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Six weeks ago order proscar 5 mg line, he was diagnosed with non-Hodgkin lymphoma with lymphadenopathy of the mediastinum buy generic proscar 5 mg line, and he has been treated with mediastinal radiation therapy discount 5mg proscar. He is afebrile cheap proscar 5 mg visa, heart rate 115 bpm with a thready pulse, respiratory rate 22 breaths per minute, and blood pressure 108/86 mm Hg. His jugular veins are distended to the angle of the jaw, and his chest is clear to auscultation. He is tachycardic, his heart sounds are faint, and no extra sounds are appreciated. He also has felt feverish and achy, has dysuria, and has developed an eye infection. Approximately 1 month ago, he was seen at an outside clinic and treated for syphilis. On exam- ination, he is afebrile, and both eyes are injected and very sensitive to light. She is allergic to penicillin, which causes shortness of breath and "swelling of her tongue. Prior to starting therapy with penicillin for the syphilis, the patient should undergo which of the following procedures? Neutrophils within the urine release this enzyme, which can be detected by urinalysis. Nitrites are converted from nitrates by some bacteria, particularly gram-negative organisms, and can be detected by urinalysis. These conditions may confer functional abnor- malities within the urinary tract or altered defenses against infection. Furthermore, frequent hospitalizations expose these patients to nosocomial pathogens and invasive instrumentation such as indwelling catheters. In symptomatic patients, bacteria typically are found in high concentrations in the urine, and specimen. In , urine cultures are often not obtained, but empiric treatment can be initiated based on the (used as a marker for pyuria) (used as a marker for bacteriuria). Symptoms of cystitis reflect bladder irritation and generally include dysuria, frequency, urgency, or hematuria. Inflammation of the joint space characterized by redness, swelling, and tenderness to touch. There may be some crepitus (creaking sound) in the joint, and, unlike inflammatory arthritis, there is often no or minimal tissue swelling (except in the most advanced disease). Over the last twenty years, he has written books and articles while working as an investigator and research worker, Dirty Medicine is his sixth book. It describes the interaction between government agencies, industry, science and health, then looks at the roles of three organisations. The American National Council Against Health Fraud is an extra-governmental agency which works with industry-connected government agencies like the Food and Drugs Administration. The American Council on Science and Health is an industry funded organisation which publishes pro-industry reports on health risks. They are all involved in innovative non-orthodox work, which has brought them under severe scrutiny and critical attack from those with vested interests in science, government or industry. Dr Jacques Benveniste is a French biologist, whose experiments with high dilution substances came under critical attack in 1988. Dr William Rea is an American pioneer in the field of illness created by toxic environments, work for which he has been frequently attacked. The British practitioners introduced in this part of the book were all attacked by the Campaign Against Health Fraud after it was set up in 1989. Cass Mann, Stuart Marshall, Positively Healthy, Photograph Alan Beck and the Pink Paper 166 Dr Jacques Benveniste / Dr Jean Monro Pat Pilkington and Penny Brohn Dr Stephen Davies / Patrick Holford Belinda Barnes / Robert Woodward and Rita Greer / Cass Mann. The last three chapters of this part look at British science and industry lobby groups, associated with food, Pharmaceuticals and industrial science. Chapter 20 introduces the Wellcome Foundation and discusses the connection of this transatlantic pharmaceutical company with the health fraud movement and the British government. By the use of a battery ofprosecuting agencies and propaganda techniques a large group of practitioners and commentators were criminalised. There were substantial similarities between these attacks and the ones which were being carried out in America. Photographs Jabar Sultan/Philip Barker/ Jad Adams/Dr Leslie Davis/Elizabeth Marsh Yves Delatte/Sandra Goodman/Dr Mumby. The Pink Paper Chapter 34 Trials of strength: Knocking out the opposition406 Joan Shenton and Meditel Dr Sharp, Jabar Sultan, Philip Barker Dr Roger Chalmers, Dr Leslie Davis Yves Delatte, Sandra Goodman, Monica Bryant Elizabeth Marsh Chapter 35 The assault on the Breakspear Hospital 507 Lorraine Hoskin. Dr Mumby Chapter 36 Mugging the cancer patients 571 Bristol Cancer Help Centre Chapter 37 Attacking healthy nutrition 608 • Stephen Davies. The writing of the book was sustained by the commitment, faith and support of a wide range of people whom I interviewed or endlessly discussed the book with: Frederica Colfox, Rita Greer, Sandra Goodman, George Lewith and Philip Barker, to name a few. Some of my old friends and new contacts helped with research and gave more time than money allowed: Tim Treuhertz, Sean Waterman, Isla Burke, Paul Clayton and John Ashton. The period of the investigation was for me a stressful and occasionally frightening period; various people gave me the right kind of support at the right time, first and foremost Elizabeth, and particularly: Peter Chappie, Mike Peters and Tony Price. Two people deserve a special mention, because out of all those who helped me, they were inspirational. Without the ideas, the example and the strengths of Cass Mann and Stephen Davies, the book could not have been finished. A book is never produced by a single person and this book more than most has been a collective endeavour. The cover to the book took two years to finalise because rather than trust to the considerable abilities of my friend Andy, I kept wanting to take control. I have to thank Ann greatly for the thorough and painstaking voluntary work which she did on the manuscript. She did so much work that sometimes I had to consider whether her name should go on the cover with mine. Sally Gold researched the list of alternative care organisations with such conscientiousness that I feared another book would grow out of it. Dr David Freed, John Ashton and Tim Treuhertz all gave sound editorial advice and support. Three people worked on typing the manuscript, Victoria Colfox, Becky Faith and Ann Webley. All were efficient and aided the progress of the book more than in the simple typing of the manuscript. Lastly I have to thank all those who helped me with legal, business and financial advice. I would however like to particularly thank Phillip Harrison whose two small seeds of help returned such a fine harvest of support for me. Any mistakes which remain, and there are bound to be some, are entirely my responsibility. I asked who was speaking and the voice identified itself as Duncan Campbell - the investigative reporter who brought the Zircon affair to light. This was all news to me, Nearing the end of a year-long investigation into Campbell and his associates, I was all too aware of the portentous nature of these phone calls. On the following Monday afternoon, a well-respected firm of solicitors, whose partners I have occasionally worked for, received a two page fax from Campbell. The letter was rounded off with the threat that he would be writing about me in the New Statesman. In the week following the fax, Campbell incessantly rang the offices of the solicitors, seeking information about me. He rang the senior partner at home, Questioning him about a Broadcasting Complaints Commission hearing and one of his clients with whom I had worked. His researchers rang around medical journalists in London to find out whether I had talked to them. Another two doctors connected to the campaign are Dr Stephen Davies and Dr Alan Stewart, who run a luxury private laboratory off Harley Street, Biolab.
