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By: W. Zapotek, M.B. B.CH. B.A.O., Ph.D.
Clinical Director, Touro University California College of Osteopathic Medicine
I began vulnerable public are often marketing fraudulent pondering the challenge of integrating alternative products or interventions erectile dysfunction pills walgreens buy extra super avana no prescription. The Internet has led to medicine into conventional medicine and the con- increased empowerment of the public through ventional medical establishment erectile dysfunction doctor in bhopal generic 260mg extra super avana fast delivery. I began to appre- access to an endless amount of medical informa- ciate more fully the need for additional research on tion erectile dysfunction treatment saudi arabia buy generic extra super avana canada. Only through that research seemingly endless amount of inaccurate or poten- can conventional medical providers know which tially misleading health information. Only Traditionally the public has turned to physicians through that research can the public truly know and other health care providers for reliable infor- which treatments are safe and effective. But multiple Ultimately I decided to pursue a two-year studies have shown that the majority of people research fellowship and a master’s degree in public who use alternative medicine do so without telling health with the goal of obtaining the skills neces- their physicians or other health care providers. Good research takes years and costs sig- the subject matter and a desire not to appear unin- niﬁcant amounts of money. This omission often gives the impression cies are funding research on alternative medicine. At times physicians may be dis- the Study of Complementary and Alternative Med- missive of such therapies because of a perception icine under the National Institutes of Health, and that there is a lack of credible and authoritative evi- the amount and quality of research on alternative dence of their effectiveness. However, Patients, on the other hand, tend to believe that the various types of alternative treatments avail- it is unimportant for health care providers to know able are also increasing. They research is conducted, there will always be numer- often believe that the alternative therapy is irrele- ous treatment options available that have little or vant to the biomedical treatment course. They may no data beyond anecdotal evidence to support their think that a decision to pursue an alternative treat- use. There will always be treatments being utilized ment does not require input from the conventional that will ultimately be shown to be safe and effec- medical establishment, since they believe these tive as well as ones that will be harmful and futile. Still others hesitate Many treatments are from healing traditions to speak openly about their use of or desire to use that have developed over hundreds, if not thou- alternative medicine because of concern that their sands, of years through a process of trial and error questions may be dismissed or they may be viewed on thousands of patients. If undergo a conventional medical evaluation as well the public cannot turn to the conventional medical as see an acupuncturist, nutritionist, massage ther- establishment, turn to their own physicians or apist, clinical herbalist, or mind-body practitioner other health care providers for reliable information (licensed clinical social worker or Ph. The conventional medical estab- the more I ﬁnd myself returning to the principles I lishment has an obligation to protect the public found to be most effective in maintaining my own from harm without limiting access to potentially health and quality of life. That path always Clearly the public’s desire for and utilization of tends to have physical, mental, and spiritual com- alternative medicine are increasing. In the I will see someone with low back pain who not United States, more than $27 billion is spent only gets a referral for acupuncture, but also is sent annually on alternative medicine. The public has to the nutritionist because of obesity and the freedom of choice to pursue alternative treat- unhealthy eating habits, to the Wellness Center to ments. However, without reliable, credible sources address deconditioning and a sedentary lifestyle, of information, it is challenging for the individual and to the mind-body practitioner to learn medita- to make informed health care decisions. Discussing tion or guided visualization to address poorly man- one’s use of alternative medicine with one’s health aged stress. I ask patients to ask themselves, “What care provider is an opportunity to share values, gives my life meaning? The relevant but also contribute to strengthening the answer for most people is not solely contained in a health care provider–patient relationship. In 1998, after ﬁnishing my training, I for a more academic environment, where I could was fortunate enough to have the opportunity to focus on teaching not only patients, but also health pursue my dream of a more integrated health care care providers. I found myself eager to get involved system and was hired to develop a program in in the research that will provide the evidence- alternative medicine for the Saint Barnabas Health based framework for integrative medicine to grow Care System in New Jersey. Therefore, in July 2002 I accepted the posi- tion, we chose to call the clinical center the Siegler tion of executive director for the Center for the Center for Integrative Medicine, as opposed to Study of Alternative and Complementary Medicine Alternative or Complementary Medicine. Conventional medicine is going through a whether the treatment is conventional or alternative.
