By E. Jose. University of Texas at Brownsville.

Research on this method of impact on the course of the disease discount 75mg lyrica, or only a poten- treatment offers hope to achieve a simple treatment tial risk of its development buy lyrica 150mg low price. It is a rare to medicines used in the treatment of a specific dis- disease involving disturbances of vision at dark 150mg lyrica amex, at ease (4). The first (β1 receptor) is arestin, and in result, there is a lack of rhodopsin located mainly in the heart, where it influences the phosphorylation. In patients, who have this muta- pulse rate and myocardial contractility, and in the tion, receptor constantly activated by light, constant- kidneys, in which it directs the release of renin. As response to stimulation by rhodopsin regeneration takes more than two hours, endogenous ligands of the sympathetic nervous sys- after which the rods again reach their full sensitivity tem, the widening of blood vessels (vasodilation) to light. In other research, in ble and unstable coronary artery disease (angina vivo, there was no phosphorylation of rhodopsin. Such variant is often associated with ele- commonly used drugs as these used in the treatment vated level of immunoglobulin E in asthma (4). In of bronchial asthma (β2 agonists), and diseases of addition, those who had Arg16Gly polymorphism, the cardiovascular system (β1 antagonists) (22). The receptor with polymor- the β1-adrenergic receptor are the results of a sin- phism at position 16 of the peptide chain, under the gle amino acid replacement at positions 49 and 389. As in the case of Gly16Arg, this receptor is the C-terminus of the peptide chain, arginine is sub- also down regulated (14). In studies carried on hamsters phism results from threonine substitution for fibroblasts, there has been shown that substitution of isoleucine at 164 position. Despite the fact, that it the glycine at position 49 in the receptor resulted in occurs rarely, it has a significant impact on the func- a decrease in the number and density of receptors on tion of the receptor. Binding to the G protein and the the cell surface as a result of its down regulation. It has Various polymorphisms within the β1 receptor also been shown that it causes disturbances in the may affect the bodyís response to medications. The process of vasodilation, thus contributing to an difference in the individualís response in humans increase in blood pressure, the frequency of hyper- with a mutated form of this protein is particularly tension and other cardiovascular diseases. In the Arg389Gly intensifies response to drugs, which are group of study there were Danish men and women β1-adrenergic receptor agonists as well as to antago- of Caucasian origin. It was shown that treatment presence of Thr164Ile is associated with increased with dobutamine or adrenaline has better effect on blood pressure and the other above-mentioned function of the heart of people with Arg389Gly changes in the cardiovascular system in women polymorphism, who underwent coronary artery (23). Thr164Ile polymorphic variant may occur in bypass grafting, in relation to persons having a patients suffering from heart failure and affects Gly389Arg polymorphism. It turned out that in treatment of cardiac failure, for example, by increas- patients with a mutation Arg389Gly, a better ing the dose of the drug (4). On the mine their potential impact on the development of basis of this result, it was assumed that persons with the disease and is useful in predicting the response Arg389Gly polymorphism in the gene encoding the to medications used during treatment. As a gested that, in order to quicker obtain the favorable result of the above diseases, there is an insufficient therapeutic effects, administration of the higher dose blood flow and myocardial ischemia, and necrosis of such drugs to persons without polymorphism of the tissue. These mutations have been compensating ineffective myocardial work are: acti- observed in diseases such as hypertension, asthma, vation of the sympathetic nervous system, stimula- obesity, and certain immune disorders. At described, there is an increase in cardiac workload, G protein-coupled receptors: abnormalities in signal transmission. Activation of both types the next step, there are changes in the structure of of receptor (β1 and β2)causes stimulation of protein the myocardium. In addition, cascade is an increase of frequency, strength and there are risk factors that can facilitate the incidence speed of contraction of the heart muscle and of heart failure. They can be divided into physiolog- increase of the relaxation phase of the muscle fibers. The second group due to the fact, that its continuous stimulation caus- includes, among others, changes in the expression of es apoptosis of cardiomyocytes. In contrast, β2 genes encoding the receptors that can influence the receptor is considered to be cardioprotective. Polymorphic variants of β-adrenergic receptors and their influence on the pathogenesis of cardiovascular disease (22, 23). Receptor Polymorphism Signal change Clinical observations Gly49 Gly49 Ser49Gly ñ increase of the susceptibility ñ reduced risk of deepening of receptor on down regulation failure, heart transplantation or death Homozygotes Arg389 ñ better treatment effects of β-blockers Arg389 in the form of an increase ñ binds stronger Gs protein in left