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Unpicking this quoted statement brings sharply into An individualized approach is demanded discount kamagra soft 100 mg with mastercard, since two focus the danger of relying on such evidence cheap kamagra soft 100 mg without a prescription. These would benefit from quite different thera- of causes purchase kamagra soft 100mg with amex, ranging from biomechanical to peutic and rehabilitation strategies – one possibly pathological, psychological and functional requiring deactivation of myofascial trigger points features, possibly involving intervertebral followed by postural re-education, the other calling disc problems, facet joint dysfunction, for joint mobilization achieved by high velocity thrust hypermobility, muscular and/or ligamentous methodology, supported by appropriate soft tissue imbalances, sacroiliac restrictions, trigger normalization possibly involving stretching and/or points and disturbed emotion/somatization core stability training. These variables make use of the word ‘massage’ manipulative attention, at precisely the same potentially uninformative, since that word covers spinal region. Both balancing, muscle energy and strain/ approaches produced good to excellent results; counterstrain techniques (Yates et al 2002). As however, since the reader is left with the will become clearer to those unfamiliar with mystery as to what ‘gold standard physical these methods (see the descriptions later in this therapy’ is, and just how breathing chapter), there can hardly be more diverse rehabilitation is achieved, the chances of methods for modifying tissue status, or reproducing the results remains questionable. However, individual, appears to offer clear benefit in a range of it is a criticism of reviewers who attempt to back and other problems. In these, the It is also important that we regularly refer to the elements of treatment used to help the patient underlying principles – as outlined in Chapter 1 – that are not tested – only the intervention of the inform clinical decision-making in naturopathic medi- discipline. This allows a greater opportunity cine in general and naturopathic physical medicine in for a non-linear dynamic interplay between particular. Chapter 7 • Modalities, Methods and Techniques 201 Tension Compression Rotation Bending Shearing Figure 7. Reproduced with permission from Lederman (1997a) Although there exist a wide range of variations of binations of these), the amount of time involved (con- manual techniques, each of these is made up of a tinuous, rhythmic, brief, lengthy, etc. Identify local and general imbalances (posture, joints this produces extension, flexion and side- patterns of use, local dysfunction). Identify, relax and stretch overactive, tight • Shearing loading: translation (shear) movements muscles. Re-educate movement patterns (including induce joint play and articulation postural imbalances) on a reflex, subcortical • Combined loading: incorporation of basis. A variety of soft tissue disengagement from the barrier, or alternating com- normalization methods are incorporated into this 202 Naturopathic Physical Medicine musculoskeletal dysfunction in general, can be under- Box 7. This ‘integrative mechanistic’ model that Massage and soft tissue manipulation methods that addresses behavioral and structural aspects of dys- involve kneading, introduce torsional load forces. As function, as well as pain psychology, postural control tissues are kneaded, soft tissues are lifted, rolled and and neuroplasticity, strengthens the rationale for squeezed, involving compressive, bending, shearing multidisciplinary treatment protocols. This may have as an objective the include direct biomechanical tissue approaches, stretching of tissues or encouragement of fluid movement re-education, psychosocial interventions movement within the tissues. Friction occurs between the sliding structures, potentially generating General health applications of physiological change by increasing connective tissue naturopathic physical medicine methods pliability (hysteresis; Norkin & Levangie 1992), as well A defining feature of osteopathic and chiropractic as possibly inducing a mild therapeutic inflammatory methodology for well over 100 years has been that response (Mock 1997). This is equally true of performed on a local area, usually across the line of naturopathic medicine, which has, in regard to manual fiber direction. Friction will increase blood flow to the area (and may induce edema if appropriate measures methods, been greatly influenced by both osteopathic are not taken to obviate this). Note: Whether friction or compression is employed in In this Position Paper the following key points are attempting to deactivate myofascial trigger points, a made: rapid inflow of oxygenated blood to the tissues occurs 1. The therapeutic benefits that methods and therapies described as follow may variously involve reduction of ischemia, as well as release of local endorphins, and possibly naturopathic physical medicine in a safe, enkephalins (Baldry 1993, Kiser et al 1983), and also a healthful and clinically integrated manner degree of mechanoreceptor stimulation affecting pain consistent with naturopathic principles and transmission (Melzack & Wall 1994). Naturopathic manipulative treatment as a therefore follows in response to simple applications of traditional, integral and essential part of focused compression or repetitive shear loading. Naturopathic medical educational programs model in most schools of manual medicine educate and train naturopathic physicians to (DiGiovanna & Schiowitz 1991, Greenman 1989). Other proposed educate and train naturopathic physicians to models for effective management of musculoskeletal safely and effectively utilize physiotherapeutic dysfunction incorporate somatic as well as behavioral medical devices, modalities, procedures and features. Langevin & Sherman (2006) have described injection therapies a pathophysiological model in which a broader – and 5. Reproduced with permission from Langevin & Sherman (2006) integration, functional training and therapeutic Whether applying pressure to help deactivate a trigger exercise programs point, or to take out slack prior to application of a high 6. Naturopathic physical medicine continues to velocity thrust technique, or in mobilizing and articu- evolve and integrate new therapeutic methods lating joints, or in use of basic massage methods, load consistent with naturopathic principles and is a feature – indeed, these treatment methods are philosophy. Examples of manipulative treatment where benefit Load is also a key word (see Chapter 2) used to has resulted in treatment of pathological conditions describe stressors (of all sorts, not just biomechanical (see separate list of beneficial massage influences later ones). All forms of load create adaptive demands, and In Chapter 10 a number of the conditions listed in when prolonged or repetitive this becomes a feature Box 7. These thoughts highlight the observation that all Therapy as a form of stress forms of therapy, manual or otherwise – involving The use of the word ‘load’ has been prominent in anything from the insertion of an acupuncture needle, these descriptions of manual methods of treatment. Placebo interventions Structural abnormalities Fear, Distress or injury Movement Pain Scoliosis Spondylolisthesis Acute ‘back sprain’ Psychosocial factors Disc herniation Pathogenic Pain behavior mechanism Job dissatisfaction Connective Neuroplasticity Genetic tissue plasticity predisposition to connective Genetic differences tissue injury in sensory proccesing Direct tissue mechanical stimulus Acupuncture Massage Yoga Manipulation B Figure 7. Based on physical examination criteria in the tion of subgroups of patients with low back pain who peer-reviewed literature, patients in the respond favorably to particular therapeutic interven- Classification group were placed into one of tions has been (and continues to be) an important four categories requiring: objective of clinical research (Borkan et al 1998). Of the many classification • stabilization approaches that have been developed, those reported • traction. The model reported by Delitto et al (1995) has been shown to be a clinically useful tool. The symmetry and standing and primary goal of treatment during this stage is seated flexion tests suggested to be pain modulation. Lumbar pattern Unilateral symptoms without • Stage 2 patients can accomplish basic signs of nerve root functions, but are limited in their activities of compression; lumbar side- daily living. The objective of treatment hypomobility at this stage is considered to be to modulate pain Adapted from Fritz et al (2003). A negative Gaenslen sign (pain provocation test 4-week mark, demonstrating a statistically significant with the patient supine, one hip taken into full difference (p = 0. The test is positive if pain is reported in Clinical prediction the sacroiliac joint (and/or thigh) on the side of the hyperextended leg. For many of these the answer may lie • Symptoms not distal to the knee in a quite different form of categorization, based on • At least one hip with internal rotation greater the answer to a simple question: Do the symptoms than 35° change for the better based on positioning? Centralization/peripheralization It is suggested that the more of these feature that are present, the greater the chance of success with manip- categorization ulation (Box 7. McKenzie (1981) has identified three major groups of Flynn et al suggest that, of these features, the most back pain patients. To understand the differences we significant is ‘duration of symptoms less than 16 need to look at the processes of centralization and days’. These are: extending the low back, or flexing it) that result in distal symptoms reducing in that limb, i. Longer than 3 weeks’ duration of symptoms becoming more proximal, even temporarily, 2. No hypomobility on spinous process springing The importance clinically is that anything that 4. Reduced discrepancy in left-to-right hip exercise, change of position or manual treatment – is medial rotation contraindicated as it will slow down recovery, and may significantly increase symptoms. In such individuals it is considered that posteroanterior spring test (hypomobility + pain) normal tissue is being strained by prolonged inappropriate posture. The recommendation is that exercise, repetitive Biopsychosocial factors: a broader movement (even if briefly uncomfortable) and classification approach manual treatment should aim to reduce O’Sullivan (2005) has produced a much wider model fibrosis and increase elasticity. This helps to illustrate commonly restricted in one or more directions, why taking a generic rather than a cookbook approach with local pain being felt at the end of range. Exercise, factor containing a number of elements and variables, repetitive