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It was in the 1930s that Lief became aware of the work of an Ayurvedic physician working in France cheap 200 mg plaquenil with amex arthritis back stretches, Dewanchand Varma buy 200 mg plaquenil amex arthritis foundation grants, whose work he studied best plaquenil 200mg arthritis treatments in dogs, and purchase plaquenil 200mg without a prescription rheumatoid arthritis exercise, assisted by his Figure 3. The approach of the tonic treatment is con- general mobilization and visceral techniques on most stitutional by its nature. Neuromuscular technique is also taught at the University of Westminster, London, as a 3-year References undergraduate degree subject, alongside a Abrams A 1918 Spondylotherapy: physio- and naturopathic degree course. In that time almost every Brinker F 1998 The role of botanical medicine in 100 portion of the body has, in some manner, been treated. American The type of manual therapy applied to particular Botanical Council tissues can be seen to be relevant to the type of tissue Broadwell R 2001 Interview with Dr Robert Broadwell, affected. Economic and Business Research, University of Utah, Station Hill Press, New York, p xxi–23 Salt Lake City Kirchfeld F 1994 Nature doctors: pioneers in Chaitow L 1980 Neuromuscular technique: a naturopathic medicine. Benedict Lust Publications, New York, Lindlahr H 1981 Natural therapeutics, vol 2: practice. Benedict Lust Lust Publications, New York, p 14 Publications, New York, p 294 Lust B 1909 How to protect ourselves against cerebro- Gillett C 1931 The Gillett course in eye, ear, nose, and spinal meningitis. Lust B 1919a Universal naturopathic encyclopedia, htm directory, and buyers guide. Benedict Lust Publications, New York, Professions, University of California, San Francisco p 369–371 Journal of the Australian Naturopathic Association. Benedict Sydney, Australia, 1945 Lust Publications, New York, p 55–56 Chapter 3 • History of Naturopathic Physical Medicine 73 Lust B 1936 Post-graduate study of naturotherapy. Benedict Lust 59:183 Publications, New York Rudolf W 1908 Homeopathy and its relation to Lust B 1937 Naturopath and Herald of Health. York Benedict Lust Publications, New York Macfadden B 1914 Macfadden’s encyclopedia of Staden L 1902a Acute and chronic disease. Benedict Lust Publications, New Publishing, New York York, p 16 Marquardt H 1983 Reflex zone therapy of the feet: a Staden L 1902b Naturopathic adviser. Benedict Lust Publications, New edition York, p 46 Metcalfe R 1902 The sweating cure for hydrophobia. Benedict Lust Publications, New York, p 333 Wendel P 1945 Bloodless surgery: with technique and treatments. For an evaluation of the evi- dence basis from which this medicine draws its clinical Definition of naturopathic physical medicine 75 modalities, a study should be made of Chapters 7, 8, 9 Self-healing and regulation (vis medicatrix and 10 in this text. It gives a • aerobic status broad outline of the context of its practice, and this • strength, stability and stamina of the somatic chapter aims to deepen and expand on these ideas to tissues consolidate the characteristic naturopathic approach • tissue healing potential after injury, evidenced to physical medicine. Many professions utilize similar by personal history, circulatory status and methods and techniques, and a few have similar natu- general immune health ralistic and holistic principles underpinning their • tissue response to stress (e. The naturopathic approach needs to be iden- inflammatory, pain) evidenced by personal tifiable in order for the profession to progress and history and provocative physical examination claim its unique position in health care provision. Since, by definition, those individuals who seek professional health assis- How this is expressed in physical terms tance already have established problems, optimal health is unlikely to be identified in clinical practice. This includes considering • infective (bacteria, viruses, parasites) whether the symptoms being experienced might rep- • immunological (antigen–antibody, cell resent positive expressions of self-regulation in- mediated). The body sets up inflammation in order to reach the This is often referred to as the ‘intelligence’ of the vis goal of resolution, repair and reorganization (Govan medicatrix naturae. On the other hand, in pioneer – see Chapter 3) himself thought that manipu- some cases, reduced activity may be what these lation was useful in infections because it ‘hastened the symptoms are requesting as their remedy. How- normal development of the inflammatory process’ ever, if these symptoms are excessive or prolonged, (Lindlahr 1918a). This runs counter to many should be how to assist in the self-healing of the indi- symptomatic treatments in other forms of medicine, vidual, without interrupting or suppressing positive and requires a brief discussion. This discussion also symptoms that may be contributing to the healing has relevance in the context of the hyperthermic mea- process. Hunter (1998) sug- reducing muscle spasm and joint stiffness gests that this is a key time for initiating constructive locally in order to increase comfortable