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This section will review the general principles of bioethics as they apply to patient care • Discuss the basic principles of bioethics as they apply to the practice of medicine (the Georgetown mantra) and will focus on the issues most pertinent to pul- • Summarize the common ethical issues that apply to all monary and critical care physicians buy discount kamagra oral jelly 100mg. Some ethicists criticize the wide application of these prin- ciples as being simplistic and sometimes irrelevant effective kamagra oral jelly 100 mg, but their simplicity and clarity have stood the test When caring for patients generic kamagra oral jelly 100 mg free shipping, decisions about what is of decades of use by frontline clinicians who lack a “right” or “wrong” course of action are not formal training kamagra oral jelly 100mg for sale. The complex and at times competing inter- • Autonomy: The patient has the right to accept ests of patients, families, the care setting, the payor, or refuse every treatment; society, the law, and physicians often complicate • Beneficence: The clinician should act in the best patient care, and these issues cannot be resolved interest of the patient; by the use of scientific methods. Pulmonary and • Nonmaleficence: “First, do no harm”; and critical care physicians are on the front lines of • Justice: The distribution of limited resources these dilemmas, but few have formal training in must be fair. Therefore, we often improvise Many (or most) bedside ethical dilemmas arise based on past experience or a “see one, do one” when two or more of these values are in conflict. At the same time, physicians as However, other conflicts are believed to arise from a group (like the rest of humanity), including pul- ethical concerns as a consequence of a lack of com- monary and critical care physicians, may not want munication among patients, families, and the to confront difficult problems and choices. With open communication This reticence was demonstrated by the land- (which may require the presence of a mediator mark Study to Understand Prognosis and Prefer- when communications have broken down), the ences for Outcomes and Risks of Treatments, in ethical issues often disappear. Despite interventions that included providing physicians with prediction • Dignity: Both the patient and the caregiver have models and decision-making tools, together with a right to dignity; and timely reports by trained nurses of patient and • Truthfulness and honesty: Clinicians should surrogate preferences, there was no improvement tell the truth. The obvious example is the com- That physician focus is obvious in the American mon conflict between a family who wants “every- Medical Association preamble to their “Principles thing” despite all evidence that “everything” will of Medical Ethics” (Table 1). In most cases, patient Autonomy autonomy dictates that the benefit must be judged by the patient’s and surrogate’s preferences, not The patient’s right to make an informed and by those of the team. Justice Second, the patient must be competent, which is defined here as having the capacity to make deci- Although justice is one of the four basic tents sions about the care (see the section “Informed of the Georgetown mantra, this should enter bed- Consent”). If patients with severe illness do not side decision making rarely, if ever, at least in the have this capacity, then we depend on surrogate United States. Autonomy depends on the proper resources in an appropriate and efficient manner, process of informed consent, where the risks, ben- but the primary role of the physician is as a patient efits, and alternatives are explained honestly. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient. A physician shall respect the rights of patients, colleagues, and other health professionals and shall safeguard patient confi- dences and privacy within the constraints of the law. A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical educa- tion; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. At the same time, we should medical decisions was found in outpatients with advocate vigorously for rational health policies cancer, the elderly, and patients with dementia. However, ethical dilemmas usually involve critically ill patients who are deeply sedated or subjective considerations, including the prefer- obviously delirious do not have decisional capac- ences of patients, their surrogates, and clinicians, ity, and their treating clinicians can determine which in turn are often influenced by their experi- incapacity. Standardized assessment tools for “evidence-based ethics” that attempts to apply these conditions may be helpful in assessing principles of evidence-based medicine to ethical delirium, which is usually underestimated in hos- dilemmas in clinical medicine. Psychiatric consultation is not Regardless of the outcome of this controversy, necessary to determine whether a patient is incom- some basic principles apply. One potentially useful petent; rather, consultations should be reserved for method includes first framing the ethical dilemma cases in which the clinician believes that the patient in the dimensions of autonomy, beneficence, non- is making an irrational decision, when there is maleficence, and justice. In most situations, physicians use the prin- ciple of “substituted judgment” and proceed with Specifc Issues a course that most patients with capacity would choose. Withdrawing Physicians are required to obtain informed life support in a patient without capacity and with consent from patients before initiating treatment, no surrogate presents a special issue. This consent requires that the cases, decisions were made by physicians with no patient is capable of understanding the relevant institutional or judicial review, contrary to their information and the consequences of treatment institution’s policies. This process should be planned and requirement may be waived if an institutional communicated to the team and the family, prefer- review board determines that the research poses ably with an organized protocol including the minimal risk, defined in U. Federal guidelines administration of analgesics and sedatives titrated as “the probability and magnitude of harm or to maintain the comfort of the patient. Prompt tion in clinical research, and critical care research extubation has the advantages of not prolonging is generally not conducted in some states unless the dying process, and the goals of care are clear there is a court-appointed guardian. Gradual withdrawal of “emergency research” in situations such as after support with the endotracheal tube in place reduces cardiopulmonary resuscitation. However, this approach may prolong the dying process, and some family It is widely accepted in modern societies that members may misinterpret this process as patients and their surrogates have the authority to an attempt to extubate the patient successfully. Withdrawing ventilatory support is generally among clinicians and ethicists on which method is deemed the moral and ethical equivalent of with- preferable. Rather, decisions on how to extubate holding it, but many families and physicians can- patients who are expected to die depend on the not help but think and act otherwise. In addi- port may be undertaken in most locations if there tion, some patients survive to be discharged from is an oral advance directive by the patient or with the hospital despite predictions that the with- the agreement of the clinical team and family; the drawal of support will lead to death; this would requirement for a written advance directive is be impossible in the presence of neuromuscular unusual. Unusual situations in which continuing is a consensus of both the medical team and the therapy with these agents are warranted during patient and family that this treatment is both the withdrawal of mechanical ventilator support unwanted and not likely to lead to a desired patient would include patients who are certain not to sur- outcome. When the decision to limit or withdraw vive more than a short interval after the with- treatment is reached, the clinician is still respon- drawal of support even without this treatment, or sible for treating the patient throughout the dying if the benefits of waiting for the return of neuro- process and being attentive to the needs of the muscular function do not outweigh the burdens. Transcranial Doppler exami- goal of maintaining patient comfort is associated nations of cerebral blood flow are safe, noninva- with a shorter time to death after extubation. The narcotic dose and the time to death, and a direct determination of a complete absence of flow using relationship between the dose of benzodiazepines this examination is unreliable in the diagnosis of and the time to death after extubation. Therefore, brain death because false-positive results may a judicious use of sedation and analgesics does not occur in 10 to 15% of cases as the result of technical appear to hasten death in these patients and should factors, which are often related to poor image be part of any standard protocol. Health care eth- establishing a precise diagnosis of brain death is ics consultation: nature, goals, and competencies—a often crucial in decisions about terminating life sup- position paper from the Society for Health and Human port and organ donation. Although the criteria for Values-Society for Bioethics Consultation Task Force diagnosing brain death have evolved, the current on Standards for Bioethics Consultation. Ann Intern guidelines and the laws in most countries require a Med 2000; 133:59–69 detailed clinical assessment that includes the pres- Summary of a task force report delineating the role of eth- ence of coma and the absence of brainstem reflexes ics committees and consultative services, with recommenda- and apnea over the course of two successive exam- tions on policies, competencies, and processes. Ann Intern Med 2005; 142:560–582 cord injury, in which a patient may be incapable of Concise overview of issues related to medicine, law, and social breathing spontaneously) would also make clinical values that covers issues related to patient care, the practice of assessment impossible. Cerebral Two-year study that shows that physicians in critical care angiography with findings that show a cessation units are not likely to know patient preferences about end- of blood flow to the brain is considered to be the of-life care, nor are they likely to change their practice even “gold standard,” and technetium nuclear imaging with intensive intervention. Do clinical and for- These two studies deal with the processes of withdrawing mal assessments of the capacity of patients in the inten- mechanical ventilatory support, indicating that the appro- sive care unit to make decisions agree? Arch Intern priate use of sedatives and narcotics is associated with mini- Med 1993; 153:2481–2485 mal patient discomfort and does not hasten the time to death Issues and methods to determine competence to make medi- after extubation. Informed consent for clinical research involv- for end-of-life care in the intensive care unit: the Eth- ing patients with chest disease in the United States. Chest 2009; 135:1061–1068 Crit Care Med 2001; 29:2332–2348 This is a thorough and thoughtful review of laws and issues These articles review ethical and practical aspects of with- surrounding performing clinical research, especially in drawing life-sustaining treatments. These sta- tistics were derived using telephone surveys and physical examinations as well as pulmonary func- tion testing of randomly selected subjects. Chronic bronchitis has been leading cause of disability-adjusted life-years in defined in clinical terms: the presence of chronic men and the seventh-leading cause of disability- productive cough for at least three consecutive adjusted life-years among women. However, the rates were slightly traditional view, recent data have shown that greater among black than white patients during this this destructive process is accompanied by a net same period. It does ognized ( 60 years), have evidence of poorly not incorporate the terms chronic bronchitis reversible airflow obstruction on pulmonary and emphysema into the definition. This find- feature in asthmatics and is so important to ing has raised a complexity of semantic issues its pathogenesis it has been incorporated into that have not been solved. However, increased been to combine two of the major pathologic responsiveness to constrictors such as metha- processes and describe such patients using the choline and histamine (but not indirect bron- term asthmatic bronchitis, but this definition choconstrictors such as cold air and bradykinin) does not have widespread acceptance. It is nisms of disease are still poorly understood, the likely that such patients have more than one reasons why only certain individuals with a posi- pathologic process with several pathways of tive exposure history become affected are not inflammation. Epidemiologic evidence sug- Such events appear to predict later findings of gests that they are not at increased risk for chronic, fixed obstructive lung disease. Nonsmokers without of other genetically determined abnormal protec- respiratory disease can expect to lose 25 to tive mechanisms against protease, oxidant, and 30 mL/yr of lung function after age 35. This family of meta- A prospective multicenter longitudinal study bolic enzymes may play an important part in cel- of the effects of smoking cessation in patients iden- lular defense by detoxifying various substances in tified with mild-to-moderate airflow obstruction tobacco smoke. These acute respiratory illnesses or Changes in the Airways of Smokers exacerbations are usually caused by viral or bacte- rial infections and are heralded by an increase in Early structural changes have been described symptoms. The