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By R. Pranck. A. T. Still University. 2018.

They also figure in both popular and professional characterizations of disease discount 400mg noroxin otc, but to a different degree buy 400mg noroxin with mastercard. For instance generic noroxin 400mg overnight delivery, (4) Disease Is Disorder is probably more important for professional conceptualization and discourse than for that of the general public trusted noroxin 400mg, whereas (7) Disease Is Being Under Attack is prominent in the thinking of patients and the public as well as traditional allopathic practitioners discount noroxin 400mg with amex, with the classic response being to drive off, poison or cut out the metaphorical "enemy. That is because the most vivid and literal examples of mechanical breakdown, imbalance, disinte- gration, and disorder are not diseases, and the way the terms are used to describe disease borrows from these more literal domains. For example, our understanding of mechanical breakdown starts with broken tools and machines, of imbalance with tripping and falling, of disintegration with objects breaking up or falling apart, and of disorder with domestic messes or social chaos. In the case of (6) Loss Of A Vital Fluid, bleeding is the literal and central example but is a symptom, and not a disease. Based on the logic of this symptomatic event, health and disease seen as fullness and deficiency of a vital fluid are cognitively mapped out. And finally, our knowledge of attacks is one more metaphorical source domain for the understanding of disease. There is a related reverse metaphor which sees War As Disease but it is not well elaborated or important in our understanding of war so far. The model Disease Is The Abnormal is a special case, not truly metaphorical but probably related to the common association of anomalies with symptoms. The health models are not as well developed as those for disease and are often understood mainly as contraries of the disease depictions, secondarily generated from them. Like "peace," health is often seen as the absence of something negative rather than a positive presence with its own integrity and content. Unfortunately, this view means that the nourishment of health as well as peace are typically neglected since, unlike the disruptions of disease and war it is easy to think of health and peace as "uncaused. These descriptions are preliminary, not definitive, and are subject to alteration upon more reflection and empirical study. But it does matter that concepts of health and disease are plural and often metaphorical, and that can be established. The conceptual structures matter because qualitative symptoms cannot be quantified into units of suffering with the help of a single standard of disease. They matter because the relevance and seriousness of any definable condition is peculiar to each particular case, and no comprehensive formula for health applies in full to any unique situation. They matter because the logic used to decide what is desirable and what is not cannot itself be mechanized when imaginative and conflicting models are so pervasive in conceptualizing health and disease. Disease Is Mechanical Breakdown In this model the body is a large machine made up of the organs which are smaller machines. The mind is also a machine, more or less tightly tethered to the body at the locus of the brain, one of the constitutive machines. One difficulty with this model when it is looked at closely, is that of specifying what all the organs should be doing when they are working well or optimally. There is a dispute between those who believe that an objective concept of proper working can be developed, usually on the basis of evolutionary fitness or some other measure of adaptation, and those who believe that the definition of proper function is a value judgment. The proper purpose and functioning of these two constituent machines turn out to be less than self-evident. Terms like "adaptive behavior" and "fitness" or "inclusive fitness," which supposedly describe the proper workings of the brain and the genome, respectively, evoke much controversy. For example, how many generations of survivors do we count in deciding whether one gene allele or another is working better to promote "fitness? So is a gene as a tiny submachine working well when it promotes reproduction of itself or of individuals of the type which contain it? In practice, good working of organs, brains and people is culturally defined, although it is probable that cross-cultural definitions of good function would be HEALTH AND DISEASE 45 in wide agreement, for example, when describing a functioning eye, ear, heart, lung, kidney or parathyroid gland. When symptoms, those most reliable markers of disease can be traced to the function of an organ, the likelihood of universal agreement on the presence of disease as mechanical breakdown is greatest. For instance, when a cluster of symptoms like chest pain, shortness of breath, wheezing and swelling of the hands and feet is traced to how the heart works, agreement that there is a breakdown of the heart is usually reached, and the heart is said to be failing. Approaching the heart in this situation as if it was a broken down machine has been quite useful.

