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HIV: OPTIONS FOR MEDICAL CARE-CASE MANAGEMENT

admin — Fri, 22 Jul 2011 11:19:57 +0000

Case managers are usually social workers or public health nurses who help coordinate the lives of people with HIV infection. People with HIV infection are in extraordinary need of help with work, home life, medical care, medical insurance, legal issues, finances, and psychological problems. Furthermore, people with HIV infection are subject to so many sudden changes in health that planning becomes difficult. Fortunately, the complexity of their needs has been recognized, and increasing numbers of organizations, programs, and other resources now satisfy these needs. The quality and quantity of these resources vary. Case management is a way of linking the people with HIV infection to the resources in their own communities. Working together with medical care providers, case managers commonly make two plans for each person with HIV infection: a medical care plan and a social work plan. The medical care plan includes plans for a range of continuing medical services, including home care, care in a clinic, hospital, nursing home, or hospice, and, when necessary, care in an addiction program or a mental health program. The social work plan includes financial plans, insurance benefits, benefits from publicly funded programs, resources for drugs, housing plans, and employment plans. The social work plan also links the person with HIV infection to community organizations that provide such services as support groups, home health care, companionship, meals in the home, and the like. The primary goal of the case manager is to be an advocate for the person with HIV infection. This means obtaining for the person with HIV infection all the services that are available and appropriate. A second goal is to obtain the best services at the lowest price. In short, a case manager knows the system, and his or her job is to make the best use of it. Case management services are sometimes funded by state health departments, by other sources of public funds, or by foundations. Insurance companies will sometimes pay for case management services. You can find out how to arrange funding for case management services by talking to the case manager or to a social worker. Both the availability and the quality of case management services vary widely in different communities. Some are not run as well as others. Some may not be networked into both the agencies that provide social services and the agencies that provide health care services for people with HIV infection. And even those that seem to be run well and well-networked are difficult to evaluate. Case management has been used to care for the elderly, for the mentally ill, and for crippled children; evaluations of the usefulness of these programs have been quite variable. As for HIV infection, there is probably no other disease in medicine where the fundamental philosophy of case management is more sound. Case managers can increasingly be found not only in comprehensive care programs but also in hospitals, clinics, state or city health departments, and community organizations dedicated to HIV infection. To find a case manager, ask if your hospital employs a case manager, and if not, if it will refer you to one. AIDS physicians and social workers will also know the names of the good case managers.*157\191\2*

DISEASES OF THE ARTERIES. SYMPTOMS OF ANEURYSMS

admin — Tue, 19 Jul 2011 11:08:06 +0000

Sometimes atherosclerosis can damage the walls of blood vessels and lead to a situation in which the arteries, including the aorta, develop abnormally widened areas called aneurysms. Aneurysms can occur in virtually any artery, but the segment of the aorta that runs through the abdomen is the most common site of localized ballooning. Other sites of aneurysm are the aorta in the chest and the arteries in the thigh and behind the knee.Causes of Aneurysm. More than 90 percent of abdominal aortic aneurysms are associated with atherosclerosis.Symptoms of Aneurysm. Most abdominal aortic aneurysms do not produce symptoms, but some people feel a pulsating sensation in the abdomen. These silent (asymptomatic) aneurysms are often recognized by careful physical examination, chest X-ray, and ultrasonography. When aneurysms do not cause symptoms and are small, they can be safely watched and do not require surgery. It is important, however, to have periodic evaluations. When aneurysms become larger the chance of sudden rupture is greater, and these should be surgically repaired.*196\252\8*

REDUCING YOUR RISK OF CORONARY ARTERY DISEASE: ELEVATED CHOLESTEROL – CHOLESTEROL LEVELS: WHAT IS HIGH?