Fungal IgE-mediated eosinophil chemotactic factor of anaphylaxis purchase proscar 5 mg, plate- asthma is a noninfectious disease resulting from let-activating factor order proscar visa, leukotrienes proven proscar 5mg, lymphokines order proscar 5mg with visa, the immune response of the atopic host. The pathoge- bronchopulmonary mycosis is an "infectious netic importance of eosinophils in these disorders disease" characterized by periods of persistent is unknown. Both types of disorders can cause long- with clinical deterioration and may predict a poor standing asthmatic manifestations in susceptible response to therapy. The reactions are generally mild and, allergic asthma in which the ubiquitous fun- therefore, little is known about the pathologic gus, Aspergillus fumigatus, colonizes the lower condition of the pulmonary infiltrates or even respiratory tract. In severe or per- may be caused by other fungi such as Candida sistent cases, corticosteroids have been used with albicans, Helminthosporium species, and Curvu- some success. This tis- festation of primary systemic vasculitis but also sue damage may result in permanent damage, occurs in association with a number of conditions, as evidenced by proximal bronchiectasis and including rheumatologic disorders (eg, systemic irreversible airways obstruction. Primary vasculitic processes order characterized by granuloma formation and affecting the lung include giant cell arteritis, pul- necrosis centered on and limited to bronchi and monary capillaritis, Takayasu arteritis, and those bronchioles. Patients with the Churg- description of one of the limited ways in which Strauss syndrome generally have long-standing bronchi and bronchioles respond to injury. Manifestations of the disease appear Parenchymal Disorders (Associated With Other to be attributable to a granulomatous inflammatory Known Disease Entities) response that results in vascular necrosis, primarily involving the lungs. It is important to separate the Churg-Strauss Systemic manifestations of the illness may include syndrome from other necrotizing vasculitides, such upper airway involvement (sinusitis, rhinitis, nasal as Wegener granulomatosis and polyarteritis polyps); skin changes (nodules, purpura, urti- nodosa, which may require treatment with caria); arthralgias; myalgias, mononeuritis multi- cytotoxic agents. The patho- lobular distribution, centrilobular nodules (espe- physiology is unknown, but these patients may cially within the ground-glass opacity), or multiple have had a primary eosinophilic infiltrative disor- nodules, especially in association with bronchial der that had been clinically recognized as asthma, wall thickening. In the United States, the most common often markedly increased and appears to correlate infections are caused by Strongyloides, Ascaris, with disease activity. Eosinophils have been shown to be Clinically, there are three distinct phases: (1) a present in the lung, however, when parasites are prodromal phase that may persist for many years, not demonstrable, which suggests that immuno- consisting of asthma, often preceded by allergic logic mechanisms may be involved. The lung disease eosinophilic pneumonia, which may recur during commonly resolves with therapy directed at the a period of years; and (3) a third, life-threatening specific parasite. This reaction cyclophosphamide may reduce the rate of relapse commonly causes nocturnal cough, dyspnea, 76 Eosinophilic Lung Diseases (Alberts) wheezing, fever, weight loss, and malaise. A his- Miscellaneous: Bronchogenic carcinoma occa- tory of residence in a filarial endemic region and a sionally is associated with lung and peripheral finding of peripheral eosinophilia 3,000/mm3 eosinophilia. This disorder affects can result in an acceleration of the infection with multiple organ systems, primarily as the result of possible fatal dissemination. They include bronchiolitis oblit- lished: (1) peripheral eosinophilia ( 1,500 cells erans organizing pneumonia, ulcerative colitis, per microliter) for 6 months; (2) involvement of mycobacterial infection, Sjögren syndrome, and various organ systems with evidence of end organ postradiation fibrosis. The major cause of morbidity and mortality is cardiac dis- Simple Pulmonary Eosinophilia (Loeffler pneumo- ease where endocardial fibrosis; restrictive car- nia): Simple pulmonary eosinophilia was origi- diomyopathy; valvular damage (supportive nally described by Loeffler in 1932. This disorder structures around the valves, especially the mitral is characterized by migratory pulmonary infil- valve, are prone to fibrosis); and mural thrombus trates accompanied by peripheral eosinophilia. The chest radiograph may show pulmo- the chest radiographic pattern may be almost nary edema and pleural effusions associated with diagnostic, with transitory and migratory ill- cardiac dysfunction but may also reveal intersti- defined peripheral, nonsegmental, and relatively tial infiltrates presumably due to perivascular homogeneous densities. In the original Other drugs, such as busulfan, interferon alfa, description of this disorder, most of the patients and hydroxyurea, may be used in steroid-unre- likely had a parasitic infection or a drug reaction. Advances in molecular diag- Currently, it is estimated that up to one-third of nostics have enabled the identification of subtypes cases do not have a clinically identifiable cause. Additionally, studies have monary eosinophilia, however, should be viewed reported success in treatment with the use of as a sign of possible underlying disease. The fol- disease usually affects middle-aged atopic women, lowing diagnostic criteria have been suggested: but it has been reported in both sexes and all ages. Semin Respir The appearance of the cell may be part of the Crit Care Med 2006; 27:142–147 body's attempt to dampen or contain the effects of Short recent review of this entity. In an Respir Dis 1989; 139:249–252 attempt to categorize these disorders, we may have Original descriptions of the"newest" idiopathic eosinophilic either appropriately or artificially connected them pneumonia. Respiration 1996; 63:129–132 In a report of a nonasthmatic patient with bronchogenic The Eosinophil granulomatosis, the authors discuss different proposed pathogenetic mechanisms. Clin Radiol 2000; 55:296–300 This review concentrates on the cell rather than the clinical Discussion of the radiographic findings in this rarely syndromes. Thorax 1952; 7:1–35 Review of eosinophilia and pulmonary eosinophilia associ- First attempt to categorize a group of disorders that shared ated with parasites. It was • Understand the epidemiology of asthma and the con- tributions of genetic predisposition and environmental updated as the "Expert Panel Report 3" in 2007. Key words: asthma; atopy; diagnosis; epidemiology; patho- These symptoms are usually associated with physiology; treatment widespread but variable airflow limitation that is at least partially reversible either spontane- ously or with treatment. This interaction causes the following known in the latter part of the 19th century and important pathophysiologic changes in asthma was even reported in Sir William Osler's Textbook patients: airway smooth-muscle contraction, of Medicine during that time period, this important hypertrophy and hyperplasia, microvascular leak- distinctive aspect of asthma was put aside for most age, activation of airway neurons, stimulation of of the 20th century. These inflammatory cells, including tinct feature allows for a more precise definition of histamine, platelet-activating factor, and a number this disease. It is believed that eosinophil-derived histopathologic findings can be found in the basic proteins, together with partial reductive airways of patients with asthma. Regeneration first appears as Histopathologic Findings simple or stratified squamous epithelium before differentiation and maturation to new ciliated and Infiltration of the airways by inflammatory mucus (goblet) cells. The presence of lymphocytes and macrophages, appear to direct of mucus is associated with hyperplasia and meta- the movement of cells to the site of airway inflam- plasia of goblet cells; it may cause lung hyperinfla- mation. The intense mucosal thickening in asthma Mast cells, usually as a result of IgE-mediated contributes to the airway wall thickness and, there- stimulation, also release preformed mediators, fore, airway wall narrowing. The smooth Neurogenic Influences: There is growing evi- muscle of asthmatic patients does not behave dence that the neural control of the airways is abnormally after isolation; there is no correlation abnormal in patients with asthma and that neuro- between airway hyperresponsiveness in vivo and genic mechanisms may augment or modulate the increased airway muscle sensitivity measures in inflammatory response. New evidence suggests that the smooth- system regulates many aspects of airway function, muscle cell may secrete cytokines and chemokines such as airway tone, airway secretions, blood flow, and express cellular adhesion molecules. A primary defect in autonomic thought of only as a passive effector cell of asthma, control, the -adrenergic receptor theory, has been responsible for bronchomotor tone, may also con- postulated for asthma. This immu- that autonomic dysfunction is a secondary defect nomodulatory function of the smooth muscle is caused by inflammation or by the effects of treat- similar to that found in epithelial cells. For instance, inflammatory mediators can evidence that smooth-muscle cells in the airways modulate the release of neurotransmitters from are capable of producing growth factors that can airway nerves such as irritant receptors and C-fiber themselves promote proliferation in an autocrine endings. There is a microvascular become exposed, causing a release of potent neu- component to airway remodeling in asthma, with ropeptides such as substance P, neurokinin A, and evidence of angiogenesis in biopsy material and calcitonin gene-related protein. The structural changes that occur in the air- This neurogenic inflammation of the airways, ways of asthmatic patients are likely to be detri- triggered by sensitized sensory nerve endings, has mental and contribute to fixed airway narrowing. It is not clear whether Acute bronchoconstriction bronchial hyperreactivity is acquired or is present Mucus plugging of airways at birth and genetically determined to appear with Bronchial wall edema the appropriate stimulus. Uncoupling of elastic recoil forces These events include viral respiratory infections, an IgE-mediated allergic reaction, and the inhalation of noxious agents such as ozone or sulfur dioxide. Studies in which the authors used a rowing, is the same for these provocative agents, wedged bronchoscope technique have shown that the mechanisms that cause the airways to constrict peripheral resistance can be 10-fold greater than vary. In many asthmatic or hypoosmolar solutions act indirectly by releas- patients, particularly children and younger adults ing pharmacologically active substances from with milder disease, airflow obstruction is com- mediator-secreting cells such as mast cells. In most elderly asthmatic dioxide and bradykinin act by directly stimulating patients and those of any age group with more airway sensory nerve endings. Atopy may be defined as the largely genetic Airway Obstruction: Airway obstruction is susceptibility for developing IgE directed to epit- another cardinal feature of asthma. The causes opes expressed on common environmental aller- of airflow limitation in patients with asthma are gens such as dust mites, animal proteins, pollens, listed in Table 1. This results in an airways (eg, nose and sinuses) and lower airways increase in lung elastic recoil forces, which act on are both important in the pathogenesis of asthma. This The term extrinsic asthma has been used to describe occurs because of the interdependence of lung asthma that is triggered by exposure to inhaled volume and airway caliber because parenchymal aeroallergens. Cellular responses may occur with attachments cause greater tethering of the airways the first exposure to a specific antigen in such at greater lung volumes. As the antigen penetrates shown to be a predictor of skin test sensitivity and beneath the mucosa, it is likely exposed to granu- asthma at age 6 years. The prevalence of atopy locytes and tissue macrophages and eventually increases throughout childhood and adolescence enters the lymphatic system after enzymatic and peaks in the second decade of life. IgE infiltrates the airways and becomes fixed atopic asthmatic patients and have a later onset of to mast cells, basophils, and dendritic cells through asthma.
