“Many people have their own way of coping and do very nicely. But often when the family is under stress things can just come apart. Sometimes the stresses are due to misperceived guilt or an effort to fix blame; sometimes fears or jealousy among siblings are the cause; occasionally, people who seem to be coping well just get tired of pretending that everything is OK, that nothing has changed. They need to unload and say, ‘I’m sick of pretending that I’m coping well. My child is sick of pretending tnat everything is still fine in school.’ This pretending that everything is OK may work for awhile, but is useful only until acceptance of the epilepsy and of its problems ultimately occurs. These are some of the things that bring a person or family in for counseling.”Counseling should be part of the initial educational process, not just directed at working out later problems. Preventive counseling should begin, then, at the time of the diagnosis. If the patient and the family don’t understand that treatment will require trial-and-error medication adjustment, they may lose trust in their doctor when other seizures occur. They will often feel that the doctor hasn’t fixed the epilepsy. If the patient has side effects of the medication and has not been made aware of that possibility, they may feel the medicine is no good rather than considering that it needs to be adjusted. Children or adolescents who never seen a seizure will have trouble understanding their friends’ reactions when a seizure occurs or the fear that others may have of a seizure’s occurring. If the family hasn’t been warned about the dangers and consequences of overprotection, then they naturally over-protect their child and have to suffer the consequences later.*219\208\8*

ALLERGIES AT WORK: OFFICE RHINITISCauses of Office RhinitisOffice rhinitis is occupational rhinitis caused by something in the office environment. The possible causes of office rhinitis are extensive. Common causes include inadequate ventilation of the workspace, cigarette smoke, chemical odors (cleaning agents, shampoos, insecticides, new furniture or carpeting), and indoor allergens, particularly dust mites and mold spores.
Sick Building SyndromeA special word about this problem is in order. Since the mid-1960s there has been a trend in the construction of office buildings toward tighter buildings. These are buildings in which the natural flow of air is impeded and is replaced by the mechanical control of ventilation. The sealed windows, prefabricated components, reduced ventilation rates are characteristics of modern construction, which when coupled with the trapping of chemicals, particles, odors (including smoke), and common indoor allergens create an unhealthy environment for many workers.Add to the above situation an event such as a fire, a water leak, the laying of new carpet, the shampooing of old carpet, the waxing of floors, etc., and many workers can become symptomatic. This is called Sick Building Syndrome, Tight Building Syndrome, or Building-Related Illness. Rhinitis symptoms as well as eye irritation, cough, chest tightness, headache, and malaise can occur. Often, the only remedy required is to improve the ventilation in the office spaces involved so that harmful particles and odors are better removed.*23/322/5*

