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TUMOR RECURRENCE AND TAMOXIFEN RESISTANCE: IS THERE ANY HARM IN CONTINUING TO TAKE TAMOXIFEN EVEN IF MY DOCTOR RECOMMENDS STOPPING?

July 26th, 2011

Perhaps one of the most alarming findings in the study of tamoxifen resistance is the evidence in humans and animals that after continued exposure to tamoxifen, tumors may actually become dependent on the drug for growth. The process is poorly understood and is being studied primarily in laboratory animals. Estrogen-receptor-positive tumors are grown in mice; when the animals are given tamoxifen, the tumors initially shrink. After about six months of continuous tamoxifen administration, however, the tumors begin to grow again. This time frame is approximately the same as is observed for the development of tamoxifen resistance in humans. Of further interest is the preliminary observation that if tamoxifen is given to mice for up to five years, then stopped, and estrogen is administered instead, the tamoxifen-resistant tumors disappear. It appears that the tumors not only avoid the inhibitory action of tamoxifen but somehow become dependent on it for continued growth.This evidence and other data on prolonged exposure of cells to tamoxifen suggest that breast cancer cells under conditions of long-term tamoxifen exposure can in fact learn to depend on the drug for growth and even be stimulated by it. Because these findings have been noted in laboratory studies on cultured cells and in animals, extrapolation to human patients is controversial. Nevertheless, several clinical studies have shown that in some women whose breast cancers began growing in the presence of tamoxifen, discontinuing the tamoxifen can itself produce a tumor stabilization or tumor regression.CAN TAMOXIFEN RESISTANCE BE PREVENTED?Although a number of advances have been made, little can yet be done to avoid tamoxifen resistance. On the assumption that tamoxifen resistance may be related to metabolism of the drug to estrogenic compounds, several laboratories are looking at experimental drugs that are similar to tamoxifen in chemical structure but cannot be metabolized into estrogenic metabolites. Some of these, as well as other new agents, are showing promise against tamoxifen-resistant tumors.*45\320\2*

THE PROCESS PARADIGM IN PSYCHIATRY: METHODS

July 11th, 2011

The basic process paradigm is that signals and information from the client-therapist pair contain their own structure and implicit evolution, that is, the solutions to the problems at hand. The method was to wait to develop a strategy until the structure had become apparent.When working with people with whom I have trouble communicating, I always refer to my video tape recording. I often make decisions only after having studied the video in order to discover which information I have not allowed myself to pick up and why I did not pick it up. If the client becomes increasingly unhappy during the session or afterwards, or if my communication to the client does not receive a favorable response, I assume that I have to change. I usually find out that I have rigid conceptions of how people t should be or am unconscious of something I am projecting onto the client which makes it impossible for me either to pick up or to deal openly with what is happening. For example, in one sitting where a woman suffering from chronic alcoholism spoke about what seemed to me to be a harmful interaction with her little children, I entered a cyclical and antagonist process with her in which I was anything but helpful, either to her or those around her. She brought up problems in myself I first had to deal with before I was even able to understand the video tape.This particular woman helped me to be definitive about my own goals in working with her and others, and helped me to become aware of the occasional discrepancy between what the therapist’s and client’s goals may be. As far as I know, my goals seem to be (1) to achieve what I interpret to be unequivocal positive response from the client, (2) to get the same response from the environment, (3) to enjoy myself to the utmost, and (4) to appreciate the nature of difficult situations. Obviously I have to be wide awake about myself because not every client will automatically join me in these expectations!*30\227\8*

