By Z. Bram. Wright State University.

Female patient participants expressed the belief that it is harder to explain health concerns to a man than to a woman buy lopid master card medications dictionary, and that it is unlikely that men would understand their concerns buy lopid now treatment 1st degree heart block. Participants indicated that women providers were preferred primarily because they were perceived as listening more and as being easier to talk to about a wider range of topics order lopid no prescription symptoms uti. Research examining gender-related communication differences in medical students has revealed that female medical students perform better on measures of interpersonal skills and communication performance than males (Bienstock purchase 300mg lopid otc symptoms valley fever, Martin, Tzou, & Fox, 2002; Laidlaw et al. These findings are consistent with findings related to female practitioners, suggesting that women have stronger communication skills throughout their medical careers. Although gender differences in communication have positive implications for female physicians, female patients may be at a disadvantage. According to Ivy and 65 Backlund (2008), women have been shown to be more tentative and less confident in their communication than men. The authors suggested that this could make females seem uncertain and incompetent in their speech. For female patients, this could increase the likelihood that their medical complaints will not be taken seriously. As an example of the tentative communication style, Ivy and Backlund (2008) discussed tag questions such as in the sentence, “This is a really beautiful day, don’t you think? Lakoff (1975) described tag questions as a form of “apology for making an assertion at all” (p. In addition to tag questions, Ivy and Backlund (2008) described a number of other communication devices stereotypically associated with women. This indicates that the female communication style, in addition to systemic gender bias, may contribute to the tendency for medical professionals to devalue women’s complaints, particularly when those complaints are vague or difficult to describe or diagnose. Diffuse Complaints and Difficult-to-Diagnose Conditions As noted above, the traditional gender-biased culture of the medical field results in a tendency for doctors to assume that women’s reports of pain are exaggerated or psychosomatic (Hamberg et al. Consequently, women with diffuse and persistent complaints due to a chronic or difficult to diagnose illness may experience difficulties in their relationship with their 66 doctors and with their treatment experience. This is supported by extensive research on chronic illnesses such as lupus, fibromyalgia, and chronic fatigue–all of which share similarities with thyroid disease (Darer et al. According to Werner and Malterud (2003), doctors report having difficulty in managing consultations involving uncertainty and unexplained conditions. As a result, patients, particularly female patients, report feeling ignored, belittled, and rejected in such consultations. Similarly, Hartman, Borghuis, Lucassen, Laar, and Speckens (2009) found that physicians find it difficult to communicate medically unexplained symptoms to patients, so they use metaphors and nonspecific language, which can have a negative effect on doctor-patient relationships. Martin and Peterson (2009) stated, “the role of the doctor is to take undifferentiated or unorganized illness and to arrive at an organized illness (more latterly a diagnosis)” (p. However, evidence indicates that doctors often have difficulty accomplishing this task. Chrisler and Parrett (1995) have noted that Systemic Lupus Erythematosus has been found in the last 40 years to be fairly common, that women are 5 to 10 times more likely than men to be diagnosed with the disease, and that women of color are disproportionately affected. Because the disease can arise at any time and can affect any of a number of internal systems, it is often difficult to diagnose. Lupus resembles many other diseases, and has as a result been called “the great impostor” (Chrisler & Parrett, 1995). Diagnoses are often uncertain, and there is no definitive test to determine the presence of lupus. Unsuccessful treatment is also common, and lupus 67 patients have been found to experience a number of psychosocial consequences, including elevated levels of depression, lowered self-esteem, changes in sexual function, and lowered body-image. These issues can be particularly troublesome for women, who have complained that doctors focus on their ability to be reproductively active (Chrisler & Parrett, 1995). Psychosocial factors such as support from others and physician help with coping strategies may help patients deal with the disease. In a study of women living with lupus, the factors most frequently cited as contributing to the struggle with the disease were uncertainty, an altered sense of identity, and managing