Not only are defenses valued as an important pro- atelectasis or consolidation = dull; pneumothorax = tective function order proscar mastercard, they are viewed as a significant and hyper-resonant; collapsed lung = dull buy genuine proscar on-line, etc buy 5mg proscar with mastercard. Evi- percussion purchase proscar with amex, 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.
For dipyridamole or adenosine testing discount generic proscar canada, drugs and foods that antagonize the effects of adenosine should be withheld order 5mg proscar with amex, especially caffeine and other methylxanthine containing drugs and beverages discount proscar 5 mg mastercard. For purely resting (viability) studies buy proscar 5mg with amex, no medication needs to be withheld; the intake of nitrates may in fact optimize the sensitivity for detecting viable myocardium. Procedure (a) Viability studies When the clinical situation simply requires an assessment of the distri- bution and extent of viable myocardium, no cardiac stress is required. A rest redistribution 201Tl protocol will detect resting ischaemia as well as myocardial 196 5. This is done by simply injecting the patient with 2–3 mCi of 201Tl and commencing imaging 15 min later. Alternatively, a single injection of a 99mTc agent at rest after administering a short acting nitrate will yield an image from which myocardial viability may be inferred by uptake alone; however, it sometimes may not differentiate hibernating myocardium from a mixture of normal myocardium and scar tissue. Where there is a question of both inducible ischaemia and viability, exercise or pharmacological stress imaging should be performed either on a 99m separate day or as a second procedure in a same day protocol (using Tc) or with late redistribution or re-injection imaging (with 201Tl). Late redistribution imaging should be done no more than 18–24 hours after injection; later times often result in images too degraded for interpretation. From an imaging standpoint, a two day protocol is preferable over a one day protocol for 99mTc labelled tracers because a full allowable dose of 99mTc may be given for both stress and rest studies. The main advantage of a one day protocol is convenience for the patient, although a two day protocol could also spare the patient a return trip for the rest study if the stress study is normal. For a one day protocol, a rest stress sequence is preferable, not only because of improved detection of defect reversibility but also because it may avoid the effect of post-exercise stunning in the rest images. When a two day protocol is used, both studies should be gated, although for practical purposes only the rest study can be gated and used to evaluate function in the true basal state. Interpretation Information useful for the interpretation of patient studies is summarized in Tables 5. Anatomical and physiological variations should be kept in mind, such as low uptake at the apex and the membranous part of the interventricular septum as well as low activity at the anterior wall (due to breast attenuation) and the inferior wall (due to diaphragmatic attenuation). Artefacts such as metallic implants, motion artefacts and bowel tracer should be excluded. Defects that persist after these latter procedures, especially after enhancement by nitrates, very likely represent an infarct. Rest defects that improve after nitrate enhanced rest imaging indicate hibernation with a critical stenosis of the supplying artery. Some studies indicate caution when making a prognosis from normal scans in patients taking beta blocking agents, which may be associated with a more advanced state of disease. The finding of totally fixed defects with an otherwise normal cardiac global function also indicates a benign prognosis. The gold standard for assessing viability has been segmental functional recovery after revascularization. However, in the opinion of an increasing number of authors, a significant improvement in life quality and/or in life expectancy after interventions should be instead considered. Dynamic imaging of the head immediately after tracer injection, referred to as radio- nuclide cerebral angiography, depicts the cerebral vasculature. However, in some developing countries, or areas where other modalities are not readily available, the brain scan is still a useful investigation to neurologists, neurosurgeons and oncologists. To avoid confusing uptake by the choroid plexus in the case of pertechnetate, 300–400 mg of potassium perchlorate is given orally prior to administration of the radiopharmaceutical. Protocols The protocols listed below should be followed: —The patient should rest quietly for a few minutes before the study. Acquisition The procedures listed below should be followed: —Brain scans and angiography are usually undertaken as planar imaging. The acquisition time is used to determine the time for the other views, for comparison purposes. Data processing and interpretation The viewing and interpretation of brain scans and angiography are usually straightforward. More activity is noticed in the skull and scalp, making the normal image look like a hot outer rim around a hollow centre. Owing to limitations in resolution, only the carotids, middle cerebral arteries and anterior cerebral arteries together are shown on the arterial phase of cerebral angiography. The arterial phase starts 6–8 s after injection, lasting for 3–5 s; the capillary or parenchymal phase lasts for 6–8 s, then the radioactivity appears inside the venous sinus, producing a venous phase. Any concentration of radiotracer outside the normal cranial distribution asymmetries or change in blood flow pattern indicates a brain or intracranial lesion. Occasionally, bilateral choroid plexus uptake in the middle of the hollow area of the brain might be mistaken for a lesion. Carotid obstruction may introduce a 'hot nose' sign on an angiogram due to collateral flow. Principle The human brain relies on continuous blood flow to supply all needed nutritional elements. Owing to the high extraction of oxygen from the blood, and the rapid adjustment of the blood flow to meet function demands, the brain has a special mechanism to regulate its blood flow. This regulation is relatively independent of the systemic circulation and is determined by regional cerebral function and metabolism. This is sometimes referred to as the 'trinity' of metabolism–function–blood-flow of the brain. Radiopharmaceuticals There are several kinds of radiopharmaceutical suitable for cerebral perfusion imaging, whose characteristics are listed in Table 5. Whatever the mechanism, retention of the tracer in proportion to cerebral blood flow is the primary requirement for imaging. After reconstitution, the radiopharmaceutical should be allowed to stand for 10 min before injection. For seizure disorders, it is important to use stable agents since the exact time of injection cannot be anticipated. The most important aspect of patient preparation is to evaluate and ensure the ability of the patient to cooperate. Whether patients are instructed to keep their eyes open or closed depends on each department's protocol, which should be followed in all studies. After a specified interval, patients are comfortably positioned to tolerate the long imaging time. Folstein mini-mental exam or other neuropsychological test), recent morphological imaging studies (e. It is also important to know if the patient has had previous studies and their results. Preferably, to minimize the duration of sedation, it should start just prior to the acquisition of the study. However, with meticulous attention to procedure, high quality images can be obtained on single-detector instruments with appropriately longer scan times (5 million total counts or more are desirable). There should be minor obliquity of the head, although the orientation can be corrected in most systems during processing. The patient's head should be slightly restrained to facilitate patient cooperation in minimizing motion during acquisition. Non-circular orbits are preferred, allowing a shorter distance to the patient at all angles. As a general rule of thumb, the highest resolution collimator available should be used. However, these collimators should be used with caution because of the possibility of missing areas of the brain. Different zoom factors may be used in the x and y directions of a fanbeam collimator. Each department should develop a protocol in data acquisition that would allow technical staff to optimize utilization of resources and reproducibility of results. Data processing The following points should be noted: (a) Image processing filters are applied in 3-D (x, y and z directions). This is achieved either with 2-D pre-filtering of the projection data or by applying a 3-D post-filter to the reconstructed images. Resolution recovery or spatially varying filters should be used with caution, as they may produce artefacts. Iterative reconstruction methods give better results and are now available in modern systems. Summation of pixels for display should be performed after complete reconstruction and oblique reorientation. Whenever possible, the surface contour should be defined individually for each transaxial slice.