movement and treatment should aim all of which interact (Fig. In this last Tight/loose indicators category, if there are no positions, movements or treatments that encourage centralization, the When evaluating the status of joints and soft tissues prognosis is poor, with poor responses likely to there should be a sense of the degrees of tension and almost all therapeutic interventions (Aina et al relaxation (the shorthand words for these two states 2004). The tissues provide the palpat- ing hands or fingers with a sense of these states which can be interpreted to reflect the tissue’s current degree Using directional preference in of activity, comfort or distress. If form closure is a feature, there should also be A useful example of ‘tight/loose’ features can be every effort to restore normal balance to the soft observed in sacroiliac dysfunction. These factors closure tests should be conducted (supine and prone) might actually be offering the body an effective means in which these features are evaluated (Lee 1997). If problems involving Treatment of these features (tight hamstrings form closure are confirmed as a major feature, then an housing active trigger points) would be unlikely to Chapter 7 • Modalities, Methods and Techniques 209 Latissimus dorsi Longissimus lumborum Iliocostalis lumborum Lumbar intermuscular aponeurosis Iliocostalis Erector spinae Multifidus Gluteus Lumbodorsal thoracis maximus aponeurosis fascia Sacrotuberous Biceps femoris Sacrotuberous Biceps femoris A Figure 7. B Enlarged view of the lumbar spine area showing the link between biceps femoris, the lumbar intermuscular aponeurosis, longissimus lumborum, iliocostalis lumborum and multifidus. Reproduced with permission from Vleeming et al (1997) have a beneficial effect until the actual stability issues variations of hydrotherapeutic and/or electrothera- of the joint are addressed – and indeed stretching the peutic attention. And apart from possible pathological changes (disc Making choices herniation, arthritis, inflammation as examples), there Depending on which elements from this selection of may also be hyper- and hypomobility conditions, staging, categorizations, identified imbalances (tight/ fibrotic changes, active myofascial trigger points, loose) and biopsychosocial factors are operating, as (core) muscular weakness, modified motor control, well as the degree of chronicity and other features, altered muscular recruitment patterns, breathing therapeutic choices might include application to local pattern and postural disorders. Level of normal Along with the classification models outlined above, resistance each of these variables can offer clues as to which of the range of potential treatment and/or rehabilitation Alarm Stage of approaches might be the most likely to enhance func- response exhaustion tionality, without undue side-effects. This defines what Selye termed the stage of To simplify decision-making it is useful to be reminded exhaustion, or collapse, where frank disease and death of the message (see Chapter 1) from which clinical follow in an inexorable progression as self-regulating decision-making in care of all health problems can mechanisms fail (see Fig. However, where Examples include the following: degenerative processes have advanced to a certain stage, recovery may be impossible, although stabiliza- • As we have seen in the discussion above, using tion and modulation of symptoms may remain a the concepts of categorization it is possible, in possibility. Treatment should offer support to the Pointers to clinical choices are not always as clear as processes involved, although recovery without these two examples, in which circumstances the gath- any therapeutic input is probable. Since naturopathic medicine embraces self-regulation Self-regulation needs help to remove obstacles as the key element in recovery or health improve- to recovery and to enhance functionality. There may be This is therefore a fundamentally naturopathic means value in a more deliberate consideration of such of treatment. Evaluation of the various modalities Selye’s general adaptation syndrome (see Chapters 1 and 2) describes a process, following the initial alarm The naturopathic dimension stage of adaptation, that continues until adaptation For clarity in making therapeutic choices we should potential is exhausted. One of the limiting factors in refer back to the summary towards the end of Chapter Chapter 7 • Modalities, Methods and Techniques 211 Box 7.

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Participant got some facilities from Rehabilitation Centre buy kamagra soft 100 mg visa, Musculoskeletal buy kamagra soft 100 mg amex, Stoke-on-Trent discount kamagra soft 100 mg free shipping, United garment factories. Providing with lift facilities, overtime facilities, Kingdom, 4North Staffordshire Rehabilitation Centre, Musculoskel- enough lighting, sitting arrangement, sick leave permission, shown etal and Rheumatology, Stoke-on-Trent, United Kingdom sympathy, payment timely and easier job is given. Maximum worker opinion for modify culoskeletal disease, avoiding inappropriate referrals to expensive their workplace. Family Physicians and Physiotherapists use a national electronic referral system for patients >18 years with no red fags or features of infammatory arthritis. The novel nature of strengthen the process of developing strategic guidance for service our service comes from the multidisciplinary nature of its work- delivery and liaison with key stakeholders in Africa, by exchang- force, its engagement with patients, stake holders and its willing- ing knowledge, experience and skills and coordinating individual ness to utilise new strategies to ensure good service model provi- efforts by each country. The average number of rehabilitation physicians 1Swiss Paraplegic Centre, Acute Care and Rehabilitation, Nottwil, and therapists of each hospital was 4. Secondary rehabilitation agencies undertake the largest ment, Nottwil, Switzerland rehabilitation medicine workload of citywide, per hospital of third rehabilitation agencies undertake the largest rehabilitation medi- Introduction/Background: The admission process of patients to a cine workload. These two levels of rehabilitation agencies under- hospital is the starting point for inpatient services. In order to opti- take the workload of outpatient rehabilitation therapy and inpatient mize the quality of the health service process, one need a better un- rehabilitation therapy was 91. Conclusion: Foshan was to identify challenges and potential improvements in the admis- has build three level rehabilitation medicine care system, but the sion process of spinal cord injury patients at a specialized clinic from rehabilitation hospitals and primary medical institutions lack the the perspective of an interdisciplinary team of health profession- capacity of rehabilitation services, the indentation of rehabilitation als. Material and Methods: Semi-structured interviews with eight physicians and therapists is big. Conclusion: This study identifed fve themes of challenges Dhaka, Bangladesh and potential improvements in the admission process of spinal cord injury patients at a specialized clinic. When planning adaptions of Introduction/Background: Assistive technology is any device that is process steps in one of the areas, awareness of effects in other felds used to enhance a person’s functioning and participation (Scherer, is necessary. Occupational therapists have expertise in assessing clients important step to optimize the admission process. Managers of other hospitals can sup- been providing these services since 2008 under the Occupational plement the results of this study with their own process analyses, to Therapy Department at The Centre for the Rehabilitation of the improve their own patient admission processes. Objectives/Purposes: The assistive devices can help a person to engage in his/her regular activities where it may not be possible otherwise due to impairment or disability. De (remediation) and continuing the modifcation of the task or the 1 2 1 3 Baets , A. Patient cen- derstraeten 1Ghent University, Rehabilitation Medicine, Ghent, Belgium, tered functional assessment is completed for each patient. Conclusion: Patient Satisfaction Survey on Assistive Devices ogy, Ghent, Belgium, 3University Hospital Ghent, Department of used very effectively for the activity of daily living. The percent body fat is reduced but ticipation frequency, extent of involvement and desire for change the differences were not signifcant (p>0. Conclusion: This in- in sets of activities typical for the home, school or community novative intervention was effective in improving physical activity. It also includes an assessment of the effect It is likely that even greater effects could be achieved by improve- of environment on children’s participation. The aim of this study ments in implementation strategies, leading to higher fdelity. Information about child and family 1The Hong Kong Polytechnic University, Faculty of Health and So- demographics is assessed by a short question-naire that includes cial Sciences, Hong Kong, Hong Kong- China, 2The Hong Kong information regarding participants’ demographic, child and family Polytechnic University, Department of Applied Social Sciences, characteristics (gender, maternal and paternal level of education, Hong Kong, Hong Kong- China level of income & current employment, age of the child if/when re-ceiving diagnosis, access to intervention etc. However, the needs of Results: Participation data reported by parents are currently being the family caregivers are often being neglected. Prepara- aimed to identify the needs of a family caregiver in taking care of a tory descriptive analyses are conducted. Mate- of children with disabilities and delays in terms of 1) home, school rial and Methods: We adopted action research as our methodol- and community patterns, 2) perceived environmental supports and ogy which aimed to improve our practice through the experiment. The Chinese version of 1) Depression Anxiety participation oriented interventions. A wide range of have an increased risk for unhealthy diets, physical inactivity and needs of those family caregivers was identifed which facilitates the weight disturbances. The nutritional education is a right food choices, 942 health habits, usage of nutrition labeling and so on. Results: A total ence- Unit of Epidemiology, Chemnitz, Germany number of 37 community residences expressed an initial interest Introduction/Background: Migrants in Germany utilize rehabilita- in participation but four loss, leaving 33 residences for baseline tive services less often than the majority population, independently measurements. A total of 33 participants, 22 men and 11 women of demographic and socioeconomic factors. The program participants were signifcant reduc- explored potential barriers that migrants