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By B. Yussuf. Bethel College, McKenzie, Tennessee.

If you can’t complete a specific exercise buy cheap provera 10mg line, ask yourself generic 10mg provera, “How can I change this exercise to make it more manageable? Specifically cheap 5 mg provera free shipping, some people have small veins that are hard to find, making it difficult to take blood. As a result, nurses, doctors, and others often try unsuccessfully to take blood from various locations and may end up causing considerable pain and bruising with each attempt. If you have small veins, you should take steps to minimize the “trauma” that normally occurs when you have blood taken. First, make sure that the person drawing your blood is experienced in drawing blood from people with small veins. Second, let the person know that it’s generally very difficult to draw your blood from the usual places. If there’s another location that tends to work better (for example, your hand), suggest that the person drawing your blood try that location first. If your fear is staying high, make sure you have given it an adequate opportunity to come down. Another factor that may pre- vent your fear from decreasing is significant life stress (for example, a hectic work schedule, frequent marital con- flict, or parenting pressures). If you’ve had a stressful day 100 overcoming medical phobias and your fear doesn’t decrease during practice, try again another day. Finally, it’s best not to engage in safety behaviors or subtle avoidance behaviors, such as distrac- tion, during your exposures. These behaviors may keep your anxiety higher over the course of your exposure practice. For people who faint, exposure should be combined with applied muscle tension exercises, which are described in chapter 6. This chapter included four case examples to illustrate how exposure therapy plays out in real life, and we also presented strategies for dealing with some of the most common obstacles that may arise during treatment. As mentioned earlier, a lit- tle more than 50 percent of people with needle phobias have a history of fainting during injections and almost 70 percent of people with blood phobias report fainting upon exposure to blood (Öst 1992). The tendency of these pho- bias to be associated with fainting is unique; it is very unusual for people with other types of phobias (for exam- ple, fears of heights, animals, or flying) to report fainting in the feared situation. If you tend to faint in your feared situations, practic- ing exposures can be especially challenging. We’ll also teach you a proven technique to help reduce 102 overcoming medical phobias the possibility of fainting. One is the cardiovascular system, which includes the heart and blood vessels, and the other is the nervous system, which includes the brain, the spinal cord, and all of the nerves that control the muscles and organs. Because the brain is above the heart when we are standing upright, gravity tends to pull blood away from the brain. There- fore, your blood needs to be under enough pressure to get it up to your brain and to keep it from pooling in your legs, in the same way that water in a two-story house needs to be under pressure to get a good flow in the upstairs shower. That blood pressure is maintained by the muscles in the walls of your blood vessels and by the rate and power with which your heart beats. When the muscles in the walls of your blood vessels contract, they narrow the diameter of the blood vessels, causing an increase in your blood pressure. If those preventing fainting 103 muscles become relaxed, blood vessels increase in diame- ter, resulting in a drop in blood pressure. So relaxed blood vessels and a slow heart rate both result in reduced blood pressure. Reduced blood pressure, in turn, results in pooling of blood in the legs (because that’s where gravity pulls it). Pooling of blood in the legs means less blood is available to get to the brain, and that means the brain is deprived of oxygen. A brain without oxygen can’t stay alert and can’t hold up the body it con- trols, so fainting occurs. Your nervous sys- tem tells your heart how fast to beat and tells the muscles in the walls of your blood vessels how relaxed to be. When the vagus nerve is activated, it tells the heart to beat more slowly and tells the muscles of the blood vessel walls to relax. Remember, a slow heart rate and relaxed blood vessel wall muscles result in decreased blood pressure, which ultimately leads to fainting. How- ever, the key thing to remember is that activation of the vagus nerve can result in fainting. Now you understand the mechanics of fainting, but we still haven’t answered the question as to why people faint when they see blood, get an injection, or are overcome with fear at the doctor’s office or in the dentist’s chair. Although the exact mechanisms are not yet fully under- stood, we do know that strong emotional reactions such as fear and