aerobic treatment: ‘The tendency for the formation of ran- exercise with a detoxifying goal domly oriented collagen fibers that restore structure • treat symptoms as a first step in management, but not function can be reduced by careful tensioning increasing patient compliance for additional of the healing tissue during the regeneration phase. An understanding of the answers to this question lie in the analysis of the con- properties of connective tissue and fascia allows for dition, in the total context of the patient, and require the selection of appropriate treatment strategies. Slow a thorough grounding in physiological pathology – deliberate movements that localize tension to the especially with regard to the effect of tissue trauma injury site, as precisely as possible, are considered and inflammation. Having a goal of self-healing means that those encountered in daily life, are encouraged. Pain- the practitioner will wait and observe symptomatic avoidance behaviors should be recognized and reactions for clues that the system is self-regulating, attempts made to reassure the patient to continue when other forms of medicine may observe the same movement therapies even in the face of some types of symptoms as suffering, and attempt to modify or sup- discomfort (see Chapter 9 for more on the topic of press them. It also creates the lish the optimal conditions for a concise and effective platform for decision-making that seeks to avoid sup- acute inflammation, with full resolution and return to pression of symptoms. Therefore, defining what is normal function, and prevention of progression to harmful for each individual is highly context driven, chronic inflammation. This requires management, and stimulation in some cases, of the inflammatory process in order to achieve resolution. In Chapter 7 Hal Brown discusses the evidence • understandable, from a functional viewpoint for and against the safety of the high velocity, (i. For example, the more robust drain- age techniques (such as those described in Chapter 7), whilst being gentle, can nevertheless stimulate a dys- First do no harm functional system beyond its adaptive capacity, and so cause an untoward reaction (Kasseroller 1998). Following this principle, the therapeutic ini- related to: tiatives that are chosen should have the best interests • vigor of touch and pressure applied to tissue of the patient at the core of the decision, and have no • velocity of technique application side-effects or long-term consequences that decrease the wellness and vitality of the system. This discussion would not be complete without the description of modalities in physical medicine being The amount of stimulus to a sensory-based system categorized as either direct or indirect. These terms can can be measured in both quantity of pressure and its relate to an identified restriction in motion, and speed of application. These are vital features in all whether the technique addresses the ‘barrier’ of modalities, as the sensory–motor reflex mechanism is restriction directly, to take it into a bind (as in prepara- highly individual, a factor that needs to be addressed tion for a high velocity thrust or a stretch), or whether at the commencement of therapy. The patient who has the tissue is taken away from the barrier into ease been involved in major trauma can be highly sensitive (Greenman 1997). Indirect techniques, by their nature, to touch, and can require a very slow and gentle initial reduce stress in the tissues during their application, contact, and progression of technique. For these reasons, they suit tude (see technique chapters, particularly Chapters 7, the methodology of naturopathic physical medicine 8 and 10). The lower ends of the spectrum are gentler (refer to Chapter 7 where such methods are described and less likely to cause reaction. Techniques can be in detail, for example under the heading ‘Positional applied for as little as a few seconds, up to hours in a release techniques’). For example, in myofascial release therapy, as soon as the tissue softens, the goal has been Constitutional issues reached. The interaction between treatment and patient is a In hydrotherapy, the temperature required might take critical one. Within each quickly, too forcefully or for too long – or inappropri- modality, there is a sliding scale of low to high appli- ately to the needs of the patient – will unsurprisingly cation of degree and duration, with ultimate responses have negative (or at least no positive) effects. The depending on complex interactions between the bio- make-up of the patient and the underlying constitu- mechanical influences being applied, and the unique tional influences are equally important. The notes on constitutional considerations in length of application to achieve the dose that does Box 4. Another benefit of dividing the dose over a principle, and reduces risk, is the use of patient educa- number of consultations is that the effect of the previ- tion and self-directed activities. When patients understand Another way of considering repetitive exposure to their condition, its causes and remedies, their comp- incremental ‘doses’ of physical treatment (e.