ventricular ejection β1 Gly389Arg ñ receptor more sensitive fraction than Gly389, to stimulation with agonist an increase the risk and antagonist of arrhythmia. In extreme cases, it may lead to the dis- brane; c) reduced constitutive activity of the recep- appearance of up to 50% of β1 receptors. After the interaction of continuous stimulation of β2 receptors, there is not the receptor with α-melanocortin, there is no answer its down regulation but there is an increase of the or it is limited and this could happened because of inhibitory Gi protein concentration. In consequence, the reduced receptor affinity for agonists or weak there is a weakening of the response to continuous signal transduction. Disorders classified in the sec- stimulation of the sympathetic nervous system (22). It was demonstrated that 80% of children More and more people around the world suffer with severe obesity have showed a partial or com- from the problem of obesity. In ilization disease are lifestyle changes, diet and the last group of receptor disorders, there are muta- genetic factors. Significant influence on the devel- tions that result in a loss of constitutive activity of opment of obesity has a mutation in the gene encod- the receptor. It is small, receptor are the most common defects observed in has only 332 amino acids. Its stimulation results in a further activation of mulation of body fat, which substantially affects the signal transmission by the relay of the second mes- conditions of life. In classical sig- body mass divided by height in meters to the second nal transduction through the receptor, protein Gs is power. Carried studies have shown that obesity results of the melanocortin signaling of appetite and energy from environmental and genetics factors. After gy supplied with food and energy spent on physical binding with α-melanocortin, receptor stimulates activity. On the con- obesity, which is a part of syndrome ñ is rare, obesi- trary, when inverse agonist ñ agouti-related protein ty is one of the phenotypic characteristics of the dis- is connected to the receptor, satiety disappears and ease, for example, in Prader and Willi syndrome it is hunger center is triggered. Frequency of monogenic obesi- in children and adults with severe cases of obesity. Higher growth and higher bone G protein-coupled receptors: abnormalities in signal transmission. Currently, a number of clinical studies are con- Regular exercise can cause increased energy con- ducted on substances that can be used as medica- sumption, cause lose weight and prevent obesity. Due to Mutations in the arginine vasopressin receptor 2 the fact that the receptors are in the brain, such drugs Vasopressin (antidiuretic hormone) is a hor- should have a good penetration of the blood-brain mone released from the pituitary in hypovolemia or barrier. Second messenger activates protein of large particles and a long N-terminal domain.

They can provide special laboratory test- The objective of this step is to test the hypotheses ing that may not be available privately and may developed up to this point order genuine lyrica line. The case definition may need to impose quarantine restrictions to prevent be revised to include a specific diagnosis buy lyrica 75 mg. Outbreaks of a poten- tory testing that may not have seemed relevant or tially zoonotic disease should be reported to the local had been cost prohibitive at the initial stages can health department purchase 150 mg lyrica mastercard. The steps described above can be expensive and The population truly at risk may be more clearly time-consuming. It is helpful to schedule one or defined and data analyses may need to be repeated two site visits solely for the purpose of conducting to get a better estimate of the association between a the investigation. Bringing 2 or 3 creates a critical situation even if a relatively small consultants along helps keep the focus on the out- number of animals are involved. After an initial introduction to the client, outlined above can always be applied, but it is the consultants may even be able to lead the investi- difficult to perform the analytic step when faced with gation to prevent it from disrupting practice sched- only a dozen or so cases. After Whether an outbreak is large and has a potential the investigation is completed, it is a good idea to international impact, like the epidemic of acute fatal schedule a follow-up visit to report the results to the pneumonia due to Hendra virus (equine Morbillivi- owner, answer any remaining questions, and to rus) in Australia, or small and localized like the 1999 make sure that your recommended preventive mea- botulism outbreak in the Southwestern United sures have been implemented. States, the steps outlined here are useful for identify- During a site visit it is imperative to keep an open ing the cause and source of the problem. Both mind and not limit questions to one particular area affected and unaffected animals need to be exam- of suspicion. It is a good idea to avoid leading ined, and a systematic, unbiased assessment in- questions, listen, and keep interpretations to oneself creases the likelihood of identifying factors associated until the end of the investigation. Conditions on with the occurrence of disease so that recommenda- the farm should be observed personally in addition to tions can be made to break the cycle and prevent interviewing