anxiety (and even extreme sorrow), as well as the threat of physical pain or injury, will activate the vagus nerve. The sight of blood, the thought of a needle, the sound of a dentist’s drill, or the smell of a doctor’s office can all produce an emotional response strong enough to activate the vagus nerve. Activation of the vagus nerve is much stronger in some people than in others (probably for genetic reasons; Page and Martin 1998), so they are more likely to faint when exposed to emotionally charged objects or situations. However, fainting in the presence of blood and related situations doesn’t require the presence of fear. In a survey of college students, Kleinknecht and Lenz (1989) found that among those who reported a history of fainting upon seeing blood, 38 percent had a full-blown blood phobia, 28 percent were somewhat fearful of blood (but didn’t have a full phobia), and 34 percent reported no fear of blood. In other words, some people occasionally faint when they see blood, despite reporting not being afraid of blood. You may be wondering why humans would develop a ten- dency to faint in the presence of blood and injury. One possibility is that, evolutionarily speak- ing, when our ancestors were living in caves and hunting wild animals to survive, if they became injured and began to bleed, then a drop in blood pressure might actually be good. Blood that is under reduced pressure has less force behind it and therefore flows more slowly and may clot more quickly. So a drop in blood pressure at the sight of one’s own blood may have resulted in fainting, but at the same time, it could have kept some of our ancestors from bleeding to death while out on the hunting grounds. Another possible explanation lies in the fact that wild animals are generally less likely to attack an uncon- scious victim. Therefore, if our ancestors were attacked by a wild animal and blood was drawn, fainting at the sight of one’s own blood may have kept the wild animal from finishing what it started, in turn allowing the victim to survive. A third possibility is that vasovagal fainting may have developed to promote the development of fear toward certain things. Fainting is an unpleasant experi- ence, and in general, people try to avoid unpleasant expe- riences and the things that cause them. If things like pain, blood, knives, the teeth of wild animals, and other dangerous threats became associated with fainting, people may have been more likely to develop a fear of these 106 overcoming medical phobias things and in turn would have learned to avoid such situ- ations, resulting in improved survival in the wild. While fainting may be helpful at certain dangerous times, it isn’t helpful in the situations where you tend to faint. There is no life-threatening danger from watching a bloody scene in a movie, getting an injection or having blood drawn, getting a filling, or having your doctor examine you. Well, it would be great if you could somehow consciously override your vagus nerve and contract the tiny muscles inside the walls of your blood vessels on command to increase blood pres- sure and in turn prevent blood from pooling in your legs. Unfortunately, you have no direct control over the mus- cles in the walls of your blood vessels.

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Diagnosis: A diagnosis of human hydatidosis is suspected based on the clinical symptoms and epidemiological circumstances provera 2.5mg low price. Imaging methods such as radiogra- phy provera 2.5mg low cost, computerized tomography provera 5mg with amex, ultrasonography, and scintigraphy are used. Ultrasonography is the first choice because it is economical, noninvasive, simple, and accurate and reveals developing cysts that generally cannot be found with X- rays (Suwan, 1995). Numerous immunobiologic tests have been used in the diagno- sis of human hydatidosis by E. Casoni’s intradermal test is not very sensitive and is nonspecific for the diagnosis. While it was once used for epidemiological surveys, the collection of drops of blood on filter paper now makes it possible to use sero- logic techniques that are much more sensitive and specific on a large scale. The techniques based on observation of arc 5 were abandoned when it was found that the respective antigen was specific not for Echinococcus but for many cestodes. Moreover, the test with selected antigens is not only highly sensitive and specific but can also distinguish among infections caused by different species of Echinococcus. But there seem to be wide variations in the sensitivity and specificity of the test among dif- ferent laboratories. The dif- ferences do not seem to be due to a variation in the methods or composition of the antigenic extracts used (Coltorti and Cammarieri, 1993). More recently, the polymerase chain reaction has also been used to detect nucleic acids from the parasite in patients’ bloodstreams (Kern et al. Results of all the tests vary according to the location