By L. Kalesch. Sierra Nevada College.

Neurological changes during childhood provide children the ability to do some things at certain ages order topiramate 200mg with mastercard, and yet make it impossible for them to do other things cheap topiramate 200 mg with mastercard. This fact was made apparent through the groundbreaking work of the Swiss psychologist Jean Piaget quality topiramate 100 mg. During the 1920s buy topiramate 100mg low price, Piaget was administering intelligence tests to children in an attempt to determine the kinds of logical thinking that children were capable of. In the process of testing the children, Piaget became intrigued, not so much by the answers that the children got right, but more by the answers they got wrong. Piaget believed that the incorrect answers that the children gave were not mere shots in the dark but rather represented specific ways of thinking unique to the children‘s developmental stage. Just as almost all babies learn to roll over before they learn to sit up by themselves, and learn to crawl before they learn to walk, Piaget believed that children gain their cognitive ability in a developmental order. These insights—that children at different ages think in fundamentally different ways—led to Piaget‘s stage model of cognitive development. Piaget argued that children do not just passively learn but also actively try to make sense of their worlds. He argued that, as they learn and mature, children develop schemas—patterns of knowledge in long-term memory—that help them remember, organize, and respond to information. Furthermore, Piaget thought that when children experience new things, they attempt Attributed to Charles Stangor Saylor. Piaget believed that the children use two distinct methods in doing so, methods that he called assimilation andaccommodation (see Figure 6. If children have learned a schema for horses, then they may call the striped animal they see at the zoo a horse rather than a zebra. In this case, children fit the existing schema to the new information and label the new information with the existing knowledge. When a mother says, ― “No, honey, that‘s a zebra, not a horse,‖ the child may adapt the schema to fit the new stimulus, learning that there are different types of four-legged animals, only one of which is a horse. Piaget‘s most important contribution to understanding cognitive development, and the fundamental aspect of his theory, was the idea that development occurs in unique and distinct stages, with each stage occurring at a specific time, in a sequential manner, and in a way that allows the child to think about the world using new capacities. Object permanence Children acquire the ability to internally represent the Theory of mind; rapid world through language and mental imagery. They also increase in language Preoperational 2 to 7 years start to see the world from other people‘s perspectives. They can Concrete increasingly perform operations on objects that are only operational 7 to 11 years imagined. Conservation Adolescents can think systematically, can reason about Formal 11 years to abstract concepts, and can understand ethics and scientific operational adulthood reasoning. Abstract logic The first developmental stage for Piaget was the sensorimotor stage, the cognitive stage that begins at birth and lasts until around the age of 2. It is defined by the direct physical interactions that babies have with the objects around them. During this stage, babies form their first schemas by using their primary senses—they stare at, listen to, reach for, hold, shake, and taste the things in their environments. Piaget found, for instance, that if he first interested babies in a toy and then covered the toy with a blanket, children who were younger than 6 months of age would act as if the toy had disappeared completely—they never tried to find it under the blanket but would nevertheless smile and reach for it when the blanket was removed. Piaget found that it was not until about 8 months that the children realized that the object was merely covered and not gone. Piaget used the term object permanence to refer to the child’s ability to know that an object exists even when the object cannot be perceived. Video Clip: Object Permanence Children younger than about 8 months of age do not understand object permanence. At about 2 years of age, and until about 7 years of age, children move into thepreoperational stage. During this stage, children begin to use language and to think more abstractly about objects, but their understanding is more intuitive and without much ability to deduce or reason. The thinking is preoperational, meaning that the child lacks the ability to operate on or transform objects mentally. In one study that showed the extent of this inability, [10] Judy DeLoache (1987) showed children a room within a small dollhouse. The researchers took the children to another lab room, which was an exact replica of the dollhouse room, but full-sized. Three-year-old children, on the other hand, immediately looked for the toy behind the couch, demonstrating that they were improving their operational skills. The inability of young children to view transitions also leads them to be egocentric—unable to readily see and understand other people‘s viewpoints. Developmental psychologists define the theory of mind as the ability to take another person’s viewpoint, and the ability to do so Attributed to Charles Stangor Saylor. In one demonstration of the development of theory of mind, a researcher shows a child a video of another child (let‘s call her Anna) putting a ball in a red box. Then Anna leaves the room, and the video shows that while she is gone, a researcher moves the ball from the red box into a blue box. The child is then asked to point to the box where Anna will probably look to find her ball.