the owner and staff. Methods in Observa- read or speak English fluently may work the most tional Epidemiology. Thechniques for investigating outbreaks of livestock to address language and reading barriers. Veterinary epidemiology, equine population is often more challenging than principles and methods. This factsheet outlines the characteristics of the early, middle and late stages of Alzheimer’s disease and briefy looks at how other forms of dementia progress. While it can be helpful for planning ahead to have some awareness of the likely progression of a person’s dementia, it is important to realise that everyone’s experience will be different. It is much more important to focus on trying to live well with dementia, meeting the needs of the person at that time, than to focus only on which stage they are in. Contents n Dementia as a progressive condition n Before dementia develops n Rate of progression n Alzheimer’s disease n Early (‘mild’) stage n Middle (‘moderate’) stage n Late (‘severe’) stage n Vascular dementia n Dementia with Lewy bodies n Frontotemporal dementia (including Pick’s disease). This means that the structure and chemistry of the brain become increasingly damaged over time. The person’s ability to remember, understand, reason and communicate will gradually decline. As dementia worsens, the person will need more and more support with daily living. At different times they may assess a person’s mental ability (in a Mini Mental State Examination for example), daily living skills (such as dressing or managing medication), behaviours, overall functioning or quality of life. Some of these scales were developed specifcally for Alzheimer’s disease and work better for that than for other types of dementia. Assessment of the extent of someone’s dementia should take account of these scales but should also take a broader view of the person, including their capabilities and needs. Looking at dementia as a series of three stages – early, middle and late – can be a useful way of understanding the changes that occur over time. However, it is important to realise that this view of dementia can only provide a rough guide to the course of the illness. This is because: n some symptoms may appear earlier or later than indicated here, in a different order, or not at all n the stages may overlap – the person may need help with one task, but may be able to manage another activity on their own n some symptoms, such as irritability, may appear at one stage and then vanish, while others, such as memory loss, will worsen over time. These include their physical make-up, other illnesses they may have, their emotional resilience, the medication they take and the support they can rely on. Before dementia develops There is good evidence that, by the time most people develop any symptoms of dementia, the underlying disease has been causing damage to their brain for years. Researchers are very interested in this ‘pre-symptomatic’ period and have developed tests to look at the brain chemistry, function and structure at this time. It is likely that any medication designed to slow down or prevent the diseases that cause dementia would work in this early phase, before the disease is fully established. Over time, the changes in the brain will begin to cause mild symptoms, but which are initially not bad enough to count as dementia. Subtle problems in areas such as memory, reasoning, planning or judgement may cause diffculties with more demanding tasks (such as preparing a meal) but they will not yet signifcantly affect daily life. About 10–15% of people with this diagnosis will go on to develop dementia each year. There are some differences between the different dementias – Alzheimer’s disease, for example, seems to have the slowest progression on average – but much of the variation is from person to person. These include age – people who develop symptoms before 65 often have a faster 4 The progression of Alzheimer’s disease and other dementias progression. Evidence also suggests that a person’s genes play a role, as does someone’s overall physical health. People with poorly controlled heart conditions or diabetes, those who have had several strokes or those who have repeated infections are all likely to have a faster deterioration. On the positive side, there is some evidence that keeping active and involved can help a person with dementia retain abilities for longer. Some of these factors affect the underlying disease processes in the brain, while others do not but still help with dementia symptoms. Those supporting someone with dementia should help them to stay active – physically, mentally and socially. The person with dementia should also try to eat healthily, get enough sleep, take medications as advised and not smoke or drink too much alcohol. It is also important for the person to have regular check-ups (for eyes, ears, teeth and feet) and vaccinations, and to keep a careful eye on underlying health conditions. A sudden change in the person’s abilities or behaviour could indicate a physical or psychological health problem or an infection. Alzheimer’s disease Alzheimer’s is the most common type of dementia and the most studied. Progression of the other common dementias can then be compared with Alzheimer’s disease. Each type of dementia tends to have particular early symptoms, because different parts of the brain are affected frst.