the financial burden (Mendelson, 2006). This suggests that, in addition to biomedical issues, effective care for individuals with lupus could include mental and emotional support. Female patients with fibromyalgia have consistently reported being questioned by doctors as to the legitimacy of their symptoms. As a result, patients employ strategies to make doctors take them seriously (Werner & Malterud, 2003). This can have negative effects on doctor-patient relationships, particularly when patients become wary of honestly discussing their symptoms and the psychosocial effects of those symptoms (Peters et al. In an analysis of the experiences of 10 women with chronic pain, Werner and Malterud (2005) sought to examine issues related to patient empowerment and how doctors can help patients deal with their difficult to diagnose symptoms. The researchers 68 discussed the feelings of helplessness doctors experience when faced with patients who have conditions about which little is understood. Additionally, the authors noted that the way in which women are encountered and their symptoms addressed can have an effect on their level of empowerment in coping with their medical issues. Even in cases where diagnoses are uncertain, physicians who take women’s complaints seriously can help the patients overcome feelings of vulnerability that exacerbate their difficulties. As is the case with lupus and fibromyalgia, there are no standard diagnostic criteria and the treatments developed to date have limited success. These include placing an exaggerated importance on rest and mistakenly assuming that they are more impaired than they are. The authors drew attention to the role of gender dynamics in explaining the differences between physicians’ and patients’ perceptions of the disease.

Other more serious problems may require drug treatments but these should always be tailored to the patient as a whole and the effects on occupation must be given due consideration purchase 300mg lopid overnight delivery treatment integrity. Before any physician reaches for the prescription pad cheap lopid 300 mg with visa medicine zanaflex, a series of points need to be considered buy lopid amex symptoms syphilis. The answers should lead the doctor to conclude that potential benefits of treatment out-weigh the risks to the patient and additionally to flight safety order 300mg lopid fast delivery medications known to cause pancreatitis. The following questions need to be answered: 31 Medical Manual What is the problem? Is the medication curative or simply intended to improve symptoms – The side effects need to be considered, particularly those causing drowsiness, dizziness, hypotension or visual effects. Drug solubility in fat and water may influence choice as might considerations of elimination and whether or not the metabolites of the drug are also active. Knowledge of half-life and speed of onset of action deserve consideration and an understanding of the aircrew irregular lifestyle. Aircrew need to understand that knowledge of the contents, mode of action and potential side effects are essential. The advisory leaflets with the preparations must always be studied and if there are doubts, an aviation doctor should be consulted. Some licensing authorities have produced advisory leaflets on this topic and crew should be encouraged to read them. Many airline doctors write short articles for company flight safety magazines covering areas such as this, to remind crews of their responsibilities. In some countries, a preparation that might be considered a health food is, in another, considered to be a medication. Generally, health foods have not undergone the same degree of assessment that medications require before release onto the market. Hence, a great deal of information about mode of action and side effects is, in many cases, unknown and quality control in manufacture can never be guaranteed. Nevertheless, such products are becoming increasingly popular and aircrew should be advised to be very cautious. A recent analysis of herbal preparations available in both eastern and western countries showed that some providers add western medicines such as steroids and amphetamines to enhance their herbal products. Aircrew should be advised that unless clear written information is provided, listing contents and possible side effects, they should not take these products. This is usually achieved by a combination of: elimination of unsafe practices; substitution of a lower risk practice; design changes to minimise risk; personal protection measures; and education. Hepatitis A, while having a low mortality rate does have a significant morbidity rate. While the careful selection of food and water will reduce the risk of contracting this disease, travellers have no control over the hygiene of the last person to handle their food before they do. It is the most vaccine preventable disease related to travel and should be offered to all travellers who are