DIET AND CANCER: SPECIFIC ASPECTS OF DIET – FAT

The intake of fat (and particularly animal fats) has been put forward as an important causative factor in breast cancer. The story starts with comparisons made between the fat intake of individuals in particular countries and deaths from breast cancer in those countries. Detailed statistics are not necessary to demonstrate that countries with a high fat intake in the diet are also those where breast cancer is common. Other studies show that the association is mainly with saturated animal tat in the diet. At first glance, this is strong evidence, and indeed it is important and cannot be ignored but it does not prove that there is a link between dietary fat and breast cancer. The information on fat consumption in these countries is not very precise. It tends to be what is known as ‘disappearance data’. The fats enter the food distribution system and disappear from it. That means a lot of them will have been eaten but that some will have been cut off and thrown away. More importantly, this link is an association and not necessarily a causation. Going back to the argument that we considered when we talked about the work of epidemiologists it will be recognized that this distinction is a very important one indeed. There are many differences between the countries on that list. In general, the rich countries have a high fat intake with lots of meat and the poor countries have a lower fat intake because their diet is generally less rich. In fact the link between gross national product and breast cancer is almost as strong as the link to animal fats. It may be any one of the factors that contribute to the wealth of these countries which is important in the development of breast cancer. Something in the difference between these countries is responsible for the different incidence of breast cancer but we don’t know what it is on the basis of the evidence given so far. It means that we have to explore further to find an answer.
What about the cohort studies? The reader will recall that in this approach groups of people are identified and the dietary flat history is taken. They are then followed over a long period of rime to see who gets breast cancer and to find out if there is any connection with their dietary fat intake as measured at the beginning of the study. Three large studies of this kind have been published during the 1980s. In the United States, the Seventh Day Adventists were followed for twenty-one years. Again in the United States, 89,538 nurses aged between thirty-four and fury-nine were followed up after giving a dietary history. In a smaller US study over five thousand women were followed up. These were immensely difficult studies to perform and requited a big logistic effort. Again it has to be said that the results were essentially negative. Ho link was found between dietary fat and breast cancer in the cohort studies.
Ideally, the whole question could be resolved by an intervention study in which some women would agree to reduce their dietary fat substantially while others would not, and we could then sec if there was a reduction in the breast cancer incidence in those who had reduced their fat. It has been argued that this should be done, but no such study has been undertaken. Preliminary work has suggested that it might be possible but that it would be a hugely expensive and very time-consuming effort, with large numbers of people having to make substantial changes in their diet. Until the kind of information that we would get from an intervention study is available we will not have a certain answer, but, in our opinion, the balance of the evidence at present is rather against a strong link between dietary fat and breast cancer.
The studies of differences between countries in fat intake and incidence of breast cancer seem to point in one direction, although not conclusively. The case-control studies and cohort studies seem to point in the opposite direction. How can we explain this?
One response to this is to say that the situation is not really confused. A perfectly consistent explanation for all the observations would be that there is no causative link between dietary fat and breast cancer. The case-control studies and the cohort studies by the analytical epidemiologists are negative and this is in keeping with this view. The comparisons between countries do not prove a causative link, they just show that there is an association and there may be another explanation that we have not yet uncovered.
*57\194\4*

DIET AND CANCER: SPECIFIC ASPECTS OF DIET – FATThe intake of fat (and particularly animal fats) has been put forward as an important causative factor in breast cancer. The story starts with comparisons made between the fat intake of individuals in particular countries and deaths from breast cancer in those countries. Detailed statistics are not necessary to demonstrate that countries with a high fat intake in the diet are also those where breast cancer is common. Other studies show that the association is mainly with saturated animal tat in the diet. At first glance, this is strong evidence, and indeed it is important and cannot be ignored but it does not prove that there is a link between dietary fat and breast cancer. The information on fat consumption in these countries is not very precise. It tends to be what is known as ‘disappearance data’. The fats enter the food distribution system and disappear from it. That means a lot of them will have been eaten but that some will have been cut off and thrown away. More importantly, this link is an association and not necessarily a causation. Going back to the argument that we considered when we talked about the work of epidemiologists it will be recognized that this distinction is a very important one indeed. There are many differences between the countries on that list. In general, the rich countries have a high fat intake with lots of meat and the poor countries have a lower fat intake because their diet is generally less rich. In fact the link between gross national product and breast cancer is almost as strong as the link to animal fats. It may be any one of the factors that contribute to the wealth of these countries which is important in the development of breast cancer. Something in the difference between these countries is responsible for the different incidence of breast cancer but we don’t know what it is on the basis of the evidence given so far. It means that we have to explore further to find an answer.What about the cohort studies? The reader will recall that in this approach groups of people are identified and the dietary flat history is taken. They are then followed over a long period of rime to see who gets breast cancer and to find out if there is any connection with their dietary fat intake as measured at the beginning of the study. Three large studies of this kind have been published during the 1980s. In the United States, the Seventh Day Adventists were followed for twenty-one years. Again in the United States, 89,538 nurses aged between thirty-four and fury-nine were followed up after giving a dietary history. In a smaller US study over five thousand women were followed up. These were immensely difficult studies to perform and requited a big logistic effort. Again it has to be said that the results were essentially negative. Ho link was found between dietary fat and breast cancer in the cohort studies.Ideally, the whole question could be resolved by an intervention study in which some women would agree to reduce their dietary fat substantially while others would not, and we could then sec if there was a reduction in the breast cancer incidence in those who had reduced their fat. It has been argued that this should be done, but no such study has been undertaken. Preliminary work has suggested that it might be possible but that it would be a hugely expensive and very time-consuming effort, with large numbers of people having to make substantial changes in their diet. Until the kind of information that we would get from an intervention study is available we will not have a certain answer, but, in our opinion, the balance of the evidence at present is rather against a strong link between dietary fat and breast cancer.The studies of differences between countries in fat intake and incidence of breast cancer seem to point in one direction, although not conclusively. The case-control studies and cohort studies seem to point in the opposite direction. How can we explain this?One response to this is to say that the situation is not really confused. A perfectly consistent explanation for all the observations would be that there is no causative link between dietary fat and breast cancer. The case-control studies and the cohort studies by the analytical epidemiologists are negative and this is in keeping with this view. The comparisons between countries do not prove a causative link, they just show that there is an association and there may be another explanation that we have not yet uncovered.*57\194\4*

