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Definition Sclerosis (hardening due to excessive production of con- nective tissue) of collagen affecting the skin (sclero- Aetiology/pathophysiology derma) and the internal organs (systemic sclerosis) order advair diskus 100 mcg with mastercard. The condition causes a thrombotic ten- Incidence dency due to loss of phospholipid dependent coagula- Rare purchase advair diskus 500mcg online, 3 per million. Pro-thrombotic stimuli such as preg- nancy, surgery, cigarette smoking, hypertension and Age the use of oral contraceptives further exacerbate this Anyage, mean onset at 40 years. Antibodies include the lupus anti-coagulant (anti-coagulant in vitro but procoagulant in vivo), anti β2glycoprotein-I antibodies and anticardiolipin Sex antibodies. A scleroderma like disor- eration and thickening of the intima and fibrosis of the der is seen following exposure to silica, vinyl chlo- adventitia is seen. Morphoea are patches of sclerotic skin on the trunk r Raynaud’s phenomenon is treated by avoiding cold, andlimbs,whichmaybelocalisedormoregeneralised. Malabsorp- r Limited cutaneous systemic sclerosis begins with tion may require changes in diet. Notreatmenthasbeenshowntoalter r Overlap syndromes have combinations of the features the long-term progression of scleroderma. Diffuse dis- of systemic sclerosis, systemic lupus erythematosus, ease with severe visceral involvement carries the worst dermatomyositis or rheumatoid arthritis. Chapter 8: Connective tissue disorders 369 Nervous system: Cardiovascular system: Ischaemic changes in central and Pericarditis, myocardial fibrosis peripheral nervous system. Peripheral causing a restrictive cardiomyopathy, neuropathy may occur due to conduction tissue fibrosis causes perineural vascular sclerosis. Respiratory system: Pulmonary fibrosis especially in lower Gastrointestinal system: lobes and pulmonary hypertension. Motility disorders including gastro- oesophageal reflux with oesophagitis, ulceration and aspiration pneumonia, malabsorption secondary to bacterial Genitourinary system: overgrowth. Sjogren’s¨ syndrome Pathophysiology There is lymphocytic infiltration of salivary glands and Definition other exocrine glands in the respiratory and gastroin- Achronic inflammatory disorder of the lacrimal and testinal tract, the skin and the vagina. Sex 9F : 1M Clinical features Aetiology r Ocular manifestations: Sensation of persistent grit- Sjogren’s¨ syndrome may be primary, or secondary to tiness, photosensitivity, tiredness and an inability to rheumatoid arthritis, systemic lupus erythematosus, produce tears (keratoconjunctivitis sicca). There is r Gastrointestinal system: Lack of saliva (xerostomia) an association with non-Hogkin B cell lymphoma. There 370 Chapter 8: Musculoskeletal system may be oral ulcers, dental caries and firm non-tender age of 40 years. The skin shows collagenous thicken- phenomenon and an association with other organ ing of the dermis with chronic inflammatory cell infil- specific autoimmune disorders in primary Sjogren’s¨ trates. Occasionally there are systemic features including vasculitis and renal tubu- Clinical features lar defects. Gradual onset of non-specific systemic features followed by symmetrical, progressive, proximal muscle weakness. Occasionally there is cardiac r Schirmer’s test for keratoconjunctivitis sicca measures involvement leading to heart failure, respiratory involve- tear production. An edge of a strip of filter paper is ment, including nonspecific interstitial pneumonia, and placed in the lower eyelid and the length that becomes oesophageal involvement, which may be sufficiently se- wetismeasured. Management Sex Acute phases are treated with corticosteroids, which 2F: 1M should be reduced gradually to a low-maintenance dose. Methotrexate, azathioprine or cyclophosphamide are Aetiology/pathophysiology used in resistant cases. Dermatomyositis is associated with malignancy of variable severity, and spontaneous remissions can (e. Chapter 8: Crystal arthropathies 371 Marfan’s syndrome Management r β-blockers have been shown to slow aortic dilata- Definition tion, and lifelong therapy is recommended by the Inherited condition resulting in abnormalities of con- European Society of Cardiology. The under- r Musculokeletal: Patients have elongated and asym- lyingpathologyisanabnormalityinskin,jointandblood metrical faces with a high arched palate. Some of the reduced upper to lower body segment ratio and an subtypes have been mapped to mutations in the collagen arm span that exceeds the patient’s height. Clinical features r Cardiovascular system: There is degeneration of the There is hyperextensible skin with normal elastic recoil, media of blood vessel walls: hypermobile joints, and fragility of blood vessels causing 1 Dilation of the aortic valve ring producing regurgi- bruising and occasionally aortic dissection and rupture. Hypermobility can lead to early osteoarthritic changes 2 Mitral valve prolapse and associated mitral valve and damage to the joints. The diagnosis is clinical and can be based on clinical cri- r Calcium pyrophosphate causes pseudogout. Once diagnosed patients require periodic r Crystallised injected corticosteroids may result in ia- aortic imaging to detect early dilation. Typically pyrosphosphate crystals are seen Xanthine Hypoxanthine within a phagolysosomal sac, whereas urate crystals are Xanthine Oxidase not confined.