innate respiratory defense system the large and small ( 2 mm) airways and in the includes an epithelial cell barrier and mucociliary lung parenchyma (Fig 2). When they are overwhelmed, are also changes in the pulmonary circulation, the foreign particles may penetrate the airway, and heart, and the respiratory muscles. Inflammatory cells migrate into the smooth muscle with extension of the muscularis epithelial layer, including polymorphonuclear layer into distal vessels that do not ordinarily con- cells, eosinophils, macrophages, natural killer tain smooth muscle. Antigens that are deposited on the epithelium are transported within the airway by antigen-presenting cells, the specialized epi- thelial M cells, and the dendritic cells. The anti- gens are transported to the bronchial-associated lymphatic tissue layer and to regional lymph nodes, where B and T lymphocytes initiate the cellular and humoral components of the adaptive immune response. This response assists in the destruction of microbes that may penetrate the airway as the innate immune system is over- whelmed and in the neutralization extracellular Figure 2. They release a number of proteinase-3 A causative link to mucus hypersecretion mediators, including proteases such as neutrophil Phagocytic ability of neutrophils impaired by cigarette elastase and matrix metalloproteinases, oxidants smoke (by suppression of caspase-3–like activity) such as the oxygen free radical H O , and toxic predisposing to respiratory infection 2 2 Macrophages peptides such as defensins. Recent cyte colony stimulating factor accounting for studies suggest that the inflammatory cellular increased neutrophilic activity and monocyte che- infiltrate, fibrosis, and muscle in the airway wall motactic protein-1 causing increased monocytic show a progression worsening of pathologic activity. These pathophysiologic abnor- local defenses to bacterial adherence because these malities in airways 2 mm have been referred to glands are known to produce deterrents such as as “small airway disease,” implying that it is a lactoferrin, antiproteases, and lysozyme. It is more important instead epithelial alterations are seen in chronic bronchitis to think of the early inflammatory changes in the are a decrease in the number and length of the cilia small airways as the first stage in a protracted and squamous metaplasia. This provides additional cause for bacterial interaction between extracellular signaling pro- growth, which, in turn, causes a release of toxins teins, oxidative stress, and proteolytic digestion of that are further damaging to the cilia and epithelial connective tissue (Fig 3). Bacterial exoproducts are known to stimulate mucous production, slow ciliary beating, impair Pathology of Chronic Bronchitis immune effector cell function, and destroy local immunoglobulins.

Greer used the special phone number she had been given and the police arrived at the premises in an exemplary one and a half minutes purchase 100 mg kamagra oral jelly with amex. It first struck me that this was a concerted campaign kamagra oral jelly 100 mg visa, on the 21st December when Duncan Campbell rang me cheap 100mg kamagra oral jelly mastercard. In December discount 100mg kamagra oral jelly with visa, he asked me about germanium and Immunomega, he accused me of advertising True-Free foods, (which as prescription items should not be promoted to consumers). Campbell attacked all the doctors who were central to the Society — Stephen Davies, Alan Stewart, Damien Downing, Belinda Dawes and Patrick Kingsley — between the time of the conference and the summer of 1992. The taking of commission on vitamin supplements, and doctor -vitamin company relations, are relatively insignificant matters in comparison with the kind of bribery and corruption which takes place between doctors and pharmaceutical companies. Campbell, however, did have a small point, if, that is, his information was correct. Stephen Davies had never taken commission nor royalties from Lamberts on any of the vitamin preparations he handled. Campbell knew this, because following the article about Patrick Holford in the Sunday Correspondent, Davies had written to Campbell and the Independent on Sunday, making it clear that he did not take commission. It has been strict policy from the word go, not to accept any royalties, to which I am perfectly entitled within the mores of the medical profession. Although both Alan Stewart and Patrick Kingsley did take commissions from Lamberts, they both used this money to have diagnostic tests done for 19 patients who could not afford to pay. In the last days of December, the material was sent to Putney by the firm in Diss so that Rita Greer could check it. Having checked it, she sent it back to Diss, and from there it was sent on to the printers in Leicester. When the material was finally sent to the printers, the package contained the colour separations for 16 pages (four positive films for each page) and 16 colour chromalins (colour proofs which give the printers a guide for colour printing). The Managing Director of the firm in Diss packed the artwork herself, and, as is common practice, taped everything down to the bottom of the box. On arrival in Leicester, the package was opened by the printers and, despite the box showing no signs of having previously been opened, only one chromalin remained in the box. The printers rang Greer who contacted the firm in Diss, and both companies complained to British Rail. Despite a thorough investigation, no one was able to find out when the material had gone missing or who had been responsible for taking it. Three days later, however, the remaining 79 negatives and chromalins turned up at a police station in Leicester, slightly scratched but otherwise undamaged. Few people also knew that the ban on germanium was not to be statutorily enforced but was a voluntary ban. Natural substances, which can be manufactured by different companies without breach of any patent or licence, are a serious problem to the pharmaceutical companies. In quick succession following the banning of germanium, two other food supplements were suddenly banned, tryptophan and niacin. Tryptophan, an effective natural tranquillizer and an anti-depressant, had been used by millions of people for over thirty years, in preference to addictive sleeping pills. In 1989, however, a Japanese chemical company, Shawa-Denko, distributed a batch of contaminated L-Tryptophan. Rumours ran riot and within a short space of time, the story was abroad that tryptophan was a deadly poison. Initially, for nine months, the ban on tryptophan was in the form of a voluntary withdrawal. Then suddenly on September 12th 1991, the Department of Health issued a statement giving retail and wholesale pharmacists and manufacturers fourteen days to clear all stock before it was officially banned. A number of practitioners who used tryptophan could not help but comment on the coincidence of the ban with the marketing of Prozac, a new chemical anti-depressant from Eli Lilly. Prozac has had the highest marketing profile of any new drug for many years, much of its advertising publicity appearing in news media. Within a short time of the ban, more sober minds voiced the opinion that it had only been one batch of tryptophan which had been contaminated and tryptophan itself was not harmful. This should be compared with the events which follow the finding that any pharmaceutical product has serious side-effects, consumers are lucky if they can get a pharmaceutical product withdrawn by the regulating authorities within five years. The banning of niacin was even more irregular than that of germanium or tryptophan. Again it is a naturally-occurring substance, again it has been used for years by natural medical practitioners, most recently to lower cholesterol levels. A voluntary ban on sustained release forms of niacin was introduced by the health trade in agreement with the DoH. The ban was limited and voluntary, for good reason: niacin is put into a large number of processed foods such as some breakfast cereals, and an across the board ban would have stirred up resentment in industry as well as being impracticable. In America, where the problem over niacin had first arisen, all forms of the substance continued to be sold legally everywhere. Orthodox medicine, the pharmaceutical companies and particularly groups like the American National Council Against Health Fraud, have waged war against this therapy because it competes with invasive surgery and high tech treatment as well as chemical pharmaceutical therapy. It centred on two preparations which, the programme said, contained substances banned by the DoH: sustained-release niacin in Sustaniacin, and germanium in Immunomega. Unless this evidence was manufactured by someone, Dr Woodward believes that it was a simple error that had occurred within the Larkhall packing department; Campbell made it into the crime of the century, insisting that Woodward was ignoring the DoH ban and selling people a poisonous substance. He hurried along to Surrey University with the Immunomega he had bought and gave it to his friend Dr Andrew Taylor to analyse. No mention was made of the fact that as a naturally-occurring substance, germanium is present in both baked beans and garlic. In fact, the amount of germanium in the tablets was less than would be obtained in the average daily diet and a thousand times less than the toxic dose of the other quite separate form of toxic, inorganic, germanium. The second vitamin supplement which Campbell had found on sale inside the Larkhall shop in Putney was sustained-release niacin. On this matter, Dr Robert Woodward was unrepentant: he was not going to collude with the voluntary ban because niacin caused no adverse effects, nor had there ever been any scientifically validated evidence that it had. Woodward maintained that the administration of niacin was the safest and cheapest way to reduce blood cholesterol quickly. Despite the fact that Campbell again used his contact with Vincent Marks and Dr Andrew Taylor and Surrey University, and despite the fact that the item and the attack upon Larkhall were obviously linked to the Campaign Against Health Fraud, no mention of vested interests was made on the programme. He had found some pills which were supposed to make you feel better but which contained a substance, in his view bad for the kidneys, called germanium. Viewers were encouraged to sneak on any mountebank or quack selling germanium or niacin. The second letter was from the member of the public, Mr Duncan Campbell, to Caroline Richmond, drawing her attention to an advert put out by Larkhall for tryptophan. The advert referred to by Campbell, was a new advert not used by Larkhall prior to the publication of their 16 page magazine, which had gone astray in transit and was not finally published until February 13th 1991. These interviews were carried out with the full rigmarole of the law, cautions being given first. One of the interviews was, however, more oppressive than would have been the case had the police been investigating a serious crime. During a long telephone call, Woodward was threatened with arrest and imprisonment. Shropshire Trading Standards Authority was to haunt Larkhall for the next two years. At the centre of the charges was the basic contention that vitamin supplements could not aid mental alertness or add more to fitness than a balanced diet. The charges themselves, however, were phrased in various ways which related to the food labelling regulations, and at the centre of these was the contention that Larkhall had knowingly made untruthful claims for their vitamin supplements. It was short-lived: within two months, Shropshire had resurrected the case bringing a whole battery of new charges. The only items stolen were three files containing the notes and text of a book she had been at work on for two years. A year later, in the spring of 1992, the harassment appeared to have stopped and Rita Greer began to run her business again from Larkhall. Nothing was stolen but stock was disturbed on the shelves as if the intruder had been looking for something. A few days later someone deliberately cut through the main telephone, fax and computer cables into the factory. Fortunately, Larkhall was prepared for such an emergency and nothing was lost from the computer records. The clean cut through large cables was in itself very sinister and obviously made by someone with expert skill and knowledge of communications. The defence turned out to be a 50 page document, which was itself highly misleading and scientifically inaccurate. The Campaign For Health Through Food was set up to focus concern upon a number of damaging developments affecting health foods and natural medicine. Holford was worried both about the attacks upon members of the nutritional community, and particularly concerned about the impending set of new rules and regulations governing vitamin supplements, which were being pushed through the European Parliament by pharmaceutical vested interests. These advisers were high-ranking experts, including: Professor Linus Pauling, Dr Philip Barlow, Alexander Schauss and Professor Michael Crawford. Holford stressed that this network of scientists, journalists and doctors and its capacity to raise money for a legal fund, would act as a deterrent against attacks by those representing the processed food industry. The interests of such eminent scientists would ensure that those who mounted attacks while choosing to ignore research material about nutrition could be countered. The Institute has been accused by inference of promoting worthless and sometimes dangerous supplements. On the basis of worthless tests, based upon a worthless philosophy of nutrition, for reasons of financial gain... These untruthful and unsubstantiated accusations could, we fear, by made against many reputable practitioners who recommend supplements.

