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Within this framework quality 40 mg levitra super active erectile dysfunction fatigue, the backlash is a statement of individualism and personal power order levitra super active 40mg with visa erectile dysfunction medication does not work. The backlash may reﬂect buy generic levitra super active 40 mg line erectile dysfunction protocol + 60 days, however, a shift in medical perspective – a shift from ‘doctor help’ to ‘self-help’. In 1991, the British Government published the Health of the Nation document, which set targets for the reduction of preventable causes of mortality and morbidity (DoH 1991). This document no longer emphasized the process of secondary prevention – and therefore implicitly that of professional intervention – but illustrated a shift towards primary prevention, health promotion and ‘self-help’. During recent years there has been a shift towards self-help and health promotion, reﬂected by the preoccupation with diet, smoking, exercise and self-examination. Prevention and cure are no longer the result of professional intervention but come from the individual – patients are becoming their own doctors. Speciﬁc criteria have been developed to facilitate the screening process and research has been carried out to evaluate means to increase patient uptake of screening programmes. These have concerned the ethics of screening, its cost-eﬀectiveness and its possible psychological consequences. Although screening programmes are still being developed and regarded as an important facet of health, there has been a recent shift from a system of ‘doctor help’ to ‘self-help’, which is reﬂected in the growing interest in health beliefs and health behaviour and the process of health promotion. However, it often does not challenge some of the biomedical approaches to ‘a successful outcome’. Perhaps promoting uptake implicitly accepts the biomedical belief that screening is beneﬁcial. It is often assumed that changes in theoretical perspective reﬂect greater knowledge about how individuals work and an improved understanding of health and illness. Therefore, within this perspective, a shift in focus towards an examination of the potential negative consequences of screening can be understood as a better understanding of ways to promote health. However, perhaps the ‘backlash’ against screening also reﬂects a diﬀerent (not necessarily better) way of seeing individuals – a shift from individuals who require expert help from professionals towards a belief that individuals should help themselves. This paper provides a comprehensive overview of the literature on screening and examines the contribution of psychological, service provision and demo- graphic factors. This comprehensive review examines the research to date on the impact of receiving either a positive or negative test result in terms of cognitive, emotional and behavioural outcomes. It then describes the concept of appraisal and Lazarus’s transactional model of stress which emphasizes psychology as central to eliciting a stress response. The chapter then describes the physiological model of stress and explores the impact of stress on changes in physiological factors such as arousal and cortisol production. Finally, it describes how stress has been measured both in the laboratory and in a more naturalistic setting and compares physiological and self- report measurement approaches. A layperson may deﬁne stress in terms of pressure, tension, unpleasant external forces or an emotional response. Contemporary deﬁnitions of stress regard the external environmental stress as a stressor (e. Researchers have also diﬀerentiated between stress that is harmful and damaging (distress) and stress that is positive and beneﬁcial (eustress). In addition, researchers diﬀerentiate between acute stress such as an exam or having to give a public talk and chronic stress such as job stress and poverty. The most commonly used deﬁnition of stress was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of ‘person environment ﬁt’. If a person is faced with a potentially diﬃcult stressor such as an exam or having to give a public talk the degree of stress they experience is determined ﬁrst by their appraisal of the event (‘is it stressful? A good person environment ﬁt results in no or low stress and a poor ﬁt results in higher stress. Cannon’s ﬁght or ﬂight model One of the earliest models of stress was developed by Cannon (1932). This was called the ﬁght or ﬂight model of stress, which suggested that external threats elicited the ﬁght or ﬂight response involving an increased activity rate and increased arousal. He suggested that these physiological changes enabled the individual to either escape from the source of stress or ﬁght. Within Cannon’s model, stress was deﬁned as a response to external stressors, which was predominantly seen as physiological. Cannon considered stress to be an adaptive response as it enabled the individual to manage a stressful event. However, he also recognized that prolonged stress could result in medical problems. The initial stage was called the ‘alarm’ stage, which described an increase in activity, and occurred immediately the individual was exposed to a stressful situation. The second stage was called ‘resistance’, which