Correlation Increased pulmonary neuroendocrine cells with between high-resolution computed tomography bombesin-like immunoreactivity in adult patients 610 Rare Interstitial Lung Diseases (Lynch) with eosinophilic granuloma discount proscar online master card. Lang- histiocytosis in adults: a clinical and therapeutic erhans cell histiocytosis in adults: report from the analysis of 11 patients from a single institution generic proscar 5mg line. Langerhans cell istry of the International Society for Heart and Lung histiocytosis: retrospective evaluation of 123 patients Transplantation: introduction to the 2005 annual at a single institution purchase proscar with visa. Downregulation abnormal smooth muscle cells purchase proscar in india, and impairment of of estrogen and progesterone receptors in the gas exchange as predictors of outcome in lymphan- abnormal smooth muscle cells in pulmonary gioleiomyomatosis. Lung transplantation for cystic lung endothelial growth factor-D is increased in serum diseases: lymphangioleiomyomatosis, histiocytosis of patients with lymphangioleiomyomatosis. Extrapulmo- to treatment with an analog of the luteinizing- nary lymphangioleiomyomatosis and lymphangi- hormone- releasing hormone in a patient with omatous cysts in tuberous sclerosis complex. Effect of a tic criteria: tuberous sclerosis complex: report of the gonadotrophin-releasing hormone analogue on Diagnostic Criteria Committee of the National lung function in lymphangioleiomyomatosis. Cryptogenic amelioration of clinical symptoms of recurrent organizing pneumonia: a report of 25 cases and a lymphangioleiomyomatosis after living-donor review of the literature. An sus-host disease and bronchiolitis obliterans orga- unusual radiographic manifestation of bronchiol- nizing pneumonia in recipients of hematopoietic itis obliterans organizing pneumonia. Bronchiolitis tial lung disease associated with juvenile dermato- obliterans organizing pneumonia syndrome myositis: clinical features and efficacy of cyclosporin primed by radiation therapy to the breast: the A. Bronchiolitis oblit- Idiopathic bronchiolitis obliterans with organizing erans organizing pneumonia: clinicopathologic pneumonia presenting with adult respiratory dis- review of a series of 45 Korean patients including tress syndrome. Although the number of cases in the United States has been decreasing, the proportion of cases in the foreign-born population has increased from 27% in 1992 to 59% in 2008. The development of an be produced by aerosol treatments, sputum induc- immune response, heralded by the development tion, aerosolization during bronchoscopy, manipu- of delayed-type hypersensitivity during the next lation of lesions, or processing of tissue or secretions 4 weeks, leads to granuloma formation with a in the hospital or laboratory. An example would be a per- fit into these categories should be judged to have a son who had an initial false-negative reaction positive reaction with indurations of 15 mm. The dictum now is as treated with rifampin/pyrazinamide have prompted follows: "the decision to tuberculin test is the deci- recommendations that urge a cautious and extremely sion to treat (and complete). The addition of pleural biopsy for ognition of the disease is essential to stop further histologic studies and culture increases the yield transmission; however, no single clinical, radio- to approximately 80%. The most frequent sites sweats, shortness of breath, and occasionally are the apical and posterior segments of the lung, hemoptysis) should be obtained. Healing of the tuberculous lesions cytokine release associated with the inflammatory usually results in a scar, with the loss of lung paren- response by the host to the organism. The risk of progres- although an endobronchial lesion may not be sion is significant, and persons who have nodular associated with a radiographic finding. In areas with 4% isoniazid resistance, the an improvement in clinical status after treatment fourth drug may be omitted from the initial regi- with antituberculous therapy, despite negative men. Once the results reveal susceptibility to microbiological studies and no other etiology isoniazid, rifampin, and pyrazinamide, therapy accounting for the illness. If amide is stopped, and isoniazid and rifampin are culture findings are not negative after 2 months of continued for an additional 4 months for a total of therapy and cavities are present on chest radio- 6 months of treatment (completion is also defined graphs, then treatment should be extended for at by the number of doses administered; Table 5). Although there are no studies that have compared five daily doses with seven daily doses, extensive experience indicates this would be an effective practice. Those who do not have a symptom- shown to be safe for use in pregnant women and atic improvement or whose culture results fail to should be administered. Pyrazinamide, although convert to negative within 2 months of treatment recommended by many authorities, has not been initiation should be evaluated for treatment failure. The need to treat with multiple current medical conditions; and (3) noncompliance drugs for a prolonged period leads to the major with prescribed treatment regimens. The responsibility for Baseline liver function tests should be performed successful treatment has clearly been assigned by for all patients beginning treatment, and monthly current guidelines to the public health program monitoring is recommended for anyone with base- or private provider, not to the patient. The most common reasons for the development of On the basis of more current experience, drug resistance are patient nonadherence to ther- rifabutin, which is a rifamycin derivative with less apy and/or physician mistakes (eg, adding a single effect on the hepatic p450 system but equivalent drug to an ineffective regimen). Outbreaks of such strains have been well for the particular patient (recent recommendations documented, resulting in significant rates of mor- can be found at http://www. These patients may experience patients with confirmed multidrug-resistant dis- the development of new ascites, lymphadenopa- ease, therapy with at least two drugs to which the thy, fever, pleural effusions, or cerebral lesions. It is are returning to their previous residence (in non- assumed that most persons have exposure to these congregate settings), and the health department organisms through the environment. It has since become the most widely used is the likely source of infection in patients with vaccine preparation in the world, despite questions soft-tissue infections. With the The following criteria should be used to estab- introduction of rifamycins, the rate of treatment lish a diagnosis of pulmonary disease caused by failures has decreased. Other etiologies for 18 months), with a minimum of 12 months for the clinical and radiologic findings should be of treatment after culture results are negative. Positive culture results from at least two sepa- historically has been frustrating and disappoint- rate expectorated sputum samples (if the results ing. Acces- Crit Care Med 2000; 161:S221−S247 sed May 4, 2009 American Thoracic Society, Centers for Disease Con- Recent recommendations concerning the concomitant trol and Prevention. Interobserver and intraobserver vari- ability may be problematic127; consensus is usually radiolucencies (some cysts are 3 cm in diameter) and hon- eycombing involving both lungs. Recently, a 6-min step dose data in place of chest radiographs would enhance was advocated as another way of assessing exercise the predictive value of such systems. Zones of "old," relatively acellular collagen bundles interstitial component is lacking and is overshad- are interspersed with aggregates of actively owed by the intra-alveolar component. The pathologic lesion respiratory bronchiolitis was originally described in an autopsy series of young cigarette smokers who died of nonpulmonary causes. At a median follow- lin-eosin) [reproduced with permission from Lynch et al, up of 42 months, 17 patients (61%) had died; J Respir Dis 2000; 21;197–214]. Azathioprine should be used with ments conclude that existing therapies are of caution in patients receiving allopurinol, and the unproven benefit but acknowledge that physi- dose should be reduced by at least 50%. Fur- requiring treatment, the British Thoracic Society ther, treatment is discontinued among patients Committee advocated combining prednisolone experiencing side effects or disease progression. Mycophenolate mofetil and other immuno- mg/kg/d for 4 weeks, with subsequent taper) suppressive agents have been used by some clini- with either oral azathioprine (2 to 3 mg/kg/d) or cians, but these agents have not been evaluated oral cyclophosphamide (2 mg/kg/d). It should prine fails may be switched to mycophenolate be emphasized that these recommendations3,232 mofetil or cyclophosphamide, but published data reflect expert opinion but have not been validated in this regard are lacking. At 48 severe symptoms and a declining course, provided weeks, there were no significant differences in that the pros and cons of therapy are discussed primary end points (physiologic parameters) honestly. We emphasize to patients that no therapy between groups, but trends favoring etanercept has been proven to influence survival or clinically were observed in some secondary end points. Azathioprine does not cause bladder injury or Novel and Future Therapies: Major advances bladder carcinomas and has less oncogenic poten- await the development of novel therapies that tial than cyclophosphamide. The decision as went right-heart catheterization to assess the acute to when to list should be left to the transplant cen- hemodynamic effects of vasodilators. One ous oxygen ameliorates pulmonary vasoconstric- third or more of patients are asymptomatic, with tion and may delay the clinical development of cor incidental findings of bilateral hilar lymphade- pulmonale. Mortality rates at 3 years and 5 years for patients Histopathology with sarcoidosis were 5% and 7%, respectively, compared with 2% and 4% among age- and gender- The histologic hallmark of sarcoidosis is the matched controls without sarcoidosis. Biopsy of extrapulmonary sites may be appropriate when specific lesions or abnormalities are identified (eg, lymphadenopathy, skin lesions, abnormal liver enzymes). These derangements in calcium metabolism reflect enhanced production of 1,2-dihydroxycalciferol by mononuclear phago- specimens from both the upper and lower lobes cytes from sarcoid granulomas. Posteroanterior chest festations or with normal chest radiographs but radiograph demonstrates extensive cystic, bullous, and with clinical suspicion of disease. Patients with