By Y. Merdarion. Ithaca College.
If you are very careful top avana 80mg free shipping pump for erectile dysfunction, it may also be possible to continue to eat or drink a few things orally top avana 80 mg on-line erectile dysfunction treatment by homeopathy, at least to retain some of the pleasures of eating normally. You should keep an eye on how your swallowing goes, and always consult with your professional advisors about the possibility of gradually changing the balance between oral and non-oral feeding, so that you can try and resume a greater proportion of oral feeding, with a view to removing the PEG method of feeding if you can. Diet and nutrition There are two broad ways in which diet and nutrition can be considered in relation to MS. The ﬁrst and less contentious relates to your general health: ideas about what is a good diet for general health do, of course, change from time to time. The second deals with the possible beneﬁcial or harmful effects that some diets themselves might have on either symptoms or, more fundamentally, on the underlying cause of the MS. Diet is the most obvious and easy to implement factor that could be changed by people with MS, and many people have focused on this issue. Also, health care professionals are often very interested in diet and its effects on all aspects of general health. Although there has been research on diet and MS, it has not been a core interest of most EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 133 researchers because Western populations are largely well-nourished – obesity and overeating, on the contrary, are major health concerns. There have been many diets that have been suggested to affect either speciﬁc symptoms or the cause of MS. There is little evidence that any of these diets has the effects that their supporters suggest – however, we here discuss a number of the more plausible diets. Essential fatty acids One of the areas of nutrition that has been researched in relation to MS has been that of ‘essential fatty acids’, which form part of the building blocks of the brain and nervous system tissue, and are essential to the development and maintenance of the CNS. Actually essential fatty acid is rather an odd phrase in lay terms, for we are used to thinking of anything ‘fatty’ as very bad for you. However, there are many kinds of ‘fats’, ranging from the saturated fats, often found in meat and dairy produce, too much of which is not good for you, to the unsaturated and polyunsaturated fats, many of which are found in vegetable sources, and from some of which key essential fatty acids are derived – these are broadly very good for you. About 60% of normal nervous system tissue is made up of these ‘essential fatty acids’. Some research has suggested that several of these essential fatty acids are present in lower quantities in the CNS of people with MS than in that of people without the disease; one theory has been that MS arose because, in their early years such people were deprived of (or unable to assimilate) these essential fatty acids in the development or maintenance of the structure and function of the CNS. However, the reasons for this lower level of fatty acids remain a matter of speculation. Some scientists have thought that the obvious remedy would be to increase the intake of these fatty acids. However, things did not prove to be as simple as that, for many of the essential fatty acids are produced indirectly by the breakdown in the body of particular constituents from the food that we eat. The use of oil from the evening primrose plant, and some other oils, has become quite common amongst people with MS, for they do provide some of these constituents in a relatively ‘purer’ form (see Chapter 3 on Complementary therapies and MS) but its effectiveness has not been proven scientiﬁcally. It is not clear, however, even if the level of the essential fatty acids is returned to ‘normal’, whether this will affect the course of MS, if the CNS damage has already been under way for some time. Research on this point has not proved conclusive, although many 134 MANAGING YOUR MULTIPLE SCLEROSIS people with MS still feel that, on a precautionary basis, they wish to continue taking these essential oils. It would not be wise to assume that, if you eat more of the food containing essential fatty acids, it will have a deﬁnite and positive effect on your MS or its symptoms. There are several reasons for this: • The deﬁciency in essential fatty acids in the brain may be a result of some other process that causes MS; remedying this deﬁciency may not of itself produce major beneﬁts in relation to the disease. It is this conversion process in the body, which changes simpler forms of fatty acids into more complex ones needed by the brain, 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.
