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By D. Trano. Drury University. 2019.

In clinical trials order 50mg voltaren arthritis without medication, the 4-mg twice-daily regimen resulted in the greatest reduction in FPG and hemoglobin A1c (HbA1c) proven 50 mg voltaren arthritis in fingers and hands pictures. When AVANDIA is added to existing therapy buy 100mg voltaren otc rheumatoid arthritis wrist brace, the current dose(s) of the agent(s) can be continued upon initiation of therapy with AVANDIA 50mg voltaren with mastercard arthritis pain relief aspirin. Sulfonylurea: When used in combination with sulfonylurea, the usual starting dose of AVANDIA is 4 mg administered as either a single dose once daily or in divided doses twice daily. If patients report hypoglycemia, the dose of the sulfonylurea should be decreased. Metformin: The usual starting dose of AVANDIA in combination with metformin is 4 mg administered as either a single dose once daily or in divided doses twice daily. It is unlikely that the dose of metformin will require adjustment due to hypoglycemia during combination therapy with AVANDIA. The usual starting dose of AVANDIA in combination with a sulfonylurea plus metformin is 4 mg administered as either a single dose once daily or divided doses twice daily. If patients report hypoglycemia, the dose of the sulfonylurea should be decreased. Renal Impairment: No dosage adjustment is necessary when AVANDIA is used as monotherapy in patients with renal impairment. Since metformin is contraindicated in such patients, concomitant administration of metformin and AVANDIA is also contraindicated in patients with renal impairment. Hepatic Impairment: Liver enzymes should be measured prior to initiating treatment with AVANDIA. Therapy with AVANDIA should not be initiated if the patient exhibits clinical evidence of active liver disease or increased serum transaminase levels (ALT >2. After initiation of AVANDIA, liver enzymes should be monitored periodically per the clinical judgment of the healthcare professional. AVANDIA, like other thiazolidinediones, alone or in combination with other antidiabetic agents, can cause fluid retention, which may exacerbate or lead to heart failure. Patients should be observed for signs and symptoms of heart failure. If these signs and symptoms develop, the heart failure should be managed according to current standards of care. Furthermore, discontinuation or dose reduction of rosiglitazone must be considered [see BOXED WARNING ]. Patients with congestive heart failure (CHF) NYHA Class I and II treated with AVANDIA have an increased risk of cardiovascular events. A 52-week, double-blind, placebo-controlled echocardiographic study was conducted in 224 patients with type 2 diabetes mellitus and NYHA Class I or II CHF (ejection fraction ?-T 45%) on background antidiabetic and CHF therapy. An independent committee conducted a blinded evaluation of fluid-related events (including congestive heart failure) and cardiovascular hospitalizations according to predefined criteria (adjudication). Separate from the adjudication, other cardiovascular adverse events were reported by investigators. Although no treatment difference in change from baseline of ejection fractions was observed, more cardiovascular adverse events were observed following treatment with AVANDIA compared to placebo during the 52-week study. Emergent Cardiovascular Adverse Events in Patients With Congestive Heart Failure (NYHA Class I and II) Treated With AVANDIA or Placebo (in Addition to Background Antidiabetic and CHF Therapy)Cardiovascular hospitalization*Investigator-reported, non-adjudicatedIncludes hospitalization for any cardiovascular reason. Initiation of AVANDIA in patients with established NYHA Class III or IV heart failure is contraindicated. AVANDIA is not recommended in patients with symptomatic heart failure. In view of the potential for development of heart failure in patients having an acute coronary event, initiation of AVANDIA is not recommended for patients experiencing an acute coronary event, and discontinuation of AVANDIA during this acute phase should be considered. Patients with NYHA Class III and IV cardiac status (with or without CHF) have not been studied in controlled clinical trials. AVANDIA is not recommended in patients with NYHA Class III and IV cardiac status. Meta-Analysis of Myocardial Ischemia in a Group of 42 Clinical TrialsA meta-analysis was conducted retrospectively to assess cardiovascular adverse events reported across 42 double-blind, randomized, controlled clinical trials (mean duration 6 months). These studies had been conducted to assess glucose-lowering efficacy