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LOW BACK CONDITIONS : STRESS AND SPASMS OF THE NECK

In a pathological situation, the stress is continuous or the reaction is almost permanent. The body behaves as if it is in a constant state of preparedness for a ‘fight’ or ‘flight’ reaction. Pathological stress is characterised by palpitations, hyperventilation, panic attacks (a combination of anxiety, palpitation, hyperventilation etc), high blood pressure, insomnia, irritability and of course muscle tension. This tension or spasm in muscles spreads all over from the jaws to the spinal muscles. The body and mind get conditioned like the Pavlovian dogs.
Tension in spinal muscles causes them to shrink in volume and decrease in length to some degree. The continuous spasm of back or spinal muscles, squashes or compresses the discs as the length of the spine is shortened. The tightness of back muscles can increase the pressure on the vertebral column and of course its disalignment at joints or compression of the discs. This is the cause of acute low backache.
Spasm of neck muscles due to stress causes decrease in blood flow through the vertebral arteries. That causes reduction of blood flow to the subconscious brain, the exact anatomical area that houses the centres for muscle tone and involuntary centres that control erect posture. Thus the muscles that stretch the spine upwards lose their power and the vertebral column loses its power to remain erect. As a result of that, scoliosis sets in. In fact most scoliosis in children is caused by the stress factor. They have abnormal spasms of muscles, which distort the normal curvature of the spine.
This loss of power in the upward-stretching muscles that maintain the erect posture, reduces the anti-gravitational force, which could be another reason why discs compress with stress. This, however, happens in the chronic stage when the stress factor is permanent and its effect is overwhelming. This is the cause of chronic low backache. Thus we can see that stress can cause acute and chronic backache, depending on the period through which they exist. Acute stress causes instant tightening of muscles and compression of discs. Chronic stress causes impaired functions of posture-maintaining nerve centres, which ultimately reduce the anti-gravitational force resulting in the disc compression.
*192\330\8*

LOW BACK CONDITIONS :  STRESS AND SPASMS OF THE NECKIn a pathological situation, the stress is continuous or the reaction is almost permanent. The body behaves as if it is in a constant state of preparedness for a ‘fight’ or ‘flight’ reaction. Pathological stress is characterised by palpitations, hyperventilation, panic attacks (a combination of anxiety, palpitation, hyperventilation etc), high blood pressure, insomnia, irritability and of course muscle tension. This tension or spasm in muscles spreads all over from the jaws to the spinal muscles. The body and mind get conditioned like the Pavlovian dogs.Tension in spinal muscles causes them to shrink in volume and decrease in length to some degree. The continuous spasm of back or spinal muscles, squashes or compresses the discs as the length of the spine is shortened. The tightness of back muscles can increase the pressure on the vertebral column and of course its disalignment at joints or compression of the discs. This is the cause of acute low backache.Spasm of neck muscles due to stress causes decrease in blood flow through the vertebral arteries. That causes reduction of blood flow to the subconscious brain, the exact anatomical area that houses the centres for muscle tone and involuntary centres that control erect posture. Thus the muscles that stretch the spine upwards lose their power and the vertebral column loses its power to remain erect. As a result of that, scoliosis sets in. In fact most scoliosis in children is caused by the stress factor. They have abnormal spasms of muscles, which distort the normal curvature of the spine.This loss of power in the upward-stretching muscles that maintain the erect posture, reduces the anti-gravitational force, which could be another reason why discs compress with stress. This, however, happens in the chronic stage when the stress factor is permanent and its effect is overwhelming. This is the cause of chronic low backache. Thus we can see that stress can cause acute and chronic backache, depending on the period through which they exist. Acute stress causes instant tightening of muscles and compression of discs. Chronic stress causes impaired functions of posture-maintaining nerve centres, which ultimately reduce the anti-gravitational force resulting in the disc compression.*192\330\8*

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BDD TREATMENTS THAT DON’T WORK: HOW MANY PEOPLE GET SURGERY, DERMATOLOGIC TREATMENT, AND OTHER NONPSYCHIATRIC MEDICAL TREATMENT FOR BDD?