Taken together cheap top avana 80mg otc erectile dysfunction causes prostate, these disorders cheap top avana 80 mg on line impotence bike riding, and in fact carry a disproportionate burden of studies indicate that ADH is present in the elderly, and illness associated with extracellular ﬂuid volume deﬁcit that provocative stimuli can both accentuate its release and excess. There appear to be defects in macrophage–T cell Decreased surface MHC class II molecule expression interactions in old animals and humans. Antigenically Decreased proportion of cells capable of clonal expansion sensitized macrophages from old mice stimulate signiﬁ- Decreased number of bone marrow precursors cantly lower levels of T-cell proliferation than young Decreased number of T-cell-dependent antibody-forming cells macrophages. Booster immunizations did not alter the mean amount of antibody produced per B cell for either age group. Although most investigators agree that the observed changes in antibody production are the result of declines Natural killer cells (NK) are cytotoxic cells that are able in T-lymphocyte function, there is evidence for a decline to lyse targets without the need for antigenic sensitiza- in intrinsic B-cell function. Murine NK function at a much lower level than the same cells from show an age-related decline in their ability to lyse spleen 56 cells. Compared to young animals, old mice vac- cytotoxic ability with age,71 in contrast to more recent cinated with phosphorylcholine generate similar levels of antibody against , but the vari- work. The actual number of NK cells seems to increase with age, while cytotoxic activity decreases,72,73 probably able heavy portions of the antibody molecules are dif- ferent. Age- related changes in B-cell function are summarized in ments for maximal activation of NK by interferon-alpha, Table 53. More recent studies have challenged this concept, showing X chromosomes of T cells from old adults are more fragile than those from young adults,77 and certain sites decreased interleukin 1 secretion with mitogen stimula- tion. Humans over age 55 exposed to as healing took twice as long in old as in young mice. When examining the sensitivity of lympho- in senescence-accelerated mice give some evidence that cyte DNA to irradiation, there were actually fewer breaks stem cells are defective in their ability to generate in double-stranded DNA in lymphocytes from old adults, granulocyte-macrophage precursor cells. Immediate obtaining of at least Option 2 three sets of blood cultures at three different points in Isoniazid, rifampin, pyrazinamide and Daily time and an echocardiogram are the most important tests ethambutol or streptomycin for 2 weeks; 123 b for the diagnosis of infective endocarditis. More recent then same drugs for 6 weeks; then Twice weekly isoniazid and rifampin for 16 weeks criteria for diagnosing infective endocarditis incorporate ﬁndings of an echocardiogram. The most common organisms miliary or disseminated tuberculosis or tuberculous causing infective endocarditis in the elderly are meningitis, osteomyelitis, and pericarditis, therapy should streptococci, including viridans group streptococci and be extended to 12 months. In patients with prosthetic treatment of latent tuberculosis infection) for elderly valve endocarditis, and are the patients or residents with positive tuberculin skin tests 113,119 dominant pathogens. Previously, stan- 118 In a long-term care setting, if a resident is suspected of dard chemoprophylaxis was 6 months of isoniazid. Four months of rifampin alone is an alternative but Elderly patients with infective endocarditis require less acceptable regimen. Ideally, if the patient is clinically stable, Elderly patients may have a higher incidence of speciﬁc antimicrobial therapy should be initiated after isoniazid-associated hepatitis, and thus careful clinical identiﬁcation of the organism from blood cultures. Baseline and follow-up liver function tests carditis are empirically treated immediately after blood (serum aminotransferase; SGOT) are obtained every 1 to cultures are obtained, and antibiotics are then adjusted 2 months. Empiric therapy normal or baseline or clinical signs of liver toxicity is an for infective endocarditis in the elderly should be indication to discontinue isoniazid (and rifampin and 113 directed toward streptococci, enterococci, and staphylo- pyrazinamide). A suggested regimen is intravenous ampicillin, mal liver function tests, the isoniazid (and other drugs) nafcillin (or oxacillin), and an aminoglycoside (e. Recurrence of liver abnormalities requires a gic to beta-lactam antibiotics should be prescribed van- trial of an alternative therapeutic regimen. Duration of therapy varies depending on severity of illness, sensitivity of the organism(s) to the antibiotics, complications of