BDD IN THE ELDERLY: MARGARET’S CASE HISTORY

July 7th, 2011

Margaret, who was 70, had also struggled with BDD for many decades. Her concerns, too, had begun when she was a teenager and persisted ever since. She’d been treated in her teens for scoliosis (curvature of the spine), which was severe and required surgery and a brace. But after several surgeries, the scoliosis was much improved and hardly noticeable. Margaret, however, was still preoccupied with it. “It’s been a concern ever since then,” she said. “I think my back still looks very ugly. I think about it for hours a day. I can’t wear certain clothes because of how it looks. I wear clothes that hide it, and I change them a lot, trying to find an outfit that makes it look better.”Margaret spent approximately 8 hours a day doing BDD-related behaviors: selecting her clothes each morning and changing them during the day, scrutinizing how other people’s backs looked, checking mirrors, and asking her husband whether she looked okay. “I still think about how awful my back looks after all these years. I keep to myself because I don’t want to draw attention to it. It’s one of the things that’s made me depressed.”A woman in her sixties, who looked far younger than her age, was obsessed with getting eye surgery to eradicate facial “lines” that resembled those of a 35 year old. She’d seen most of the plastic surgeons in town, and she spent hours a day frantically examining the lines in mirrors and applying creams and makeup. Because of the lines, she restricted her activities and rarely left the house without wearing sunglasses.Given that untreated BDD may be a fairly chronic disorder, it isn’t surprising that it exists in the elderly. However, it isn’t known how common BDD is in this age group. The average age of the people I’ve seen is the thirties; I’ve seen far fewer elderly people with BDD. Does BDD “burn out” as people age, becoming less severe or remitting altogether? Conversely, can it become more severe over time, and can the elderly be particularly distressed and impaired because of the cumulative effect of suffering over so many years? Might they be particularly embarrassed about seeking help? Further research is needed to answer these important questions.*164\204\8*

UPPER RESPIRATORY TRACT INFECTIONS: ACUTE SINUSITIS

June 25th, 2011

Sinusitis is perhaps the most misunderstood infection of the upper respiratory tract. Sinusitis is defined as inflammation of the paranasal sinuses and contiguous nasal mucosa, regardless of the cause. Acute sinusitis is among the most common conditions treated by primary care physicians and is a common reason for the administration of antibiotics. Many clinicians consider sinusitis to be primarily of bacterial origin, but this is untrue. Although acute bacterial sinusitis does occur, acute sinusitis is often viral and therefore does not necessitate treatment with antibiotics. Distinguishing viral from acute bacterial sinusitis is difficult, and this has led to the widespread overuse of antibiotics for the treatment of sinusitis.The clinical features of sinusitis include purulent nasal discharge, nasal congestion, facial pain, maxillary toothache, and occasionally fever or cough. The clinical features of viral rhinosinusitis and acute bacterial sinusitis are similar. However, acute bacterial sinusitis typically develops secondarily to viral rhinosinusitis. During a viral upper respiratory tract infection, thick nasal secretions accumulate in the sinuses. Bacterial super-infection can subsequently result. Some authors have suggested that the high intranasal pressures generated during nose blowing may be a contributing factor for the introduction of bacterial pathogens into the sinus cavities. Other causes of acute bacterial sinusitis are less common and include seasonal allergies, mechanical obstruction of sinus drainage, swimming, prolonged nasal intubation, and extension from a dental infection into the sinus cavity.No diagnostic test easily distinguishes between viral rhinosinusitis and acute bacterial sinusitis. Sinus aspiration, although performed in some research studies, is not practical for routine diagnosis of acute bacterial sinusitis. The value of radiologic studies, including computed tomographic scans of the sinuses, is also limited because radiographic studies are unable to distinguish changes due to viral rhinosinusitis from those caused by acute bacterial sinusitis.18The decision to treat patients with antibiotics most often must be made on clinical grounds alone. Acute bacterial sinusitis is unlikely in patients whose symptoms are less than 7 days in duration. Patients whose symptoms have lasted more than 7 days are more likely to have bacterial sinusitis. However, the duration of illness alone is insufficient to suggest bacterial sinusitis. As discussed earlier, up to 25% of patients with viral rhinosinusitis will still have symptoms at 14 days. Other clinical predictors that suggest acute bacterial sinusitis include maxillary tooth or facial pain (especially unilateral), unilateral sinus tenderness, and mucopurulent nasal discharge. Worsening of symptoms after initial improvement is another clue to acute bacterial sinusitis.Even if a patient is suspected of having an acute bacterial sinusitis based upon these clinical predictors, it is often not necessary to prescribe antibiotics. A recent meta-analysis showed that although there is some benefit to treating patients with acute bacterial sinusitis, the benefit is small, and resolution of symptoms typically occurs without antibiotics. Patients with mild or moderate symptoms can be treated with nasal decongestants and analgesics, as discussed in the previous section. Current recommendations suggest the use of antibiotics in patients with severe symptoms of acute bacterial sinusitis, as outlined earlier. Even if antibiotics are used, decongestants should be administered to maintain sinus drainage.The choice of initial antibiotic therapy is empiric and based on knowledge of the organisms likely to cause acute bacterial sinusitis. Failure of treatment should result in a broadening of the antibiotic spectrum and prompt consideration of diagnostic sinus aspiration.Complications of bacterial sinusitis are rare but can be serious. These complications include meningitis, brain abscess, and periorbital cellulitis. Currently, there are no data to suggest that early treatment prevents the development of these complications.The possibility of fungal sinusitis should be strongly considered in the immunocompromised host. Rhinocerebral mucormycosis is an acute invasive fungal sinusitis that typically occurs in patients with organ transplants, diabetes mellitus, or neutropenia (due to hematologic malignancy or immunosuppressive medications). It rarely affects hosts with a normal immune system. A black necrotic palatal or nasal eschar may be seen and is a clue to the diagnosis. When an invasive fungal sinusitis is suspected, therapy with intravenous amphotericin В should be initiated, and urgent surgical consultations should be obtained.*35/348/5*