travelling from low risk to higher risk countries. The hepatitis A vaccination is highly efficacious and has a very low side-effect profile. Hepatitis B has a significant initial morbidity and mortality and can cause long term complications and premature death. The vaccination is indicated for anyone who is at risk of having casual sex, will be playing contact sports or will be in endemic areas for six months or more. Travellers should seek specific medical advice in relation to their risk of this disease. As there are several strains of the bacteria that cause this disease, travellers should seek specific advice as to their risks from this disease. The risks associated with the use of this vaccine should be discussed with a medical practitioner prior to planned travel. While education plays a part in minimisation of the risk, studies have shown that compliance with basic food safety rules decreases rapidly over time as complacency takes over. While vaccination against Hepatitis A and Poliomyelitis is efficacious, the careful selection of food and water is still the mainstay of protection from the other food and water borne diseases. Special attention should be applied to the prevention and management of diarrhoeal diseases in children as these can lead to sudden death. The risk of exposure to the vectors and the diseases varies according to country, areas within a country, living conditions and season. Thus those who plan to travel to developing countries or to rural areas in developed countries should include a risk assessment by a competent travel medical practitioner. Whilst abstinence may be the gold standard in the prevention of sexually transmitted diseases, condoms, when used, can reduce the risk. The risks of acquiring sexually transmitted diseases are highly variable between countries and travellers who are at risk should seek advice prior to travel. Any traveller who has been exposed to the risk of a sexually transmitted disease should seek advice and treatment from a physician who has knowledge and experience of the risks associated with a particular country. It is important to remember that sexually transmitted diseases are: common; expensive to treat; sometimes asymptomatic; often resistant to treatment; associated with subsequent infertility; sometimes associated with premature death. Travellers should be wary about self-diagnosis and treatment and should bear in mind that medications, which have been banned in developed countries, may still be readily available in third world pharmacies. These effects can be exacerbated when leaving the air conditioned atmosphere of the aircraft or airport lounge and passengers and crew should be mindful of the weather conditions in both departure and arrival ports when planning travel. Sudden exposure to highly polluted air can exacerbate or unmask respiratory and cardiac conditions. In tropical areas interaction with marine organisms, corals and parasites can lead to symptoms ranging from minor irritation to death. It is exacerbated by: stress; over eating; dehydration; increasing age; travelling east; sleep deprivation; excessive alcohol consumption. In general, passengers should allow a reasonable period (1 to 2 days) for adjustment prior to engaging in serious sightseeing or business.

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However buy lopid with mastercard symptoms hypothyroidism, the elevated relative risk estimate for swimming in any other Hutt pool is entirely compatible with a chance result lopid 300mg cheap 5 medications related to the lymphatic system. While interpreting the results of an analytic epidemiological investigation into an outbreak generic lopid 300mg without a prescription treatment rosacea, always consider whether the results obtained could be due to bias order 300mg lopid treatment 4s syndrome. Bias may be defined as any systematic error in an epidemiological study that results in an incorrect estimation of the association between exposure and disease. Bias affects the size of the relative risk estimate, making it larger or smaller than the true (but unknown) value. For further information and more in-depth discussion, the interested reader may refer to any good 49 textbook of general epidemiology. However, careful consideration can often determine in which direction the bias is likely to operate (i. Selection bias: This occurs when there are systematic differences between those selected for a study and those who are not selected. Information bias: This occurs when there is misclassification of the disease or exposure status. Confounding: This occurs when an exposure of interest is correlated with another exposure that is an independent risk factor for the disease. Their common feature is that the relationship between exposure and disease is different for those who participate in a study compared with those who are eligible to participate, but do not do so. A particular example of this type of bias occurs in