RELIEVING ARTHRITIS: JUVENILE RHEUMATOID ARTHRITISJuvenile rheumatoid arthritis is a form of chronic arthritis in children that is also referred to as Still’s disease, juvenile chronic polyarthritis, and juvenile chronic arthritis. It rarely begins before the age of one year, but it may start anytime after the first year. There are different types of juvenile rheumatoid arthritis that begin at different ages and more often in one sex or the other. It has been estimated that 5 percent of all cases of rheumatoid arthritis begin before the age of sixteen.Juvenile rheumatoid arthritis (JRA) is defined as the onset of the disease under age sixteen. It has some features that distinguish it from rheumatoid arthritis (RA) in adults. These clinical differences include high fever, rash, high white blood cell count, eye involvement, growth disturbances, and increased tendency to have the disease localize in a single joint. In about 20 percent of cases the onset is acute and rapidly progressing, with general symptoms of illness such as fever and rash associated with enlargement of the spleen and inflammation of the pericardial sac around the heart, and in some cases these manifestations may be present for several weeks before the joint inflammation is evident.In one third of these cases the disease begins in a single joint (monoarticular), and in half the cases the onset resembles adult RA and includes more than one joint (polyarticular). Pauciarticular JRA involves only a few joints and may affect the eyes. Skeletal growth in bones adjacent to inflamed joints may be either accelerated or retarded. If the heart is affected, the illness may be confused with acute rheumatic fever, but JRA frequently begins before age five, the joint symptoms do not migrate from joint to joint, the vertebrae in the neck are involved, the white blood cells are markedly increased, and rash frequently occurs.The synovial tissue lining the joints becomes inflamed and the synovitis may last for weeks, months, or years. If the synovitis persists for a long enough period of time, the cartilage at the ends of the bones within the joint and the bone underlying the cartilage may be damaged. The cartilage may not regenerate at all, although it does have slight regenerative properties. Damage to the ligaments and tendons surrounding joints may also occur. Permanent joint damage occurs because the bones may be dislocated or fused together, tissue may be destroyed, and muscles and other structures surrounding the joint may shorten (contractures), causing deformities in the absence of damage within the joints. These serious complications do not occur often, and most children do not sustain permanent joint damage or deformity.The diagnosis is based solely on the presence of the characteristic clinical findings and the careful exclusion of other conditions that also are associated with arthritis and joint pains. Destructive joint changes, occurring late in severe cases of the disease will be noted in X-rays, but there are no other specific diagnostic tests that establish the diagnosis.Complete remission occurs in 50 percent or more of the children with JRA. The major consequences of this illness are permanently restricted joint function, heart disease, and chronic eye inflammation.At least 75 percent of the children who have JRA will recover from their illness without having any important residual disability if they are given what is generally accepted as proper care during active periods of their illness. Currently approved methods of treatment are symptomatic – directed against the symptoms of the disease – and not curative. This is because the underlying factors responsible for JRA are poorly understood.Treatment of this chronic illness consists of medication, physical and occupational therapy, psychological reinforcement (to offset the discouraging aspects of JRA), and surgery (to reconstruct joint damage). Education and counseling are important because the affected child’s needs and limitations may have a great impact on family activities and the uncertainty of the diagnosis and prognosis cause severe psychological stress for everyone concerned.Although cortisone-related (steroid) drugs such as Prednisone can often work magic in this illness, their use must be limited to the severe manifestations that do not respond to aspirin and other non-steroid drugs. The possibility of cardiac damage and loss of vision require careful medical supervision. Another serious problem associated with steroid therapy is that steroids cause growth retardation, and although they may be necessary in the management of this illness, they may augment the growth retardation that is a natural feature of JRA.It is possible that what we call JRA is more than one disease. If your child is among the estimated 250,000 cases in the United States, the specialist you consult will review this matter with you in depth, since each type of the illness has certain physical and laboratory characteristics, follows a particular course, affects more girls than boys or vice versa, and is associated with different kinds of complications.*6/295/5*

CLASSIFYING THE IRRITABLE BOWEL SYNDROME: TRYING THE COMMON-SENSE APPROACH – RESTING THE BOWEL, TAKING A BULKING AGENT FOR DIARRHOEA & CAN MY DOCTOR GIVE ME ANYTHING FOR DIARRHOEA?Resting the BowelIf your stool is frequent and fluid, rest and take fluids only, but avoid milk and citrus drinks. Filtered, bottled or boiled water, apple juice or clear vegetable stock thickened with arrowroot or slippery elm powder (the pure powder, not the milk drink containing slippery elm), will both soothe and heal the bowel. White rice cooked in a lot of water until it becomes a creamy liquid has the same effect.Taking a Bulking Agent for DiarrhoeaIsogel (or linseed) is as helpful for diarrhoea as it is for constipation. Take it with only enough fluid to get it down and it will act as a sponge and absorb excess fluid in the bowel.Can my Doctor Give Me Anything for Diarrhoea?Yes. It could be Imodium capsules (also available over the counter as Arret) or a kaolin and morphine mixture. Resort to medicine only when you have tried resting and fluids. There are two reasons for this. One is ‘letting your guts have their say’; if they are trying to clean out toxins it is a mistake to interrupt this. The other reason is that although the drugs are certainly effective in stopping the diarrhoea, they can also leave you with constipation, and so the cycle goes on.*21\326\8*