face in rehabilitative care, tions in the Triglyceride (p=0. Lit- J Rehabil Med Suppl 55 Poster Abstracts 275 tle is known about non-participants. Respondents were recruited ference in any of the measured parameters between the two groups. Results: Four categories of reasons could be identifed that respondents described as barriers 944 for using rehabilitative care. Third, fears and reservations concerning particular treatments/excises during rehabilitation were 1Huai’an Maternity and Children Care, Children Rehabilitation, reported, which respondents considered discomforting or cultur- Huai’an, China ally inadequate. Conclusion: Respondents expressed several reservations con- posture, causing activity limitation, attributed to non-progressive cerning rehabilitative services comprising language-, culture- and disturbances occurring in the developing fetal or infant brain. Unknown data could be available from mater- which---unlike migrant- or culture-specifc services---are able to nal questionnaire which including maternal health care and nutri- take into account the heterogeneous needs of an increasingly di- tion during pregnancy, environmental factors, delivery situation verse population. This study describes an N:M matched case-control study conducted in Huai’an, Jiangsu province, China, to investigate rela- tive epidemiologic risk factors for children cerebral palsy. An N:M matched case-control study was conducted with 114 cerebral palsy cases and 1286 non-cerebral palsy controls. Conclusion: The main risk factors Introduction/Background: Obesity and Overweight among young of cerebral palsy focus on gestation and perinatal period. The inci- women represent serious health issues with an increasing global dence rate would be lower, if we take precautions and reduce the prevalence. Both groups received instructions to fol- damage in perinatal period were early intervened mainly by our low a balanced diet throughout the course of the study. The tal barriers perceived by people living with spinal cord injury in course of the intervention was 3 months. Results: 3 months and 18 months after the intervention, the community survey of the Swiss spinal cord injury Cohort study. And the difference is signifcant for statistics ticipation was measured with the Nottwil Environmental Factors (p<0. Perceived barriers were compared across people with tal retardation and other sequelae which were caused by perinatal different demographic and lesion characteristics. Multivariable brain damage, and promote the development of movement, cogni- regression modelling applying fractional polynomials was used tive, language, social and other functions. And its mechanism may to evaluate the overall perceived impact of barriers in relation to be related to the promotion of brain development, promoting dam- demographics, spinal cord injury characteristics, and physical in- aged neuronal repair. Results: Most perceived barriers were climatic condi- tions and inaccessibility of public and private infrastructure. Older participants, those with longer time since injury and participants 946 with complete lesions indicated more problems with access. Takahashi5 land experience participation restrictions due to environmental bar- 1 2 riers; in particular women, people with non-traumatic spinal cord Hanno-Seiwa Hospital, Rehabilitation Center, Hanno, Japan, To- injury and limited physical independence. However, our convalescent rehabilitation hospital car- 1Raja Isteri Pengiran Anak Saleha Hospital, Department of Inter- ries out the travel for outpatients as recreation every year. Now we nal Medicine, Bandar Seri Begawan, Brunei report our trial of the trip carried out in Oct, 2013. Material and Methods: 13 patients, 10 patients’ family, 1 doctor, 4 nurses, 1 care Introduction/Background: Geriatric medicine is a new medical sub- worker, 8 therapists and 2 other persons participated. The gender was 4 men and 9 wom- needs of older inpatients is essential for service development and en. Material and Methods: Retrospective review of electron- tients needed assistance in ambulation and activities of daily living. Pre-admission Results: Participants stayed at a hotel with a hot spring in Nikko, function, co-morbidities and input from allied health professionals Tochigi on 2nd and 3rd, Oct 2013. Medical staffs assisted patient’s were classifed under the following categories: medical treatment, toileting in a restroom at each place. Days under other hot spring bathing and a banquet, and events on the second day teams were coded separately. Outcome measures such as length of were sightseeing and shopping in a neighboring park. Results: The karaoke which were held at a banquet deepened the friendship 76 admissions consisted of 63 patients, equal gender proportions. No accidents such as fall oc- 67% with severe functional impairment and 26% with full function. On the other hand, a mattress had to be piled up instead of a More than a third had dementia. Only one-ffth were independent bed because preliminary negotiations with hotel staffs were insuf- with mobility. Conclusion: When stroke patients want to make a trip, it is were referred for physiotherapy input, 25% occupational therapy important to secure safety. Many medical staffs who comprehend input, 60% dietetics and 30% for speech language therapist input.

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Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Detoxification and substance abuse treatment: Co- occurring medical and psychiatric conditions. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Incorporating alcohol pharmacotherapies into medical practice: A review of the literature. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Center for Tobacco Research and Intervention, University of Wisconsin Medical School. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Achievements in public health, 1900-1999: Tobacco use -- United States, 1900-1999. Substance abuse treatment for injection drug users: A strategy with many benefits. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Smoking-attributable mortality, years of potential life lost, and productivity losses: United States: 2000-2004. State Medicaid coverage for tobacco-dependence treatments --- United States, 2009. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Vital signs: Overdoses of prescription opioid pain relievers--United States, 1999-2008. Vital signs: Colorectal cancer screening, incidence, and mortality--United States, 2002-2010. Vital signs: Current cigarette smoking among adults aged =18 years --- United States, 2005--2010. Centers for Medicare and Medicaid Services, Center for Consumer Information and Insurance Oversight. Meta-analytical review of the efficacy of nicotine chewing gum in smoking treatment programs. Medical marijuana laws in 50 states: Investing the relationship between state legalization of medical marijuana and marijuana use, abuse and dependence. Developmental neurocircuitry of motivation in adolescence: A critical period of addiction vulnerability. Prevalence and comorbidity of major internalizing and externalizing problems among adolescents and adults presenting to substance abuse treatment. Self- reported alcohol and drug use in pregnant young women: A pilot study of associated factors and identification. Comparison of the Alcohol Dependence Scale and diagnostic interview schedule in homeless women. Advancing quality improvement research: Challenges and opportunities - Workshop summary. Relationships between frequency and quantity of marijuana use and last year proxy dependence among adolescents and adults in the United States. Institute on alcohol, drugs, and disability: From grassroots activity to systems changes. Chronic illness histories of adults entering treatment for co-occurring substance abuse and other mental health disorders. Twelve-step attendance trajectories over 7 years among adolescents entering substance use treatment in an integrated health plan. 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Working with and through felt expe- rience in the present moment order kamagra soft 100 mg without a prescription, the method then seeks Further reading to provide the missing experience and heal the core 1 cheap kamagra soft 100 mg with visa. Quest Books kamagra soft 100 mg visa, At the core of the Hakomi method can be found the Wheaton, Illinois guiding principles of mindfulness, non-violence, 2. LifeRhythm, Mendocino, ness – a relaxed and alert, self-observing state of con- California sciousness – is employed by the therapist and the 3. Levine P, Frederick A 1997 Waking the tiger: client in order to study present experience as it unfolds healing trauma: the innate capacity to in the therapeutic session. North client to stay with experience as it deepens into core Atlantic Books, Berkeley, California organizing material and ultimately bring this material into consciousness. Spondylotherapy (percussion techniques) The principle of non-violence promotes working cooperatively with the system that is being studied. Working Percussion methods have obvious diagnostic/assess- in alignment with this principle, the Hakomi therapist ment value, where they can help to provide informa- views the client’s resistance as important and works tion in regard, for example, to localization of diseased to support it, rather than break through it or overcome lung tissue, such as pleural effusion = stony dull; it. Not only are defenses valued as an important pro- atelectasis or consolidation = dull; pneumothorax = tective function, they are viewed as a significant and hyper-resonant; collapsed lung = dull, etc. Evi- percussion, particularly when applied spinally (spon- dence of core beliefs (how one views oneself and the dylotherapy), is to stimulate visceral organs via the world) exists both in the mind and the body; these spinal pathways, or to influence the nervous system beliefs not only determine thinking and behavior pat- locally or more generally. In Hakomi, the therapist and client are continually Naturopathy, states: ‘Spondylotherapy is a method of working the mind–body interface. This principle assumes that the client’s process will In addition, experts in the field of myofascial trigger unfold precisely according to the needs of the system, points, Travell & Simons (1992a), suggest that these and the therapist’s role is to facilitate and support that can be treated effectively using a series of percussive process. Health of the human system depends upon the health Methodology of the communication between the parts of that To treat a trigger point using percussion: system. The unity principle also recognizes the inter- dependence of human beings and, as such, assumes 1. The muscle is lengthened to the point of onset mutuality in the therapeutic relationship. The clinician uses a hard rubber mallet, or Janse et al (1947) provide a variation on this approach, reflex