of the cyst and its physio- logical state. The immunodiagnostic tests seem to be less sensitive for detecting pul- monary than hepatic hydatidosis. Several investigators are looking for antigens char- acteristic of fertile or live cysts, since these cysts are the only ones that can cause secondary hydatidosis. Knowledge of whether a cyst is sterile or dead enables the doctor to be more conservative in treatment. Even though there is no reason why the immunological methods for diagnosing cysts cannot be adapted to domestic animals, there apparently has been no incentive to do so. The traditional method of diagnosing hydatidosis in these species is post- mortem examination in slaughterhouses or packing plants. Intestinal echinococcosis in the definitive hosts is traditionally diagnosed by administering a strong purgative, generally arecoline hydrobromide, and searching for the parasite in the feces. The maximum effectiveness of this technique is about 65% if both the feces and the vomit are examined. Besides being slow and tedious, this method is dangerous because the eggs of Echinococcus are infective when they are eliminated. The specificity and sensitivity of the former test were 95% to 99% and 80% to 93%, respectively. The specificity and sensitivity of the latter were 100% and 94%, respectively (Deplazes and Eckert, 1996). Control: At present, conventional control measures consist of: 1) educating the rural population about hydatidosis and its control; 2) centralizing the slaughtering of animals for food in units with veterinary control; 3) ensuring sanitary conditions for slaughtering done on ranches and preventing dogs’ access to raw viscera; 4) reduc- ing the number of dogs on the ranches and treating them for Echinococcus on a reg- ular basis. A fifth measure has recently been added: looking for human hydatidosis during primary health care visits. This has made it possible to diagnose many unsus- pected cases and interest the population in the control campaign. Recently, joint and coordinated implementation of these health measures, both medical and veterinary, has resulted in noteworthy improvement in the results of the control campaigns. One of the first examples of organized control was the campaign on Cyprus, which was carried out only in the area controlled by the Government of Cyprus; cer- tain areas of the island remained uncontrolled. Studies carried out in the period 1993–1996 showed that the parasite had returned in 20% of the communities checked. A consolidation campaign was then initiated, this time emphasizing both control of the intermediate hosts and treatment of dogs. The cam- paign carried out in Tasmania, Australia, reduced the rate of infection in dogs from 12. New cases of human hydatidosis fell from 19 in 1966 to 4 in 1982; in practice, the disease was no longer found in young people (Australia, 1973). In 1991, however, hydatid cysts were found in cattle in the north- ern part of the state, where the parasitism was thought to have been eradicated. In Iceland, health education and a highly motivated population were the main factors in the success of the campaign to eradicate the infection. The main objective of the program was to develop an understanding of the problem and a sense of responsi- bility in the people. Campaigns for control on islands, such as Cyprus, Iceland, New Zealand, and Tasmania, in Australia, have shown that the area under control must remain totally closed to the introduction of new definitive or intermediate hosts; otherwise, the initial phase of attacking the problem must be followed by a permanent, indefinite consolidation phase (Economides et al. Observations in Bulgaria also indicate that, even if com- plete eradication is achieved, control activities should continue to ensure that the infection does not recur. Administrative and economic problems between 1983 and 1995 necessitated sus- pension of the control measures, and the incidence returned to the previous levels (Todorov and Boeva, 1999). In Peru, suspension of the control programs in a hyper- endemic area was associated with a five-fold increase in the incidence of the human infection (Moro et al. In Latin America and other developing areas where socioeconomic and cultural conditions differ from those in Iceland, New Zealand, and Tasmania (Australia), the relative effect of each known control procedure must be evaluated to adapt them to the environment, or new procedures must be found. Regional programs for the con- trol of hydatidosis are being carried out in four Latin American countries (Argentina, Chile, Peru, and Uruguay). For example, in the control program being carried out in Río Negro, in the southern part of the country, the canine population is subject to diagnostic treatment or deparasitization, the infection in sheep is being detected and controlled in the slaughterhouses, classes are being taught in the schools, community health education is being promoted through the media, and