Primary and Secondary Syphilis- Neurologic or ophthalmic signs or symptoms- Treatment failureAlthough patients with primary and secondary syphilis often have early CNS invasion by spirochetes, the majority of these patients do not go on to develop clinical neurosyphilis when given the standard treatment regimens used for primary and secondary syphilis. Therefore, a CSF evaluation is not recommended in patients with primary and secondary syphilis in the absence of clinical manifestations of neurosyphilis.
Latent Syphilis- Neurologic or ophthalmic signs or symptoms- Evidence of active tertiary syphilis (e.g., aortitis, gumma, iritis)- Treatment failure- HIV infection with late latent syphilis or syphilis of unknown durationA common problem in the primary care setting is the elderly patient with some cognitive deficits who is found to have a reactive serologic test for syphilis with an unknown or remote history of treatment. While strict adherence to sexually transmitted disease treatment guidelines would dictate a CSF evaluation in these cases, the likelihood of having treatable disease in this population is small, and there are no recent data in favor or against this practice.*169/348/5*
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Anti-Infectives Comments Off
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A parent who has RA may find the adventure of childrearing especially challenging. For one thing, children require structure and routine, and it’s hard to maintain consistency when you have a condition that fluctuates. On good days you may not need help from your kids, or you may be able to participate in activities with them. On bad days you may require their help and understanding. Despite the unpredictable nature of your arthritis, you must try to be consistent in your interactions with your children and your response to them.
For example, if one week you say, “Jimmy, I want you to clean up your room. I don’t feel well,” and a week later, when you’re feeling better, you say “Jimmy, why don’t you go watch cartoons while I clean up your room?” it’s not going to take too long for Jimmy to realize that he will have to do more when you are feeling bad and will be rewarded when you feel well. It’s far better to separate Jimmy’s responsibilities from your physical condition: “Jimmy, you’re six years old now, and we think you’re big enough to clean your room each week.”
Erase from your mind any feelings of guilt you may have for not doing everything for your children. Guilt provides no positive direction and only allows your children to manipulate you. Redirect your energy toward teaching lessons in responsibility and independence which will last your children a lifetime. A final note: there’s nothing to prevent you from rewarding children for taking on new responsibilities. This is another real-life lesson because we frequently are rewarded for a job well done.
A second caution to parents is to avoid making a promise such as ‘We’ll do this if I feel well.” When something’s coming up which is important to the child, develop a backup plan. This may entail something as simple as making it okay for the other parent and the child to participate in the activity without you. If you are a single parent, think about asking the parents of your child’s friend to help out if you are feeling ill. Do not wait until the day of the occasion to make alternate plans, as this may leave you feeling trapped. Again, the goal is not to link your child’s hopes too closely to your level of health on a given day.
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Pneumococcal
Pneumococcal vaccine should be a routine immunization for all adults over the age of 65 years and for younger adults with chronic cardiopulmonary disease, anatomic or functional asplenia, cirrhosis, and diabetes mellitus. Since antibiotic-resistant strains of Streptococcus pneumoniae are being increasingly reported throughout the world and access to effective antibiotics may be limited while abroad, the pneumococcal vaccine should also be considered for travelers to developing countries.Influenza
In the United States, vaccination against influenza is routinely recommended for persons 65 years of age or older, for those with chronic cardiopulmonary conditions, and for persons who anticipate disease exposure. The influenza vaccine is also recommended for all international travelers during influenza season. While influenza typically occurs from November until March in the Northern Hemisphere, the incidence of the disease peaks from April until September in the Southern Hemisphere. Furthermore, influenza may occur at any time of year in the tropics. Practitioners should administer the most current vaccine available, since this is formulated on the recent epidemiology of the influenza virus.
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Apart from vaginal changes I have just discussed, there are few physiological reasons why getting older should erode a woman’s sex life. The studies suggest that the main problem for women is staying interested in sex. Here are some ways to keep desire aflame.
