LEPTOSPIROSISLeptospirosis, caused mainly by the spirochete Leptospira interrogans, is a zoonosis that is common in tropical and subtropical climates. It infects wild and domestic animals, particularly rodents, and the organism is excreted in their urine. Transmission to humans occurs when leptospires enter through abraded skin, mucous membranes, or conjunctiva following contact with urine-contaminated soil or water. Exposure to the organism is either occupational (gardening, farming) or recreational (swimming, rafting, crossing streams).Leptospirosis may occur as two clinically distinguishable syndromes. The more common syndrome (85-90% of cases) is anicteric leptospirosis, which manifests as a biphasic illness. After an incubation period of 7 to 12 days (range, 2-20 days), the initial septicemic phase is characterized by the abrupt onset of high fevers, headaches, and myalgias. Conjunctival suffusion, muscle tenderness, a maculopapular skin rash, and hepatosplenomegaly may also be noted. After 4 to 7 days, defervescence occurs. Two to 3 days later, during the secondary immune phase, leptospires disappear from the blood and cerebrospinal fluid, but circulating antibodies may cause immune-mediated aseptic menigitis, uveitis, or chorioretinitis. Icteric leptospirosis, or Weil’s syndrome, is less common (5-10%) and may be characterized by hepatic, renal, and vascular dysfunction. Fever, jaundice, and azotemia typically develop, and hypotension due to vascular collapse may ensue. The diagnosis is usually established retrospectively by serologic tests. Blood, urine, and cerebrospinal fluid can be obtained for culture. Empiric therapy with doxycycline or penicillin should be initiated if the diagnosis is considered.*204/348/5*

Tune out. If you’re wondering where the time goes, it may be getting zapped by cathode rays. “If you look at 35 hours a week of TV, you realize you’re watching somebody else be creative, rather than creating something for yourself,” says Dr. Fiore. “If you’re able to keep your TV viewing under 5 hours a week, you have a lot of extra time. You can find 15 or 20 hours to learn to play the piano or the guitar, or to learn Italian or to do a number of things that can be enhancing and enriching.”
Make eating a happy time. Add a joke du jour to the dinner menu. Don’t allow your evening repast to become a nightly gripe session about what went wrong that day. “This day and age, the table at dinner becomes a stress pot,” Dr. Collins says. “Everyone comes to the table bringing their stresses of the day. Pretty soon your digestive tract is grinding away and no one’s happy. We try to, at our table, have everyone bring a joke or have some humor. It’s a very important way of uncoupling stress.”
Let leisure suit you. Don’t fill every waking moment with something you must do. As Dr. Collins puts it, “Leisure time has become stressful in our lives.” Do something relaxing and noncompetitive, whether it’s reading, meditating or taking a walk. “You need leisure time in order to be productive,” says Dr. Fiore. “I love the paradox in that statement.”
Meditate. The best way to shut down an overactive stress-response system is to meditate, says Dr. Collins. “Yoga, tai chi, all of those things that are related to self-understanding, I think, are essential.”
Check out certified yoga schools in your area, recommends Dr. Collins. Or look for stress management courses offered at hospitals.
Retreat. Go on a weekend retreat in the country. Leave your watch at home. Slow down and take time to explore your emotions and feelings for a change. You’ll come back rested and renewed.
Take a vacation. If you thought National Lampoon’s Vacation was a documentary film, you may need to change your approach to your own summer getaways. The point of a vacation is to relax and get away from the pressures of the office and daily life. Too many men trade their hectic, stressful jobs for hectic, stressful vacations, says Alvin Baraff, Ph.D., a clinical psychologist and the founder of MenCen-ter, a counseling practice in Washington, D.C. The typical take-no-prisoners executive gets up at dawn to see every sunrise, visits every museum and historical site in the guidebook and takes more pictures than a photographer for National Geographic. “He comes back from vacations more tired than when he left,” says Dr. Baraff.
This time, try slowing down. Sleep late. Read a good novel. And don’t try to see  everything. “Whatever you wind up seeing,” says Dr. Baraff, “will be more than what you’ve seen.”
*634\257\8*

COGNITIVE-BEHAVIORAL THERAPY FOR BDD: COGNITIVE RESTRUCTURING (COGNITIVE THERAPY)  - STEPS OF BEHAVIORAL EXPERIMENTSMany people with BDD have appearance-related beliefs that they believe are true but never really check out. For example, if you assume that people are staring at you intently but you avoid looking at them (because you’re sure you’re being stared at and are too anxious), you don’t have much of a chance to see if your assumption that they’re staring at you is true or not. Or if you always wear a hat or heavy makeup when you go out, you don’t have a chance to see if people react to you in an unusual way if you go out without them.Behavioral experiments allow you to test whether your beliefs are actually true. They combine cognitive techniques, exposure, and response prevention. They’re similar to cognitive restructuring in the sense that the goal is to learn how to objectively evaluate the accuracy of your BDD-related beliefs and to develop more accurate and realistic beliefs. And, as with cognitive restructuring, you act like a scientist, collecting objective evidence for and against your beliefs. However, cognitive restructuring is done with pen and paper, by filling out thought records, whereas behavioral experiments are done in real-life situations. Another difference is that behavioral experiments involve actual testing of your beliefs, rather than thinking them through as you do with cognitive restructuring. Behavioral experiments also involve exposure and response prevention, in that you go out into various situations that you might usually avoid, and you do the experiment without doing your rituals.In a nutshell, a behavioral experiment involves the following steps:Steps of a Behavioral Experiment2. You design a specific experiment that will test your hypothesis, and you write it down on a behavioral experiment form (see below);3. You then go into the situation and carry out the experiment, collecting evidence about what actually happens and determining whether your hypothesis is confirmed or not;4. You then complete the behavioral experiment form, writing down what actually happened, whether your prediction came true, and what you learned from the experiment.*309\304\8*