involved coping and attempts to reverse the eﬀects of the alarm stage. They there- fore did not address the issue of individual variability and psychological factors were given only a minimal role. For example, whilst an exam could be seen as stressful for one person it might be seen as an opportunity to shine to another. This response is seen as non speciﬁc in that the changes in physiology are the same regardless of the nature of the stressor. This is reﬂected in the use of the term ‘arousal’ which has been criticized by more recent researchers. Therefore, these two models described individuals as passive and as responding automatically to their external world. Life events theory In an attempt to depart from both Selye’s and Cannon’s models of stress, which emphasized physiological changes, the life events theory was developed to examine stress and stress-related changes as a response to life experiences. These ranged in supposed objective severity from events such as ‘death of a spouse’, ‘death of a close family member’ and ‘jail term’ to more moderate events such as ‘son or daughter leaving home’ and ‘pregnancy’ to minor events such as ‘vacation’, ‘change in eating habits’, ‘change in sleeping habits’ and ‘change in number of family get-togethers’. However, this obviously crude method of measurement was later replaced by a variety of others, including a weighting system whereby each potential life event was weighted by a panel creating a degree of diﬀerentiation between the diﬀerent life experiences. The individual’s own rating of the event is important It has been argued by many researchers that life experiences should not be seen as either objectively stressful or benign, but that this interpretation of the event should be left to the individual. For example, a divorce for one individual may be regarded as extremely upsetting, whereas for another it may be a relief from an unpleasant situation. They reported that a useful means of assessing the potential impact of life events is to evaluate the individual’s own ratings of the life experience in terms of (1) the desirability of the event (was the event regarded as positive or negative); (2) how much control they had over the event (was the outcome of the event determined by the individual or others); and (3) the degree of required adjustment following the event. This methodology would enable the individual’s own evaluation of the events to be taken into consideration. The problem of retrospective assessment Most ratings of life experiences or life events are completed retrospectively, at the time when the individual has become ill or has come into contact with the health profession. This has obvious implications for understanding the causal link between life events and subsequent stress and stress- related illnesses. For example, if an individual has developed cancer and is asked to rate their life experiences over the last year, their present state of mind will inﬂuence their recollection of that year. This eﬀect may result in the individual over-reporting negative events and under-reporting positive events if they are searching for a psychosocial cause of their illness (‘I have developed cancer because my husband divorced me and I was sacked at work’).
Gaseous exchange in lungs m Which of the following statements about the mucous membranes of the nasal cavity is not true? Left lung F The vocal folds change position by the movement of the cartilage known as c generic levitra super active 20mg free shipping impotence urology. These sacs are the smallest parts of the lungs levitra super active 40 mg overnight delivery impotence at 50, so it makes sense that molecular exchange would take place here discount levitra super active 20 mg with amex erectile dysfunction treatment pdf. Note that the question asks you to choose from the list provided, not from the entire structure of the body. Chapter 9 Fueling the Functions: The Digestive System In This Chapter Getting down and dirty with digestion basics Examining the mouth Spending time in the stomach Passing through the intestines and other organs for enzyme digestion t’s time to feed your hunger for knowledge about how nutrients fuel the whole package Ithat is the human body. In this chapter, we help you swallow the basics about getting food into the system and digest the details about how nutrients move into the rest of the body. You also get plenty of practice following the nutritional trail from first bite to final elimination. Before jumping into a discussion on the alimentary tract, we need to review some basic terms. Ingestion: Taking in food Digestion: Changing the composition of food — splitting large molecules into smaller ones — to make it usable by the cells Deglutition: Swallowing, or moving food from the mouth to the stomach Absorption: Occurs when digested food moves through the intestinal wall and into the blood Egestion: Eliminating waste materials or undigested foods at the lower end of the digestive tract; also known as defecation The alimentary tract develops early on in a growing embryo. The primitive gut, or archen- teron, develops from the endoderm (inner germinal layer) during the third week after concep- tion, a stage during which the embryo is known as a gastrula. At the anterior end (head