Inject novelty into marital lovemaking. Many long-married women lose interest in making love because they have fallen into a rut. They have intercourse at the same time and place and in the same way year after year. When sexuality becomes predictable, the most fiery passion turns ho-hum. One antidote is to vary the sex act itself. Have intercourse on the floor, in the bath, or in the woods. Experiment with a vibrator. Read erotic literature together. Role play each other’s fantasies.
Everything may not work out, but experimenting may help bring back some sexual spice.
Bring back your courtship. Your romance may need rekindling too. Go away for a romantic weekend with your husband. Surprise him with a candlelight dinner, served in a filmy nightgown. Seduce him!
Take care of yourself. Keep physically healthy. Exercise. Spend time on how you look. Maintaining sexual desire depends on feeling sexually desirable – taking pride in your appearance, keeping your passion for life. In some ways becoming an older beauty is easier, because as we age how we look is increasingly tied to what we do. While nature has a firm hand at twenty, at fifty nurture (work!) takes over an increasing share. The saying that after forty we get the face and body we deserve has its bright side. If we take action to be attractive, attractive we really can be.
Keep sexually active. It you have no current partner, buy a vibrator. Masturbate; develop a fantasy life. If you have a partner, take the initiative sometimes. Don’t always wait passively to be seduced. In their classic studies, Masters and Johnson were surprised to find that the three most sexually active older women they tested produced just as copious amounts of lubrication when aroused as the twenty-year-olds. So they concluded that sexual activity itself may even prevent the physiological losses thought to be inevitable. Staying sexually active seems as much a cure for “losing it” sexually for women as it is for men.*4/159/5*
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Flexibility is a measure of the range of motion, or the amount of movement possible, at a particular joint. Improving your range of motion through stretching exercises will enhance your efficiency of movement and your posture. In addition, flexibility exercises have been shown to be effective in reducing the incidence and severity of musculo-tendinous injuries.
A regular program of stretching exercises can enhance psychological as well as physical well-being. Tai chi is an ancient Chinese form of exercise that combines stretching, balance, coordination, and meditation; it is widely practiced in the West today. Yoga, which originated in India and also combines stretching, coordination, balance, and meditation, is even more widely practiced. Both are excellent for improving flexibility. Many factory workers in the United States now begin their workdays with simple forms of flexibility exercises, a concept introduced from Japan.
Flexibility is enhanced by the controlled stretching of muscles that act on a particular joint. The primary strategy is to decrease the resistance to stretch (tension) within a tight muscle that you have targeted for increased range of motion. To do this, you repeatedly stretch the muscle and its two tendons of attachment to elongate them.
The three major types of stretching techniques are static, proprioceptive neuromuscular facilitation (PNF), and ballistic. Static techniques involve the slow, gradual stretching of a muscle and its tendons, holding the muscle or muscle group at a point of mild discomfort (a burning sensation is felt within the muscle), followed by the slow return to the starting position. When static stretching is done properly, it stimulates the tension receptors to allow the muscle being stretched to relax and permit the muscle to be stretched to greater length. Proprioceptive neuromuscular facilitation (PNF) techniques have been shown to be superior to other stretching techniques for improving flexibility; unfortunately, PNF techniques in their original form are quite complex and a certified athletic trainer or physical therapist may be required to help you perform them correctly. Several PNF techniques (e.g., hold/relax, contract/relax) have been simplified to the point that they can be performed with an exercise partner or even alone. With PNF techniques, a 6-second contraction of the muscle to be stretched is followed by an assisted stretch of 10 to 30 seconds’ duration. Ballistic stretching involves repeated bouncing motions, during which the muscle and tendon are rapidly stretched and returned to resting length. This process can be likened to taking a rubber band between two fingers, rapidly pulling it apart, and then releasing the tension, again and again. And just as a rubber band can snap in your fingers if you apply too much tension, the muscle fibers being stretched in this way can be torn during these rapid movements. The risk of injury with ballistic stretching is so high that this type of stretching is no longer recommended.