Explore to make a positive impact on the hospital envi- her answers with her and find out why she chose ronment purchase 100mg topiramate free shipping. Identify the ethical problem and explore possible buy topiramate 200mg fast delivery, involve the husband and child in deci- solutions to the problem buy 200mg topiramate free shipping. Acting: Assist the mother to plan new behaviors ing assistance for the patient at a higher level) discount topiramate 200mg line. For example, if superiors and presenting your case in a competent she values her child, she may reduce the number manner. Covering for another nurse who is not perform- colleagues ing her job competently, short-staffing d. Autonomy: Respect the decision-making capacity the role of the nurse in certain situations of autonomous persons (e. Justice: Distribute benefits, risks, and costs fairly rights by being a strong patient advocate. Fidelity: Be faithful to promises you made to the nurse could also check with the drug manufacturer to public to be competent, and be willing to use see if the company has a discount for needy patients. Raines vocalizes the health benefits of taking his entrusted to your care without first seeing to blood pressure medication and lists three reasons for his/her needs). Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Failure to ensure patient safety: Update knowl- Intellectual: ability to integrate ethical principles edge on patient safety and new interventions and use an ethical framework and decision-making to prevent and reduce injury. Improper treatment or performance of Technical: ability to integrate ethical agency to treatment: Use proper techniques when perform- provide the technical nursing assistance necessary ing procedures and follow agency procedures. Failure to monitor and report: Follow physician Interpersonal: ability to advocate for patients whose orders regarding monitoring of patient unless values may be different from personal ones changes in the patient’s condition necessitate a Ethical/Legal: ability to identify and develop the change in the frequency of monitoring; report essential elements of ethical agency, cultivate the need for change to physician. Medication errors and reactions: Listen to that dictate and justify professional conduct patient’s objections regarding medication and 4. Failure to follow agency procedure: Advise the appropriate person of procedures that need to be revised. Equipment misuse: Learn how to operate equip- ment in a safe and appropriate manner. Knowledge of the state (or province) Nurse Prac- tice Act and standard of nursing care where the 1. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. There are increasing numbers of older people liv- attorney may call the first nurse to testify as a fact ing longer with multiple chronic illnesses who witness if he or she has knowledge of the actual are not institutionalized. With more sophisticated technology, people can base testimony on only firsthand knowledge of the be kept alive and comfortable in their own homes. Healthcare consumers demand that services be about facts, the nurses should simply testify, “I do humane and provisions be made for a dignified not remember that. Primary care offices: Make health assessments, ethical/legal competencies are most likely to be assist physician, and provide health education used in this situation? Ambulatory care centers and clinics: A nurse Intellectual: knowledge of law and sources of law practitioner may run these centers, which and ability to identify potential areas of liability usually provide walk-in services and are open at in nursing times other than traditional office hours. Mental health centers: Nurses who work in crisis tance in a competent, legally appropriate manner intervention centers must have strong communi- Interpersonal: ability to work collaboratively with cation and counseling skills and must be other members of the healthcare team and legal thoroughly familiar with community resources department specific to the needs of patients being served. Rehabilitation centers: These centers use a action healthcare team comprising physicians, nurses, 3. What resources might be helpful for the nurses in physical therapists, occupational therapists, and this case? Long-term care centers: Help patients maintain management programs, malpractice arbitration panel function and independence with concern for the Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Provide direct care, supervise others, serve meet the needs of families of patients on hospice as an administrator, and teach. With the trend toward discharging patients earlier, available resources to ensure everyone’s access to hospitals more often focus on the acute care needs safe, quality healthcare of the patient. Along with this focus has come a Ethical/Legal: knowledge of ethical and legal princi- proliferation of services offered by the hospital ples related to patients with terminal illnesses aimed at the outpatient. If the Multiple Response Questions cost of hospitalization is greater than that assigned, 1. False—remains at the hospital insurance providers do not cover the costs of respite 10. Describe the procedure to the patient in detail so hospice care programs and states that she will sign he/she will know what to expect. What intellectual, technical, interpersonal, and/or or Medicaid; see if procedures are covered and ethical/legal competencies are most likely to bring what amount the patient will be responsible for. With patient’s permission, check with family; if healthcare services and settings available to meet necessary, check into home healthcare possibili- the needs of families caring for dying patients ties, hospice, or extended-care facilities. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition.