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Further- the specific physiologic impairments that characterize the more cheap noroxin 400mg visa, although there is a general sense that senescence senescence of each species noroxin 400 mg without prescription. The two most popular has been a field characterized by a plethora of mecha- candidates for the weak link theories are the neuroen- nistic theories buy discount noroxin 400mg online. Both the generally fall into two categories order noroxin 400 mg visa, which can broadly be neuroendocrine system and the immune system exhibit referred to "loose cannon" theories and "weak link" profound and specific functional impairments during theories purchase noroxin 400 mg with amex. Failure of the neuroendocrine system would be The "loose cannon" theories posit that some entropy- expected to produce profound impairments in homeo- producing agent is slowly wearing away at cellular macro- static systems, including the loss of reproduction and molecular constituents. Considerable evidence suggests that oxidative damage increases with Similarly, failure of the immune system would be age. For example, it now appears in more, simultaneous overexpression of two different fact that, far from the expected relationship between enzymes that attenuate free radical damage, superoxide declining growth hormone and age-related mortality, dismutase and catalase, significantly increases the life mice with growth hormone deficiency exhibit increased span of fruit flies;20 no effect was seen when only one life span compared to wild-type mice, whereas mice with elevated growth hormone exhibit reduced life span. Similarly, exposure of nematodes to small molecules that mimic effects of superoxidase Similarly, although autoimmune processes cause type dismutase and catalse also increased life span. The major means by which glucose has been pro- roendocrine and immune systems do exhibit impairments posed to promote senescence is through nonenzymatic with age, little is known about the more primary mecha- attachment to proteins and nucleic acids through Schiff nisms that drive these changes. Therefore, in their current base formation, followed by an irreversible formation incarnations, none of the entropic theories of aging are of Amadori products, the same process that produces complete, and it cannot be said that considerable evi- glycated hemoglobin. Mobbs Physiology of Aging Although this derivation is far from accomplished, simply being able to formulate such a precisely quantitative As organisms age, they accrue functional impairments in question is evidence of the state of gerontology as a sci- virtually every physiologic system. Analysis suggests that at least the form Shock and his coworkers developed a general rule of of the Gompertz curve may arise from evolutionary thumb that many physiologic systems accrue impair- effects, involving a decline in the force of natural selec- 28 ments at a rate of about 5% to 10% per decade after the tion acting on age-specific mortality. In the top panel that a heart rate more than 80% of maximum attainable (A), the survival curve (fraction of initial population left during a stress test is dangerous, and that the maximum alive as age increases) of a typical ("normal") population heart rate attainable during a stress test reliably is compared with the survival curve of a genetically decreases by about 1 beat per minute each year during similar population placed into an optimum environment aging. The rate of this decline is reduced by about half ("enhanced environment") or a population modified in highly trained athletes, but even in such athletes, genetically or subject to dietary restriction. Note that an maximum heart rate and maximum oxygen consumption enhanced environment can increase average life span rate nevertheless decline with age. In contrast, genetic variance and dietary restriction can increase not only average life span but maximum life span as well. When these same data are plotted in terms The Gompertz Curve of rate of mortality (the number of individuals that have The essential feature of senescence, at least when applied died over an arbitrarily small unit of time), the mortality to mortality, is that the rate at which death occurs rate of all groups increases exponentially with age and increases with time. If the rate at which death occurred reaches the same high rate toward the end of life; the were constant (e. In most species, nential increase (although then the rate increases even senescence, manifest as an increase in the rate of mortal- faster toward the end of life), whereas genotype and ity with age, can be described by a remarkably simple dietary restriction can actually change the rate at which mathematical function. Because mortality rate increases species that have been studied, including flies, nematodes, exponentially with age, these effects are more easily and rodents, increases exponentially with time, first understood by subjecting the rate data to a logarithmic observed in humans by Benjamin Gompertz after observ- transform. After such a transform, log (mortality rate) ing actuarial statistics and reported in 1825. Normal and enhanced envi- pertz equation can be stated succinctly as Rm(t) =-(1/n) ronment groups have similar slopes. If anything, the dn/dt = R e(at), where Rm(t) is the mortality rate at time enhanced environment group may exhibit a slightly * 0 or age t, n = the number of survivors at time t, R0 is the higher slope because the intercept is lower, whereas mortality rate at time t = 0, interpreted as a vulnerability genotype and dietary restriction can actually decrease the factor depending on the hostility of the environment, slope of this transform. This When the rate of mortality becomes high enough, an equation can be linearized by log transform into arbitrarily small number of individuals will be left alive lnRm(t) = ln(R0) + at. In practice, maximum The intercept of this line is generally dependent on the life span is determined empirically, and in humans is gen- hostility of the environment, whereas the slope is depend- erally assumed to be around 125 years (for women; some- ent on the genetic background of the population, for what lower for men). Normal, standard