Of the three types of flexibility exercises, static stretches are the most commonly used. The primary goal of static stretching is to cause permanent elongation of the targeted muscle or muscle group, thus permitting greater range of motion at a given joint. With static stretching, the end position is held for 10 to 30 seconds, and each of the major muscle groups should be stretched at least four times in close succession for optimal improvement. To achieve this goal, a comprehensive stretching program must be performed a minimum of two to three days a week.
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Unnecessary jealousy is the most tragic of all. If one could only realize its implications, one would never be guilty of it. It implies that one does not believe himself attractive enough to hold another except by force. And that is an insult to oneself or at least an indication of an inferiority complex. Or it implies that one’s husband or wife is insincere or incapable of a deep and lasting emotion. If this is false, then the jealous person himself has shown that he does not really know or love the other. On the other hand, if it is true, why should he continue to desire the love of such a one?
Some foolish people, however, even enter marriage with the assumption that jealous watchfulness is the normal thing and may be heard to boast how they are not going to let their husband or wife out from under their eye. The popular moral tradition is partly to blame for this because it tacitly approves jealousy and sometimes even murder (“the unwritten law”) in the case of marital infidelity. It assumes that love, even though it has to be hypocritical, is a duty, and that failure to do one’s duty merits revenge. To call love a duty is obviously a contradiction in terms, and it is difficult to see how any intelligent person could value dutiful love. The double standard of morality also has led many women to believe that all men are naturally unfaithful, and therefore to be guarded carefully.
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Research has revealed that the species originated in Mexico and Central America some 70,000 years ago. Four times it colonized North America, each time being almost wiped out by glaciers during successive ice ages. Each new wave of evening primrose cross-pollinated with survivors and so continued the line.
American Indians are supposed to have used the evening primrose for hundreds of years. According to folklore, a tribe called Flambeau Ojibwe was the first to realize the medicinal properties of the evening primrose plant. They used to soak the whole plant in warm water to make a poultice to heal bruises, they used the plant for skin problems and asthma, and brewed a cough mixture from the roots.
From America, the evening primrose spread all over the world. Botanists first brought the plant from Virginia to Europe in 1614 as a botanical curiosity.
Most of the strains, however, came to Britain during the next century as stowaways in cargo ships carrying cotton. As cotton is light, soil was used as ballast. The ballast was dumped on reaching port, and with it stray seeds of evening primrose. Even today there are areas around the major ports, such as Liverpool, where evening primrose plants – descendants of the cotton ballast – grow in profusion.
In Europe, the evening primrose became known as ‘King’s Cure All’ by those who knew its almost magical medicinal properties. For centuries, however, the evening primrose was left to straggle along without anyone but a few specialist herbalists taking much notice. It wasn’t until this century that scientists began to look at the plant for its industrial potential in such things as paint.
In 1917 a German scientist called Unger examined the plant, and found that the seeds contained 15% oil, which was extractable with light petroleum. In 1919 the Archives of Pharmacology published a paper by Heiduschka and Luft who were the first to do a detailed analysis of the oil. They extracted 14% oil with ether, and apart from the normal oleic and linoleic acids, found a new fatty acid, which they named gammalinolenic acid (y-linolenic acid). In 1927, three German scientists repeated the Heiduschka and Luft test, and came up with a more detailed analysis of the chemical structure of this gammalinolenic acid (GLA).
Twenty-two years later Dr J.P. Riley, a British biochemist in the Department of Industrial Chemistry at Liverpool University, came across the German papers on evening primrose oil and decided to analyze the oil for himself, but this time using modern techniques. So Dr Riley set off for the sand hills near Southport in Merseyside and picked a bunch or two of evening primrose plants. He dried the plants, separated the seeds, and extracted the oil. To his great satisfaction, he found for himself the unique gammalinolenic acid.
It wasn’t until the 1960s, however, that British scientists began investigating the oil for its possible health uses. The first experiment was on rats. The aim of this experiment was to compare the biological activity of the commonly-found linoleic acid with the rare gammalinolenic acid.