Studies have found that 6%-20% of people seeking cosmetic surgery have BDD. One of these studies found that only 7% of women seeking cosmetic surgery had BDD, whereas 33% of the men did. While more studies are needed to confirm these findings, they suggest that a substantial proportion of people— especially men—who have cosmetic surgery may have BDD. In a study that I and my dermatologist colleagues did, 12% of 268 patients seen by the dermatologists had probable BDD. In a study in Turkey, 9% of 159 patients seen by a dermatologist had BDD. These percentages, too, are fairly high.
What about the flip side of this question: the percentage of people with BDD who seek and receive these types of treatments? In a study I did of 250 adults with BDD who saw me for an evaluation or treatment, a majority of them (76%) had sought surgery or medical treatment for their perceived appearance flaws. These 250 individuals requested a total of 785 treatments, so most of them had requested multiple treatments. One person had sought 35 different treatments! Two thirds of the 250 people had actually received surgery or another medical treatment. The group as a whole had actually received a total of 484 such treatments. The results from my series of 200 people with BDD were very similar. In other words, people with BDD seek and receive a lot of nonpsychiatric treatment.
Dermatologic treatment was the type most often asked for and received. It was sought by 55% and received by 45% of the 250 people with BDD. This makes sense when you consider that skin and hair preoccupations are the most common BDD concerns. People most often were treated with antibiotics, but they also received other treatments such as minoxidil for perceived hair thinning. Some even got very powerful treatments—isotretinoin (Accutane) or dermabrasion – for precieved or minimal acne.
*342\204\8*

BDD TREATMENTS THAT DON’T WORK: HOW MANY PEOPLE GET SURGERY, DERMATOLOGIC TREATMENT, AND OTHER NONPSYCHIATRIC MEDICAL TREATMENT FOR BDD?Studies have found that 6%-20% of people seeking cosmetic surgery have BDD. One of these studies found that only 7% of women seeking cosmetic surgery had BDD, whereas 33% of the men did. While more studies are needed to confirm these findings, they suggest that a substantial proportion of people— especially men—who have cosmetic surgery may have BDD. In a study that I and my dermatologist colleagues did, 12% of 268 patients seen by the dermatologists had probable BDD. In a study in Turkey, 9% of 159 patients seen by a dermatologist had BDD. These percentages, too, are fairly high.What about the flip side of this question: the percentage of people with BDD who seek and receive these types of treatments? In a study I did of 250 adults with BDD who saw me for an evaluation or treatment, a majority of them (76%) had sought surgery or medical treatment for their perceived appearance flaws. These 250 individuals requested a total of 785 treatments, so most of them had requested multiple treatments. One person had sought 35 different treatments! Two thirds of the 250 people had actually received surgery or another medical treatment. The group as a whole had actually received a total of 484 such treatments. The results from my series of 200 people with BDD were very similar. In other words, people with BDD seek and receive a lot of nonpsychiatric treatment.Dermatologic treatment was the type most often asked for and received. It was sought by 55% and received by 45% of the 250 people with BDD. This makes sense when you consider that skin and hair preoccupations are the most common BDD concerns. People most often were treated with antibiotics, but they also received other treatments such as minoxidil for perceived hair thinning. Some even got very powerful treatments—isotretinoin (Accutane) or dermabrasion – for precieved or minimal acne.*342\204\8*

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IBS AND FOOD INTOLERANCE

We are all familiar with stories of severe allergic reactions where a person reacts violently to one food and has to avoid it for life; we hear people say: ‘I dare not eat fish/strawberries/peanuts/eggs because my mouth swells up, my eyes itch and I have trouble breathing.’ This condition is widely recognized by the medical profession and it is accepted that prompt medical intervention is often necessary. The condition that is less well known and accepted medically is that of food intolerance.
What Happens in Food Intolerance?
The toxic colon and Candida have already been discussed. Because of these and other conditions including damage from drugs and pollution, it seems our digestive systems are becoming less efficient. Because of this, larger molecules of undigested food are allowed to pass into the bloodstream. The immune system attacks them because they are unfamiliar and the result can be trouble in any part of the body. The symptoms are not dramatic and easily recognized, as in food allergy, but there can be a confusion of odd symptoms which may mimic numerous other conditions such as asthma or arthritis. After years of this problem the sufferer can have severe weight loss and be completely exhausted. Milder symptoms include:
• bloating
• flushing
• palpitations
• headache
• anxiety or depression after eating the offending foods.
*80\326\8*

