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Stage 2: Coping The next stage in the self-regulatory model is the development and identification of suitable coping strategies cheap cozaar american express. Coping can take many forms order 50 mg cozaar with mastercard, which will be discussed in detail later in this chapter and in Chapter 11 purchase cozaar with amex. However, two broad categories of coping have been defined that incorporate the multitude of other coping strategies: approach coping (e. When faced with the problem of illness, the individual will therefore develop coping strategies in an attempt to return to a state of healthy normality. This involves individuals evalu- ating the effectiveness of the coping strategy and determining whether to continue with this strategy or whether to opt for an alternative one. This process is regarded as self-regulatory because the three components of the model (interpretation, coping, appraisal) interrelate in order to maintain the status quo (i. Therefore, if the individual’s normal state (health) is disrupted (by illness), the model proposes that the individual is motivated to return the balance back to normality. For example: s Symptom perception may result in an emotional shift, that may exacerbate the perception of symptoms (e. The aim of the study was to test directly elements of Leventhal’s self-regulatory model and to examine whether the way an individual makes sense of their illness (their illness repre- sentation) and the way they cope with their illness (their coping strategies) relates to their level of functioning (the outcome measure). Methodology Subjects A total of 520 members of the Australian and New Zealand Myalgic Encephalomyelitis Society were sent an invitation to take part in the study, of whom 308 returned the consent forms and were sent a questionnaire. These subjects ranged in age from 18 to 81, 61 per cent were married, 55 per cent had received tertiary education and the mean length of illness was 10. Design The study involved a cross-sectional design with all subjects completing a questionnaire once. Measures Subjects were sent a questionnaire consisting of the following measures: 1 The Illness Perception Questionnaire. This questionnaire measured illness representa- tions and included items reflecting the following aspects of illness representations: s Identity: This consisted of a set of 12 core symptoms (e. Subjects were asked to rate each symptom according to how often they experienced them from ‘never’ to ‘all the time’. Results The relationship between components of illness representations The results showed that a strong illness identity was related to a belief in serious con- sequences and a more chronic time line (e. The relationship between illness representations and coping The results showed a positive relationship between identity (the illness representation) and coping strategies such as planning venting emotions, behavioural disengagement and mental disengagement (e. The results also showed a positive relationship between consequences (the illness representation) and coping strategies such as planning, suppression of competing activities, seeking emo- tional social support, venting emotions, mental disengagement (e. In addition, the results showed a positive relationship between internal control/cure (the illness representation) and coping strategies such as active coping, planning, positive reinterpretation and a negative relationship with behavioural disengagement (e. Finally, the results showed a belief that the illness would last a long time (the illness representation) was related to coping by suppressing competing activities, behavioural disengagement (e. The relationship between illness representations and level of functioning The results showed that the illness representation components of illness identity, emo- tional causes of the illness, controllability/curability and consequences had the strongest overall association with measures of functioning, suggesting that individuals who had the most symptoms, believed that their illness was out of their control, caused by stress and had serious consequences, showed low levels of psychological adjustment and well-being and higher levels of dysfunction. In addition, the results provide support for Leventhal’s self-regulatory model as illness representations were related to coping and a measure of outcome (level of functioning). However, because of the cross-sectional nature of the design it is not possible to say whether illness representations cause changes in either coping or outcome and as the authors conclude ‘only a prospective design can clarify some of these issues’. Problems with assessment This dynamic, self-regulatory process suggests a model of cognitions that is complex and intuitively sensible, but poses problems for attempts at assessment and intervention. For example: 1 If the different components of the self-regulatory model interact, should they be measured separately? For example, is the belief that an illness has no serious consequences an illness cognition or a coping strategy? For example, is the appraisal that symptoms have been reduced a successful outcome or is it a form of denial (a coping strategy)? The individual processes involved in the self-regulatory