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REHABILITATION AFTER SPINAL CORD INJURY: BECOMING A RESEARCH SUBJECT

During the course of your rehabilitation, or at a routine follow-up visit with your doctor, you may be asked to participate in a research study on some aspect of rehabilitation. How can you decide whether or not to volunteer to be a research subject? This is a highly personal decision.
One consideration is whether the research has scientific merit. Any study that is performed in a reputable research institution must be reviewed and approved by the Institutional Review Board (IRB) for human subjects’ research. This board consists of a group of physicians and other clinicians from the institution and representatives of the lay public. The IRB is charged with determining whether the proposed study has scientific credibility (in other words, is relevant and well-designed) and whether the ratio of potential risks to potential benefits is acceptable (relatively small risk to individual subjects and a relatively good chance that the drug or technology will prove beneficial for a particular condition).
All studies involving medication, surgery, or any significant risk require a written document that explains the rationale, the risks, and the expected benefits of the study to potential subjects. For an approved study, you will be asked to review and sign this document, called an Informed Consent. If you are not offered such a document, be wary about participating in the study. You may not be adequately informed or protected against potential harm. If a study has not been approved in writing by the applicable IRB, you would be unwise to participate.
Another consideration in deciding whether to participate in a study is whether it could have direct benefit for you. Some research studies must involve teaching you a new skill (for example, relaxation training) or providing a medication with the potential to alleviate pain or spasticity. Other studies may have the potential for helping others in the future, but no possibility of an immediate benefit to you as a subject. You should clearly understand the potential for direct benefit or not, and this may be an important factor in your decision to participate. Even with an IRB-approved study, it is wise to check with your own physician before volunteering.
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CHANGING THE HORMONE BALANCE BY HAVING TABLETS OR INJECTIONS – CORTICOSTEROIDS FOR CANCER SYMPTOMS

In the types of cancer listed above, corticosteroids produce their benefits by acting against the cancer itself. Corticosteroids can also produce benefits in these and other types of cancer indirectly by acting on a complication of the cancer rather than the cancer itself. There are certain symptoms of cancer that can be controlled temporarily by corticosteroids, regardless of whether or not the cancer itself is sensitive to these hormones.
For example, corticosteroids can temporarily relieve the symptoms of cancer in the brain — headache, nausea and vomiting, drowsiness and blurred vision. They relieve these symptoms by reducing the swelling and pressure around the brain cancer, not by shrinking the cancer itself. By the same means, that is, reducing the swelling around it but not the size of the cancer itself, they can also temporarily improve breathing due to pressure on the wind pipe, congestion due to pressure on blood vessels, or numbness and paralysis of the legs due to pressure on the spinal cord.
Corticosteroids can also control symptoms of excessive calcium in the blood—nausea, vomiting, thirst and the production of very large amounts of urine. They do this simply by lowering the calcium level, not by acting on the cancer. They can also improve energy and appetite, again without having any effect on the cancer itself. Fever is another symptom that can be relieved by these hormones. Corticosteroids can also be used to treat a certain type of anaemia which is caused by some types of cancer. Anaemia due to antibodies against red blood cells (haemolytic anaemias) can often be corrected by corticosteroid treatment.
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REDUCING YOUR RISK OF CORONARY ARTERY DISEASE: IMPROVING YOUR ACTIVITY LEVEL – WARM UP BEFORE EXERCISING – THREE IMPORTANT WARM-UP EXERCISES

Left, Calf stretch. Starting position: Stand an arm’s length away from a wall and rest your forearms on the wall with your forehead on the back of your hands. Point your toes straight ahead. Bend your right knee and bring it toward the wall. Keep your left leg straight with the heel on the floor. Movement: Slowly move your hips forward, keeping your back straight until you feel a stretch in your left calf. Hold this position for 30 seconds and then repeat with the other leg.
Middle, Thigh stretch. Starting position: Stand and place your right hand on a wall or a solid piece of furniture to aid in balance. Reach behind you and grasp your left foot or ankle from the outside with your left hand. Movement: Slowly pull your left foot toward your seat until you feel muscles stretch in the front of your thigh. Hold this position for 30 seconds. Then repeat it with your right leg (and right hand). If you cannot reach your foot or ankle, grasp the hem of your pants.
Right, Hamstring stretch. Starting position: Sit on the floor with your left leg extended straight forward and your toes pointing toward the ceiling. Bend your right knee and place the sole of your right foot on your inner left thigh. Movement: Bend forward at the waist and slowly move both hands down your left leg until you feel a stretch in the back of your left thigh. Hold the position for 30 seconds. Repeat, using your right leg.
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EAT YOUR WAY TO HEALTHY BONES: ARE YOU AN APPLE OR A PEAR?