The rats were put on a diet lacking in essential fatty acids, and after a few weeks they developed loss of hair and skin problems. They were then divided into two groups. One group was fed linoleic acid and the other group was fed gammalinolenic acid. The results of this first experiment were remarkable. The rats in the GLA group recovered more rapidly than the other group, and there was evidence that the GLA was far more efficiently taken up by the cells of all the important tissues and organs of the body.*2/60/5*
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Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
If you are in a great deal of pain and discomfort, your physician may recommend use of NSAIDs. I personally believe that medication is a short-term solution, and other steps must be taken to correct this problem.Exercise
When a joint is injured, the knee begins to swell, which can hamper the movement of the knee and can cause the muscles to atrophy or weaken, placing more force on the joint at a time when it is least able to sustain it. Therefore, it is very important to get the joint moving as soon as possible and to keep the muscles strong. For articular cartilage problems such as arthritis or chondromalacia, I recommend a low-impact exercise program that strengthens the muscles without stressing the joint. Activities such as swimming, riding a stationary bicycle, or even using a cross-country ski machine could be beneficial. (If you use a stationary bicycle, set the seat in such a way so that you do not bend you knee more than 90 degrees, because it often causes discomfort.) If you are disciplined about exercising, you may work out on your own. However, if you exercise haphazardly, you may need to work out with a trainer or at an exercise rehabilitation center. In this world of medical cost containment, there will unquestionably be a cutback in rehabilitative services, so that patients will be required to exercise on their own.“Washing Out” the Joint
Very often, a patient with an injured joint may have difficulty extending her leg and keeps the knee in a flexed position. This is often due to a protective spasm of the hamstrings, and gentle exercise may help return the leg to normal motion. However, a “locked” leg may also result from a torn or jagged piece of cartilage that is caught in the joint (either between the tibia and the femur or the patella and the femur) and is preventing full extension. If your doctor suspects that this is the case, he may arthroscope the knee to “wash out” the debris and smooth out the surface. Although this isn’t a permanent solution, many patients feel better.Reattaching the Cartilage
If a big piece of articular cartilage with its underlying bone is ripped off in an injury, it may be possible to reattach it back into position using wires or absorbable pins. If indeed, there is a significant bone attached, the injury is an osteochondral fracture, and if there is a short interval (roughly 4 to 8 weeks) between injury and surgery, there is an excellent chance that the fracture will heal if pinned back into position. If the injury does not include a bone surface, the articular cartilage by itself cannot be reattached with any certainty of success. Instead, attention is directed to the bone to produce fibrocartilage, which, although biomechanically inferior to articular cartilage, will fill the defect.
It would be wonderful if there was a synthetic material that could be used to “paint” back missing areas of articular cartilage. Unfortunately, there is nothing comparable that is available now. Although investigation and experimentation is being done, today there are only three methods of replacing absent cartilage:
Procedures designed to stimulate or regenerate the growth of cartilage cells.
Bulk allografts (bone transplants).
Cartilage cell growth and subsequent transplantation.Regeneration of Cartilage. Since the 1800s, scientists have dreamed of developing a way to get the body to regenerate articular cartilage, and although there have been some promising developments in this field, it is still highly experimental. In the body, cartilage is produced by special cells that, depending on their location, have the ability to produce either bone, fibrous tissue, or cartilage. We don’t know the precise triggers that “turn on” these cells and instruct them to produce cartilage. We do know, however, that injuring the bone can in many cases trigger the growth of cartilage. There are several ways that we do this, but basically they all involve making the bone bleed. In some cases, the surgeon will drill holes in the bone to stimulate these special cells to grow cartilage. Another procedure called abrasion arthroplasty involves a more aggressive procedure that causes more bleeding and hopefully produces more fibrocartilage. All of these procedures to stimulate fibrocartilage production can be done arthroscopically, but because the bone is actually involved, the procedures are associated with more discomfort than routine arthroscopy.
