EXERCISES AND REHABILITATION IN RHEUMATOID ARTHRITIS: ENDURANCE, OR AEROBIC, EXERCISESIt is essential that you consult your doctor before beginning any aerobic program.When your arthritis is controlled, your joint flexibility is at its optimum, and your muscles are strengthened, you are ready to begin improving your stamina. Aerobic exercise will enhance your fitness by improving your heart and lung function as well as circulation.To gain aerobic benefits from your exercise, you must (1) raise your heart rate to a conditioning level known as the target heart rate; (2) maintain your target heart rate for fifteen to thirty minutes in each aerobic session; (3) perform your aerobic program at least three times each week.These three principles are your goal. They are not intended to be the first step, and most people do not gain all of the benefits from an aerobic program from the very beginning. If aerobic exercise is new to you, begin your program slowly. In time you will be fit enough to satisfy all three of these principles.Trying to perform too much aerobic exercise too soon is counterproductive. You may experience extreme fatigue, shortness of breath, dizziness, and increased joint pain. Don’t overdo it.*79/209/5*

BDD AND BODY IMAGE: WHAT IS BODY IMAGE?Body image—something we all have—is a complex concept. Researchers have offered various definitions over the years. One offered by psychologists Thomas Cash and Thomas Pruzinsky is the following: Body image consists of the internal, subjective representations of physical appearance and bodily experience. Another useful definition from Paul Schilder, is “the picture of our own body which we form in our mind; that is to say, the way in which the body appears to ourselves.” Body image is our internal self-portrait. BDD is a problem with body image, not actual appearance.Body image is an umbrella term for a large number of concepts. It consists of many dimensions and has been said to include such diverse concepts as the body’s position in space, perception of bodily sensations, and attractiveness. When even more broadly defined, it’s been referred to as body ego, body schema, and self-concept. Body image has been said to embrace our view of ourselves, not only physically but also psychologically, sociologically, and psychologically. Usually, however, narrower definitions (such as those of Drs. Cash and Pruzinsky) are used.The scientific literature on body image has a long and scholarly history. It’s been explored not only by neurologists, psychologists, and psychiatrists, but also by social scientists and philosophers. Luminaries such as Henry Head, Paul Schilder, Sigmund Freud, and Seymour Fisher have investigated such mysteries as how we distinguish self from non-self, and the cause of bizarre body-image experiences such as the phantom limb syndrome (the experience of still feeling the presence of one’s limb following amputation) and neglect (denial of the existence of parts of the body after brain damage).*209\204\8*

CLINICAL EVALUATION FOR RHEUMATOID ARTHRITIS: JOINTS, FATIGUE AND FIBROMYALGIAWhich joints are important in RA?In RA, the diarthrodial joints, or those that have a space between them and move, are the ones that are most affected-this means those joints like the jaw, the wrists, elbows, and those in the hands and feet. When a doctor examines a patient with the disease, he or she looks for symmetrical involvement of the joints of the wrist and the hands, though not every sore finger joint has to mirror one on the opposite hand. The knuckles of the hands and the toe joints are the most commonly affected.
Are the hands very important in RA?Yes, arthritis of the hands and wrist helps make the diagnosis. A swollen wrist or swollen knuckles are very important factors when making the diagnosis of RA.
Is fatigue common in rheumatoid arthritis?Fatigue is very common in the early and late stages of RA and may reflect the overall body inflammation present along with low-grade fever, aches, and pains that lead to numerous complications like depression and lack of sleep.
What is fibromyalgia?Fibromyalgia is a condition characterized by generalized soft-tissue achy pain and stiffness. This condition is common in those with RA and is felt in addition to arthritic pain. It is often dismissed as being “all in one’s head” because of the vagueness of the symptoms, but it is a very real, very painful condition.
How is fibromyalgia diagnosed?The pain must be widespread-felt above and below the waist and often on the left and the right sides of the body. In addition, there must be pain in the spinal bones of the neck or back or in the chest. There also may be low back pain. The doctor looks for trigger points of pain-eighteen areas of the body where, when pressure is applied, pain is felt in those with fibromyalgia. Pain-not just tenderness- must be felt in at least eleven of the eighteen pressure points to confirm a diagnosis of fibromyalgia.*24/141/5*