hammer, to hit the trigger point at as follows: exactly the same place, approximately 10 times. As to location of application, this team of authors – The trigger points in muscles that they list as bene- who comprised two chiropractors and an osteo- fiting most from percussion techniques include path (Wells) – note that percussion is most effective quadratus lumborum (Travell & Simons 1992b), when applied ‘to the area marking the junction of brachioradialis, long finger extensors and peroneus the transverse processes and the body of the longus and brevis. One or two percussive repetitions braced by the thumb and index finger are applied per second. Treatment The degree of force applied during percussion is also would be applied only if the area is painful to palpat- of three types: ing pressure. A mild ‘flare up’ of symptoms and increased sensitiv- ity in the area treated would normally indicate that Treatment may be offered daily, on alternate days or the desired degree of stimulation had been achieved. B Percussion technique (spondylotherapy) for reflexive effects or treatment of trigger points (slow percussion). Reproduced with permission from Chaitow (2001) Research was carried out on the cerebral This approach is, therefore, not one that produces haemodynamics of patients with cerebral birth injury instant results, but that influences and gradually har- before and after acupressure (percussion as well as nesses the potential for recovery and improvement compression techniques) therapy. Chapter 7 • Modalities, Methods and Techniques 269 • Tuberculosis • Malignant tumors • Hemorrhagic disease • Skin disease in area to be treated • Poor constitutional states such as malnutrition or asthenia Naturopathic perspectives The use of percussion to stimulate or decrease visceral activity as part of a therapeutic intervention, where such outcomes seem to offer benefit to self-regulation, fits with naturopathic principles. He gives the example motion was performed 10 to 15 times during each of a muscle spasm that can be released by placing the session to each of the following muscles in order: muscle in a position of functional rest followed by coccygeus, iliococcygeus, pubococcygeus, and application of sustained pressure. At the practitioner’s discretion, 10 On the other hand, neurostimulation is most easily to 15 seconds of ischemic compression was applied to achieved by deep and rapid short-duration percus- trigger points. A typical treatment lasted fewer than 5 sion at a rate of approximately 2 per second – inter- minutes. Each massage was scheduled at least 2 days spersed with brief rest periods as suggested by Janse apart to allow for any inflammation or discomfort from et al (above). Cautions The researchers in this study noted that: • Acute disease The technique is easy to learn and carries minimal • Severe heart disease risk. Nurses, or even the patient’s partner, can learn 270 Naturopathic Physical Medicine and apply the technique, making this therapy Safety accessible to patients unable to see a physical There are clear issues relating to the potential for inap- therapist. Licensing pelvic floor muscle compression, stretching, and right and scope of practice issues are also of paramount angle ‘strumming’, with the simultaneous use of importance. The treatment itself, if protocols are fol- external muscle stretching or heat application to facili- lowed, is relatively painless, commonly successful in tate greater muscle relaxation. This was followed by mitigating distressing symptoms, and carries little or transvaginal or transrectal posterior traction with an no risk. Cognitive behavioral therapy, used as part of manual therapy, is advocated by some researchers (McCracken & Turk 2002): Our premise is that, in addition to releasing painful myofascial TrPs, the patient must supply the central nervous system with new information or awareness to progressively quiet the pelvic floor. Surgery and a variety of electrical approaches (Caraballoa et al 2001) are used in treating such conditions. Regrettably, since most such problems appear to A involve excessive tone of the pelvic floor muscles, many such patients are referred for Kegel-type toning exercise, with predictably negative results. A question also needs to be asked regarding inap- propriate use of core-stability (Pilates) type exercises for such patients, who above all need to reduce tone rather than increase it. B Physiological effects Removal of sensitized, local, pain-generating areas (trigger points) and normalization of high-tone muscles appears to allow normal function to be restored in many patients with apparently intractable Figure 7. A coccyx with two segments is shown here but coccyges can be in one, two, three or Cautions four segments. Redrawn from Maigne & • Active inflammatory conditions or actual Chatellier (2001) pathology involving the tissues of the region. Chapter 7 • Modalities, Methods and Techniques 271 1 2 A 3 B 6 4 C E D 5 Figure 7. Muscles: A, coccygeus; B, iliococcygeus; C, pubococcygeus; D, puborectalis; E, obturatorius internus. Redrawn from Pool-Goudzwaard et al (2004) • Clearly since this approach is aimed at therefore orients the anterior lesser curve of the reducing tone it will be of little value in stomach to the right and the greater posterior curva- conditions associated with low-tone pelvic ture to the left. The pylorus is therefore rotated supe- floor musculature – where toning exercises are riorly and the cardia inferiorly. Indirect approaches The motility cycle is divided by Barral & Mercier Researchers such as the French osteopaths Barral & into two phases which are termed inspir and expir, that Mercier (1988) and the British osteopath Caroline are unrelated to the breathing cycle. Stone (1999) have documented the existence – in Inspir describes the inherent motion and expir the health – of symmetry in inherent axes of rotation return to neutral afterwards (7–8 cycles per minute). With An example of this is that the liver’s inherent inspir disease, these motions are claimed to be at variance phase involves rotation posterosuperiorly (its mobil- with one another. Additionally, there exists an inher- feel the expir phase (although inspir is more ‘active’, ent organ motility, possibly relating to embryological as there is less resistance to it), being a return to development phases. As an example, Barral & Mercier describe how, Just as joints have articulations, so do viscera. The transverse rotation cavity and pericardium in the heart) as well as a system 272 Naturopathic Physical Medicine of attachments (including ligaments, intercavity pres- place the thumb of the left hand alongside the nails of sure, various folds of peritoneal structures forming the right fingers. Unlike most simultaneously, the left hand thumb being twisted joints, few muscular forces directly move organs. This achieves an appreciable breaking-up, Visceral biomechanics relate to the movements that the without trauma or hurt to the patient, of tensions, organs make against each other, and against the walls adhesions, congestions, etc. Obviously ‘articulate’ by utilizing sliding surfaces formed by the these flicks with the hands need to be repeated a peritoneal (and pleural or pericardial) membranes that number of times to feel a discernible difference in the surround the organs and line the body cavities. Stanley Lief achieved dramatic changes to normal body movement including bending and in tissue structure and functional improvements in locomotion, as well as body processes such as micturiti many types of abdominal stresses including digestive on]. The methodology of positional release is commonly Naturopath and chiropractor Stanley Lief, developer utilized in visceral manipulation, i. All these would normally be outside the scope of the conventional Safety manual therapist. But, with [this] technique, a The methods of indirect visceral manipulation are practitioner can achieve almost dramatic benefits. Boris Chaitow described this method as follows: Validation of efficacy = 3 (see Table 7. Chapter 7 • Modalities, Methods and Techniques 273 In physical therapy (physiotherapy) settings more Physiological effects direct methods are employed. For example, Pierce & Enhanced mobility and motility would be anticipated Webber (1996) report that: to produce functional improvement, as well as Visceral manipulation is a treatment involving specific enhanced circulation to, and drainage from, organs. Using these techniques, a trained Cautions therapist is able to break down the adhesions formed • Malignant or other serious diseases of the between the connective tissue layers over individual lungs, liver, spleen or associated organs organs. Studies have shown that adhesions are formed • Recent abdominal or thoracic surgery when the serous fluid between connective tissues thickens and becomes more viscous in nature during • Hepatitis the inflammatory process. This phenomenon can occur • Infectious mononucleosis after trauma such as motor vehicle accidents, direct • Osteoporosis blows to the rib cage, surgery, and some illnesses. In • Fracture, dislocation or other painful some fibromyalgia patients, visceral manipulation dysfunction involving the joints of the thoracic therapy may offer an important adjunctive therapy cage or spine towards the restoration of efficient lateral-costal breathing. Barral J-P, Mercier P 1988 Visceral ments would seem to be safely achieved by use of the manipulation. You should be seated or standing on the right, hand towards the umbilicus (see Fig. Place your right hand over the lower ribs, molding to should rotate anteroinferiorly around a transverse their curve, covering the outer aspect of the liver. Ideally with eyes closed you are trying to assess the as the fingers seem to press more closely. Each of these planes of movement can be assessed motion would be the opposite to that palpated during separately before they are assessed simultaneously, this phase. Periodically the patient should be asked to hold the Kuchera suggests that tenderness and tension in the breath for a 20-second period, to see whether this mesentery (see Fig. Reproduced with permission from Chaitow (2003) Chapter 7 • Modalities, Methods and Techniques 275 Box 7. With the fingers maintaining the above position, the • No pain should be produced by this. The thumb should also be flexed, and the contact can be via its tip or its lateral border, or a Exercise 3: ‘Breaking adhesions’ (Chaitow 1980) combination of both. Having located an area of contracted (often points of contact are both on soft tissue structures, sensitive) tissue, the middle finger locates the point and the effect of the manipulation is achieved, not of maximum resistance and the tissues are drawn by pulling or twisting these apart, but by a towards the practitioner, to the limit of pain-free combination of movements that impart torsional and movement.