end), the oral cavity, nasal passages, and salivary glands develop from a small depression called a stomodaeum in the ectoderm (outer germinal layer). The anal and urogenital structures develop at the opposite, or posterior, end from a depression in the ectoderm called the proctodaeum. In other words, the digestive tract develops from an endodermal tube with ectoderm at each end. Under normal conditions, food moves through your body in the following order (see Figure 9-1): Mouth → Pharynx → Esophagus → Stomach → Small intestine → Large intestine When you swallow food, it’s mixed with digestive enzymes in both saliva and stomach acids. Circular muscles on the inside of the tract and long muscles along the outside of the tract keep the material moving right through defecation at the end of the line. Use the terms that follow to identify the parts of the digestive system shown in Figure 9-1. The alimentary tract forms from the following layer(s) of the developing embryo: a. Mouth → Pharynx → Stomach → Esophagus → Small intestine → Large intestine Nothing to Spit At: Into the Mouth and Past the Teeth In addition to being very useful for communicating, the mouth serves a number of important roles in the digestive process: Chewing, formally known as mastication, breaks down food mechanically into smaller particles. The act of chewing increases blood flow to all the mouth’s structures and the lower part of the head. Saliva from salivary glands in the mouth helps prepare food to be swallowed and begins the chemical breakdown of carbohydrates. Interestingly, studies have shown that taste preferences can change in reaction to the body’s specific needs. In addition, the smell of food can get gastric juices flowing in preparation for digestion. The mouth’s anatomy begins, of course, with the lips, which are covered by a thin, modified mucous membrane. The vestibule is the region between these dental arches, cheeks, and lips, whereas the oral cavity is the region inside the dental arches. Entering the vestibule The inner surface of the lips is covered by a mucous membrane. Within the mucous membrane are labial glands, which produce mucus to prevent friction between the lips and the teeth. The cheeks are made up of buccinator muscles and a buccal pad, a subcutaneous layer of fat. Elastic tissue in the mucous membrane keeps the lining of the cheeks from forming folds that would be bitten during chewing (usually — most people have bitten the insides of their cheeks at one time or another). Also stashed away in the cheek, just in front of and below each ear, is a parotid gland, which is the largest salivary gland; it releases saliva through a duct opposite the second upper molar tooth. Two other pairs of salivary glands also secrete into the mouth: the submaxillary glands along the side of the lower jaw and the sublingual glands in the floor of the mouth near the chin. The dental arches are formed by the maxillae (upper jaw) and the mandible (lower jaw) along with the gingivae (gums) and teeth of both jaws. The gingivae are dense, fibrous tissues attached to the teeth and the underlying jaw bones; they’re covered by a mucous membrane extending from the lips and cheeks to form a collar around the neck of each tooth. The gums are very vascular (meaning that lots of blood vessels run through them) but poorly innervated (meaning that, fortunately, they’re not generally very sensitive to pain). You have a number of different kinds of teeth, and each has a specific contribution to the process of biting and chewing. Babies between 6 months and 2 years old “cut,” or erupt, four incisors, two canines, and two molars in each jaw. These teeth are slowly replaced by permanent teeth from about 5 or 6 years of age until the final molars — referred to as wisdom teeth — erupt between 17 and 25 years of age. An adult human has the following 16 teeth in each jaw (for a total set of 32 teeth): Four incisors, which are chisel-shaped teeth at the front of the jaw for biting into and cutting food Two canines, or cuspids, which are pointed teeth on either side of the incisors for grasping and tearing Four premolars, or bicuspids, which are flatter, shallower teeth that come in pairs just behind the canines Six molars, which are triplets of broad, flat teeth on either side of the jawbone for grinding and mixing food prior to swallowing Regardless of type, each tooth has three primary parts, which you can see in Figure 9-2: Crown: The part that projects above the gum Neck: The region where the gum attaches to the tooth Root: The internal structure that firmly fixes the tooth in the alveolus (socket) Chapter 9: Fueling the Functions: The Digestive System 147 Teeth primarily consist of yellowish dentin with a layer of enamel over the crown and a layer of cementum over the root and neck, which are connected to the bone by the periodontal membrane. Cementum and dentin are nearly identical in composition to bone; enamel consists of 94 percent calcium phosphate and calcium carbonate and is thickest over the chewing surface of the tooth. Depending on the structure of the tooth, the root can be a single-, double-, or even triple-pointed structure. In addition, each tooth has a pulp cavity at the center that’s filled with connective and lymphatic tissue, nerves, and blood vessels