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Animals seldom attacked cheap kamagra oral jelly 100mg amex, such as horses buy 100 mg kamagra oral jelly with amex, sleep 302 much longer than those in constant danger generic 100 mg kamagra oral jelly overnight delivery, like bats buy kamagra oral jelly 100 mg. When much growth is required slow wave sleep and the overall amount of sleep are increased. When less sleep is needed, as in hypothyroidism, the amount of slow wave sleep is diminished. During winter, melatonin indirectly affects the gonads to reduce reproduction potential, a fact that is of particular relevance in season-breeding reptiles, amphibians, and birds. According to Famuyiwa and Adewuya (2008) the effectiveness of melatonin in getting children with neurodevelopmental disorders to sleep is questionable and it has a potential for causing adverse effects; sleep hygiene measures should take precedence in such cases. Anonymous (2009) states that the evidence for the use of melatonin for primary insomnia is limited. The homeostatic model emphasises need for sleep (stronger with time wake – adenosine, an inhibitory neurotransmitter, plays a role here) while the circadian model states that sleep propensity has a circadian (24 hour) pattern for sleepiness and attention. Depending on clock time, circadian issues can attenuate or promote homeostatic drive. Drugs capable of changing the circadian clock, such as in rodents, are known as chronobiotics. Daily injections of melatonin can entrain the activity cycle of rodents kept in perpetual darkness. Fruit flies were important in discovering how circadian clocks (transcriptional regulatory loop wherein each calculates its 24-hour period via an oscillating cycle of transcription and translation), with a similar mechanism throughout much of biology, work. Drosophila containing long- and short-day and arrhythmic mutants was to lead to similar discoveries in other living creatures. Melatonin levels and rhythms have been reported to be normal in both 305 unipolar depression and seasonal affective disorder. Excess nocturnal melatonin secretion, possibly related to nocturnal hypoglycaemia, has been reported in untreated females with anorexia nervosa. Therefore, between B and C, there may be a lower brain stem sleep- promoting area, and, between A and B, there may also be a rostral arousal area. More recently, it has been determined that a small group of neurones in the posterolateral hypothalamus secrete the neuroexcitatory peptides hypocretin 1 and 306 hypocretin 2 (orexins A and B). These neurones project widely throughout the brain, including areas associated with arousal, such as the locus coeruleus, the raphe nuclei, and the thalamus. The arousal produced by hypocretin 1 may occur via activation of histamine-1 receptors. Lesion studies in the rat suggests that cholinergic input from the nucleus basalis in the forebrain is important for suppressing slow wave activity during wakefulness. Sleep is inhibited by interleukins 4, 10 and 13, prostaglandin E2 and a number of other substances. Rats deprived of sleep for two weeks or more die, probably of infection, although short-term sleep loss may sometimes enhance host defences. Almost all biological functions have some rhythm and the length of the rhythm varies, e. Examples of rhythms include the sleep-wake cycle, hormonal levels, body temperature, and the menstrual cycle. Also rhythms may be phase advanced (brought forward in time) or delayed (brought backward in time). The first circadian clock was discovered in mimosa plants that continue to open and close their leaves each day despite being deprived of sunlight: this discovery, in 1729, is attributed to Jean Jacques d’Ortous de Mairan (1678-1771), a French 85 daily sleep/waking rhythmicity. Examples of exogenous zeitgebers are the normal workday, set mealtimes, sunrise and sunset (The photoperiod, daily variations in intensity of light, is the chief zeitgeber for synchronizing circadian clocks. Jet lag is important here: if one goes from E to W one experiences a phase delay which is less of a problem than the phase advance (shortening) associated with travelling from W to E. The latter represents the opposite of the 310 natural tendency to lengthen the biological day. Exposure to artificial light for seasonal affective disorder or changing the sleep-wake cycle (as in sleep deprivation) may ameliorate symptoms. A cycle occurs of protein production which then inhibit transcription, degradation of these proteins, followed by further transcription. It also gets photic and non-photic information from the lateral geniculate nucleus, as well as non-photic data from median raphe, ventral subiculum, and infra-limbic cortex. Anticipation of 313 food delivery, arousing activity (running on a wheel), and deprivation of sleep are known zeitgebers in rodents. Cows sleep with their eyes open (as can humans) and meanwhile continue to chew the cud. The fact that these plants carry out these actions every 22 hours when in constant light was recorded in 1832 by Augustin Pyrame de Candolle (1778-1841), a Swiss botanist and physician. Circadian rhythms have a mean (level at which the oscillation takes place), a period (time to complete a cycle), an amplitude (distance between mean and peak of cycle’s oscillation), and an acrophase (time of the peak of the circadian rhythm’s phase). Masking or masking effect refers to the influence of environmental factors (temperature and light intensity and duration, food, social activities, etc) and internal states (e. Researchers have bred hamsters with different innate circadian rhythms (20-25 hours) – if the suprachiasmatic nucleus is transplanted from one hamster to the other the recipient’s rhythm changes to that of the donor. Shift workers appear to adapt less well than do people who traverse multiple time zones. Journeying home in daylight (which is much brighter than office lighting) interferes with adaptation. Such signals induce a second messenger cascade leading to altered concentration concentration of clock gene products. The molecular clock then regulates the rhythmic expression of genes or other functions of cells, e. The term ‘social zeitgeber’ has been used for social factors that entrain biological rhythms, e. Dopamine mainly promotes wakefulness, but it is active during sleep during positive (awarding) emotional states. Glutamate is an excitatory neurotransmitter that seems critical for the waking state, and is 317 the transmitter of the ascending reticular activating system. After a true epileptic seizure there is an increase in the serum prolactin, which does not occur following a pseudoseizure; there is also a rise in the serum cortisol but this is much less specific. Attacks of bronchial asthma commonly occur at night because of exaggerated bronchial constriction and may cause insomnia; the sole symptom may be a cough; some cases of insomnia are secondary to management with adrenergic agents; fatalities are most likely among those whose peak expiratory flow rate fall the furthest. The sleeper is pale and peaceful, heart and breathing are slow, and it is difficult to rouse him/her. Speech may be indistinct, behaviour automatic, and response to the environment is reduced. Sleep drunkenness (inertia following on final awakening), sexsomia (abnormal sexual behaviour), and sleep-related violence may seen as variants of confusional arousals. This is due to removal of tryptophan from stores as a result of stimulation of protein synthesis, for which tryptophan is required. Examples are blood and urine tests, drug assays , 327 radiological examinations (skull, chest, etc. A blunted growth hormone response to insulin challenge has been reported in depression. Low serum albumin levels may be of aetiological significance in confused patients. All brain-imaging techniques utilise computers to construct a series of 2-dimensional slices from a succession of one-dimensional data. Regarding imaging, functional segregation of parts of the brain has helped understanding of symptoms, but functional integration is better for understanding fundamental disease mechanisms. Such measures must be integrated with the complete clinical picture, mindful of individual idiosyncrasies. A single lateral film is usually adequate unless specific pointers suggest further work. Meningiomata may erode bone or cause bony overgrowth, the internal 330 auditory meatus may be eroded by a neuroma, abnormal vascular marking may mean tumour (including vascular tumour), osteolytic lesions may infer multiple myeloma or multiple metastatic deposits, and the skull may appear generally thick or woolly in osteitis deformans. The posterior clinoid processes are eroded 331 332 by increased intracranial pressure , and the pituitary fossa (sella turcica: ‘Turkish saddle’) can be widens with tryptophan depletion. This meets a pouch of the floor of the third ventricle which becomes the posterior pituitary. The ‘empty sella’ syndrome is usually a result of flattening of a normally functioning pituitary. Half of all adults have a calcified pineal gland, which may be displaced by a pathological process. Other structures may also show calcification, such as the falx cerebri and the choroid plexuses, and, sometimes, parts of a tumour. Calcification can occur in the walls of an aneurysm or an angioma, in tubers of epiloia, and in the basal ganglia in the case of excessive parathormone levels. This is recorded 334 as a difference in electrical potential between two active recording electrodes. These are produced by the inhibitory and excitatory postsynaptic potentials on neuronal dendrites close to the surface of the brain. It is prominent when in a relaxed state with the eyes closed or during hypnosis,(Craggs & Carr, 1992) but disappears with eye opening, concentration, or anxiety. Alpha rhythm is also lost during sleep or with psychotropic drugs and it slows in old age and in almost every neurological illness. Beta rhythm is usually of lower voltage than alpha, is present normally, but increases with concentration, anxiety, or minor tranquillisers; it replaces alpha rhythm during stimulation or when the eyes are opened; best seen over mid-scalp (somatosensory/motor cortex).