admin — Sat, 09 Jul 2011 10:03:51 +0000

In a sense, it is incorrect to think of a cholesterol (or triglyceride) level as being strictly abnormal or normal. Although ranges of cholesterol levels have been identified which are considered “too high,” there is no “magic number” that separates risky levels from safe levels. Actually, the ranges for adults are based on a consensus of expert investigators and physicians. They have identified levels of lipids in the blood above which the risk for development of coronary complications is high enough to warrant changes. People with cholesterol or triglyceride levels in the higher-risk zones are said to be hyperholesterolemic, hypertriglyceridemic, or simply hypertrglylipldemic (hyper means “high,” lipid means “fat,” emic means “in the blood”). But, as with all risk factors, being in the “high” range does “hot-guarantee that coronary artery disease will develop, nor does being in the “low” range guarantee avoiding it.Lipid levels are described as the number of milligrams that are present in 1/10 of a liter of blood (about 1/2 cup). The unit of measurement is expressed as milligrams (mg) per deciliter (dl)— mg/dl. Of course, this value can be calculated from the measurement of lipids in a much smaller blood sample.*241\252\8*

HIV INFECTION AND ITS EFFECTS ON INTERPERSONAL RELATIONS: RELATIONSHIPS WITH YOUR CHILDREN-DECIDING WHO WILL TAKE CARE OF THE CHILDREN

admin — Sun, 26 Jun 2011 08:27:55 +0000

To decide who should look after the children, parents need to consider a number of questions. Who wants the child? Who does the child like? Who is fit enough? Who is trustworthy? Who is emotionally capable of caring for a child? Who will think of the child first, will protect the child? Whose house is suitable? Who has enough room for a child? Who feeds their own children well? Who will pay attention to education, to developing the child’s talents? Who values what you do? Who has the money to take on a child? Who has the physical energy? Who has a stable home life, is in a stable long-term relationship, has stable relationships with other relatives? Who holds a job? Who is not drinking or using drugs? Needless to say, no one is saint enough to meet all these qualifications. For many parents, deciding who should look after their children comes down to two questions: Who among my friends and relatives do I love the most? Who loves me the most? Some parents have several children and need to consider whether to try to keep them together or to place them in separate surrogate families. Social workers generally advise keeping brothers and sisters under one roof: they say siblings do best together. But keeping the children together is not always possible. If not, perhaps their surrogate families will take on the responsibility of keeping brothers and sisters in touch with each other. Perhaps, if everyone agrees, this can be made part of a legal agreement. Some parents have raised children alone. They need to consider a further question of whether they want the child’s other parent to have custody of the child. In all states, at the death of one parent, custody of the child will normally be assigned to the remaining parent. If you do not want the child’s other parent to have custody, see a lawyer. Sometimes the other parent will legally sign off his or her parental rights. Sometimes another person—an especially close relative or friend—can be given legal custody instead. In any case, your state’s Department of Social Services or Friend of the Court can advise you on this decision, and help you find the attorney to make the necessary arrangements. Once parents have made these decisions, they discuss the decisions with everyone concerned. When talking to their children, they often do not discuss their decisions outright. Instead, they tell the children gradually. They say, “What do you think it would be like living with your aunt?” Or they say, “If anything ever happened to me, your grandmother will look after you.” Or, “If I should get sick, your cousin will care for you for a while.” Whether people discuss this decision with their children gradually or outright, one way or another, they do let the children know who will take care of them. Children need this reassurance. When talking to their relatives, they must be more forthright. This is not always easy: sometimes the people not chosen, especially relatives, are upset at the decision. Helen, though her sons are nearly grown, asked her father and stepmother to watch out for the boys and take them in when necessary. They all agreed. Helen also has a sister she did not choose, in truth because she trusted her father and stepmother more. But she did not want to hurt her sister, and so she gave her sister what she thought was a palatable reason for the decision: that the father and stepmother had more money, and that taking on two young men would thus be less of an imposition on them than on her. In general, people find reasons for explaining their decisions that are not personal but are external to the person. In other words, they did not choose a certain person because he or she is more trustworthy, or has a better marriage, or a better temper, but because she or he has a better income, or better benefits, or a bigger house, or no other children, or children the same age. When deciding what sort of legal arrangements to make between your children and their surrogate parents, get advice. The three options are custody, guardianship, or adoption. Custody means the person you choose has temporary responsibility for the child. A guardian has certain but not all parental rights. And adoption is the legal equivalent of biological parenthood. You can choose an option and make the necessary arrangements at any time. Helen has a friend who has her second opportunistic illness and who arranged for her mother to legally adopt her young child; the mother is now that child’s legal parent. Many agencies offer advice on this subject: the state Department of Social Services, social workers, and such private social services as Catholic Charities, Jewish Family and Children’s Services, and Lutheran Social Services can help. In any case, to guard your rights as a parent, make any such arrangements only with the advice of your own lawyer.
*94\191\2*

