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HIV: OPTIONS FOR MEDICAL CARE-PHYSICIANS: OTHER SPECIALISTS AND CHOOSING A PHYSICIAN

HIV infection directly or indirectly affects virtually every organ of the body, and no physician, regardless of training, can alone treat all the conditions associated with HIV infection. As a result, people with HIV infection, especially people with AIDS, are likely to be referred to such specialists as neurologists, psychiatrists, oncologists, gastroenterologists, ophthalmologists, dermatologists, and pulmonary specialists. Referrals to such specialists almost always come from the primary care physician or the AIDS physician. These physicians will select specialists based on the reputation of the specialist within the medical community, on their previous interactions with the specialist, and on the specialist’s specific interest or expertise in AIDS.
Choosing a Physician-What is the best way for someone with HIV infection to go about selecting a physician? Begin by asking your primary care physician if he or she feels comfortable caring for a person with HIV infection. If not, ask for an appropriate referral: the medical community has an effective communication network, and your physician will either know or can easily find out who has a good reputation within the profession for the care of people with HIV infection. Physicians are the best source of advice about other physicians.
If you do not already have a primary care physician, another source of information is by word of mouth from other people with HIV infection, although some caution is called for here: watch out for people who confuse medical competence with a good bedside manner. What impresses patients and what impresses physicians are often quite different, and your highest priority is competent and comprehensive care.
Other sources are AIDS hotlines, community organizations devoted to AIDS, nurses, and the centers that run tests for antibodies to HIV. The yellow pages may have listings for physicians with a special interest in AIDS, but the relevant listings are more likely to be of physicians
specializing in infectious diseases. You can then contact the infectious disease specialists directly and ask for either an appointment or a referral; they will know well the available local resources for treating HIV infection. City, county, and state medical societies often have lists of physicians with specialized interests; however, these lists may reflect those who have paid their dues and need the patients, rather than those who offer high-quality services.
In general, to choose a physician, ask another physician, check certification, be cautious about a physician who advertises medical services, find out his or her reputation among their peers, and look for a physician who has privileges to admit patients to a good hospital. Hospitals review physicians carefully before allowing them the privilege of admitting patients, and hospitals of good quality will accept only reputable physicians.
Some people with HIV infection select an AIDS physician for conditions related to HIV infection, and continue to see their primary care physicians for all other conditions. To repeat, primary care physicians are increasingly treating people with HIV infection during the earlier stages and calling in infectious disease specialists or AIDS physicians when treatment becomes more complicated or specialized. Either plan for medical care is appropriate.
Regardless of what kind of physician you see or where you live, if you have questions about your medical care, you can ask for a second opinion or get a consultation with another physician. That is, you can go to another physician or clinic that specializes in the treatment of AIDS and ask to have the program of your medical care reviewed. To have the program reviewed thoroughly, you need to bring (or send) copies of all your hospital records and your physician’s office records. These records will include the results of x-rays, scans, biopsies, and any other tests, plus the diagnoses and treatments. This not only simplifies the consultation but prevents unnecessary duplication of visits or tests.
You need not worry that you will offend your own physician by asking for such a consultation. In normal medical practice, second opinions are often encouraged and, for many procedures, are sometimes required. Moreover, given the seriousness of HIV infection and the speed with which recommendations for treatment change, second opinions are often considered a very good idea.
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PUBLIC TRANSPORTATION FOR PEOPLE WITH SPINAL CORD INJURY: BUSES AND RAIL SYSTEMS

