HOW DIABETES IS TREATEDThirteen-year-old Gary Krajewski has a far stricter routine than most boys his age. He gives himself insulin injections twice a day, and six times each day he pricks his finger to test his sugar level. He has to watch his diet, too. “I was eating a lot of candy before this happened,” he says. “I was a basic little kid, ya know?” But Gary is philosophical about the chores of living with Type I diabetes. “I’m probably healthier than most kids,” he adds. “I’m not eating that junk food.”Tony Paolo, who learned at forty-six that he had Type II diabetes, also has a strict routine. Three days a week he gets up early to work out. He has thirty pounds to go to get down to the weight his doctor suggested as a goal. That means no splurging at mealtime, either. He weighs out his portion of breakfast cereal, eats low-fat meats, and counts calories all day, trying to stay within a 2,000-calorie limit. At first he checked his blood sugar level twice a day, before breakfast and after dinner, but now he has been able to cut back to twice a week. Tony is glad about that. “You get used to the routine,” he says, “but not the pinprick.” So far his careful routine is keeping his diabetes under good control, without the need for oral hypoglycemic drugs.The treatment of diabetes may thus be quite different, depending on the type of disease:Type I diabetes: Insulin; diet and exercise are also important.Type II diabetes: Diet and exercise; oral drugs or insulin may also be needed. Diabetes treatment puts a lot of responsibility on the patient, but typically a whole health-care team is there for help, advice, and support. In addition to the doctor, who prescribes medications, outlines a plan of diet and exercise appropriate for the patient’s condition and life-style, and periodically monitors how well the disease is being controlled, the team may also include a dietitian and a diabetes nurse-educator. Medical specialists, such as an ophthalmologist (eye doctor) and a podiatrist (foot doctor), and perhaps a psychiatrist and a social worker, are also available for special needs.*27\268\2*

TRAVEL TIPS FOR PEOPLE WITH RHEUMATOID ARTHRITIS (RA) Sometimes people with RA give up vacation trips and other activities involving travel because they are afraid that they’ll encounter insurmountable obstacles or barriers when they’re away from home. Traveling is a wonderful pastime, though, and one you need not deny yourself. With careful planning, people with RA can travel wherever they choose.
Medical Tips for TravelersAlways discuss your vacation plans with your doctor. Ask him or her to recommend physicians where you are going who will consult with you and treat any unexpected problems that arise.Take along one or two weeks’ worth of medication beyond what you expect to need, as well as extra prescriptions from your doctor in case your trip is prolonged unexpectedly.Keep your medication separate from your luggage; that way, if your luggage is misplaced or stolen, you will still have your medication. It’s best to keep your medication with you.Carry a description of your medical problems and a list of your medications on your person. Wearing a Medic Alert bracelet or necklace designating your medication allergies and other important medical information is a good idea. If you are planning to travel out of the country, find out what your health insurance will cover in terms of medical care in other countries. Optional coverage is sometimes available.
Driving TipsStop the car frequently, and get out and stretch. This will help you avoid stiffness and soreness.Rental cars often have such features as tiltable steering wheels, cruise control, and power steering. Rental cars with wide-angled rear-view and side mirrors (helpful if you have neck arthritis), adjustable headrests, and auto aids such as padded steering wheels and right and left hand controls are also sometimes available.In cold weather have someone else warm up the car before you get into it.Lever aids that can be put on door and ignition keys help those who find it difficult to turn a key because of arthritis in the fingers.Grab handles can be attached to the ridge of the roof to help you get in and out of the car.Keep medications in the glove compartment rather than in the trunk so they will not be exposed to extreme changes in temperature.Pack snacks and a beverage so you can take your medications on schedule.*123/209/5*

FEVER IN RETURNED TRAVELERS: LABORATORY INVESTIGATIONThe initial laboratory evaluation should focus on diseases that are life-threatening, and the chief considerations are falciparum malaria and typhoid fever. Thick and thin blood films for malaria and blood cultures for typhoid fever are important initial diagnostic steps in the evaluation of febrile travelers. Thick smears for malaria are more sensitive, whereas thin smears are better for the determination of the malaria species. If the initial blood films are negative and malaria is still suspected, smears should be repeated every 8 to 12 hours, particularly during febrile episodes, for several days. Blood cultures for typhoid fever, as well as other enteric infections, are usually positive within the first week of illness.Other useful screening tests include a complete blood cell count with a differential (paying close attention to eosinophilia), blood chemistries, liver-associated enzymes, and a urinalysis with urine culture. Since most viral and rickettsial infections are diagnosed by demonstrating an antibody response, storing a tube of acute serum when a patient is first evaluated may provide the diagnosis when accompanied with a convalescent sample at a later date.*201/348/5*