FORMS OF ARTHRITIS: WHAT IS OSTEOARTHRITIS?

admin — Sat, 11 Jun 2011 08:15:33 +0000

Osteoarthritis is an insidious villain that develops gradually, often exhibiting no symptoms for decades. It creeps up on us during our 30s and 40s, usually becoming noticeable in our 50s and 60s.Also known as degenerative arthritis or degenerative joint disease, osteoarthritis occurs when cartilage begins to break down and no longer acts as a cushioning pad in the hands, hips, knees, back, and other joints. Without this protective padding, bone will rub against bone. Pain, tenderness, swelling, stiffness, and sometimes deformity can result.If you suffer from osteoarthritis, you are not alone. The Arthritis Foundation estimates that there are about 15.8 million Americans with osteoarthritis, the majority of them women. In fact, knee arthritis is the most common cause of disability in the developed world.The condition doesn’t affect how long you will live, but it can make everyday activities and life in general, very uncomfortable for those unlucky enough to have the more serious forms of the disease. But there is some good news: Although osteoarthritis has widely been regarded as an inevitable part of aging, like wrinkles or gray hair, some evidence suggests that it may be preventable.*6/306/5*

MEDICAL ADVISER: DIAGNOSIS OF CANCER

admin — Thu, 09 Jun 2011 07:49:21 +0000

One of the most important single procedures used by the physician is the use of his hands in order to palpate or feel changes that have occurred underneath the surface of the body. As medicine is practiced in some parts of the world, patients seldom get time even to remove the necessary clothing to permit the doctor to look at the skin or to put his hands on various portions of the body in order to feel changes that have taken place.When there is a suspicion of a new growth the doctor will look to see if there is any visible sign of a change on the surface of the body. He will then press with his fingers to determine whether or not lumps may be felt underneath the skin, or whether the outlines of various organs in the abdomen have been changed from what is usually felt.New instruments have been developed that enable the doctor to project his powers of observation in a way that was not possible fifty years ago. There is now an electrically-lighted instrument for every entrance and exit of the human body. The cystoscope, the bronchoscope, the esophagoscope, and the gastroscope are types of instruments which enable the doctor to look into the urinary bladder, the bronchial tubes, the stomach, and many other portions of the body.With the X-ray the doctor can detect changes in the outlines of organs inside the body, and by combinations of the use of the X-ray with the use of certain drugs that can be taken internally he can get pictures of changes in outline and in functioning of various tissues of the body. He can even see tumors which project into the cavities inside the brain. In addition, there are devices such as the electroencephalograph which enable the doctor to determine changes in the function of the brain. There are also functional tests for the kidney, the stomach, the liver, the heart, and other vital organs.Transillumination means that light is thrown through the tissues of the body; this is one of the tests that is used particularly in studying the breast for the presence of new growths.New also in the study of cancer is the use of radioactive isotopes. We know today that certain chemical substances taken into the body will be carried by the blood to certain organs or tissues, where they are deposited. Thus, more than 90 per cent of iodine taken into the body goes directly to the thyroid gland. Calcium is deposited in bones and teeth. Some substances go directly to the liver. Radioactivity attached to these chemical substances goes with them, and they can then be detected in various portions of the body by use of the device called the Geiger counter, which shows the presence of the radioactive substances by a clicking sound. All over the country research is now being made to determine how valuable radioactive isotopes can be in aiding not only in diagnosis but also in treatment of cancer.New also in the study of cancerous changes are the studies that are now being made on the blood. Certain conditions such as excessively rapid growth of the red blood cells, called polycythemia, or excessively rapid growth of white blood cells, as in leukemia, can only be detected by examining specimens of the blood under the microscope. Since these conditions come on insidiously, a proper examination will always include the taking of a specimen of blood and an observation of this blood under the microscope. It will include also counting of the cells in the blood, because there are several different types of cells and the relative percentages of various types of cells in the blood may be of the greatest significance in relation to determining the existence of these conditions that are called cancer of the blood.*3/318/5*