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Reproduced with permission from Chaitow (2006) 176 Naturopathic Physical Medicine Box 6 buy cheap plaquenil 200mg on line arthritis back pain injections. C7 • If plaquenil 200mg line arthritis medication arava, however order plaquenil 200 mg amex juvenile arthritis relief, translation of the segment towards the • The middle finger pads will be on C5 plaquenil 200 mg free shipping severe arthritis in neck and back, the ring finger right from the left produces a sense of resistance/ pads on C4 and the little finger pads on C3, bind, then the segment is restricted in its ability to stabilizing these segments. B With the head/neck in a neutral position, the practitioner sequentially guides individual segments into translation in both directions in order to sense indications of restriction and tissue modification. If a restriction is sensed, its increase or decrease is evaluated for retesting with the segment held in greater flexion and then extension. Reproduced with permission from Chaitow (2006) 178 Naturopathic Physical Medicine Box 6. Is there a springing sensation, or a harsh In this way you can assess both the quality and quantity end-feel? Does the repeated with your thumb contact on L4, L3, L2 and segment ‘spring’ appropriately? Once the lumbar joints have been assessed on one side the process is repeated on the other. Anteroposterior movement • The patient should be side-lying with knees and hips flexed, and with both knees just off the edge of the table. This hypothesis is based on the (left side): similar embryological origin of the innervation of somatic and visceral tissue. According to Lewit (1999a), the first signs of viscero- In a randomized study, Nicholas et al (1987) observed somatic reflexive influences are vasomotor (increased that: ‘Myocardial infarction is accompanied by char- skin temperature) and sudomotor (increased moisture acteristic paravertebral soft tissue changes which are of the skin) reactions, skin textural changes (e. Chapter 6 • Assessment/Palpation Section: Skills 179 Korr (1976) has compared any facilitated area of the • T6 central and right 6th rib, resistant to passive spine to a ‘neurological lens’, in which stress factors axial rotation to the left, side-bending right, which impinge upon any aspect of the body or mind flexion; translation anterior and left. Cholelithiasis linkages McFarlane Tilley (1961) listed the possible implica- tions of segmental facilitation, in various spinal • ‘At 10th (and sometimes 11th) thoracic level regions, based on osteopathic clinical observations: the paraspinal tissues will usually display responses to facilitation’ (Larson 1977), • Myocardial ischemia: rigid musculature in any resulting in immediate increased tissue two adjacent segments between T1 and T4 resistance to passive axial rotation to the left, (usually left, but not essentially so). An exercise • Female and male reproductive organ problems: derived from Beal’s work is illustrated in Box 6. These observations from premier osteopathic re- Johnston’s recommendations regarding searchers should inform naturopathic practitioners and physicians of the potential for influencing somatic somatic findings of visceral origin structures in order to encourage resolution of dys- Johnston, over many years of clinical research, has functional segmental patterns and indirectly (reflex- identified a number of predictable segmental (spinal) ively) the somatic sources of these patterns. It is clear locations and motion characteristics that relate to vis- from a naturopathic perspective that this would not cerosomatic reflex activity. He terms these ‘linkages’ be the end of the story, but in conjunction with appro- (Johnston 1988). These have all been demonstrated to priate focus on digestive status and function, and on have a high inter-rater reliability when tested by other any associated psychosocial factors, would ensure clinicians. The test becomes part of self-treatment when the patient is asked to perform the test regularly at home to encourage enhanced balance. Splinting will usually be more widespread than the two adjacent segments commonly associated with segmental facilitation, and no attempt should be made to reduce such splinting, which is protective. He has presented evidence showing that correcting Balance represents an accurate snapshot of the cervical dysfunction can improve standing posture if current functional efficiency of the individual’s neu- disequilibrium problems can be shown to be associ- romusculoskeletal integration. Bohannon et al (1984) have identified widely The test is suggested – according to Lewit (1999a, p. Cervical association acceptable (most commonly involving C1, C2 and C3) may be • After 70 years of age, 4 seconds is normal. Liebenson (2001) explains the need for precision in Cervical involvement with balance assessment when faced with patients with balance problems and gait disturbances: ‘Differentiating between Lewit (1999a) has shown the importance of Hautant’s primary