A pear-shaped figure (hips wider than waist) offers health benefits compared to an apple shape (waist greater than hips), which has been associated with higher rates of high blood pressure, heart disease, stroke, and type II diabetes. Abdominal fat usually indicates more fat around the internal organs, which is part of the problem. There’s also apparently a connection to higher insulin levels and poor carbohydrate metabolism (due at least in part to too many simple carbohydrates in the diet). The increase in Cortisol and other stress hormones that results is what leads to the chronic health problems mentioned above—and, in all likelihood, to low bone density as well.
Beyond glancing in the mirror to see your general shape, the best guide to where you fall is your waist-to-hip ratio, which you find by dividing your waist measurement by your hip measurement. (Take the measurements a few times, and average them, to ensure accuracy—tape measures are very fickle.) To be a “pear,” the number should be .8 or less for women and up to .9 or 1.0 for men. Anything higher makes you an apple.
If you find you have an apple shape, you should cut back on sugar and carbohydrates to protect your health. When you do, you’ll also probably lose weight and move closer to being a pear. If you need more motivation to make the change, get a fasting blood sugar level and a fasting insulin level, then a “two-hour postprandial” sugar and insulin test—your numbers after drinking a sugary drink your doctor prescribes—to see how your body handles sugar (a simple carbohydrate). Anything up to 22 is considered normal according to conventional wisdom, but issues surrounding carbohydrate metabolism are generally underrecognized, and I think you should be concerned about anything over 14 (or even a 9 or 10 fasting). Higher numbers are considered prediabetic.
The pear shape is more common in women, thanks to the wider hips childbearing requires. A pear can have just as much body fat as an apple, but the distribution lower on the body is not as dangerous as right around the middle (the spare-tire look).
Some women don’t fall clearly into one category or the other—big thighs, big tush, big stomach. If that’s you, I’d recommend playing it safe, and considering yourself open to the hazards of the apple shape and taking action accordingly.
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COPING WITH SEIZURES AND EPILEPSY: RECURRENT TONIC-CLONIC SEIZURES: EPILEPSY

If seizures do recur a parent may use different coping mechanisms than a child. You have already been through the initial shock of seeing tonic-clonic shaking. You have probably come to terms with your initial anxiety. Perhaps you know what to do this second time and are less frightened than at first. But you may be discouraged. Your hopes that a seizure would not recur have been dashed. What is worse, your physician has now used the word “epilepsy.” Although epilepsy simply means recurrent seizures, the term carries yet a lot of baggage—myths, mystiques, and prejudices, as we have discussed earlier in this book.
When many people think of epilepsy, they think of the child who is severely handicapped by continuing seizures. Yet they are a small subgroup of children with epilepsy. The largest group are those with “benign epilepsy of childhood,” which seems to be outgrown, and a third group has seizures that can be controlled with medicines and that also are, often, outgrown. For most children (eight out of ten) with epilepsy, seizures can be controlled—yes, completely controlled. When a child’s epilepsy is under control, it shouldn’t significantly alter his life or yours. The myths are wrong!
For one in five children with epilepsy, however, seizures may be difficult to control. Control will require trying out different medications, coping with their side effects, and perhaps even surgery. Your life and your child’s life are obviously going to change in significant ways.
Which group will your child fit into? After just a second, or even after a third tonic-clonic seizure, it may be difficult to tell.
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LIVING WITH DIABETES: TRAVEL, PARTIES AND DATES

Can you travel if you have diabetes? Certainly. Just make sure you take adequate supplies of insulin, syringes, testing materials, and any other equipment you need. Modern insulin preparations will keep well at room temperature for a month or more, though they should be protected from extremes of heat and cold. (Never ship insulin supplies in the baggage compartment of an airplane, which may become boiling hot or freezing cold.)
If you plan to visit a foreign country, know how to say important phrases like “I have diabetes” and “I need a doctor” in the language of the land, even if you can’t say anything else. Another good precaution is to take along a doctor’s note stating that you have diabetes and must carry injection equipment to treat your condition—otherwise you might be suspected of being a drug addict or dealer and wind up in jail.
The diabetes routines can complicate a social life. Sticking to a strict diet can be hard, especially when you are at a party or on a date. The insulin injections pose additional problems, since the timing of your next shot may be awkward, and you can’t miss or even delay a meal.
There are ways of getting around such problems gracefully. For instance, if you know that there will be a long wait for dinner, you can take a little snack beforehand to keep your insulin satisfied. (Be sure to deduct the calories from your meal later.) To avoid overeating without hurting the cook’s feelings, eat at least a little of a special dish and say something complimentary like “I really wish I could eat more.”
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MANAGING CANCER RISKS