in type 2 diabetes, and prospectively planned adjudication of cardiovascular events had not occurred in the trials. Some trials were placebo-controlled and some used active oral antidiabetic drugs as controls. Placebo-controlled studies included monotherapy trials (monotherapy with AVANDIA versus placebo monotherapy) and add-on trials (AVANDIA or placebo, added to sulfonylurea, metformin, or insulin). Active control studies included monotherapy trials (monotherapy with AVANDIA versus sulfonylurea or metformin monotherapy) and add-on trials (AVANDIA plus sulfonylurea or AVANDIA plus metformin, versus sulfonylurea plus metformin). A total of 14,237 patients were included (8,604 in treatment groups containing AVANDIA, 5,633 in comparator groups), with 4,143 patient-years of exposure to AVANDIA and 2,675 patient-years of exposure to comparator. Myocardial ischemic events included angina pectoris, angina pectoris aggravated, unstable angina, cardiac arrest, chest pain, coronary artery occlusion, dyspnea, myocardial infarction, coronary thrombosis, myocardial ischemia, coronary artery disease, and coronary artery disorder. In this analysis, an increased risk of myocardial ischemia with AVANDIA versus pooled comparators was observed (2% AVANDIA versus 1. An increased risk of myocardial ischemic events with AVANDIA was observed in the placebo-controlled studies, but not in the active-controlled studies. This increased risk reflects a difference of 3 events per 100 patient-years (95% CI -0. Forest Plot of Odds Ratios (95% Confidence Intervals) for Myocardial Ischemic Events in the Meta-Analysis of 42 Clinical TrialsA greater increased risk of myocardial ischemia was also observed in patients who received AVANDIA and background nitrate therapy. For AVANDIA (N = 361) versus control (N = 244) in nitrate users, the odds ratio was 2. This increased risk represents a difference of 12 myocardial ischemic events per 100 patient-years (95% CI 3. Most of the nitrate users had established coronary heart disease. Among patients with known coronary heart disease who were not on nitrate therapy, an increased risk of myocardial ischemic events for AVANDIA versus comparator was not demonstrated. Myocardial Ischemic Events in Large Long-Term Prospective Randomized Controlled Trials of AVANDIAData from 3 other large, long-term, prospective, randomized, controlled clinical trials of AVANDIA were assessed separately from the meta-analysis. These 3 trials include a total of 14,067 patients (treatment groups containing AVANDIA N = 6,311, comparator groups N = 7,756), with patient-year exposure of 21,803 patient-years for AVANDIA and 25,998 patient-years for comparator. Duration of follow-up exceeded 3 years in each study. ADOPT (A Diabetes Outcomes Progression Trial) was a 4- to 6-year randomized, active-controlled study in recently diagnosed patients with type 2 diabetes nas_ve to drug therapy. It was an efficacy and general safety trial that was designed to examine the durability ofAVANDIA as monotherapy (N = 1,456) for glycemic control in type 2 diabetes, with comparator arms of sulfonylurea monotherapy (N = 1,441) and metformin monotherapy (N = 1,454). DREAM (Diabetes Reduction Assessment with Rosiglitazone and Ramipril Medication, published report2) was a 3- to 5-year randomized, placebo-controlled study in patients with impaired glucose tolerance and/or impaired fasting glucose. It had a 2x2 factorial design, intended to evaluate the effect of AVANDIA, and separately of ramipril (an angiotensin converting enzyme inhibitor [ACEI]), on progression to overt diabetes. In DREAM, 2,635 patients were in treatment groups containing AVANDIA, and 2,634 were in treatment groups not containing AVANDIA. Interim results have been published 3 for RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes), an ongoing open-label, 6-year cardiovascular outcomes study in patients with type 2 diabetes with an average treatment duration of 3. RECORD includes patients who have failed metformin or sulfonylurea monotherapy; those who have failed metformin are randomized to receive either add-on AVANDIA or add-on sulfonylurea, and those who have failed sulfonylurea are randomized to receive either add-on AVANDIA or add-on metformin. In RECORD, a total of 2,220 patients are receiving add-on AVANDIA, and 2,227 patients are on one of the add-on regimens not containing AVANDIA. For these 3 trials, analyses were performed using a composite of major adverse cardiovascular events (myocardial infarction, cardiovascular death, or stroke), referred to hereafter as MACE. Myocardial infarction included adjudicated fatal and nonfatal myocardial infarction plus sudden death.