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In our experiments we chose normal human urine as the most economical source for the isolation of 150 antineoplastons purchase advair diskus 500 mcg otc. This is an enormous subject and not one which can be examined in great detail here without straying miles down the road from the subject of urine therapy generic advair diskus 500mcg with visa. In 1979, Gary Null, a famous New York City talk show host and consumer advocate, published a series of excellent articles on the suppression of cancer cures in the U. One of the cancer treatments that has been suppressed involves the use of these antineoplastons that naturally occur in urine, discovered by Dr. Gary Null, interviewed Burzynski in October 1979 and revealed hidden facts on Antineoplaston A: "We can see how the cancer blackout works by looking at the case of a young Polish doctor named Stanislaw Burzynski. In the past few years, this doctor has published ten papers on the positive results of a substance called antineoplaston a on certain types of tumors. Burzynski found life under communism difficult and decided to come to the United States to seek more freedom for his scientific research. Documented cases of spontaneous remission and prolonged cancer arrest in humans led Dr. The body must have some way, he thought, to correct errors that occur in cellular differentiation and to redirect potential cancer cells into normal paths. They appear to "normalize" cancer cells without inhibiting the growth of normal cells. Actually, urine therapy has been used as folk remedy for cancer and other ailments for over 2,000 years. Even within the past 30 years, at least 45,000 injections of urine or urine extract were given in the United States and throughout Europe without any toxic side effects. Burzynski presented his startling results to the annual meeting of the Federation of the American Societies for Experimental Biology. His work was channeled into other areas of research, and his superiors discouraged his pursuit of cancer therapy. For example, there was the case of a 63-year old white male with lung cancer that had spread to the brain. Burzynski, the patient had received chemotherapy and cobalt treatment, whereby a part of the brain tumor had been reduced. However, a new tumor had sprung up in another part of his brain, and doctors decided that nothing more 153 could be done. After just two weeks of the antineoplaston treatment, in which the patient was given the substance intravenously, the tumor on the left lung decreased substantially. After a month both brain metastases decreased in size and, in six weeks, also disappeared. Amazingly, the only side effects of this highly effective treatment were chills and fever. These were attributed to the release of toxic products into the bloodstream after the breakdown of cancer cells. Burzynski still uses his treatment successfully in his lab in Houston today, although he is continually assaulted by the medical society in Houston and has been refused research grants from the American Cancer Society and the National Cancer Institute — even though his findings on the anticancer properties of antineoplaston A have been confirmed in tests by prestigious research centers all over the U. Your Own Perfect Medicine After several unsuccessful surgeries for endometriosis, I was told that I would need more surgery. After my doctor told me that he was scheduling another operation for me, I canceled the surgery and flew to Mexico to get an alternative treatment for cancer patients that I was told also had possibilities for treating my case. The man in the bed next to mine had a cancerous brain tumor the size of a large grapefruit bulging from his head. One of his eyes, nearly eaten away by the cancer, was now just a mass of bloody, unrecognizable tissue. These were hopeless, desperate people, many of them only in their twenties and thirties – but what could they do? It has been reported that: "Nearly two-thirds of all cancer patients will eventually die of their diagnosed cancer, either before or after the arbitrary five-year limit. She told me that in desperation she had gotten into her car and driven 156 from her home in the Midwest to Mexico in hopes of finding some help. She asked me if I knew of any place that she could buy laetrile — she thought that perhaps she could treat herself with it, but I was unable to help her. The bleak look of hopeless despair on her face was horrifying, and I would have loved to have been able to hand her a book on urine thera- 1 py — it was something she could have used herself, for free, in her own home, that undoubtedly would have given her control over her health and, at the very least, an excellent fighting chance. After all, she had everything to gain and nothing to lose by using this safe, proven natural therapy. It is instructive as showing once again that operations merely deal with effects and do not remove the cause of the disease from the body. The lady in question was 45, and had a growth of some size in her left breast, the right one having been removed two years previously for a similar growth. She fasted and was treated according to my method for nineteen days, and then reported that the growth had entirely vanished. Cancer is a frightening disease, but with the assiduous and wise use of natural healing methods such as urine therapy, proper nutrition, herbs, rest, homeopathic remedies, etc. Before you resort to any conventional cancer treatment, go to your local library and research your case by reading material related to different treatment options.