THE BONE DENSITY PROGRAM: HOW NOT TO BE A STATISTICAt least 25 million Americans have osteoporosis, and another 34 million people have bone density low enough to be at increased risk of fractures. Almost all of these cases could have been prevented.At least a third of American women who have been through menopause—and half of women over 65—have osteoporosis. By age 75, the proportion of women with osteoporosis goes up to 89 percent. Up to 18 percent of women ages 25 to 34 already have low bone density—during the years when bones should be at their peak. Simple steps, starting young, would put all these percentages close to zero.One in two postmenopausal women will break a bone (or bones) as a result of low bone density. With good bone mass, you may have to worry about your bones if you have a dramatic skiing accident or something of the sort, but tripping over a loose electrical cord will be only annoying, not dangerous.More women have osteoporosis than have heart disease, strokes, diabetes, or arthritis. A woman’s risk of having a hip fracture is higher than the combined risk of developing breast, uterine, or ovarian cancer. Genetics and other factors beyond your control play the largest role in determining whether you get the other diseases, but you have the power to avoid low bone density altogether— and you’re holding it in your hand right now.Osteoporosis is a leading cause of death in elderly women. Some studies show a death rate as high as 50 percent within a year after a hip fracture. The rate of death remains higher than otherwise expected for years after a hip fracture, even in patients who seem to have made a full recovery. This easy preventive program can literally save your life.About half of people who fracture a hip are permanently unable to walk unassisted, and never regain their accustomed level of social activity. Keeping bones healthy and strong keeps you healthy and strong, living the life you choose, no matter how long the run.*9\228\2*

RELAXATION TRAINING FOR WAYWARD NERVES: CREATIVE VISUALIZATION – BIOFEEDBACKIn biofeedback training electronic instruments feed back information to you about what is happening in your body. A lead isattached to the hand or head, or both. By means of a light getting brighter and dimmer, noise getting louder or softer, or by the position of a pointer on a screen, you can actually see what happens when you tighten and relax muscles or speed up and slow down your breathing. This enables you to become familiar with what your body feels like when your blood pressure is normal, when your pulse is steady and when your muscles are relaxed. The aim is to achieve this state without the machine. A course usually consists of half-hour sessions over an uninterrupted six to eight week period.Biofeedback training is used in some NHS hospitals. You could ask your GP about it or you could buy a small biofeedback machine; they are often advertised in health magazines. Two leads are attached to your fingers and these measure the amount of tension; the machine emits a shrill sound if you are tense, and drops to a gentle clicking noise as you relax. You could also try Autogenic Training. Whilst it is better to have a teacher, if you really want to change, you can achieve very good results yourself.*112\326\8*