human cases are being sought out, reported, and treated. China officially initiated a national program for the control of hydatic dis- ease between 1992 and 1995, based on education, improvement of sanitation in slaughtering livestock, and deparasitization of dogs (Chai, 1995). This vaccine is highly effective, but marketing problems have created a roadblock to its widespread use. With regard to individual human protection, the following are recommended: avoid- ing close contact with dogs that may carry the eggs of the parasite on their tongues or coats and avoiding ingestion of raw vegetables and water that may have been contam- inated with the feces of infected dogs. This is particularly important in the household gardens of sheep ranches where local dogs roam and sometimes defecate. Humoral immunity in the prepatent primary infection of dogs with Echinococcus granulosus. Neotropical echinococcosis in Suriname: Echinococcus oligarthrus in the orbit and Echinococcus vogeli in the abdomen. Risk factors associated with human cystic echinococcosis in Florida, Uruguay: Results of a mass screening study using ultrasound and serology. Inmunodiagnóstico de hidatidosis: evaluación de antígenos de líquido hidatidíco y de líquido vesicular de cisticerco de Taenia crassiceps.

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However purchase provera cheap online, because the size of the effect was mod- est trusted 10 mg provera, these authors questioned the usefulness of garlic for treating hypercholesterolemia; whereas other investigators concluded that buy discount provera 2.5 mg, on the basis of a number of new rigorously designed controlled studies, there is increasingly less evidence for lipid-lowering properties of garlic prepara- tions. However, this does not preclude garlic as a useful option for enhancing car- diovascular health. Marginal reduction of blood cholesterol levels is only one of garlic’s potential effects on coronary artery disease. The direct effects of garlic on aortic elasticity, its antioxidant properties, and antiplatelet aggre- gation effects need evaluation before judgment on the impact of garlic on cardiovascular health can be made. Modest changes to the pathogenesis of coronary heart disease at diverse levels may well combine to provide a meaningful clinical outcome. Use of garlic may not be clinically justified according to a reductionist approach in which each of its effects is individu- ally evaluated. However, it may be regarded as a valuable health adjunct when the totality of its clinical impact is appreciated. Although garlic is regarded as one of the potentially safe herbs,35 garlic supplementation does affect warfarin activity. Such reservations are consistent with the universal applicability outcome criterion of the biomedical model. Within the frame- work of the infomedical model, any intervention that achieves a health gain without untoward effects is deemed clinically worthwhile. When the focus is on the individual and subjective data are considered, garlic can be an important intervention option in the treatment of a patient seeking a “natu- ral” approach. Chapter 1 / The Science of Nutritional Medicine 13 The Dilemma of the Common Cold Nutritional controversy not only surrounds the use of particular nutrients and herbs, it also besets the prevention and management of prevalent ail- ments somewhat resistant to conventional medication. Despite widespread lay belief, the medical profession generally regards prevention of colds by vita- min C as a myth. Linus Pauling’s conclusion in the 1970s that vitamin C had physiologic effects on the common cold was of major importance, because it conflicted with the prevailing consensus that the only physio- logic effect of vitamin C on human beings was prevention of scurvy. Pauling’s extrapolation of this finding to the general population was in error as to the magnitude of the effect, but its general thrust has not been invalidated. A recent American survey indicated that two of three patients believed that vitamin C reduced cold symptoms. A clinical trial demonstrated an 85% decrease in flu and cold symptoms in the test group, compared with the control group. In one review 23 studies were analyzed, and the authors concluded that vitamin C in daily doses of 2 g or greater was most effective in managing the common cold. Trials of zinc supplementation for colds have been ongoing for more than a decade, with contradictory results. Furthermore, not only may the medium in which the active principle is delivered affect outcome, variations in the pathogenesis of the condition may modify therapeutic efficacy. In one trial it was reported that zinc acetate had no effect but that zinc gluconate may reduce the average duration of symptoms by 1 day, from 3. The dose of the nutrient 14 Part One / Principles of Nutritional Medicine used, the frequency and duration of administration, and the form or chemi- cal environment of the supplement