population dynamics; enhanced environment, dynamic pattern as might be observed by idealized optimization of environ- ment, leading to "rectangularization" of the survival curve; enhanced genotype or dietary restriction, dynamic pattern observed by single gene mutations that extend maximum life span (such as AGE-1) or by dietary restriction regimens that extend maximum life span. Depicted in this way, rate of mortal- ity increases exponentially with age (Gompertz function). Note that rectangularization of the mor- tality curve may decrease initial rate of mortality but does not necessarily increase maximum life span and may indeed lead to increased mortality rate during the late period of life, whereas genetic or dietary enhancement of maximal life span is expected to entail decreased rate of mortality but not necessarily a decreased initial mortality rate. In humans, the generally population of heterologous individuals in this phenome- accepted range of applicability is between ages 20 and 80 non has yet to be determined. A particularly interesting recent development is evidence in both humans and other species29,30 that the Pathology Versus Senescence slope of the linearized Gompertz equation (that is, the increase in the rate of mortality, or the second derivative The Gompertz equation applies not only to mortality but of survival) begins to decrease at very old ages, and also to diseases and may be used to resolve a major and possibly the rate of mortality becomes constant (e. These remarkable results have profound ogy, or disease, and what is commonly (although, as we implications for our view of the process of senescence, have seen, unrigorously) called normal aging?

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This applies to sol- diers discount 400 mg noroxin with amex, o½cers cheap 400mg noroxin otc, military ambulance sta¨ discount noroxin 400mg without prescription, nurses cheap 400 mg noroxin free shipping, combat lifesavers noroxin 400mg low price, and surgeons. Training medics requires focused learning objectives and diverse trajectories to reach the objectives. The subjects are soldiers without medical background, noncommissioned o½cers and medical sta¨, and physicians and surgeons. Ob- viously, there is a need to ¯exible training equipment with su½cient realism to emphasize triage. Education and training of triage proto- cols can be facilitated with computer-based training facilities, like interactive video (62). Vossen (63) was the ®rst to report such a system and demonstrate its potential to education. However, interactive video does not support sensing the real atmosphere of a mass casualty in a combat situation. It does not support user feedback other than selecting icons: The ability to interact physically with a patient is not present. In the next gen- eration of triage-training systems, a hardware dummy of the human anatomy could be seen through a VE display device. This type of augmented reality in medicine can be applied to see a patient (either human or dummy) through an advanced optical display device while internal structures and/or surface injuries are projected onto the patient. In real-life triage sessions scanned patient data (volume data rather than polygo- nal data) can also be projected onto such a dummy. Kerlin and Johnson (60) recommend that soldiers to carry their own medical records in opto-electronic format for diagnostic purposes. With this so-called image-save-and-carry (ISAC) philosophy, the scanned images can be projected onto the casualty in second-line medical care and perhaps even in ®rst-line medical care. Optionally, triage support can be delivered by an expert located in one of the higher eche- lons, who can be consulted through teletriage and VE technology supporting computer±human interfacing. Diagnostics and interventional therapy are two steps in the treatment of malignant tumor cells and rely heavily on decisions made by the physician on the basis of visual impressions. One of the most important treatment methods is conformation radiotherapy of tumors, i. The close vicinity to the target area of radiosensitive organs, such as the optic nerves, the spinal cord, and the brainstem, often means that conventional radiotherapy cannot administer a su½ciently high dose to the tumor without inducing serious damage to the surrounding healthy tissue. With conformal precision radiotherapy planning, the target area is delineated in scanned patient data and visually presented to the operator. Optimal directions for irradiation can be computed from a desired dose distribution (67). Such therapy planning can be carried out in VE in which the patient can be modeled and the planning results can be shown. In a graphic environment, however, there are essentially no constraints imposed to the handicapped. VE technologies have the potential to interface a disabled person to computer systems, giving the person access to the wide area of the information society, including electronic network services. Interactive learning of sign language can be facilitated with a VE simulation system. Legal signs modeled by hands attributed with DataGloves can be automatically interpreted by the computer system, and incomplete signs can be shown correctly (69). Such a system can keep track of the score of an individual user, who might ®nd this talking mirror interesting and encouraging to use. VE technology can also be used in the rehabilitation of muscles and the nervous system after surgery or accidental 48 VES IN MEDICINE; MEDICINE IN VES damage. Conventional rehabilitation sessions are often experienced as dull, and VE technology may give rehabilitation a new dimension. A patient may be motivated in therapeutic rehabilitation via interaction with a playful or even competitive VE simulation. Motor functions can be stimulated by playing with virtual objects with a minimum of energy or e¨ort. Diseases may be recognized from response times and ®nger movements of a patient wearing a DataGlove, and dysfunctions at a perceptive level can be concluded from a patient who senses a growing con¯ict of sensory input. Also the relationship between the electroencephalogram (EEG) and speci®c cognitive activities in VE can be investigated in a therapeutic session.