The techniques that are designed for restraint and the care of the individual after restraint must allow for safe restraint of the most vulner- able sections of the community erectile dysfunction symptoms treatment purchase cheap extra super avana online. New research into the effects of restraint may possibly lead to a greater understanding of the deleterious effects of restraint and the development of safer restraint techniques erectile dysfunction and alcohol order 260 mg extra super avana with amex. Although this experimental work is being performed erectile dysfunction workup aafp buy genuine extra super avana on-line, the only particular advice that can be offered to police officers is that the prone position should be maintained for the minimum amount of time only, no pressure should be applied to the back or the chest of a person restrained on the floor, and the individual should be placed in a kneeling, sitting, or stand- ing position to allow for normal respiration as soon as practical. It should be noted that an individual who is suffering from early or late asphyxiation may well struggle more in an attempt to breathe, and, during a restraint, this increased level of struggling may be perceived by police offic- ers as a renewed attempt to escape, resulting in further restriction of move- ment and subsequent exacerbation of the asphyxial process. Officers must be taught that once restrained, these further episodes of struggling may signify imminent asphyxiation and not continued attempts to escape, that they may represent a struggle to survive, and that the police must be aware of this and respond with that in mind. Since these matters were first brought to forensic and then public atten- tion and training and advice to police officers concerning the potential dan- gers of face down or prone restraints, especially if associated with any pressure to the chest or back improved, there has been a decrease in the number of deaths during restraint. However, even one death in these circumstances is too many, and it is hoped that by medical research, improved police training, and increased awareness of the dangers of restraint that these tragic deaths can be prevented. Positional asphyxiation in adults: a series of 30 cases from the Dade and Broward County, Florida, medical examiners offices from 1982 to 1990. Effects of positional restraint on oxygen saturation and heart rate following exercise. The effect of simulated restraint in the prone position on cardiorespiratory function following exercise in humans. The effect of breath holding on arterial oxygen saturation following exercise in man. All these fac- tors can be affected by drugs and alcohol, greatly increasing the risk of acci- dents. Many medical conditions (and their treatments) may impair fitness to drive and are considered first. In many jurisdictions, including Canada, Australia, and the United Kingdom, it is the motorist’s responsibility to inform the licensing authority of any relevant medical conditions. Similar requirements generally apply in the United States, except that six states (California, Delaware, Nevada, New Jersey, Oregon, and Penn- sylvania) require physicians to report patients with seizures (and other condi- tions that may alter levels of consciousness) to the department of motor vehicles (1). Drivers have a legal responsibility to inform the licensing authority of any injury or medical condition that affects their driving ability, and physicians should take great pains to explain this obligation. Occasionally, especially when dealing with patients suffering from dementia, ethical responsibilities may require doctors to breach confidentiality and notify patients against their will or without their knowledge (2); this situation is discussed in Subheading 2. When in doubt about the appropriate course of action, physicians should consult the appropriate guidelines. In Australia, the Austroads Guidelines for Assessing Fitness to Drive provides similar information (4). In the European Union, where Euro- pean Community directives have developed basic standards but allow dif- ferent countries to impose more stringent requirements, there is still variation from country to country. The situation is even more complicated in the United States, where each state sets its own rules and where federal regulations for commercial vehicles apply as well. Often, much of the required regulatory information can be acquired via the Internet or from organizations and foun- dations representing patients who have the particular disease in question. It should be assumed that all adults drive; drivers with disabilities should be given special consideration and may require modification of their vehicle or have certain personal restrictions applied. Cardiovascular Diseases Several studies have demonstrated that natural deaths at the wheel are fairly uncommon and that the risk for other persons is not significant (5,6). Even so, requirements for commercial drivers are generally much more rigid than for individuals, and in the United States, the Federal Highway Adminis- tration prohibits drivers with angina or recent infarction from driving. Restrictions for noncommer- cial car driving after first acute myocardial infarction are 4 weeks in United Kingdom but only 2 weeks in Australia.