LIVING WITH EPILEPSY: DIET AND EPILEPSYThere is very little evidence that modifying your diet can affect the number or severity of your seizures. However, some people do notice that certain foods seem to precipitate attacks (milk seems to do it for some people, chocolate or coffee for others). So it is worth looking at your diet to see whether seizures do tend to occur more often after some particular food or drink. If you think they do, test out your theory! Give up the food for a month and mark on your seizure chart the date that you gave it up. At the end of one month see if you have had fewer seizures than in the previous month. Then reintroduce the food into your diet, marking your chart with the date you started eating it again. After another month, check the number of seizures you have had. If your seizure frequency has gone up again, it might be worth eliminating that particular food for good. Sometimes this dietary modification works for an individual, even if we know of no scientific reason why it should.EVENING PRIMROSE OILEvening primrose oil is a popular remedy, widely used to relieve symptoms in a huge variety of conditions, including eczema, premenstrual syndrome, rheumatoid arthritis and asthma. Although it is generally a very safe treatment, evening primrose oil should not be taken if you have, or have ever had, epilepsy, or if you have a strong family history of epilepsy. Evening primrose oil actually has the potential to precipitate symptoms of undiagnosed temporal lobe epilepsy.THE KETOGENIC DIETFasting has long been known to be one way of reducing seizure frequency. What happens in fasting conditions is that body fat is broken down to produce energy. No one knows why this should reduce seizure frequency in people with epilepsy, but there is no doubt that in some it does. One theory is that the breakdown of fats on a large scale makes the body more acidic, and from experience it has been found that this acidity acts as an anticonvulsant.The ketogenic diet is a diet which contains a very large proportion of saturated fat (animal fats and some vegetable oils), and a drastically reduced proportion of protein and carbohydrate, so that about 90 per cent of the body’s daily energy requirements come from fat. (In a normal, healthy Western diet fat provides 30-35 per cent of the daily energy needs.) So, just as happens in fasting conditions, the massive breakdown of fats makes the body more acidic, and this is probably why the diet tends to reduce seizure frequency.There is nothing new about the ketogenic diet. In fact it is one of the oldest treatments for epilepsy. The real problem with the diet is that it is both extraordinarily nasty and very difficult to prepare. Very few adults ever tolerate it for long, though it is occasionally given to children as a last resort. But since the first really effective anticonvulsant drug, phenytoin, appeared on the market the diet has largely fallen into disuse, and nobody has much regretted its passing.So why, now in the 1990s, has the ketogenic diet suddenly re-emerged, like Frankenstein, from what most people would consider a timely grave? The answer to this question provides a very good example of medication by media.The diet’s new-found popularity is due largely to an American film producer whose child has epilepsy. Despite numerous visits to eminent neurologists who tried every possible drug, the child’s seizures proved almost impossible to control. In desperation the father researched epilepsy treatments in the local library and came across the ketogenic diet, which no one had suggested to him.He introduced his child to the diet and was very fortunate in that the child’s epilepsy improved. He then made a video film describing the way the diet had miraculously transformed his child’s life (and, rather unfairly, how all the doctors he had seen had failed to help). The film was seen widely on television. A spate of articles in the popular press followed, and the ketogenic diet is now the rage in the United States; there are also signs that parents in many other parts of the world are starting to ask why this miracle treatment has not been prescribed for their children.How effective the diet really is, is still a matter of medical debate. The enthusiasts (and they include some very eminent doctors) say as many as half the children who try it achieve a 50 per cent reduction in seizures. Those who are less enthusiastic, though equally reputable, quote figures of around 5 per cent or less. No one doubts that it works for some children, or that when it does fail it is often because it is difficult to apply properly, and heartily disliked by the child.There are also questions about the long-term implications for a child’s health which most parents (and doctors) will probably want answered before they embark on the ketogenic diet:• Will it make my child fat?It should not do so if the diet is correctly balanced. The child’s total daily calorie intake should not alter; what changes is the balance of foods. Only if the child eats more than they need to satisfy their daily energy requirements will they get fat.• Will it increase the chances of my child developing heart disease?We are so conditioned to associate a high-fat diet with heart disease that it is difficult to believe that the ketogenic diet can be healthy. But in the short term at any rate there is no evidence that children who have been given the diet develop the fatty plaques in their blood vessels which are the cause of heart disease. However, for those few children who have a family history of high blood cholesterol (hyperlipoproteinaemia) the diet may be a real danger. Any child who starts the diet should be monitored carefully to check the levels of blood cholesterol.• Are there any other health problems associated with the diet?A few children develop kidney stones on the diet, and itmay also have an effect on the immune system, though there is no evidence that this effect causes any significant problems in the short term.If you are tempted to put your child on the ketogenic diet:Do not try it if your child’s epilepsy is already well controlled by drugs.Do not try it unless you are able (and willing) to put a lot of time and effort into preparing your child’s food.Do not try it unless you have a supportive medical team including a trained dietician to help you.Do not try it if there is any family history of high blood cholesterol.Think about how your child will feel. No child likes to be different. The child with epilepsy starts off with a built-in difference from other children which they have to learn to live with. It will not make them feel any better if they are debarred even from eating the same biscuits, buns, sweets, hamburgers, ice-creams – all the snacks and junk foods that their friends eat and which most children enjoy.If you decide to try it:Learn all you can about food preparation. A skilled cook can make the diet much more acceptable – even, its supporters would say, quite appetizing.Encourage your child to become involved both in the choice of food and its preparation. They are much more likely to stick with it if they have some control over it.Be prepared for a difficult time at first as the child’s body adjusts to the diet. To begin with the child may be irritable because their blood sugar is low, but after a week or two this should settle down.Listen to your child. If they really hate the diet, and many do, ask yourself if it is worth putting them through it for what may be only a small reduction in seizures.• If, after three or four weeks, there has been no improvement in seizure control, give it up.WATER LOADSome years ago a medical scare story was published in the press suggesting that a certain brand of lemonade had been found to cause seizures. The facts were rather different; the lemonade was entirely innocent. The seizures were not lemonade-induced but due to the fact that it had been a hot summer’s day and the sufferer had drunk more than two litres of the stuff. He had given himself a huge ‘water load’ – too much liquid drunk too quickly, which is known sometimes to trigger a seizure.When you are thirsty, do not drink huge amounts to quench your thirst. A glass of water is fine but if you drink, say, two or three pints all at one time you risk precipitating a seizure. There is no need to restrict your overall fluid intake, but try to drink little and often rather than allowing yourself to develop a real thirst that might make you want to drink very deeply.*57\193\2*