Essential to being a part of society at large is “getting there.” Transportation is vital for independent living and participation in the community. You need to travel to the grocery store, your workplace, the bank, your church or synagogue, the theater, the laundry, the dime store, your friend’s home, the park. How do you get to your many destinations?
Buses
If you live in a city with good public transport, you may rely on this system to get from place to place. Buses that “kneel” or have wheelchair lifts open up the world for people with disabilities. Under the Americans with Disabilities Act, all new fixed-route, public transit buses have to be accessible, and additional “paratransit” systems must be provided for people unable to use the buses. Although bus system accessibility is mandated, call your transportation authority to confirm you’ll be able to get an accessible “us on the route you need and at the right time.
Public paratransit systems provide accessible minibuses or taxis for People with disabilities. Various payment systems are used, so call ahead for information. You may also be eligible for economic assistance. Note that many of these transit systems require advance notice of a day or two for pick-up time, so be sure to plan ahead.
Some counties and cities have special van services available for people with disabilities, at no cost. These services also require advance notice for pick up. Some take people anywhere in the area; others may be available only for transportation to medical appointments.
The use of taxicabs can be fraught with problems if you use a wheelchair. John Hockenberry relates several instances when taxis cruised by him as he hailed them from his wheelchair. He describes the anger and frustration he felt in these situations. Many taxi drivers assume that a wheelchair user needs to be lifted into the cab, or they simply don’t want to bother with stowing the wheelchair in the taxi. When possible, call a cab company ahead of time if you must rely on a taxi.
Rail Systems
Under the Americans with Disabilities Act, rail systems must have at least one accessible car on each train. Railway depots must also be accessible. City dwellers depend on subway systems for much of their commuting. People with disabilities who want to use the subway should check whether elevators are available and if they are in working order. Not all subway stops have elevators, so you may need to plan to embark or disembark at specific stations.
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EPILEPSY AS A PSYCHO-SOCIAL DISEASE: COUNSELING IS NOT FOR EVERYONE

“Counseling is not for everyone. Some don’t need it, and some don’t want it. If a person or a family doesn’t want it, then it will be of no use to them. All you can do is leave the door open for them to come back later. Another possibility is to try to connect a family with another family or a support group that may be less threatening.
“Sometimes counseling is crisis intervention; something catastrophic has happened and the individual needs to talk about it. Sometimes families just need help or further discussion in order to understand better the information the physician has given them. But sometimes intervening in those crises or rediscussing the interpretation of the information uncovers a whole can of worms. Suddenly the counselor finds other underlying stresses in the family that need to be addressed. Families who are dealing with epilepsy are just like other families with all their stresses and tensions. Epilepsy is an additional stress, one that can exacerbate and expose all of the others.
“All families need to be able to communicate, and a counselor gives both the individual and the family an opportunity to do just that. They need to talk about the epilepsy but also to talk about all of the other things which affect families, things like expectations, fears, responsibilities, restrictions, and feelings about themselves and others.
“Counseling and education should involve the child, even the child as young as five or six. It is a disservice to leave them out. Involving them early begins the process of ownership of their condition which, over the long run, is so important in helping them to cope.
“The counselor doesn’t cope for them. The child, the teenager, the adult, the family will have to cope for themselves. All I’m there to do is to be the catalyst, to give them the tools to achieve the benefits of confidence and independence.”
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BACH FLOWER REMEDIES: VERVAIN REMEDY – THE NEGATIVE VERVAIN STATE

In the negative VERVAIN state the person keeps his mind over-busy with one project after another, rushing through the first project so that he can start the second. In the process he gives no respite to his body or to his mind. When the body gets tired, the mind by its sheer will-power forces it to continue the work, like a tyrant driving the slaves to work beyond their power.   In his over-enthusiasm he forgets to realise, rather he has no time to realise that even the most robust machines, made of steel, require some period of rest, if they are to be saved from total breakdown, and there is a law called “the fatigue of materials which applies to even non-living structures of steels. So what happens to the frail structure of the human body, when it is forced to work in top gear continuously without rest, can be easily foreseen—there may be breakdown of any over-taxed part of the body or a total breakdown of the health.
The retribution to the tyrant mind (who drove the body to over-work) comes in the form of tension and over-anxiousness, worry and sleeplessness. The nerves become taut, the muscles, the tendons and ligaments loose their flexibility, the joints become stiff. Gout, hyper-tension, nervousness, mental depression and a score of other ailments follow the general breakdown of health.
When the sufferer is unable to work with the same speed as before due to failing health, his mind feels tortured because of his helplessness in the timely execution of his projects.
Like a spend-thrift person, who consistently lives beyond his means, ultimately comes to grief, the negative Vervain person after consistently using enormous energies to keep going even when physical strength is exhausted comes to a sorry end—a physical wreck suffering from muscle tension, pain in eyes, headache etc. and an irritable nervous temperament. Vervain remedy given to the above person would curb his inclination to over-doing things or getting ahead of himself, at the same time retaining his enthusiasm in supporting a good cause. If he has to do several projects-he first fixes the priorities and then executes the jobs one by one. While doing one job, he puts his mind and soul in that job and does not let the burden of other projects weigh on his mind. If he has “to sell” a good idea to others, he does not, in his over – enthusiasm, do overtalking till the other man feels bored, but would allow the other person to talk also.
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BACH FLOWER REMEDIES: ROCK WATER TYPE OF PERSON