all influence outcome. The stage of the infection at which therapy is initiated and the extent to which the supple- ment is absorbed affect efficacy. The patient’s nutritional and immune status, any associated disorders, and other medications also have an impact. A systematic review of current thinking in nutritional medicine is being undertaken; the objective is to determine how food, herbs, and nutrients may promote health and prevent disease. Although superficially the framework of the drug-paradigm testing model provides a gold standard for evaluating nutritional intervention, per- functory implementation of this framework invites erroneous conclusions. Results from clinical trials are poor or largely fail to support epidemiologic findings that suggest antioxidants reduce the risk of cardiovascular disease and cancer. These include fail- ure to recognize that nutrients achieve their outcome as a result of synergistic metabolic interrelationships, that stereochemistry influences effi- cacy, and that it is simplistic to presume a direct dose-response relationship in a cybernetic system. In contrast, the ability of an intervention to achieve discernible improvement in the individual patient demands recognition within the infomedical model. When certain individuals respond to a nutritional intervention, the frame- work of the infomedical model leads the investigator to consider the reason for such discrepancies. Issues ranging from biologic individuality to age- specific responses need to be addressed. The possibility that subclinical depletion of one or more nutrients may distinguish responders from nonre- sponders needs to be explored. Failure to have prescribed an effective clini- cal dose and the prospect of having unbalanced nutrient-nutrient interactions also need to be considered. Within the infomedical framework, a marginal but statistically insignificant improvement triggers a search for reasons that some patients respond when others do not. Instead of encour- aging rejection of the intervention, such a marginal improvement serves as an impetus for further investigation to achieve better understanding. Reliable information about the efficacy, safety, and cost of nutrient and herbal interventions is a prerequisite for cost-effective care. Such data are not always available, and concern has been expressed that control of nutritional Chapter 1 / The Science of Nutritional Medicine 15 and herbal products by licensing of remedies with equivocal benefits and few risks, as evidenced by a long history of safe use, may increase societal health care costs. However, a calculation based on observational data sug- gests that 170 to 250 persons would need to take vitamin E for 10 years to prevent one myocardial infarction or stroke. A protective effect of vitamin E against fatal myocardial infarction has not been demonstrated. It is possible, or even probable, that each condition for which a nutrient provides benefit will have a unique dose-effect curve. Because of the great amount of time required, conduction of trials that adequately probe the dose-effect curve for promising nutrients for each condition they might affect or studies of all the possible combinations of other micronutrients that might act to enhance effectiveness is an insurmountable task. It has even been suggested that a new paradigm needs to be used whereby the pharmacologic effects of traditional herbs such as ginseng can be understood in the light of their polyvalent actions as demonstrated by ginseng saponins with their positive antimuta- genic, anticancer, antiinflammatory, antidiabetes, and neurovascular effects. In fact, for most psychiatric disorders, a given treatment is not considered effective without a placebo control. The placebo response rate in psychiatric conditions varies widely across patient groups; it may be as high as 65% in a group of patients with major depression. For example, it is difficult to judge how much of the clinical improvement is due to the treatment in open studies in which a treatment is given to a group of patients and their response is hypotheti- cally contrasted to the treatment outcome with a known drug. A second type of investigation compares the experimental treatment with a drug of estab- lished efficacy. Even if an experimental treatment appears comparable to a standard drug in terms of response, it may be that a placebo would have done as well as either treatment over the course of the study. Investigations in which a treatment is compared with placebo, sometimes with the use of a standard drug as a third arm of the study, therefore remain an important dimension in therapeutic validation. Such methodological modifications are making it increasingly appropriate and feasible to evaluate alternative med- icine by means of scientifically accepted methodology. The infomedical model accepts that intervention in the face of uncertainty is normal.

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