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As the program often experience an increase in muscle classes continued purchase kamagra oral jelly 100 mg overnight delivery, more techniques were introduced purchase kamagra oral jelly online, pain which may discourage them from continuing to progressing through progressive muscle relaxation cheap kamagra oral jelly 100mg free shipping, work on improving their level of ﬁtness. Pellegrino release-only relaxation and visualization, cue- (1997) notes that a prescribed, supervised exercise controlled relaxation and differential relaxation. This program is beneﬁcial for ﬁbromyalgia patients, and occupied the whole 1-hour class. It is worth noting, however, that in both only groups the tender point counts had fallen signiﬁcantly 2. Such a program After 12 months fewer participants in the aerobic can include walking, water aerobics, using an exercise group fulﬁlled the criteria for ﬁbromyalgia; exercise bicycle, or performing a low impact by this time only 75 (55%) participants still met these aerobic program diagnostic criteria. The goal is to achieve improvement, but also to achieve a stable baseline For people with ﬁbromyalgia prescribed graded aerobic exercise is an effective treatment that leads to 4. Compliance is a consider- relaxation and ﬂexibility able problem, giving high dropout rates. Future strategies to (male and female, age range 18–70 years), evaluated increase the efﬁcacy of exercise as an intervention the effect on their conditions of either graded cardio- should confront the issue of compliance. Potential vascular ﬁtness exercise or relaxation and ﬂexibility strategies include additional cognitive behavioral activities, to which they were randomly assigned. Both forms of intervention helped a good number Exercise therapy comprised an individualized of participants, although clearly aerobic activity pro- aerobic exercise program, mostly walking on tread- duced the most beneﬁt. When people ﬁrst started classes cost, high-beneﬁt outcome should be seen as offering they usually did two periods of exercise per class a beacon for individuals in chronic pain. Sadly, despite periods of 25 minutes at an intensity that made them obvious beneﬁts, individuals commonly slip back into sweat slightly while being able to talk comfortably in old habits, abandon exercise regimes and return to complete sentences. Exercise routines should be introduced condition and how to manage it, with a group who gradually – see the protocol used by Richards & Scott attended these same lectures but who also received (2002) described above (page 458) – with caution and six 1-hour sessions of physical training. Unsupervised home exercising is probably with doing nothing in similar patients) were untreated unwise until the individual has attended classes during this entire study but received treatment after where the degree, intensity and timing of exercise can it was over. Patients participated Fitness, ﬂexibility and strengthening in the study for 3 weeks (total of 15 sessions). Patients were evaluated by the number In another study (Martin et al 1996) the beneﬁts of of tender points, visual analog scale for pain, exercise (ﬁtness, ﬂexibility and strengthening) pro- Beck’s Depression Index and Fibromyalgia grams were compared with relaxation exercises in a Impact Questionnaire for functional capacity. In Both groups of patients (those doing active exercise, group 1, there were statistically signiﬁcant and those doing relaxation) met three times a week differences in number of tender points, visual for 6 weeks to carry out their routines under supervi- analog scores, Beck’s Depression Index and sion. At the start, both groups had the same amount Fibromyalgia Impact Questionnaire scores after of pain, stiffness, etc. Six months exercises, 18 completed the course, along with 20 (of later, in group 1, there was still an the 30) in the relaxation group. Both groups showed improvement in the number of tender points (p an improvement in the number and sensitivity of <0. However, cises were much improved compared with the relax- there was no statistical difference in Beck’s ation group. What this study shows is that a number Depression Index scores compared to the of people (about a third) fall out of such programs for control group (p >0. Those that complete their mostly complain about pain, anxiety, and the assignments usually beneﬁt, and exercising appropri- difﬁculty in daily living activities. Results showed a signiﬁcant combined with six sessions of education decrease in pain and high blood pressure (Mannerkorpi et al 2000). The conclusion individuals were randomized to a treatment was that a combined spa and physical therapy and a control group. The treatment group program may help to decrease pain and was advised to ‘match the pool exercise to improve hemodynamic response in patients their threshold of pain and fatigue’. All