model will now be examined in greater detail. However, symptom perception is not a straightforward process (see Chapter 12 for details of pain perception). For example, what might be a sore throat to one person could be another’s tonsillitis and whereas a retired person might consider a cough a serious problem a working person might be too busy to think about it. Pennebaker (1983) has argued that there are individual differences in the amount of attention people pay to their internal states. For example, Pennebaker (1983) reported that individuals who were more focused on their internal states tended to overestimate changes in their heart rate compared with subjects who were externally focused. Being internally focused has also been shown to relate to a perception of slower recovery from illness (Miller et al. Being internally focused may result in a different perception of symptom change, not a more accurate one. Mood, cognitions, environment and symptom perception Skelton and Pennebaker (1982) suggested that symptom perception is influenced by factors such as mood, cognitions and the social environment. Mood: The role of mood in symptom perception is particularly apparent in pain perception with anxiety increasing self-reports of the pain experience (see Chapter 12 for a discussion of anxiety and pain). In addition, anxiety has been proposed as an explanation for placebo pain reduction as taking any form of medication (even a sugar pill) may reduce the individual’s anxiety, increase their sense of control and result in pain reduction (see Chapter 13 for a discussion of anxiety and placebos). In an experimental study, participants were exposed to low intensity somatic sensations induced by breathing air high in carbon dioxide. They were then told that the sensation would be either positive, negative or somewhere between and were asked to rate both the pleasantness and intensity of their symptoms. The results showed that what the participants were told about the sensation influenced their ratings of its pleasantness. The results also showed that although people who rated high on negative affectivity showed similar ratings of pleasantness to those low on negative affectivity they did report more negative meanings and worries about their symptoms. This indicates that expectations about the nature of a symptom can alter the experience of that symptom and that negative mood can influence the attributions made about a symptom. Cognition: An individual’s cognitive state may also influence their symptom per- ception. This is illustrated by the placebo effect with the individual’s expectations of recovery resulting in reduced symptom perception (see Chapter 13). Ruble (1977) carried out a study in which she manipulated women’s expectations about when they were due to start menstruating. She gave sub- jects an ‘accurate physiological test’ and told women either that their period was due very shortly or that it was at least a week away. Pennebaker also reported that symptom perception is related to an individual’s attentional state and that boredom and the absence of environmental stimuli may result in over-reporting, whereas distraction and attention diversion may lead to under-reporting (Pennebaker 1983). Sixty-one women who had been hospitalized during pre-term labour were randomized to receive either information, distraction or nothing (van Zuuren 1998). The results showed that distraction had the most beneficial effect on measures of both physical and psychological symptoms suggesting that symptom per- ception is sensitive to attention. Symptom perception can also be influenced by the ways in which symptoms are elicited.

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Both diseases are rare in developing countries and among cultures that eat whole cheap cozaar online master card, unprocessed foods purchase cozaar 25 mg visa. As well buy generic cozaar 50mg on-line, it wasn’t until the mid-1900s that these diseases became a problem in North America. Consumption of fast foods and processed and refined foods and ingestion of chemical food additives is common. It is also possible that the inflammation may stem from the immune system’s response to infection with a virus or bacterium. Since the diseases are more common among those with a family history, genetic mutations may also be to blame. While there is no known medical cure for Crohn’s disease or colitis, there are a variety of lifestyle approaches, supplements, and medications that can reduce the symptoms and even bring about long-term remission. Some people with these diseases experience inflammation in other areas of the body (joints, skin, and eyes). Depending on your situation and the severity of the symptoms and intestinal damage, your doctor may prescribe drug therapy to control the inflammation. Commonly used drugs include sulfasalazine, mesalamine (Asacol), and corticosteroids, such as prednisone. As well, these drugs have serious side effects, so it is important to discuss the benefits and risks with your doctor. Iron supplements are used for anemia, which occurs from chronic intestinal bleeding. For severe cases, surgery to remove the diseased portions of the bowel may be necessary, but this is always the last resort. One study of people with colitis found that 