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Arteriosclerosis refers to the laying down of these crusty plaques on the inside of blood vessels that may retard the flow of blood or be the basis of blood clots that then occlude the artery buy cheap cleocin gel 20gm online acne 30s. Rosenman cleocin gel 20 gm without a prescription acne neck, it is hard to escape the conclusion that emotions may play a role in hardening of the arteries wherever it occurs, though it is clear that genetics (it pays to pick the right parents), blood pressure, diet, weight and exercise all play important roles. Mind and Body 153 An important report was published in the prestigious British journal Lancet in July 1990 (Vol. Dean Ornish of the University of California San Francisco School of Medicine did a randomised, controlled study in which they demonstrated that life-style changes (practised for a year) could actually reverse the process of atherosclerosis (arteriosclerosis, hardening) in coronary arteries. The patients in the experimental group were put on a low-fat, low-cholesterol vegetarian diet; participated in stress-management activities like meditation, relaxation, imagery, breathing techniques and stretching exercises; and did moderate aerobic exercise regularly. In addition, there were twice weekly group discussions to provide social support and reinforce adherence to the life-style change program. The control (nonexperimental) group of patients showed an increase in coronary atherosclerosis. With the decrease in blockage of the coronary arteries, experimental patients also experienced a reduction in the frequency, duration and severity of angina (chest pain) while the control group had an increase in angina over the one-year period. This obviously important report shows what has long been suspected: that it is not just diet, exercise and other purely physical factors that determine whether or not there will be hardening of the arteries but psychosocial factors as well. I predict that further experimentation will identify the person’s emotional state as being the most important variable and that intensive psychotherapy alone will demonstrate a similar reversal of atherosclerosis. The medical term for this is tachycardia, with rates from 130 to 200 beats a minute. The most common form of this is paroxysmal auricular tachycardia (PAT) and, in my experience, it is usually induced by emotional factors. Regardless of that, it should always be treated by one’s family doctor, internist or cardiologist. Irregularity of heart rhythm may also be referred to as 154 Healing Back Pain palpitation. I have experienced these intermittently all my life and, again, they are clearly the result of emotional things. They too should be investigated and managed by your doctor to be sure they are not the result of a cardiac abnormality. It is generally accepted that these conditions are mediated through the autonomic nervous system. Finally, a disorder known as mitral valve prolapse is a very common abnormality of one of the leaflets of a heart valve. The leaflet becomes “floppy” and does not perform normally, so that a murmur can often be heard. It sounds scary but is very common, occurs more often in women than in men, and seems not to be associated with functional disability. I have had it for years and continue to be very active, and I perform vigorous aerobic activity on a regular basis. What is intriguing about it is that some doctors think it is psychogenic, that is, anxiety induced. And there is considerable evidence in the medical literature that it is related to abnormal autonomic activity (editorial in The Lancet, October 3, 1987, titled, “Autonomic Function in Mitral Valve Prolapse”). Recently an article appeared in the July 1989 issue of Archives of Physical Medicine and Rehabilitation (Vol. Since TMS and mitral valve prolapse are both induced by abnormal autonomic activity and TMS is clearly the result of emotional factors, it is tempting to include mitral valve prolapse in that list of physical disorders that have their genesis in the realm of the emotions. Using myself as an example, I have experienced TMS, gastrointestinal symptoms, migraine headache, hay fever, dermatologic conditions and mitral valve prolapse, and so have a large number of my TMS patients, suggesting that the same thing is at the root of all of them—repressed, undesirable emotions. Mind and Body 155 Let me repeat a very important point: The idea that emotions can stimulate physiologic change is impossible for most physicians to accept, and they are, therefore, cut off from the possibility of understanding a large number of ills that now plague human beings. In summary, five cardiovascular disorders probably related to the emotions have been briefly described. It is of great interest that three of the five, hypertension, palpitations and mitral valve prolapse, are mediated through the autonomic nervous system. THE MIND AND THE IMMUNE SYSTEM Contemplation of the complexity of animal biology is awe inspiring and overwhelming. It is designed to protect us from foreign invaders of all kinds, the most important of which are infectious agents, and from dangerous enemies that are generated within, like cancer. It is composed of a variety of defense strategies: it can generate chemicals to kill invaders; it can mobilize armies of cells to swallow them up; and it has an elaborate system whereby it can recognize thousands of substances that are foreign to our bodies and then neutralize them.