Impaired consciousness and cerebral hemorrhage on Anticardiolipin IgG and IgM antibodies admission are associated with a poor outcome kamagra soft 100mg sale. The first study was ter- The advantage of dose-adjusted intravenous heparin minated after inclusion of 10 patients in each group buy cheap kamagra soft 100mg line, therapy discount kamagra soft 100 mg line, particularly in critical ill patients, may be the as an interim analysis documented a beneficial effect fact that the activated partial thromboplastin time of heparin treatment on morbidity and mortality. Both studies were tory effect of heparin may be immediately antagonized criticized for inadequately small sample size [8]or with protamin, while such an antidote is not available baseline imbalance favoring the placebo group [6]. Immediate anticoagulation is recommended, even A meta-analysis of the studies on immediate anti- in the presence of hemorrhagic venous infarcts. Chapter 11: Cerebral venous thrombosis According to current guidelines [1], oral anti- complications. Acetylsalicylic Thrombolysis acid should be avoided, as the patients’ bleeding risk may be increased due to the concomitant anticoagu- Despite immediate anticoagulation, some patients lation treatment. Severe headache may require treat- show a distinct deterioration of their clinical condi- ment with opioids, but dose titration should be tion, and this risk seems to be especially high in performed cautiously in order to avoid over-sedation. A potential publication bias in the For the treatment of headaches, paracetamol current published work has been assumed, with pos- should be preferred over acetylsalicylic acid 173 sible under-reporting of cases with poor outcome and because of the patients’ bleeding risk. One study identified focal sensory deficits rapid improvement of headache and visual function. A hemorrhagic lesion diuretic drugs are not as quickly eliminated from in the acute brain scan was the strongest predictor of the intracerebral circulation as in other conditions post-acute seizures [22]. Osmodiuretics common in patients with early symptomatic seizures may thus reduce venous drainage and should there- than in those patients with none. Increased intracranial pressure in most cases Epileptic seizures should be treated with paren- responds to improved venous drainage after anti- terally administered antiepileptic drugs (phenytoin, coagulation. Chapter 11: Cerebral venous thrombosis occluded cerebral veins, but also in order to prevent Infectious thrombosis the recurrence of intra- or extracerebral thrombosis. Antithrombo- ingly favorable, with an overall death or dependency tic prophylaxis during pregnancy is probably unneces- rate of about 15% [2]. However, women on vitamin K antagonists nancy, deep venous system thrombosis, intracranial should be advised not to become pregnant because of hemorrhage, coma upon admission, age and male sex. The main causes of acute death are transtentorial herniation secondary to a large hemorrhagic lesion, multiple brain lesions or diffuse Special aspects brain edema. Fatalities after the acute phase are predominantly eclampsia, gestational or chronic diabetes mellitus). There is a high incidence of intracranial hemorrhages (40–60% hemorrhagic infarctions, 20% intraventricular bleedings). A significant number of Recurrence of cerebral venous children are left with a considerable impairment thrombosis (motor or cognitive deficits, epilepsy). Future developments Treatment of bacterial infections with broad antibiotics and surgery. Open questions con- Treatment of epileptic seizures with parenterally cern many of our current management decisions, administered antiepileptic drugs (phenytoin, such as the role of local or systemic thrombolysis, valproic acid, levetiracetam). It is mandatory to increase the level of evidence supporting our diagnostic or Acknowledgement therapeutic decisions through prospective registries, The author expresses his gratitude to Dr Ioannis case–control studies, and, whenever possible, random- Tsitouridis, Director of the Department of Diagnostic ized controlled trials. Prognosis of The most common and frequently the first cerebral vein and dural sinus thrombosis. Martins and Lara Caeiro Cognitive functions are related to our ability to build lesions are circumscribed, the conceptual representa- an internal representation of the world, the concep- tion system is not affected and these patients are not tual representation system, based on a large-scale demented. Although tion, organized according to their specific processing these tests are also included in brief exams of cogni- capacities. In fact, language impairment will affect typed, since it follows the distribution of the vascular the majority of cognitive functions and needs to be territories. However, in the hyperacute stage symp- ruled out before proceeding to the assessment of toms are likely to be amplified by additional regions orientation, memory or executive functions. It is also a rough plasticity mechanisms make neuroanatomical corre- measure of aphasia severity. Presented objects should be venous thrombosis the pattern of cognitive defects is common and easily recognized (spoon, comb, spec- less stereotyped due to the variability of lesion local- tacles, pencil, wristwatch), to make the task specific ization, size and number, or particular pathogenic for aphasia and not sensitive to cultural factors or mechanisms that may cause diffuse impairment. Patients’ responses vary from pauses (word- In this chapter we will present the most common finding difficulties), tip-of-the tongue phenomenon, cognitive and neurobehavioral deficits secondary to paraphasias, the use of supraordinal responses (fruit stroke, according to symptom presentation. There are rare patients who suffer from a selective naming difficulty affecting a single category of names Language disorders (“category-specific impairments”), such as living Language disorders, or aphasia, occur following peri- entities, actions but not objects, or proper names sylvian lesions (middle cerebral artery territory) of the but not common names. These unusual cases demon- left hemisphere and have a marked impact on the strate that the mental lexicon/semantic system is 178 individual quality of life, autonomy and the ability organized by the functional or physical properties of to return to work or previous activities. Chapter 12: Behavioral neurology of stroke The analysis of speech is performed during spon- with posterior temporal lesions, while inferior frontal/ taneous or induced conversation (asking patients to opercular lesions tend to impair the understanding of tell you an episode or to describe a picture). To make this sounds that do not belong to the lexicon) and sen- classification easy the listener should try to ignore the tences, to evaluate the ability to decode, retain briefly content of speech (as if listening to a foreign lan- in memory and reproduce phonemes (speech guage) and concentrate on the effort, speech rate sounds). Transcortical aphasias are characterized by and the number and duration of pauses. Fluent a disproportionate capacity to repeat, compared to speech “sounds” normal as opposed to nonfluent other language abilities. Verbal auditory comprehension is tested through In conduction aphasia, in contrast, patients have out- simple verbal commands (“close your eyes”, “raise standing difficulty in repeating pseudowords or even your arm”, etc. Effective language recovery, in adults, depends Speech fluency mostly upon the reorganization of the intact areas of Fluent Non-fluent the left hemisphere in the neighborhood of the lesion [3]. Normal output Slow output Four cardinal tests are useful for a bedside evalu- ation of aphasia and to localize lesions, since they (words/minute) Single words have neuroanatomical correlates: (1) confrontation Normal phrase Telegraphic sentences naming; (2) analysis of speech (fluent and nonflu- length ent); (3) verbal auditory comprehension; (4) repeti- tion of words, pseudowords and sentences. Effortless Effortful Language should be evaluated before cognitive No pauses Hesitations, pauses, interruptions assessment. Normal prosody Loss of prosody Certain brain lesions may impair the ability to Sounds “normal” Sounds “atypical” read (alexia or acquired dyslexia) or to write (agra- phia/dysgraphia). Taxonomic classification of aphasia Speech fluency Lexical comprehension Word-pseudoword repetition Aphasia type Non-fluent Normal Normal Transcortical motor Non-fluent Normal Poor Broca’s Non-fluent Poor Normal Isolation of speech areas Non-fluent Poor Poor Global Fluent Normal Normal Anomic Fluent Normal Poor Conduction Fluent Poor Normal Transcortical sensory Fluent Poor Poor Wernicke’s 179 Section 3: Diagnostics and syndromes found in aphasia but may occur in isolation following but are unable to read function words or nonwords lesions of the left hemisphere. In contrast, in “surface The study of patients with reading or writing dyslexia” patients can read aloud regular words and disorders has contributed to the understanding of pseudowords (because they can convert letters, writ- the cognitive processes subserving those abilities and ten graphemes, to their corresponding sound), but to the building of theoretical models of them. They have difficulty reading irregular words or accessing have shown that there are separate pathways to pro- their meaning. These opposite types of impairment cess particular categories of words (regular vs. This information has been incorpor- and a step-by-step conversion that is useful for read- ated into the assessment and classification of these ing new or infrequent words. Likewise, in central agraphias, the writing impair- Alexia and agraphia can be classified as central or ment is similar across different output modalities peripheral, depending on whether the impairment (handwriting, spelling or typing) and can be of a affects the central processing or the afferent or effer- “deep type” (phonological dysgraphia) with preserved ent pathways. In this syndrome, patients can read through the tactile There are also cases whose defect involves the “graph- and auditory modalities (read a word that is spelled emic buffer” (a short-term memory “device” that aloud to them), showing that the central processing is enables the writer to keep the word “on line” as it is intact. They can also write to dictation or sponta- being written in real time), which is characterized by a neously. However, they cannot associate visually pre- particular difficulty writing long words. In contrast, sented written words with their sound or meanings peripheral agraphia is a selective damage in the selec- (cannot read). This syndrome results from a discon- tion or the act of drawing letters (during handwriting) nection between the visual areas and the “word form that can be overcome by typing or the use of ana- area”, due to left temporo-occipital infarcts involving grams and is associated with normal spelling. Deep forms of dyslexia and dysgraphia are associ- In central dyslexias, the impairment is indepen- ated with large left hemisphere strokes [5], while dent of the presentation modality (visual, auditory or surface types result from more limited lesions. It is tactile) and therefore also involves writing and spell- possible that reading and writing/spelling rely on ing. Declarative Alexia and agraphia are commonly found in apha- Semantic sia, but may occur in isolation following lesions of the left hemisphere. Alexia can be classified as Episodic central and peripheral, and as ‘deep’ and ‘surface’ Implicit types. Procedural Priming – facilitation from a previous exposure Neglect Classic conditioning Neglect is an inability to attend to, orient or explore the hemispace contralateral to a brain lesion. Since Sensory recording systems the right hemisphere is dominant for selective atten- tion, this syndrome is usually observed following right hemisphere stroke (affecting some 36–80% of acute stroke patients) [7] and affecting awareness of Neglect is an inability to attend to, orient or explore the left-hand side. Neglect has a negative impact on the hemispace contralateral to a brain lesion, usu- daily living activities and on functional recovery, ally of the right hemisphere. Selective attention relies on a large network Memory disturbances involving the anterior cingulate gyrus (responsible Memory is not a unitary function. It consists of five for its motivational aspects), frontal-parietal and independent systems and involves three processes superior temporal regions (afferent and intentional/ (encoding, storing/consolidation and retrieval). Both exploratory aspects) as well as subcortical structures, depend on specific neural networks that may dissoci- such as the thalamus and the striatum. It may be evident memory traces (fractions of seconds, seconds or “for in different types of space: in the personal space life”), content (explicit knowledge or motor routines) (forgetting to dress, groom the left side of the body), and access to consciousness (explicit or implicit). It may be present spontaneously or during retrieving information that was already stored). In its most severe form it comprises ano- result from posterior cerebral artery, posterior com- sognosia or denial of illness/impairment and a loss of municating artery, anterior and posterior choroidal identification of body parts as belonging to the self. Infarcts in the terri- performed in the peri-personal space and require the tories of the two last arteries can also be secondary to patient to draw, copy or cross out lines or other stimuli subarachnoid hemorrhage and its complications and (cancellation tasks) or to read or write. A qualitative to the surgical and less often to the endovascular analysis of the defect allow us to further classify the treatment of aneurysms located in these arteries. Anterolateral and medial thalamic hemor- or partial recovery of memory disturbances can be rhages, caudate and intraventricular hemorrhages and expected. Bilateral infarcts produce global and severe venous infarcts due to thrombosis of the deep venous amnesia and a persistent deficit, with slow and limited system also produce memory defects. In thalamic amnesia confabulations, A quarter of posterior cerebral artery infarcts intrusions and perseveration are frequent.