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However 100mcg advair diskus mastercard, crossings do occur and often do not do harm to This is made clear in the Oath which requires that the physi- either the practitioner or the patient order 500mcg advair diskus. Should harm come from cian will conduct himself or herself “In purity and holiness,” a boundary crossing, the action is then defned as a boundary will treat the sick, “will keep them from harm and injustice,” violation. For ex- ample, sexual behaviour with a patient is widely acknowledged Boundaries clarify the necessary distance between the doctor as harmful. Keeping healthy boundaries is often automatic triggering an angry and defensive reaction, is widely acknowl- and usually easy but can at times be diffcult for both patient and edged not to be harmful. It is important for the profession to have detailed guidelines and limits for appropriate boundary behaviour and Boundary crossings may, at times, simply be communication equally important to allow the for the doctor-patient relation- blunders. At other times, they indicate an innovative or an in- ship to be reasonably fexible—in keeping with any genuine tuitive departure from the common treatment protocol. Boundaries elucidate the roles and expectations addressing each other using frst names could be fne in many involved in the physician–patient relationship. Boundaries thus defne the limits of the therapeutic than simply as “Gertrude”, or worse yet: “Gertie”). Therapeutic frame Occasionally, physicians are required to negotiate diffcult and Boundaries between doctor and patient are particularly impor- sensitive boundaries. At times this is described as “dancing tant since they defne the therapeutic frame. These principles are as follows: here is that treatment must take place within a structural and 1. Physicians should remember that it is for the patients’ conceptual space defned by certain parameters. When physicians self-disclose they should always and “the norms” of the therapeutic encounter, which help de- consider the current stage the relationship is in (later fne a therapeutic milieu that is benefcial to the development in the doctor-patient relationship somewhat more of a therapeutic experience. Physicians should not disclose those things that are a successful, high-quality treatment. Physicians should think about how their self-disclosure zone” (or more optimistically a “pastel zone”) that is somewhat would sound to other people. Entering this gray or pastel zone may, at times, be Summary helpful, yet it is always risky and certainly could be detrimental. By Although most boundary transgressions are conceptualized setting, and then following reasonably clear and appropriate as being “over” the boundary (the doctor is intrusive or the boundaries, physicians make their life easier and simpler, and abusive), it is important to realize that sometimes the doctor increase their sense of joy in the practice of medicine. Case resolution The resident is an outstanding resident with no history of Guthiel and Gabbard’s article, The concept of boundaries in clinical boundary issues. The resident agrees that this particular practice: Theoretical and risk-management dimensions, is an excellent incident was a boundary crossing, and if not well managed overview of boundary issues. There are acknowledges that the wording of the comment was pertinent boundaries for the many various facets of the doctor awkward, inappropriate and clearly it was not helpful to patient relationship. In reviewing the principles of physician self- limited to disclosure, the resident realizes that what was disclosed did • social role, not sound appropriate to either the patient or her parents. The • money, meeting is tense but helpful; the family express that the • gifts and services, comments were seen as inappropriate and harmful but also • clothing, acknowledge that it was intended to support the patient and • language, normalize her self-image. The resident acknowledges that • self-disclosure, and the words were hurtful and demonstrates how to handle • physical contact. The complaint is dropped, Since self-disclosure is such an important boundary and since the resident is more mindful of their use of language in the case included an unwise self-disclosure it is worthwhile to discussing sensitive subjects, and the patient remains in the briefy cover this topic. Physician self-disclosure Most physicians would agree that sharing some personal details Key references with a patient is necessary and even helpful. The concept of bound- ing personal information may lead to disclosing increasingly aries in clinical practice: Theoretical and risk-management intimate and potentially sensitive information. At a basic level, medical education must occur in a life, such as intimate relationships, plans to have a family, health specifc sequence for the learner to move successfully from issues and the needs of family members. At the same time, the learning and acquisition of experience through which students become Self-refection on the personal and professional implications residents and then practising physicians is multi-layered. It will aid in planning the stages of that all physicians develop basic core competencies in all of training and in ensuring personal and professional satisfaction their Roles (Medical Expert, Communicator, Collaborator, with outcomes. That being said, there can be many chooses to emphasize each of these Roles within their career, roads to the same goal. Personal refections on a career of transi- cian are the move from medical school training to residency, tions. Journal of the American Academy of Psychiatry and the Law from residency to practice, and from active practice to eventual Online. For example, a physician who has chosen to Respecting the lifecycle: rational workforce planning for a sec- establish her own practice and focus on clinical aspects of tion of general internal medicine.

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