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If acidosis is suspected cheap 100mg voltaren visa arthritis treatment prevention, Janumetshould be discontinued and the patient hospitalized immediately purchase voltaren 50mg without a prescription joint & arthritis relief 1500. Janumet has not been studied in combination with insulin generic 100mg voltaren with amex arthritis in your neck. Janumet should generally be given twice daily with meals buy discount voltaren 100 mg bacterial arthritis in dogs, with gradual dose escalation, to reduce the gastrointestinal (GI) side effects due to metformin. The following doses are available:50 mg sitagliptin/500 mg metformin hydrochloride50 mg sitagliptin/1000 mg metformin hydrochloride. Patients inadequately controlled with diet and exercise aloneIf therapy with a combination tablet containing sitagliptin and metformin is considered appropriate for a patient with type 2 diabetes mellitus inadequately controlled with diet and exercise alone, the recommended starting dose is 50 mg sitagliptin/500 mg metformin hydrochloride twice daily. Patients with inadequate glycemic control on this dose can be titrated up to 50 mg sitagliptin/1000 mg metformin hydrochloride twice daily. Patients inadequately controlled on metformin monotherapyIf therapy with a combination tablet containing sitagliptin and metformin is considered appropriate for a patient inadequately controlled on metformin alone, the recommended starting dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and the dose of metformin already being taken. For patients taking metformin 850 mg twice daily, the recommended starting dose of Janumet is 50 mg sitagliptin/1000 mg metformin hydrochloride twice daily. Patients inadequately controlled on sitagliptin monotherapyIf therapy with a combination tablet containing sitagliptin and metformin is considered appropriate for a patient inadequately controlled on sitagliptin alone, the recommended starting dose of Janumet is 50 mg sitagliptin/500 mg metformin hydrochloride twice daily. Patients with inadequate control on this dose can be titrated up to 50 mg sitagliptin/1000 mg metformin hydrochloride twice daily. Patients taking sitagliptin monotherapy dose-adjusted for renal insufficiency should not be switched to Janumet [see Contraindications ]. Patients switching from co-administration of sitagliptin and metforminFor patients switching from sitagliptin co-administrated with metformin, Janumet may be initiated at the dose of sitagliptin and metformin already being taken. Patients inadequately controlled on dual combination therapy with any two of the following antihyperglycemic agents: sitagliptin, metformin or a sulfonylureaIf therapy with a combination tablet containing sitagliptin and metformin is considered appropriate in this setting, the usual starting dose of Janumet should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose). Gradual dose escalation to reduce the gastrointestinal (GI) side effects associated with metformin should be considered. Patients currently on or initiating a sulfonylurea may require lower sulfonylurea doses to reduce the risk of hypoglycemia [see Warnings and Precautions ]. No studies have been performed specifically examining the safety and efficacy of Janumet in patients previously treated with other oral antihyperglycemic agents and switched to Janumet. Any change in therapy of type 2 diabetes should be undertaken with care and appropriate monitoring as changes in glycemic control can occur. Janumet (sitagliptin/metformin HCl) is contraindicated in patients with:Renal disease or renal dysfunction, e. Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. History of a serious hypersensitivity reaction to Janumet or sitagliptin (one of the components of Janumet), such as anaphylaxis or angioedema. Lactic acidosis is a rare, but serious, metabolic complication that can occur due to metformin accumulation during treatment with Janumet; when it occurs, it is fatal in approximately 50% of cases. Lactic acidosis may also occur in association with a number of pathophysiologic conditions, including diabetes mellitus, and whenever there is significant tissue hypoperfusion and hypoxemia. Lactic acidosis is characterized by elevated blood lactate levels (>5 mmol/L), decreased blood pH, electrolyte disturbances with an increased anion gap, and an increased lactate/pyruvate ratio. When metformin is implicated as the cause of lactic acidosis, metformin plasma levels >5 ~lg/mL are generally found. The reported incidence of lactic acidosis in patients receiving metformin hydrochloride is very low (approximately 0. In more than 20,000 patient-years exposure to metformin in clinical trials, there were no reports of lactic acidosis. Reported cases have occurred primarily in diabetic patients with significant renal insufficiency, including both intrinsic renal disease and renal hypoperfusion, often in the setting of multiple concomitant medical/surgical problems and multiple concomitant medications. Patients with congestive heart failure requiring pharmacologic management, in particular those with unstable or acute congestive heart failure who are at risk of hypoperfusion and hypoxemia, are at increased risk of lactic acidosis. The risk of lactic acidosis may, therefore, be significantly decreased by regular monitoring of renal function in patients taking metformin and by use of the minimum effective dose of metformin. In particular, treatment of the elderly should be accompanied by careful monitoring of renal function. Metformin treatment should not be initiated in patients ?