participants stayed for treatment group, to a signiﬁcant degree, in 10 days at a Dead Sea spa. Physical functioning and tenderness ﬂoats in warm water sourced from hot springs moderately improved in both groups. The various methods of balneotherapy in the Dead double-blind, placebo-controlled trial involved 35 Sea area. A signiﬁcant improvement was found weeks) on a surface ‘magnetized at a magnet surface in dolorimetric threshold readings after the ﬁeld strength of 1100 gauss, delivering 200–600 gauss treatment period in women. The controls slept on a sham non- was that balneotherapy appears to produce a magnetized pad. The results showed that patients statistically signiﬁcant, substantial sleeping on the magnetized pads experienced a sig- improvement in the number of active joints niﬁcant decrease in overall pain, fatigue and total and tender points in both male and female muscle pain score, and also showed improvement in patients. A placebo effect was noted in that both pool exercise (temperate temperature) groups reported being less tired on waking. Symptoms most effectively when used in combination may begin just before menstruation starts or as long (massage, movement, relaxation, exercise, etc. In most women, symptoms • Manual lymphatic drainage and extremely light disappear by the time menstruation has ﬁnished. Chiropractic and • Various forms of exercise (aerobic, graduated menstrual/premenstrual symptoms weight training, etc. A trial found that women who received chiropractic • Balneotherapy and pool-based exercise and treatment, consisting of spinal manipulation, reported treatments such as Watsu have all been shown to signiﬁcant reductions in back pain and menstrual dis- be both safe and relatively effective, particularly in tress (Kokjohn et al 1992). Visual analog scale scores premenstrual irregularities indicated that both abdominal and back pain decreased Dysmenorrhea refers to the occurrence of painful men- almost twice as much in the spine manipulated group strual cramps of uterine origin, a common gynecologi- compared to the sham group. One possible treatment is spinal Other similar studies have shown positive beneﬁts manipulative therapy, the hypothesis being that (Walsh & Polus 1998). Meta-analy- as it can also be altered by hormonal inﬂuences associ- sis was performed using odds ratios for dichotomous ated with menstruation. The outcome measures were pain relief or pain intensity (dichotomous, visual analog scales, • tenderness and/or lumpiness of the breasts descriptive) and adverse effects. There was no difference (placebo) treatment, involving ‘very light or very in adverse effects experienced by participants in the rough’ massage of points not related to reﬂex effects. The Toftness technique was Symptom records were kept daily for the week prior shown to be more effective than sham treatment by to the next period. The results are described as follows: one small trial, but no strong conclusions could be ‘At the end of the study the reﬂexology group reported made due to the small size of the trial and other meth- a 45% decrease in both somatic and psychological odological considerations. The conclusion was that symptoms, compared with a 20% reduction in the overall there is no evidence to suggest that spinal placebo group. Yoga, exercise and menstrual symptoms Example: One of these reviewed studies involved 138 Chen (2005) compared the effect of yoga with aerobic women, ages 18–45, with primary dysmenorrhea and walking exercise on menstrual disorders. Treat- clusion: Yoga has better therapeutic effects on men- ment for both groups took place on day 1 of cycles 2, strual disorders as compared with other forms of 3 and 4, and prophylactic treatment of three visits took exercise, although all methods produced beneﬁt in a place during the 7 days before cycles 3 and 4. Although a wide range of measurements and assess- ments were made during the four consecutive men- Physical medicine therapeutic strual cycles, no clinically meaningful changes were measures for menstrual and observed.
For example buy cheap kamagra oral jelly on-line, in 2004 the Chinese drug regulatory authority cut the number of drug wholesalers in the country from 16 purchase 100 mg kamagra oral jelly free shipping,000 to 7 buy kamagra oral jelly without prescription,445 (Yadav et al. This is still many more than in the United States, Europe, or Japan, but it is an admirable move in a more sustainable direction. Proponents of the current drug wholesale system maintain that a small number of wholesalers cannot serve the drugs market of developing coun- tries. They reason that a system of three or four large primary wholesalers may work in Europe or North America, but in developing countries a few companies could never guarantee fne-mesh distribution (Foundation Strat- egy Group, 2005; McCabe, 2009). Medicine shops in Kenya, for example, report buying from a range of pharmaceutical