To be sure that the potential benefits of a trial are larger than its potential risk, the FDA requires that all trials be supervised by an independent review panel. This review panel, called the Institutional Review Board (IRB), must be composed of representatives from both the medical field and the nonmedical public. Most IRBs include representatives from law, nursing, medicine, and the clergy, as well as researchers who are expert in clinical trials. This group has the job of watching out for the participants’ interests, seeing that scientific standards are upheld, and protecting medical ethics. At periodic intervals during the course of the trial, the IRB reviews the results. Any serious or unexpected toxicity must be reported immediately to both the IRB and the FDA. If the toxicity is serious and is thought to be related to the drug, all participants in the trial must be notified, and the informed consent form must be revised accordingly. Many trials, and especially those at multiple medical centers dealing with treatments of serious conditions such as HIV infection, are also supervised by a Data Safety Monitoring Board that scrutinizes the data from the trials every six to twelve months. The Data Safety Monitoring Board, made up of experts in the field who are not involved in the trial, is also privy to unblinded results. This board is different from the IRB because it has access to data from all centers participating in the trial, not just the local center. The board’s purpose is to stop the trial as soon as valid results combined from all centers emerge about the drug’s effectiveness or toxicity. Six months into the phase two trials of AZT, the Data Safety Monitoring Board’s review of the unblinded data convinced it to stop the trial and give all participants AZT. One year into the second big AZT trial, the data showed that the drug was beneficial when the CD4 count was below 500, arid that it was less toxic at low doses; the trial was stopped and all participants with low CD4 counts were given low doses of AZT.*188\191\2*
“In many cases fathers are more fortunate than the mothers who are at home because they don’t have to live with the problem twenty-four hours a day. They go to work and have other distractions and other responsibilities. Too frequently the burden (and it can be a burden) falls on the mother, and that’s not fair. One of my jobs is to try to make sure that the father stays involved, that he comes in for the counseling sessions, and that he shares some of the burden. I don’t mean just the physical care of the child. He must shoulder some of the emotional burden, as well. Men often handle grief in a different fashion from women. They can bury themselves in their work and avoid having to face their grief and their emotions. This is less common with women, who seem to take on the responsibility, even when it grinds them down. They have to face the problems hourly, without a refuge. Working women can have an even worse problem. Rather than using work as a refuge, work becomes an additional responsibility. They still have the child and the problem back home. We find that many parents don’t share these problems very well. They need help in communicating with each other, and in learning to share the burdens. It is important to try to keep the lines of communication open between the husband and wife. It is surprising how often they just don’t talk. It is essential that the wife get some relief from her role, even if it is just an hour or two to go out to the market without the child, to go shopping on a Saturday when the husband is off work, to go away for a weekend or to a movie and dinner. A brief respite can make things more tolerable.*233\208\8*
Lipids are measured by analyzing a blood specimen. Eating before the blood test does not affect the level of blood cholesterol. However, it has an effect of the blood triglyceride level. Because both are usually measured from the same specimen, youfor a minimum of 12 hours before your blood is drawn. Do not drink alcohol for a full 24 hours before the test. If you follow these guidelines, your physician will have an accurate measure of your cholesterol, triglycerides, and other blood lipids, rather than depending on unreliable data that merely reflect when and what you last ate.Fasting before a blood test for lipids does not mean that your results will be precisely the same day after day, even if you make no change in your diet, exercise, or medications. Your lipid levels may vary by about 10 percent from day to day. The importance of a blood test for lipids, therefore, is not to detect small changes in results to make a large issue out of whether a particular value is several points “too high.” Rather, it is to establish in a general sense what your risk level is, and to determine whether the response to diet, exercise, or medication is satisfactory.*240\252\8*