POST-TRAUMATIC STRESS SYNDROME

June 14th, 2011

When stress breakdown symptoms have been experienced over a period of time in relation to one specific stress, the person may become conditioned to associate the symptoms of breakdown with memories of the stressful situation. Just as a person can be conditioned to associate unpleasant or pleasant memories with odours or sounds, the person who has undergone severe stress may re-experience some of the feelings experienced at the time of the stressful event when these are triggered by stimuli which rekindle memories of the event.Thus, a person who experienced anxiety with the sound of helicopters in a war zone may re-experience some of that anxiety at the sound of a helicopter passing overhead years later. If a person held prisoner in an airplane hijacking experienced stage three symptoms, mention of the event or associations with it might recall the memories of what the breakdown symptoms felt like.Moreover, if the person still has a lot of unresolved feelings and repressed conflicts about this stressful period of his life, then the rekindled feelings might re-introduce those emotional conflicts. This vicious cycle of after-effects can be called the post-traumatic stress syndrome.It is not the aim of this book to deal with the post-traumatic stress syndrome, a complex problem requiring those skills necessary to examine conflicts which have been repressed into the unconscious mind. The correct treatment of post-traumatic stress disorder is by skilled psychotherapy.
*38/129/5*

EPILEPSY AND ITS SPECIAL FORMS/EPILEPSY SYNDROMES: JUVENILE MYOCLONIC EPILEPSY OF JANZ

June 3rd, 2011

Juvenile myoclonic epilepsy is a relatively newly recognized syndrome unfamiliar to many physicians who do not work in the field of epilepsy. It is easily recognized, if you know what to look for and know what questions to ask of the patient. It is also easily treated.Epilepsy of Janz starts in late childhood or adolescence, often about the time of puberty. Its hallmark is mild myoclonic jerks, most common as the person is going to sleep or awakening in the morning. An adolescent will describe jerking of the arms or legs, a feeling of being very “jumpy.” Some patients have told us that they set their alarm clocks to wake up early and then stay in bed for one half hour to an hour, until the jumpiness wears off. They say that if they get up more quickly the jerking gets much worse.If a person has early morning seizures, informing your doctor about the jerks that precede them may make it easier to diagnosis this particular form of epilepsy.Occasionally, the jerking builds up and becomes sufficiently severe so that the person experiences a clonic or a tonic-clonic seizure. In addition, people may experience absence seizures.The EEG between seizures, in this form of epilepsy, often shows a fast, multiple- or double-spike pattern followed by slow waves, with fast rapid spikes occurring during the jerks. When the diagnosis is suspected, the best way of confirming it is a sleep EEG, continued for ten or fifteen minutes after the person awakens. It is during this time that the jerks and the characteristic EEG pattern are most likely to be seen.Diagnosis is important because although this form of epilepsy responds poorly to many medications, it is usually easily controlled with valproic acid. The seizures often recur when this medication is withdrawn. A familv history of epilepsy may occur in as many as 40 percent of siblings of those with the epilepsy of Janz. Studies of these families are beginning to provide clues to its genetic basis.*92\208\8*

BACH FLOWER REMEDIES: CHICORY CHILD

May 22nd, 2011