ADVENTURES ON MEMORY LANE: MEMORY GAUNTLET

admin — Tue, 17 May 2011 16:08:27 +0000

How does our brain, endowed with such powerful but open-ended abilities, acquire complex mental skills through individual experience and culture? What is the brain machinery of the “emergent properties” we have noted, including wisdom, competence, and expertise?We will get to the matters of wisdom, but gradually. In order to navigate an uncharted territory—and the neurobiology of wisdom is such a territory—we must first link it to something better known and better understood: the adventures on memory lane.One of the central points of this narrative is that wisdom is intricately connected with memory—a certain kind of memory, generic memory. Before we can tackle wisdom head on, we need to understand how this particular kind of memory works and how it is different from other kinds of memory. As we will see, a close and direct relationship exists between generic memories and patterns, and between the processes underlying their formation in the brain.All, or at least most, memories are formed and stored in the brain’s youngest and most elaborate part, the neocortex. In addition, certain memories require the support of various subcortical (or to be quite pedantic about it, non-neocortical) structures and other memories do not require such extra support. Those memories that depend on such additional structures are very vulnerable to decay and to the effects of neurological illness. By contrast, those memories that depend on the neocortex alone, and do not depend on the additional structures outside the neocortex, are relatively invulnerable to decay and can withstand the assault of neurological decline, even dementia, for much longer. Most of the memories of this latter kind are generic memories. But what is a generic memory? To understand this, we need to consider some basic facts of remembering and forgetting.What did you have for dinner twenty-three years ago today? Don’t worry. I am just trying to make a point: It is ridiculous to expect that anyone could remember such an inconsequential bit of trivia so many years later. Unless, of course, the dinner was a White House state dinner to which you had been invited. But had I asked you this question one day after the fact, you would have answered it precisely and unhesitatingly, state dinner or not. It was in your memory once, but now it is not; it’s gone, forgotten. Memories for trivial, inconsequential events continue to decay very rapidly every hour following the events, and this decay is characterized by a steep power function. And thank God for that, because had you permanently kept all the memories that had ever, if fleetingly, been formed in your head, your head would be the mental equivalent of a city like Pompeii buried in lava and volcanic ash. Morsels of useful knowledge would be obscured by huge amounts of useless information—informational noise, informational trash.There are some people with the uncanny propensity to remember everything without forgetting anything, although such cases are quite rare. Far from being a gift, this almost without exception proves to be a disabling, paralyzing curse. Aleksandr Luria described a case of a provincial newspaper reporter with the mixed blessing of clinging for the rest of his life to every memory ever formed, no matter how incidental and generally irrelevant. He described the unbearable and self-defeating condition of being constantly overwhelmed by a deluge of overlapping memories and images. Most of us are spared this fate, because what enters our long-term memory store is highly selective and most fleeting memories formed in our heads are not granted this privilege.So forgetting as a normal phenomenon is, on balance, a good thing, as long as it is limited to inconsequential information. But forgetting may become abnormal, caused by various forms of brain damage, and then it is called amnesia. As we will see later, various forms of amnesia exist, as well as various degrees of its severity, ranging from relatively benign “senior moments” to a global catastrophic deficit when the patient loses the ability to remember what happened to him or to her ten minutes ago.Amnesia may be caused by a number of brain diseases. They include traumatic brain injury sustained in car accidents or on the job, interruption of oxygen supply to the brain, viral, bacterial, or parasitic brain infections, diseases of brain vasculature, chronic alcohol abuse coupled with nutritional deficiencies leading to the so-called Korsakoff’s syndrome, or severe seizure disorder, to name a few. These diverse disorders have certain things in common: They are likely to interfere with the brain’s ability to form memories, to store them, and to access them when the need arises. We will revisit amnesia later; but for now let’s focus on the ways normal memories are formed.What do we mean when we say that certain knowledge has become part of the long-term memory store? A new memory begins forming the moment you encounter whatever it is you are learning: a new face, a new fact, or a new sound. The input engages the parts of your brain in charge of the senses, and then some higher-order brain systems in charge of analyzing and processing the new information and relating it to some previously acquired knowledge. This activity changes the very neural machinery engaged in the process, and the resultant change in the neural networks involved in receiving and processing the new information is memory. The process of memory formation has begun. New proteins are being synthesized, new synapses (contacts between nerve cells, neurons) are developing, and other synapses are being strengthened relative to the surrounding synapses. This is the essence of new memory formation.The first lesson to be drawn from this description is that memories are formed in the same brain structures, and involve the same neural networks, that participate in processing the information as it first arrives. In the past, many scientists believed that separate “memory warehouses” existed in the brain, removed from the brain regions originally involved in processing information that was being memorized. Today we know that no such separate “memory warehouses” exist, nor are there any neural “memory trains” shipping information from place A to place B. Instead new memories begin their neural life in the cortex and stay put right there for the duration of their “natural life.”In other words, the perception of a certain thing and the memory of that same thing share the same cortical territory; in fact they share the same neuronal networks. This was demonstrated with great elegance by Stephen Kosslyn. Using a high-tech research tool known as PET (positron-emission tomography), he identified the brain regions involved in mental imagery, the areas of the brain that were lighting up when the subjects were asked to bring before their “mind’s eye” the images of various familiar things. The activated areas turned out to be the same that were activated when the subject would actually see the objects.Likewise, it was fashionable for many years to talk about “short-term memory systems” and “long-term memory systems,” as if they resided in different parts of the brain. This misconception still persists in various professional and lay circles removed from state-of-the-art neuroscience. But in reality these are two stages of the same process involving the same brain structures, rather than two separate processes involving different brain structures.Much in the brain’s blueprint is plain impractical, defying the popular notion that the course of evolution is somehow inexorably and linearly directed toward improvement. For example, our brain stem contains a number of nuclei responsible for the brain’s arousal and activation. They are packed so tightly in a single small area of the brain that damage to this area can in effect wipe out most of these nuclei with a single blow, producing a catastrophic impairment of arousal. This is precisely what happens in coma, which is caused by damage to this strategic area of the brain, the brain stem. A blueprint so devoid of redundancy and backup safety features would have been flunked in any school of engineering or design. A more “sensible” design guided by evolutionary wisdom, had there been such a thing, would have resulted in a much more distributed placement of the critical nuclei responsible for arousal and activation with ample backup and redundancy, so that not all of them end up in one neural “basket.”By contrast, the central feature of our memory machinery, the fact that memories are stored in the same networks that had received the information in the first place, would please any aficionado of design parsimony and economy, and anyone faithfully believing in the “wisdom of nature.” When changes in the network become lasting and robust, the information becomes firmly ensconced in long-term storage. The changes that will have taken place in the network are chemical and structural. Synaptic contacts will have been altered and new receptors formed. The memory thus created will be robust and relatively invulnerable to any assault on the brain, whether it is traumatic brain injury, viral brain infection, or dementia.*22\302\2*