100 mL of aloe vera juice twice daily resulted in a complete remission or an improvement in symptoms in 47 percent of cases, compared with 14 percent of those given a placebo. Herbal teas made from chamomile, slippery elm, and marshmallow can be very soothing to an inflamed gastrointestinal tract. The best sources of these fatty acids are salmon, herring, mackerel, albacore tuna, and sardines. During flare-ups when the intestines are inflamed, raw vegetables and fruits can be irritating, so it is best to cook (steam) these foods. There was a significant clinical improvement (reduction in symptoms) in 78 percent of people who were given wheat grass compared to 30 percent who were given placebo. Wheat grass contains vitamins A, C, E, B-vitamins, calcium, magnesium, potassium, iron, natural en- zymes, and chlorophyll. Carrageenan, a compound used to stabilize milk proteins, has been shown to induce ulcerative colitis in animals. One study found that those who eat fast foods at least two times per week more than triple their risk of developing Crohn’s disease. Try an elimination diet to determine if food allergies are worsening your symptoms. One study also found that fish oil supplements reduced the risk of relapse and flare-up. Taking a quality multivitamin every day can help restore nutrient levels and improve overall health. Those with severe damage to the intestine may not be able to absorb B12 so injections can be taken. Replacing the flora with probiotic supplements C can help improve digestion and nutrient absorption and relieve constipation and diarrhea. Dosage: Look for a product that provides at least one billion cells per capsule and take twice daily. Some research has shown that it can reduce symptoms of both Crohn’s disease and colitis, similarly to prescription drugs. Curcumin (from the spice turmeric): Has been shown to help maintain remission in indi- viduals with ulcerative colitis. Greens supplements: Contain barley and wheat grass, which can help soothe an inflamed intestine and provide essential nutrients. It is the most common psychiatric ailment in Western society, affects approximately 1. Depression is most often caused by a number of underlying factors, including: Biological: Imbalance of neurotransmitters (chemical messengers in the brain— dopamine, serotonin, and norepinephrine), or hormone imbalance (low estrogen, progesterone, testosterone, thyroid) such as post-partum depression D Environmental: Exposure to chemicals that disrupt brain chemistry (cigarette smok- ing, heavy metals, prescription and recreational drugs) Nutritional: Deficiency of vitamins (B12), minerals (magnesium), or essential fatty acids; food allergies Situational: Stress, trauma, injury, divorce, job loss, death of a loved one Anyone suffering with depression should seek professional help to determine the underlying cause and an appropriate treatment. Studies estimate that 20 per- cent of people with insomnia suffer from major depression and 90 percent of people with depression have insomnia. Side effects include nausea, weight gain/loss, headaches, anxiety, nervousness, insomnia or drowsiness, diarrhea, sweating, tremor, and sexual dysfunction. There are numerous drug interactions; con- sult with your pharmacist before taking any other prescription or natural products. Since food allergies can also trigger depression, refer to Appendix D for information on identifying possible allergies. Foods to include: • Vegetables, fruits, whole grains, nuts, and seeds are good sources of vitamins, minerals, and essential fatty acids, which may be depleted in those with depression. Foods to avoid: • Sugar, refined carbohydrates, and caffeine can cause mood swings and irritability. Lifestyle Suggestions • Acupuncture: Studies have found it beneficial for depression. D • Counselling: Therapy with a psychologist or psychiatrist can be very beneficial. Aim for 30 minutes of activity daily—walking, cycling, swimming, yoga, or any activity you enjoy. Studies show benefits for depression, especially for those not getting adequate response to antidepressant drugs. Not recommended for those with bipolar disorder (manic-depression) as it can worsen the manic symptoms. Dosage: 400–1,600 mg daily on empty stomach; start with a low dose and gradually increase if needed. John’s wort: Increases neurotransmitter levels, and is effective for mild to moderate depression. May take two to four weeks to notice benefits; side effects are rare and include stomach upset, fatigue, itching, sleep disturbance, skin rash, and sun-sensitivity. John’s wort interacts with many drugs, such as oral contraceptives, blood thinners and other anti- depressants; check with your pharmacist. Suntheanine: A patented extract of theanine (an amino acid present in green tea), it re- duces stress and anxiety without causing drowsiness or addiction, and also improves sleep quality. It works quickly to promote calming (30 minutes to one hour), and there are no known side effects. Take 400–1,000 mcg folic acid along with 50–100 mg of other B-vitamins daily to support brain function. Ginkgo biloba: Improves blood flow to the brain; improves memory and cognitive function; may also improve serotonin response. Eat a healthy diet and avoid sugar, refined/processed foods, caffeine, and alcohol.