-U80 years of age unless measurement of creatinine clearance demonstrates that renal function is not reduced, as these patients are more susceptible to developing lactic acidosis. In addition, metformin should be promptly withheld in the presence of any condition associated with hypoxemia, dehydration, or sepsis. Because impaired hepatic function may significantly limit the ability to clear lactate, metformin should generally be avoided in patients with clinical or laboratory evidence of hepatic disease. Patients should be cautioned against excessive alcohol intake, either acute or chronic, when taking metformin, since alcohol potentiates the effects of metformin hydrochloride on lactate metabolism. In addition, metformin should be temporarily discontinued prior to any intravascular radiocontrast study and for any surgical procedure [see Warnings and Precautions ]. The onset of lactic acidosis often is subtle, and accompanied only by nonspecific symptoms such as malaise, myalgias, respiratory distress, increasing somnolence, and nonspecific abdominal distress. There may be associated hypothermia, hypotension, and resistant bradyarrhythmias with more marked acidosis. Metformin should be withdrawn until the situation is clarified. Serum electrolytes, ketones, blood glucose, and if indicated, blood pH, lactate levels, and even blood metformin levels may be useful. Once a patient is stabilized on any dose level of metformin, gastrointestinal symptoms, which are common during initiation of therapy, are unlikely to be drug related. Later occurrence of gastrointestinal symptoms could be due to lactic acidosis or other serious disease. Levels of fasting venous plasma lactate above the upper limit of normal but less than 5 mmol/L in patients taking metformin do not necessarily indicate impending lactic acidosis and may be explainable by other mechanisms, such as poorly controlled diabetes or obesity, vigorous physical activity, or technical problems in sample handling [see Warnings and Precautions ]. Lactic acidosis is a medical emergency that must be treated in a hospital setting. In a patient with lactic acidosis who is taking metformin, the drug should be discontinued immediately and general supportive measures promptly instituted. Because metformin hydrochloride is dialyzable (with a clearance of up to 170 mL/min under good hemodynamic conditions), prompt hemodialysis is recommended to correct the acidosis and remove the accumulated metformin. Such management often results in prompt reversal of symptoms and recovery [see Contraindications ; Warnings and Precautions ]. Before initiation of therapy with Janumet and at least annually thereafter, renal function should be assessed and verified as normal. In patients in whom development of renal dysfunction is anticipated, particularly in elderly patients, renal function should be assessed more frequently and Janumet discontinued if evidence of renal impairment is present. Levels In controlled clinical trials of metformin of 29 weeks duration, a decrease to subnormal levels of previously normal serum Vitamin Blevels, without clinical manifestations, was observed in approximately 7% of patients. Such decrease, possibly due to interference with B-intrinsic factor complex, is, however, very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin or Vitamin Bsupplementation. Measurement of hematologic parameters on an annual basis is advised in patients on Janumet and any apparent abnormalities should be appropriately investigated and managed. In these patients, routine serum Vitamin Bmeasurements at two- to three-year intervals may be useful. As is typical with other antihyperglycemic agents used in combination with a sulfonylurea, when sitagliptin was used in combination with metformin and a sulfonylurea, a medication known to cause hypoglycemia, the incidence of hypoglycemia was increased over that of placebo in combination with metformin and a sulfonylurea [see Adverse Reactions ].

The feared social or performance situations are avoided or else are endured with intense anxiety or distress safe voltaren 50mg is arthritis in the knee a disability. In individuals under age 18 years cheap voltaren 50mg line arthritis in dogs operation, the duration is at least 6 months purchase voltaren 50 mg line arthritis neuropathic pain. The fear or avoidance is not due to the direct physiological effects of a substance (e cheap voltaren 50mg free shipping arthritis in dogs baby aspirin. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e. At this point, there are two primary theories:Environmental Exposure: People with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning or social modeling. Earlier Negative Social Consequences: Being the victim of bullying, facing a particularly embarrassing situation in public, having a disability or being disfigured and being teased or extremely self-conscious about it. Other possible causes of social phobia include:an overactive amygdala, the part of the brain that controls fear responsesa brain chemical imbalancegenetics may play a relatively minor roleFor comprehensive information on social phobia and other forms of anxiety, visit the Anxiety-Panic Community. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging. The person recognizes that the fear is excessive or unreasonable. The phobic situation(s) is avoided or else is endured with intense anxiety or distress. In individuals under age 18 years, the duration is at least 6 months. The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder, such as Obsessive-Compulsive Disorder (e. Besides a familial history of anxiety disorders, it may by also true that human beings are biologically prone to acquire fear of certain animals or situations, such as rats, poisonous animals, animals with disgusting appearance, such as frogs, slugs or cockroaches, etc. Fear of certain situations or things can also be the result of learned experiences from child or adulthood. Traumatic events often trigger the development of specific phobias. For comprehensive information on specific (simple) phobia and other forms of anxiety, visit the Anxiety-Panic Community. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Merck Manual, Home Edition for Patients and Caregivers, last revised 2006. Fighting Phobias, The Things That Go Bump in the Mind. In the past 20 years especially, psychiatric research has made great strides in the precise diagnosis and successful treatment of many mental illnesses. Where once mentally ill people were warehoused in public institutions because they were disruptive or feared to be harmful to themselves or others, today most people who suffer from a mental illness--including those that can be extremely debilitating, such as schizophrenia --can be treated effectively and lead full lives. Recognized mental illnesses are described and categorized in the book Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. This book is compiled by the American Psychiatric Association and updated periodically. It can be purchased through the American Psychiatric Press Inc. For comprehensive information on mental illness, here is the Mental Illness Table of Contents with all the information you need to know. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Overview of depression, anxiety, schizophrenia and substance abuse. When people hear the phrase "mental illnesses," often they will conjure up the images of a person tortured by the demons only he or she sees, or by the voices no one else hears. This, of course, is the version of mental illnesses that most of us have developed from movies and literature. Films and books trying to create dramatic effect often rely on the extraordinary symptoms of psychotic illnesses like schizophrenia, or they draw on outmoded descriptions of mental illnesses that were evolved during a time when no one had any idea what caused them. Few who have seen these characterizations ever realize that people suffering even from the most severe mental illnesses actually are in touch with reality as often as they are disabled by their illnesses. Moreover, few mental illnesses have hallucinations as symptoms. For example, most people suffering from a phobia do not have hallucinations or delusions, nor do those with obsessive compulsive disorder. The unrelenting hopelessness, helplessness and suicidal thoughts of depression, the despair brought by alcoholism or drug abuse, may be hard to comprehend, but these are real, painful emotions, not hallucinations or delusions. These widespread assumptions about mental illnesses also overlook one other important reality: as many as eight in ten people suffering from mental illnesses can effectively return to normal, productive lives if they receive appropriate treatment--treatment which is readily available. Psychiatrists and other mental health professionals can offer their patients a wide variety of effective treatments. It is vital that Americans know that this help is available, because anyone, no matter what age, economic status or race, can develop a mental illness. During any one-year period, up to 50 million Americans -- more than 22 percent -suffer from a clearly diagnosable mental disorder involving a degree of incapacity that interferes with employment, attendance at school or daily life. Some 8 million to 14 million Americans suffer from depression each year. As many as one in five Americans will suffer at least one episode of major depression during their lifetimes. About 12 million children under 18 suffer from mental disorders such as autism, depression and hyperactivity. Two million Americans suffer from schizophrenic disorders and 300,000 new cases occur each year. Nearly one-fourth of the elderly who are labeled as senile actually suffer some form of mental illness that can be effectively treated. Suicide is the third leading cause of death for people between the ages of 15 and 24. People suffering from mental illnesses often do not recognize them for what they are. About 27 percent of those who seek medical care for physical problems actually suffer from troubled emotions. Mental illnesses and substance abuse afflict both men and women. Alcohol, Drug Abuse and Mental Health Administration indicate men are more likely to suffer from drug and alcohol abuse and personality disorders, while women are at higher risk of suffering from depression and anxiety disorders. The personal and social costs that result from untreated mental disorders are considerable--similar to those for heart disease and cancer. According to estimates by the Substance Abuse and Mental Health Services Administration (SAMHSA), Institute of Medicine, the direct costs for support and medical treatment of mental illnesses total $55. Emotional and mental disorders can be treated or controlled, but only one in five people who have these disorders seek help, and only four to 15 percent of the children suffering severe mental illnesses receive appropriate treatment. This unfortunate reality is further complicated by the fact that most health insurance policies provide limited mental health and substance abuse coverage, if any at all.

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P We do not know how to Love our self in healthy ways because our parents did not know how to Love themselves order voltaren 50 mg on line rheumatoid arthritis wrist. P We were raised in shame-based societies that taught us that there is something wrong with being human voltaren 50mg on line arthritis diet wheat. P That does not mean just romantic relationships purchase voltaren 50 mg arthritis back support, or family relationships buy voltaren 100 mg otc arthritis meaning, or even human relationships in general. P Instead of being traumatized in a foreign country against an identified enemy during a war, as soldiers who have delayed stress are - we were traumatized in our sanctuaries by the people we loved the most. Traditionally, in this society, men have been taught that anger is the only acceptable emotion for a man to express, while women are taught that it is not acceptable for them to be angry. P If it is not ok to own all of our emotions then we can not know who we are as emotional beings. P P The condition of codependence is about giving power over our self esteem to outside sources/agencies or external manifestations. P We were taught to look outside of our selves to people, places, and things - to money, property and prestige, to determine if we have worth. P We make money or achievement or popularity or material possessions or the "right" marriage the Higher Power that determines if we have worth. P We do not know how to Love our self in healthy ways because our parents did not know how to Love themselves. P We were raised in shame-based societies that taught us that there is something wrong with being human. P The messages we got often included that there is something wrong: P with making mistakes; P with not being perfect; P with being sexual; with being emotional; with being too fat or too thin or too tall or too short or too whatever. P As children we were taught to determine our worth in comparison with