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Bulk formers such as Metamucil® or 86 CHAPTER 11 • Bowel Symptoms Perdiem Plus® may be helpful because they absorb water and there- fore make the stool firmer cheap extra super levitra 100 mg visa coffee causes erectile dysfunction. When it is used to treat diarrhea trusted 100mg extra super levitra impotence at 17, a bulk former should be taken no more than once a day, and it should not be followed by the recommended extra fluid that is needed when a bulk former is used to treat constipation. In extreme cases, medica- tions that slow the movement of the bowel muscles may be needed to control diarrhea, such as Kaopectate®, Imodium®, or Lomotil®. A loose stool in a person with MS most often is caused by something other than MS! Depending on the location of demyelinated areas, many alterations of normal speech patterns may occur as the result of MS. Most such alterations affect speech production, resulting in dysarthria, or slurred speech, ranging from mild difficulties to severe problems that make comprehension impossible. Demyelination in the cerebellum, the area of the brain involved with balance, is the primary cause of speech difficulties. If the tongue, lips, teeth, cheeks, palate, or respiratory muscles become involved, the speech pattern becomes even more slurred (dysarthric). Although exercises are sometimes advocated, they usually are not successful for this type of speech problem. The following is a list of exercises that may be done once or twice a day for 20 to 30 minutes with several repetitions: 1. Open the mouth, and then try to pucker with the mouth wide open; do not close the jaw, hold, relax. Open the mouth and stick out the tongue; be sure the tongue comes straight out of the mouth and does not go off to the side; hold, then relax. Stick out the tongue and move it slowly from corner to cor- ner of the lips; hold in each corner, relax; be sure the tongue actually touches each corner each time. Stick out the tongue and try to reach the chin with the tongue tip; hold at the farthest point, then relax. Stick out the tongue and try to reach the nose with the tongue tip; do not use the bottom lip or fingers as a helper. Stick out the tongue; pretend to lick a sucker, moving the tongue tip from down by the chin up to the nose; go slowly and use as much movement as possible, then relax. Stick out the tongue and pull it back, then repeat as many times and as quickly as possible; rest. Move the tongue all around the lips in a circle as quickly and as completely as possible; touch all of both the upper lip, corner, lower lip, corner in a circle; rest. Open and close the mouth as quickly as possible; be sure lips close each time; rest. Say "pa-pa-pa-pa" as quickly as possible without losing the "pa" sound; be sure there is a "p" and an "ah" each time; rest. Say "pataka, pataka, pataka" (or "buttercup") as quickly and as accurately as possible; rest. Tremors of the lips, tongue, or jaw also may affect speech by interfering either with breath control for phrasing and loudness or with the ability to voice and pronounce sounds. It may involve making changes in the rate of speaking or in the phrasing of sentences. Although it sounds relatively simple, it takes a lot of practice and learning to monitor yourself. These may include the use of a communication board (letter, word, or picture) and a variety of electronic systems. Recently a number of computerlike devices have been developed that fall under what is called "augmentative communication. Food may "stick" in the throat, go into the wind- pipe (trachea), or travel sluggishly and inefficiently, causing coughing, sputtering, and anxiety. Signs of swallowing dysfunc- tion include: • Gurgling sounds and sounds of congestion • Spitting or coughing after meals • An inability to "get the food down" • W ei ght loss • Pneumonia • Throat clearing • Choking • weak voice A swallowing evaluation should include a speech pathologist’s examination. An "x-ray in motion" (videofluoroscopy) is important to demonstrate the specific location of problems in the swallowing mechanism. This may be done by: • Modifying food textures, because some foods may be swal- lowed more easily than others. Sometimes a commercially available thickening agent or gelatin must be added to increase bulk. Milk products may need to be limit- ed because they "stick" in the throat and may be irritating.

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In experimental studies or clinical trials extra super levitra 100 mg without prescription diabetic erectile dysfunction pump, a specific intervention is per- formed and the effect of the intervention is measured by using a control group (Table 1 purchase extra super levitra 100mg with visa erectile dysfunction help without pills. The control group may be tested with a different diag- nostic test, and treated with a placebo or an alternative mode of therapy (6,10). Clinical trials are epidemiologic designs that can provide data of high quality that resemble the controlled experiments done by basic science investigators (7). Studies are also traditionally divided into retrospective and prospective (Table 1. These terms refer more to the way the data are gathered than to the specific type of study design. In retrospective studies, the events of interest have occurred before study onset. Retrospective studies are usually done to assess rare disorders, for pilot studies, and when prospec- tive investigations are not possible. If the disease process is considered rare, retrospective studies facilitate the collection of enough subjects to have meaningful data. For a pilot project, retrospective studies facilitate the col- lection of preliminary data that can be used to improve the study design in future prospective studies. For example, in a case-control study, subjects in the case group (patients with hemorrhagic brain aneurysms) are compared with subjects in a control group (nonhemorrhagic brain aneurysms) to determine a pos- sible cause of bleed (e. Prospective studies, therefore, are the preferred mode of study design, as they facilitate better control of the design and the quality of the data acquired (6). Prospective studies, even large studies, can be performed effi- ciently and in a timely fashion if done on common diseases at major insti- tutions, as multicenter trials with adequate study populations (11). The major drawback of a prospective study is the need to make sure that the institution and personnel comply with strict rules concerning consents, protocols, and data acquisition (10). Persistence, to the point of irritation, is crucial to completing a prospective study. For example, a cohort study could be per- formed in which the risk factor of brain aneurysm size is correlated with the outcome of intracranial hemorrhage morbidity and mortality, as the patients are followed prospectively over time (9). The strongest study design is the prospective randomized, blinded clin- ical trial (Table 1. Blackmore known and unknown confounding factors, and blinding helps to prevent observer bias from affecting the results (6,7). However, there are often cir- cumstances in which it is not ethical or practical to randomize and follow patients prospectively. This is particularly true in rare conditions, and in studies to determine causes or predictors of a particular condition (8). Finally, randomized clinical trials are expensive and may require many years of follow-up. For example, the currently ongoing randomized clini- cal trial of lung cancer CT screening will require 10 years for completion, with costs estimated at $200 million. The evidence that supports much of radiology practice is derived from cohort and other observational studies. More randomized clinical trials are necessary in radiology to provide sound data to use for EBI practice (3). What Is the Diagnostic Performance of a Test: Sensitivity, Specificity, and Receiver Operating Characteristic (ROC) Curve? While a perfect stan- dard of reference or so-called gold standard can never be obtained, careful attention should be paid to the selection of the standard that should be widely believed to offer the best approximation to the truth (12). In evaluating diagnostic tests, we rely on the statistical calculations of sensitivity and specificity (see Appendix 1 at the end of this chapter). Sen- sitivity and specificity of a diagnostic test is based on the two-way (2 ¥ 2) table (Table 1. Sensitivity refers to the proportion of subjects with the disease who have a positive test and is referred to as the true positive rate (Fig. Sensitivity, therefore, indicates how well a test identifies the sub- jects with disease (6,13). Specificity is defined as the proportion of subjects without the disease who have a negative index test (Fig. Specificity, therefore, indicates how well a test identifies the sub- jects with no disease (6,10). It is important to note that the sensitivity and specificity are characteristics of the test being evaluated and are therefore usually independent of the prevalence (proportion of individuals in a pop- ulation who have disease at a specific instant) because the sensitivity only deals with the diseased subjects, whereas the specificity only deals with the nondiseased subjects.