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Vitamin A is essential for selenium levels in British and Euro- with anomalies after mothers took defciency in children: Keshan disease vision buy kamagra soft 100mg line, reproduction discount 100 mg kamagra soft otc, immunity kamagra soft 100mg, skin pean wheats to be generally 10–50 high levels of vitamin A75,76 have led that results in an enlarged heart with and epithelial integrity, and the trans- times lower than in American or to some concern about high doses poor function, Kashin-Beck disease duction of light into neural signals in Canadian wheats. It is especially critical during from such wheat, a staple grain for sistent pattern of anomalies has myxedematous endemic cretinism periods wherein cells rapidly prolifer- example, would fail to help consum- been observed74, caution has been that results in mental retardation. Pregnancy should be methionine and is incorporated into as do about 600 provitamin A carot- Defciency avoided during drug administration body proteins along with the methio- enoids that represent precursors of nine. Only about 10% of the and for 3 months thereafter, because ments often are based on sodium sel- latter compounds can be converted • Although defciencies are rare in the likelihood of deleterious effects enite and sodium selenate, forms that to vitamin A, although both types industrialized nations, they repre- is among the highest of the known are not absorbed or utilized as opti- are found in nature. In general, decrease as the gestation advances but lesterol (>35mg/day) has been asso- niacin status is tested through urinary more so in the last trimester. Whether ciated with possible consequences for biomarkers, which are believed to be observed changes represent poor vita- infant development, nausea and vom- Vitamin B3 (niacin) more reliable than plasma levels. Cereals, meat, fsh and non-cit- cooking technique called nixtamal- rus fruits are the major contributors the placebo often is equally as effec- • Niacin is found in a variety of foods ization is employed to increase the of vitamin B6. In summary, supporting evidence including liver, chicken, beef, fsh, bioavailability of niacin during maize fortifed cereals, beef liver and other for its effectiveness when adminis- cereal, peanuts and legumes, and meal or masa production. Although synthetic B12 study of 10,622 women aged 15–46 combined degeneration of the spinal for years for use during pregnancy is used to fortify certain food products found an overall prevalence of B12 cord may be irreversible. Vitamin D2, ergo- upper limit of 100mg/day of vitamin marily results from low intake of tor for pregnancy complications and calciferol, is synthesized by plants. Most often these defects Vitamin D3, cholecalciferol, is synthe- been reported in individuals ingesting vitamin B12 with infrequent causa- mimic those found with folic acid sized by mammals. In particular, Irish investi- vitamin D are numerous and primar- day) with some evidence of adverse mer defciency most usually occurs gations have provided strong support ily come from animal origin (liver oils effects at 500mg/day. No credible in individuals older than 50 years of for a correlation between lower vita- and fatty fsh such as salmon, herring adverse effects have been noted at age, whereas malabsorption results min B12 status, independent of folate and tuna). Pernicious a population not exposed to folic acid some brands of breakfast cereal are anemia results from the lack of intrin- fortifcation or supplement82. Avoiding consumption of min B12 defcient are liable to have This is of particular importance for sources include but are not lim- all animal-based foods (strict vegan) infants who, over time, show lethargy, individuals living in northern lati- ited to red meat, chicken, fsh, milk, is not necessary to develop defciency, irritability, or developmental delay if tudes with limited sunlight, in popu- yogurt, cheese and liver78. The upper limit is cium is transferred from the mother whose diets contain food which have meaning this advice, it is, in the opin- 40mg/day for women and 34mg/day to the fetal skeleton, primarily during poor zinc availability26,27. We these circumstances, vitamin D def- believe, from a public health point of • Teratogenicity – it is not clear whether ciency during pregnancy may result view, that supplementation of higher zinc defciency causes human struc- Defciency tural malformations86, because much in adverse outcomes in the fetus that amounts is more practical, because persist long term, including rickets. A dose of 250μg/ • Zinc defciency is rare in North decreased maternal folate levels as a fetal dyad have been conducted in the day appears safe and represents the America but may be prevalent in confounder26,27. Dietary Reference Intakes for Vitamin A, Vita- This chapter reminds readers of the impor- it does not address the real needs of patients pregnancies, and maintained through and min K, Boron, Chromium, Copper, Iodine, Iron, Man- tant relationship between maternal diet and but rather presents them with theoretical after menopause into the senior years with the ganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Public Health Committee of the American the mother has adequate amounts during the ing reliance on transportation as opposed to this will be of therapeutic value. Institute of Medi- pregnant patients regarding diet and nutri- Physicians must view pregnant patients (and ing of fruits, vegetables, meat, fsh, grains, fat, cine. This includes advising them to select high quality multivita- Iron, Manganese, Molybdenum, Nickel, Silicon, particularly true in the literature relating to nuclear households of one or two, the neces- min, mineral and micronutrient supplements Vanadium, and Zinc. Also, it is important cipal resource for the ‘Essential maternal/fetal daily-requirements-for-teenagers-and-active- ing one’s micronutrients in pregnancy through to remember that food choices often are based building blocks’ section of this chapter – and females diet requires planning, patience and know- on inherent tastes, that tastes are at least to are particularly grateful to Professor Wolfgang 10. World Association of Perinatal Medicine, the ledge about foods, in particular nutrient-dense some degree related to culture, and that cul- Holzgreve for his guidance. If one is not inher- roles of long-chain polyunsaturated fatty acids alone pregnant women: leafy vegetables such ently biased against supplementation, it is not 1. Dietary Reference Intakes: Macronutri- current knowledge and consensus recommen- as chard, collard greens, kale and mustard diffcult to envision circumstances whereby ents. Lan- assessment, prevention and control, a guide for pro- favin, Niacin, Vitamin B6, Folate, Vitamin B12, tial: required diteary intake and consequences cet 1991;338:131–7 gramme managers. Am J Clin Nutr versus lymphocyte subsets and markers of dis- Suppl):S101–11 2006;64:15–30 2000;71:179S–88S ease progression and infammatory response 81. J R increases (n-3) fatty acid status and alters Biol Trace Elem Res 1997;56:31–41 2004;134:3319–26 Soc Med 2008;101:282–9 selected risk factors for heart disease in veg- 69. A as to whether to continue or initiate a new comparison of therapeutic drug usage in preg- medication in an open, supportive and infor- nancy across Europe documented that 64% mative manner. Most conditions that require of women used at least one drug during their medication involve drug exposures at low lev- pregnancy3, while, in France, pregnant women els of relative and absolute risks. Whereas it potential impact of the condition and its vari- is plausible to collect data regarding the usage ous treatments on maternal and fetal health; of medications in the preconception period, establishing effective treatment for chronic it would not be wrong to imagine that such conditions before conception; and counsel- usage is higher than the rates that have been ing women to avoid the use of non-essential documented in pregnancy. Table 1 Preconceptional counseling on the use of describes simple strategies for prescribing medications is of importance, as the con- medication preconception and during preg- sumption of medications is on the rise, new nancy. In used to determine possible detrimental repro- contrast, the embryonic period (implantation Avoid multiple medications if possible and choose those that are ‘safe’ (anticonvulsants, antihyperten- ductive harm. Although such studies may be to 8th week of gestation) involves organogen- sives) and in the smallest dose possible helpful, especially if fndings indicate no addi- esis and encompasses the most critical time Determine what is the best method to monitor therapy (asthma: peak fow meters; hypertension: por- tional risk, their results do not reliably predict with respect to structural malformations. Whereas specifc harmful effects relate to the The healthiest mother is most likely to deliver the healthiest infant timing and duration of drug exposure during Focus on the underlying disorder, not on the drug alone, to explain any additional risk to the fetus (hy- this relatively brief but critical time of devel- pertension and fetal growth restriction, seizures and childhood seizures, systemic lupus and fetal growth Pharmacokinetics of drugs in pregnancy opment, information in humans is minimal or restriction) Only a few drugs are clearly linked with specifc birth defects (phenytoin, warfarin, alcohol, methotrexate, inconsistent regarding long-term effects, such The physiological