Bulk Allografts. Bulk allografts are pieces of bone and/or cartilage that are taken from a cadaver and put in the patient. For years, this procedure has been done in tumor patients. Unfortunately, many of these cancer patients also underwent chemotherapy and radiation treatments and thus were immunosuppressed, which made them prone to infection. As a result, there was a rather significant complication rate—as high as 50 percent—including severe infection, possibly requiring amputation.
The use of bulk allografts for cartilage transplantation in nonimmunosuppressed patients should result in a lower complication rate. As of this writing, however, there are too few cases to collect any significant data.
Cell Transplantation. Cell transplantation is another experimental method of replacing lost articular cartilage that has received a great deal of publicity lately. In this procedure, cartilage cells are taken from the patient and then cultured in the laboratory. The cells multiply, producing an abundance of cartilage, and then are reintroduced surgically into the patient. Theoretically, cell transplantation will heal, thus restoring the surface with normal articular cartilage. This experimental procedure was recently reported in the Scandanavian medical literature. The results were promising; however, the patient population was small and primarily had minor defects on either the patellar-femoral or tibia surface. The femoral surface defects appeared to do better than the tibial defects. As exciting as this new procedure may be, it leads many unanswered questions including: How big a defect can be filled? Will it be applicable to all three compartments—the patellar-femoral, the medial femoral-tibial, and the lateral femoral-tibial? Will the patient be able to return to sports? Only time and experience will answer these questions.
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1. Chewing
Chew all your food until it becomes liquid (at least 50 times per mouthful). Chewing is the very beginning of the digestive process; if we fail to fulfil this simple task we can cause havoc to the remainder of the digestive system.
Unfortunately many people eat on the run, or while preoccupied with other things and ingest them along with the food inflicting them on the digestive systems and perpetuating them. If we chew thoroughly we break this chain, as chewing causes us to slow down, creating a more harmonious eating experience, stress-free digestion and a happier digestive system.
Please remember to chew very well, especially if you have a tendency to overeat.
2. Exercise
Keeping physically active does not necessarily mean jogging or going to the gym. Each type of physical activity has a different effect upon our physical and mental state.
Long walks are especially recommended as is ‘constructive exercise’, like cleaning the house. House-cleaning not only gives you the opportunity to stretch your body in many ways as vigorously as you wish, but also creates order in your immediate external environment, and so in your body and your mind. Ever tried thinking clearly in a chaotic room?
We tend to choose leisure activities that compound our nature, so that a more physically aggressive person will take up some vigorous sport, whereas someone who is inclined to daydream will gravitate towards meditation. However, very often the more physically oriented person would benefit from meditation, just as the person leading a more sedentary life would benefit from something more vigorous. Choose some activity that complements and harmonizes your nature.
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The best that can happen is that your child will remain seizure free and that there will be an improvement in his learning and behavior. Many adults say, “I’m not so tired any more. I feel so much better. I can think much more clearly.” Many parents say, “Mary is a different child.
Her school work is better. She’s not so irritable and she’s not so tired all the time. I never realized the medicine was affecting her in that way.” Another benefit is that your child would not have to take medication each day, a reminder of his potential problem. He would no longer have “controlled” epilepsy. Now he would be either “recovered” or “cured” and could get on with his life, unimpeded.
For the normal child who has only a 5 to 10 percent chance of having another seizure, we would recommend discontinuing medication. In general, the consequences, should a seizure recur, will be small. For the handicapped child who may have a 50 percent chance of another seizure, we would also recommend trying to discontinue medication. The consequences of another seizure for him are also small, but since he may be less able to compensate for the subtle effects of medication on learning and behavior, the benefits of being free of medication may be even greater. Should a seizure recur, and if it is apparent that the child is functioning better off the original medication, it may be possible to substitute a less toxic anticonvulsant.
On balance, we believe that avoiding the chronic effects of medication and their effects on learning and psychological function outweigh the risks of another seizure in most children who have been seizure-free for two years.
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