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Some series have reported good results in the Surgery may be appropriate for some back pain suffer- treatment of back pain purchase 20 gm cleocin gel mastercard acne zapper zeno. It is beyond the scope of a pain clinician cleocin gel 20 gm free shipping acne facials, although it within the context of multidisciplinary treatments. Reasons for referral may include significant disc pro- lapse with neurological features and increasing neuro- Injection therapy logical signs with spinal stenosis. Microdiscectomy, laminectomy and spinal fusion are examples of surgical Epidural injections interventions. Surgery for degenerative conditions Epidural steroid injections give short-lived pain relief affecting the lumbar spine has had disappointing for a minority of patients with radicular symptoms. There is no scientific evidence to show the long- This effect does not translate into improved function- term effectiveness of surgical interventions compared ing for most. They do not appear effective when there with placebo, or conservative management strategies. Providing a series of injec- There is an appreciable incidence of persistent pain fol- tions does not appear to improve outcome. The ‘failed back syndrome’ affects an incidence of morbidity with epidural injections: up to 15% of back surgery patients. Recurrence of the original problem, an undiagnosed source of pain and • Post-dural puncture headache. NHS Centre for Reviews and Dissemination: emphasis has moved from pain relief to improve- http://www. Churchill best way to deliver this sort of care for the needs of Livingstone, London. Occupational Health • A wide-ranging societal approach may, in the long Guidelines for the Management of Low Back Pain at Work – term, be the most effective way of dealing with Evidence Review. Some consider such suffering inevitable Direct result of disease Pancreatic pain from primary and may expect that pain will increase in severity with pancreatic cancer Back pain from bony disease progression. Research shows us that Nerve root compression pain 95% of this pain is easily controlled using simple proto- cols. As ever, the successful relief of pain depends upon General effects of Painful pressure areas the careful evaluation of symptoms and constant review. The knowledge that prognosis is limited, or uncertain, gives pain heightened meaning. Unrelated causes Ischaemic heart disease Osteoarthritis Cancer patients can experience pain as a direct result Cholecystitis of their disease, or indirectly from more general Diverticular disease effects of illness, the treatment and unrelated causes (Table 23. Most disease-related pain is chronic, but patients also experience acute pains and accurate rating scale (NRS) with follow-up monitoring may assessment is essential. It is important to recognize that illustrate the response to treatment for individuals. In most cancer patients with pain have multiple sites and frail patients who may find pain difficult to describe, causes for their pain. Every pain described by the simpler pain scales, such as FACES or behavioural patient must be evaluated and treated individually. Assessment of cancer pain Management of cancer pain The assessment of pain in patients with cancer can be Diagnosis of the cause of each cancer pain is important misleading. As the pain is often chronic, the physio- in order to direct management appropriately. Efforts logical signs we associate with acute pain (tachycardia, should first be made to reverse the cause while symp- hypertension, etc. Frequent to link the severity of pain as reported by the patient reassessment of pain and its response to treatment is with their physical appearance. Expression of pain will be affected by other taken that ‘pain is what the patient says hurts’. Failure to address Baseline visual analogue scale (VAS) or numerical such issues may result in poor pain control. These guidelines (the ‘WHO Non-pharmacological measures including complemen- analgesic ladder’) comprise a step-wise approach to tary therapies are important to many cancer patients pain relief (Table 23.