endo- carditis, valve involvement (e. Antimicrobial As the American population ages and the incidence of therapy for infective endocarditis generally is for 4 to 6 childhood rheumatic heart disease has declined, the inci- weeks; prosthetic valve endocarditis requires at least 6 dence of infective endocarditis has risen in the elderly; weeks of treatment. Pneumococcal bacteremia in adults: age-dependent dif- ferences in presentation and in outcome. Infectious complications of diabetes melli- elderly: incidence, ecology, etiology and mortality. Approach to fever and infec- echocardiography: clinical features and prognosis com- tion in the nursing home. Community-acquired bacteremic a long-term-care facility: a ﬁve-year prospective study of urinary tract infection: epidemiology and outcome. Hematologic Problems 825 A normal or reduced reticulocyte count should prompt the consideration of hepatic or endocrine disorders. If Transfusion is associated with signiﬁcant risks, such as these screening surveys are negative, an additional labo- volume overload, immunologic transfusion reactions, and ratory test should be preformed. Consequently, transfu- Bone marrow aspirate and biopsy sion should not be given simply because a patient’s Serum iron, TIBC, transferrin saturation, and ferritin hemoglobin or hematocrit has reached an arbitrary level. Indications for transfusion include acute blood loss with symptoms of hypovolemia, progressive symptoms of decreased oxygen delivery such as angina or increasing Examination of the blood and bone marrow is fre- confusion, or symptomatic anemia that is refractory to quently sufﬁcient to establish or exclude the diagnoses nontransfusion therapy. When transfusion is used to treat of leukemia, myeloma, myeloﬁbrosis, myelodysplasia, or refractory anemia without loss of blood volume, concen- inﬁltration of the marrow with metastases.
W ithin m inutes purchase top avana 80mg online erectile dysfunction when drunk, I went into an uncontrollable and very distressing neurological spasm generic top avana 80 mg overnight delivery erectile dysfunction with new partner. Two days later, I had recovered fully from this idiosyncratic reaction but I have never prescribed the drug since, even though the estim ated prevalence of neurological reactions to prochlorperazine is only one in several thousand cases. Conversely, it is tem pting to dism iss the possibility of rare but potentially serious adverse effects from fam iliar drugs – such as throm bosis on the contraceptive pill – when one has never encountered such problem s in oneself or one’s patients. Chapter 5 of this book (Statistics for the non- statistician) describes som e m ore objective m ethods, such as the num ber needed to treat (N N T) for deciding whether a particular drug (or other intervention) is likely to do a patient significant good or harm. Decision making by press cutting For the first 10 years after I qualified, I kept an expanding file of papers which I had ripped out of m y m edical weeklies before binning the less interesting parts. If an article or editorial seem ed to have som ething new to say, I consciously altered m y clinical practice in line with its conclusions. All children with suspected urinary tract infections should be sent for scans of the kidneys to exclude congenital abnorm alities, said one article, so I began referring anyone under the age of 16 with urinary sym ptom s for specialist investigations. The advice was in print and it was recent, so it m ust surely replace traditional practice – in this case, referring only children below the age of 10 who had had two well docum ented infections. H ow m any doctors do you know who justify their approach to a particular clinical problem by citing the results section of a single published study, even though they could not tell you anything at all about the m ethods used to obtain those results? H ow m any patients, of what age, sex, and disease severity, were involved (see section 4. If the findings of the study appeared to contradict those of other researchers, what attem pt was m ade to validate (confirm ) and replicate (repeat) them (see section 7. W ere the statistical tests which allegedly proved the authors’ point appropriately chosen and correctly perform ed (see Chapter 5)? D octors (and nurses, m idwives, m edical m anagers, psychologists, m edical students, and consum er activists) who like to cite the results of m edical research studies have a responsibility to ensure that they first go through a 6 W H Y READ PAPERS AT ALL? Decision making by expert opinion (eminence based medicine) An im portant variant of decision m aking by press cutting is the use of "off the peg" reviews, editorials, consensus statem ents, and guidelines. The m edical freebies (free m edical journals and other "inform ation sheets" sponsored