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Theophylline Prolonged half-life Shortened half-life toxicity (including seizures and potentially fatal cardiac Figure 8 order cozaar 25mg with mastercard. Pharmacokinetic variability of newer antiepileptic drugs – When is monitoring needed? Clinical Neuropharmacology 2006; Stamp L cozaar 25mg mastercard, Roberts R generic cozaar 50mg, Kennedy M, Barclay M, O’Donnell J, Chapman P. The use of low dose methotrexate in rheumatoid arthritis – are we entering a new era of therapeutic drug monitoring and pharma- Herxheimer A. Early in embryonic development, exogenous substances accumulate in the neuro- ectoderm. The human placenta possesses multiple Because experience with many drugs in pregnancy is severely enzymes that are primarily involved with endogenous steroid limited, it should be assumed that all drugs are potentially metabolism, but which may also contribute to drug metabo- harmful until sufficient data exist to indicate otherwise. It is convenient to divide pregnancy into four In the placenta, maternal blood is separated from fetal stages, namely fertilization and implantation ( 17 days), the blood by a cellular membrane (Figure 9. Most drugs with a organogenesis/embryonic stage (17–57 days), the fetogenic molecular weight of less than 1000 can cross the placenta. Diffusion occurs if the drug is in the • Most drugs cross the placenta by passive diffusion. Placental function is also modified by changes • Placental function is modified by changes in blood flow. Pethidine, administered as an anal- At this stage, the fetus is differentiating to form major organs, gesic can cause fetal apnoea (which is reversed with naloxone, and this is the critical period for teratogenesis. Anaesthetic agents given during Caesarean deviations or abnormalities in the development of the embryo section may transiently depress neurological, respiratory and that are compatible with prenatal life and are observable post- muscular functions. Drugs that interfere with this process can cause gross haemostasis defect in the baby, and predisposes to cerebral structural defects (e. Thalidomide was unusual in the way in which a very small dose of the drug given on Key points only one or two occasions between the fourth and seventh weeks • Fertilization and implantation, 17 days. Even after organogenesis is almost complete, drugs can still have significant adverse effects on fetal growth and Although it is generally considered that sperm cells damaged by development. Finasteride, an anti- • Drugs used to treat maternal hyperthyroidism can cause androgen used in the treatment of benign prostatic hyperplasia, fetal and neonatal hypothyroidism. Major malformations that interfere with normal function • Warfarin can cause fetal intracerebral bleeding. Two principal problems face synthesis, is used under specialist supervision to assist those who are trying to determine whether a drug is terato- closure of patent ductus arteriosus in premature infants. This does not necessarily mean that they are teratogenic in humans at therapeutic doses. Indeed, the metabolism and kinetics of drugs at high doses in other species is so different from that Table 9. Consequently, if the Thalidomide Androgens incidence of drug-induced abnormalities is low, a very Cytotoxic agents Progestogens large number of cases has to be observed to define a Alcohol Danozol significant increase above this background level. Effects Warfarin Diethylstilbestrol on the fetus may take several years to become clinically Retinoids Radioisotopes manifest. For example, diethylstilbestrol was widely Most anticonvulsants Some live vaccines used in the late 1940s to prevent miscarriages and preterm births, despite little evidence of efficacy. Exposure to stilbestrol in utero has also been associated with a Gastric emptying and small intestinal motility are reduced. This T-shaped uterus and other structural abnormalities of the is of little consequence unless rapid drug action is required. More complete (but with apparent volume of distribution and, although clearance is inherent practical difficulties) data collection by the unaltered, their half-life is prolonged. Thus, in practice, these changes are rarely of pharmacological Known differences in drug effects in pregnancy are usually significance. They may cause confusion in monitoring of explained by altered pharmacokinetics (Figure 9. This has been documented for digoxin, lithium, ampicillin, cefalexin and gentamicin. Metabolism↑ Key points Known differences in drug effects can usually be explained ↑Renal Excretion↑ by altered pharmacokinetics. Increased volume of blood flow distribution, hepatic metabolism and renal excretion all tend to reduce drug concentration. If in doubt, consult the British National Formulary, appendix 4 (which is appropriately conservative). The fetus is most sensitive to adverse Antimicrobial drugs are commonly prescribed during preg- drug effects during the first trimester. Trimethoprim is a theoretical teratogen and that most women do not present to a doctor until five to as it is a folic acid antagonist. There