Cancer is no longer an automatic death sentence. Oncologists continually increase our chances of surviving cancer with new and improved medical care as well as better early detection tests. But we each hold the key to fulfilling our own hopes by doing what we can to prevent cancer. Regular checkups and monthly self-exams improve the odds of survival by providing early diagnosis. Proper diet, regular exercise, and attempts to stay clear of carcinogens help improve the odds of avoiding cancer.
Making personal choices
- Stop smoking. Smoking accounts for about 30 percent of all cancer deaths and 90 percent of all lung cancer deaths. Those who smoke two or more packs of cigarettes a day have lung cancer mortality rates 17 to 25 times greater than those of nonsmokers.
- Avoid excessive sunlight. Almost 600,000 cases of non-melanoma skin cancer diagnosed each year in the United States are considered to be sun related.
- Avoid excessive alcohol consumption. Oral cancer and cancers of the larynx, throat, esophagus, breast, and liver occur more frequently among heavy drinkers of alcohol.
- Do not use smokeless tobacco. Use of chewing tobacco or snuff increases risk for cancer of the mouth, larynx, throat, and esophagus and is highly habit forming.
- Properly monitor estrogen use. Estrogen treatment to control menopausal symptoms may increase risk for endometrial cancer. While estrogen therapy does seem to lower women’s risk for heart disease and osteoporosis, it should not be undertaken without careful discussion between a woman and her physician.
- Avoid occupational exposures to carcinogens. Exposure to several different industrial agents increases risk for various cancers. Risk from asbestos is greatly increased when combined with cigarette smoking.
- Avoid obesity. Risk for colon, breast, ovarian, endometrial and uterine cancers increases in obese people.
- Eat your fruits and vegetables. Eat at least five serving fruits and vegetables every day to reduce your risk.
- Cut back on fats. Reduce fat consumption, especially rated fats and red meats, to reduce risk for colon, bi prostate, pancreatic, and ovarian cancers.
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WHY YOU CAN’T STAY AWAKE: SNORING

Snoring, of course, is the most prominent symptom of sleep apnea. I want to make it clear, however, that snoring and OSA are not synonymous. While virtually all OSA patients snore— long and loud—not everyone who snores has a clinically significant OSA problem.
People who snore have been the targets of humor, and anger, for centuries. And no wonder: The Guinness Book of World Records has clocked the loudest snore at 87.5 decibels—equivalent to the noise of a bus’s diesel engine heard from the rear seat or the sound of a pneumatic drill as it breaks up concrete. Not infrequently snoring is cited as one reason a married couple seeks a divorce.
Among people aged thirty to thirty-five, 20 percent of men but only 5 percent of women snore. As age increases, however, so does the incidence of snoring. Half of the population over the age. of forty snores. Most of this group is still men, but by age sixty the split is closer to 60-40. By age sixty-five the division is roughly even, with as many as 6 to 7 million elderly Americans snoring away through the night. Science has proposed no sound theory (excuse the pun) to explain why there is a difference in the incidence of snoring between younger men and women.