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Other uses have included continuous infusion of management encompass a broad range of treatments and muscle relaxants for patients with muscle spasm from physical modalities cheap 20 gm cleocin gel with mastercard skin care hospitals in hyderabad, many of which carry low risks for spinal injury buy cleocin gel 20gm line acne jeans shop, multiple sclerosis, or end-stage Parkinson’s adverse effects (Table 28. Whether these invasive high-tech strategies are appropriate drug regimens, these interventions often appropriate for patients with all kinds of chronic pain enhance therapeutic effects while allowing medication remains controversial. These techniques are expensive, 7 doses to be kept low to prevent adverse drug effects. Studies have cation of high-tech strategies for patients who might be shown that patient education programs alone signifi- equally well managed using oral medications that are not 80,81 78,79 cantly improve overall pain management. In general, invasive methods carry risk grams often include content about the nature of pain, and should be used only when oral medications become how to use pain diaries and pain assessment instruments, ineffective or the oral route of administration is no longer how to use medications appropriately, and how to use viable. Intervention Comments Limitations Education Content should include basic knowledge about pain May require substantial time (diagnosis, treatment, complications, and prognosis), other available treatment options, and information about over- the-counter medications and self-help strategies Exercise Can be tailored for individual patient needs and lifestyle; Maintenance is critical and difficult to moderate-intensity exercise should be maintained for continue indefinitely 30 min or more 3–4 times a week and continued indefinitely Cognitive-behavioral therapy Should be conducted by a trained therapist Requires substantial cognitive function Physical modalities (heat, A variety of techniques are available for application Heat and cold should be used with caution cold, and massage) in those with cognitive impairment to avoid thermal injuries Physical or occupational Should be conducted by a trained therapist Not appropriate for maintainence therapy; therapy can be expensive if not reimbursed Chiropractic Has been shown to be as effective as Mackenzie exercises Potential spinal cord or nerve root for acute back pain impingement should be ruled out before any spinal manipulation Acupuncture Should be provided only by a qualified acupuncturist Effects may be short lived and require repetitive treatments Transcutaneous electrical Should initially be applied and adjusted by an experienced Effects are often short lived; clear placebo nerve stimulation (TENS) professional effects have been observed Relaxation and distraction Therapeutic modalities require individual acceptance and Patients with cognitive impairment may not techniques may require substantial training be good candidates 344 A. Meier the costs for caregiving at home in cases of advanced based pharmacologic therapies to decrease the rate of dementia exceed the costs of nursing home care. Treatment with cholinesterase inhi- chronic stress associated with caring for a spouse with bitors can modestly improve cognitive function and pos- Alzheimer’s disease has also been associated with sibly improve activities of daily living in patients with decreased immunity and associated comorbidities, in- mild to moderate Alzheimer’s dementia. There is less evidence to support viding information about support groups and community using Hydergine, statins, nonsteroidal anti-inflammatory services, including hospice. The needs of patients and caregivers change the rate of decline for patients with vascular dementia. Every cognitive and behavioral benefits, at least in the short dementia patient goes through all three stages; however, term, from reality orientation. In the early stages of dementia, it is important to Physicians need to tailor care to the individual patient inform both patients and caregivers of the diagnosis. The patient with dementia may have or Educating patients and families about the course of the develop other chronic medical problems, including disease will help them make plans for medical care, finan- coronary artery disease, vascular ulcers, osteoarthritis, cial affairs, and the way that they want to spend their diabetes, renal insufficiency, and malignancy. At this stage of the disease, threatening illness, such as acute myocardial infarction, patients can still make decisions for themselves. Physi- pneumonia, or urinary tract infection, could strike during cians should ask them about their preferences for medical any stage of dementia. Specifically, patients tional stress on caregivers; the burdens of dressing should be asked under what circumstances they would changes, administering medications, and giving injec- no longer wish life-prolonging technologies, such as a tions fall to them. Many patients respond to this question by patient’s ability to understand and comply with therapy. Patients should also be asked to designate one or more primary decision makers in preparation for the time when they are no longer able to make medical deci- sions for themselves. Early conversations about advance directives prepare family members for the burden of decision making in late dementia and may reduce later stress associated with sur- rogate decision making. Patients and family members should be reassured that goals might change as the disease progresses. For example, early in the course of dementia, goals may be preserving auton- omy, financial planning, continuing to participate in social After a medical evaluation to exclude reversible causes activities and travel, ensuring safety, prolonging life, and of dementia, physicians should implement evidence- forming a care plan for more advanced stages of disease. J Gerontol Ser A Biol Sci Med Sci Cochrane Library Cochrane Library Drugs Aging Cochrane Library J Am Geriatr Soc. J Am Geriatr Soc Hospice Care for Patients with Advanced Progressive Dementia Nurs Res Prim Psychiatry. Obsession with Pain and Suffering A Flexible Self Accepting Dependency Losing Control 31 The Science of Neoplasia and Its Relationship to Aging Robert E. This chapter provides a systematic review of the major areas of study Cancer poses a significant health issue for the elderly. The in cancer biology and, importantly, provides a scientific incidence and mortality from cancer are progressively basis for a link with aging biology where relevant. Even within the 65 to 84 age group, the incidence of cancer has increased steadily over the past 20 years. Furthermore, we are presently in the midst of a dramatic increase in the size of the older cohorts in our society due to Environmental and cellular factors have been identified increased longevity and the aging "baby boom" genera- as etiologic factors for cancer development. The consequence cause of death and is one of the most feared diseases in of this disruption is altered expression of gene products this age group. Indeed, the risk of dying from cancer critical for cell growth, which can lead to neoplasia. The incidence of lung, colon, breast, prostate, and B-cell hematologic malignancies, such as chronic lymphocytic leukemia and multiple myleoma, all increase with age.