changes during pregnancy as learning or behavior problems (functional diethystilbestrol, cis retinoic acid, valproic acid, carbamazepine) exert a marked impact on drug pharmacoki- teratogenesis) that may result from chronic Experience with frst trimester exposure for any drug is often too limited in humans to be considered netics and hence established therapeutic rang- prenatal exposure to given medications. As the placenta essen- contraindicated in pregnancy (category X) is possibility of fetal harm appears remote tially acts as a lipid barrier between the mater- listed in Table 3. B Animal studies do not indicate a risk to the fetus and there are no controlled human nal and fetal circulations and drugs cross it by studies, or animal studies do show an adverse effect on the fetus but well controlled passive diffusion, transfer of drugs to the fetus studies in pregnant women have failed to demonstrate a risk to the fetus is unavoidable. General anesthetics D Positive evidence of human fetal risk exists, but benefts in certain (for example, life-threaten- ing or serious diseases for which safer drugs cannot be used or are ineffective) may make use Intravenous anesthetics induce anesthesia of the drug acceptable despite its risks Human teratogenesis rapidly; common examples are thiopentone X Studies in animals or humans have demonstrated fetal abnormalities or there is evidence of and propofol, though the latter has not been fetal risk based on human experience, or both, and the risk clearly outweighs any possible Teratogenesis is defned as structural or func- used during the frst and second trimesters beneft tional dysgenesis of the fetal organs. Lack of understanding of the Commonly used inhalation anesthetics for products developed to treat conditions full and exact mechanisms of teratogenicity include halothane and nitric oxide. Halo- Safety information data specifc to pregnancy such as oxytocics and/ makes it diffcult to predict, on pharmacologi- thane can induce hepatotoxicity, and because or cervical ripening agents, human data on the cal grounds, that a given drug will produce of its property of relaxing the smooth uter- The safety and effcacy of drugs at a given dos- proper dosage and frequency of administration congenital malformations. Milk concentrations are Table 3 Examples of contraindicated drugs and their known adverse effects on the developing human genital defects, but other reasons, including roughly 40–60% of maternal serum levels. In an investigation infant was attributed to the mother’s sul- Drugs First-trimester fetal effects Second- and third-trimester of 1427 malformed newborns compared with fasalazine therapy (3g/day). Immunosuppressants Embryopathy Use of codeine during labor produces neona- Doxycycline Effect on bone growth Various abnormalities ranging from karyo- tal respiratory depression to the same degree I-131 Fetal thyroid development, typing abnormalities to multiple structural as other narcotic analgesics. It is also used in phosphamide during the second trimester, the Tetracycline None known Staining of teeth familial Mediterranean fever, Behcet’s disease period of neuroblast multiplication, have not Thalidomide Limb reduction (gastrointestinal/ and amyloidosis. To lower the risk of Praziquantel is not a teratogen in animals, but up is required to exclude subtle cartilage and hemorrhagic disease of the newborn, vitamin there are few human data. The major abnor- treatment courses may often need to be pre- Except for eighth cranial nerve damage, no nytoin, carbamazepine and valproic acid, are malities produced by anticonvulsants are neu- scribed. Because of this potential toxicity, the reports of congenital defects caused by strep- considered safe for use during breastfeeding; ral tube, orofacial and congenital heart defects. The Collaborative however, observation for adverse effects such use of praziquantel during pregnancy should Neural tube defects are mainly caused by sodi- Perinatal Project6 monitored 50,282 mother- as drowsiness is recommended for women be reserved for those cases in which the para- um valproate (1–2%) and carbamazepine (0. In neither group was evidence found to sparse regarding the long-term effects of new- and postnatal growth restriction, motor or suggest a relationship to large categories of er antiepileptic drugs on cognition and behav- Antibacterials: betalactam drugs, mental defciency, short nose with broad nasal major or minor malformations or to individ- ior when used in pregnancy and lactation. Aminoglycoside antibiotics have drugs, antituberculosis drugs, mus, epicanthus, wide fontanelles, low-set or no detectable teratogenic risk for structural antifungal drugs and antiviral drugs abnormally formed ears, limb deformities, nail defects. This broad spectrum antibiotic crosses Primidone produces abnormalities similar to Chloramphenicol the placenta, chelates calcium and is deposited those produced by phenytoin. The risk for any single drug is about 6–7% Chloramphenicol should be avoided in late thic agent effective in the treatment of ascaria- The effects on bone are minimal, but discolor- (i. The syndrome usually starts 2–9 a risk of 15%, and for those taking a combina- rats, and is therefore not recommended for use ing of the permanent teeth is most likely when days after therapy is begun and causes vom- tion of valproate, carbamazepine and phenyto- during pregnancy. Its use in pregnancy 10 times the recommended dose of 400μg/ The observation of limb reduction defects at should be confned to life-threatening condi- day for normal pregnant woman. A recent study examining the effect of Nitrofurantoin er anticonvulsants, it is diffcult to ascertain albendazole during pregnancy is not recom- intrauterine exposure to quinolones suggested the teratogenic risk of these agents in isola- mended. Two study group infants Vancomycin is a bactericidal antibiotic with a had anomalies (tetralogy of Fallot and con- The adrenal cortex synthesizes two classes inhibits placental microsomal aromatase and fetal ototoxic effect. Based on these data, the coids and mineralocorticoids) having 21 car- in some pregnant women without complica- synthesis in bacterial cytoplasmic membranes. Except Antiprotozoal drugs: antiamebic in patients receiving replacement therapy for and antimalarial drugs Quinine adrenal insuffciency, glucocorticoids are nei- Trimethoprim inhibits the reduction of dihy- ther specifc nor curative, but rather are con- drofolate to tetrahydrofolate and readily Metronidazole sidered palliative because of their anti-infam- Newer agents have effectively replaced qui- crosses the placenta appearing in measurable nine to treat malaria. The use of trimeth- Most of the published evidence now suggests teratogenic risk can be documented, its use Prednisolone is the biologically active form oprim in pregnancy was associated with an that metronidazole does not present a signif- during pregnancy should be avoided. A study of 229,101 patients was increased with use during the second and has been reported, but the validity and the exposed to prednisolone, prednisone and third months after the last menstrual period clinical signifcance of this fnding is question- Antituberculous drugs methyl-prednisolone during the frst trimes- but not before or after this time. Metronidazole is contraindicated during ter failed to show any association between to avoid trimethoprim in the frst trimester 17 the frst trimester in patients with trichomo- Rifampicin these agents and congenital defects. The American prednisolone was used throughout the preg- administration, if prescribed, must always be No controlled studies have linked the use of nancy, cataracts in the newborn occurred in College of Obstetricians and Gynecologists accompanied with folic acid. All concluded that rifampicin was not are advised to wait at least 4 hours after a dose The use of metronidazole for trichomoniasis a proven teratogen and recommended use of before nursing their infants. Griseofulvin or vaginosis during the second and third tri- the drug with isoniazid and ethambutol if nec- Betamethasone use for therapy of pre- mesters is acceptable, as either a single 2-g oral 14 essary. The American Academy of Pediatrics term labor is associated with decreases in Griseofulvin is a systemic agent used to treat dose or a 7-day course of 750–1000mg/day in considers rifampicin to be compatible with respiratory distress syndrome, periventricular fungal infections of the skin, hair and nails. Griseofulvin other alternatives with established safety pro- precipitate myasthenic crisis in patients with use is contraindicated during pregnancy, and fles are available. In these cases, the patient Ethambutol myasthenia gravis, induce hyperglycemia and pregnancy should be avoided for 1 month after should be counseled about the potential risks rarely a hypertensive crisis. Men should not try to father chil- and informed consent obtained before initiat- No congenital defects are linked to ethambu- betamethasone have no effects on the fetus, dren within 6 months of treatment. Follow-up studies information on breastfeeding while taking aza- tinued at least 3 months prior to conception older children had well developed social com- have not shown any differences in cognitive thioprine is without consensus. Hydrocortisone and rheumatologists advise avoidance of azathio- written language and arithmetic, a picture its inactive precursor cortisone present small prine if possible, or counsel against breast- reminiscent of the non-verbal learning dis- ability syndrome28.