HIV INFECTION AND ITS EFFECTS ON INTERPERSONAL RELATIONS: HELPLESSNESS, DEPENDENCY, AND CONTROL-NO ONE WANTS TO GIVE UP CONTROLJune 24th, 2011
Alan Madison: One of the worst thoughts for me is, I don’t want people taking care of me. No one wants to give up that control. I come from proud people. I’ve always felt the need to do it on my own. No One Wants to Give up Control-Like Alan, all people want to “do it on their own.” By that, they usually mean that they do not want to rely on other people; they want to rely only on themselves. They take care of their own needs. They want to do their fair share in a relationship, not only taking advice and help, but also giving it. When something goes wrong, they fix it; when someone has a problem, they solve it. They can do what they set out to do. In short, they have the sense that they are in control of their own lives. HIV infection seriously undermines a person’s sense of control. People with HIV infection have intervals of illness during which they depend on others for things they normally provide for themselves. Their dependency ranges from needing someone to shop, clean, and cook for them to needing someone to dress, bathe, and feed them. They dislike this dependency. They say that being dependent is hard on their self-esteem, their sense of self-worth. They don’t feel like normal adults any more; they feel like babies. Their caregivers have a different problem with the sense of control. Instead of feeling dependent on someone else, they feel helpless to change things. The person they love is sick and in emotional pain, and they can do nothing to fix that. They can fix problems that are physical—they can shop, clean, cook, give medications, talk to doctors, dress and bathe and feed the person they love. But problems that are emotional—anger, depression, fear, guilt—are often unfixable, or at least not fixable in the same way. Caregivers still want to fix them, to correct them, to make them disappear. Faced with an inescapable virus and inevitable emotions, caregivers feel helpless and stupid. Different aspects of loss of control bother different people. Some dislike what seems like a reversion to childhood: at times, they need to be changed, bathed, dressed, groomed, fed, driven. Helen Parks, who has lived alone all her adult life, says she worries “about moving in with my parents and not having time to myself and having to have my dinner fixed and my clothes washed. I won’t have my mother drive me or change me.” June’s son, who had been a doctor, now lives with her: “It was hard for my son to come home at age thirty-four and have his mom care for him,” she said. “How much he can do for himself depends on how he’s feeling. He always wants to do as much as he can for himself.” Lisa said her husband “had a tremendous fear of being bedridden and me caring for him.” Adults who must accept being cared for like a child feel they are a burden. Because their bodies must be cared for by others, they feel they have lost their dignity. Some young people with HIV infection are upset that they may be unable to take care of their parents. They see this as losing control. They had expected, as they became adults, to care more and more for their parents, and they dislike the reversal in roles. Steven has two aging great-aunts and a grandfather he feels responsible for: “I should be taking care of them. I should see that they’re getting their medication or their new glasses. People shouldn’t be doing these things for me.” Other people hate giving up their roles with their partners. Lisa said that the more she took out the garbage, paid the bills, and mowed the lawn, the more her husband felt he was losing control, and the unhappier he became: “Sometimes he was grateful,” she said, “and sometimes he just screamed.” Dean said, “My partner used to be a cook, it’s okay with me that he does most of the cooking. I had always done the heavy work, and sometimes still do. But sometimes I can make no contributions. The days I can’t contribute are awful, just awful.” Others worry about financial dependency on/their parents or on the welfare system: Helen says, “I’m surely not one for welfare.” As people get sicker, they depend more and more on the social service and medical systems. Both systems require people to give up control, one system over their personal resources, the other over their bodies. The requirements, though necessary, are distressing. People who give over control of their resources and their bodies feel they have little left of their own. They feel powerless, ineffective, and incompetent.