exten- alveolar septae or pleural surfaces; traction bron- sive fibrosis, honeycombing, and lung distortion chiectasis; and distortion or displacement of ves- are not likely to respond to therapy with cortico- sels, bronchi, or interlobar tissues. Characteristic patterns of Given the variability of Dlco and the expense uptake have been noted in sarcoidosis (eg, of obtaining lung volumes, spirometry and increased uptake in lacrimal, salivary, and parotid flow-volume loops are the most useful and cost- glands and hilar and mediastinal lymph nodes). Patients may have a limited role in patients with normal with pulmonary symptoms or derangements in chest radiographs and suspected sarcoidosis to pulmonary function require more frequent stud- detect clinically silent extrathoracic sites of 67Ga ies. Because of the potential for spontane- teristic of Löfgren syndrome, yet spontaneous ous resolution and the toxicities associated with remissions occur in 85% of patients in this set- corticosteroid therapy, indications for treatment ting. Although several studies suggested short-term improvement with Pathogenesis corticosteroid therapy, relapses often occurred after the cessation of therapy. The lack of efficacy may The inciting signals responsible for the exuber- reflect the study designs because patients with ant granulomatous response and its subsequent stage I disease, minimal or no symptoms, and progression to fibrosis (or resolution) have not normal lung function were often enrolled into been identified. In most of these studies, high rates mononuclear phagocytes (eg, monocytes and of improvement or stabilization were noted in both macrophages) and activated T-helper/inducer treated and untreated patients. The remaining to be individualized according to clinical response 58 untreated patients with persistent radiographic and presence or absence of adverse effects.
The rest of the patients remain asymptomatic and have a clin- ically latent period of 8 to 10 years buy proscar 5 mg without prescription, on average buy proscar on line, before the clinical manifestations of immunocompromise appear cheap proscar 5mg on line. The clinical presentation ranges from fever without respiratory symptoms proscar 5 mg otc, to mild, persistent, dry cough, to significant hypoxemia and respiratory compromise. In addition, the radiographic presentation can be highly variable, ranging from a near-normal chest film to a diffuse bilateral infiltrate, to large cysts or blebs (but almost never causes pleural effusion). Definitive diagnosis can be established by use of Giemsa or silver stain to visualize the cysts but usually requires induction of sputum using aerosolized hypertonic saline to induce cough or bronchoalveo- lar lavage to obtain a diagnostic specimen. Patients who are allergic to sulfa can be treated with alternative regimens, including pentamidine or clindamycin with primaquine. A more indolent or chronic history of cough and weight loss, especially in a patient who has a high-risk background (prison, homeless, immigrant), should raise the question of tuberculosis. Presumptive diagnosis often is made based on the radiologic appearance, supported by serologic evidence of infection. This diagnosis is considered if there is a single mass lesion or if the lesions do not regress after 2 weeks of empiric toxoplasmosis therapy with sulfadiazine with pyrimethamine. If this is the case, historically, the next diagnostic step has been stereotactic brain biopsy. It is a chronic indolent infection, which often presents with vague symptoms of mood or personality changes, headaches, or visual disturbance. If the diagnosis is considered, one can screen for evidence of cryptococcal infection by a serum cryptococcal antigen or perform a lumbar puncture. Treatment of cryptococcal meningitis requires induction with intravenous amphotericin B plus flucytosine, then chronic suppression with oral fluconazole. This can be manifested as viremia with persist- ent fever and constitutional symptoms, retinitis that can lead to blindness, esophagitis that can cause severe odynophagia, colitis, and necrotizing adren- alitis, which occasionally destroys sufficient adrenal tissue to produce clinical adrenal insufficiency. Treatment with clarithromycin and ethambutol and rifabutin is required for weeks in an attempt to clear the bacteremia. Because of the frequency and severity of common opportunistic infections, antimicrobial prophylaxis is routinely given as a patient's immune status declines. She is admitted to the hospi- tal with a 2-week history of fever, shortness of breath, and a dry cough. Which of the following is recommended as a useful prophylactic agent in this patient at this point? Patients often have a diffuse bilateral infiltrate on chest X-ray and an elevated serum lactic acid dehydrogenase level. This page intentionally left blank Case 8 A 58-year-old man presents to the emergency room complaining of severe pain in his left foot that woke him from sleep. He has a history of chronic stable angina, hypercholesterolemia, and hypertension, for which he takes aspirin, atenolol, and simvastatin. He has experienced pain in both calves and feet with walking for several years, and the pain has gradually pro- gressed so that he can now only walk 100 feet before he has to stop because of pain. He occasionally has experienced mild pain in his feet at night, but the pain usually gets better when he sits up and hangs his feet off the bed. This time, the pain was more severe and did not improve, and he now feels like the foot is numb and he cannot move his toes. On physical examination, he is afebrile, with heart rate 72 bpm and blood pressure 125/74 mm Hg. His chest is clear to auscultation; his heart rhythm is regular with a nondisplaced apical impulse, an S4 gallop, and no murmurs. He has bilateral femoral bruits, and palpable femoral and popliteal pulses bilaterally. His pedal pulses are diminished, but they are present on the right but absent on the left. The left distal leg and foot are pale and cold to touch, with very slow capillary refill. He previously had symptoms of bilateral calf claudication but now has sudden onset of pain, pallor, and pulselessness in the left foot. Understand the clinical presentation of a patient with atherosclerotic peripheral vascular disease, including acute limb ischemia. Considerations This patient has diffuse atherosclerotic vascular disease, including coronary artery disease, carotid disease, and peripheral vascular disease. His history of calf pain with walking, but resolution with rest, is classic for claudication. Recently, the perfusion of his left leg likely was worsening, requiring his wak- ing up and dangling his leg to enable blood flow and to help the pain. The patient complains of sudden onset of pain, pallor, and pulselessness, indica- tive of acute arterial occlusion. His limb ischemia may result from acute arte- rial occlusion caused by an embolus, usually arising from a dislodged thrombus from the heart, or a previously diseased proximal artery. Depending on the level of occlusion, the patient may require urgent arterial thromboembolec- tomy, or possibly arteriography, to first determine the arterial anatomy and define the best mode of revascularization. Hypertension, dyslipidemia, and elevated homocysteine levels also play significant roles. It is ischemic pain and occurs distal to the site of the arterial stenosis, most commonly in the calves. The symptoms often are progressive and may severely limit a patient's activi- ties and reduce the patient's functional status. An individual with proximal stenosis, such as aortoiliac disease, may complain of exertional pain in the buttocks and thighs. Severe occlusion may produce rest pain, which often occurs at night and may be relieved by sitting up and dangling the legs, using gravity to assist blood flow to the feet. On physical examination, palpation of the peripheral pulses may be dimin- ished or absent below the level of occlusion; bruits may indicate accelerated blood flow velocity and turbulence at the sites of stenosis. Bruits may be heard in the abdomen with aortoiliac stenosis and in the groin with femoral artery stenosis. Elevation of the feet above the level of the heart in the supine patient often induces pallor in the soles. If the legs are then placed in the dependent position, they frequently develop rubor as a result of reactive hyperemia. Systolic blood pressures are measured by Doppler ultrasonography in each arm and in the dorsalis pedis and posterior tibial arteries in each ankle. In fact, blood pressures in the legs often are higher than in the arms because of an artifact of measurement, so the normal ratio of ankle to brachial pressures is more than 1. Further evaluation with exercise treadmill testing can clarify the diagnosis when symptoms are equivo- cal, can allow for assessment of functional limitations (eg, maximal walking distance), and can evaluate for concomitant coronary artery disease. Management The goals of therapy include reductions in cardiovascular morbidity and mor- tality, improvement in quality of life by decreasing symptoms of claudication and eliminating rest pain, and preservation of limb viability. Smoking is, by far, the single most important risk factor impact- ing both claudication symptoms and overall cardiovascular mortality. Besides slowing the progression to critical leg ischemia, tobacco cessation reduces the risk of fatal or nonfatal myocardial infarction by as much as 50%, more than any other medical or surgical intervention. In addition, treatment of hypercho- lesterolemia, control of hypertension and diabetes, and use of antiplatelet agents such as aspirin or clopidogrel all have been shown to improve cardiovascular health and may have an effect on peripheral arterial circulation. Carefully super- vised exercise programs can improve muscle strength and prolong walking dis- tance by promoting the development of collateral blood flow. Specific medications for improving claudication symptoms have been used, with some benefit. Pentoxifylline, a substituted xanthine derivative that increases erythrocyte elasticity, has been reported to decrease blood viscosity, thus allowing improved blood flow to the microcirculation; however, results from clinical trials are conflicting, and the benefit of pentoxifylline, if present, appears small. It has been shown in randomized controlled trials to improve maximal walking distance. This can be accomplished by percutaneous angioplasty, with or without placement of intraarterial stents, or surgical bypass grafting. Angiography (either conventional or magnetic resonance arteriogra- phy) should be performed to define the flow-limiting lesions prior to any vas- cular procedure.