ACUTE INFECTIOUS DIARRHEAL DISEASES: SELECTED HOSTS

admin — Fri, 06 May 2011 15:34:12 +0000

Immunosuppressed PatientsInfection with HIV and other immunocompromised states such as receiving chemotherapy, steroids, or other immunosuppressive agents usually necessitate empiric antimicrobials for all bacterial causes of diarrhea, as these patients are at increased risk for certain infections and may exhibit more severe illness. Alcoholics and patients with cirrhosis should avoid raw shellfish because of increased risk for severe infections due to Vibrio species. Listeria monocytogenes may be found in soft cheeses, cold deli meats, and raw dairy products. Infection is fecal-oral, and bacteremia or meningitis is often preceded by enteritis. All immunocompromised patients and pregnant women should avoid such foods.
TravelersTravelers to underdeveloped countries are exposed to a variety of novel bacteria and parasites and are often subject to poor food and water handling. The likelihood of acquiring diarrhea in certain geographic areas is as high as 50%. The most common pathogen is ETEC but other bacteria and parasites cause disease as well. Strategies for prevention include avoidance of water, fresh fruits, and vegetables. The use of antimicrobial prophylaxis is usually not recommended, except in patients with at-risk comorbidities, but may be considered in travelers to high-risk areas who have underlying illnesses or those in whom diarrheal would prove problematic (short trips for important business, politicians, honeymooners). If preventive medicine is requested by the traveler, bismuth subsalicylate (2 tablets with meals and before bed) is 62% effective in eliminating diarrhea.
Hospitalized PatientRoutine stool samples for culture as well as ova and parasite studies in hospitalized patients who develop diarrhea after their third day of admission are rarely positive and are not cost effective. Stool should be sent for C. difficile toxin assay, and if found negative, noninfectious causes such as medication and enteric feeding should be considered.*74/348/5*