IBS AND FOOD INTOLERANCEWe are all familiar with stories of severe allergic reactions where a person reacts violently to one food and has to avoid it for life; we hear people say: ‘I dare not eat fish/strawberries/peanuts/eggs because my mouth swells up, my eyes itch and I have trouble breathing.’ This condition is widely recognized by the medical profession and it is accepted that prompt medical intervention is often necessary. The condition that is less well known and accepted medically is that of food intolerance.What Happens in Food Intolerance?The toxic colon and Candida have already been discussed. Because of these and other conditions including damage from drugs and pollution, it seems our digestive systems are becoming less efficient. Because of this, larger molecules of undigested food are allowed to pass into the bloodstream. The immune system attacks them because they are unfamiliar and the result can be trouble in any part of the body. The symptoms are not dramatic and easily recognized, as in food allergy, but there can be a confusion of odd symptoms which may mimic numerous other conditions such as asthma or arthritis. After years of this problem the sufferer can have severe weight loss and be completely exhausted. Milder symptoms include:• bloating• flushing• palpitations• headache• anxiety or depression after eating the offending foods.*80\326\8*

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LIVING WITH EPILEPSY/SCHOOL: LEARNING AND BEHAVIOR – LEARNING BY LISTENING

Learning by listening is also a multi-stage process. It involves hearing and paying attention to what is said. It involves transmission of the electrical signals to the association cortex where they must be recognized and associated with memories and actions. Thus, another type of learning problem might be associated with problems in hearing, attending, word recognition, and the association of words with memories.
These are but two of the many multi-step processes that may cause a child to have difficulties with learning. It is rare for anyone to be completely abnormal. More commonly, the child seems to function poorly in one or more processes, with a learning problem the result. Some children learn better by listening to information, others by reading information. Most children will find their own best learning style. Some children with greater weaknesses in one area will require special help to get around their areas of difficulty and to maximize their strengths.
A child who is having learning problems in school, whether he has epilepsy or not, should receive a careful psychological and educational evaluation to identify his areas of strengths arid weaknesses. Only then will the teachers be able to find the best way to help that child to learn. For some children this will mean extra help. For others it may require resource teachers with special training. For still others it may mean repeating a grade, being placed in a slower class, or being placed in a special education class. Each child and his problems are unique. The child and his problems must be individually assessed and a plan developed to meet that child’s specific needs. All of these statements are true for the child with learning problems, whether or not that child has epilepsy. They are not different for the child with epilepsy, the problems are only more common.
*243\208\8*

LIVING WITH EPILEPSY/SCHOOL: LEARNING AND BEHAVIOR  - LEARNING BY LISTENINGLearning by listening is also a multi-stage process. It involves hearing and paying attention to what is said. It involves transmission of the electrical signals to the association cortex where they must be recognized and associated with memories and actions. Thus, another type of learning problem might be associated with problems in hearing, attending, word recognition, and the association of words with memories.These are but two of the many multi-step processes that may cause a child to have difficulties with learning. It is rare for anyone to be completely abnormal. More commonly, the child seems to function poorly in one or more processes, with a learning problem the result. Some children learn better by listening to information, others by reading information. Most children will find their own best learning style. Some children with greater weaknesses in one area will require special help to get around their areas of difficulty and to maximize their strengths.A child who is having learning problems in school, whether he has epilepsy or not, should receive a careful psychological and educational evaluation to identify his areas of strengths arid weaknesses. Only then will the teachers be able to find the best way to help that child to learn. For some children this will mean extra help. For others it may require resource teachers with special training. For still others it may mean repeating a grade, being placed in a slower class, or being placed in a special education class. Each child and his problems are unique. The child and his problems must be individually assessed and a plan developed to meet that child’s specific needs. All of these statements are true for the child with learning problems, whether or not that child has epilepsy. They are not different for the child with epilepsy, the problems are only more common.*243\208\8*

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REDUCING YOUR RISK OF CORONARY ARTERY DISEASE: HANDLING STRESS – STRESS MANAGEMENT TECHNIQUES – AVOID DEPENDING ON STIMULANTS & EXERCISE

Avoid depending on stimulants such as excessive caffeine, alcohol, and nicotine to regulate your moods.
Exercise.   Henry  David  Thoreau found that chopping wood not only helped cure him of loneliness in his self-imposed isolation at Walden Pond but also helped him get over mental blocks in his writing. Exercise may improve your blood pressure, lower triglycerides and raise HDL cholesterol improve glucose tolerance and prevent or reverse type II diabetes, help you lose weight, and, of course, make you more physically fit. Exercise also helps reduce anxiety and may help reduce mild depression and raise self-esteem. When you think of it, exercise is the appropriate action for the physiological ‘fight-or-flight’ stress response.
*326\252\8*

REDUCING YOUR RISK OF CORONARY ARTERY DISEASE: HANDLING STRESS – STRESS MANAGEMENT TECHNIQUES – AVOID DEPENDING ON STIMULANTS & EXERCISEAvoid depending on stimulants such as excessive caffeine, alcohol, and nicotine to regulate your moods.Exercise.   Henry  David  Thoreau found that chopping wood not only helped cure him of loneliness in his self-imposed isolation at Walden Pond but also helped him get over mental blocks in his writing. Exercise may improve your blood pressure, lower triglycerides and raise HDL cholesterol improve glucose tolerance and prevent or reverse type II diabetes, help you lose weight, and, of course, make you more physically fit. Exercise also helps reduce anxiety and may help reduce mild depression and raise self-esteem. When you think of it, exercise is the appropriate action for the physiological ‘fight-or-flight’ stress response.   *326\252\8*