Defining an intimacy comfort zone and staying within its boundaries is a challenge for any two people who want to establish and maintain a lasting relationship. Using sex to do that is a very risky business, however. When someone who prefers a, lot of personal space and emotional distance gets involved with someone who prefers intense involvement and lots of closeness; sex becomes yet another battleground. For example, intimacy tensions surfaced almost immediately in Dan and Barbara’s relationship, and sex problems eventually followed.
Recalling their long-distance courtship, Dan said, “I always looked forward to Barbara’s visits, but when they were over was always glad to see her go. By Sunday morning, I was checking my watch every ten minutes and thinking, ‘Enough alread I need to be alone.’ ” It was not just Barbara’s presence that le him feeling like he could not breathe, but also her personal!
Barbara was energetic and talkative, curious and bubbly—or, to quote Dan, “She wanted to know everything about me and do everything with me every minute of every day.” Barbara thrived on togetherness. The closer she could get to Dan, the happier she would be. And she wanted this closeness to occur immediately.
While he was in graduate school, the geographical distance between their homes provided Dan with an external boundary to maintain the emotional distance he needed. However, once they married, Barbara immediately realized that Dan preferred “a lot of space,” and she tried to give it to him. “It was easy enough to tell when I was getting on his nerves,” she recalled. “He’d just shut me out, wouldn’t hear a word I said even though he was looking right at me. So I’d just back off for a while. Lots of times I would want to have sex, but I figured that if Dan was off in his own little world and didn’t want to do other things with me, he certainly wouldn’t want to have sex with me. So, I just didn’t let him know I was interested. I held back until I couldn’t stand it anymore.”
In this way, Barbara and Dan developed a covert, unsteady compromise on the amount of closeness in their relationship, staying well within their intimacy comfort zones for many years. “Having children helped,” Barbara acknowledged. “They needed so much love and attention that I didn’t have a lot left over for Dan and that seemed to suit him just fine.” Things went awry, however, when the children grew older. Then outside pressures—connected to Dan’s starting his own business— left Dan needing even more distance than before. Barbara, who was pushed beyond the limits of her own comfort zone, felt anxious, abandoned, and unable to back off any further. So, she began to pursue Dan sexually, sometimes with obsessive determination, in attempts to regain reassurance that she was attractive, needed, and loved. She did not realize that her attempts to get closer to Dan essentially resulted in his pulling further away from her. Because Barbara and Dan, like many other couples, were mismatched in their intimacy needs, they experienced a constant tug of war. While sexual contact became the means for Barbara to gain intimacy, ISD and sexual avoidance became the means for Dan to gain the distance he required.
*118\261\8*

STHMA IN CHILDREN: MAKING CHILDREN INDEPENDENTASTHMA SELF-MANAGEMENT programme should aim at imparting asthmatic children the skills necessary to deal with their health problem independently and, over a period of time, to assume the responsibility of looking after themselves. At the same time, parents have to learn to let go and give children the responsibility for managing their own asthma.Self-management helps children develop a better control of their asthma with fewer disruptions in their life.It also dispels the idea that doctors and the medicines are the sole means of controlling asthma. Children also begin to realise the importance of their own behaviour and lifestyle. However, the level of responsibility depends on the child’s age and maturity levels.How to encourage children to learn these skills? Everyone needs encouragement and support to learn something new. This is equally true for every children. Perhaps, parents can follow what is called the Social Learning Theory. This principle is as applicable to asthma self-management as to any other situation.It consists of :positive reinforcementsmall stepsspecific goals*108\260\8*