Malaria is an important component buy discount lyrica 75mg online, and so is maternal mortality: much more so than in India order 75mg lyrica amex. We estimate that there are over 600 purchase discount lyrica line,000 excess female deaths each year from this source alone. For instance, the female deficit in cardiovascular disease is also large in sub-Saharan Africa. The main female deficit is at older ages where non-communicable diseases, such as cardiovascular and respiratory diseases, are important. A detailed description of these findings is postponed to the main sections of the paper, but one question arises immediately. Is it possible that the difference in mortality rates by gender between developing and developed countries is simply due to changing compositions of disease? In this case, excess female deaths in developing countries would arise not from lack of “similar care” for men and women, but from the changing disease environment. That transition refers to changes in the causal composition of mortality (with development), with infectious diseases giving way to chronic and degenerative ailments as the leading causes of death. Conventional wisdom states that infectious diseases and undernutrition do not discriminate across gender, while there is a female advantage in chronic and degenerative disease. Age-by-age calculations that do not control for compositional effects of disease composition might then record a number of “missing women”, but they would not be missing due to any lack of “similar care”. Contrary to what we might expect, we find that the epidemiological transition plays a minimal role. These results compel us to confront the question of various ages and various diseases when studying missing women. The aggregate female deficit in South and East Asia has been mainly attributed to parental preferences which discriminate against young or unborn girls. Our findings suggest that excess female mortality is a more universal phenomenon (both over age and over disease). The available data for births from sub-Saharan parents in the United States suggests similar numbers as well. There is a remarkable congru- ence between these numbers and what we observe in the three regions today. Expressed as a proportion of the female population, the number of missing women in the United States in 1900 is larger than in India and China today, and slightly smaller than in sub-Saharan Africa. We use the relative death rates of males and females in developed countries today, but perhaps there is “natural” variation in such relative rates with development. Our position, on which we expand in Section 6, is that there is little or no reason for such variation and, moreover, that an examination of existing data for poor countries cannot settle the issue because we have no separate way to argue that those countries exhibit no gender discrimination. That includes the historical United States; we have no reason to believe that it was discrimination-free. For some categories, such as missing women from Injuries, we would argue the dominant cause must be discrimination across gender. There may be lack of similar care in treatment, there may be gender-based violence, and some of the excess may also be due to different cultural and sexual norms. Similarly, in the case of cardiovascular illness, excess female deaths may stem from unequal treatment, but also may be due to differential incidence. Put another way, if we want to restrict ourselves to defining missing women as the number of females who have died due to discrimination, then the original estimates need to be seriously revised downwards. An accounting exercise cannot separate the role of direct gender discrimination from other factors—biological, social, environmental, behavioural, or economic—in explaining excess female mortality. But it allows us to ask these questions, and to assess the comparative impor- tance of each potential category. Our decomposition puts all these varied sources into one unified and comparable framework, and it therefore has the potential to inform future research in these areas. The Sen counterfactual Sen describes how skewed sex ratios can be translated into absolute numbers of missing women: To get an idea of the numbers of people involved in the different ratios of women to men, we can estimate the number of “missing women” in a country, say, China or India, by calculating the number of extra women who would have been in China or India if these countries had the same ratio of women to men as obtains in areas of the world in which 9. All we can argue is that the developed countries today set a norm that other countries, including the historical United States, can be measured against. When that number is added to those in South Asia, West Asia, and North Africa, a great many more than 100 million women are “missing”. These numbers tell us, quietly, a terrible story of inequality and neglect leading to the excess mortality of women. For Sen, this counterfac- tual is just the overall sex ratio in countries where men and women presumably “receive similar care”. True, Sen’s baseline ratio—the average overall sex ratio for Europe, North America, and Japan—is somewhat optimistic for female