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LES OBVIOUS CAUSES OF HYPERTENSION: ENDOCRINE CONDITIONS

Hypertension is also associated with various endocrine (hormonal) problems, including Cushing’s disease and thyroid disorders. Researcher Dr. Peter К. T. Pang has presented new evidence that a particular hormone called parathyroid hypertensive factor (PHF) plays a part in hypertension in some people. Dr. Pang first discovered that the PHF hormone was present in blood samples of hypertensive animals. When he injected a PHF antibody into hypertensive animals, their blood pressure went down. This finding is an outcome of relatively new research, but its conclusions are quite convincing. As more PHF research is done, including investigating new treatments aimed at this cause, I’m sure we will be hearing more about PHF and hypertension in the near future.
Female menopause and its male counterpart, andropause (declining testosterone levels in middle-aged men), also belong in this category, since a reduction of some sex hormones can result in increased blood pressure. High blood pressure may also develop rapidly toward the end of pregnancy, and in pregnant women who already have hypertension, it often becomes more severe. In most cases, high blood pressure that develops during pregnancy returns to normal after delivery.
*46/313/5*

LES OBVIOUS CAUSES OF HYPERTENSION: ENDOCRINE CONDITIONSHypertension is also associated with various endocrine (hormonal) problems, including Cushing’s disease and thyroid disorders. Researcher Dr. Peter К. T. Pang has presented new evidence that a particular hormone called parathyroid hypertensive factor (PHF) plays a part in hypertension in some people. Dr. Pang first discovered that the PHF hormone was present in blood samples of hypertensive animals. When he injected a PHF antibody into hypertensive animals, their blood pressure went down. This finding is an outcome of relatively new research, but its conclusions are quite convincing. As more PHF research is done, including investigating new treatments aimed at this cause, I’m sure we will be hearing more about PHF and hypertension in the near future.Female menopause and its male counterpart, andropause (declining testosterone levels in middle-aged men), also belong in this category, since a reduction of some sex hormones can result in increased blood pressure. High blood pressure may also develop rapidly toward the end of pregnancy, and in pregnant women who already have hypertension, it often becomes more severe. In most cases, high blood pressure that develops during pregnancy returns to normal after delivery.*46/313/5*

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HIV: RESOURCES-WHERE TO GO FOR HELP: TYPES OF SERVICES

Many organizations offer help of different types to people affected by HIV. The list of these resources, however, is a moving target. Any such list—and there are many—gets outdated fast. New organizations spring up, change the services they offer, change their addresses and phone numbers, expand, merge, or go out of business. Most lists of resources are updated every few months.
Given that, the best thing this book can do is list the types of services that can be available to people affected by HIV, list a few national resources that offer these services, and offer advice on how to find resources that are local.
Types of Services-The types of services an organization offers will depend on, among other things, the purpose of the organization and its geographical location. The range of services is immense, from problems specific to some people (e.g., Spanish-speaking educational counselors) to problems shared by everyone with HIV infection (education on preventing transmission). If the organizations do not offer the services themselves, they will recommend other organizations that do offer the services.
The following is a list of the services organizations may offer. If you need any of these services, call a national organization (see below) to find who in your local area offers the services. Or find a local resource (see below) that offers them.
Alcoholism: the national organization Alcoholics Anonymous (AA) has information on which of its local branches offer groups specific to people with HIV infection who also have problems with alcohol.
Buddy systems: buddies are volunteers, sometimes trained, who provide services that range from filling prescriptions and driving you to the grocery store to cleaning the refrigerator and holding hands.
Children with HIV infection
Counseling: can be individual or group counseling (see below, Support groups)
Drug use and HIV infection
Financial problems
Government reports
HIV testing
Home health care
Hospice care
Hotlines: toll-free phone numbers, either community, state, or national. Ask any question about HIV infection and about services available to people with HIV infection.
Housing problems
Insurance problems
Legal services
Minorities and HIV infection, including organizations with
Spanish-speaking counselors
Nursing homes
Physician referral
Political action, speakers’ bureaus
Preventing transmission of HIV
Religious counseling
Safer sex
Scientific research reports
Sexually transmitted disease testing and treatment
Social workers, who help with plans for recuperating at home, with plans for finances and insurance, with recommendations to different organizations. They are hired by mental health centers, churches, social service agencies, and virtually all hospitals.
Support groups: groups can be specifically for women, gays, drug users couples, caregivers, spouses, the worried well, and people who are HIV-positive, or who have ARC, or who have AIDS.
Transportation
Visiting nurse programs
Women and HIV infection
*249\191\2*