and general wholesalers both in and outside of the shop’s district, as well as mobile vendors and manu- facturers (Amin and Snow, 2005). Analysis of successful distribution chains, such as the Coca-Cola distribu- tion chain, suggests this is a false dichotomy, however (Yadav et al. ColaLife, a nonproft, has been using Coca-Cola’s fne-mesh distribution chain to bring oral rehydration and zinc supplements to remote areas since 2008 (ColaLife, 2012). Steps toward a more controlled and effcient wholesale market can protect patients in the markets most hurt by bad- quality drugs. A reduction in the number of licensed wholesalers and use of more effcient distribution chains can help the wholesale market around the world. With every transaction on the chain, there is a risk of the drug supply’s being compromised. Crimi- nals take advantage of places where the distribution chain breaks down and medicines depart from documented chain of custody. Drugs that leave the proper distribution system are called diverted drugs; the markets that trade diverted drugs, or more generally, markets that trade with little authorized oversight, are called gray markets. Drug diversion is the means through which medicines approved for sale in one country are sold in others, where they may not be registered. On the surface, drug diversion is not the public health threat that falsifed and substandard medicines are (Bate, 2012). Some countries have made legal provisions for importation of unregistered lifesaving drugs that are not available in local markets (Zaza, 2012). Others argue that thieves bring good-quality drugs to otherwise neglected markets, and that, issues of fraud aside, the end consumer is no worse off (Bate et al. If thieves traffcked solely in quality-assured medicines, then this point might be valid. Once a medicine leaves the responsible chain of custody, there is no way to ensure that it has been properly stored. As Chapter 3 explains, drug quality research indicates that unregistered medicines are sometimes dangerous (Bate et al. By chance, drug diversion may bring good Key Findings and Conclusions • When stolen drugs are reintroduced to the legitimate supply chain, there are no records of the products’ handling or storage conditions. Pedigree requirements prevent stolen drugs from entering the legitimate mar- kets and facilitate efcient recalls. Drug diversion is roughly synonymous with theft, and trade in diverted drugs is an indicator of the relative ease with which criminals exploit weak- nesses on the distribution chain. In the United States, for example, the resale of prescription drugs is a common problem, but illicit vendors also circumvent the regulated distribution chain at other points. In developing countries, the sale of donated drugs for proft is a common type of diversion (World Bank, 2005). Small-scale theft, also called pilfering, happens mostly between the vendor and patients; larger cargo heists tend to happen to bulk drug pack- ages, generally between the manufacturer and the vendor. Pilfering and Heists Many diverted drugs are donated ones, pilfered and resold by health workers (Ferrinho et al. The theft and resale of free drugs is engrained in the pharmacy and clinical culture in some countries, where it is seen as a professional perk for otherwise underpaid government health workers (Lim et al. This theft defrauds donors and con- tributes to drug shortages at legitimate dispensaries (Bate, 2012), thereby encouraging the distal causes of poor-quality drugs. In March 2010, $75 million worth of medicines were stolen from an Eli Lilly warehouse in Connecticut (Efrati and Loftus, 2010) and later partially recovered in Florida (Muskal, 2012). Freight Watch International, a supply chain security company, estimates that theft of pharmaceuticals in the United States increased 283 percent between 2006 and 2008 and have remained roughly constant since then (FreightWatch, 2011b). Ware- house heists such as the Lilly theft are relatively diffcult to orchestrate; by far the more common route is theft of a loaded trailer (see Table 5-2) (FreightWatch, 2011b). Cargo theft is not confned to the United States; Freight Watch Interna- tional sees it as a serious problem in Brazil, Great Britain, India, Mexico, Russia, and South Africa as well (Fischer, 2012; FreightWatch, 2011a). Countering the Problem of Falsified and Substandard Drugs 212 Copyright © National Academy of Sciences. Fund fnances a line of artemisinin combination therapies for the Affordable Medicine Facility in eight countries, including Nigeria and Ghana (Global Fund, 2012). These drugs are packaged differently from those meant for the public sector (Bate, 2012; Bate et al. Roger Bate was therefore able to recognize Global Fund products meant for Nigeria and Ghana in Lomé, Togo (Bate, 2012). Thirty percent of the diverted samples he collected in Togo failed quality tests, a failure his team attributed