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Despite being intended to prevent suVering order kamagra oral jelly 100mg with mastercard, termination of pregnancy for fetal abnormality can cause intense distress and regret (Green and Statham purchase kamagra oral jelly 100 mg on line, 1996; Santalahti 100mg kamagra oral jelly with mastercard, 1998) discount kamagra oral jelly 100 mg line. New reproductive technologies align with other current trends, such as risk management, consumerism and economic pressures (Beck 1992; Winkler, 1998) to encourage women to expect to have a ‘perfect’ baby, closer to a consumer commodity than a valued person with ordinary human failings. Some analysts see these trends as undermining the status and value of children (O’Neill, 1994; Brazier, 1996), others criticize them as ‘feto-centric’ (Rothman, 1996: p. Women who escaped from having enfor- ced surgery tended to give birth normally, so questioning the medical expert- ise on which fetal rights arguments are based. While women’s lives are complicated by pregnancy, many women welcome pregnancy as personally fulWlling and status-enhancing – as demonstrated by the demand for infertility services. Yet during recent dec- ades, universal prenatal screening has encouraged a tendency towards treat- ing every pregnancy, however greatly desired, as provisional, creating a culture of ‘Do you really want it? Decisions about ‘therapeutic’ abortion are treated as medically informed technical choices about ‘handicap’ rather than as moral decisions that profoundly aVect human relationships, identity and obligations, and the meaning of parenthood as an unconditional or else a provisional relationship. Are women truly in- Prenatal counselling and images of disability 199 formed and respected, or are the choices they are asked to make illusory, overly constrained by economic and social pressures, or unwanted burdens for women who would prefer not to know or to choose? Economically, could the considerable funds and resources devoted to prenatal screening be used more eVectively to prevent and treat disease and disability, which are far more commonly acquired than innate? How scientiWc can prenatal counselling be, given high rates of false positive and false negative results of initial screening, and the inability to assess how severely aVected a fetus is, with the unknown impact of the potential child’s future lifestyle? Although opt-in individual testing at the request of women who have aVected relatives with a genetic condition is beneWcial, there is a strong case for showing that mass prenatal screening causes more harm than good (Clarke, 1997). Disabled people’s perspectives The pros and cons listed so far can all be based on mainstream medical and moral assumptions: that health and independent personal fulWlment are the highest goods; that it is therefore right to prevent and avoid illness and disability, to the extent of preventing disabled lives; that such lives inevitably will be costly, dependent lives of suVering; and that it is kind and responsible to the potential person and to the family, especially the mother, to relieve them of these burdens. Radical views of disabled people Disability activists contrast the term ‘people with a disability or handicap’ with that of ‘disabled people’ (Oliver, 1996; Asch, 1999, 2000). They argue that the former phrase emphasizes a deWcit in the person, and the latter term denotes how they are disabled more by an uncaring society than by any impairment or learning diYculty (Goodey, 1991; Ward and Simons, 1998) they may have. They criticize the medicalization of disability, saying that they wish to be treated by doctors when they are ill or injured or have a condition which can be cured or palliated, but not otherwise. Many disabilities are not susceptible to any medical treatment and, according to the activists, in cases when doctors cannot do good they can do harm, both to the individual and more generally, by pathologizing disabilities. With other critical researchers, they challenge geneticization (Lippman, 1991), its eugenic tendencies (Paul, 1992) and its fatalistic reductionism to genetic inXuences and away from social inXuences and human agency (Rose, 1995). Perhaps they are equally extreme, one exaggerating pathologies, the other over-denying them, and neither attending to the lived realities of people’s daily lives which, Lippman (1994) urges, should be examined carefully. Issues include women making respon- sible prenatal decisions, the goodwill of the staV who work with them, and the diverse and expert but little-known views of disabled people. Shakespeare tries to steer a middle course between the polarities of denial of the limita- tions of very severe disability, on the one hand, or else fearful pity and dread about very severe disability, on the other. Attempts to analyse maternal–fetal relations and prenatal decisions are trapped in another powerfully dismissive demarcation: pro-life versus pro- choice. Yet decisions about a greatly desired though impaired pregnancy illuminate the complications in right-to-life arguments versus women’s actual right to choose freely when they want neither available option – neither a severely impaired child nor an abortion. Ramazanoglu (1989) argues that feminist research is a matter of examining and holding together contradictions instead of futile attempts to ignore or resolve them superWcially, and this links to concepts of ‘maternal holding on’ watching and waiting (Ruddick, 1990) in contrast to ‘masculinist’ decisive rapid intervention which prenatal counselling tends to facilitate. Prenatal counselling and images of disability 201 Research with disabled people During a European project (see Acknowledgements) researchers investigated the views on prenatal screening of physicians, midwives, pregnant women, the general public, experts and reports in the mass media and professional journals. The Wrst, through general questions about their family and friends, education and work, problems, enjoyments and aims, built up a picture of interviewees’ views on the quality and value, and the possible suVering and costly dependence of their lives. As reviews of Medline and other website data-sets show, the medical literature on these conditions is mainly drawn from medical records and research about associated pathology, and from quantitative psychologi- cal surveys of anxiety, depression, intelligence and quality of life. In contrast, we used qualitative methods, a less formal interview style, and open questions asking for detailed replies; we looked for variety instead of measuring common factors. We contacted small groups of people through informal networks in order, we hoped, to avoid seeming perhaps intimidat- ingly professional, and to stress that we saw them as persons rather than patients. Everyone was sent a leaXet before they agreed to take part about the topics we would raise, and about their rights: to consent or refuse; to withdraw or withhold information; and to maintain conWdentiality. We were worried at Wrst about whether we should risk asking questions that might be painfully probing, but we were soon reassured by the responses; almost everyone talked calmly and frankly as if they were used to discussing issues such as screening for their condition. The 50 interviewees Cystic Sickle Spina Down’s Conditions Thalassaemia Wbrosis cell biWda syndrome Interviewees 10 10 10 5 5 Men 5 2 6 1 4 W om e n Age range 26–39 17–30 21–33 18–33 20–43 Median age 33 24 29 26 30 Mainstream school 10 9. This worked very well, as the previous discussion had helped to order and clarify their views, and the sheets gave them some editorial control over how we would use their views. In contrast to mainstream medical and psychological traditions, our ap- proach, methods and language yield diVerent and, we would argue, more realistic insights into the daily lives of people with serious congenital condi- tions. Among the people with Down’s syndrome, for example, one helped to run a youth club, one taught on courses about empowerment, assertion and safer sex for people with learning diYculties and was an artist, and two were actors who shared in creating plays about disability and genetics. Qualitative research such as this study cannot produce measurable, generalizable Wndings about the abilities and experiences of these Wve groups of people. Yet the study can challenge general assumptions, by showing how these interviewees did not Wt the negative images propounded in the prenatal medical literature. I was worried when he showed me into the family living room where his sister and girlfriend were already sitting, as I expected that their presence would inhibit him. I avoid the standard research practice of asking families to regroup to allow for a private interview, partly because their decisions and family dynamics are such useful data and partly because I would assert a potentially inhibiting power balance. During the interview he spoke about his shorter life expectancy, and when the young women objected he said that they always avoided the subject, but he wanted to talk about it with them. Like other interviewees he tried to make his employment record at least as good as that of his colleagues, to prevent his condition being used as an excuse to dismiss him. Like many of the interviewees, when asked about his hopes and aims, Tim spoke freely about being a partner and becoming a parent, spontaneously raising these issues and relieving me of the worry that I might upset or embarrass him by introducing them. Jane was delighted to return to work and to caring fully for her family after her recent heart transplant, but others were frustrated at not being able to Wnd suitable work. Having returned to live with her parents, she would ‘like to be able to do things more spontaneously, have more energy, spend less time with my parents and have more self-identity, be stronger and more conWdent’. Jenny said that she would love to be married and have children but felt that no one would want to take on the responsibility of caring for her and that she was not strong enough to have a child. It has stopped me from making plans and getting on with my life, like going to university or doing things which might be boring for a few years but lead on to something better’. Asked what he might want to change about himself, again like some of the others Rob replied, ‘I’m happy with my character, I’m very happy with what’s