HIV: RESOURCES-WHERE TO GO FOR HELP: TYPES OF SERVICESMany organizations offer help of different types to people affected by HIV. The list of these resources, however, is a moving target. Any such list—and there are many—gets outdated fast. New organizations spring up, change the services they offer, change their addresses and phone numbers, expand, merge, or go out of business. Most lists of resources are updated every few months.     Given that, the best thing this book can do is list the types of services that can be available to people affected by HIV, list a few national resources that offer these services, and offer advice on how to find resources that are local.     Types of Services-The types of services an organization offers will depend on, among other things, the purpose of the organization and its geographical location. The range of services is immense, from problems specific to some people (e.g., Spanish-speaking educational counselors) to problems shared by everyone with HIV infection (education on preventing transmission). If the organizations do not offer the services themselves, they will recommend other organizations that do offer the services.     The following is a list of the services organizations may offer. If you need any of these services, call a national organization (see below) to find who in your local area offers the services. Or find a local resource (see below) that offers them.     Alcoholism: the national organization Alcoholics Anonymous (AA) has information on which of its local branches offer groups specific to people with HIV infection who also have problems with alcohol.     Buddy systems: buddies are volunteers, sometimes trained, who provide services that range from filling prescriptions and driving you to the grocery store to cleaning the refrigerator and holding hands.     Children with HIV infection     Counseling: can be individual or group counseling (see below, Support groups)     Drug use and HIV infection      Financial problems      Government reports      HIV testing      Home health care      Hospice care     Hotlines: toll-free phone numbers, either community, state, or national. Ask any question about HIV infection and about services available to people with HIV infection.     Housing problems      Insurance problems      Legal services     Minorities and HIV infection, including organizations with      Spanish-speaking counselors     Nursing homes     Physician referral     Political action, speakers’ bureaus     Preventing transmission of HIV     Religious counseling     Safer sex     Scientific research reports     Sexually transmitted disease testing and treatment     Social workers, who help with plans for recuperating at home, with plans for finances and insurance, with recommendations to different organizations. They are hired by mental health centers, churches, social service agencies, and virtually all hospitals.     Support groups: groups can be specifically for women, gays, drug users couples, caregivers, spouses, the worried well, and people who are HIV-positive, or who have ARC, or who have AIDS.     Transportation      Visiting nurse programs      Women and HIV infection*249\191\2*