to degradation (Bate, 2012). Outward evidence of diversion is not always so clear, but a drug sold in a country where it is not registered is often diverted and therefore sus- pect. A national sample of essential medicines in Cambodia found that unregistered drugs are six times more likely to be falsifed than registered ones (Khan et al. Similarly, in Ghana, researchers found unregis- tered oxytocin samples to be uniformly substandard (Stanton et al. Diverted drugs are dangerous partly because there is no reliable record of what conditions they have been transported in. The uterotonic drugs ana- lyzed in Ghana are unstable at room temperature, for example (Stanton et al. They might have failed quality testing because of exposure to tropical temperatures and humidity in travel. Drug Resale and Late Diversion Drugs can also be diverted late in the distribution chain, after the drug has reached the patient. This is a far less common point of diversion than diversion at the vendor level and earlier. Drug diversion through resale is a growing concern in the United States, where a 2008 survey estimated that between 5 and 10 percent of American high school students take prescription pain killers, Copyright © National Academy of Sciences. A study of American college students found that more than one-third of those taking a prescription drug had diverted it at some time, but generally this diversion was infrequent sharing among friends, not predictable sales (Garnier et al. Other research suggests that Medicaid recipients and other patients sell their medicines for proft in unregulated street markets (Inciardi et al. Pill brokers may buy medicines from patients, especially elderly ones, or work with unscrupulous doctors to arrange prescriptions for kick- backs (Inciardi et al. In some ways, drug resale is similar to pilfering as both methods of drug diversion happen in small amounts and attract little attention from the authorities. Small thefts and large diversions compromise the integrity of the drug distribution chain and confdence in the quality of medicines.
Dramatic Behavior Patients who are extremely dramatic may project their own thoughts and discomforts onto others or believe their own perceptions and ideas to be entirely accurate buy discount kamagra oral jelly. For example purchase kamagra oral jelly 100mg visa, if they are feeling lonely kamagra oral jelly 100mg lowest price, vulnerable, or inadequately validated, such patients may accuse staff of purposely ignoring them, belittling them, or being incompetent. Meanwhile, they may also project warm feelings and suddenly become overly intimate or familiar with some staff members. Dramatic invidiuals—many of whom meet criteria for borderline or histrionic personality disorder in the official psychiatric parlance —engage their physicians and nurses in relationships that are intensely intimate or staggeringly conflictual. The dramatic patient thus seduces some staff members while alienating others; with some personnel, the dramatic patient acts charming and delightful, whereas with others the dramatic individual is devaluing, belligerent, and toxic. When clinicians who have had completely different experiences with a dramatic patient confer, they are at odds over how to handle the patient’s demands. This discord creates tremendous tension, one that is relieved when clinicians acknowledge they have had contradictory emotional experiences with a patient. Leaving the patient’s bedside in order to cool down, think of a new strategy, or consult a colleague is better than acting impulsively. As with the dependent patient, communicating understanding of the patient’s plight —in other words, validating their feelings—is important. Statements such as, “Given all that you’ve been through, I can only imagine how hard this is” can be helpful. Further, even more than what is said, listening and eliciting the patient’s experience is usually most beneficial: “I want to make sure I better understand what you are going through. Family members play an integral role in encouraging and comforting critically ill patients and informing distant loved ones of patients’ progress or problems. With the exception of those patients who, prior to hospitalization, expressed their preferences for medical care, relatives are also responsible for learning about a patient’s diagnosis and prognosis and making decisions for critically ill patients who lack the capacity to make medical choices for themselves. On Time Schedule appointments for family conferences or treatment updates and try, as best as possible, to be on time. Respect the Patient’s Uniqueness These appointments are as much about what you say as how well you listen. Occasionally, before the physician can provide information regarding prognosis, family members will foreclose discussion and disagree with the doctor or other family members about how much workup or end-of-life treatment