Out of the 38 Flower Remedies, this is the only remedy which is not derived from any flowers. It is water—pure simple water derived from natural springs located in hills far from human habitat. Rock Water relates to the soul qualities of adaptability and inner freedom.
Rock Water type of person is a man of principles, and he can make any sacrifices to stick to his principle. No inducements or threats can make him compromise with his conscience, and do anything against his principle. But positive type Rock Water person is not over-rigid in his beliefs. He is open to conviction. If he is convinced that his erstwhile belief was wrong, he is amenable to change it for the more rational one. But whatever believe he has at anytime, he sticks to it at all costs. He is aptly termed as an “adaptable idealist” whose ideals may come to fruition and he may derive silent pleasure if others feel induced to adopt those ideals in their lives.
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HRT AND BREAST CANCER

There was frightening discovery in 1976, when the highly respected New England Journal of Medicine reported a study linking menopausal oestrogens to an increase in breast cancer. Numerous studies since then have confirmed this finding, showing that oestrogen can increase the risk of breast cancer by up to 60 per cent.
Is there any protection then for the breasts by combining oestrogen and progestogen? The answer seems to be no, and combined HRT may even increase the risk. A landmark study in 1989 of 23,244 women which was reported in the New England Journal of Medicine found that women using HRT had twice the risk of breast cancer after nine years. The most worrying finding was that those women who were taking combined oestrogen and progestogen had over Jour times the risk of developing breast cancer after six years’ use. They concluded from the incidence of breast cancer in those women taking HRT that breast cancer ‘is not prevented and may even be increased by the addition of progestogens’.
An editorial in the same edition of the New England Journal of Medicine commented that the findings confirm early results that oestrogen plus progestogen could be more carcinogenic (cancer forming) than oestrogen alone/ However, the comment continued, ‘The data are not conclusive enough to warrant any immediate change in the way we approach hormone replacement.’
By now you should be speechless. But in 1992 the same research team announced that they had followed up these 23,244 women over the intervening four years and found the same risks for breast cancer with oestrogen alone that they had found in 1989. However, that the breast cancer risk of taking opposed HRT (oestrogen and progestogen) was even greater than they had originally thought.
I have seen women who have been put on HRT to help with menopausal symptoms (such as hot flushes, etc.) and then been told to take Tamoxifen (the anti-oestrogen hormone) to help protect them against the risk of breast cancer,  which  might  be  caused  as  a  side  effect  from  taking the  HRT.
Tamoxifen has a list of side effects of its own (noted in the British National Formulary, a drug reference book published by the British Medical Association and the Royal Pharmaceutical Society of Great Britain) including rashes, alopecia (hair loss) and visual disturbances. It is possible that these women will later be given more medication to help get rid of the side effects caused by the Tamoxifen (which was, as you remember, given to reduce the side effects of the HRT in the first place). Interestingly, the first side effect mentioned for Tamoxifen in the British National Formulary is hot flushes! More HRT needed?
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CHILDREN WITH DIABETES AT SCHOOL

Examinations and reviews
School reviews, whatever the pupil’s age, are always times of stress. Examinations may determine the future; higher education colleges and universities and many employers use examination grades as a criterion for choosing candidates for interview. It is therefore vitally important that the diabetic pupil:
1.     Does not miss classes because of his diabetes
2.   Is able to concentrate during class
3.     Devotes the necessary time to homework and studying for exams
4.   Performs at his best during the review.
Do not miss classes
Careful monitoring of the diabetes and rapidly sorting out any problems, particularly the blood glucose level during coughs and colds, should minimize the time spent away from school. You should be able to concentrate well if your blood glucose level is normal, whereas very high or low blood glucose levels may cause muddled thinking.
Studying for exams
This inevitably involves a lot of sitting and reading with little energy output. Coupled with increasing stress as the examination approaches, this tends to raise the blood glucose level. This may become worse if you ‘worry eat’ while working- many small nibbles soon add up. Your normal diet may need to be decreased and low calorie snacks added. Resist the temptation to allow your blood glucose level to run high ‘just until the exam is over’. Your brain may not be working as efficiently as it should if the blood glucose level is high. If you take up an academic career there will be many examinations to come, so you must get used to taking them in your stride.
Some people with diabetes find that their blood glucose levels fall when they are worrying about grades. It is therefore important to check the blood glucose to find out what is happening.
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High blood pressure is a dangerous condition at any time and if you suspect that you may be suffering from this condition, then you should discuss this with your practitioner.