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PATHOGENESIS AND CLINICAL PRESENTATION OF TULAREMIA

Francisella tularensis, the causative agent of tularemia, is an aerobic, gram-negative coccobacillus. Tularemia is a zoonotic disease that humans may acquire through diverse environmental exposures and can develop into a severe and sometimes fatal illness. Voles, mice, squirrels, rabbits, and hares are natural reservoirs of infection. Humans may acquire infection in various ways:
- Bite from an infected arthropod (tick, deerfly, mosquito)
- Handling infectious animal tissues
- Ingestion of contaminated foods or liquids
- Inhalation of infected aerosols
Transmission from person to person has not been documented. An aerosol release would be the most likely route used in a bioterrorist event.
Pathogenesis
After F. tularensis is inoculated into the skin, mucous membranes, gastrointestinal tract, or lungs, the organisms are taken up by macrophages, where they multiply and spread to regional lymph nodes. The bacteria can then disseminate to organs throughout the body, particularly targeting the lymph nodes, spleen, liver, lungs, and kidneys. Bacteremia may be present during dissemination. F. tularensis can remain viable in the environment for weeks and is able to resist temperatures below freezing. However, it is easily killed by heat and disinfectants.
Clinical Presentation
Clinical illness due to tularemia occurs after an incubation period of 1 to 21 days (average, 3 to 5 days), and as few as 10 to 50 organisms may cause disease. The onset of tularemia is abrupt and is characterized by fever, headaches, rigors, and generalized body aches (especially low back). Patients occasionally complain of abdominal pain, diarrhea, and vomiting. Pulmonary symptoms include a dry or slightly productive cough, substernal chest discomfort, dyspnea, and pleurisy. A pulse-temperature deficit is found in less than half of patients. The overall case-fatality rate is approximately 2%.
Tularemia can appear in one of six forms in humans, depending on the route of inoculation:
Ulceroglandular tularemia usually occurs following an infected arthropod bite but may also be acquired after the inoculation of skin with infected blood or body fluids. A papule usually appears at the inoculation site, becomes pustular, and then ulcerates. Fever, chills, headaches, and malaise accompany the cutaneous findings. Regional lymphadenitis occurs within days of the appearance of the papule.
Oculoglandular tularemia follows inoculation of the conjunctiva by contaminated hands, infected tissue fluids, or infectious aerosols. Patients have painful, purulent conjunctivitis with preauricular or cervical lymphadenopathy. Fever, chemosis, periorbital edema, and pinpoint conjunctival ulcers may also be noted.
Glandular tularemia is characterized by fever and tender lymphadenopathy, without ulceration.
Oropharyngeal tularemia may be acquired by ingesting contaminated foods or liquids or by inhaling infectious aerosols. Patients typically develop an acute exudative pharyngotonsillitis with cervical or retropharyngeal lymphadenopathy.
Typhoidal tularemia occurs mainly after inhalation of infectious aerosols but can occur after intradermal or gastrointestinal inoculation. This is a systemic illness characterized by fever, headaches, weight loss, and malaise without lymphadenopathy. Abdominal tenderness and he-patosplenomegaly may be present on physical examination. Patients may develop shock, delirium, or coma.
Pneumonic tularemia may occur after the inhalation of organisms (primary disease) or following the hematogenous spread of any form of tularemia to the lungs (secondary disease). Disease onset is abrupt, with high fevers, dyspnea, nonproductive cough, and pleuritic chest pain. Patients may rarely develop mucopurulent sputum or hemoptysis. On examination, inspiratory crackles may be heard in the involved areas of the lungs, and pleural friction rubs are common.
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PATHOGENESIS AND CLINICAL PRESENTATION OF TULAREMIAFrancisella tularensis, the causative agent of tularemia, is an aerobic, gram-negative coccobacillus. Tularemia is a zoonotic disease that humans may acquire through diverse environmental exposures and can develop into a severe and sometimes fatal illness. Voles, mice, squirrels, rabbits, and hares are natural reservoirs of infection. Humans may acquire infection in various ways:- Bite from an infected arthropod (tick, deerfly, mosquito)- Handling infectious animal tissues- Ingestion of contaminated foods or liquids- Inhalation of infected aerosolsTransmission from person to person has not been documented. An aerosol release would be the most likely route used in a bioterrorist event.
PathogenesisAfter F. tularensis is inoculated into the skin, mucous membranes, gastrointestinal tract, or lungs, the organisms are taken up by macrophages, where they multiply and spread to regional lymph nodes. The bacteria can then disseminate to organs throughout the body, particularly targeting the lymph nodes, spleen, liver, lungs, and kidneys. Bacteremia may be present during dissemination. F. tularensis can remain viable in the environment for weeks and is able to resist temperatures below freezing. However, it is easily killed by heat and disinfectants.
Clinical PresentationClinical illness due to tularemia occurs after an incubation period of 1 to 21 days (average, 3 to 5 days), and as few as 10 to 50 organisms may cause disease. The onset of tularemia is abrupt and is characterized by fever, headaches, rigors, and generalized body aches (especially low back). Patients occasionally complain of abdominal pain, diarrhea, and vomiting. Pulmonary symptoms include a dry or slightly productive cough, substernal chest discomfort, dyspnea, and pleurisy. A pulse-temperature deficit is found in less than half of patients. The overall case-fatality rate is approximately 2%.Tularemia can appear in one of six forms in humans, depending on the route of inoculation:Ulceroglandular tularemia usually occurs following an infected arthropod bite but may also be acquired after the inoculation of skin with infected blood or body fluids. A papule usually appears at the inoculation site, becomes pustular, and then ulcerates. Fever, chills, headaches, and malaise accompany the cutaneous findings. Regional lymphadenitis occurs within days of the appearance of the papule.Oculoglandular tularemia follows inoculation of the conjunctiva by contaminated hands, infected tissue fluids, or infectious aerosols. Patients have painful, purulent conjunctivitis with preauricular or cervical lymphadenopathy. Fever, chemosis, periorbital edema, and pinpoint conjunctival ulcers may also be noted.Glandular tularemia is characterized by fever and tender lymphadenopathy, without ulceration.Oropharyngeal tularemia may be acquired by ingesting contaminated foods or liquids or by inhaling infectious aerosols. Patients typically develop an acute exudative pharyngotonsillitis with cervical or retropharyngeal lymphadenopathy.Typhoidal tularemia occurs mainly after inhalation of infectious aerosols but can occur after intradermal or gastrointestinal inoculation. This is a systemic illness characterized by fever, headaches, weight loss, and malaise without lymphadenopathy. Abdominal tenderness and he-patosplenomegaly may be present on physical examination. Patients may develop shock, delirium, or coma.Pneumonic tularemia may occur after the inhalation of organisms (primary disease) or following the hematogenous spread of any form of tularemia to the lungs (secondary disease). Disease onset is abrupt, with high fevers, dyspnea, nonproductive cough, and pleuritic chest pain. Patients may rarely develop mucopurulent sputum or hemoptysis. On examination, inspiratory crackles may be heard in the involved areas of the lungs, and pleural friction rubs are common.*215/348/5*

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REQUIRED IMMUNIZATIONS: YELLOW FEVER