Those with low self-concept discrepancies were those who listed similar traits on all three lists cheap topiramate 200mg amex. Their ideal purchase topiramate 100 mg visa, ought buy 200 mg topiramate visa, and actual self-concepts were all pretty similar and so they were not considered to be vulnerable to threats to their self-concept discount 200 mg topiramate. The other half of the participants, those with high self-concept discrepancies, were those for whom the traits listed on the ideal and ought lists were very different from those listed on the actual self list. After obtaining this baseline measure Higgins activated either ideal or ought discrepancies for the participants. Participants in the ideal self-discrepancy priming condition were asked to think about and discuss their own and their parents‘ hopes and goals for them. Participants in the ought self-priming condition listed their own and their parents‘ beliefs concerning their duty and obligations. For high self-concept discrepancy participants, however, priming the ideal self-concept increased their sadness and dejection, whereas priming the ought self-concept increased their anxiety and agitation. These results are consistent with the idea that discrepancies between the ideal and the actual self lead us to experience sadness, dissatisfaction, and other depression-related emotions, whereas discrepancies between the actual and ought self are more likely to lead to fear, worry, tension, and other anxiety-related emotions. For participants with low self-concept discrepancies (right bars), seeing words that related to the self had little influence on emotions. For those with high self-concept discrepancies (left bars), priming the ideal self increased dejection whereas priming the ought self increased agitation. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. One of the critical aspects of Higgins‘s approach is that, as is our personality, our feelings are also influenced both by our own behavior and by our expectations of how other people view us. This makes it clear that even though you might not care that much about achieving in school, your failure to do well may still produce negative emotions because you realize that your parents do think it is important. Based on your understanding of psychodynamic theories, how would you analyze your own personality? Are there aspects of the theory that might help you explain your own strengths and weaknesses? Based on your understanding of humanistic theories, how would you try to change your behavior to better meet the underlying motivations of security, acceptance, and self-realization? Terror management and aggression: Evidence that mortality salience motivates aggression against worldview-threatening others. A new look at defensive projection: Thought suppression, accessibility, and biased person perception. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. Self-discrepancies as predictors of vulnerability to distinct syndromes of chronic emotional distress. Self-discrepancies and emotional vulnerability: How magnitude, accessibility, and type of discrepancy influence affect. Outline the methods of behavioral genetics studies and the conclusions that we can draw from them about the determinants of personality. Explain how molecular genetics research helps us understand the role of genetics in personality. One question that is exceedingly important for the study of personality concerns the extent to which it is the result of nature or nurture. If nature is more important, then our personalities will form early in our lives and will be difficult to change later. If nurture is more important, however, then our experiences are likely to be particularly important, and we may be able to flexibly alter our personalities over time. In this section we will see that the personality traits of humans and animals are determined in large part by their genetic makeup, and thus it is no surprise that identical twins Paula Bernstein and Elyse Schein turned out to be very similar even though they had been raised separately. A gene is the basic biological unit that transmits characteristics from one generation to the next. These common genetic structures lead members of the same species to be born with a variety of behaviors that come naturally to them and that define the characteristics of the species. These abilities and characteristics are known as instincts—complex inborn patterns [1] of behaviors that help ensure survival and reproduction(Tinbergen, 1951). Birds naturally build nests, dogs are naturally loyal to their human caretakers, and humans instinctively learn to walk and to speak and understand language. Rabbits are naturally fearful, but some are more fearful than others; some dogs are more loyal than others to their caretakers; and some humans learn to speak and write better than others do. Personality is not determined by any single gene, but rather by the actions of many genes working together. Furthermore, even working together, genes are not so powerful that they can control or create our personality.

