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The Halperns live in a modest purchase 10mg atorlip-10 fast delivery cholesterol levels controversy, one-story home north of Boston—no railing on the front step cheap 10mg atorlip-10 otc cholesterol what foods are high, piles of yellowing papers and other “stuff” cramming every corner of space. They seemed thrilled to have a visitor, saying this was their social event for the week. The elderly couple careened dangerously to and fro in their obstacle-filled home. Halpern’s newly made fudge; they showed me photographs of grandchildren. The Halperns had been married forty-nine years and neither finished a sentence during the entire interview—the other intervened. The most heart-wrenching mo- ments came when they talked about their isolation. People make self-sacrifices, big and small, rather than “burden” others, especially their children. Mildred Stanberg, in her late eighties, lives near her children, but they rarely see her on weekdays. Stanberg recounted, “and we all went to the Arnold Arboretum,” a 200-acre park within metropolitan Boston. While 4 percent of people without mobility problems report these feelings, 31 percent of those with major mobility difficulties do. Perhaps this is not surprising in light of pain and physical discomforts, societal attitudes, and isolation. Some people spoke openly about depression, as did Barney Fink, who has Parkinson’s disease (chapter 3). We had a third-floor apart- ment; we couldn’t afford to move—we had gone from two paychecks down to one. The only way that I could get out of the building with my son was if somebody helped me out. They waited until after Christmas, because you don’t fire anybody at Christmas time. Between those three 76 / How People Feel about Their Difficulty Walking things, my self-esteem was at an all-time low. The comments of Candy Stoops and Gerald Bernadine highlight a crit- ical issue. Often people with mobility problems have many other things going on in their lives. In addition, according to the survey, people with mobility difficulties are much more likely than others to say that their overall health is “poor” (see Table 3). People with mobility problems are much more likely to be poor, unemployed, uneducated, divorced, and to live alone (chapters 6–7). Once we account for these various factors, people with mobility problems are roughly twice as likely as others to report being depressed or anxious. Unfortunately, clinicians frequently fail to recognize depression, es- pecially in persons with chronic illnesses (Olkin 1999). However, roughly 70 percent of people with major mobility problems are not frequently depressed or anxious. Yet because of widespread expec- tations that depression is inevitable, fanciful explanations often purport to explain why people are not depressed. Ah, but you are not suffering, in a situation in which suffering should occur. It must be because you are brave, coura- geous, plucky, extraordinary, superhuman. Virtually all persons with disabilities I know have been told how brave they were, some- times for simply getting up in the morning. More often, how- ever, people seem less angry at their physical limitations than at the atti- tudes of people around them, especially when people feel invalidated, that others don’t believe or respect them. Anger is particularly acute among people in pain or with stigmatized conditions, such as obesity. She chafes when her personal assistant shows up late and doesn’t seem motivated to help. She feels that her physicians How People Feel about Their Difficulty Walking / 77 don’t understand her situation or why she uses a wheelchair, that they be- lieve she just isn’t trying. They risk appearing ungrateful and antagonizing the very persons they need for assistance.

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For example 10 mg atorlip-10 amex high cholesterol foods dr oz, in response to the headline: Patient Dies of Alternative Cancer Remedy order atorlip-10 10 mg mastercard cholesterol belongs to which of the following groups, in the British Medical Journal (Gottlieb 2001), Lade (2000:1491) wrote as follows: “Why not make a headline such as: 10 000 people died from complications of cancer this week even though they had the standard conventional treatment. Therefore, Health Canada would do better to broaden its scope to address the safety of all interventions, whether alternative or allopathic, rather than focus exclusively on the safety of alternative therapies (Balon et al. In addition, regarding the efficacy of these therapies, policymakers need to widen the boundaries of what is considered valid evidence of the effectivene- ss of a therapy to include more than just methods consistent with the natural science model. However, placebos have been shown to be associated with considerable response rates among patients with active disease. This proves that therapies lacking obvious scientific bases for effecting disease improvement may nonetheless work. Therefore, Health Canada would be wise to adopt an approach such as that advocated by a small minority of authors who suggest the benefits of using more than one type of evidence. For example, Barton (2000:256) suggests a “flexible approach in which randomised controlled trials