that enter the tooth through the root canal via an opening at the bottom called the apical foramen. Now you know why it hurts so much when dentists have to drill down and take out that part of an infected tooth! Moving along the oral cavity The roof of the oral cavity is formed by both the hard palate, a bony structure covered by fibrous tissue and the ever-present mucous membrane, and the soft palate, a mov- able partition of fibromuscular tissue that prevents food and liquid from getting into the nasal cavity. The uvula, a soft conical process (or piece of tissue), hangs in the center between those folds. Beyond the soft palate, the palatopharyngeal (or pharyngopalatine) arch curves sharply toward the midline and blends with the wall of the pharynx, ending at the dorsum (back) of the tongue. Another structure, the anterior palatoglossal (or glossopalatine) arch, starts on the surface of the palate at the base of the uvula and continues in a wide curve forward and downward, ending next to the posterior (back) one-third of the tongue. At the base of these arches and between the folds lie the palatine tonsils — if a surgeon hasn’t removed them because of frequent childhood infections. The faucial isthmus or oropharynx is the junction between the oral cavity and the pharynx (described in detail in Chapter 8). It opens during swallowing and closes when you move the dorsum of the tongue against the soft palate when breathing.
In many jurisdictions discount 20 mg levitra super active fast delivery erectile dysfunction doctor new orleans, including Canada purchase levitra super active 40mg with visa impotence 18 year old, Australia purchase 40 mg levitra super active with amex impotence natural remedy, and the United Kingdom, it is the motorist’s responsibility to inform the licensing authority of any relevant medical conditions. Similar requirements generally apply in the United States, except that six states (California, Delaware, Nevada, New Jersey, Oregon, and Penn- sylvania) require physicians to report patients with seizures (and other condi- tions that may alter levels of consciousness) to the department of motor vehicles (1). Drivers have a legal responsibility to inform the licensing authority of any injury or medical condition that affects their driving ability, and physicians should take great pains to explain this obligation. Occasionally, especially when dealing with patients suffering from dementia, ethical responsibilities may require doctors to breach confidentiality and notify patients against their will or without their knowledge (2); this situation is discussed in Subheading 2. When in doubt about the appropriate course of action, physicians should consult the appropriate guidelines. In Australia, the Austroads Guidelines for Assessing Fitness to Drive provides similar information (4). In the European Union, where Euro- pean Community directives have developed basic standards but allow dif- ferent countries to impose more stringent requirements, there is still variation from country to country. The situation is even more complicated in the United States, where each state sets its own rules and where federal regulations for commercial vehicles apply as well. Often, much of the required regulatory information can be acquired via the Internet or from organizations and foun- dations representing patients who have the particular disease in question. It should be assumed that all adults drive; drivers with disabilities should be given special consideration and may require modification of their vehicle or have certain personal restrictions applied. Cardiovascular Diseases Several studies have demonstrated that natural deaths at the wheel are fairly uncommon and that the risk for other persons is not significant (5,6). Even so, requirements for commercial drivers are generally much more rigid than for individuals, and in the United States, the Federal Highway Adminis- tration prohibits drivers with angina or recent infarction from driving. Restrictions for noncommer- cial car driving after first acute myocardial infarction are 4 weeks in United Kingdom but only 2 weeks in Australia. In general, ischemia itself is not considered an absolute disqualification, provided treadmill stress testing demonstrates that moderate reserves are present (7). Similarly, individuals with controlled hy- pertension are usually considered fit to drive, although physicians, no matter what country they are in, must give serious thought to just what sort of medi- cation is used to control hypertension; clonidine, methyldopa, reserpine, and prazosin can produce somnolence and/or impair reflex responses. Patients with dysrhythmias treated with medication or with the implan- tation of a defibrillator/pacemaker present a special set of problems (8). The tendency in the United States has been to treat such individuals as if they were epileptics (i. Until recently, that period was 6 months in a majority of jurisdictions but is increasingly Traffic Medicine 353 being shortened to 3 months in many locations. In the United Kingdom, patients with implantable cardioverter defibrillators are permanently barred from hold- ing a group 2 license but may hold a group 1 license, providing the device has been implanted for 6 months and has not administered