feet, lumbar and cervical disorders is test (Box 6. It is possible for a skilled practitioner to use this type of refinement to calculate the degree of abnormal Figure 6. If the test results in an abnormal degree of rotation then it should be repeated periodically during and after the use of therapeutic tactics directed at normal- Notes on other balance influences izing dysfunctional patterns revealed during normal Gagey & Gentaz (1996) note: assessment, possibly involving the feet, spine, pelvis, neck or the eyes. When a normal subject keeps his or her head turned to In addition, Gagey & Gentaz suggest other possible the right, the tone of the extensor muscles of the right causes of, and treatment options for, disturbed balance, leg increases, and vice versa for the left side. The using ‘the law of semicircular canals’ difference between these two angles of rotation • plantar input, where mechanoreceptors in the [i. Such deviations may be the result of trigger hand contacts to rest on the appropriate suture, as points or shortened fibers within the musculature the same rocking motion is introduced via the action (deviation will usually be towards the side of of the right hand contacts on the maxillae. Are there any • A hard end-feel to opening, especially when the areas where this is diminished? And, if so, what might range is significantly reduced, may indicate anterior the significance of this be? Cranial assessment, including temporomandibular joint Coronal suture palpation, and observation and palpa- than another. What a surprise it was for us to discover tion of the temporomandibular joint, are outlined in that the axes of motion reproduce exactly those of Boxes 6. The discovery of this phenomenon was purely empirical, and tends to Notes on visceral palpation confirm the idea that ‘cells do not forget’. Accurate visceral palpation requires a high degree of palpatory literacy that can only be accomplished by Additionally, visceral motion is influenced by: practice. There is an inherent axis of rotation in each of these Stone (1999) has described the movement of motions (mobility and motility). In healthy organs, the organs: axes of mobility and motility are generally the same. With disease, they are often at variance with one Visceral biomechanics relate to the movements that the another, as certain restrictions affect one motion more organs make against each other, and against the walls Chapter 6 • Assessment/Palpation Section: Skills 183 Box 6. In some cases the hand can adapt wide postural changes take place that have been char- itself to the form of the organ. Let the hand ances that occur as antagonists become inhibited due passively follow what it feels – a slow movement of feeble amplitude which will show itself, stop to the overactivity of specific postural muscles. The effect on spinal and pelvic mechanics of these imbalances would be to create an environment in This is visceral motility. Empty the release and stretch whatever is over-short and tight, mind and let the hand listen. One visceral palpation exercise for motility – of the In his classic text on body mechanics, Goldthwait liver – is described in Chapter 7 under the subheading (1945) described the changes that are commonly found ‘Visceral manipulation’ (see page 273). The viscera heart, displacing this organ and resulting in ‘articulate’ by utilizing sliding surfaces formed by the traction on the aorta. General assessments: posture and • The pancreas is mechanically affected, respiration interfering with its circulation. Weak muscles: (1) serratus anterior; (2) lower and middle trapezius; (3) deep neck flexors. Shortened muscles: (1A) pectoralis major; (2A) upper trapezius and levator scapulae; (3A) suboccipitals; (3B) sternocleidomastoid. Reproduced with permission from Chaitow (2003b) Chapter 6 • Assessment/Palpation Section: Skills 185 • The prostate becomes affected due to functional tests such as scapulohumeral circulatory dysfunction and increased pressure, rhythm test, core stability (Liebenson 2005, making hypertrophy more likely. Norris 1995) • Similarly, menstrual irregularities become more • Gait analysis is described in Chapter 9. The scope of this chapter does not allow a detailed • Spinal and rib restrictions become chronic, summary of these topics, and the following texts are making this problem worse. Churchill Livingstone, Edinburgh Kuchera (1997) discusses gravitational influences on • Lewit K 1999 Manipulation in rehabilitation of posture: the motor system, 3rd edn. Butterworth- Gravitational force is constant and a greatly Heinemann, London underestimated systemic stressor. Of the many • Liebenson C 2005 Rehabilitation of the spine, signature manifestations of gravitational strain 2nd edn. Mosby, St Louis Kuchera & Kuchera (1997) add a perspective that makes clear how varied are other contextual influ- ences on ‘postural decay’: Breathing pattern evaluation Posture is distribution of body mass in relation to Garland (1994) has summarized the structural modi- gravity over a base of support.