to pursue. Some special situations related to the emotional life of family members bear examination in further detail. These include: the guilty family member; the family member compelled to preserve the dignity or “fighter status” of their loved one; and the vindictive family member. Physician interventions or “conversational reframes” in these situations are aimed, not at coercion, but at enhancement of doctor–family and family–family conversation about how best to proceed with a critically ill family member’s care. To assuage their guilt, these family members demand that “everything” be done for their relative, to the point of pushing for futile assessments and treatments. Reframing the dilemma for these family members, giving them a sense of authority, and explaining how they can be helpful can change the family–staff dialogue. For example, one intensivist told a particularly guilty son whose mother had suffered a severe stroke: “I know you’ve had to be away for several years and not been able to play a day-to-day role in your mother’s care. However, this is a really big opportunity to help support your mother, who is dying, and your sister, who is struggling. When dealing with end-of-life care, some family members will demand that “everything” be done because they don’t want their loved one to appear weak. In these situations, one should listen closely to why it is important that the patient’s status as a “fighter” be maintained. Wasserman studied responses provided by relatives of patients who had attempted suicide and found that a family’s request for “do not resuscitate” orders sometimes reflected anger toward the patient . Eliciting these feelings during a family meeting may help family members acknowledge the hostile origins of their decisions and feel they have acted less impulsively and more thoughtfully about how to proceed with a loved one’s care. Finally, in those situations where discussions over care reach a standstill and interventions stimulate little movement, referral to an ethics consultant or committee (particularly with regard to end-of-life care) or patient-rights advocate (regarding a family member’s grievance) may be helpful in resolving conflict. Utilizing this framework, practitioners pay special attention to Setting up the interview; eliciting patient’s and family’s Perceptions about their illness and treatment; Inviting patients and family members to be active participants in the process asking them about the quality (type) and quantity of information they would like; providing the patient and their supports with medical Knowledge; Empathically responding to the Emotions of those hearing bad news; and Summarizing and Sharing a Strategy for how best to proceed. Ultimately, no matter what protocol one utilizes, clinicians should remember that: (1) having a mindful framework versus “therapeutic winging it” is key; (2) there is great medical and psychologic intensity in this type of work and, as such, any kind of news (be it good or bad) is hard to deliver ; (3) even under the best circumstances, the most compassionate caregivers can sometimes come across as less empathic ; (4) problematic interactions can be an opportunity for self- and team reflection and improvement; and (5) learning to address the needs of families better requires an openness to reflection and whole-team commitment . Being Emotionally-attuned and Empathic Observe patients’/families’ emotions Consider that emotion and name it to oneself Identify the reason for this emotion (it may be coming as a surprise or confirm a worst fear) Connect the patient’s affect and what you believe is driving it (e. Addressing difficult interactions and challenging personalities entails a commitment on the part of the practitioner to take an empathic stance, recognizing that behind the most troubling behavior is a person, someone in anguish whose words and actions represent his/her best attempts to cope with pain. Patients and family members with traumatic pasts, poor coping strategies, and/or formal personality disorders often respond to limit-setting and validation of their distress, entailing a description of how they are expected to act and what they can expect from their caregivers. Myhren H, Ekeberg O, Stokland O: Job satisfaction and burnout among intensive care unit nurses and physicians. Azoulay E, Pochard F, Kentish-Barnes N, et al: Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Trenoweth S: Perceiving risk in dangerous situations: risk of violence among mental health inpatients. Whitehome K, Gaudine A, Meadus R, et al: Lived experience of the intensive care unit for patients who experienced delirium. Azoulay E, Pochard F, Chevret S, et al: Half the family members of intensive care unit patients do not want to share in the decision- making process: a study in 78 French intensive care units. Tanco K, Rhondall W, Perez-Cruz P, et al: Patient perception of physician compassion