is minimal experience in pregnancy childbearing potential should be assumed to be pregnant until with the fluoroquinolones (e. If drugs (or envi- infection in the mother, antiviral agents should be avoided in ronmental toxins) have more subtle effects on the fetus (e. Falciparum malaria (Chapter 47) has an especially minor reduction in intelligence) or cause an increased incidence high mortality rate in late pregnancy. This is particularly relevant in the use in pregnancy (whether inadvertent or planned) and associ- management of labour when the use of opioids, such as pethi- ate these with outcome. This will require significant investment dine, depresses the fetal respiratory centre and can inhibit of time and money, as well as considerable encouragement to the start of normal respiration. In neonates, the chief withdrawal symptoms are tremor, irritabil- Key points ity, diarrhoea and vomiting. Chlorpromazine is commonly Prescribing in pregnancy is a balance between the risk of used to treat this withdrawal state. Paracetamol is preferred to adverse drug effects on the fetus and the risk of leaving aspirin when mild analgesia is required. However, untreated maternal disease may cause morbidity arthritis), ibuprofen is the drug of choice. Local anaes- potential; • discuss the potential risks of taking or withholding thetics used for regional anaesthesia readily cross the pla- therapy with the patient; centa. However, when used in epidural anaesthesia, the drug • seek guidance on the use of drugs in pregnancy in the remains largely confined to the epidural space. Pregnant British National Formulary, Drug Information Services, women are at increased risk of aspiration. Respiratory depression in the newborn is not usually a prob- Epilepsy in pregnancy can lead to fetal and maternal morbid- lem with modern general anaesthetics currently in use in ity/mortality through convulsions, whilst all of the anticon- Caesarean section. Several studies have shown an increased vulsants used have been associated with teratogenic effects incidence of spontaneous abortions in mothers who have had (e. However, there is no doubt that the benefits of tionship is not proven, and in most circumstances failure to good seizure control outweigh the drug-induced teratogenic operate would have dramatically increased the risk to mother risk. As meals, avoiding large volumes of fluid and raising the head of in non-pregnant epilepsy, single-drug therapy is preferable. If symptoms are prolonged or severe, drug treatment Plasma concentration monitoring is particularly relevant for may be effective. If ineffective, prochlorperazine is the increase in hepatic metabolism may cause considerable an alternative.

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Personal efects with the body can also provide informa- tion discount 50 mg cozaar otc, such as a cellular telephone buy cozaar 25 mg on-line, business cards discount cozaar online visa, phone numbers, and keys. Eyeglasses and contact lenses can be examined and compared to the known history of a person. Tings such as body habitus, height, weight, eye color, sex, circumcision, stature, hair type (e. Occupational stigmata, though more commonly used decades ago, may also be revealed during an external examination. Te presence or absence of certain diseases can be helpful in establishing iden- tity, especially when medical records are available. Conditions like cholelithiasis or nephrolithiasis (gallstones and kidney stones) may have been diagnosed prior to death. Te absence of organs, due to either surgery or congenital malforma- tion, can be distinctive. While surgeries like appendectomies, hysterectomies, and cholecystectomies are too common to be distinctive, splenectomies, neph- rectomies, or other procedures may be more useful. Implanted devices, such as pacemakers or defribillators, can ofen be traced through the manufac- turer to the recipient. Findings at autopsy may assist in determination of age, including the presence of arcus senilis (opaque ring surrounding the cornea), the presence of osteophyte formation along the vertebral bodies, and the clo- sure of growth plates. Pulmonary anthracosis may indicate the decedent was a smoker, though signifcant anthracosis may be seen in coal miners who do not smoke. Other inhalational lung diseases may also provide information about the decedent’s occupation, such as silicosis (Figure 5. A complete toxicologic evaluation should also be performed, even if not related to cause of death. Te presence of certain medications or illicit chemi- cals may give information regarding lifestyle or possible medical facilities. For example, if methadone is present, treatment facilities could be contacted for helpful information. Identifying characteris- tics, such as a broken bone resulting in a malunion or varus/valgus deformity of a long bone, can also be used (Figure 5. Radiographs may reveal the presence of foreign material, such as old bullets or shrapnel (Figures 5. Te presence or absence of growth plates or the extent of osteophyte formation (Figure 5. Te determination of stature is performed by measuring