happening in my life at the moment’, and he was more keen to talk about how to change society. For example, one man with Down’s syndrome described being pushed and shoved in the street by his neighbours, and another was fed up with being Prenatal counselling and images of disability 205 treated by new work colleagues as if he were stupid, though he added, ‘They learn in the end, and then they realize that are the ones who look silly’. Their conditions did not appear to dominate their lives in most cases, and much time was spent talking about the many things they had in common with their ‘ordinary’ peers: work or unemployment, income, housing, relationships, leisure activities and ambitions. The other more disabled people with spina biWda included a young single mother who was also a college student, and Richard and Vivian who both used wheelchairs. He enjoyed going to city clubs with friends, and could haul himself in his chair up and down stairs, so he used underground trains despite oYcials trying to stop him. He said that when he joined mainstream secondary school, the wheelchair users were all taught mobility and coping with stairs and pave- ment kerbs, which helped him to become very Wt. You do feel low and in pain and angry with people and it is important to have friends and to go out for a drink’, and she talked enthusiastically about her many interests. Vivian was planning to have a baby and she talked of her mixed feelings about taking folic acid to reduce the risk of the baby having spina biWda, yet ‘being proud that I have spina biWda’ because it had given her such experience, knowledge and opportunities she would not otherwise have had. They also tended to say that they would respect any decision made by prospective parents after being properly informed, whether to continue or end a pregnancy aVected by their condition, though they hoped the pregnancy would continue and some had mixed feelings. For example, two men with Down’s syn- drome, who had been talking intently about their acting, suddenly looked very sad when asked about screening, and said they did not want to talk about it, as if the subject was too painful. However, the interviewees had far more similarities than diVerences, including the ways they reXected on their lives, and their belief that they suVered from the general stigma of disability more than from their actual condition. This raises questions about why the prenatal literature, policy makers and counsellors make so little mention of the potential range of each condi- tion from mild to severe, of the increasingly eVective treatments which Jenny mentioned, and of the possibility that some therapeutic abortions may prevent potentially rewarding lives. A further complication for prenatal predictions is the mismatch, shown particularly by the people with spina biWda, between the degree of severity of physical disability and the way people value and enjoy their lives. Prenatal counselling and images of disability 207 The implications of the interviews for prenatal counselling and maternal–fetal relations The overall impression given by the interviewees was of very interesting, thoughtful and pleasant people. Most of them appeared to value and enjoy their lives, sometimes despite pain and serious illness, as much as any average group of 40 young adults might say they do. One man with sickle cell anaemia was in such pain that his interview took place over three separate visits, but this was because he was so keen to take part. Their friends appeared to value them, and so did their families, with one exception as might be expected in any group of 40 adults (her mother had died and her father had remarried). Most interviewees had far more in common with their ‘ordinary’ peers than diVerences, and none showed any clear reason why their life would have been better prevented. Even allowing for the artiWcial nature of the research interview, and the way our methods partly shape the evidence, as is inevitable in every type of research, the interviewees provide compelling evidence for questioning the assumptions on which prenatal policies and counselling are based – that it is reasonable to prevent such lives. The interviewees challenge the view that it is kinder to terminate any aVected pregnancy, however mildly the fetus might be aVected, because life is so awful for the severest cases. Repeatedly, interviewees spoke of the crucial importance to them of being involved in mainstream society – schools and colleges, homes and jobs, clubs and pubs and friendships. They tended to stress their need to see beyond their condition as a personal predicament, and to press for greater inclusion by challenging negative attitudes in society, and by showing how they could be involved. They were grateful to parents who encouraged them to be strong and who, as one woman with Down’s syndrome said of her mother, were ready to ‘Wght for my rights [even through] the High Court, the High Court of Justice!

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Interestingly cheap 100mg kamagra oral jelly amex, the introduction of the report by the group of advisers to the European Union (European Commission order kamagra oral jelly 100 mg overnight delivery, 1997) states 100 mg kamagra oral jelly fast delivery, ‘As there is no dis- crimination against twins per se buy kamagra oral jelly 100 mg online, it follows that there is no per se objection to genetically identical human beings’. This makes it clear that one must Wnd other arguments than the noumenon (‘thing in itself’) of cloning (its ‘real existence’) in order to counter arguments in favour of human reproductive cloning. The argument of dignity is underlined, using the Kantian categorical precept – ‘to treat each and everyone as an end to themselves and not merely as a means to an end’. Of course we know that a clone obtained by somatic cell nuclear transfer would not be totally identical to the adult donor of the nucleus, because of the recipient cytoplasm bearing the maternal mitochondria; but more im- portantly, the same argument can be used against reproductive cloning by embryo-splitting and transfer to diVerent surrogate mothers at diVerent times. To quote the report: It would be absurd to consider that an adult and his clonal duplicate who must necessarily be born much later, and is bound to have a diVerent life history, could be to any degree presented as two copies of a single and identical person. To believe such a thing would be to fall victim to the reductive illusion which is born of the dismal confusion between identity in the physical sense of sameness (idem) and in the moral sense of selfness (ipse). The report continues: [N]evertheless, although to possess the same genome in no way leads two individuals to own the same psyche, reproductive cloning would still inaugurate a fundamental upheaval of the relationship between genetic identity and personal identity in its 156 F. The uniqueness of each human being, which upholds human autonomy and dignity, is immediately expressed by the unique appearance of body and countenance which is the result of the singularity of each genome. The autonomous human being (who may be deWned as one who is ‘submitted to his or her own laws’) may allegedly be threatened in this very quality by facing his or her relatively identical clones. Can we not argue instead that the best way to counteract discrimination is to accept diVerence as a valuable addition to the rich tapestry of life rather than fear its conse- quences? Indeed if dignity has to be deWned in any essential manner, as it must be if enshrined in international declarations, it is the unique quality of all human beings, also recognized in their diVerences, even if there is a degree of sameness, which gives us dignity. This is obviously absurd, and we have therefore to conclude that even if normal sexual reproduction were a necessary condition for human liberty, it is far from being a suYcient one. It seems reasonable to suppose that the constraints im- posed by the father’s sexual identity would somehow aVect the cloned child; would this be a reduction of the child’s liberty? Ethical issues in embryo interventions and cloning 157 Perhaps feminist psychoanalytical arguments can help us understand the problem of identity – for example, the work of Julia Kristeva (1991) and Luce Irigaray (see Whitford, 1991). Kristeva argues that we cannot respect and accept strangers if we have not accepted our own portion of strangeness, in other words, the stranger within ourselves (Kristeva, 1991). The implication for cloning is that the parent(s) seeking reproductive cloning cannot accept that strangeness carried in the matrix of the gestating mother. In the same analytical vein, one could argue that the fantasy of immortality, or the desire for genetic perpetuation at any cost by those who cannot procreate, seems a more narcissistic venture than the often unconscious choice of a reproductive partner. In a similarly psychoanalytical fashion, Irigaray begins from the Lacanian account of the mirror stage in identity development, but adds a feminist twist. For men, ego formation depends on coming to see the world as a mirror, on which the male projects his own ego; women are part of the mirror, so that they never see reXections of themselves (Whitford, 1991: p. The implication for cloning, after the manner of both Kristeva and Irigaray, is that deeper psychoanalytical forces are at work in popular revulsion at the idea. Because the identity of the subject is shaky, and subjectivity itself something to be constructed rather than a given, cloning poses a threat to our personal identity which we Wnd diYcult to tolerate. Another psychoanalytical question concerns the child thus conceived, rather than the parent – how will the child cope with building his or her sexual identity? Therapeutic cloning (or other applications of cloning technology which do not involve the creation of genetically identical individuals) has led to much less dismay. The European Commission Group of Advisors on the Ethical Implications of Biotechnology (1997) report reiterates in its summary that: As far as the human applications are concerned, it distinguishes between reproductive and non-reproductive (research), and also nuclear and replacement and embryo splitting limited to the in vitro phase, i. The European report stresses that therapeutic cloning should aim either to throw light on the causes of human disease or to contribute to the alleviation of suVering. All raise questions about what respect is owed to the embryo, its moral status, as well as about human rights, including the right to reproduce and the right to a family life. Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Bioethics Convention. Currently only 1 in 50 women of child-bearing age becomes pregnant following a renal transplant, and it may be that many more would welcome the chance of biological parenthood if their fertility problems could be overcome. However, some reviews (Sturgiss and Davison, 1992; Davison, 1994) have suggested that pregnancy in the graft recipient, unlike the rare pregnancy in patients undergoing dialysis, is usually likely to lead to a live birth, and that pregnancy may have little or no adverse eVect on either renal function or blood pressure in the transplant recipient. The current medical consensus is that if, prior to conception, renal function is well preserved, and if the patient does not develop high blood pressure, only a minority of transplant recipients will experience a deterioration of their renal function attributable to pregnancy (Lindheimer and Katz, 1992). It is inevitable that the rapid return to good health enjoyed by the majority of women following successful renal transplantation should encourage them to consider conception. Lockwood was due to severe, recurrent pre-eclampsia, a potentially life-threatening condition of late pregnancy causing raised blood pressure and renal compli- cations, which can progress to cause Wts and cerebro-vascular accidents (strokes). Sterilization by tubal ligation was offered and accepted under these circumstances, in view of the anticipated further deterioration of her renal function with any subsequent pregnancy. There was a significant further ad- vance of her renal disease, necessitating the initiation of haemodialysis (a kidney machine) two years later, and a living, related donor renal transplant (from her mother) was subsequently performed. After the transplant, Mrs A remained well and maintained good kidney function on a combination of anti-rejection drugs, steroids and blood pressure tablets. At age 26, a reversal- of-sterilization operation was performed because she had become so distressed by her childlessness, but hysterosalpingography (a test to check for fallopian tubal patency) two years later, when pregnancy had not occurred, showed that both tubes had once again become blocked. Mrs A’s pregnancy test was positive 13 days after embryo transfer, and an ultrasound scan performed at eight weeks’ gestation showed a viable twin pregnancy. Throughout the treatment cycle and during pregnancy, the patient’s anti- rejection drugs (azathioprine and prednisolone) were continued at mainte- nance doses. The pregnancy was complicated at 20 weeks’ gestation by a right deep vein thrombosis, affecting the femoral and external iliac veins, and anti-coagulation with heparin and warfarin was required. Spontaneous rupture of the mem- branes, leading to premature delivery, occurred at 29 weeks’ gestation; the twins were delivered vaginallyand in good condition three hours later. After delivery of her babies, Mrs A remained well and her renal graft continued to function normally, with no change in immunosuppressive or antihypertensive (blood pressure) medication required. Risks to the mother, the fetus and the neonate Severe pre-eclampsia and eclampsia can result in irreversible damage to the maternal kidney, particularly due to acute renal cortical necrosis. Women who have recurrent pre-eclampsia in several pregnancies or blood pressures that remain elevated in the period following delivery (the puerperium), especially if they have pre-existing renal disease and/or hypertension, have a higher incidence of later cardiovascular disorders and a reduced life expect- ancy (Chesley, Annitto and Cosgrove, 1989). Pregnancy is recognized to be a privileged immunological state, and therefore episodes of rejection during pregnancy might be expected to be lower than for non-pregnant transplant recipients. Nevertheless, rejection episodes occur in nine per cent of pregnant women, occasionally in women who have had years of stable renal function- ing prior to conception. More rarely, rejection episodes occur in the puer- perium, when they may represent a rebound eVect from the altered im- munosuppressiveness of pregancy. Immunosuppressive (anti-rejection) drugs are theoretically toxic to the developing fetus; however, maternal health and graft function require im- munosuppression to be maintained. A large French study of women with pre-existing renal damage reported a prematurity rate of 17 per cent and a spontaneous abortion rate (miscarriage) of 20 per cent, as compared to 164 G. Severe pre-eclampsia can present as a progressive condition, tending to occur with greater virulence in successive pregnancies (Campbell and MacGillivrey, 1985). This, after all, had been the rationale behind the original decision to sterilize the patient after the death of her second baby, precipitated by pre-eclampsia and extreme prematurity. The successfully functioning trans- planted kidney had been donated by the patient’s mother and therefore, as an organ, was 30 years older than the patient herself. An editorial review (Davison and Redman, 1997) reported that 35 per cent of all conceptions in renal transplant patients failed to progress beyond the Wrst trimester because of therapeutic (approximately 20 per cent) and spon- taneous (approximately 14 per cent) abortions. Problems occur some time after delivery in 11 per cent of all women with transplants, unless the pregnancy was complicated prior to 28 weeks’ gestation, in which case remote problems can occur in 24 per cent of pregnancies. However, of the conceptions that continue beyond the Wrst trimester, 94 per cent end success- fully, in spite of a 30 per cent chance of developing hypertension, pre-eclampsia, or both. The hormone drug regime involves supra-physiological levels of oestradiol, which are associated with a higher risk of thrombotic (blood-clotting) episodes than in normal pregnancy. Arguments that could be advanced against oVering fertility treatment to renal transplant recipients, such as whether it is in the best interests of the patient to be helped to achieve a state as a result of which she may suVer chronic ill health or even early death, have also been advanced against permitting ‘old’, i. In both instances, one could argue that as long as the risks associated with fertility treatment and pregnancy were thoroughly explained to and accepted by the woman (and her partner), then to refuse treatment on the sole ground that her health may deteriorate is unacceptably paternalistic on the part of the clinicians involved. Mrs A stated that if she had not agreed to the sterilization (which she claimed she had been placed under undue pressure to accept at the time she was diagnosed with renal failure), then she would not only have been able to, but deWnitely would have tried to, achieve a further pregnancy, as she did after the reversal of sterilization was performed. Lockwood authorities as encouraging fertility units to feel justiWed in refusing treatment to women with signiWcant health problems (or to post-menopausal women) as it would, so they claim, not be in the ‘interests of the child’ to be born to a mother with reduced life expectancy due to chronic ill health or comparative- ly advanced age. Apart from the obvious rejoinders that society happily countenances men becoming fathers at an age when their life expectancy is reduced, and the medical profession’s heroic eVorts to assist women with serious health problems who become pregnant spontaneously, it is unques- tionably in the interests of the child. After all, the child will only be born if his transplanted mother is oVered fertility treatment and she should be oVered such treatment, even if he loses his mother at an early age or has to deal with the consequences of her ill health, as otherwise he won’t exist! The supposed stigma of illegitimacy is now vastly reduced to the point of being negligible, as are other historical reasons, such as those cited by PfeVer (1993), namely the stigmas of adultery and masturbation. Other reasons for secrecy, such as protecting patient conWdentiality and the more controversial claim that secrecy beneWts the doctor, I will not explore. Widdows examination of the procedure – including doctors’ practices of making social decisions about access and donors, which they are not qualiWed to make (Haimes, 1993). In addition, recent ad- vances in genetics have strengthened claims that knowing one’s genetic parentage is an important part of understanding one’s own identity (at least medically). Two main reasons given for keeping the donor anonymous are: Wrst, a practical reason, that anonymity is necessary to ensure that there are willing donors; and second, that anonymity ensures that donors have the ‘correct attitude’. First, the supposition that if donor anonymity were removed, then donors would no longer be willing to donate sperm can now be tested against the evidence which is emerging in countries where anonymity has been removed. At Wrst sight such evidence appears to suggest that both donors and potential parents were uncomfortable with the removal of donor anonymity – donors were less The ethics of secrecy in donor insemination 169 willing to donate and parents were choosing to go to countries which continued the practice of donor anonymity. A further possibility is that this increase in couples seeking treat- ment outside Sweden is an indicator not of dissatisfaction among donors with the removal of anonymity, but of the dissatisfaction of medical advisors, who adopted the practice of ‘advising and referring couples to have treatment outside Sweden’ (Daniels and Lalos, 1995: p. However, Daniels and Lalos do note that their view is contested by Bygdeman (cited in Daniels and Lalos, 1995), who argues that both the decline in donors and the trend for couples to seek treatment abroad was a direct reaction to the fact that their anonymity would no longer be protected. However, Daniels and Lalos conclude that ‘despite this limitation, it is clear that the number of available donors is increasing’ (Daniels and Lalos, 1995: p. To support this conclusion they cite statistics from the University Hospital of Northern Sweden, which had collected donor Wgures both before and after the introduction of the law.