after more optimistic vs a less optimistic message: a randomized clinical trial. Today, such units are frequently filled to capacity with complicated patients suffering from multiple life-threatening illnesses. As technology has advanced, patients with once terminal illnesses are surviving episodes of deterioration, raising ever more complicated ethical issues . Staff may not be prepared to handle their emotional reactions to these challenges while simultaneously tending to the technical and clinical aspects of intensive care. Selye defined stress as the nonspecific result of any demand on the body, and observed that different organisms and biologic systems respond to stress in a stereotyped and predictable three-part pattern. The initial alarm reaction (characterized by activation of the sympathetic nervous system and various hormonal, immunologic, and psychologic responses) is followed by the stage of resistance, during which the organism establishes a temporary homeostasis by marshalling various reserves to adapt to the new situation. However, the body’s ability to adapt is finite, and, with continued exposure to the stressor, its reserves become depleted and the organism enters a stage of exhaustion. Researchers in biology and sociology have expanded this work to encompass processes ranging from individual cellular responses to stress to the reactions of individuals and social systems to external and internal stressors. Regardless of the field, low job satisfaction is often predicted by a small number of factors: little participation in decision-making, ambiguity about job security, poor use of skills, and lack of clarity about role. These stressors are consistent with the demand–control model of the effects of job demands on worker’ well- being. This model predicts that the fewer demands and more control a worker has on the job, the less stress he will experience . For example, the Return to Work Study found that subjects with low-demand, high- control jobs were substantially more likely to return to work after a period of medical disability .
These mushrooms are found in much of the Northern Hemisphere and are known to grow elsewhere order kamagra oral jelly 100 mg fast delivery. Due to the possibility that an effective dose is close to a poisonous dose order on line kamagra oral jelly, and because of variations in potency effective kamagra oral jelly 100mg, these mush- rooms are easily poisonous and have even been mixed with milk as bait to kill ﬂies. Persons seeking amanita sometimes accidentally ingest Amanita phal- loides, also called Death Cap and Death Cup, which can be deadly poisonous to the kidneys and liver. Confusion with other dangerous mushrooms has also harmed people seeking Amanita muscaria. The Amanita muscaria mushroom has been used to treat alcohol overdose and to relieve nervousness, fever, and pain of sore throat, nerves, and joints. The natural product contains muscimol, a chemical that initially acts as a stim- ulant but that can later produce temporary loss of muscular control as the drug action proceeds. In various animal species muscarine chloride can cause spasms and constrictions and lower blood pressure. The relevance of those studies to humans is unclear; for example, a dose that would poison a human leaves a monkey unfazed. The ibotenic acid in amanita can produce hallucinations; a case report mentions visual hallucinations lasting for days after ingesting the mushroom. The mush- room is said to produce euphoria and to cause changes in sensory perceptions. Some persons consume the fungus for spiritual purpose, a practice that some authorities date back to ancient Buddhist times, with the Buddhists perhaps learning the custom from still older examples among forest peoples in north- ern Europe and Asia. One user describes the experience as lacking in feelings of hap- piness, or love, or sexual impulses—a lack that sets amanita apart from many drugs that are used recreationally. A scientist who engaged in self- experimentation had similar results of emptiness. Of 6 subjects who received the mushroom in an experiment, all were nauseated, 2 vomited, 1 had hal- lucinations, and several had sensory distortions. The supervising researcher wondered if variations in supplies of the natural product explained why the experiment’s results differed so greatly from hallucinations and pleasures reported by other persons. Personality, ex- pectations, and surrounding environment can shape the experience. A re- searcher interviewed 18 persons who ate Amanita muscaria or Amanita pantherina; half had eaten the mushrooms deliberately, and half thought they were consuming something else. In contrast, the mushroom’s effects were enjoyed by every individual who deliberately ate it. Because active chemicals from the natural product are excreted into urine, people can dose themselves again by drinking their own urine, a dosage method that may horrify