These preventable diseases include adenovirus purchase 200mg topiramate overnight delivery, cholera buy generic topiramate 200 mg online, diphtheria buy discount topiramate 100 mg online, Haemophilus influenzae type b (Hib) buy cheap topiramate 200 mg on line, hepatitis A, hepatitis B, influenza, Japanese encephalitis, Lyme disease, measles, meningococcal disease, poliomyelitis, rabies, rotavirus, rubella, tetanus, tuberculosis, typhoid, varicella, and yellow fever. Adults should also review their immunizations every time they travel to a for- eign country regardless of their age. Absolute contraindications for the use of vaccines include anaphylactic reaction to a spe- cific vaccine or component of another vaccine or moderate or severe illness. Therefore, healthcare profes- sionals perform a blood test to determine detectable levels of antibodies in the bloodstream for preventable diseases such as Rubella. If antibodies are detected in sufficient quantity, then the patient is immune to the disease. Healthcare professionals are required to be vaccinated for many common communicable diseases in order to prevent acquiring the disease and passing the disease along to patients. Be sure to include the date of vaccination, route and site, vaccine type, manufacturer, lot number, and expiration date, name, address, and title of individual administering vaccine. Be sure to include the date of vaccination, route and site, vaccine type, manufacturer, lot number, and expiration date, name, address, and title of individual administering vaccine. Some of the side effects of these drugs include nausea and vomiting and an increased risk of tumor growth. Summary The immune system provides a natural defense against pathogens and against abnormal cells that might lead to cancer. This system differentiates between self- cells and non-self cells by protein on the surface of the cell. Microorganisms are antigens and considered non- self cells and cause the immune system to generate antibodies that neutralize and destroy the antigen. A vaccine contains a small amount of a pathogen that is enough to stimu- late the production of antibodies, but not sufficient for the patient to acquire the disease. Once antibodies for a specific pathogen are generated, the immune system can quickly regenerate the antibodies when the pathogen invades the body again. In the next chapter we look at medications that are used to treat gastrointesti- nal and digestive diseases. Antibody-mediate immunity occurs when the immune system produces (a) antibodies that neutralize, eliminate or destroy an antigen (foreign protein). Cell-mediated immunity is especially useful in identifying and ridding the body of self-cells that are infected by organisms that live within host cells. Passive immunity can also occur through immunization by giving the patient a vaccination against the pathogen. However, a stomach ache and other aliments of the gastrointestinal system are not as easily cured by removing stress. Problems with the gastrointestinal system can include vomiting, ingesting toxins, diarrhea, constipation, peptic ulcers, and gastroesophageal reflux disease. In this chapter, you’ll learn about common gastrointestinal disorders and about the medications that are frequently prescribed to treat these conditions. Small pieces of food are voluntarily moved to the back of the mouth and moved down to the esophagus in a process commonly referred to as swallowing. When the food reaches the esophagus, it is moved to the stomach and intestines with an involuntary move- ment called peristalsis. The esophagus is a tube connecting the oral cavity to the stomach and is lined with mucous membranes that secrete mucus. These are the superior (hyperpharyngeal) sphincter and the lower sphincter that prevents gastric juices from entering the esophagus (gastric reflux). The stomach is a hollow organ that holds between 1000 to 2000 mL of con- tents that takes about 2–3 hours to empty. These are the cardiac sphincter (located at the opening of the esophagus), and the pyloric sphincter (that connects the stomach to the head of the duodenum). The stomach has mucosal folds containing glands that secrete gastric juices used to break down food (digest) into its chemical elements. Mucus-Producing Cells Mucus-producing cells release mucus that protect the stomach lining from the gastric juices. The small intestine extends from the ileocecal valve at the stomach to the duo- denum. The cecum is attached to the duodenum, which is the site where most medication is absorbed. This results in the intestinal juices having a higher pH than the gastric juices in the stomach. Hormones, bile, and pancreatic enzymes trypsin, chymotrypsin, lipase, and amylase digest carbohydrates, pro- tein, and fat in preparation for absorption in the small intestine. The small intestine lead into the large intestine where undigested material from the small intestine is collected.