case-control studies when controls are selected from a different population to the cases. For example, if cases and controls tended to be selected from different neighbourhoods of different socio-economic statuses or ethnic mixes, then the magnitudes of the odds ratios may simply reflect the different prevalence of exposure factors in the two types of neighbourhood, rather than any true risk factors for disease. Where there is overlap between the neighbourhoods, then the degree of bias will be reduced to that which relates to the amount of overlap. Even when there is perfect overlap between the areas from which cases and controls are obtained, there may still be selection bias. An example of this, which may be referred to as “overmatching”, would be when controls were selected as family members of cases. In such a situation, cases and controls will be similar for many possible exposures, and true risk factors, particularly those which are connected with family circumstances, could be obscured. The effect of such overmatching would be to bias the relative risk estimate toward 1. Similar (but generally less severe) bias can occur when controls are selected as neighbours or friends of the cases. Neighbours and friends may share various exposures (including hobbies, socioeconomic factors and workplaces) leading to a degree of overmatching. It may be that those who participate are systematically different from those who do not participate. This would be of particular concern if participants in a study came forward on a self-selected basis and identified themselves as available for a study. Information bias Information bias affects the classification of subjects in a study as exposed or unexposed, or as ill or not ill. For example, subjects who were ill with a disease not related to the outbreak might be classified in the outbreak investigation as ill, or subjects actually exposed might be classified as unexposed, or vice versa. The impact of the misclassification will differ depending on whether it differs between study groups (differential misclassification) or is similar across study groups (non- differential misclassification). Non-differential misclassification tends to bias relative risk estimates toward 1. The direction of the bias may often be determined by considering a two-by-two table and thinking about how subject numbers will change (i. Recall bias and interviewer bias are particular examples of information bias that may occur in outbreak investigations. Recall bias occurs if those who are ill and those who are not ill tend to report exposures differently. For example, people who are ill may have given much more thought to the exposures that they have experienced than people who are not ill. This will differentially affect the quality of information obtained from cases and non-cases. Cases may tend to report having consumed particular foods more frequently, whereas non-cases may not do so, if only because they have forgotten. The effect of this would be to make such foods appear as risk factors for disease, when in fact they may not be. Interviewer bias may occur when interviewers are aware of who is or has been ill and when they report information differently because of this. For example, if an interviewer has developed their own view of what the most likely exposure is, then they may tend to selectively interpret and report cases as having had that exposure, and vice versa for non-cases. Confounding Confounding is regarded as a bias by some authors, and as different from a bias by other authors, because its effects can be eliminated in data analysis (provided information on the confounding factor is available). For these guidelines, we have classified confounding as a bias because, like selection bias and information bias, it can affect the size of relative risk estimates obtained in a study and adequate data for its effects to be eliminated in the data analysis are not always available. Confounding occurs when the exposure of interest is correlated with another factor (the confounder) that is itself independently associated with the outcome (disease) under investigation. The exposure of interest may itself also be a risk factor for the disease or it may not really be associated with the disease at all. The confounding makes the exposure of interest appear to be associated with the disease (or more strongly associated if it is also a risk factor).

