, symmetric pupils. Motor and sensory examination is non-focal, and cerebellar testing is notable only for an intention tremor on finger-nose-finger test. Gait is normal and speech is fluent and without errors. Laboratory testing shows a hemoglobin of 10.3 g/dL and a leukocyte count of 11.7 x 10(9)/L. Electrolyte results fall within the normal range, and her serum creatinine is 1.7 mg/dL. Qualitative CK-MB and troponin I tests are positive, and the sample has been sent to the STAT lab for quantitative testing. Serum carboxyhemoglobin level is 15% with normal serum pH on an arterial blood gas. An ECG reveals deep, down-sloping inferior and lateral ST-segment depressions which were not present on a routine cardiogram 1 month prior. You have many questions about this patient's care. What symptoms and physical signs need to be addressed and treated? What additional diagnostic testing should be performed? What treatment regimen is appropriate and what should be avoided? What are the risks or delayed complications from her illness? Are there special considerations for this or other patient populations?

Elizabeth Needham

Needham was taken from the pillory alive, but died on 3 May 1731, the day before she was due to stand in the pillory (this time at New Palace Yard) for the second time. With her last words she apparently expressed great fear at having to stand in the pillory again after the severe punishment she had received the first time. The Grub Street Journal, the satirical journal allied with Alexander Pope and others of Hogarth's friends, sardonically reported that the populace "acted very ungratefully, considering how much she had done to oblige them". Her demise was celebrated in a mocking rhyme: Ye Ladies of Drury, now weep Your voices in howling now raise For Old Mother Needham's laid deep And bitter will be all your Days. She who drest you in Sattins so fine Who trained you up for the Game Who Bail, on occasion would find And keep you from Dolly and Shame Now is laid low in her Grave...

Case vignette: unanticipated propinquity.

UNANTICIPATED PROPINQUITY. Dr. Marge N. O'Vera has a reputation in the community as a thoughtful, caring, and highly ethical psychotherapist. For more than a year she has been treating Greta Grievance, helping her to cope with emotional and financial insecurities in the aftermath of a highly contentious divorce. During a therapy session, Ms. Grievance tells Dr. O'Vera that she has decided to sue the attorney who represented her during the divorce. Ms. Grievance believes that he did not represent her interests effectively and that she foolishly took his advice in accepting a very inferior settlement. She has retained another attorney who, she tells O'Vera, will soon be calling to request information on the stress of the divorce and Ms. Grievance's continuing need for therapy. Dr. O'Vera will be asked to testify as to the harm caused to her client and resulting treatment expenses. As Ms. Grievance gets up to leave, she tells Dr. O'Vera, "I'm so glad you'll help me teach that awful Tom Tort a lesson." As she hears the name of Attorney Tort for the first time, Dr. O'Vera begins to sweat. Thomas Tort, attorney at law, is also a client of hers. She had no idea that he had been Ms. Grievance's divorce lawyer. She has treated him for recurring major depression over several years and knows that he probably was sufficiently depressed so as to compromise his professional work at the time he represented Ms. Grievance. When she is named as an expert witness for the plaintiff, Attorney Tort will learn that his therapist was also treating Ms. Grievance. At the same time, her duty of confidentiality precludes her informing others that Tort is also her client. What is Dr. O'Vera to do?

Family Business (Once Upon a Time)

Mr. Gold locates Ingrid and calls her out. Ingrid, knowing how well Gold works, tells him that she wanted Emma to find out about their past as part of her plan. Gold says he's there to offer her a deal, saying that if she declined, she'd better watch out. Then, Ingrid replies by saying that if there was something that he wanted from her, he should just take it, but she knows that he can't and needs leverage to make her accept the deal, so she turns him down, and warns Mr. Gold to stay out of her way. As Belle helps Elsa at the library, Elsa is convinced that everyone doesn't know if Anna is in Storybrooke, but Belle says otherwise and decides to seek out the answer back at the pawn shop. When Gold returns, she "uses" the fake dagger on him to take her to the Snow Queen's lair. After they find it, Belle orders Gold to stay outside while she goes in, but there is no sign of the Snow Queen anywhere. Belle then hears a voice, which draws her to a mirror, where an image of Belle taunts her

Test your skills: a worsening rash.