WHAT TO DO IF YOUR CHILD HAS A SECOND BIG SEIZURE: WHEN SHOULD YOU CALL FOR HELP OR AN AMBULANCE? – IS THERE ANYTHING ELSE I COULD DO DURING THE SEIZURE? WHAT ABOUT MOUTH-TO-MOUTH RESUSCITATION?”Is there anything else I could do during the seizure? Shouldn’t I put something in my child’s mouth to keep him from biting his tongue?”The answer is, “No, you should not.” Unfortunately, in many generalized seizures, the patient may bite his tongue. But putting something in the mouth is difficult. Prying the mouth open to put in a spoon or a stick is more likely to break a tooth. If, by chance, someone does have his mouth open early in the seizure, you could put a handkerchief or a shirt sleeve or something soft between the teeth to prevent biting of the tongue. Unfortunately, most people clench their teeth at the start of the seizure. Never put your finger in the person’s mouth because it can be badly bitten.”What about mouth-to-mouth resuscitation. Will this help?”No! The patient will breathe on his or her own. Plus, during the seizure, your mouth-to-mouth resuscitation cannot get air into the lungs.It is hard to watch somebody have a seizure and frustrating not to be able to intervene, to stop this terrible thing, not to be able to help. But the best thing you can do is to remain calm. By staying calm, others around you are more likely to remain calm, and when your child wakes up, often confused, he will be surrounded by a less hysterical, more supportive environment.*51\208\8*

THE BEVERLY HILLS DIET – PHASE ONE FIRST WEEK: THE INSIDE STORYDuring the first week, you will only be having fruit. Don’t forget to wait two hours before changing from one fruit to another. Before you decide to make that change, be sure you don’t want any more of the first fruit. Once you have finished it, you can’t go back to it.If your day ends with a limited-quantity item, remember that it’s the last thing you can eat. Save it until late in the evening so you don’t have to go hungry. You might even want to take it to bed with you. Remember, hungry is one thing you’ll never be again.When you buy your pineapple, make sure it is ripe. If it’s not it will make your mouth sore. (See Chapter VII on shopping.)If after looking over the first week’s diet, you think you might get tired of pineapple and papaya, don’t. Remember, it’s their little enzymes that are burning up the fat and digesting all that extra protein that’s clogging your system.Don’t think I’d fill your system with pineapple and papaya for no good reason. Pineapples, and to a lesser degree, strawberries, have a high concentration of the enzyme bromaline which interacts with and actuates the hydrochloric acid in your stomach to help burn up the fat.*67\251\8*

DEALING WITH UNPREDICTABLE PERIODS: SPOTTINGEvery time my husband and I have intercourse I notice that I stain afterwardsI am not in any pain during sex so I don’t understand why I’m bleeding.-K.Q.Poughkeepsie, New YorkA woman who spots after sex should immediately see a doctor. She might have a lesion or an erosion on her cervix, an active sore that is irritated during sex. There are also cases where spotting after sex has turned out to be a cervical growth—a cancer or a polyp. So a woman should make an appointment with her doctor to have a Pap smear and put her mind to rest that she does not have cancer. A cervical sore can be treated with medication, or eliminated with electrocautery or cryosurgery, a freezing technique. A cervical polyp must be surgically removed.If she has no cervical abnormalities, then her spotting might mean that her uterus is being irritated during active sex. In that case it is usual to experience some cramping and subsequent spotting.Every so often during masturbation, orgasm, or for no apparent reason, a woman feels a cramp and notices a slight stain which is usually the shedding of a few blood cells from the uterine lining. Sometimes an inadequate progesterone level during the last two weeks of a woman’s cycle might result in mild uterine contractions which cause bleeding. Most of the time this type of spotting is not dangerous, but if it happens two months in a row, a woman should visit a doctor who could treat her condition with progesterone in the form of tablets or suppositories.*51\333\2*

HOW MUCH HEART DISEASE IS CAUSED BY OBESITY?Increased insulin resistance caused by obesity often leads to a dyslipidaemic state, macrovascular atheroma formation, endothelial dysfunction and microvascular complications. Similarly, with the increased risk of hypertensive disease, cardiovascular disease is much more common in obese individuals.According to National Audit Office estimates: - the increased risk of an obese adult developing hypertension is 4.2-fold in women and 2.6-fold in men- the increased risk of myocardial infarction of 3.2 in women and 1.5 in men- the increased risk of angina of 1.8 in both men and women.In terms of causality, it has been stated that obesity is responsible for 17% of all cardiovascular disease. In other words, if obesity were wholly prevented or treated, 17% of cardiovascular cases would be prevented. In Canada in 1997 it was estimated that cardiovascular disease accounted for 54% of the direct costs of obesity. In primary care, almost one-third of cardiovascular patients have been found to be clinically obese.*4/312/5*