others. P If we were smarter than, prettier than, better grades than, faster than, etc. In a codependent society everyone has to have someone to look down on in order to feel good about themselves. P And, conversely, there is always someone we can compare ourselves to that can cause us to not feel good enough. The condition of codependence is about giving power over our self esteem to outside sources/agencies or external manifestations. We were taught to look outside of our selves to people, places, and things - to money, property and prestige, to determine if we have worth. We make money or achievement or popularity or material possessions or the "right" marriage the Higher Power that determines if we have worth. We take our self-definition and self-worth from external manifestations of our own being so that looks or talent or intelligence becomes the Higher Power that we look to in determining if we have worth. All outside and external conditions are temporary and could change in a moment. If we make a temporary condition our Higher Power we are setting ourselves up to be a victim - and, in blind devotion to that Higher Power we are pursuing, we often victimize other people on our way to proving we have worth. That we all have equal worth as Spiritual Beings, as sons and daughters of the God-Force / Goddess Energy / Great Spirit - not because of any external manifestation or outside condition. Instead of being traumatized in a foreign country against an identified enemy during a war, as soldiers who have delayed stress are - we were traumatized in our sanctuaries by the people we loved the most. Instead of having experienced that trauma for a year or two as a soldier might - we experienced it on a daily basis for 16 or 17 or 18 years. A soldier has to shut down emotionally in order to survive in a war zone. We had to shut down emotionally because we were surrounded by adults who were emotional cripples of one sort or another. When a society is emotionally dishonest, the people of that society are set up to be emotionally dysfunctional. In this society being emotional is described as falling apart, losing it, going to pieces, coming unglued, etc. The goal is balance between emotional and mental - between the intuitive and the rational. If it is not ok to own all of our emotions then we can not know who we are as emotional beings. Often we got validated and affirmed by one parent and put down by the other. When the parent who is "loving" does not protect us - or themselves - from the parent that is abusive, it is a betrayal that sets us up to have low self esteem because the affirmation we received was invalidated right in our own homes. And being affirmed for being who we are is very different than being affirmed for who our parents wanted us to be - if they could not see themselves clearly then they sure could not see us clearly. In order to survive, children adapt whatever behavior will work best in helping them get their survival needs met. A dysfunctional relationship is one that does not work to make us happy. Codependency is about having a dysfunctional relationship with self. Because we have dysfunctional relationships internally we have dysfunctional relationships externally. We try to fill the hole we feel inside of our self with something or someone outside of us - it does not work. I am a "Counselor for Wounded Souls," a non-clinical, non-traditional therapist - a healer, teacher, and spiritual guide whose work is based upon Twelve Step Recovery Principles and emotional energy release/grief process therapy. My expertise is in codependency recovery, emotional healing, inner child work, Spiritual awakening and integration, personal empowerment and self-esteem, relationship dynamics, alcoholism/addiction recovery, and teaching people how to Love themselves. I have pioneered innovative, powerful techniques for emotional/inner child healing that allows individuals to learn how to relax and enjoy life while they are healing. I am also the author of Codependence: The Dance of Wounded Souls - a Joyously inspirational book of Mystical Spirituality that combines Twelve Step Recovery, Metaphysical Truth, Quantum Physics, and inner child healing. The healing paradigm that I share in my book and on my web site is one which has evolved in my personal recovery over the past 16 years and in my therapy practice over the past 10 years. I specialize in teaching individuals how to become empowered by having internal boundaries. My work is based on the belief that we are Spiritual Beings having a human experience and that the key to healing (and integrating Spiritual Truth into our emotional experience of life) is fully awakening to our Spiritual connection through emotional honesty, grief processing, and inner child work. The goal of the work is to be able to relax and enjoy life in the moment - while healing and learning how to have healthy, loving relationships with self and other humans. It is the unique approach and application of the concept of internal boundaries, coupled with the Spiritual belief system I teach, that make the work so innovative and effective. The wounding that needs to be healed is the result of being raised in a shame-based, emotionally dishonest, Spiritually hostile environment by parents who were raised in a shame-based, emotionally dishonest, Spiritually hostile environment. The disease which afflicts us is a generational disease that is the human condition as we have inherited it. Our parents did not know how to be emotionally honest or how to truly Love themselves. So there is no way that we could have learned those things from them. We formed our core relationship with ourselves in early childhood and then built our relationship with ourselves on that foundation. We have lived life reacting to the wounds that we suffered in early childhood. Living life in reaction to old wounds is dysfunctional - it does not work to help us find some happiness and fulfillment in life. It is a belief system that allows for the possibility that maybe there is an Unconditionally Loving Higher Power - a God-Force, Goddess Energy, Great Spirit, whatever it is called - which is powerful enough to insure that everything is unfolding perfectly from a Cosmic Perspective.