A mother brings her 5-year-old boy in to your office because she is concerned about a rash on his legs that seems to be worsening. She tells you that he had a runny nose and a mild cough a week earlier, but that those symptoms resolved before the rash developed. He has also complained of "belly pain." The boy's mother says he has been less active and more irritable since the onset of the rash, and that he is hardly eating. She also tells you that earlier in the day, her son told her that it hurts to walk. A complete review of systems is otherwise negative. The 5-year-old was born at term without complication. He has met all developmental milestones and his immunizations are up to date. He takes no medications. The boy's vital signs are normal. He has an erythematous maculopapular rash distributed on his legs symmetrically; it is palpable, nontender, and nonblanching. You detect no abnormalities in abdominal, neurologic, or musculoskeletal examinations. A complete blood count (CBC) and basic metabolic panel (BMP) reveal mild leukocytosis with a normal differential. Urinalysis shows moderate blood and trace protein. Laboratory results are otherwise normal. What's your diagnosis?

Re'eh

Rabbi Shila of Nawha (a place east of Gadara in the Galilee) interpreted the word "needy" (, evyon) in to teach that one should give to the poor person from one's wealth, for that wealth is the poor person's, given to you in trust. Rabbi Abin observed that when a poor person stands at one's door, God stands at the person's right, as says: "Because He stands at the right hand of the needy." If one gives something to a poor person, one should reflect that the One who stands at the poor person's right will reward the giver. And if one does not give anything to a poor person, one should reflect that the One who stands at the poor person's right will punish the one who did not give, as says: "He stands at the right hand of the needy, to save him from them that judge his soul."

An evidence-based approach to managing the anticoagulated patient in the emergency department.

You start another busy shift with a double row of charts waiting to be seen. Your first patient is an elderly man who fell 1 hour prior to presentation. He did not lose consciousness, but he was dazed for a few minutes. He complains of a mild headache but denies any neck pain. He takes warfarin for valvular heart disease. He looks good and has no focal neurological complaints. His mental status is normal, he has a negative head CT scan, and his INR is 3.9. His family wants to take him home, which would help relieve some of the congestion in the ED, but you wonder what would be best. To observe and repeat imaging? Reverse his anticoagulation? Change his dosing regimen of warfarin? In the next room, you quickly evaluate a 51-year-old obese woman with nonspecific back and abdominal pain that started 24 hours before and has slowly progressed to become intolerable. She denies fever, chills, nausea, or vomiting. She is on the last day of a 5-day course of ciprofloxacin for a UTI. She takes warfarin for a pulmonary embolus that occurred 2 months prior. Her hematocrit is mildly decreased, and her white blood count is normal; however, the INR is 6.8. You wonder if her abdominal pain is related to the UTI, or if it could be somehow related to the prolonged INR. In fact, you wonder why her INR is so prolonged...

List of Person of Interest characters

Devon Grice Devon Grice (played by Nick Tarabay) is a Crimson 6 agent who was trained by Sameen Shaw herself when she was still working as an ISA operative. When they meet in New York whilst both on different ends of the same mission, Grice lets her live. When a Samaritan representative refuses to allow Control to review the contents of a relevant threat's laptop, she secretly enlists Grice's help to continue the investigation. When Control discovers the impending "Correction" and labels it as a Samaritan-sanctioned terrorist attack, she has Grice investigate the supposed target: the Supreme Court. When the "Correction" is revealed to be a purging of persons seen as threats to Samaritan, Grice is executed by an operative for his previous betrayal. Brooks Brooks (played by Theodora Miranne) is another Crimson 6 agent and Grice's partner.

Juan: a 9-year-old Latino boy with ADHD.