therapy (shock and/or symptomatic antitachycardia pacing) (3). Epilepsy Epilepsy is the most common cause of collapse at the wheel, accounting for approx 30% of such incidents. In the United Kingdom, epilepsy is a pre- scribed disability (along with severe mental impairment, sudden attacks of disabling giddiness, and inability to meet eyesight requirements), and car driv- ing is not allowed for at least 1 yr after a seizure. All 50 of the United States restrict the licenses of individuals with epilepsy if their seizures are not well controlled by medication. Most states require a 6-months seizure-free period and a physician’s statement con- firming that the individual’s seizures have, in fact, been controlled and that the individual in question poses no risk to public safety. The letter from the physician is then reviewed by a medical advisory board, which may or may not issue a license. In the United States, even if the patient, at some later date, does have a seizure and cause an accident, the physician’s act of writing to the board protects him or her from liability under American law, provided the letter was written in good faith. Withdrawal of antiepileptic medication is associated with a risk of seizure recurrence. One study showed that 41% of patients who stopped treatment slowly developed a recurrence of seizures within 2 years, compared with only 22% of patients who continued treatment (9). The legal consequences of discontinuing medication without a physician’s order can be devastating. Patients who stop taking antiseizure medication and then cause an accident may face future civil liability and possibly even criminal charges if they cause physical injury (10). Of course, rules vary from country to country but, in general, a patient with seizures who does not inform the appropriate regulatory agency may face dire consequences (including the legitimate refusal of the insurance carrier to pay for damages). Diabetes Diabetes may affect the ability to drive because of loss of consciousness from hypoglycemic attacks or from complications of the disease itself (e. In January 1998, the British government introduced new restrictions on licensing of people with insulin-dependent diabetes (11). These 354 Wall and Karch restrictions were based on the second European Union driver-licensing direc- tive (91/4389), and under most interpretations of the law, they prevent insu- lin-treated diabetics from driving light goods and small passenger-carrying vehicles. In response to concerns expressed by the diabetic community in Brit- ain, the British Diabetic Association commissioned a report that found little evidence to support the new legislation. Regulations were therefore changed in April 2001 to allow “exceptional case” drivers to apply to retain their enti- tlement to drive class C1 vehicles (3500–7500 kg lorries) subject to annual medical examination. In the United States, the situation varies from state to state, but in many states, individuals with diabetes are subject to restrictive licensing policies that bar them from driving certain types of motor vehicles (12,13). However, the risk of hypoglycemia differs greatly among insulin-requiring diabetics, and today most insulin-dependent diabetics use self-monitoring devices to warn them when their blood glucose levels are becoming too low. Thus, several states have dropped blanket restrictions and allow for case-by-case evalua- tions to determine medical qualifications for diabetics. In some states, physi- cians are specifically required to notify authorities of the patient’s diabetic conditions, but in all states, it is the patient’s responsibility to do so. As with patients with seizure, failure to notify may expose the patient to both civil and criminal liability. Vision and Eye Disorders The two most important aspects of vision in relation to driving are visual acuity and visual fields. Visual acuity may simply be defined as the best obtainable vision with or without spectacles or contact lenses. Most coun- tries require a binocular visual acuity greater than 6/12 for licensing pur- poses. In the United Kingdom, the eyesight requirements are to read a car number registration plate at 20. Ethical Considerations Although it is generally a patient’s responsibility to inform the licensing authority of any injury or medical condition that affects his or her driving, occasionally ethical responsibilities may require a doctor to inform the licens- ing authorities of a particular problem. If a patient has a medical condition that renders him or her unfit to drive, the doctor should ensure that the patient understands that the condition may impair his or her ability to drive. If patients continue to drive when they are not fit to do so, the doctor should make every reasonable effort to persuade them to stop, which may include informing their next of kin. If this still does not persuade the patient to stop driving, the doctor should disclose relevant medical information immediately, in confidence, to the medical adviser of the licensing authority. Before disclosing this information, the doctor should inform the patient of the decision to do so, and once the licensing authority has been informed, the doctor should also write to the patient to confirm that disclosure has been made (15).