The cytoskeleton acts as both a high cellular motility (primal dimension movement) skeleton and a muscle buy kamagra oral jelly 100 mg free shipping. There are three filaments that (Lorenz et al 1996) cheap 100 mg kamagra oral jelly free shipping, their larvae are motile and they make up the cytoskeleton: actin filaments generic kamagra oral jelly 100mg, microtu- commonly have flagella to draw in nutrients from the bules and intermediate filaments trusted kamagra oral jelly 100mg. The sliding, phagocytose foodstuffs (Leys & Eerkes-Medrano assembly, and disassembly of actin and microtubules 2006), such as bacteria, demonstrates that radial con- cause cell movement. The microtubules and the actin traction is still a key movement pattern in sponges. The transpor- As cellular differentiation became better defined, so tation method of endocytosis (drawing nutrition into the first of the major body plans arose, the diploblastic the cell from the outside) requires the cytoskeleton. The diploblastic body plan uti- The cytoskeleton helps the cell acquire particles. In modern times: A the diploblastic body plan is found in anemones and jellyfish; B the triploblastic acelomate body plan is found in flatworms; C the triploblastic, with hemocele plan is found in roundworms; and D the triploblastic with celom basic architecture is found in fish, amphibians, lizards and mammals all the way through to man 322 Naturopathic Physical Medicine anemones and jelly fish – each of which exhibits this ‘The importance of movement approaches to naturo- same radial contraction pattern as their primal dimen- pathic patients’ above). The majority of body plans from the late Neopro- Such organisms often float on the currents and the terozoic are represented by the sponges or the comb direction of their efforts may be governed more sig- jellies, jelly fish and sea anemones (Erwin et al 1997). Their movements may be is widely described as the ‘Cambrian explosion’, due seen as ‘preconscious’ or autonomic – reflecting their to the proliferation of multicellular organisms, brought close association with respiration and digestion. By the has relevance with regard to the ontogenetic develop- close of the Cambrian, some 490 mya, all body plans ment of movement. They are exposed to the natural were established – and even migration from sea-based rhythms and cycles of life and literally have to go with living to life on land brought with it only minor the flow. How this pertains to human development How this pertains to human development and movement rehabilitation and movement rehabilitation Activation of the deep intrinsic muscles of the spine Our phylogenetically oldest muscles are ontogeneti- and the peripheral joints should be effortless and cally the first we learn to use, both in utero and in occur without the need for thought. This learning reason that ‘feeling’ commands, instead of ‘doing’ occurs early in life before volitional motor control and commands (Lee 2003), should be utilized when cause/effect learning have developed (see Table 9. Such segmentation allows for muscles and the only ones to retain their primitive sequential radial contraction and is the basis for the two metamerism. They extend between two successive largest animal groups on Earth, the vertebrates and the transverse processes, neural spines, neural arches insects (Drews 1995). In humans, the only examples would Kent & Carr (2001) state that the immediately evident be rectus capitis posterior minor, obliquus capitis feature of axial muscles in fish and tetrapods is their superior, obliquus capitis inferior, interspinales, metamerism. This primitive arrangement, in combination intertransversarii anteriores/posteriores/laterales/ with a metameric vertebral column, allows fish and mediales, rotatores, and possibly levatores costarum. Note: The Disappearance of epaxial myosepta (literally meaning intercostals would not be categorized – even though segmented back muscles) in amniotes gave rise to long, they are depicted as segmentally attached between strap-like or pennate bundles disposed of dorsally to the ribs, which are a component of axial anatomy. This is transverse processes (erector spinae), leaving only a because the intercostals, the scalenes and the entire vestige of metamerism in the deepest bundles. Such abdominal wall are formed from one embryonic sheet bundles in modern-day humans would include the and the ribs literally grow around from the spine and intertransversarii, the interspinales and the rotatores through this muscle sheet to artificially divide it. Hypaxial myomeres (abdominal muscle segments) were gradually replaced by strata of broad muscular Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 323 Flatworms – radial/direction specific and into the outside world. In the same way trate sequential contraction and, as such, required that cell size in Earth’s environment is limited due to greater computational power through an organized atmospheric oxygen pressure and the ability to oxy- and complex nervous system. This nervous system genate the cell (Astrand et al 2003), so flatworms would utilize as its mainframe a longitudinal cord of needed to remain flat in order to diffuse oxygen across nervous tissue. This was the advent of the chordates their gut walls to their inner tissue layer (Erwin et al (Raff 1996). This was mainly due to the fact that they lack the ability to ‘carry’ nutrients as they do not have a How this pertains to human development circulatory system (see Fig. It is only later (around 7 have one orifice through which to engulf food and months postnatal) that more gross, volitional through which to excrete waste. For the flat- • In the same way that it cannot be assumed that an worm to move forward through a sequential radial untrained person’s muscles are as large as they contraction – a peristaltic motion – would require, or would be if he or she had trained, it also cannot be at least imply, that it is concurrently digesting food assumed that an untrained person’s nervous system in an inward direction. This would imply a relatively inefficient training effect (adaptation) in both the muscles movement mechanism – a kind of one-step-forward, (increased size) and the nervous system (improved one-step-backward motion, based on digestive and activation and coordination of muscles) (Sale eliminative cycles. Starfish are categorized as triploblastic acoelomates and, as such, can be viewed as further down the evo- • Indeed, Bompa (1999) explains that neural lutionary road than jelly fish and anemones, and their adaptations to exercise are the primary reason for behavior may be seen in human ontogenetic terms as strength gains in the first 8 weeks of any new the naval radiation pattern in the womb – where the training program, and only after this period does central point of stability (or technically where the hypertrophy predominate as the primary means of fetus is held in a ‘closed chain’ environment1) is via strength gain. At any point beyond 8 weeks in utero, can be explained by the phenomenon of facilitation the four limbs have formed and the head, forming the (see Box 9. This results in forma- Roundworms – radial/direction specific tion of five approximately equal appendages radiat- The emergence of roundworms (see Fig. This pattern in the Neoproterozoic – brought with it changes in the is maintained throughout intrauterine development digestive process. At this stage of development, round- worms now had a unidirectional gut tube, rather than the bidirectional gut tube of the diploblastic and acoe- 1When the body is biomechanically in a closed chain it means lomate triploblastic body plans of earlier designs. Therefore, in These were the first organisms capable of leaving this example, the arms, legs and head are in an open chain traces of their existence through meandering trails, environment as they can overcome resistance of the amniotic fluid, but the fixed point of the fetus – the point that cannot burrows and fecal pellets that could only have been move – is its attachment to the uterine wall via the placenta left by creatures with a complete gut tube (Erwin and umbilical cord. Additionally, such movement patterns 324 Naturopathic Physical Medicine would require a ‘soft skeleton’ of fluid-filled spaces motor control at the spine at the expense of breathing. Many invertebrates use such hydrostatic even under the same perturbation loading – the dia- systems to move, and many vertebrates use hydro- phragm would resume its respiratory function. However, until such time, nificantly to their compressive resistance (Bogduk lumbopelvic stability can be maintained through 1997). Active absorption of foodstuffs Fish (1st dimensional mastery) – lateral into a blood system (hemocele) meant that digestive efficacy was further enhanced and therefore metabolic flexion/direction specific efficiency optimized. This would allow for optimal As the complexity of organisms increased, and the delivery of nutriment to the working parts – whether nervous control of this complexity became more fun- this was the nervous system, the musculature or the damental to the organism’s survival, bony encase- digestive system itself. Such efficacy would allow the ment of the neural components became commonplace worm to evolve greater muscle mass as oxygen deliv- (Kardong 2002). The skull had already formed to ery to the tissues could now operate via the active protect the brain, but the longitudinal cord of nervous vehicle of blood, rather than passive diffusion. Longitudinally the effects of bony spinal development were that there arranged musculature would also allow for some was now a new movement option. Rather than degree of flexion-extension (as seen in the caterpillar); sequential peristaltic contraction, there was now the however, without a bony spine the flexion-extension option to contract the musculature down the entire would be little more than a transient ‘ripple’ down the length of the body on one side, then, using the stretch body segments. This would provide an How this pertains to human development efficient cyclical means of moving forward through and movement rehabilitation water and made use of the viscoelastic properties of In terms of motor control, this movement is exploit- mesodermal (muscle) tissue. In humans, of course, the appen- bony strut would be required to prevent ‘telescoping’ dicular extensions (arms and legs) are also employed of the body under the load of unilateral longitudinal to facilitate movement. This has been demonstrated in work by roundworm bauplans, digestion became less depen- Hodges et al (2001) in which they confirm Lewit’s dent on movement and, in fact, with a decreased utili- (1999) assertion that the diaphragm is a respiratory zation of the peristaltic action of the body wall, would muscle with postural functions, while the transversus require a further functional separation of the digestive is a postural muscle with respiratory function. Therefore, any creature that by Hodges and colleagues (2001) showed that human has mastery of a movement pattern beyond a peristal- subjects, when under perturbation loads, would tic forward creep, must have evolved a celomic cavity recruit both transversus and diaphragm to optimize to allow gross movement without compromising Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 325 digestive efficiency. Indeed this is what the fossil movement skill with them to swamps to clamber over record and morphological studies suggest. On The earliest animals to truly master motion in the land, however, this mastery brought with it some frontal plane (above and beyond the primal dimen- serious limitations. It is at this juncture in evolution (and Gracovetsky (1988) describes how any ground-lying in every vertebrate development after fish) that we objects, such as rocks, stones, fallen trees, would need find development of a celomic cavity. This solution would result initially in axial same layer of embryological tissue (the lateral plate rotation which, when coupled with lateral flexion, mesoderm) as the abdominal wall musculature (see would culminate in motion in the sagittal plane. The structure sequence of events is corroborated by Kent & Carr therefore is interrelated with the function. Gracovetsky (1988) believes that this provided a solution to both the ground-lying How this pertains to human development objects and the fact that, until this juncture, the mass and movement rehabilitation of muscle responsible for moving the organism forward on land was intra-abdominal and therefore • In the infant human, and in many apes, lateral was competing for space with the vital viscera in the flexion is utilized as a primary trunk pattern in abdominal cavity. This seriously limited the potential both gait and other gross movements – such as for significant hypertrophy. One of the characteristics An alternative solution, Gracovetsky (1988) argues, of early gait is a laterally directed arm swing (to was to develop effective flexion-extension of the trunk compensate for frontal plane motion of the trunk), and limb which brought with it a number of benefits as opposed to the drive forward and backward in over lateral flexion: more accomplished sprinters (Haywood & Getchell 2005). In a competitive and found in the gym environment, train the user hostile environment, this would have been primarily in the sagittal plane; hence frontal plane highly desirable. Of course, the story is far more lateral flexion/direction specific/ complex than this, but it does provide a general over- coupled rotation view of our understanding of the evolution of verte- From this point in the evolution of vertebrate design, brate biomechanics – including our own – based on we can turn to the work of Gracovetsky (1988) to the fossil record. This then provides a greater insight provide a concise, insightful description of upcoming to how human biomechanics have evolved and are events. This understanding is fundamental Having mastered motion in the frontal plane in the to helping solve problems when the biomechanics water, the first amphibious pioneers brought this break down. From this, Ahlberg (personal communication, Lateral flexion → Axial rotation → Flexion-extension 2000) agrees it can be inferred that, consistent with How this pertains to human development Gracovetsky’s interpretation, axial rotation may be and movement rehabilitation allowed (as a mechanical necessity) during evolution from lateral flexion to sagittal flexion-extension. Mastery (active) axial rotation When compensation patterns are present, injury may occur either centrally at the spine or Indeed, even in a human infant, it takes many years peripherally in a limb. The end result is an It is interesting to note that the only two true bipeds attempt to increase the power from the arm, alive today are birds and humans, and that both of increasing the tension locally through the arm and them have significant spinal rotation, and both are the grip required on the racket, club or other able to sing and generate rhythm. Across a period of time, cumulative is believed to be intrinsic in the spinal cord circuitry stress to the tendons of the extensor and/or flexor of bipeds – to effectively generate rhythmic gait. Mammals (2nd dimensional mastery) – The astute observer may, at first, consider that a cat’s reflexes, its ability to right itself, might be considered flexion-extension/direction specific/ more advanced than human reflexes, and conse- coupled lateral flexion-axial rotation quently may question the idea that human mastery of What Gracovetsky (1988) only touches on within his the transverse plane is greater than feline mastery. True mastery of the transverse plane – or the invested, a cat could simply not be taught to ride a 3rd dimension – requires significant nervous system bike, let alone jump a bike, somersault a bike, nor development, which is why it has only really been jump out of a helicopter with skateboard in hand to mastered by the primates – although some cats and land in a 30-foot high half pipe performing all kinds birds may also merit the award of transverse plane of mind-bending tricks. As has been pointed out (P Ahlberg, Profes- leopard standing on its hind legs and flicking a sor of Evolutionary Organismal Biology, Uppsala football up with one paw and juggling it on the other University, Sweden, personal communication, 2000), paw is unthinkable – if amusing! The point is that, rotation in the transverse plane does occur in certain no matter how it is viewed, the human nervous lower vertebrates, including dinosaurs, lizards, snakes system can be developed far above and beyond that and birds. However, significant rotation would only of the average cat and it is this development, these appear to be limited to birds in the cervical portion kinds of abilities which the average person might and mammals, particularly cats, in the lumbar region. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 327 How this pertains to human development this day – are not man-eaters, since they have an and movement rehabilitation abundance of other easier prey to satiate them.