and observation studies have complementary roles,” and White and Ernst (2001:112) allow that uncontrolled clinical trials can be used “as ‘pilot’ or ‘feasibility’ studies to guide subsequent controlled research. From the perspective of the lay user of alternative therapies, greater weight is accorded to lay referral systems and individual experiences of efficacy over medical referral and expert validation in lay participation in these forms of health care (Low 2001b; Kacperek 1997; Boon et al. In general, the conceptual models of assessing efficacy employed by lay people are complex; they are made up of different combinations of elements of both alternative and allopathic healing ideol- ogy, and in these models, lay people assign greater weight to the role of subjective perceptions—over positivistic measures—in establishing the effectiveness of a therapy (Low 2001b). Moreover, lay people show a relative lack of interest in why something works (Low 2001b), suggesting a greater concern with outcomes than with mechanisms of action. A primary concern with outcomes is consistent with the current vogue in evidence-based medicine. Indeed, even the Lords Select Committee concluded that a lack of explanation for the efficacy of these therapies “should not be a barrier to acceptance by... Therefore, any research strategy concerned with the inclusion of alternative approaches to 124 | Using Alternative Therapies: A Qualitative Analysis health and healing within Medicare should accord a prominent place to lay perspectives on alternative therapies. SUGGESTIONS FOR FUTURE RESEARCH Canadian policy researchers have concluded that more research needs to be done prior to inclusion of alternative and complementary therapies within Canadian public health provision (Achilles 2001; Tataryn and Verhoef 2001). I would add that in particular, research on the efficacy of these therapies from the lay perspective is required. Very few studies have examined how lay people assess the effectiveness of the alternative and complementary approaches to health and healing they use. Furthermore, the bulk of this literature does little more than report that people believe that they derive a benefit from their participation in alternative and complementary therapies10 and/or are highly satisfied with their experiences with these therapies. Such research would provide us with a more holistic understanding of what works and also with better evidence to determine which therapies should be included within Medicare. Another direction for future research concerns the following question: To what extent do alternative approaches to health and healing continue to constitute a challenge to biomedical dominance and thus serve as a catalyst for change within allopathic health care? For example, Schneirov and Geczik (1996) argue that the users of alternative therapies are members of a new social movement that presents an institutional challenge to bio- medicine, and Wolpe (1990:922) concludes that alternative practitioners serve as “gatekeepers of orthodox medicine” who have the freedom to experiment with new therapies which can then be incorporated into allopathic practice, thus expanding the range of therapeutic techniques available under public health care provision. However, Schneirov and Geczik (1996:638) also assert that participation in alternative approaches to health and healing constitutes a social network movement that is “submerged within everyday life rather than engaging in visible political Conclusion | 125 activities that confront authorities. Therefore, research should track the influences of the movement towards integration of allopathic and alternative approaches to health and healing, in addition to the inclusion of alternative therapies within public health provision, to determine the effect of these processes on the potential of alternative therapies, as well as on the lay people and practitioners who use them, to continue to play an innovative and revolutionary role within the health care system. Portions of this chapter were previously published in the journal Evidence-Based Integrative Medicine(2003), 1(1):65–76. See also Birch (1997); Calmels (1999); Fitter and Thomas (1997); Gadsby et al. See Barton (2000); Bender (1999); Bossuyt (2001); Calmels (1999); Critchley et al. See Barton (2000); Bossuyt (2001); Drew and Davies (2001); Ernst (2000a,1999, 1997); Ernst and Barnes (1998); Ernst and Fugh-Berman (1999); Gadsby et al. The few authors who critique the RCT method do not suggest that it is inappropriate as a means of assessing the efficacy of alternative and complementary therapies; rather, their critiques centre on refinements of the RCT method (Bossuyt 2001; Thomas and Fitter 1997). Appendix: The Therapies Listed below are brief explanations of the alternative therapies and healing systems mentioned in this book. No consensus exists concerning how to define alternative or complementary health care (Low 2001a; Nahin and Straus 2001; Pawluch 1996). In addition, there are different schools of the same therapy and practitioners do not always agree about fundamentals of a therapeutic approach (Nahin and Straus 2001). Therefore, the following definitions are meant merely to acquaint readers with any therapies they may be unfamiliar with.