SKIN AND DIGESTIVE SYSTEM

admin — Thu, 28 Apr 2011 15:04:13 +0000

There are a great many skin complaints that have their roots in this kind of condition, and many authorities have in the past shown how closely related these two conditions may be. It is certainly true to say that no skin abnormality should be treated by other measures until the trouble in the alimentary tract has been cleared up. Dr. Kellogg gives the following conditions of the skin which he maintains are directly due to alimentary toxemia:”Formation of wrinkles; thin, inelastic, starchy skin; pigmentation of the skin – yellow, brown, slate-black, blue; muddy complexion; offensive secretion from skin of flexures; thickening of the skin of the back of the upper arm; irritability of j the skin; sweating of the palms of the hands and the soles of j the feet; eruption of the skin; sores and boils; pemphigus; pruritus; herpes; eczema; dermatitis; lupus erythematosus; acne rosacea; cold, clammy extremities; dark circles under the eyes; seborrhea; psoriasis; pityriasis; alopecia; lichen; planus; jaundice. An infinitesimal amount of poison may suffice to cause skin eruption.”This list covers practically all the known forms of disease that may affect the skin, so that what Dr. Kellogg was saying, in effect, was that disordered function of the bowel was at the bottom of them all. From much practical experience one must say that this is substantially true, but it does not follow that all the treatment that is used can be approved. There is no doubt that the ordinary methods of purging the bowels by certain drugs is very harmful and will not help the condition of the skin. In recent years it has been discovered that certain vitamins are synthesized in the bowel, and taking powerful medicines will upset this extremely important function. The same applies – in a lesser degree, of course – to the practice of colonic irrigation. Such a method, if it is overdone, can disturb the intestinal flora, and it may be a long time before the natural condition can be restored.The condition should be rectified by the use of suitable food and the elimination of enervating habits. In the meantime the usual alarmist attitude about frequent movement of the bowels should be ignored. If a proper diet is adopted there is no need to panic even if the bowels do not act for a few days, and the use of a small enema to keep the lower bowel free from accumulations is all that is necessary.
*20/154/5*

PUBERTY

admin — Fri, 15 Apr 2011 12:56:06 +0000

All of a sudden, strange things start to happen to our young Miss as she begins to grow up.It can commence anywhere from nine years of age onwards. In recent years, for reasons unknown, it seems to be commencing at a younger and younger age in western lands. No doubt it is tied up with today’s sophisticated way of living, earlier psychological development and earlier mental stimulation, all of which play a potent part. It is referred to as puberty.Suddenly the system starts to develop potent chemicals, called sex hormones, and these have a rapid and far-reaching effect on many parts of the system.Suddenly breast development commences. The unnoticed, flat, pinkish nipples become more marked, rounded and protrude as they rapidly increase in size. This is most noticeable between the ages of 8 and 15. Pubic hair commences to grow, this becoming obvious in the 8-14 age group at any time. Underarm hair also makes an appearance.Menstrual periods make a tentative start, and anywhere from 10 to 161?2 years they will become more and more regular. There is usually a dramatic increase in height; this is called a ‘height spurt’ and takes place in the 9-141?2 age bracket.The skinny, school-age child is transformed within a few short years into a modern young woman of vastly different appearance and shape. Most tend to put on weight, but there is an alteration of the system’s fat deposits, giving the body the characteristic female curves which tend to remain for life. In brief, Nature has transformed her into an adult, with the physical and psychological issues that this involves.But although the ages quoted are ‘averages’, the range is enormous and varied. Many develop sexually at an early age. Others are late developers, and often they may reach the age of 18 or 20 before some of the typical secondary sexual characteristics (as the doctors say) have appeared. This is especially so in regard to breast development.