Your weight and the foods you eat play an important role in the prevention of hypertension. It is therefore very important to maintain the correct weight-for-term during your pregnancy. Celery, apples and cucumber are foods that have natural diuretic properties so they are also good foods to pick on when you have a craving for something that may not be as nutritious. These foods are also low in calories.
Supplementing the diet with evening primrose oil and calcium can also be of benefit. Clinical studies have found that by supplementing the diet of women with evening primrose oil and/or calcium their blood pressure was reduced. One trial found that supplementing the diet of pregnant women with between l,000 mg and 2,000mg of calcium daily reduced their blood pressure, and may prevent the onset of pregnancy induced hypertension, (Kawasaki, N. et al. Effect of calcium supplementation on the vascular sensitivity to angotensin 11 in pregnant women.
Supplementation with evening primrose oil may also help slow the development of, or prevent, high blood pressure during pregnancy. I have found that evening primrose oil, at a dose of one to two 500mg capsules up to three times daily, effectively treats hypertension.
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COPING WITH EPILEPSY/ACCEPTANCE: THE BIGGEST PROBLEM – EMPHASIZING

“I’ve certainly seen good counseling done by nurses, psychologists, social workers, psychiatrists, and doubtless many others. But I’ve also seen well-trained counselors who may be excellent with other types of problems but who feel uncomfortable working with kids or with adults who have epilepsy. To be a good epilepsy counselor, a deep knowledge about epilepsy and how it affects people is important. Many counselors are just not sufficiently familiar with seizures and their effects and so are unable to help families become comfortable and cope. Sometimes the personalities of the counselor and the parent or child do not mesh. If working with one counselor is unsuccessful, try another. Counselors must remember that, unlike other handicapping conditions, epilepsy is not present all the time. It is not a visible handicap. It’s not like cerebral palsy or mental retardation. You have to help the kids and the families to cope in a different fashion, with an episodic condition.
“Before we stop, I want to emphasize again the words control, self-image, and ownership. Everyone wants control. You have to help children and adolescents with epilepsy to take control. You can’t do it for them. It’s not the counselor’s epilepsy. It’s not my problem. They have to do the work. It’s their choice. They have to develop their self-image, and giving them small things at which they can succeed is a first step. They have to develop the self-image before they can achieve the control.
“You know, what keeps me doing this is that the rewards are so great. Can you imagine how it feels to have people like Jenny’s family tell me that they would not be a whole family if I hadn’t been there? That’s pretty big stuff. And the kids—you’ve become a part of their lives. While you may not need to continue to see them or counsel them, they’ll just call you up to touch base and let you know how things are going. It’s hard to beat that feeling.”
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SKIN AND FACIAL COSMETICS: TONERS, FACIAL SCRUBS, MASKS AND T-ZONE PRODUCTS

Toners
There are basically two types of toners available. The first is an astringent-type toner which is very drying and should only be used on oily skin. It contains alcohol and oil-absorbing chemicals so is unsuitable for people with normal to dry skin.
The second type of toner is basically water, which makes the skin feel cooler and fresher.
Facial scrubs
The main purpose of facial scrubs is to exfoliate the skin, making it appear smoother and more polished. Scrubs usually contain beads or granules which act as a mild abrasive. The skin, however, exfoliates itself every fourteen days and does not really require help to remove dead skin cells. In addition, abrasive scrubs can be very irritating to the skin, especially where there is acne. Overall, the benefits of facial scrubs are limited.
Masks
There are two main types of masks available. The first is a moisturizing mask which contains many different moisturizers. The mask is left on the skin for about twenty minutes and then rinsed off. This is just another method of applying a moisturizer. Although it can be relaxing to use masks, they do not achieve more than moisturizers and will not prevent wrinkles.
The second type of mask is a cleansing or clay mask which can be useful for oily skin. These masks absorb oil, making the skin drier and tighter. However, they can also be very irritating and often cause dermatitis.
T-zone products
These products are designed mainly for the area around the nose, chin and central forehead where excess oil is produced. They are essentially oil-absorbing products and are useful for people who get an ‘afternoon glow’ on their noses. Examples include Almay Oil Control Lotion and Nutrasorb.
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