Arthritis and rheumatism are commonly used terms that refer to chronic conditions involving joint pain, stiffness, and swelling that result in limited movement. The term arthritis is derived from two Greek words: arthron, which means joints, and itis, which means inflammation.As many as one in seven Americans suffers from some form of arthritis. In fact, arthritis is the number-one cause of disability in America. In its most advanced stages, arthritis limits everyday activities such as walking, dressing, climbing stairs, and getting in and out of bed. Arthritis can strike at any age (though it’s far more common in people over 50), and it restricts activity more often than cardiovascular disease, cancer, or diabetes. For some reason, women are affected more often than men. There are four common forms of arthritis:- osteoarthritis- rheumatoid arthritis- gout- juvenile rheumatoid arthritisOther disorders of the joints and connective tissue include:- lupus- Sjogren’s syndrome- Reiter s syndrome- ankylosing spondylitisFor two of these types of arthritis, osteoarthritis and rheumatoid arthritis, there are alternative treatments available that have been scientifically researched and found to have some benefit. Osteoarthritis, the most common form of arthritis, has been treated with glucosamine, chondroitin, S-adenosylmethionine (SAMe), and several types of herbal remedies. There is reasonably good evidence that some of these may offer considerable help for sufferers of this type of arthritis.*2/306/5*
The placental barrier consists of a four-layer, semi-permeable membrane separating maternal and fetal circulation. When we say something crosses the placenta, we mean it passes through this membrane. Inside a placenta are caPillary-filled branches soaked by spumes of mother’s blood. The placental barrier does an admirable job of keeping out bacteria, which are usually too large to pass into the placental branches. Special immune agents swiftly dispatch those that do manage to sneak through.However, in recent years scientists have had to revise their perception of an impenetrable placental fortress. When it comes to toxic chemicals, the placenta is not really a barrier at all. Chemical substances carried in the mother’s circulation are sorted by the placenta that are primarily based on molecular weight, electrical charge and fat solubility. In other words, small, neutrally charged molecules that readily dissolve in fat are afforded free passage regardless of their capacity for harm. In a sense it is a total free ride for all for toxins!*2/165/1*
Fortunately, when Larry left that second time, I was better prepared for my parenthesis—a time of trial and struggle that can be brief or seemingly endless. Actually, Larry’s bitter reaction to Where Does a Mother Go to Resign? wasn’t a new parenthesis at all. His angry exit from our lives only forced me to realize that the problem which began for me on that night at the flagpole on Disneyland’s Main Street had really never gone away. When Larry returned after his first absence of eleven months, I thought everything was “okay” and so did Bill. Larry’s “phase” was over, and we just didn’t talk about it. How wrong we were.But now here I was, locked in another measurement of time and, until God chose to remove the ends of the parenthesis, I would have to live in another vacuum. Some people might call it a pit or a cave, but whatever you choose to call it, it’s a contained situation. You can’t go back and wish it were only a day ago or even two years ago. And you can’t jump ahead—out of the pit into a happy, carefree time. Until God kicks the ends out of your parenthesis, you have to handle today, today.This doesn’t mean you ignore or negate God’s promises and instructions. But you may have to settle for not being sure you understand what’s going on—at least at the moment.I love the cartoon caption that says, “Mother said there’d be days like this . . . she failed to mention that they could go on for months at a time.”‘One thing that helps is not to deny you’re in the process. If you hurt, admit it. As one bumper snicker* advises:WHEN YOU’RE DOWN AND OUT LIFT UP YOUR HEAD AND SHOUT . . . “I’M DOWN AND OUT!”That’s the first step in handling your parenthesis. The next step is to realize that whatever the problem is, it won’t last forever. I was talking to a gal who has some real problems, and she told me her favorite Scripture verse is, “And it came to pass …” I looked at her rather quizzically and she laughed and added, “Just think, all this could have come to STAY!”
Pain Has a “Passing Through” StageSince every parenthesis has come to pass, you have to go through a “passing through” stage. It’s okay to admit you’re suffering and hurting, and you might even be angry with God. But then you go on to make the most of this particular time frame. As the passage from James reminds us, it’s a chance to grow. So give it all you’ve got, and see what you can learn from this pain.All the promises of God are there, and they’re real, and they’re true, but right now you’re bleeding, you’re raw and hurting, and you have to hang on to those promises even if they don’t seem to work for you at the moment. As you go through the pain, it will lessen. The pain will flatten out and dilute itself, and then you can look back and realize how far you’ve come. You can start living with the parenthesis behind you! There may be occasional dips back into the pits, but you know you are getting out of that parenthetical period.Every time you feel closed in, or like you are smothering in a tight little box with the lid nailed down, imagine you are stepping over that horrid little parenthesis. You are going to get over this, and when you do climb over it and then look back, you will realize you’ve reached new gains and new values. You