Each and every bitemark case that has proceeded to trial buy cheap topiramate 100mg online, and especially those that have been reported buy topiramate 200 mg otc, contain valuable information that can help odontologists in obtaining purchase topiramate 200mg with visa, analyzing buy cheap topiramate 200 mg online, and presenting bitemark evidence in a court of law. Had these cases been reviewed and analyzed by attorneys and odontologists in some of the bitemark cases that followed, 316 Forensic dentistry many of the issues that made them problem cases may have been and should have been avoided. Milone, already noted, the following signifcant and problematic cases will be discussed in the next section, on problem cases: Oklahoma v. It can be argued that, if bitemark analysis is prop- erly conducted, there should be no problem cases. Is there a common theme in these cases even though the individuals and circumstances are diferent? Te details of the following few cases will hopefully shed light on the problems and pitfalls of bitemark analysis and help prevent errors in the future. She had been sexually assaulted and the cause of death was listed as manual strangulation. A forensic dentist from the University of Oslo, Professor Ferdinand Strom, collected the bitemark evidence and he and another dentist testifed in the original trial in 1958 linking the teeth of Torgersen with the bitemark (Figures 14. Te only other physical evidence was the presence of nonspecifc feces on Torgersen’s shoes and some common tree needles in his jacket pockets and the cufs of his trousers. Te court engaged Professor Gisele Bang of Sweden to review the original materials in 1975. A team of persons believing in Torgersen’s innocence succeeded in convincing the Norwegian court to look into the matter again. In 1999 and 2000 Professors Gordon MacDonald and David Whittaker of Scotland and Wales reviewed the material and wrote reports generally supporting the earlier conclusions. David Senn from Texas to Oslo to review the remaining materials in the University of Oslo laboratory of Professor Tore Solheim. Te breast had been placed in Kaiserling’s solution and sealed in a plastic container since the autopsy. Senn opened the case and examined, photographed, and made impres- sions of the remarkably well-preserved breast (Figures 14. He reviewed all of the material made available and duplicated or photo- graphed the items. Returning to the United States, he examined and tested all of the materials and determined that there were multiple inconsistencies between the tooth marks on the breast and the 1957–1958 models of the teeth of Torgersen. Among the forensic dentists that had previously examined the materials there were three diferent opinions as to which teeth had made the 318 Forensic dentistry Figure 14. He sent them de-identifed duplicate materials and solicited their independent opinions. None of the three knew the details of the case or the identity of the victim or suspect. All three independently wrote reports stating that the person rep- resented by the dental models provided could not have made the bitemarks on the breast. In 2001 the Supreme Court of Norway held a special hearing to again review the evidence in Torgersen’s case. In most countries that would have been the end of the story, but Torgersen’s team succeeded in getting a new hearing before a commission for criminal case review (Kommisjonen for Gjnopptakelse av Strafesaker). Whittaker again testifed for the prosecu- tor (Professor MacDonald had died in the interim) and Dr. Tis commission, to the great surprise of Torgersen’s team, also refused to recommend a new trial for Torgersen. Torgersen and his 320 Forensic dentistry remarkably determined defense team still refuse to give up, and in September 2009, over ffy years afer his original conviction, there is still an active efort to obtain a new trial. It was the opinion of some that the bite had been inficted afer her death (Figures 14. Lester Luntz, Harold Perry, and Irvin Sopher, testifed that Milone was “without doubt” the biter. Tree additional forensic odontologists, none of whom was involved with the initial trial, gave a joint opinion that Richard Milone inficted the bitemark on the leg of Sally Kandel. Steven Smith, Raymond Rawson, and Larry Pierce brought the total number of forensic odontologists in this case to ten. Tey further opined that “there were distinguishing irregularities between the bitemarks found on Macek’s victims [more on this below] and Sally Kandel. Smith and Rawson were asked on many occasions to disclose the bases for their opinions, the information has never been presented publicly or to forensic odontology groups. Tis brought the total number of forensic odontolo- gists in this case to eleven, six stating that Milone made the bitemark and fve opining that he did not. Te case had been further complicated by the introduction of evidence that a convicted serial killer, Richard Macek, may have also killed Sally Kandel. Many of the features of the case were similar, including the slitting of eyelids and the presence of a bitemark, but Macek had, unfortunately, had his teeth removed before he became a suspect. In the presence of a psychi- atrist and the chief jailer Macek made a written confession to the murder of Sally Kandel, giving details that, according to the psychiatrist who later wrote a book containing the information, he could not have known if he were not present when Kandel was murdered.