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The second half of this chapter will give samples of how this metaphor both works to facilitate our understanding of some aspects of illness and fails to help us grasp what is going on with others 100 mg extra super levitra free shipping erectile dysfunction treatment yoga. WHY AND (PROVISIONALLY) HOW DISEASE IS A RADIAL CATEGORY The "disease" category begins at the level of symptoms generic extra super levitra 100 mg amex erectile dysfunction medications list, basic components of disease entities. It is apparent on first inquiry, although detailed empirical confirmation is needed, that the symptom, such as a "cut," a "bloody nose," a "headache," "blindness," "numbness," "vomiting" or "fever" is the level on which most of us would start to understand the whole system of concepts topped by "disease in general. In George Lakoff’s terms, embodied symptoms are "directly under- stood" whereas the understanding of disease as an underlying unified pattern of symptoms is indirect. Although the capacity to have symptoms is certainly healthy, within limits, the actual presence of them is not in most instances. If disease were entirely a social construction HEALTH AND DISEASE 55 there should be cultures that would embrace chest pain, headaches, arthralgias, sore throats and rashes as healthy. Any author denying that symptoms provide an experiential, cross-cultural foundation for disease ought to produce such examples for our edification. Having said that much about the most basic symptoms, there are some experi- ences which can be considered symptoms to a varying degree, and in some contexts these are not even thought of as symptoms. For example, shortness of breath, fatigue, anxiety, depression, forgetfulness and itching are almost always experiences we would rather get over, but the mere fact that they are generally unpleasant does not turn them into basic constituents of disease any more than unpleasantness renders hunger or homesickness pathological. Factors like the age of a person experiencing these discomforts, the reason for and nature of their onset as well as their intensity determine whether they are considered out of place. It is when they are wrong for the circumstances that they become symptoms, and then they function just like symptoms of the more incontrovertible type, i. They have other cognitive features which structure the symptoms, locate them in a context and assign them a history as well as meaningful implications. Although symptoms are the groundwork, a much larger semantic architecture is built on them. Notions of etiology, nature of onset, patterns of progression, symptom clusters, signs, pathophysiology, epidemi- ology and prognosis also constitute diseases. For this reason, symptoms are not diseases by themselves, and prototypical members of the "disease" category, such as pneumonia, are not at the most basic level in the cognition of illness. Individual diseases are instead complexes of features like those just mentioned, among which the symptoms are at the basic level. Whereas it is "self-evident" whether someone has a cough, a runny nose and a fever it is not automatically evident on the surface whether the person has a cold, influenza, whooping cough or pneumonia. In the case of a classical category, all members have essential defining features plus added features which differentiate them one from another. In contrast, the members of the "disease" category are generated from their connection to central members but do not have even all of the main features of these central members. In addition, an abstractionist analysis of the "disease" category will not work because any skeletal features which could be asserted to apply in common to all the varying members (i. Their number is always fluctuating and controversial, because of conflicting and evolving 56 CHAPTER 2 principles for lumping and splitting and disputes about the relative significance of "natural kinds" versus "social constructs. The cluster of ideal cognitive models is generated from the bottom up, starting with our experience of symptoms and what we have found out about their causes and cures. Beginning with symptoms, understanding builds up to individual disease concepts and their sub-categorical variants, then the classes of disease, like infectious diseases and vascular diseases, and at last, disease in general. The broader categories are understood in terms of the more specific ones, by and large. As we have already seen, there is no classical criterion, no univocal set of necessary and sufficient features to define disease literally. Depending on the vagaries of ongoing research, academic fashion and the mutually contradictory pronouncements of authorities at different times and in different places, category assignments shift, drift and are often in dispute. There is very little about this whole system which accords well with classical category structure. Central members of this category are extended by cognitive proximity, analogy and metaphor to increas- ingly peripheral examples.

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