Require that all needed: brief interventions; comprehensive pharmaceutical treatments for addiction be assessment to determine disease stage discount kamagra soft 100mg mastercard, provided only by a physician or in severity and the presence of co-occurring accordance with a treatment plan managed health conditions; stabilization; acute by a physician purchase 100 mg kamagra soft otc. Screening instruments should be adjusted or developed -14- to coincide with appropriate definitions of Use the Leverage of Public Policy to Speed risky substance use purchase 100mg kamagra soft free shipping, and assessment Reform in Health Care Practice instruments should be adjusted or developed to mirror diagnostic criteria for addiction. As a condition of approaches, including pharmaceutical accreditation, accrediting organizations therapies (provided or managed by a should stipulate requirements for all physician demonstrating the core facilities and programs providing addiction competencies of addiction medicine or treatment with regard to professional addiction psychiatry) and psychosocial staffing (e. Recognize addiction as a individuals who engage in risky substance primary medical disease and standardize the use or who may have addiction. These language related to the spectrum of include, but are not limited to law substance use severity in current and enforcement and other criminal justice forthcoming diagnostic instruments. Public payers and connected with a trained health professional private health insurance companies should for intervention, diagnosis, treatment and encourage participating providers and disease management. Pursue and gain to the same mandatory licensing processes recognition of addiction medicine by the as other health care facilities. As a condition of Through these actions, assure that addiction licensure, federal, state and local medicine training programs are available to governments should stipulate that all physicians, that training opportunities within facilities and programs providing addiction addiction psychiatry are expanded, and that treatment adhere to established national such specialty care is formally recognized minimum standards for accreditation. Require that all health insurers--  Implement a national public health public and private--provide coverage for all campaign. Implement a nationwide public insured individuals for patient education, health campaign through federal agencies screening and intervention for risky charged with protecting the public health to substance use and treatment and educate the public about all forms of risky management of addiction (involving all substance use and addiction. As a Invest in research designed to improve and condition of reimbursement, public payers track progress in addiction prevention, and private insurance companies should be treatment and disease management and to find a cure for addiction. Create a unified national institute focused on substance use and addiction, recognizing the overarching disease of addiction rather than continuing the focus on different manifestations of the disease--tobacco, alcohol, other drug use-- and including the risky use of all addictive substances. Include in the research portfolio addiction involving behaviors other than substance use, and focus on the causes, correlates, consequences, interventions, policies and possible cures for all manifestations of the disease. The portfolio of the institute also should include health conditions resulting from risky use and addiction and other conditions which increase the risk of developing addiction. In many but not all cases, it involves the use of nicotine, † alcohol and other drugs. Addiction involving these substances typically originates with use in adolescence when the brain is still developing 2 and is more vulnerable to their effects. If untreated, it can become a chronic and relapsing condition, requiring ongoing professional 3 treatment and management. Although there has been an evolution in scientific understanding of the disease, public attitudes and health care practice have not kept pace with the science. Terms used to describe different levels of substance use and addiction’s many forms lack precision, obscuring important differences in the use of addictive substances and the nature and severity of the illness and complicating our ability to treat it effectively. The term addiction also has been used in reference to compulsive behaviors involving eating, gambling and other activities that affect the brain’s reward system and which may develop independent of or in combination with other manifestations of addiction. This report, however, focuses only on addiction involving nicotine, alcohol and other drugs. Use of these Advances in neuroscientific research, including substances can result from an existing brain animal studies and brain imaging, demonstrate dysfunction; use also can alter the structure and clearly that addiction is a primary and often function of the brain, dramatically affecting * 4 8 chronic disease of the brain. The amount and for developing the disease include a genetic duration of substance use that results in brain predisposition and a range of biological, changes and addiction depends on the individual 5 † 9 psychological and environmental influences. There is a growing body of evidence showing the brain circuits that are implicated in substance As yet, there is no conclusive biological marker addiction in general also are involved in other of addiction; therefore the diagnosis of addiction compulsive or addictive behaviors such as those is based on its symptoms including the related to gambling, certain forms of disordered compulsive use of addictive substances, eating (e. These are beginning to explore whether substance symptoms that characterize addiction are addiction might be part of a syndrome cognitive and behavioral manifestations of the 11 characterized by: underlying disease and its effects on the brain. The foundations of the disease may exist in certain individuals even before they ever use an  Shared neurobiological and psychosocial addictive substance and, in some cases, once the antecedents (risk factors); disease develops it persists even when an individual is not actively engaged in substance  Production of desirable effects upon 12 use. It is not the substances a person uses † that make them an addict; it is not even the The addictive potential of a substance is quantity or frequency of use. Addiction is about determined not only by its intrinsic ability to what happens in a person’s brain when they are stimulate the reward circuits of the brain, but also by exposed to rewarding substances or rewarding the speed with which it crosses the blood-brain behaviors, and it is more about reward circuitry barrier (i. Other physical signs such as intoxication, withdrawal, needle-related findings, co-infections, and laboratory findings--such as abnormalities in * A primary disease indicates that it is not simply a liver function tests or positive breath or urine tests-- symptom or effect of another disease or condition. With assessment, pleasure seeking, impulse control/ repeated use of addictive substances, the brain inhibition, emotion, learning, memory and stress begins to expect this stimulation and an addicted 15 control. On involving another substance; for example, a neurological level, this reinforcement is a nicotine use can prime the brain, making it more process carried out by chemical messengers that susceptible to developing addiction involving 18 ‡ 22 flood the reward circuits of the brain. Signals in the environment such as Virtually all addictive substances affect the seeing a drug-using friend or passing a bar, or * pleasure and reward circuitry deep in the brain emotional signals such as feeling stressed or sad which is activated by the neurotransmitter also become associated with the addictive † 19 23 dopamine. As use continues, the pleasure associated with Definition of Addiction the dopamine release that results from the American Society of Addiction Medicine ingestion of an addictive substance--or from its anticipation--can become consuming to the point Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. This is reflected in an At the same time, the brains of substance-using individual pathologically pursuing reward and/or individuals may adapt to the unnaturally high relief by substance use and other behaviors. Compared to non-substance users, the addiction often involves cycles of relapse and brains of chronic substance users appear to have remission. Without treatment or engagement in lower baseline levels of dopamine, making it recovery activities, addiction is progressive and difficult for them to achieve feelings of pleasure 24 can result in disability or premature death. The cognitive control of an motivated or directed actions such as attaining addictive substances and also influences dopamine ‡ levels in the brain. Although certain when he or she wants to cut down or stop using specific genetic factors predispose an individual 37 an addictive substance, it becomes extremely to addiction involving a particular substance, 30 difficult to do so. Advances in genetic research have enabled People may choose to take drugs, but no one chooses to be an addict. Genetic variations may affect a person’s ability The Risk Factors for Addiction 41 to metabolize an addictive substance or to 42 tolerate it. Studies have found that genetics Genetic factors play a major role in the account for between half and three quarters of development of addiction as do individual † 43 the risk for addiction. Genetic factors appear biological and psychological characteristics and to be stronger drivers than environmental factors 31 44 environmental conditions. A factor influences them to have a higher tolerance for that is particularly predictive of risk, however, is alcohol are at increased risk of developing the age of first use; almost all cases of addiction begin with substance use before the age of 21, 35 when the brain is still developing. Genetic Risks * Twin and adoption studies confirm a genetic role in the likelihood of substance use and the from environmental similarities. Identical twins are genetically identical and fraternal twins share an * These studies help distinguish the roles of genetics average of 50 percent of their genes, but both types of and environment in the development of addiction. Adopted children with biological tendency toward heightened dopamine response parents who have addiction involving alcohol also are at increased risk because of their are at least twice as likely as are adopted enhanced or above average experience of reward 56 children without such parents to develop or pleasure from engaging in substance use. Individuals Other biological risks may involve damage or † whose genetic makeup produces involuntary deficits in the regions of the brain responsible 57 skin flushing and other unpleasant reactions to for decision making and impulse control. Psychological Risks It’s theoretically possible to take kids before Clinical mental health disorders such as they first drink, find out whether they have any depression and anxiety and psychotic disorders gene variations, and say to them, ‘If you choose such as schizophrenia, as well as behavioral to be a drinker, then be careful because it’s very disorders such as conduct disorder and attention- likely that you’ll need to drink more to have the 58 50 deficit/hyperactivity disorder --and sub-clinical same effect. Individuals whose brain University of California, San Diego development has been altered by stress are more sensitive to the effects of addictive substances and more vulnerable to the development of Other Drugs. Twin military duty, are at increased risk of developing studies have found genetic risks for 62 addiction. People who have risk-taking or hallucinogen, opioid, sedative and stimulant use 63 impulsive personality traits or who have low 53 64 and addiction. Expectations play a role in substance use as well, since people who expect that using In addition to genetic variations, certain addictive substances will be a positive and individuals have neurological, structural or rewarding experience--in terms of physical functional differences that make them more effects, mood or behavior--are likelier to smoke, 54 susceptible to addictive substances. This is in drink alcohol or use other drugs than are those part due to individual differences in how the 67 with more balanced or negative expectations. Some research indicates that individuals with a Environmental Risks naturally low level of dopamine response to addictive substances are at increased risk of Many factors within an individual’s family, engaging in substance use in order to achieve a social circle and community, as well as the greater experience of reward. Other research larger cultural climate, increase the likelihood suggests that individuals with a biological that an individual will use addictive substances and develop addiction. The of cases, addiction originates with substance use 82 nature of the parent-child relationship is key; before the age of 21. Because the parts of the people who come from families with high levels brain responsible for judgment, decision- of parent-child conflict, poor communication, making, emotion and impulse control are not weak family bonds and other indicators of an fully developed until early adulthood, unhealthy parent-child relationship are at adolescents are more likely than adults to take 69 increased risk of substance use and addiction. At the same time, because these or convey approval of such use are at increased regions of the brain are still developing, they are 70 risk as well. Homes where liquor and combination of early initiation of use and medicine cabinets are open to teens increase the genetic, biological, psychological or 73 chances that teens will use these substances. Widespread access to controlled prescription drugs contributes to the misuse of these … [addiction] is not simply a disease of the 75 substances and increased access to marijuana brain, but it is a developmental disorder, and it 71 marketed as medicine is linked to increased begins early in life--during adolescence. Community tolerance of high levels of substance use or of experimenting with and --Nora D. Risky Use and Addiction Exposure to advertising and marketing messages Frequently Co-occur with Other that promote or glamorize smoking and drinking Health Conditions increases the chances that these substances will 78 be used and misused. Direct-to-consumer marketing of controlled prescription drugs may Individuals with addiction are likely to have co- 87 encourage substance use by conveying the occurring health conditions. Smoking causes 79 bladder, esophageal, laryngeal, lung and oral message that there is a pill for every ill. From 2000-2004, the top three causes Environmental influences can exacerbate of smoking-attributable death were lung cancer, existing genetic, biological and psychological risks for substance use, further increasing the * As is true of much of health research, the research chances that an individual will engage in risky on the neurological effects of addictive substances on substance use, sometimes to the point of 80 the adolescent brain primarily has been conducted on addiction. Alcohol consumption chronic disease--like heart disease, hypertension, contributes to diseases that are among the top diabetes and asthma--defined as having a clear causes of death, including heart disease, cancer biological basis, a behavioral component, 90 and stroke. Addiction involving alcohol is environmental influences, unique and linked to cirrhosis, alcoholic hepatitis, chronic identifiable signs and symptoms, a predictable pancreatitis, cardiomyopathy, heart arrhythmias, course and outcome and the need for continued 104 stroke and neoplasms of the liver, pancreas and management following treatment. Heavy alcohol use and addiction involving alcohol are associated with the Like any other chronic condition, addiction 92 incidence and re-infection of tuberculosis.

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