Differential diagnoses of the rash • Streptococcal (presumed) infection spreading to the soft tissues; this is much less common in young healthy patients compared to the elderly; its distribution would be diffuse rather than discrete lesions buy topiramate 100 mg low price, and was excluded by negative culture of the lesions generic 200mg topiramate overnight delivery. The patient had taken a few doses of paracetamol buy 200 mg topiramate, leaving the penicillin as the likeliest candidate by far as the cause quality 100mg topiramate. Management Management consists of: • stopping the penicillin and substituting an alternative antibiotic if required: cultures were negative in this case at this stage • a short course of steroids, e. In the previous 24 h he had become unwell, feel- ing feverish and with a painful right knee. He works in an international bank and frequently travels to Asia and Australia, from where he had last returned 2 weeks ago. Otherwise examination of the cardiovascular, respiratory, abdominal and nervous systems is normal. His right knee is swollen, slightly tender, and there is a small effu- sion with slight limitation of flexion. The diagnosis is made by microscopy of the discharge, which should show Gram- positive diplococci, and culture of an urethral swab. The swab should be inoculated onto fresh appropriate medium straight away and kept at 37°C until arrival at the laboratory. Immediate treatment on clinical grounds with ciprofloxacin is indicated; penicillin should be reserved for gonorrhoea with known penicillin sensitivity, to prevent the development of resistant strains. Septic monoarthritis is a complication of gonorrhoea; other metastatic infectious complications are skin lesions and, rarely, perihepatitis, bacterial endocarditis and meningitis. The pain was intermittent, worse at night, and relieved by ibuprofen, which she bought herself. She worked part-time stacking the shelves in a supermarket and was a very active and compet- itive tennis and badminton player. She indicated that the pain was over the vertebrae of T5/6, but there was no tenderness, swelling or deformity. The full blood count, urea creati- nine and electrolytes, calcium, alkaline phosphatase and phosphate were all normal, as was urine testing. She was advised that the pain was musculoskeletal due to exertion at work and sport, and she was prescribed diclofenac for the pain. After a few weeks of improvement, the pain began to get worse, being more severe and occurring for longer periods and seriously disturbing her sleep. If there is nothing to suggest osteoporosis or trauma then the commonest cause of this is a tumour metastasis. The tumours that most frequently metastasize to bone are carcinoma of the lung, prostate, thyroid, kidney, and breast. Examination of the patient’s breasts, not done before the X-ray result, revealed a firm mass 1–1. Urgent biopsy confirmed a carcinoma and she was referred to an oncologist for further management. Review of the first X-ray after the lesion was seen on the second film still failed to iden- tify a lesion, emphasizing the need to repeat an investigation if there is sufficient clinical suspicion of an abnormality, even if an earlier investigation is normal. Examination of the breasts in women should be part of the routine examination, particu- larly after the age of 40 years, when carcinoma of the breast becomes common. Fifteen years earlier the patient had had a cadaveric renal transplant for renal failure due to chronic glomerulonephritis caused by immunoglobulin A (IgA) nephropathy. Originally this was with prednisolone and azathioprine, but later it was converted to ciclosporin. His only other medication is propranalol for hyper- tension which he has taken for 20 years. Examination The lesion is as described on the right forearm and there are several solar hyperkeratoses on his cheeks, forehead and scalp (he is bald). No other abnormalities are found apart from the transplant kidney in the right iliac fossa. The risk factors are his age, the many years exposure to sunlight as farmer, and the chronic immunosuppression. There is an increased risk of several different types of malignancy in patients on chronic immunosuppression, and skin cancer is now well recognized as a fre- quent complication of chronic immunosuppression unless preventative measures are used. With improving survival rates for transplant patients in general, there is a potential increase in the incidence and prevalence of skin malignancy. Patients on long-term immunosuppres- sion for whatever reason should be strongly advised to avoid direct exposure to sunlight as much as possible, and certainly not to sunbathe, and to use high-factor barrier creams. They should cover their skin in the lighter months (April to September inclusive in the northern hemisphere) – no shorts, sleeveless tops or shirts, and a hat to protect the scalp and forehead. This is particularly irksome but even more important for children and young adults who have a potentially longer period of exposure to sunlight ahead of them. The damage caused to skin by sunlight is cumulative and irreversible, and when transplanted at the age of 50 years this patient had already had over 30 years’ occupational exposure to ultraviolet radi- ation. His immunosuppression needs to continue and should be kept at as low a dose as is compatible with preventing rejection of his transplant.