EPISODES OFTEN MISTAKEN FOR SEIZURES: IS IT FAINTING OR A SEIZURE?Many changes in motor function or behavior are commonly mistaken for seizures. These include fainting, tics, and other sudden jerking movements, breathholding spells, migraine headaches, and episodic changes in behavior. Doctors who are aware of these types of behaviors can take a careful history and can usually separate them from seizures.Is It Fainting or a Seizure?It had been a long church service and, as usual, Rebecca had almost been late. Her alarm had not gone off, and when her mother had called her there had barely been time to get dressed. No time for breakfast. Her mother told me, “The sermon was long and dull, and she remembers standing for the hymns and feeling dizzy. The next thing she remembers is waking up outside the church. She doesn’t remember passing out. The paramedic who happened to be there asked me if Rebecca had epilepsy. Does she? You’ll tell me the truth, Doctor, won’t you?”Fainting spells are commonly misdiagnosed as seizures. Indeed, some people have been treated for “epilepsy” for years when they had simply fainted. Fainting is caused by lack of blood going to the brain. Since one of the brain’s important activities is to maintain consciousness and posture, when there is not enough blood the person may become dizzy and slump to the floor. This decrease of bloodflow to the brain may be due to slowing of, or even brief pauses in, the heart rate. Or it may result from prolonged standing, with the blood becoming pooled in the legs or in the abdomen with not enough blood available to pump to the brain. Or it could result from anemia, with insufficient red blood cells to carry oxygen to the brain.In each case, the lack of blood initially causes a paleness, followed by sweating. The person feels “lightheaded,” or dizzy. The room seems to spin, and he or she slumps (not crashes) to the ground. As soon as the person is lying down, the heart does not have to pump blood up to the head, the blood supply to the brain is immediately increased, and within seconds he regains consciousness. He will usually still be pale and sweaty, may briefly be confused, and may still feel weak. Even though he has had a change in motor function and consciousness, he has not, however, had a seizure since that change was not caused by abnormal electrical activity in the brain.*20\208\8*

DIABETES THROUGH THE AGES: THE HUNT FOR THE HORMONESoon after the end of “World War I, a young Canadian orthopedic surgeon named Frederick Banting read about the experiments in which the ducts of the pancreas were tied off. He was particularly interested in diabetes because a neighbor’s child had recently died of the disease. Banting believed that extracts of the pancreas had not yielded an active hormone because the powerful digestive enzymes of the pancreas must be breaking down the islet hormone during the extraction process. If the ducts were first tied off, the digestive portion of the pancreas would shrivel and stop producing its digestive juices. Then the hormone could be extracted without being destroyed in the process.To test his idea, Banting needed a laboratory. He went to the chief of biochemistry at the University of Toronto, Professor John J. R. Macleod, to ask for support. At first Macleod refused because funds were scarce. But Banting was persuasive, and he was given a lab and a graduate student named Charles Best to help with the experiments.Banting and Best removed the pancreases of several experimental dogs. They injected extracts from these organs into the veins of normal dogs. The dogs’ blood sugar levels fell. Next the researchers injected the extract into dogs previously made diabetic by removal of the pancreas. Their blood sugar level fell, too! In fact, if enough of the extract was injected, the blood sugar level dropped below normal. Banting and Best wanted to call their hormone extract “isletin,” but Professor Macleod insisted that the older name insulin be used.Banting and Best tried insulin injections on human patients at Toronto General Hospital in 1921. Their first patient was a fourteen-year-old boy named Leonard Thompson. His diabetes had been diagnosed two years before, and doctors had used the only treatment they knew of—a starvation diet of only 450 calories a day. The boy was still alive, but just barely; he weighed only seventy-five pounds. The insulin injections brought his blood sugar level down dramatically. He was able to eat a more normal diet, gained weight, and lived to maturity.Banting presented a paper on his discovery at the 1921 meeting of the Association of American Physicians, and interest in insulin grew. Macleod assigned his whole staff to work on the problems of isolating insulin and experimenting with it. At first it took half a pound of steer pancreas to produce enough insulin to treat one patient for two weeks. But Best developed methods for large-scale production. Soon commercial manufacturers were producing supplies of the hormone for doctors to use on diabetic patients all around the world.The 1923 Nobel Prize in Medicine or Physiology was awarded to Banting and Macleod for the insulin breakthrough. Banting was furious. He and Charles Best had done all the work on the basic discovery, yet Best was not even mentioned in the award. At first Banting refused to accept the prize, but eventually he did, and he immediately gave half of his $25,000 share of the award to Best.*6\268\2*

PREVENTING CARDIOVASCULAR COMPLICATIONS OF DIABETESDiabetes mellitus is responsible for several health complications, including an increased risk for vascular disease and coronary artery disease. Everything else being equal, the risk of heart disease is increased five times in a diabetic woman and two times in a man. The jury is still out, however, on the question of whether careful control of the blood sugar level can decrease or slow these cardiovascular risks.Eliminating other risk factors, such as smoking, high blood cholesterol levels, high blood pressure, obesity, and lack of exercise, is especially important for people with diabetes. Any of these factors increases the risk already caused by the presence of diabetes. Refer to the detailed discussions on stopping smoking, eating for better health, and improving your activity level for approaches to prevention.Signs of deconditioning*Feeling tired most of the time Being unable to keep up with others of your age Avoiding physical activity because you know you will quickly become fatiguedHaving shortness of breath or fatigue with walking a short distance or taking a few stairs*These symptoms can also occur because of heart problems or other diseases. If there is no medical explanation for the symptoms, gradually increasing your activity level will help you improve your physical condition.*269\252\8*