survival, including as it does war losses and a different age composition, but the more conservative numbers, most notably the alternative calculations by Coale (1991), still yield enormous figures: around 60 million. Our approach Throughout, we apply variants of the Sen–Coale counterfactual, first to every age group, and then to age/disease groups. Briefly, we suppose (for each age or age-disease category) that the relative death rates of females to males are “free of bias” in developed countries. We compare these rates with the actual relative rates in the country of interest, and obtain missing women under that category. In particular, we address which age and disease categories house the missing women that are identified overall by Sen and Coale. First, the choice of any counterfactual, including the one we use, can be challenged. We simply do not know if the “natural”, “discrimination-free” relative death rates for women and men are the same in poor and in rich countries. To know this, we must somehow assert that some poor regions do not have discrimination and use the relative death rates for those supposedly discrimination-free regions as benchmarks instead. Such an alternative may be useful from the viewpoint of robustness, though far from conclusive. Second, any missing women we do estimate may be “missing” for a variety of reasons. We do not suggest that all these numbers must be attributed to, say, discrimination. Indeed, our discussion throughout and especially in Section 6 will explicitly assert that there are several potential channels, all worth exploring in future research. Sen’s “terrible story of inequal- ity and neglect” is possibly true in large part, but other stories may need to be told as well. The fact that there may be excess female deaths at various age groups is well known, and we do not claim to have discovered this. First, we develop a precise decomposition and take it to the data for developing countries, thereby obtaining a breakdown of missing women by age in India, China, and sub-Saharan Africa. To our knowledge, these relative numbers by age have never been calculated or discussed before. Coale (1991, Table 1) uses the West model life tables to predict the overall sex ratios “that would exist in the absence of. This leads to a lower estimate of missing women compared to Sen’s, because—in Coale’s words—the actual sex ratio in these countries “is an inappropriate standard: it is the result of past male war losses and of an age composition that reflects past low fertility”, in addition to any absence of discrimination.

Qualitative Trustworthiness Data trustworthiness and quality was verified through use of the following techniques: prolonged engagement buy lyrica 150 mg without prescription, triangulation best buy lyrica, member checking buy lyrica 75mg line, and reflexive journaling. Prolonged Engagement Prolonged engagement involves an understanding of the culture one plans to investigate, as well as building trust with one’s participants (Creswell, 2007; Schensul & LeCompte, 1999). Because I have been a member of The Thyroid Support Group since 2004, trust had been established with the group owner-moderator and potential participants. In addition, as a member, I have a comprehensive understanding of the context and phenomena under study. Triangulation Triangulation includes the use of different sources, theories, and investigators in an attempt to substantiate evidence (Creswell, 2007, 2008; Schensul & LeCompte, 1999). I collected data from an interview guide and had planned to collect personal electronic 105 journals or diaries. Triangulation was achieved by using more than one theoretical position (feminism and social constructionism) to interpret the data (theoretical triangulation; Denzin, 1970). I also used the services (on a voluntary basis) of a colleague for data interpretation (consensual validation; Eisner, 1991). Member Checking Member checking involves seeking and including participants’ feedback in assessing the credibility of the study’s findings (Creswell, 2007; Schensul & LeCompte, 1999). At the end of each interview, participants reviewed their individual interview transcript for accuracy. I also asked the participants to review the findings of the research for accuracy and thoroughness. Reflexive Journaling Reflexive journaling involves acknowledging and keeping a record of one’s personal thoughts and feelings while conducting research in an attempt to eliminate researcher bias (Creswell, 2007; Moustakas, 1994). I maintained a record of personal thoughts and feelings that occurred throughout the research process. Dissemination of Findings I will be the sole researcher involved in the dissemination of the findings. First, results will be shared with participants who indicated an interest in reading the study. Second, I plan to publish a condensed form of the study in a scholarly journal so that healthcare professionals can utilize the information in practice and future research. Third, I will condense the study to 106 the scope of a conference paper with the intention of presenting the study and its results at appropriate conferences. Summary This qualitative, phenomenological study explored the lived experiences of a