CANCER: EPIDEMIOLOGY – HOW CONCLUSIVE? (part 1)We have outlined the ways in which epidemiologists can describe and analyse the vast amount of information now being collected about human cancer in populations. Can they produce conclusions from these studies? The answer is: probably not from any single study. Only the intervention studies can generate precise answers to precise questions, and these are few and far between and very difficult to perform adequately. In most other situations, conclusions are reached by adding together the suggestions derived from the descriptive and the analytical studies, often when several such studies have been performed. In addition, facts that emerge from experimental science in the laboratory or from clinical sciences often need to be built into the overall equation before conclusions can be reached.Why are single descriptive studies often fallible? Even if we find that one population or group is more prone to cancer than another, we may have considerable difficulty in determining which factor (or combination of factors) is responsible for the higher incidence of the disease. It is very unlikely that the two populations or groups will be different from each other in only one respect or in a very limited number of ways. The number of variations between them (both environmental and generic) is likely to be enormous. The population which is more exposed to the risk (or combination of risks) in which the cancer epidemiologist is interested may be different from the other population in a host of other ways that could just as easily account for the higher incidence of cancer. A cancer may have many interacting causes, some of which are, as yet, unknown. The epidemiologist may thus overlook some of the variations between the exposure characteristics of the two populations which might explain the different rates of cancer.The ideas that we have to teat in epidemiology have to come either from initial observations in populations (like the connection between smoking and Jung cancer, or between occupation and certain cancers) or from the laboratory. We often do not have precise enough ideas to test, and some of our ideas may be wrong. We are fortunate when a clinician comes up with a due like that which occurred for Percival Pott from his observations of chimney-sweeps. Similar astute clinical observations have led on to other detailed epidemiological studies which have reached helpful conclusions. The link between bone cancer and the use of radioactive substances in manufacturing was first described this way, as was the link between asbestos and the very serious form of chest cancer known as mesothelioma.*19\194\4*

DIAGNOSING ASTHMA IN CHILDREN: PHYSICAL EXAMINATION – CLOSE COOPERATION WITH THE DOCTOR IS IN THE CHILD’S BEST INTERESTIt is important for the parents to remember that close cooperation with the doctor is in the child’s best interest. They should never shy away from discussing their child with the doctor, even when they may feel that the progress is slow.After having taken the history and physically examining the child, the doctor may feel the necessity of substantiating his findings with laboratory examinations, like X-ray of the chest, examination of the blood and analysis of the pattern of breathing by studying the results of Lung Function Tests like Peak Expiratory Flow Rate (PEFR) Function Test and /or Spirometery. (Discussed in Chapter 9—How to Ascertain Asthma: The Diagnostic Tests).Before prescribing medicines, the doctor would certainly need to know about the medicines, the child may already be taking and with what effect.A short clinical examination is conducted each time the child comes for follow up, and some laboratory investigations may need to be repeated so as to assess properly the course of this disease.*48\260\8*

RECOMMENDED IMMUNIZATIONS: HEPATITIS A AND IMMUNOGLOBULINThe risk of hepatitis A is present worldwide, particularly in areas where poor hygiene and sanitation allow fecal contamination of food or water. Hepatitis A is the most frequently occurring vaccine-preventable disease among travelers. The incidence of hepatitis A in non-immune travelers to a developing country is 3 cases per 100 persons per month, and this rises to 20 cases per 1000 persons per month in those who travel to rural areas where poor hygienic conditions are present.The development of inactivated hepatitis A virus vaccines in the mid-1990s made long-term protection against this infection possible. These vaccines are recommended for all international travelers except those going to destinations in North America (except Mexico), Western Europe, Japan, Australia, and New Zealand. There are two safe and highly efficacious inactivated hepatitis A virus vaccines available in the United States, Havrix (SmithKline Beecham) and VAQTA (Merck). The immunization schedule in adults for both formulations consists of a single 1.0 mL intramuscular dose. This is highly efficacious and lasts at least several years. For more sustained protection, one should get a single 1.0 mL booster 6 to 18 months later. After both injections, a traveler has protective antibody levels for at least 10 years. Travelers should preferably receive vaccination 4 weeks prior to departure to provide optimal immunity. Both vaccines provide protective antibody levels in 94% to 100% of patients within 4 weeks of vaccination, and they can be used interchangeably. The main adverse effect is injection site soreness. The safety of the vaccine for pregnant women has not been determined. Simultaneous administration with other travel vaccines (at different sites) does not interfere with the immune response.Immunoglobulin protects travelers against hepatitis A virus infection through the passive transfer of preformed antibodies. Active immunization is preferred, but the CDC recommends that travelers who are unable to receive hepatitis A vaccine at least 4 weeks prior to departure be given immunoglobulin at the time of hepatitis A immunization, since protection might not be completed until 4 weeks after vaccination.Immunoglobulin should also be offered to travelers who are allergic to the vaccine, younger than 2 years of age, or pregnant. It is given by intramuscular injection and can provide protection for 3 to 5 months, depending on the dose used (0.02 mL/kg or 0.06 mL/kg). Immunoglobulin provides protection against hepatitis A infection in 85% to 90% of those inoculated. Its major disadvantage is its limited time of protection (only 3 to 5 months). Adverse effects are very rare and consist mainly of local discomfort. Immunoglobulin has never been shown to transmit hepatitis В virus, hepatitis С virus, or human immunodeficiency virus. Simultaneous administration of hepatitis A vaccine and immunoglobulin results in lower antibody titers than when only hepatitis A vaccine is given, but protective antibody levels exceed those achieved when immunoglobulin is given alone and persist for 6 months, at which time the booster dose is due. The MMR and varicella vaccines should not be given concurrently with immunoglobulin.*183/348/5*