HIV: PROBLEMS OF THE DIGESTIVE SYSTEM-LOSS OF APPETITE

Loss of appetite has several possible causes. One cause can be HIV itself, which somehow causes an altered sense of taste: food just doesn’t seem to taste good. Other causes are depression, drugs, opportunistic infections, or infections of the mouth.
Treatment depends on the exact cause. When the cause is HIV and an altered sense of taste, the best treatment is to learn your preferences and eat accordingly. A person with an altered sense of taste often has a particular problem with protein-rich foods, particularly with red meat. The solution in that case is to find other sources of protein: poultry, fish, eggs, and cheese are all excellent sources of protein. So are dried beans and rice. A person with an altered sense of taste also seems to have the best appetite in the morning: try to eat large, nutritious breakfasts. If you have a preference for foods at different temperatures, indulge your preference. Try eating foods that smell good: the senses of smell and taste are closely connected. Try adding herbs, bacon, garlic, olives, cheese—anything that livens up the flavor of the food and “doesn’t disagree with you.
Some opportunistic infections of the mouth (thrush, herpes, aphthous ulcers, and Kaposi’s sarcoma), discussed in the preceding section, cause pain with eating. When eating hurts, people often lose their appetites. In this case, avoid foods that cause pain. Stay away from salt and seasoned salts; from hot spices like pepper, chili pepper, and paprika; and from acidic foods like vinegar, citrus fruits and juices, tomatoes, pineapple, and pickles. Try food at moderate or cool temperatures. Try foods that are soft and won’t irritate the mouth: mild cheeses, cottage cheese, yogurt, cooked eggs, cream soups, ice cream, puddings, popsicles, ground meats, baked fish, bread, noodles and pastas, and cooked or canned fruits.
Another cause of appetite loss is the emotional reaction to having HIV infection. At times, people become anxious or depressed and lose interest in eating. Both anxiety and depression can occur at any stage of this infection, but they are especially common at the time the person first learns of a positive blood test, and at the time of the first opportunistic infection. One way to fight this might be to make eating a special event: put on some music, prepare the food so it looks attractive, think of a meal as a break from your worries, relax, take your time with the meal. Eat your favorite foods. Keep snacks around: ice cream, cheeses, canned fruit, crackers, peanut butter. Small meals are less filling; try several small meals a day. Eating is often a social event, and many people enjoy food best in someone else’s company.
Still another cause of loss of appetite is fatigue: people are simply too tired to eat. Fatigue can also interfere with their ability to prepare a meal if they live alone. If you eat less because you are tired, be careful to eat meals especially high in calories and protein, so that even if you eat less, you get the same level of nutrition. Try milkshakes, dried fruits, peanut butter, ice cream, cheese, sour cream, hot chocolate, custard, cream soups, scrambled eggs or an omelet with cream cheese, noodles with cheese and cream. Preparing main courses that are high in protein and calories and then freezing them also saves energy: spaghetti sauce, chili, pot roasts, beef or chicken or lamb stews, and soups all taste good made in large amounts, frozen, and reheated; they freeze well. High-protein main courses are also sold prepared and frozen in grocery stores. In either case, frozen food can be reheated on the stove or in a microwave oven. Keep
ready-to-eat and nutritious snacks on hand. Many communities also have organizations that will prepare or deliver meals.
Drugs can also be the cause of an altered appetite. Virtually any of the drugs listed below as causes of nausea and vomiting can reduce the appetite, and the list is certainly incomplete.
In general, the treatment for appetite loss depends on the situation: if you have a sore mouth, get treatment for the sores; if drugs are responsible, consider alternatives to those drugs; tailor meals to your own tastes; and accommodate meals to fatigue. When appetite loss is temporary, try to get in as many calories as possible without regard to the nutritional value: you simply are not going to become malnourished in a few days. Try fortifying foods with oil, butter, mayonnaise, a little dried milk, grated cheese, cream. Try making shakes out of combinations of different foods: milk, ice cream, instant breakfast, buttermilk, bananas or strawberries or peaches or apricots or pears, fruit juice, yogurt, honey, cocoa, chocolate syrup, peach or pear or apricot nectars, ginger ale, brown sugar.
Most important is drinking enough fluids: healthy people can survive over one hundred days without food, but no one can survive more than a few days without fluid. Drink fluids that are high in calories and protein—milk, shakes—instead of diet drinks, coffee, or tea. Routinely stir some dried milk into your milk.
If people with HIV infection eat poorly for weeks or months, a physician should be consulted. In some cases, the physician may prescribe an appetite stimulant such as Megace. In extreme cases, the physician may use a feeding tube—a tube placed through the mouth and into the
stomach, or through the abdomen and directly into the stomach—so nutrition is maintained despite the inability to eat. An alternative, discussed in a later section on wasting, is to feed people intravenously.
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SKIN CARE: THE HISTORY OF COSMETICS

Cosmetics have been used for over 4000 years. People have always been conscious of their appearance and have always devised ways to ‘improve’ upon it. Rouge was used as far back as 1500 ВС to colour the lips and cheeks, and the ancient Egyptians used henna for colouring the hair and eye pencils to highlight the eyes. The Greeks preferred blond hair and used saffron to lighten the hair pigment. They also used lanolin as a moisturizer.
Around AD 100 the Romans felt that a white complexion was the most beautiful. They took milk baths and used powdered chalk to make the complexion paler. Soon after, lead and arsenic powders were introduced to whiten the skin. These ‘cosmetics’ led to many deaths due to poisoning. During the Elizabethan era white lead powders again became popular and again many deaths occurred in the name of beauty.
In 1938 major regulations were brought to bear on the cosmetic industry as a result of multiple adverse reactions. Apart from the fatal lead powders, coal tar dyes, which were used for colouring the hair, caused blindness. Cosmetic authorities deemed that cosmetics were intended to beautify or cleanse the body, but should not alter the biological activity or structure of the skin. The Cosmetic and Toiletries Association took it upon itself to regulate cosmetic products in order to minimize side effects, however, as mentioned, the Federal Government has now passed legislation to regulate unsubstantiated therapeutic claims. Cosmetic companies are now also required to list all the ingredients in their products on the labels.
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