have completed a segment of growth as a person.If any of God’s prophets knew what it was like to go through a parenthesis, it had to be Jeremiah. In fact, you could say his entire life was one parenthesis after the other. And yet God told him, “For I know the plans I have for you . . . they are plans for good and not for evil, to give you a future and a hope” (Jer. 29:11, TLB).I have come to love that verse because hope makes all the difference. Learning to relinquish Larry completely to God enabled me to face another (actually the same) parenthesis and know I could get through. I had said “Whatever, Lord,” and I had meant it!After Larry left, the SPATULA ministry began to take off. I’d share on television and radio shows, or I would speak in churches and conferences and people would ask, “Well, how is your son now?” And I would have to say, “Well, he’s disowned us. He’s changed his name, and he says he never wants to see us again.”That wasn’t real hopeful news to share, but it was true at the time. All I had to hang on to was a love for God and a love for Larry and all those parents who had suffered the loss of a child or, worse, the pain of having a child reject their values and opt for a different lifestyle that leaves God out.*14\316\2*
Primary peritonitis in children may mimic acute appendicitis, with fever, abdominal pain, nausea, vomiting, diarrhea, diffuse abdominal tenderness, rebound tenderness, and hypoactive or absent bowel sounds. In cirrhotic patients, the presentation is often atypical and may present insidiously with no signs of peritoneal irritation. The most frequent symptoms are fever (69%) and abdominal pain (59%). Other signs and symptoms include hepatic encephalopathy (54%), abdominal tenderness (49%), diarrhea (32%), ileus (30%), shock (21%), and hypothermia (17%). Approximately 10% of patients with SBP have no signs or symptoms. Because of the variable clinical picture, patients with cirrhosis who have unexplained deterioration, especially hepatic encephalopathy, should undergo a diagnostic paracentesis.Tuberculous peritonitis usually appears gradually, with fever, malaise, weight loss, night sweats, and abdominal distension. The abdomen is often described as being “doughy” on palpation. Surgery or laparoscopy typically reveals multiple nodules over the peritoneal and omental surfaces with adhesions. C. immitis causes a granulomatous peritonitis and manifests variably.*88/348/5*
Port wine stainThis reddish-purple birthmark is a major cosmetic blemish which can occur anywhere on the body. It is caused by an increased number of blood vessels under the skin’s surface, and becomes darker and more lumpy with time.Today, laser treatment of birthmarks is common. Previously, lasers such as the argon were used, but these caused several problems, especially scarring. Copper vapour lasers and pulsed dye lasers are now used to treat wine stains. This should be done early in life as the results are superior. In addition, major psychological problems can be avoided.
Strawberry birthmarksThese dark red, strawberry-like growths usually appear in the first few weeks of life, enlarge rapidly, and may bleed. They may cause major cosmetic disfigurement and can even obstruct vital organs such as the eyes. Because most strawberry birthmarks resolve by the age of seven, they largely go untreated unless there is some obstruction to breathing or to the vision. Older treatments such as radiation therapy were abandoned as they caused scarring. Nowadays, with sophisticated lasers such as the pulsed dye, the copper vapour and the Nd-Yag available, these marks can be successfully treated. This is best done early in childhood.
Pale brown birthmarksPale brown birthmarks are often due to an accumulation of pigment but do not have an increased risk of malignant melanoma (potentially deadly tumour). They occur at birth or appear soon after and are not generally very visible. These birthmarks often become more noticeable during summer as they grow darker following sun exposure. During winter they grow paler. They do not usually require treatment although some people have them removed for cosmetic reasons.
Progesterone therapy is one of the most controversial therapies for PMS, yet it is one of the most widely used. Supporters of British researcher Dr Katharina Dalton, who has researched the treatment for over 30 years, are largely responsible for its widespread use.Despite the enthusiasm, proper studies of progesterone versus a dummy pill have failed to show any benefit with this hormone therapy. But because a few women do seem to benefit many doctors feel if s worth a try if other methods have failed.Dr Dalton and other doctors who follow her teaching believe that natural progesterone should not be taken by mouth because it breaks down before it has a chance to work. So vaginal or rectal ‘suppositories’ – a gel-based ‘pellet inserted into the vagina or rectum – are used instead. Sometimes daily injections are given and work is being done on a tablet form.The dose is 400mg to 800mg taken twice a day, starting on day 12 of the cycle. Treatment usually lasts for a minimum of six months but some women may need to carry on for up to two years or until the menopause if they are over 40.Progestogens are synthetic forms of progesterone which can be taken as tablets by mouth.Dydrogesterone is the type of progestogen most often prescribed. The main drawback of progestogens is that some women find they tend to produce more side-effects than natural progesterone, especially weight gain and irregular periods.Critics of progestogen treatment say its chemical structure is so different from that of progesterone that it does not work and actually makes PMS worse Once again, though, there have been no studies to support or refute this claim.*47\120\4*