A child would not give his toys to another child for playing with even if they are spare and useless for his own self, and even if he used the other child’s toys for playing with. A negative cherry type does not like loneliness. He wants company. Even the company of a child would do for him. This desire of company is also for a selfish end. He wants some body who can shout or call for some body’s help if, he meets with an accident and is incapacitated to shout for help.He assumes a very exaggerated sense of self importance, and feels that every thing, which he possesses is for his exclusive use and everybody on whom he has control should do exactly as he wishes. He would call his child or wife from another room to fetch him a glass of water, lying on his side table (which he can easily fetch himself).If he cannot get his own way, he becomes fretful and weeps with a sense of wrong. He recounts the good deeds he has done for the benefit of others, for which he does not get corresponding response. He feels self-pity and is sad. With tearful persuation he invokes other people’s sympathy.*85\308\8*

SKIN IN HEALTH: DYNAMIC QUALITY OF SKIN

May 15th, 2011

The skin, being one of the most important organs of the body, depends for its health and well-being on the normal functioning of the whole of the system.The Nature Cure contention that health is indivisible applies especially to the skin, and needs emphasizing particularly in this connection because so many people have failed to appreciate it. In the back of their minds, and as a result of mistaken ideas, they hold fast to the notion that the skin is only the covering of the body and bears little relationship to the internal environment. At the cost of constant repetition we must eradicate this fallacious idea, or else we shall completely fail to make clear the Nature Cure interpretation of skin diseases.A healthy skin can easily be recognized. It is of good appearance, showing no blemishes at all, and of uniform colour. Except where hardened by the pressure of an occupation it is soft, almost velvety, and just moist enough to be pleasantly smooth. It is difficult to describe in words the texture of a healthy skin; it is easily recognized by pressure of the fingers. An important sign of a healthy skin is its elasticity or free movement. It can be picked up and rolled under fingers, and shows a healthy pink reaction when this is done.This flexibility or easy movement of the skin is particularly important in relation to its circulation. In the skin itself and just under it there is a supply of connective tissues, and it is through these tissues that the lymph circulation is distributed. Now the lymph is related to the inter-cellular fluid of the body, which is about three and a half times as great in volume as the whole of the blood in the body.   This inter-cellular fluid has sometimes been called the “sea-water,” of the body because in it we find a similar chemical make-up to that of the sea, containing as it does, sodium, calcium, potassium and magnesium. It is in this great fluid medium that the cells live, so we must consider it to be of even greater immediate importance than the blood itself.Apart from the chemical make-up and alkalinisation of this fluid-which is, of course, directly affected by the waste products of cell activity and normal defective elimination- the important mechanical factor in this fluid is its constant movement. Behind the blood circulation we have, as we know, the force of the heart pump, but there is no such arrangement for the inter-cellular fluid. Yet it is moving all the time-in certain circumstances, more so than in others-and this movement holds the secret of life and death, because any failure means a cessation of the life-force, energy or call it what you will.A healthy skin – one that moves freely over the underlying parts-plays a very important part in the dynamic quality of this life-giving and life-sustaining fluid. It keeps up on the periphery of the body a constant stimulation of the “sea-water” of the system, and thus preserves the alkaline balance of the tissues and prevents areas from being congested with the toxins of cell life.
*10/154/5*