sample of 16 women diagnosed with thyroid disease in order to answer questions regarding their treatment experiences and the effect of gender on their relationships with their doctors. Using the phenomenological approach of Stevick/Colaizzi/Keen as modified by Moustakas (1994) and enriched by Van Manen (1997), I identified common themes as well as discordant information among the participants. Two approaches to understanding participants’ experiences, social constructionism and feminism, were used in data interpretation. Results of this study may, consistent with Van Manen’s five principles and the university’s mission to effect positive social change, result in improvements in medical practice with female patients with thyroid disease. In Chapter 5, the findings are interpreted and discussed along with implications for social change and recommendations for further research. A phenomenological approach was used in order to examine the meaning of the experience of thyroid disease treatment as described by women who had experienced treatment for thyroid disease. Based upon the theories of social constructivism and feminism, the following research questions were answered: “What are the treatment experiences of women with thyroid disease? I discuss the setting, participant demographics, data collection and management, data analysis, evidence of trustworthiness, and the major themes and subthemes that emerged during data analysis. Setting Data were collected via individual online chat interviews with members of The Thyroid Support Group. Before each interview, participants were informed that they had the right to leave the study at any time for any reason, without explanation. Participants were provided with free, international crisis hotline telephone numbers in case they felt upset as a result of their interviews (see Appendix D, Consent Form). It is not known if any of the participants used the crisis hotline telephone numbers provided. No unexpected events occurred that might have influenced my interpretation of the data. The median age was 54 years, with the youngest participant at 32 years old and the oldest participant at 82 years old. The sample was mostly Caucasian (14 out of 16 participants), with one participant identifying as Hispanic and another participant identifying as Czech Polish. The majority of the participants (15 out of 16) reported having education beyond high school. More specifically, three participants reported having “some college,” two had associate’s degrees, seven had bachelor’s degrees, and three had master’s degrees. Eight of the participants reported having male doctors, six reported having female doctors, and two reported having both male and female doctors. The majority of the participants’ doctors were Caucasian (13 out of 18 total doctors), two were Middle Eastern, one was Asian, one was East Indian, and one was Nigerian (see Table 2). Eight participants specified Hashimoto’s disease diagnoses, and one participant specified having a diagnosis of Grave’s disease. Half of the participants (eight out of 16) reported 109 taking natural thyroid medication alone as treatment for thyroid disease. More specifically, five reported taking Armour thyroid, two reported taking Nature-throid, and one reported taking compounded porcine thyroid. Three participants reported taking a combination of natural thyroid and synthetic thyroid medications. More specifically, three participants reported taking levothyroxine, one reported taking a combination of Synthroid and Cytomel, and one reported taking Tirosint and Cytomel. Additional diagnoses reported by the participants included hypertension (four out of 16), osteopenia (three out of 16), diabetes (two out of 16), high cholesterol (two out of 16), and breast cancer (two out of 16). Because Moustakas’s method is a form of phenomenological research that explicitly uses the experience of the researcher as a part of the research, my own textural- structural description is included as well. In order for the reader to fully understand the essence of the participants’ experiences with thyroid disease treatment and the doctor- patient relationship (Polkinghorne, 1989), I provided narratives in the participants’ own words where necessary. Each interview lasted between half an hour to one hour each, depending upon how much each participant chose to share. After each interview, participants were asked to review their interview transcript for accuracy and thoroughness. I copied and pasted each automatically-transcribed interview onto a password-protected thumb drive. In an attempt to triangulate data gathered from the interviews, I asked participants to provide copies of their electronic journals or diaries. However, no electronic journals or diaries were available because none of the participants had electronic journals or diaries to share. As such, I responded to the interview questions, which resulted in a total of 16 interviews. Data Analysis After completing each interview, I followed the Stevick/Colaizzi/Keen method as modified by Moustakas (1994). I wrote a textural-structural description for each participant’s experience, including my own, based on her responses to the interview questions (see Appendix G).