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Older women young boy stories-OLDER WOMAN/ YOUNGER MAN – Movies List on MUBI
Sign in. Unrated min Drama, Romance, War. Stig is a 15 year old pupil on the verge of adulthood. Viola is 37 years old and his teacher. He is attracted by her beauty and maturity.
Adele fans Bare pussies pics obsessed with her new look. Suzi Pugh says her marriage works because of the year age gap between her and her husband, not in spite of it. When Older women young boy stories traveling and often duringshe writes poetry, essays, and short stories. He was so irresistible, that he was a danger to Start Slideshow. How to start a business, according womdn the experts. Stay Smart. PG 98 min Comedy, Romance. Here, men who have dated much older womrn explain what it was really like. The owners of a house placed on sale are found dead, their bodies discovered by two interested buyers.
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First story in my new Older women young boy stories called 'Tales from the Spider-verse' Is rated M for a reason, but not until chapter two Jasinda Wilder Goodreads Author. Diva studios Andrews Goodreads Author. Want to Read Currently Reading Read. I also take my cans, magazines, bottles, and plastic to the recycle center 60 miles away in Uvalde. The Education of Caroline The Education of Jane Harvey-Berrick Goodreads Author. Brodie having a deep love of comics since childhood, has a special connection to the Marvel Copper vrs brass prices recycling Bucky Barnes for reasons very few people know. Mari Carr Goodreads Author. My second affair - three years later, at 17 - was in many respects the result of this, because the building blocks of young love, of which I knew nothing, were not required. Hill Goodreads Author 4. Erin Noelle Goodreads Author. They might look and act a little more like men, but they are still children. Share or comment on this article:.
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- I was looking for a temp gig to fund a trip to Europe before starting university.
- To vote on existing books from the list, beside each book there is a link vote for this book clicking it will add that book to your votes.
- He is a lovely boy, beginning to experience the emotional and physical changes that come with the onset of manhood; beginning to notice girls, but still childish enough, very occasionally, to try to inveigle his lanky frame into the marital bed when he wakes up at night feeling frightened or insecure.
- Viagra made it possible.
Age gap relationships are something society seems to be obsessed with. When it comes to younger men dating much older women, there's a whole different set of power dynamics at play. I was 25 and she was Her ex and her kids treated her like shit, and unfortunately she let them. Together we made a life running a business together that was successful enough for us to afford two homes, three nice cars, and a boat. Eventually I realised that while I had a damn good life, I was not happy.
Age is not just a number. It eventually gets to the point where you can see the huge difference. I got tired of the mum jokes and I was totally out of my element when her kids visited. I hated how they treated her and it became a source of contention for us. She was no longer interested in sex and I was a raging year-old by then. We started sleeping apart because her back hurt. Things really started to fall apart when I realised I was taking care of her more and more, and I started to resent her for it.
Eventually I realised that unless I left I would be miserable. I told her after 13 years together, that I thought it was time for us to part ways. She was totally devastated. Age matters a lot. The main difference is finance and career. The first thing I noticed about being with an older woman is that they know what they want in bed, so the sex is mind blowing. It can be frustrating.
We've been married 14 years. Ironically, she's the naive one and I have way more life experience so it kind of balances out. We have a great marriage. We've been dating since I was 18, and I plan on proposing early next year.
It's amazing. There's never any arguing or fights, never any jealousy. She's emotionally mature, so there's never any drama. If there's something we disagree on which I can't even think of an example for , there's no contention. The emotional maturity is probably one of the most attractive things. She's more self conscious with the age difference than I am, but its not a big deal for either of us especially after three years.
All of our friends are great and no one is judgmental. Unfortunately, my parents were not so pleased with my decision to date an older woman , so my relationship with them has been But her family is great. She has children older than me, and children younger than me. That was a little weird at first, but nowadays I just view them as family.
Sexually there's no issues. We have matching libidos. When we first started seeing each other it was sex 10 times a week, literally.
But after the honeymoon phase, we settled to a comfortable three to four times a week. Overall, things are great. I couldn't be happier. I was 26 and she was 38 when we met. It was an amazing, life affirming relationship with someone who truly loved me and I truly loved her. In 10 years time she would have been 48 and I would have been 36, I would be in a prime of my life trying to motivate an older woman to act as young as I would be.
If I were 42 when she was 48, there wouldn't be much difference to notice. Four to seven years is barely noticeable. I got with a year-old at 29, and we will age pretty well together. Type keyword s to search. Today's Top Stories. Hilary Duff shared the first Lizzie McGuire pic. Adele fans are obsessed with her new look. Meghan Markle's latest hairstyle is major.
Brooke Lynn Hytes on Drag Race experience. How to start a business, according to the experts. Westend61 Getty Images. Here, men who have dated much older women explain what it was really like. Related Story. She definitely reveals too much about her personal life on the Internet. Advertisement - Continue Reading Below.
More From Relationships. A guide to surviving 'zombieing'. Miley defends "you don't have to be gay" comments. Photos from this Queer Prom will give you feels. True Love or True Lies is back and very queer! How to know if you're settling in your couple. Love Island Australia has a same-sex couple! How men really feel about dating taller women. Beanie Feldstein fell in love while on a film set.
Busting Sex Myths. In this country, I sometimes feel terribly frustrated by the treatment by lobby groups, politicians and media of sex abuse as a crime almost exclusively perpetrated by males. As a divorcee, I suppose she was vulnerable, but she could have prevented it all with a word - or even a roll of the eyes at my sad attempts to interest her. Reinventing Yourself. How to Vote To vote on existing books from the list, beside each book there is a link vote for this book clicking it will add that book to your votes. I also take my cans, magazines, bottles, and plastic to the recycle center 60 miles away in Uvalde. Each mother is infatuated with the teen and they will do whatever it takes to have him.
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Story of Older Woman and Younger Man
Sign in. R 91 min Horror, Mystery. Secure within a desolate home as an unnatural threat terrorizes the world, a man has established a tenuous domestic order with his wife and son. Then a desperate young family arrives seeking refuge. R min Comedy, Crime, Drama. In the summer of , a sheltered teenage boy comes of age during a wild summer he spends in Cape Cod getting rich from selling pot to gangsters, falling in love for the first time, partying and eventually realizing that he is in over his head.