PHYTOFACTS: LINSEEDS (FLAX SEEDS) AND SOYAOther potent phytoestrogens are the lignans, found in linseeds (also called flax seeds) which have the effect of modulating body oestrogens and seem to exert a protective effect specifically against breast cancer, to inhibit the promotion of breast cancer and to inhibit the production of the enzyme aromatase which increases oestrogen levels. Phytoestrogens from linseeds are acted on by the intestinal micro-flora bacteria to produce active phytoestrogens which are up to 100-800 times more plentiful than those derived from other foods.     The way forward-Some people take readily to using soya and find that eating more oriental dishes, and replacing milk with soya milk, is fine. For others, however, it must be said that when faced with a block of tasteless tofu, they just run out of ideas. It helps to be creative and sneak it into Western-style dishes by the back door. For instance, mashing tofu into casseroles, or pureeing it with vegetables is an easy way to slip in a couple of ounces here and there. The dried beans cook in just the same way as other beans such as flageolet or pinto beans. Using soya milk as a substitute for cow’s milk in cooked dishes and for sauces is straightforward – it makes the creamiest porridge imaginable. An excellent, filling breakfast is to use tofu in a morning ‘milk’ shake, along with fruit, to get your daily dose of phytonutrients.*85\240\2*

DIAGNOSING RHEUMATOID ARTHRITIS: DIAGNOSTIC TESTSPhysicians rely on diagnostic tests to help them provide quality care to people with RA. Diagnostic tests can take the form of blood analyses, joint fluid analyses, urine analyses, and x-rays. (As might be expected, evaluation of blood and joint fluid requires that a needle be used to obtain specimens.) Diagnostic tests can be requested for any one (or more) of the following reasons:- To make a diagnosis of RA.- To monitor disease activity in RA.- To rule out other types of arthritis.- To detect complications of RA.- To screen for potential side effects of a medication.In addition to laboratory analyses of body fluids and x-ray evaluation, physicians rely heavily on the patient history and physical examination to make a diagnosis of RA, as discussed above. In fact, early in the course of RA, when the results of diagnostic tests may be normal, the physician relies on an evaluation of each person’s description of symptoms and the physical exam to make a diagnosis. When the findings from laboratory tests are inconclusive, making the diagnosis often requires a significant amount of observation time. Patience is required from both the physician and the patient in this case.*18/209/5*

DEPRESSION AND SUICIDE: WORKING WITH THE TOTAL PROCESSIn the midst of a depressed episode, Frau R. is identified with the process of being angry and hopeless about life for not giving her the youthfulness, pleasure and mechanical abilities she once had. Though there are fleeting moments in which she switches and seems to want help, by and large she is against life.As long as we are unclear about the structure of her process, we are bound to take the unoccupied part in her pattern. In Frau R.’s pattern, the unoccupied part is the healer who is trying to get her to live. In her depressed and nasty state, the more she hears about help, the more she rejects it. The more she rejects it, the more she splits off her secondary request for help and the more the social worker, psychiatrist, psychotherapist, hospitals and police are trapped into trying to be helpful.This is a vicious and dangerous cycle because if we constantly act like helpers, she never gets the chance to help herself and is constantly in the position of the depressed one who wants to die. But this situation can be reversed by knowing the process structure well enough to flip the two processes.After trying for about twenty minutes to be the helper and attempting different approaches, I decided to side with the dying process since everything else resulted in negative feedback. Thus I played her primary process better than she could, hoping that she would take on the social worker’s process of being helpful and hopeful. I looked down and spoke slowly and in a depressed voice:Amy: I am now ready to go. Nothing worked, nothing helps. I want to go off alone and think it all over. Nothing can be done here anyway. Too bad.Frau R.:  No, I am happy that you are here.I noticed that this was her first positive response and I was genuinely surprised to see that my plan had actually worked.Amy:  Really?Frau R.: Yes. For me you are a stranger and it was a great help and a good thing that I could talk about such intimate things with you. I am even getting good at talking about myself [she giggles].Social Worker: Frau R., that is the first time I have ever seen you laugh!Amy: Give me a coffee, I have had enough here and want to go.The social worker did not notice what I was doing and said:Social Worker:  Amy, do you not see any chance for helping her? Stay!Frau R.: Yes! Do you see any possibility of helping me? Now I would be really interested if you could tell me something helpful!*91\227\8*