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It is this conversion process in the body generic cleocin gel 20 gm without a prescription acne 2009 dress, which changes simpler forms of fatty acids into more complex ones needed by the brain generic cleocin gel 20 gm fast delivery skin care routine quiz, that appears to be defective in people with MS. So, even if you have eaten good quantities of the simpler fatty acids, they may not be converted into the vital and more complex ones. In principle, whilst more of the fatty acids should assist nervous system function, the relationship between one and the other, and particularly in reducing any symptoms that you might have, appears to be very complex. Nevertheless, there are a number of studies, not many of them scientifically well designed, which suggest that there may be specific benefits to MS from increasing your intake of those foods that help form complex essential fatty acids, and from decreasing your intake of saturated fats. Although many people believe that this broad strategy can help fight the disease, most scientists and doctors do not. To get technical for a moment, there are two important families of essential fatty acids for brain function. The first of these is called the EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 135 ‘omega-6 group’, with linoleic acid as its ‘parent’ – the parent meaning the basic fatty acid from which all the others in the family are derived. Foods rich in the omega-6 family are those such as: • sunflower and safflower seed oil • evening primrose oil • offal such as liver; kidney, brains, sweetbread • lean meat • legumes (peas and beans). Food rich in the omega-3 family are: • green vegetables • fish and seafood • fish liver oils • linseeds • certain legumes. The difficulty is that most of these foods contain only small quantities of the relevant fatty acids, and then only in their simplest form. However, one or two foods have been found to have not only larger quantities of essential fatty acids, but to have them in a form that is closer to that needed by the brain. For example, the oil of the evening primrose plant has become a very popular dietary supplement for people with MS, because it is unique and contains large quantities of a substance called gamma-linoleic acid, a more complex form of linoleic acid, which is converted into further important fatty acids by the body. In principle, the effects of taking these fatty acids could be profound on some key characteristics of the underlying pathology of MS, but in formal clinical trials the results have not been as good as hoped for, although there is some evidence from one or two good trials that attacks of MS may be fewer over time in those taking additional fatty acids. However, these results do not approach the more dramatic findings from studies on the latest immune-based drugs. Many people with MS continue to take evening primrose oil even if, for example, they do not follow religiously all the other dietary recommendations, either as a kind of ‘insurance policy’, in that they are doing something that they hope will help the MS, or – and there are reasonable grounds for this – knowing that is not actually harmful, and may be helpful to your general health. It is likely to be a more costly alternative than modifying your diet to include some of the other foods 136 MANAGING YOUR MULTIPLE SCLEROSIS containing essential fatty acids, but may be easier to manage. We must state again that the effectiveness of evening primrose oil has not been proven scientifically. Saturated fats People argue about whether changes in your saturated fat intake will make any difference to your MS. If, in general, essential fatty acids are ‘good’, then you could increase your intake of these as we have noted, and/or reduce your intake of the ‘bad’ saturated fats. Of course, there are general health grounds for suggesting that you should lower your intake of saturated fats, but some people who have devised low saturated fat diets for their MS claim that such diets may be far more beneficial for their MS. Again, there is little formal evidence that reducing your intake of saturated fats will specifically stabilize or improve your MS. Exclusion diets Cutting out saturated fats is an exclusion diet, but there are other diets that cut out many more specific substances. MS symptoms are considered by some people to be an allergic reaction to certain foods or drinks, and this view has led to other exclusion diets. One such diet is the ‘gluten-free diet’, in which it is argued that gluten has produced damage in the digestive and elimination system and has made the MS worse. Thus by eliminating gluten it is hoped that damage to the intestine can be prevented. Such diets were developed from those for people with coeliac disease who cannot absorb fats when gluten is present from cereal grains. At one stage these diets gained considerable popularity, but the burden placed on people with MS to stick to a very rigid gluten-free diet, together with disappointing results for many people and a lack of scientific support, has led to their decline. The relative success claimed for very different diets in particular individuals suggests not so much that these diets are improving MS, but that concomitant problems are possibly being helped in some way by the diets. Of course, if your general health is better, you will feel better, and certain (but not all) symptoms of your MS might be a little improved. The key issue is balancing whatever benefits that you may be gaining against the costs, time and resources that you have to devote to maintaining what can be a formidable dietary regimen. EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 137 A healthy diet There are certain general dietary principles now widely accepted for general health which, on those grounds alone, should be considered by people with MS.

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