THE SELF-POISONER: PATTERNS OF SELF-INDUCED TOXICITY – APPROVALITIS

April 23rd, 2011

When the victims of approvalitis of one generation become parents, they tend to dominate their children in the same manner in which they were dominated as children. This cycle of chronic infection is typified in families in which each generation is obsessed with controlling and dominating the next generation.Approvalitis leads to chronic self-immobilization when the person consistently represses all independent action for fear it might incur disapproval from other people. Instead, the victim awaits his cues about what he should do and how he should act. He vainly hopes with or enjoyed socially. The privacy of his home was the only area of his life in which he allowed himself any expression. He was entirely unaware of his self-poisoning pattern, in spite of the fact that he had migraine-type headaches and chronic hypertension, which he used as excuses for his tyrannical behavior toward his family. While still in grade school, his three children had already developed the same timid reactions to disapproval. They were already characterized by their teachers as “ideal, beautifully behaved children whose parents should be proud of them.”As long as a person continues to postpone living his own life, waiting to be “graduated” by earning the stamp of approval of another, he continues to poison himself.*51\350\8*

HIV INFECTION AND ITS EFFECTS ON THE EMOTIONS: ANGER AND ENERGY-DEPRESSION AND HOPE AND WHAT DEPRESSION FEELS LIKE

April 18th, 2011

Helen Parks: Sometimes I’m in my room, in my chair, and I think about the people in all the stages of this disease and the people who have left the world with this disease. And I wonder what I’m going to do when I get sicker. I get confused. I get drastic thoughts. I sit in my chair and cry. I get real depressed.     Steven Charles: I think, maybe they’ll come up with something that will help, but I don’t think so. You start to wonder why you’re going to the doctor, why take the medication, why fight for another month, another year, just to be sick longer.     What Depression Feels Like-Depression is one of the most painful feelings a person can have. People say they feel alone and helpless in an indifferent world. They say they lose interest in things, have no energy, feel generally tired. They doubt themselves or blame themselves or feel they have failed. Like Helen, they have “drastic thoughts”: they think about dying, sometimes about killing themselves. Sometimes depression affects not only the mind, but also the body. Some people report they cannot think as clearly or quickly as they used to. Some stop eating, others eat too much. Some cannot sleep, others sleep too often. In general, people dealing with depression say they are mostly sad and lonely, and they often cry a lot: “For a while, I cried all the time,” said Lisa Pratt. “I didn’t want to cry in front of my family. I cried when I was alone—in the car, in the shower.”     At bottom, depression seems to be the absence of hope. Hope is the sense that life is good, that it holds comforts and delights, that what you do makes a difference, that one way or another things will be all right. Sometimes, for a while, this sense of hope fails you. “What good are all my comforts, my things?” said Alan Madison, who for a long time had spent his extra money on collecting art from the 1920s. “I’ve always worked for comfort in my old age. Now maybe I’m not going to be old. I’ve always thought, next year it’ll be different. I’ll get a new haircut, be more outgoing. Now maybe I have no next year.”     Faced with hopelessness, people feel helpless. They feel they have no alternative but to continue feeling depressed. They feel they no longer have the power to change how they act or how they feel. Some people, especially early in the course of the infection, consider suicide.     Depression varies in intensity and duration. Sometimes it is a mild feeling of being “down.” Sometimes it is severe, and feels like despair.     For most people, depression comes and goes: “I get bouts of these depressions,” says Steven. The bouts can last a few hours, a few weeks, a few months.
*67\191\2*

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