Juan, a 9-year-old Latino male, was referred to a community clinic by his third-grade teacher for evaluation of classroom behavior problems. He is an only child and lives with both parents. At home, Juan speaks Spanish with his parents although he occasionally speaks English with his father. His father came to the U.S. from Mexico as a small child and completed the 12 grade in the U.S. Juan's mother completed 8 grade in Mexico and immigrated to the U.S. as a teenager.Juan's mother reported that he has had no significant medical problems. Her report of his behavior included an inability to focus on tasks at hand and easy distractibility. She was concerned that the principal of the school mentioned that Juan may be asked to repeat the 3 grade or change schools. In the clinic, Juan sat quietly but appeared to be daydreaming and attentive to the conversation. The pediatrician called the principal who expressed frustration with Juan's behavior. In class, he was very fidgety, did not pay attention and usually did not answer questions. He also bothered other students when they were working. The principal explained that because Juan's school was a Spanish language immersion school, there were no special education services available. If a student at the school required special education services, he or she would be transferred to another school in the same school district. An evaluation for an Individualized Education Plan (IEP) indicated that Juan had above average cognitive ability (90 percentile), with superior ability to problem solve and process information simultaneously (99 percentile). The Woodcock Johnson III (Spanish version) indicated average achievement in academic skills, with low average in reading fluency, comprehension and spelling. On the Test of Auditory-Perceptual Skills, Juan tested generally low average in all domains, and was at the 14 percentile for both auditory number and auditory word memory. On the Test of Visual-Perceptual Skills, Juan scored above the 92 percentile. Juan did not qualify for special education services on the basis on the standardized tests. However, because of the individual attention required by Juan, a transfer to another school was considered inevitable if his classroom behaviors did not improve. Juan's mother and teacher filled-out the NICHQ Vanderbilt Assessment Scale. Their responses were consistent with the diagnosis of ADHD, inattentive type. In discussion of treatment options with the family, the possibility of stimulant medication use was raised. Juan's mother was opposed to the medication because of what she had heard from her friends-that these medications had bad side effects and did not work most of the time. Juan's father, however, was in favor of the medication because it might assist Juan to stay at the school. After several clinical visits that included further information about ADHD, behavioral treatment, and reviewing information from the school, Juan's parents agreed to a trial of medication. Juan was evaluated for a follow-up visit 2 weeks after starting fourth grade; he had been taking a stimulant medication for one month. He seemed much happier about school and was proud to report that he has completed all of his assignments in school as well as homework assignments, and he did well on a math quiz. Juan's mother was also pleased with his progress. The pediatrician called the principal, who reported that Juan was an entirely different student. He now sat at his desk and wrote down the assignments. He seemed eager to learn and able to be attentive in the classroom. The principal was amazed at the difference.

Who Do You Trust?

After a brief chat with Bergen (and his dummies "Charlie McCarthy", "Mortimer Snerd" and "Effie Klinker") the couples would try to answer four questions. The first was a match question, where the spouses tried to match each other's answer to a question about their married life. The remaining questions were of general knowledge, where after the category was revealed, the husband chose whether to answer himself or "trust" his wife to do so, hence the name of the show. The first correct answer won $100, the second added $200, and the third $300. For the fourth question they could wager any of their winnings by answering a question from one of six categories ranging in value and difficulty from $100 to $600. If the couple won no money, they would answer a very easy $100 question. The couple with the most money competed with the winners from the previous week's show to name as many items as possible in a category with the couple coming up with the most answers receiving $100 a week for a

Disproportionate Representation of Children of Color and Parents with Disabilities in the Child Welfare System: The Intersection of Race/Ethnicity, Immigration Status, and Disability.