And if they had any questions or news to tell discount 50 mg voltaren mastercard arthritis treatment machine, I would let them know I was available purchase voltaren 50 mg overnight delivery arthritis back pain relief exercises. It started happening to my 10-year-old daughter this spring order voltaren 100 mg fast delivery arthritis in dogs treatment australia. The pants I hemmed up in June were too short by October buy 100mg voltaren overnight delivery arthritis in neck solutions, despite only being washed once. As a loving mom and adolescent medicine specialist, these are heady times for me. I am proud of my daughter and thrilled to see her embark on this road toward womanhood. Puberty, often first recognized at the onset of breast development, usually begins about the time a girl turns 10. For instance, it may occur between the ages of 8 and 14 in white girls, and may begin as early as 7 years of age in African American girls. Puberty is outwardly manifested by two main sets of changes:Rapid increases in height and weight, referred to as the height and weight spurtsDevelopment of breasts, and pubic and axillary (underarm) hairTracking the changes during puberty These changes, and the other physical changes of puberty, occur in a predictable sequence. Knowing the timing of these changes, related to each other and related to the sexual maturity ratings, is very helpful. And she knows that she is likely to have her first menstrual period about 2 years after her breasts first started developing. The height spurt usually begins just before or after breast budding develops. Over a period of about 4 years, girls grow close to a foot taller than they were at the beginning of the height spurt. The bones that grow first are those furthest from the center of the body. The growth in the spinal column alone accounts for 20% of the height increase. This is why it is important to check for scoliosis (sideways curvature of the back) before puberty begins. A slight curve can turn into a much larger one during all that growth. This is, of course, when she can never get enough to eat. Fully 50% of ideal adult body weight is gained in puberty. In girls, the proportion of body weight in fat increases from about 16% to nearly 27%. Lean body mass, especially muscle and bones, also increase substantially. Most of you know of the importance of good calcium intake for all women, especially growing teenagers, pregnant women, and nursing mothers. Milk and other dairy products are the least expensive, most convenient sources. Calcium is also available as a nutritional supplement in tablet form, but many teenagers find the tablets too large to swallow comfortably. Your daughter may like the fruit or chocolate-flavored calcium-supplement chews available in drugstores now. The table below summarizes the events at each stage of development. The average (mean) age listed here can vary widely; about 2 years either side of these listed ages will usually be considered normal. The areola (pigmented area around the nipple) enlarges and becomes darker. It raises to become a mound with a small amount of breast tissue underneath. A few long, downy, slightly darkened hairs appear along the labia majora. At the end of this stage, the body fat has increased to 18. Peak height velocity (maximum growth rate) is reached. Development of breast tissue past the edge of the areola. Moderate amount of more curly, pigmented, and coarser hair on the mons pubis (the raised, fatty area above the labia majora). Menarche (first menstrual period) occurs in 20% of girls during this pubic hair stageHair is close to adult pubic hair in curliness and coarseness. Area of pubis covered is smaller than adults, and there are no hairs on the middle surfaces of the thighs. Continued development of breast tissue; in side view, areola and nipple protrude. After menstruation begins, girls grow at most 4-5", usually less. It is normal for some long pigmented hairs to grow on the inner thighs. Parents often have concerns about whether their daughter is starting puberty too early or too late, or whether she is progressing normally. But whenever you are uncertain, it is best to seek out medical advice. No menstrual period by between the ages of 13 m to 14. In a girl who is at Sexual Maturity Rating 3 or higher, cyclic abdominal pain (pain similar to period cramps) every 3 to 5 weeks, but no menstrual periods. Development of pubic hair but no breast development within 6 to 9 months. They are:Asymmetry (one breast much larger than the other): This may be minimal, or it may be visible even when your daughter is dressed. Some girls with asymmetric breast size are embarrassed to wear a swimsuit, regardless of the extent of asymmetry. In severe cases, plastic surgery is the ultimate answer. This can be performed in teenagers after puberty and after the breasts are fully grown. Very large breasts: Very large breasts can be a source of constant embarrassment and self-consciousness from puberty onwards. They can also cause medical difficulties, namely back problems. Remember also that teenagers are famously self-conscious about their appearance. Once your daughter is older, she will hopefully have developed more self-confidence. She will then be in a better position to make an educated decision about breast augmentation. Inverted nipple(s): An inverted nipple means just that: the nipple is pointed inwards, rather than outwards. Looking at the breast from the side, you do not see the tip of the nipple protruding. A new non-surgical treatment has recently become available. Tuberous breast disorder: This is a fairly uncommon disorder that often goes unrecognized until a new mother has difficulty breast-feeding.