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Unilateral (monocu- lar) temporal hemianopia may result from a lesion anterior to the chiasm which selectively affects only the ipsilateral crossing nasal fibers (junctional scotoma of Traquair) order atorlip-10 10mg online cholesterol levels test kits. Unawareness of visual field loss buy atorlip-10 10mg with visa cholesterol levels for adults, anosognosic hemianopia, occurs principally with right-sided brain lesions. Bilateral homonymous hemianopia or double hemianopia may result in cortical blindness. Cross References Alexia; Altitudinal field defect; Anosognosia; Cortical blindness; “False-localizing signs”; Macula sparing, Macula splitting; Quadrantanopia; Scotoma; Visual field defects Hemiataxia Hemiataxia is ataxia confined to one half of the body. The vast major- ity of isolated hemiataxic syndromes reflect a lesion of the ipsilateral - 147 - H Hemiballismus cerebellar hemisphere, but on occasion supratentorial lesions may cause hemiataxia (posterior limb of the internal capsule, thalamus). However, in almost all of these cases hemiataxia coexists with ipsilat- eral hemiparesis (ataxic hemiparesis, q. References Luijckx G-J, Boiten J, Lodder J, Heurs-van Raak L, Wilmink J. Journal of Neurology, Neurosurgery and Psychiatry 1994; 57: 742-744 Cross References Ataxia; Ataxic hemiparesis; Cerebellar syndromes; Cerebellopontine angle syndrome; Lateral medullary syndrome Hemiballismus Hemiballismus is unilateral ballismus, an involuntary hyperkinetic movement disorder in which there are large amplitude, vigorous (“flinging”) irregular movements. Hemiballismus overlaps clinically with hemichorea (“violent chorea”); the term hemiballismus- hemichorea is sometimes used to reflect this overlap. Hemiballismic limbs may show a loss of normal muscular tone (hypotonia). Anatomically, hemiballismus is most often associated with lesions of the contralateral subthalamic nucleus of Luys or its efferent path- ways, although there are occasional reports of its occurrence with lesions of the caudate nucleus, putamen, globus pallidus, lentiform nucleus, thalamus, and precentral gyrus; and even with ipsilateral lesions. Pathologically, vascular events (ischemia, hemorrhage) are the most common association but hemiballismus has also been reported with space-occupying lesions (tumor, arteriovenous malformation), inflammation (encephalitis, systemic lupus erythematosus, post-strepto- coccal infection), demyelination, metabolic causes (hyperosmolal non- ketotic hyperglycemia), infection (toxoplasmosis in AIDS), drugs (oral contraceptives, phenytoin, levodopa, neuroleptics) and head trauma. Pathophysiologically, hemiballismus is thought to result from reduced conduction through the direct pathway within the basal gan- glia-thalamo-cortical motor circuit (as are other hyperkinetic involun- tary movements, such as choreoathetosis). Removal of excitation from the globus pallidus following damage to the efferent subthalamic-pall- idal pathways disinhibits the ventral anterior and ventral lateral thala- mic nuclei which receive pallidal projections and which in turn project to the motor cortex. Hemiballismus of vascular origin usually improves spontaneously, but drug treatment with neuroleptics (haloperidol, pimozide, sulpiride) may be helpful. Other drugs which are sometimes helpful include tetra- benazine, reserpine, clonazepam, clozapine, and sodium valproate. Movement disorders following lesions of the thalamus or subthalamic region. Movement Disorders 1994; 9: 493-507 - 148 - Hemifacial Spasm H Martin JP. It may replace hemiballismus during recovery from a contralateral subthalamic lesion. Cross References Chorea, Choreoathetosis; Hemiballismus Hemidystonia Hemidystonia is dystonia affecting the whole of one side of the body, a pattern which mandates structural brain imaging because of the chance of finding a causative structural lesion (vascular, neoplastic), which is greater than with other patterns of dystonia (focal, segmental, multifocal, generalized). Such a lesion most often affects the con- tralateral putamen or its afferent or efferent connections. Brain 1985; 108: 461-483 Cross References Dystonia Hemifacial Atrophy Hemifacial atrophy is thinning of subcutaneous tissues on one side of the face; it may also involve muscle and bone (causing enophthalmos), and sometimes brain, in which case neurological features (hemiparesis, hemianopia, focal seizures, cognitive impairment) may also be present. The clinical heterogeneity of hemifacial atrophy probably reflects pathogenetic heterogeneity. The syndrome, sometimes referred to as Parry-Romberg syndrome, may result from maldevelopment of auto- nomic innervation or vascular supply, or as an acquired feature fol- lowing trauma, or a consequence of linear scleroderma (morphea), in which case a coup de sabre may be seen. Advances in Clinical Neuroscience & Rehabilitation 2004; 4(3): 38-39 Larner AJ, Bennison DP. Some observations on the aetiology of hemi- facial atrophy (“Parry-Romberg syndrome”). Journal of Neurology, Neurosurgery and Psychiatry 1993; 56: 1035-1036 Cross References Coup de sabre; Enophthalmos; Hemianopia; Hemiparesis Hemifacial Spasm Hemifacial spasm is an involuntary dyskinetic (not dystonic) move- ment disorder consisting of painless contractions of muscles on one - 149 - H Hemiinattention side of the face, sometimes triggered by eating or speaking, and exac- erbated by fatigue or emotion. The movements give a twitching appearance to the eye or side of the mouth, sometimes described as a pulling sensation. Patients often find this embarrassing because it attracts the attention of others. Paradoxical elevation of the eyebrow as orbicularis oris con- tracts and the eye closes may be seen (Babinski’s “other sign”). Hemifacial spasm may be idiopathic, or associated with neurovas- cular compression of the facial (VII) nerve, usually at the root entry zone, often by a tortuous anterior or posterior inferior cerebellar artery.

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