the long bones and utilizing multiple formulae developed for such a purpose. Pelvic morphology is the best indicator for determining sex, as a woman’s pelvis is wider and shallower with an obtuse subpubic angle and an oval inlet. Te cranium can also be used to attempt to determine sex, if the pelvis is not available. A male’s skull tends to have a receding forehead, prominent brow ridges and occipital protuberance, and a large mastoid process. If the skeleton is that of a younger person (less than thirty years), growth plates can help delineate age as the plates tend to close (fuse) at certain stages 74 Forensic dentistry of development. As the person becomes older, age-related changes can be seen, such as osteophyte formation, calcifcation of the cartilaginous margins of the ribs, and wearing changes of the symphysis pubis. Tese changes, along with fusion of the cranial sutures, can be used to approximate age. Ancestry becomes more and more complex as our society becomes more global and less isolated. Traditionally, anthropologists acknowledged three races: Caucasoid, Mongoloid, and Negroid. Ancestry determi- nations ofen combine the classic features of each race, and computer pro- grams are used to determine a likely lineage. Classically, Negroid crania show wide nasal orifces, round/oval orbits, and alveolar prognathism; Caucasoid crania have narrow nasal orifces, parabolic palates, and rectangular orbits; and Mongoloid crania ofen demonstrate elliptical palates, complex cranial sutures, and square orbits (see Chapter 8). When a cranium is present, facial reconstruction can be performed in addition to anthropologic analysis. Te forensic artist is given the anthro- pologic data of approximate age, sex, ancestry, and physical attributes (e. Te morphologic properties of the cranium are combined with the artist’s presumptive rendition of the sof tissue features, includ- ing eye color and hairstyle, to generate either a sketch or model of how the deceased looked in life (Figure 5. A photo of the resulting face can then be distributed to the media or local community in an attempt to fnd a witness who can identify the individual. Unfortunately, the resulting image does not always accurately approximate the deceased and may end up misdirecting the investigation. Forensic medicine and human identifcation 75 Anthropology and facial reconstruction are rarely used alone to estab- lish identity. Should no materials be present to allow for such a presumptive identifcation, several databases exist for comparison of unidentifed persons to missing per- sons. Te information is then cross-referenced against known missing persons to fnd similar, matching cases. If similar cases are found, the investigating agencies are able to contact each other to obtain the information required to establish a positive identifcation. Unfortunately, not all unidentifed persons or missing persons get placed into the system. Its purpose is to provide a “…role-based access to enter and search records of the unidentifed, while allowing the public access to information that may assist in the identifcation of these individuals. In 2007, the National Institute of Justice began funding the National Missing and Unidentifed Persons System (NamUs). Te database will be searchable by and accessible to medical examiners, forensic scientists, law enforcement, and the general public. Extensive photographs should be taken, including photos of all distinguishing characteristics—eyes, tattoos, scars, etc. In cases of deceased individuals, a full autopsy should be performed, thoroughly docu- menting all disease processes, presence and absence of organs or tissues, organ weights, and detailed and accurate descriptions of all pertinent positive and nega- tive fndings. One unidentifed person can require a great deal of organization and doc- umentation to establish identity; however, in cases of natural or man-made disasters, organization is a necessity. All bodies/body parts, including any and all corresponding property, must be kept separate and uniquely marked. Each body requires the same examination outlined above in an orderly and organized manner, yet it must be conducted as rapidly as possible. In addi- tion, mass disasters may include the need for decontamination of the bodies, a media contact person for the central dispersion of information, as well as a centralized record-keeping system. It is important to remember that identifcation is an extremely important task that allows for the grieving process of loved ones to begin as well as a thorough investigation of the death. Identifcation can only be accomplished through the meticulous examination of the remains. Tough there is always the pressure to rush, one must not sacrifce quality for the rapid answer, as the quick answer is ofen not the correct one. Te science of fngerprint identifcation has evolved over time from the early use of fngerprints to mark business transactions in ancient Babylonia to their use today as core technology in biometric security devices and as scientifc evidence in courts of law throughout the world.

Z. Felipe. College of Eastern Utah.