An almost 5-year-old girl is referred to a developmental-behavioral clinician for developmental evaluation because of language and learning concerns. Her developmental screening in the primary pediatrics office showed scores concerning for delays in communication, social-emotional, gross, and fine motor domains. Her mother has concerns about her language. Her mother's primary language is Spanish, but the patient and her siblings speak primarily English. She speaks in short phrases and sentences with grammatical errors. Her mother understands approximately 75% of what she says, and strangers understand approximately 50%. She uses gestures and facial expression, is social and friendly, demonstrates pretend play, and plays well with her siblings and other children her age. She has occasional meltdowns, but there are no other major behavioral concerns. She feeds herself with utensils and is able to dress herself. She toilet trained recently, at about age 4.5 years.She did not receive early intervention before age 3 years and had no previous evaluations. She did not attend preschool or child care. Her mother reported that they were referred to the school district twice, but she had trouble requesting the evaluation.She lives with her parents and 2 brothers. The patient's parents immigrated to the United States from Mexico 7 years ago. They are both farm workers, and extended family members are in Mexico. On reviewing family history, the clinician learns that the patient's mother had trouble learning and attended school until she was 12 years old. She did not receive extra help at school. The child's mother said that she forgets things and "has trouble with reading and writing fast." The patient's 10-year-old brother has an individualized education plan and is in a substantially separate classroom. He has inclusion activities of recess, art, and music. He receives speech-language therapy and academic support for reading and writing. The patient's mother becomes tearful and shares that Child Protective Services was notified because of her inability to request the school evaluation, but a case was not opened.Developmental evaluation reveals expressive language at a 33-month-old level and receptive language at a 39-month-old level. Cognitive testing shows extremely low verbal comprehension, borderline visual spatial skills, and fluid reasoning in the low average range. Working memory and processing speed fall in the borderline range. The clinician learns at a follow-up visit that the patient's mother was evaluated by state disability services and has mild intellectual disability.What is your next step in management? What feedback or resources would you provide to the pediatric clinician and family?

Re'eh

The Gemara turned to how the community should convey assistance to the pauper. Rabbi Meir taught that if a person has no means but does not wish to receive support from the community's charity fund, then the community should give the person what the person requires as a loan and then convert the loan into a gift by not collecting repayment. The Sages, however, said (as Rava explained their position) that the community should offer the pauper assistance as a gift, and then if the pauper declines the gift, the community should extend funds to the pauper as a loan. The Gemara taught that if a person has the means for self-support but chooses rather to rely on the community, then the community may give the person what the person needs as a gift, and then make the person repay it. As requiring repayment would surely cause the person to decline assistance on a second occasion, Rav Papa explained that the community exacts repayment from the person's estate upon the person's death. Rabbi

Drug-facilitated sexual assault: educating women about the risks.

"Andrea," an 18-year-old college freshman, walked into her first fraternity party with a few of her sorority sisters. As she walked through the crowded house, one of the fraternity boys handed the girls large plastic cups. Another boy circulated through the crowd, filling up the cups of all guests from two pitchers of beer. When he filled Andrea's cup, he smiled and was polite and charming. She thought his act of filling her cup was kind and gentlemanly, and was flattered by his attention. She didn't notice he used a different pitcher for her than he had for her friends. She and her friends continued to mill through the crowd, sipping their beer. About 20 minutes later, Andrea suddenly had trouble focusing her vision. She felt disoriented and "drunk" even though she had only consumed a third of her beer. She started feeling nauseated, and tried to find her friends. The polite boy who had poured her beer asked her if she was all right, and offered to take her up to his room so she could rest. She followed him, grateful to be able to lie down. Forty-five minutes later, her concerned friends searched the house for Andrea. They found her upstairs passed out in a bedroom, lying on her side; she had vomited and her clothes were disheveled. Suspecting only alcohol intoxication; they picked her up, and walked her out of the party. After Andrea slept for about two hours, she woke up and told her friends something wasn't right. She had only drunk a small amount of her beer, and had no recollection after she walked up the stairs with the boy. She burst into tears, stating she feels some vaginal discomfort, and is afraid she may have been raped. Her friends looked at each other, thinking, "How did this happen and what are we supposed to do?"