Following the success of the levonorgestrel implant system, new directions in slow-release mechanisms are being studied. The aim is to produce ‘friendlier’ progestogens with more progesterone action and less androgen (masculinising) effect. Those being produced from levonorgestrel (such as gestodene) are of this type.
Implants
The pure progesterone implant
This provides effective contraception for up to five months using six pellets compressed into a single cylinder 11.8 mm in length and 3.2 mm in diameter. There is, however, a high rate of cylinder and pellet extrusion — that is to say, the cylinder/pellet is pushed out to the skin surface. Refinement is required to overcome this.
The ST-U35 implant
This derivative of 19-nor-progesterone is contained in a silastic capsule. One capsule suppresses ovulation for up to six months, while five capsules give contraceptive cover for up to 18 months. The major drawback is abnormal bleeding patterns, and a shorter duration of effectiveness than that of Norplant. A new release system is being studied.
The ketodesogestrel implant
This progestogen is the breakdown product of a third-generation progestogen (desogestrel) which is currently in use in the COC Marvelon. The silastic capsule prevents ovulation and is effective for up to two years. A side effect is menstrual irregularity. Efforts are under way in the UK, China and Sweden to perfect the system.
Capronor implant and fused pellets
These are under investigation and could be available for use in the late 1990s. Both are bio-degradable (they break down and are absorbed after a few years). Both systems are recoverable during the first 18-24 months prior to the start of the disintegration process. Capronor contains levonorgestrel while the pellets incorporate norethisterone fused with cholesterol. Again, irregular menstrual bleeding is the main side effect, but both provide highly effective contraception.
By the end of the decade improved implants which are effective for one to five years will be on the market. They may prove to be the first choice of contraception for many women in the future.
Vaginal rings
The use of silastic as a reservoir for bringing hormones into contact with the vaginal mucous membrane is being developed. This has the advantage of using natural oestrogen and progesterone under the control of the user, in other words, the user may remove the device when she wishes, which is not possible with injectable or implanted contraceptives: vaginal rings may also be used in the future for delivering HRT in the menopause.
The World Health Organisation is currently developing a progestogen-only ring using levonorgestrel which, after insertion, is left continuously in the vagina. Another ring using both a progestogen and ethinyl oestradiol, in different sections of the device, is also being tested. It is used cyclically, being left in place for three weeks then removed for one. This may become an alternative to the low-dosage COC pill.
Progestogen-releasing lUCDs
A promising method of contraception has recently gained regulatory approval in its country of origin, Finland. A silastic capsule containing a progestogen (levonorgestrel) is incorporated into the stem of an intra-uterine device. Its slow-release delivery lasts up to five years. There is a marked reduction in menstrual blood loss, although spotting may occur for the first three months after insertion. Pelvic infection is minimal and neither blood pressure nor body weight is affected.
This device may eventually be used as a possible source of the progestogen for endometrial protection used by women in association with menopausal oestrogen replacement therapy.
*41\222\2*

Excessive production of male sex hormones is observed in men particularly when there are tumors of the male sex glands. Such tumors have been observed by physicians in many cases. Occasionally excessive growth of tissue of the anterior pituitary gland or in other portions of the brain may stimulate the sex glands excessively, so that large amounts of male sex hormones are thrown into the circulation. The manifestations of excessive secretion vary with the time when the condition occurs. If it comes on before the young boy has reached puberty, the excessive gland material may cause puberty to come on much sooner than normally. Associated with this precocious pseudo-puberty is a too-early development of all of the male sex characteristics, including excessive growth of the sex organs, the development of a large amount of hair around the sex organs and under the arms, and, even in little boys, the development of a beard and a mustache, a deep voice and similar conditions. Physicians have observed that excessive amounts of male sex gland material will cause increased secretion of the oil glands in the skin, and associated acne is not uncommon. There may often also be changes in the growth of the skeleton. In this instance, the trunk, the arms and legs are found to be short due to too-early closure of the points from which the bones grow. Associated also with these developments may be excessive and definitely increased muscular development and strength; the so-called “infant Hercules.”
If the excessive secretion of glandular material comes on after the body has passed puberty, the condition manifests itself by accentuation of the masculine character. Obviously, the skeleton has already developed so that there cannot be effects on the skeleton.
The only known treatment for excessive activity is removal of the tumor which is responsible. Removal of portions of the tumor or of all of the tumor would naturally result in lessening the amount of sex gland material. This can be measured by chemical study so that the return to normal can be definitely known. If, however, the tumor material should return and grow again, the excess of glandular secretion can be determined through examination of the urine. In this way the physician can trace the progress of the tumor growth.
Fortunately tumors of the male sex gland are relatively rare. Doctors believe that these tumors occur more often when there has been failure of the male sex gland to descend into the sac, which it normally does before ten or eleven years of age, if not sooner. Experience has shown that the best thing to do whenever there is any tumor of this area is to have it removed by surgery as soon as possible. If the tumor is not a malignant tumor, it is in any event a threat. If, however, it is a malignant tumor, the growth quite certainly threatens life itself. In fact, so definitely is that threat known that it has become customary to use the X-ray to irradiate the area from which the tumor has been removed, to make certain that all excessive action has been stopped.
If the male sex gland is retained and fails to descend into the sac, its function may be destroyed by the heat to which it is subjected in the body.
Failure of sexual gland function causes psychosexual changes in the males, including loss of initiative and drive. Some psychiatrists feel this effect is wholly mental and results from a feeling of inferiority because the person knows of his deficiency.
Sexual precocity associated with excess of testosterone or androsterone has also been noted with adrenal and pituitary gland tumors.
*1/318/5*

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