Americans but that a few other cultures have ac- cepted calmly. Unwanted amanita effects can include twitching, cramps, abdominal dis- comfort, sweating, nausea, vomiting, diarrhea, dizziness, confusion, rapid heartbeat, difﬁculty in moving around, high body temperature, and convul- sions. Users can become manic and then sleepy, with those conditions alter- nating back and forth until a person collapses. Scientiﬁc journals contain many articles about brain damage caused by ibotenic acid, although conditions of experiments do not necessarily duplicate what happens when mushrooms are eaten. A person who received a dose of ibotenic acid in an experiment de- veloped a headache for two weeks. Under laboratory conditions amanita ex- tracts cause red blood cells to clump together. They are about the size of a cherry and come from palm trees in the Indian Ocean region, grown in countries such as India, China, and the Philippines. The product is used not only as a drug but also as a dye and in the leather tanning industry. Drug use of areca nut is common in South Africa, India, Taiwan, and other areas of South Asia and the Paciﬁc basin. The product has been unfamiliar in the United States, but is available and is used in some immigrant communities. Areca nut is a popular recreational stimulant relieving tension and produc- ing euphoria, regularly used by perhaps 200 million to 600 million persons, making it one of the most popular substances in the world. Effects may be unpleasant for new chewers: nausea, dizziness, burning sensation in the mouth, a closing sensation in the throat. As with alcohol, in lands ranging from India to New Guinea areca nut has a place in religious and other ceremonies (engagements to marry, offerings to spirits), but the product’s main use is secular. In some places, areca nut is a social lubricant, much as beer is used in the United States. Paraphernalia involved with consuming areca nut may be either utilitarian or highly decorated functional artwork. As with tobacco quids, users typically spit out areca nut juice, staining walls or other targets. Because such a practice may potentially promote the spread of disease, in some places large cans are lined with plastic bags and used as spittoons. Comments from one user make the substance sound like fast-acting caf- Areca Nut 49 feine; another user talked of a mild background stimulation accompanied by pleasant enhancements of perception; still another user described a brighten- ing of colors, with motions around him becoming jerky, as in old-time silent movies or modern Internet videos, and said he felt relaxed. Areca nut usage is seen more often in older persons than in younger and may therefore be declining. One survey found up to 16% of high school students in Taiwan regularly using the substance. Areca nut and nicotine both inﬂuence some of the same parts of the central nervous system in similar ways. Chewing the substance can slow or accelerate pulse rate, raise or lower blood pressure, promote sal- ivation and tremors, and increase body temperature and sweating. Traditional healing applications include treatment of edema, hep- atitis, gum disease, inadequate urine output, and gastrointestinal complaints including both constipation and diarrhea. Investigators ﬁnd that areca nut reduces schizophrenia symptoms in schizophrenic chewers. Although areca nut is a stimulant, its ability to improve workplace perfor- mance is unproven. One laboratory study demonstrated that the substance is unlikely to worsen job performance; another laboratory study showed im- provement in some reaction time; still another showed longer reaction time. Tests of workers who operated heavy earth-moving equipment while using areca nut found evidence that the men were more alert, but otherwise they exhibited no effect that would inﬂuence job performance; measurements in- cluded short-term memory, reaction time, and eye-hand coordination. Experiments with areca nut’s pyridine alkaloid are- coline indicate that the chemical can improve memory in mice, and arecoline produces the same beneﬁt in persons suffering from Alzheimer’s disease (al- though improvement may be marginal). Still other chemicals isolated from areca nut seem to have potential for inhibiting formation of plaque on teeth, although in practice areca nut chewers have more plaque than nonchewers. Chewers, however, also seem to have less tooth decay than nonchewers, and areca nut toothpaste has been marketed. Areca nut chewing is linked to a lower prevalence of a bowel disease called ulcerative colitis, but the possible protective effect has not been differentiated yet from tobacco smoking of chewers (nicotine is known to improve ulcerative colitis). One alcohol extract of areca nut has been successfully tested as a treatment for skin wrinkles, making people look younger. Another alcohol extract shows promise in treat- ing inﬂammations, allergies, and cancer.