Votes: 8, R 92 min Crime, Drama, Romance. A veteran high school teacher befriends a younger art teacher, who is having an affair with one of her year-old students. However, her intentions with this new "friend" also go well beyond platonic friendship. R min Drama. As her marriage crumbles, a judge must decide a case involving a teenage boy who is refusing a blood transfusion on religious principle.
Unrated min Drama, Romance, War. Stig is a 15 year old pupil on the verge of adulthood. Viola is 37 years old and his teacher. He is attracted by her beauty and maturity. She is Votes: 5, R min Drama, Mystery, Thriller. A high school French teacher is drawn into a precocious student's increasingly transgressive story about his relationship with a friend's family.
R 98 min Comedy, Drama, Romance. A widower and two of his sons become infatuated by their beautiful housekeeper, and all three set out to seduce her using their own unique methods. Votes: 2, A teenage boy becomes smitten with his new drama teacher and pursues her, despite the perilous risks of being found out. Votes: 1, R min Comedy, Drama. As France is nearing the end of the first Indochina War, an open-minded teenage boy finds himself torn between a rebellious urge to discover love, and the ever-present, almost dominating affection of his beloved mother.
Votes: 7, A married couple and their teenage twins move to Meadowlands, a friendly and seemingly safe suburban town, to start a new life. Here, they will soon realize that secrets and mysteries are plentiful, and past is a difficult thing to bury. R 93 min Drama. In , during the swirl of glamour and intrigue that turned President John F. Kennedy's Washington into Camelot, a lonely year-old Catholic school boy comes of age. R 81 min Comedy, Drama. Sam has been expelled from every school and now he must find a creative way to pay for school, which he finds in an escort business entitled Cougars, Inc.
Director: K. Votes: 3, R min Drama, Thriller. A rich but lonely woman, Frances Austen, one day invites a homeless young man from a nearby park to her apartment and offers to let him live there. However, she has no intention of ever letting him leave again. PG 98 min Comedy, Romance. Based upon the true story of "Sonny" Wisecarver. In , Sonny made headlines nationwide due to his affairs with 2 older adult women.
He was so irresistible, that he was a danger to A vengeful widow is out to seduce the relatives of the man she blames for her husband's death.
Unrated 85 min Comedy, Drama, Romance. An insecure young Asian man, played by Japanese pop star Goro Inagaki, meets an interesting sensual European woman who teaches him the secrets of love and life. Votes: Bullied by his father to grow up, a teen fights between the love of his step-mother over his father's life.
R 80 min Drama, Romance. Mary-Jane asks, "Do all women fall in love with a boy, or just those without sons?
Lucy has a party where Mary-Jane notices Julien, 14, R min Comedy, Drama, Romance. A worried husband finds a lover for his depressed wife, but she falls in love with a bullied thirteen-year-old math prodigy and wants to have the boy's baby. A boy in his early teens develops a crush on a grown woman old enough to be his mother only to discover she is also attracted to him. Marion Emmanuelle Bercot is a headstrong and Not Rated 71 min Comedy, Drama. A black-and-white study of a social environment in London, concentrating on a pair of unlikely new friends and the girl they both fancy.
Andras Vajda grows up in a turbulent, war-torn Hungary, where he procures local girls for the occupying G. Disappointed by girls of his age, he meets Maya, a A twelve-year-old daughter, Louise dreams of imitating her venerated mother, Nora. She is suddenly confronted with an ambiguous situation: how to continue to love her despite Helmut, her They like each other, so she talks to him about herself, her spirituality, mysticism and existence itself.
They become inseparable, so his jealous mother confronts her. The love of Nissim for his widowed sister-in-law, Rosa in the Old City of Jerusalem at the turn of the century.
Under very old Jewish religious law, Nissim has the duty and obligation to Based on the novel by Sidonie-Gabrielle Colette. Friends since infancy, Philippe and Vinea have always regarded themselves as brother and sister.
But as adolescence segues into puberty, the two youngsters fall in love. Nate, a young man who wants his first time to be special, may have found what he's looking for when the beautiful, smart, older woman, for whom he does odd chores, hints that she is attracted to him.
Unrated 90 min Drama. Sixteen year old Kristian is very shy, and is struggling to adjust to his new Copenhagen school. He makes friends with two very different boys, nonconformist Henrik, and bullying clique leader Patrick, who he soon discovers is gay.
Angelina Maccarone 's intense drama deals with the obsessive relationship between a confused teenager and an elder woman. Elsa Seifert successfully works as probation officer, but the A hopelessly yearning hippie is left alone with a newborn baby when his just married parents go for a vacation, but wittily he finds a solution to get back his expatriate girlfriend, utilizing the baby who has no idea what is going on.
She uses essentials oils and her hands to soothe her client's inner well-being. Yuriko also has a PG min Drama. TV 42 min Comedy, Drama. Abbud hopes that the gang's field trip to a Canadian wilderness camp can get him some alone time with Tea. Chris lusts after his favorite teacher, but has some competition.
Meanwhile the Carla celebrates two years since her suicide attempt with her husband and the support group. Robert and Lily have seemingly overcome all obstacles, allowing them to truly let themselves fall in love. Robert and Miller's relationship hits a stumbling block.
Miller turns to Lily, revealing a personal secret from his past that informs who he has become. Robert takes Lily to dinner at his mom's house. TV 45 min Crime, Drama, Mystery.
A star high school basketball player disappears, and the investigation reveals that he gave an STD to a couple of his classmates. Robert takes Lily on a picnic in Central Park. It is the perfect date until the weather turns sending them seeking shelter. All the while, Miller is watching and pulling strings. The owners of a house placed on sale are found dead, their bodies discovered by two interested buyers. Sara is working solo on the death of a cheerleader at a high school.
Director: Richard J. Odo tries to change the nature of a rapidly maturing Jem'Hadar infant, Quark finds, whilst Sisko tries to break his son's relationship with a 20 year old Dabo girl. Monica gets a shock when she finds out her boyfriend is a high school student.
Chandler finds out his colleagues don't like him when Phoebe temps as his secretary.

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I started this project in May 2017, not really knowing what I was letting myself in for. The idea was that we would be participating in various sporting events throughout the year and that we would then get people to sponsor us per km, thus helping adult cancer patients to embrace their dreams. Never in my mind did I think that BUCKET OF HOPE would change my life so much. But it did… I started with this project while Elizma was still fighting cancer herself and while raising funds for other cancer patients we were also trying to embrace as many of Elizma's dreams as we could. In March 2018 Elizma lost her fight against cancer, but she left a legacy that will last for ever. The last post that Elizma shared on Facebook was BUCKET OF HOPE and that was a sign for me… I had to continue to help to raise funds to be able to help as many cancer patients as possible. Mother Teresa once said: "If you can't feed a hundred people, then feed just one". And that is the motto of BUCKET OF HOPE. We cannot reach all the cancer patients, but we can go out every day and try to help at least one cancer patient. And I will continue to do so.
We are helping cancer patients to embrace their dreams and seeing those happy faces and to be able to give them some of kind of hope is incredible. Dreams might vary from being on top of Table Mountain to just being able to shop while in a wheelchair. We are grateful for the opportunity presented to us every day to be able to help someone out there. We will continue to do so and want to encourage anyone who feels that he/she wants to make a difference in someone's life to contact us and become a supporter of BUCKET OF HOPE.


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World News: A white male in his 30s who was known to police killed four individuals and injured 21 others on Saturday in a firearm frenzy between the west Texas urban communities of Midland and Odessa that began with a traffic stop and finished when he was killed by officials, experts said.
The presume seized a postal van and opened discharge on cops, drivers, and customers before being shot dead outside a multiplex film complex in Odessa, police said.
Specialists initially thought there were two shooters driving two vehicles, yet Odessa Police Chief Michael Gerke told a public interview on Saturday evening that he accepted there was just one.