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We had to shut down emotionally because we were surrounded by adults who were emotional cripples of one sort or another buy voltaren 100mg otc arthritis pain relief ankle. When a society is emotionally dishonest cheap voltaren 50mg mastercard arthritis in the knee mayo clinic, the people of that society are set up to be emotionally dysfunctional discount voltaren 50mg online arthritis pain spreading. In this society being emotional is described as falling apart buy cheap voltaren 100 mg on line arthritis relief foods, losing it, going to pieces, coming unglued, etc. The goal is balance between emotional and mental - between the intuitive and the rational. If it is not ok to own all of our emotions then we can not know who we are as emotional beings. Often we got validated and affirmed by one parent and put down by the other. When the parent who is "loving" does not protect us - or themselves - from the parent that is abusive, it is a betrayal that sets us up to have low self esteem because the affirmation we received was invalidated right in our own homes. And being affirmed for being who we are is very different than being affirmed for who our parents wanted us to be - if they could not see themselves clearly then they sure could not see us clearly. In order to survive, children adapt whatever behavior will work best in helping them get their survival needs met. A dysfunctional relationship is one that does not work to make us happy. Codependency is about having a dysfunctional relationship with self. Because we have dysfunctional relationships internally we have dysfunctional relationships externally. We try to fill the hole we feel inside of our self with something or someone outside of us - it does not work. I am a "Counselor for Wounded Souls," a non-clinical, non-traditional therapist - a healer, teacher, and spiritual guide whose work is based upon Twelve Step Recovery Principles and emotional energy release/grief process therapy. My expertise is in codependency recovery, emotional healing, inner child work, Spiritual awakening and integration, personal empowerment and self-esteem, relationship dynamics, alcoholism/addiction recovery, and teaching people how to Love themselves. I have pioneered innovative, powerful techniques for emotional/inner child healing that allows individuals to learn how to relax and enjoy life while they are healing. I am also the author of Codependence: The Dance of Wounded Souls - a Joyously inspirational book of Mystical Spirituality that combines Twelve Step Recovery, Metaphysical Truth, Quantum Physics, and inner child healing. The healing paradigm that I share in my book and on my web site is one which has evolved in my personal recovery over the past 16 years and in my therapy practice over the past 10 years. I specialize in teaching individuals how to become empowered by having internal boundaries. My work is based on the belief that we are Spiritual Beings having a human experience and that the key to healing (and integrating Spiritual Truth into our emotional experience of life) is fully awakening to our Spiritual connection through emotional honesty, grief processing, and inner child work. The goal of the work is to be able to relax and enjoy life in the moment - while healing and learning how to have healthy, loving relationships with self and other humans. It is the unique approach and application of the concept of internal boundaries, coupled with the Spiritual belief system I teach, that make the work so innovative and effective. The wounding that needs to be healed is the result of being raised in a shame-based, emotionally dishonest, Spiritually hostile environment by parents who were raised in a shame-based, emotionally dishonest, Spiritually hostile environment. The disease which afflicts us is a generational disease that is the human condition as we have inherited it. Our parents did not know how to be emotionally honest or how to truly Love themselves. So there is no way that we could have learned those things from them. We formed our core relationship with ourselves in early childhood and then built our relationship with ourselves on that foundation. We have lived life reacting to the wounds that we suffered in early childhood. Living life in reaction to old wounds is dysfunctional - it does not work to help us find some happiness and fulfillment in life. It is a belief system that allows for the possibility that maybe there is an Unconditionally Loving Higher Power - a God-Force, Goddess Energy, Great Spirit, whatever it is called - which is powerful enough to insure that everything is unfolding perfectly from a Cosmic Perspective. That everything happens for a reason - there are no accidents, no coincidences, no mistakes. It would be possible for someone to use the tools and techniques that I teach - for inner child healing and setting internal boundaries - to change some of their codependent/reactive behavior patterns and work on healing their childhood emotional wounds without a Spiritual belief system underlying the work. It would be possible but in my view would be kind of silly. A Spiritual belief system is simply a container for holding all our other relationships. Why not have one that is large enough to hold it all? In my personal recovery, I found that I needed a Spiritual container large enough to allow for the possibility that I was not a flawed, shameful being. I searched until I found some logical, rational means to explain life in a way that would allow me to start letting go of the shame I was carrying and start learning how to be Loving to myself. For me it became a simple choice: either there is a higher purpose to this life experience or there is not. So, I chose to believe that there is a Spiritual purpose and meaning to life. And choosing to believe in a Loving Higher Power has transformed my life from an ordeal to be endured to an adventure that is exciting and Joyous much of the time. The bottom line for me is that it works for me, it is functional, for me to believe that there is Spiritual purpose and meaning to life. The tools and techniques, insights and beliefs, that I set out in my book and web site work. They work to support the idea that each and every one of us is Lovable and worthy. We are Spiritual Beings having a human experience - this is the polar opposite of the beliefs which underlie Civilization - it changes the whole game. Robert Burney, author of Codependence: The Dance of Wounded Souls , calls his private practice "Counseling for Wounded Souls. Robert is a non-clinical, non-traditional therapist a healer, teacher, and Spiritual guide whose private practice is based upon Twelve Step Recovery Principles and emotional energy release/grief process therapy. His practice is based on the belief that we are Spiritual Beings having a human experience and that the key to healing is awakening to consciousness of our Spiritual connection. He emphasizes that thepurpose of healing is to learn how to enjoy being alive. Robert is based in Cambria on the the Central Coast of California. He spends part of each week in Santa Barbara and works with clients in Los Angeles. In the spring of 1991, Robert Burney was asked to speak in several different venues on the subject of Codependence. In the course of those speaking engagements he heard himself making statements to a general audience that he had never considered saying in public because of their controversial nature. To his surprise he found that the practical process level tools and techniques that he utilized in his private therapy practice were merging with mystical and magical knowledge he had acquired writing a book that was an adult fable about the history of the Universe the first book of a trilogy. Although he experienced a great deal of fear about making such controversial statements in public, he was compelled to further explore this message that he felt coming through him. He arranged dates in June of 1991 to give a talk in Cambria and Morro Bay, California.

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