directly or indirectly by the pharm aceutical industry) are replete with potted recom m endations and at-a-glance m anagem ent guides. But who says the advice given in a set of guidelines, a punchy editorial or an am ply referenced "overview" is correct? Professor Cynthia M ulrow, one of the founders of the science of system atic review (see Chapter 8), has shown that experts in a particular clinical field are actually less likely to provide an objective review of all the available evidence than a non-expert who approaches the literature with unbiased eyes. Chapter 8 of the book takes you through a checklist for assessing whether a "system atic review" written by som eone else really m erits the description and Chapter 9 discusses the potential lim itations of "off the peg" clinical guidelines. Decision making by cost minimisation The general public is usually horrified when it learns that a treatm ent has been withheld from a patient for reasons of cost. M anagers, politicians, and, increasingly, doctors can count on being pilloried by the press when a child with a brain tum our is not sent to a specialist unit in Am erica or a frail old lady is denied indefinite board and lodging on an acute m edical ward. Yet in the real world, all health care is provided from a lim ited budget and it is increasingly recognised that clinical decisions m ust take into account the econom ic costs of a given intervention. As Chapter 10 argues, clinical decision m aking purely on the grounds of cost ("cost m inim isation" – purchasing the cheapest option with no regard for how effective it is) is usually both senseless and cruel and we are right to object vocally when this occurs. Expensive interventions should not, however, be justified sim ply because they are new or because they ought to work in theory or 7 H OW TO READ A PAPER because the only alternative is to do nothing – but because they are very likely to save life or significantly im prove its quality. H ow, though, can the benefits of a hip replacem ent in a 75 year old be m eaningfully com pared with those of cholesterol lowering drugs in a m iddle aged m an or infertility investigations for a couple in their 20s? Som ewhat counterintuitively, there is no self evident set of ethical principles or analytical tools which we can use to m atch lim ited resources to unlim ited dem and. As you will see in Chapter 10, the m uch derided quality adjusted life year (QALY) and sim ilar utility based units are sim ply attem pts to lend som e objectivity to the illogical but unavoidable com parison of apples with oranges in the field of hum an suffering. There is another reason why som e people find the term "evidence based m edicine" unpalatable. This chapter has argued that evidence based m edicine is about coping with change, not about knowing all the answers before you start. In other words, it is not so m uch about what you have read in the past but about how you go about identifying and m eeting your ongoing learning needs and applying your knowledge appropriately and consistently in new clinical situations. D octors who were brought up in the old school style of never adm itting ignorance m ay find it hard to accept that som e aspect of scientific uncertainty is encountered, on average, three tim es for every two patients seen by experienced teaching hospital consultants22 (and, no doubt, even m ore often by their less up to date provincial colleagues). An evidence based approach to ward rounds m ay turn the traditional m edical hierarchy on its head when the staff nurse or junior doctor produces new evidence that challenges what the consultant taught everyone last week. For som e senior clinicians, learning the skills of critical appraisal is the least of their problem s in adjusting to an evidence based teaching style! If you are interested in reading m ore about the philosophy and sociology of evidence based m edicine, try the references listed at the end of this chapter. They are certainly aware that high blood pressure is the single m ost com m on cause of stroke and that detecting and treating everyone’s high blood pressure would cut the incidence of stroke by alm ost half. M ost of them are aware that stroke, though devastating when it happens, is a fairly rare event and that blood pressure tablets have side effects such as tiredness, dizziness, im potence, and getting "caught short" when a long way from the lavatory. But when I ask m y students a practical question such as "M rs Jones has developed light-headedness on these blood pressure tablets and she wants to stop all m edication; what would you advise her to do? They sym pathise with M rs Jones’ predicam ent, but they cannot distil from their pages of close written text the one thing that M rs Jones needs to know.
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