DIETS FOR PEOPLE WITH DIABETES: ALCOHOLAlcohol is not a recommendation, however, if diabetes is well controlled, moderate use of alcohol is unlikely to adversely affect blood glucose. However, it is important to verify this through blood glucose monitoring. Patients who take insulin should limit their intake to not more than two drinks per day (one drink equals 12 oz beer, 5 oz wine or 1 oz distilled alcohol). If alcohol is consumed, it should not be counted as part of the meal plan, but in addition to the meal plan. In the fasting state alcohol may produce hypoglycemia. This is because alcohol cannot be converted to glucose, inhibits gluconeogenesis, and augments or increases the effects of insulin by interfering with the counter-regulation of insulin-induced hypoglycemia.Alcohol is metabolized in a manner similar to fat. Even though extra calories are consumed, total food intake should not be reduced. When calories intake is being restricted, as in individuals trying to reduce their body weight, alcohol is best substituted for fat (one drink equals two fat exchanges, or about 100 kcal that would have been consumed as fat).Here are some guidelines for alcohol use. For insulin users:1. Limits to two small drinks per day.2. Drink only with food.3. Do not cut back on food.4. Abstain if there is a history of alcohol abuse, during pregnancy and lactation.5. For non-insulin users:6. Substitute for fat calories.7. Limit to promote weight loss or maintenance.8. Limit if triglycerides are elevated.9. Abstain if there is a history of alcohol abuse, during pregnancy and lactation.Alcohol calories cannot be substituted with diet calories. 1 g of alcohol = 7 calories.*9/356/5*

AEROBIC EXERCISES FOR PERSONS WITH RHEUMATOID ARTHRITIS: TAKING YOUR PULSETo find out what your actual heart rate is, you must learn to take your pulse. Turn your hand over so that you are looking at your left palm. Use the tips of your right index, middle, and ring fingers to feel for the pulse. Place your fingertips at the base of your thumb on the bone at the edge of your wrist. Then, slowly slide your fingertips toward the middle of the wrist, feeling for a pulsation. (If you feel tendons, you have gone too far.) You’ll need practice to learn how much pressure to exert. Too much pressure will stop the pulse. Not enough pressure will prevent you from feeling it. Practice by using different degrees of firmness.Once you find the pulse, you will need to count the pulsations to get your heart rate. Use a watch that measures seconds. Count the number of pulsations occurring in a fifteen-second period. Then, multiply that number by four. This will give you your actual heart rate in beats per minute.For your convenience, the following chart lists some target heart rates for various ages as well as the number of pulsations you should count at your wrist in a fifteen-second period if you have reached your target heart rate. If you like, select the row that is closest to your age and use that number as your target rate.*81/209/5*

ALCOHOL: THE FUTUREIt is possible to take a reasonable guess at what will happen in the future or what could potentially happen by noticing how close a client comes to the secondary process. The following interaction gives me the feeling that Herr G. has the potential to develop all sides of himself.Amy: Herr G., I saw how you spoke a few minutes ago. I was impressed. I now want to show you what I saw. Take a good look at me now. You said [I act like G., using his gestures in order to anchor his courage], I do have the courage to act. Now 1 do have this courage though I did not have the courage in the past.Herr G. (amazed and proud):  Did I say that?Amy: You did, and today you have the courage to give up alcohol and today you have guilt feelings because today, now, you are an alcoholic even though you know that you have the courage to give it up.Herr G. grins from ear to ear and clasps his hands in a gesture of triumph.Herr G.: Look. I am astounded by myself, by my own courage. You know, I always had it.*121\227\8*