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The incidence of side-effects forms a bell-shaped curve buy generic noroxin 400mg, showing some who have no side-effects while others have many purchase noroxin 400 mg fast delivery. Its daily subcuta- neous injection usually causes some redness and itching at the injection site when treatment is initiated buy noroxin 400 mg amex. One unique side-effect does occasionally occur; it is very infrequent and usually does not recur cheap 400mg noroxin with mastercard, but some people may expe- rience a sudden warm or hot sensation throughout the body along with chest tightness buy generic noroxin 400mg line, shortness of breath, and a feeling of depres- sion. If an aggres- sive approach with emergency medicine is applied, increased prob- lems occur; thus, it is recommended that if this side-effect is pres- ent, rest for twenty minutes and do not panic. At full dose Avonex® has fewer side- effects because it is given at a lower total dose each week. Knowing this, it is recommended that high dose interferon (Betaseron®, Rebif®) be initiated at a quarter of the final dose each time it is taken 20 CHAPTER 2 • Managing the Disease Process until the side-effects abate. The dose then is increased to a half dose until stable, then three-quarters, then full. Medication that will lower temperature is helpful (ace- toaminophen, ibuprofen, etc. Small needle injections of interferon (Betaseron®, Rebif®) lead to more skin discoloration than the longer needle injection (Avonex®). Common sense tells us that intramuscular injections are best performed by a helper. That is not true for every- one but it holds for most people who have any problems with coor- dination or weakness. If one develops actual skin breakdown, a decision as to whether the treatment can be tolerated must be made. With interfer- on therapy, blood and liver tests should be monitored for a period of time, because sometimes significant changes can occur. In the meantime, there appears to be little relevance to measuring them because they correlate poorly with effect. Mitoxanthrone (Novantrone®) comes with the above mentioned heart concerns but it can also suppress the function of the blood and liver. Care must be taken that the i’s are dotted and the t’s crossed; that may be best done by a physician who is used to administering such chemotherapy agents (an oncologist or cancer doctor). THE TREATMENT OF ACUTE ATTACKS The treatment of acute attacks has changed little in the past decade. Cortisone medication including methylprednisolone, dexamethasone, 21 PART I • The Disease and Its Management prednisone, and others continue to be commonly used to shorten the attack. These potent anti-inflammatory drugs diminish the swelling within the brain and spinal cord that is seen as cells of the immune system invade and attack the nervous system. They are clearly associated with osteoporosis, cataracts, psychological changes, skin acne, weight gain, and salt and water imbalance. Thus their effect on acute attacks must be weighed against potential problems from the treatment. General drugs that affect the immune system include azathio- prine (Imuran®) and methotrexate. Studies do not show them to be as effective for relapsing MS as the newer medications, but for some people with either relapsing or progres- sive MS they may help to control progression of the disease. They clearly are not for everyone with MS and must be selected and used with expert advice. The back- bone to MS management has been and continues to be the man- agement of symptoms. Everyone with MS should be aware of the many ways that the symptoms of MS can be managed, with the goal of improved quality of life. Symptoms in MS may be divided into those that are caused directly by demyelination within the brain and spinal cord and those that are not. If you lose myelin in the part of the brain or spinal cord that influences strength, you will develop weakness; if you lose myelin in the part that controls coordination, you will become uncoordinated; and if you lose myelin in the part that con- PART II • Managing MS Symptoms trols sensation, you will develop numbness, pain, burning, or itch- ing. Symptoms in MS may be divided into those that are caused directly by demyeli- nation within the brain and spinal cord and those that are not. People who have primary symptoms sometimes also suffer from problems that are only indirectly caused by the disease; these are called secondary symptoms. For example, some people who are weak and stiff develop decreased movement at the joints, which are called contractures, and immobility can lead to osteoporosis or skin breakdown. Chronic disease may lead to changes in how one looks at life and tackles life’s stresses.

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