The suspect is accepted to have shot the cop who ceased his vehicle on Interstate 20 at around 2.30 p.m. neighborhood time and afterward went on a shooting binge that spread dread through strip malls and cinemas on a bustling Labor Day occasion end of the week in the two urban communities, which lie around 32 km separated in the Permian oil blast region of West Texas.
Video appeared by a neighborhood CBS subsidiary demonstrated the white postal van colliding with a vehicle at rapid outside the Cinergy cinema complex in Odessa before the man accepted to be the speculated shooter was swarmed by police. Theatergoers were seen running shouting out of the complex.
Police said the shooter was shot and murdered in the parking area of the multiplex."We do accept we have the danger contained yet I can't be 1,000% certain about that," Odessa Police Chief Michale Gerke told a news meeting.
Gerke said the suspect was known to him yet he declined to remark on a thought process in shootings.
At any rate, three cops were among the injured, CBS partner CBS 7 announced.
A representative for the Medical Center Hospital in Odessa said it took in 14 exploited people, yet that it was too early to give subtleties."Take hold of your friends and family, appeal to God for this town, stop and give your petitions for the people in question," the clinic's chief, Russell Tippin, told columnists.
At a certain point equipped police went through the Music City Mall in Odessa, driving stays for TV channel CBS 7, situated inside, to dodge off-screen as the structure went into lockdown.
Saturday's shooting came after 22 individuals were killed at a Walmart store around 410 km west of Midland in the city of El Paso, Texas on August 3.


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Karen Leaphart started 2019 unhappy and unhealthy. After a few years of steady weight increase, she found herself at the doctor with an ultimatum: Lose weight in six months or begin medication for high cholesterol. Karen needed serious help. Nothing she had been doing was working to get the weight off, and she wanted lasting weight-loss success for a healthier future.
Basically, cross training involves regularly incorporating a form of exercise other than your sport of choice to strengthen your muscles and decrease your risk of injury. Cross training gives your body a break from the repetitiveness of your usual sport and creates muscular balance. Danielle Pape, certified personal trainer with the Lake Health Integrative Medicine team, gives her best advice on how runners can use cross training to improve their fitness levels:
When it's cold and dark outside, you might be tempted to snuggle up inside where it's warm and cozy instead of venturing out to exercise. But staying active all year is important for your health and well-being. If you have children, it also sets a good example for them, especially if you do activities together.
Kat Shuster, a Lake Health athletic trainer with the Lake Health Sports Medicine team, gives her top tips for staying active during the winter:
When Can I Start Exercising after Weight Loss Surgery?
Topics: Bariatric Weight Loss Surgery, Fitness
Weight loss surgery patients find that success comes from not only the surgery, but from lifestyle changes that their bariatric surgery center help them achieve. Exercise is an important component of healthy living and weight management after bariatric surgery. How soon can you start exercising after weight loss surgery? Bariatric surgeon Dr. Aviv Ben-Meir shares what he recommends for his patients.
Running can be both challenging and exhilarating at the same time. Brad Morgan, MEd, AT, ATC, with Lake Health Sports Medicine, offers some important tips to ensure your runs are also safe:
How Much Water Should You Drink in Winter?
Topics: Fitness, Student Athletes, Sports Medicine, Athletes, Running
When it's cold out, you might not feel thirsty. You sweat less in cooler temps as well. So how much water do you need to drink in the winter months? John Smith, MBA, MSEd, ATC, LAT, director of Lake Health Sports Medicine, explains:
If you have osteoporosis-or are at risk for developing it-you may wonder what types of exercise are beneficial for you. Following your doctor's advice for medication, nutrition and exercise can help strengthen your bones and prevent fractures.
Anne Owens, BSN, MA, ERYT, a registered yoga teacher with Lake Health, explains how yoga can be safe and improve bone density:
Barre is one fitness trend we're betting is here to stay. While barre can seem intimidating (you may start to picture a ballet class), it is a great workout that you can do without any prior dance experience. It can even be modified for different fitness levels.
We all look forward to the warm days of summer! Sunshine, longer days and warmer weather make spending time outside extra enjoyable. However, for those who like to exercise or work outside, it is important to realize the possible risks.
Should I focus on strength training or cardio? Which do you do first during a workout? How do I choose a strength-training program? What is high-intensity training? How do I fit cardio into a busy schedule?
Danielle Pape, fitness expert and certified personal trainer at the Lake Health Wellness Institute, has the answers to these common questions and more!


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Feb 28: BoR
March 4: Snow Camping-Caving
March 18: Ano Nuevo state park
Scoutmaster Update
Chris Webb christopherawebb@comcast
A quiet week for Scouting, but hopefully your week off was fun and exciting!
This Tuesday
Main Troop - Order of the Arrow Election. If you are a member of the Order of the Arrow, this is an official OA event and you are authorized to wear your OA Sash. Patrol Leader Elections. Box Fort dodge-ball.
New First Year (Joined 2017) Parents Orientation Presentation.
Boards of Review - You should have or will receive an e-mail from Mrs. Stanley if you will be on a BoR Tuesday. You are required to attend in full Class A uniform and bring your Scout Handbook.
First Year Program - Requirements and paper-work catch up for their last meeting.
Snow Camping-Caving March 4-6.
Zoe Hu firstname.lastname@example.com
Sign ups are open. Click here.
Informational briefing meetings on Feb 21 and 28.
Ano Nuevo Activity is Open for Sign-Ups!
Caroline Tice firstname.lastname@example.com
If you like beautiful nature hikes and getting to look at cute baby animals, this is the activity for you! On Saturday, March 18, we will be going to Ano Nuevo state park, where the northern elephant seals come ashore every year to mate & give birth. We will take a docent-guided walking tour of the breeding grounds to see the elephant seals (adult & baby) in their natural habitat. This is a 2.5 hour walking tour over 3 miles of moderately strenuous terrain (sand, sloping terrain, etc). It is a beautiful park and a unique opportunity to see these amazing animals.
If you are interested in this activity, PLEASE sign up SOON. SPACES ARE LIMITED!! We can only take about 20 scouts and 4-5 adults. Don't wait too long and miss this wonderful opportunity! Sign up here.
Reminder: Philmont 2018 Interest Sign-Up is Open
NOTE: First-come, first-serve pending Scoutmaster approval. $100.00 deposit required when signing up.
NOTE: Preference will be given to uniformed adults, the activity coordinator, committee members, and then other adults.
Sign up at this site: https://sites.google.com/a/troop33.org/www/activities/2018/philmont_2018
Reminder: Sign-ups are open for Camp Oljato!
Details here
Dates 7/02/17 - 7/08/17
Cost $500 through March 31; $515 April 1 through June 10.
We have space for 50 Scouts and 6 adults.
Payment schedule.
Payments must be made by these dates to hold your spot. There are no refunds.
January 31, 2017 - deposit $100
March 31, 2017 - balance of camp fees $400 (early bird)
April 1 – June 10, 2017 - $415
Reminder: Calling all Future Troop Guides!
Scouts, are you looking to boost your leadership skills and give back to the troop?
Have you been a Den Chief and would like to move up to the next level? Are you looking for a new Position of responsibility?
At the end of March the troop will be getting a bumper crop of first year scouts joining the troop.
Mr. Rutner, Mr. Poppitz and Mr. Stanley need to find new troop guides for the incoming firsties in 2017.
If you are up for the challenge, contact any of the first year ASM's
Mr. Tom Poppitz email@example.com, Mr. Stanley firstname.lastname@example.com, Mr. Rutner Ross Rutner firstname.lastname@example.com.
You can also come speak with us during any meeting.
Reminder: Attention Star Scouts needing EDGE training!
For Star scouts who want to work on their EDGE training, we have a couple of opportunities coming up. If you are interested, please send me an email and I will place your name on a list. As spots open up, I will fill those spots with the scouts on the list.
Two opportunities coming up involve navigation (Second class requirement 3a and 3d). If you are interested in training scouts in these requirements, please send an email to:
The dates are being finalized but should be in mid-January and March.
Jun Kim
For questions on an activity or event, contact the activity owner listed. As an activity owner to have your items included in the T33 Weekly blast, please submit them to Sundeep Gupta email@example.com by 5 pm Sunday for the following week's edition.
News >