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In some cases where key information composition and qualifications cheap kamagra oral jelly 100mg with amex, provided could not be identified or where requirements services buy kamagra oral jelly 100mg line, quality assurance activities and the use were unclear 100mg kamagra oral jelly visa, we called or e-mailed the relevant of patient outcomes data 100 mg kamagra oral jelly visa. Because licensing and certification requirements Case Study of Addiction Treatment are found in a wide variety of laws and regulations and can change on a state-by-state in New York basis, findings from this review cannot be guaranteed to be complete and current. The goal of this work was to provide an in-depth look at one state/city parallel * Using the Lexis/Nexis database to supplement information related to state laws and regulations † available on the Internet. Relevant findings from these analyses and illustrative quotes from key informants are incorporated into the report. If so, do you think it requires some type of intervention or treatment for members other than the addict? Q6 When people are looking for help for an addiction problem, who do they usually turn to or where do they go and why? Q7 When someone gets help for an addiction problem, what type of help do they usually receive? Q9 What is your definition of effective treatment for substance abuse or addiction? Q11 Under what conditions does effective treatment of addiction require treatment of co-morbid psychiatric conditions? Q12 What do you think can be done to make treatment more science- or evidence-based? Is evidence from research findings accessible and understandable to providers, as well as to policymakers and advocacy groups? Q14 What do you think stands in the way of people getting quality, effective treatment and of providers offering quality, effective treatment? Q16 Do you think there should be minimum standards of knowledge, skills and/or training for an individual to provide treatment? Coppola, John, Executive Director, New York Association of Alcoholism and Substance Abuse Providers, Inc. Senator Biden * Titles and affiliations represent those at the time of Key Informant participation. Edward, Immediate Past President, American Medical Association Hoffman, PhD, Norman G. West, Chief Executive Officer and Executive Director, National Association of Drug Court Professionals, National Drug Court Institute Humphreys, PhD, Keith N. The number corresponding to each response option represents the percent, among those responding to the question, that provided the particular response. For each one I mention, please tell me how much of a problem you think it is in your community--a very serious problem, somewhat serious problem, not too much of a problem, or not a problem at all. Insufficient treatment programs and services for people addicted to illegal drugs 28. Now I am going to mention various substances some people may consume and I would like you to tell me what level of use would, in your personal opinion, indicate that a person has a serious problem. To give you an example, some people might say that a person who eats fried foods once a week does not have a problem but if someone eats fried foods several times a day then they do have a serious problem and should seek help to change their diet. Should it be complete abstinence, reduced use, fewer negative consequences from use or the goal should be set by the patient? Suppose someone close to you realized they had a major problem with addiction to alcohol, tobacco, prescription or other drugs, how confident would you be that you knew or could find out where to go or call or send them to get the help they would need: very confident, somewhat confident, not too confident or not at all confident? If someone close to you needed help for an addiction, where would you turn for information or help? Would you say you are very confident that you know what treatment for addiction involves, somewhat confident, not too confident, or not at all confident that you know what is really involved when someone gets treatment for addiction? When you think about treatment for addiction, what kinds of treatments come to mind? Now I would like to read two views about medicines to treat addictions and have you tell me which one comes closer to your personal point of view. Now I would like to read two views about medicines to treat addictions and have you tell me which one comes closest to your personal point of view. Statement A: It is good news that there are medicines to treat addictions, because addictions are medical conditions that medicine can help. People have suggested various reasons why some people with addiction do not get the help they need. Now I am going to mention some approaches society could take to address the problem of addiction to alcohol, tobacco, prescription and other drugs. For each approach, please tell me how important you think it is--very important, somewhat important, not too important, or not important at all? Educate the public about the disease of addiction and the possibility of recovery 73. To your knowledge, has anybody close to you, like a parent, child, sibling, close friend, etc. To your knowledge, has anybody close to you, like a parent, child, sibling, close friend, etc. Are you, yourself, addicted to alcohol, or prescription or other drugs right now, or have you been addicted to them in the past? I know this is a sensitive topic, but let me reassure you that this is for research purposes only and that all your responses will be completely anonymous and confidential. Are you, yourself, addicted to tobacco right now, or have you been addicted to it in the past? I know this is a sensitive topic, but let me reassure you that this is for research purposes only and that all your responses will be completely anonymous and confidential. Regardless of how you may be registered, how would you describe your overall point of view in terms of the political parties? Thinking about your general approach to issues, do you consider yourself to be liberal, moderate or conservative? For statistical purposes only, would you please tell me which one of the following categories represents your total household income? The number corresponding to each response option represents the percent, among those responding to the question, that provided the particular response. What types of payment for addiction/substance abuse treatment services are accepted by your facility? Other responses include chemical dependency centers, case management, and counseling. What is the name of the county in which the treatment facility of which you are the director is located? What is the total number of full-time and part-time clinical staff currently employed at your facility? Last month, about how many staff members in total resigned, were let go, retired or left your facility? On average, about how long do staff who are directly involved in providing client treatment stay employed with your facility? Under which of the following conditions would a client/patient be dismissed by your center or asked to leave the program before completing the treatment course? Other responses include aggressive and violent behaviors, non-compliance, smoking, and legal issues. What are the top two sources from which clients/patients are referred to your facility for treatment? How would you describe the attitude of the surrounding community toward having a treatment facility in the neighborhood? If your facility does any advertising or outreach to attract patients/clients, which two of the following methods does it use most often? Which of the following steps does this facility take to continually improve treatment quality? Other responses include performance improvement committees and in- service training. For each of the following health conditions please indicate whether you think…  It cannot be treated at all; once a person has it, he or she always will suffer from it and its symptoms;  It can be managed so that the symptoms are kept in check even though the individual continues to have the underlying problem; or  It can be treated successfully so that the individual no longer suffers from the problem. Which of the following do you think are the main factors involved in developing… (i) Addiction to tobacco? What should be a treatment provider’s main treatment goal for…* (i) Someone addicted to tobacco? Addicted to Addicted to Addicted prescription tobacco to alcohol illegal drugs Complete abstinence from the substance 49. In your opinion, where should the money come from to pay for treating substance abuse and addiction? How important is it for a treatment facility to have each of the following comprehensive assessment services available to clients/patients? Not at all Slightly Moderately Very important important important important Substance use behavior 0. How important is it for a treatment facility to have each of the following interventions/therapies available to clients/patients? Not at all Slightly Moderately Very important important important important Detoxification 8. Not at all Slightly Moderately Very important important important important Transportation services 4. Which one of the following types of professionals do you think is best qualified to provide addiction treatment services? Addiction treatment services refers to services such as the following: cognitive/behavioral therapy, pharmacotherapy.

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