Further information on the pharmacology and ethnomedical use of ginger is available purchase lopid 300 mg on-line treatment 5ths disease. Langner E purchase 300 mg lopid medicine hat mall, Greifenberg S order 300mg lopid visa symptoms and diagnosis, Gruenwald J: Ginger: history and use generic lopid 300mg amex symptoms 8 months pregnant, Adv Ther 15:25-44, 1998. Vutyavanich T, Kraisarin T, Ruangsri R: Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial, Obstet Gynecol 97:577-82, 2001. Bliddal H, Rosetzsky A, Schlichting P, et al: A randomized, placebo-controlled, cross-over study of ginger extracts and ibuprofen in osteoarthritis, Osteoarthritis Cartilage 8:9-12, 2000. Afzal M, Al-Hadidi D, Menon M, et al: Ginger: an ethnomedical, chemical and pharmacological review, Drug Metabol Drug Interact 18:159-90, 2001. Its potential to improve cerebral ischemia has resulted in its use for sympto- matic treatment of dementia, vertigo, and tinnitus of vascular origin. Current publications suggest that although ginkgo is of questionable use for memory loss and tin- nitus, there is more convincing evidence that it has some effect on dementia and intermittent claudication. Other constituents include proanthocyanidins, glucose, rhamnose, and organic acids. It reduces inflammation and thrombosis by its antioxidant activity and potent platelet-activating factor inhibition. Platelet-activating factor is a phospholipid released by platelets, macrophages, and monocytes, which aggregates platelets and enhances inflammation. It may influence the metabo- lism of neurotransmitters, possibly by stimulation of prostaglandin synthesis. The anti-stress and neuroprotective effects of Ginkgo biloba extract may be related to suppression of glucocorticoid biosynthesis. This is usually available in the form of 40-mg tablets or in liquid form at a concentration of 40 mg/mL. Clinical trials support the use of ginkgo in the treatment of patients with mental deterioration associated with aging such as problems with memory, con- centration, and alertness; dizziness; and tinnitus. Most, although not all, clinical trials support the use of ginkgo extracts in the treatment of dementia. A double-blind, placebo-controlled, parallel-group, multicenter study demonstrated that patients with uncomplicated Alzheimer’s disease or multi-infarct dementia showed significantly less decline in cognitive function when they received a 120-mg dose (40 mg three times daily) of Ginkgo biloba extract over a 26- week period. A study in which hippocampal primary cultured cells were used demon- strated that G. Animal studies have shown that chemical induction of a permanent deficit in cere- bral energy metabolism can be reversed and ongoing deterioration in learn- ing, memory, and cognition partially compensated by using G. Even though some reviewers have deemed the clinical relevance of the improvement moderate, gingko has also been found to increase walking distance. Although gingko deserves consideration for the treatment of tinnitus,13 its use in the management of age-related macular degeneration has yet to be clarified. Other potential repercussions of interactions are increased blood pres- sure when gingko is combined with a thiazide diuretic and coma when it is combined with trazodone. Side effects are uncommon; however, gastrointestinal disturbances, headaches, dizziness, tinnitus, peripheral visual shimmering, and hypersen- sitivity reactions (e. John’s wort, ginseng, echinacea, saw palmetto, and kava, Ann Intern Med 136:42-53, 2002. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Wettstein A: Cholinesterase inhibitors and Gingko extracts—are they comparable in the treatment of dementia? Comparison of published placebo- controlled efficacy studies of at least six months’ duration, Phytomedicine 6: 393-401, 2000. Bastianetto S, Ramassamy C, Dore S, et al: The Ginkgo biloba extract (Egb 761) protects hippocampal neurons against cell death induced by beta-amyloid, Eur J Neurosci 12:1882-90, 2000. Hoyer S, Lannert H, Noldner M, et al: Damaged neuronal energy metabolism and behavior are improved by Ginkgo biloba extract (Egb 761), J Neural Transm 106:1171-88, 1999. Linde K, ter Riet G, Hondras M, et al: Systematic reviews of complementary therapies—an annotated bibliography. An overview of results of completed clinical trials, Fortschr Med 118:157-64, 2001 (abstract). Ernst E, Stevinson C: Ginkgo biloba for tinnitus: a review, Clin Otolaryngol 24: 164-7, 1999. The name Panax is derived from the term panacea, and ginseng is regarded as a cure-all. Ginseng is known as an adaptogen, capable of normalizing phys- iologic disturbances. It has traditionally been used as a tonic to adapt to stress and restore vitality. Ginseng is reputed to enhance vitality, boost the immune response, and promote cellular metabolism and longevity. Analysis of commercial ginseng preparations from the genera Panax and Eleutherococcus made in the United States revealed that the products were correctly labeled as to plant genus; however, marked variability was observed in the concentrations of con- stituents. The activity of ginseng is largely related to the combination and relative concentration of the ginseno- sides found in the main and lateral roots of the plant. The ginsenoside con- tent of different species of ginseng varies widely, as does the ginsenoside 557 558 Part Three / Dietary Supplements content within a single species cultivated in two different locations.

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