Immunization against yellow fever is required by certain countries for entry, according to WHO regulations. Yellow fever is a rare but potentially fatal viral infection that is endemic in equatorial Africa and South America, where the virus is transmitted by day-biting mosquito vectors. The clinical presentation of the disease ranges from a mild febrile illness to a life-threatening disease characterized by hepatitis, renal failure, hemorrhagic fever, and shock. Case-fatality rates range from 23% (sub-Saharan Africa) to 65% (South America). The CDC and WHO regularly publish listings of areas with current yellow fever activity.
Yellow fever vaccination is required for entry by many countries within the areas of endemicity. Other countries may require proof of vaccination if one is traveling from an endemic area to prevent introduction of the disease. It is important to note that several countries within the yellow fever endemic zones do not require the immunization. Thus, immunization should be based on risk of exposure and not requirements. Practitioners can obtain country-specific requirements for yellow fever vaccination from the CDC’s Health Information for International Travel. Yellow fever vaccine is recommended for persons older than 9 months of age who plan to live in or travel to areas where yellow fever is reported. Vaccination is also recommended for travel in rural areas of countries that do not officially report yellow fever but that lie within the endemic zone. For purposes of international travel, the vaccine must be administered at an approved yellow fever vaccination center. A list of these centers can be obtained from local or state departments of health. The vaccine is valid for 10 years and should be documented on the Official International Certificate of Vaccination Against Yellow Fever. The yellow fever vaccine (YF-VAX, Aventis Pasteur) is a live-attenuated virus preparation made from the 17D yellow fever strain grown in chick embryo cultures. It is delivered as a single subcutaneous inoculation of 0.5 mL and induces neutralizing antibodies in 99% of recipients within 30 days of receipt. Immunity is likely lifelong, but, as mentioned, revaccination is required at 10-year intervals.
Reactions to the yellow fever vaccine are generally mild and include headaches, myalgias, and low-grade fevers. However, an analysis of yellow fever vaccine recipients in the United States from 1990 to 1998 found that persons 65 years of age or older were at an increased risk for neurologic or systemic reactions. Thus, the vaccine’s use should be considered carefully in this population and given only to those traveling to areas that report yellow fever. Yellow fever vaccination is not recommended in immunocompromised persons or in those with egg allergies. Vaccination should also be avoided in pregnancy, and non-immune women should postpone travel to high-transmission areas until after delivery. If the travel itinerary of a pregnant woman does not present a substantial risk, and immunization is required only for entry, the pregnant traveler should be given a waiver letter from her physician. Pregnant women who must travel to areas with active ongoing transmission should be vaccinated, since it is believed that the small risk to the mother and fetus from the vaccine is outweighed by the risk of yellow fever. Serologic response to yellow fever vaccine is not inhibited by administration of other vaccines, although if live virus vaccines (varicella, MMR) are not given concurrently, their administration should be separated by 1 month.
*182/348/5*

REQUIRED IMMUNIZATIONS: YELLOW FEVERImmunization against yellow fever is required by certain countries for entry, according to WHO regulations. Yellow fever is a rare but potentially fatal viral infection that is endemic in equatorial Africa and South America, where the virus is transmitted by day-biting mosquito vectors. The clinical presentation of the disease ranges from a mild febrile illness to a life-threatening disease characterized by hepatitis, renal failure, hemorrhagic fever, and shock. Case-fatality rates range from 23% (sub-Saharan Africa) to 65% (South America). The CDC and WHO regularly publish listings of areas with current yellow fever activity.Yellow fever vaccination is required for entry by many countries within the areas of endemicity. Other countries may require proof of vaccination if one is traveling from an endemic area to prevent introduction of the disease. It is important to note that several countries within the yellow fever endemic zones do not require the immunization. Thus, immunization should be based on risk of exposure and not requirements. Practitioners can obtain country-specific requirements for yellow fever vaccination from the CDC’s Health Information for International Travel. Yellow fever vaccine is recommended for persons older than 9 months of age who plan to live in or travel to areas where yellow fever is reported. Vaccination is also recommended for travel in rural areas of countries that do not officially report yellow fever but that lie within the endemic zone. For purposes of international travel, the vaccine must be administered at an approved yellow fever vaccination center. A list of these centers can be obtained from local or state departments of health. The vaccine is valid for 10 years and should be documented on the Official International Certificate of Vaccination Against Yellow Fever. The yellow fever vaccine (YF-VAX, Aventis Pasteur) is a live-attenuated virus preparation made from the 17D yellow fever strain grown in chick embryo cultures. It is delivered as a single subcutaneous inoculation of 0.5 mL and induces neutralizing antibodies in 99% of recipients within 30 days of receipt. Immunity is likely lifelong, but, as mentioned, revaccination is required at 10-year intervals.Reactions to the yellow fever vaccine are generally mild and include headaches, myalgias, and low-grade fevers. However, an analysis of yellow fever vaccine recipients in the United States from 1990 to 1998 found that persons 65 years of age or older were at an increased risk for neurologic or systemic reactions. Thus, the vaccine’s use should be considered carefully in this population and given only to those traveling to areas that report yellow fever. Yellow fever vaccination is not recommended in immunocompromised persons or in those with egg allergies. Vaccination should also be avoided in pregnancy, and non-immune women should postpone travel to high-transmission areas until after delivery. If the travel itinerary of a pregnant woman does not present a substantial risk, and immunization is required only for entry, the pregnant traveler should be given a waiver letter from her physician. Pregnant women who must travel to areas with active ongoing transmission should be vaccinated, since it is believed that the small risk to the mother and fetus from the vaccine is outweighed by the risk of yellow fever. Serologic response to yellow fever vaccine is not inhibited by administration of other vaccines, although if live virus vaccines (varicella, MMR) are not given concurrently, their administration should be separated by 1 month.*182/348/5*

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