As it turned out erectile dysfunction doctor in chennai order extra super avana with paypal, about four years prior to my meet- “Enabling” means facilitating the other’s passage ing them erectile dysfunction pills don't work purchase extra super avana, these ﬁve advanced practice nurses had through life transitions and unfamiliar events erectile dysfunction protocol book scam buy extra super avana 260 mg online. Speciﬁcally, it was “maintaining belief,” which means sustaining faith proposed that if women were guided through in- in the other’s capacity to get through an event or depth discussion of their experience and felt un- transition and face a future with meaning. This derstood, informed, provided for, validated, and means believing in the other and holding him or believed in, they would be better prepared to inte- her in esteem, maintaining a hope-ﬁlled attitude, grate miscarrying into their lives. Content for the offering realistic optimism, helping ﬁnd meaning, three counseling sessions was derived from the mis- and going the distance or standing by the one cared carriage model—a phenomenologically derived for, no matter how his or her situation may unfold model that summarized the common human re- (Swanson, 1991, 1993, 1999a, 1999b). Women were randomly assigned to two levels of The Miscarriage Caring Project treatment (caring-based counseling and controls) and two levels of measurement (“early”—comple- As my postdoctoral studies were coming to an end, tion of outcome measures immediately, six weeks, Dr. Barnard challenged me and claimed, “I think four months, and one year postloss; or “delayed”— you’ve described caring long enough. It’s time you completion of outcome measures at four months did something with it! Counseling took place at one, gathering interviews were so often perceived by ﬁve, and eleven weeks postloss. Outcome measures in- that, at the very least, open-ended interviews in- cluded self-esteem (Rosenberg, 1965); overall emo- volved aspects of knowing, being with, and main- tional disturbance, anger, depression, anxiety, and taining belief. We suspected that if doing-for and confusion (McNair, Lorr, & Droppleman, 1981); enabling interventions speciﬁcally focused on com- and overall miscarriage impact, personal signiﬁ- mon human responses to health conditions were cance, devastating event, lost baby, and feeling added, it would be possible to transform the tech- of isolation (investigator-developed Impact of niques of phenomenological data gathering into a Miscarriage Scale). That conversation ultimately A more detailed report of these ﬁndings is pub- led to my design of a caring-based counseling lished elsewhere (Swanson, 1999a). The next thing I knew, I was writing a proposal Participants were within ﬁve weeks of loss at en- for a Solomon four-group randomized experimen- rollment; 89 percent were partnered, 77 percent tal design (Swanson, 1999a, 1999b). The primary purpose of the study tional disturbance, anger, and depression; and (2) was to examine the effects of three one-hour-long, with the passage of time, women attributed less caring-based counseling sessions on the integration personal signiﬁcance to miscarrying and realized of loss (miscarriage impact) and women’s emo- increased self-esteem and decreased anxiety, de- tional well-being (moods and self-esteem) in the pression, anger, and confusion. Additional aims of the In summary, the Miscarriage Caring Project study were to (1) examine the effects of early versus provided evidence that, although time had a heal- delayed measurement and the passage of time on ing effect on women after miscarrying, caring did women’s healing in the ﬁrst year after loss, and (2) make a difference in the amount of anger, depres- develop strategies to monitor caring as the inter- sion, and overall disturbed moods that women ex- vention/process variable. This study was unique An assumption of the caring theory was that in that it employed a clinical research model to the recipient’s well-being should be enhanced by determine whether or not caring made a difference. Swanson: A Program of Research on Caring 357 I believe that its greatest strength lies in the fact that presession moods (thus enabling examination of the intervention was based both on an empirically the association between counselor presession derived understanding of what it is like to miscarry mood and self or client postsession ratings of and on a conscientious attempt to enact caring in caring). Of course, to complete the Caring Professional Scale (investi- the greatest limitation of that study is that I derived gator-developed). Women, having been left alone the caring theory (developed from the interven- to complete the measure, were asked to place the tion) and conducted most of the counseling ses- evaluations in a sealed envelope. Hence, it is unknown whether similar results in another room, the counselor wrote out her would be derived under different circumstances. I am currently making consisted of 18 items on a ﬁve-point Likert-type a concerted effort to rectify this situation and to ex- scale. It was developed through the Miscarriage amine what it is like for diverse groups of women to Caring Project and was completed by participants experience both miscarriage and caring. The items document that, as claimed, caring had indeed oc- included: “Was the health-care provider that just curred. First, approximately 10 percent of the inter- took care of you understanding, informative, aware vention sessions were transcribed. The items were derived from the car- study, found she could not approach analysis of the ing theory.
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