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Antiinflammatory therapy is still greatly under- also more likely to have a drinking problem cheap 200mg plaquenil otc rheumatoid arthritis supplements, to used buy generic plaquenil 200mg arthritis fingers bending, especially in socioeconomically disadvantaged groups cheap plaquenil 200 mg amex arthritis for dogs. For preg- 118:3546–3556 nant women with asthma purchase 200mg plaquenil arthritis in the knees treatment for pain, inhaled cromolyn should be the This article discusses how cytokines orchestrate the chronic first-line therapy, followed by inhaled budesonide if symp- inflammation and structural changes of the respiratory tract toms worsen. Inflammatory genes are regulated by inhaled magnesium sulfate in addition to a -agonist for the proinflammatory transcription factors such as nuclear factor- treatment of an acute asthma exacerbation appears to have κB and activator protein-1. Clin line-derived asthma control can be achieved in a majority of Chest Med 2007; 28:685–702 patients; however, the asthma of a significant percentage of This review underscores the differences between asthma in patients cannot even be well controlled with this combina- the young and elderly. This article is taken five evaluating sublingual immunotherapy and two evaluat- from the American College of Chest Physicians Evidence- ing subcutaneous immunotherapy, reported a reduction in Based Practice Guidelines on Cough, which was published symptom and medication scores. The different educational interventions for adult patients treatment of an acute asthma attack is not compromised by consulting with an acute asthma exacerbation. Minimal car- emphasizing self-capacity to manage asthma exacerbation diac effects are seen in most patients; however, there are very and the use of peak flow rate reduce the morbidity of patients few data on this subject in patients with preexisting heart with asthma. Chest 2003; 123(suppl):447S–449S This article examined the efficacy of immunotherapy for This article discusses more recent thinking on the genetics asthma in ragweed-sensitive patients. Thorax 1999; 54:265–267 objective measures of improvement of asthma and allergy This interesting article discusses the influence of estrogens during the first year of therapy, the improvement was not and progesterone on asthma. Their use in patients with severe asthma or those with This is an evidence-based review of developments from the premenstrual exacerbations of asthma will require future past few years in asthma management. The author concludes that, “[a]t the present literature search up to 2005 on a number of approaches to [time,] there is not enough evidence to suggest any change to asthma therapy including allergen avoidance, dietary manip- current prescribing practice. This altered epithelium becomes an important source of media- article enhances our knowledge of how viruses can adversely tors, chemokines, and growth factors that sustain ongoing affect lung or immune development in asthma patients. Cochrane scheduled albuterol treatment in asthma: genotype- Database Issue 4, 2005 stratified, randomised, placebo-controlled cross-over This Cochrane Database review presents data on the use of trial. By contract, the Arg/Arg geno- Am J Med 2003; 115(suppl):39S–44S type group had lower morning peak flow rates during the This article reviews the association between gastroesophageal treatment with albuterol. It is present in greater concentrations in steroid-naive monoclonal antibody, in patients with severe allergic asthma asthmatic patients compared with healthy control individu- that is refractory to corticosteroid therapy. Exp Opin Drug Saf 2007; 6:15–26 104 Asthma (Braman) This article reviews the literature on asthma or use of anti- little evidence for an IgE-mediated mechanism. Compari- responsible for occupational asthma, may work through the son of high-dose inhaled flunisolide to systemic cor- overproduction of matrix metal-loproteinase-9, which may ticosteroids in severe adult asthma. It gives further evidence for systemic responsiveness to methacholine persist in subjects who are steroid withdrawal as a cause of Churg-Strauss syndrome removed from exposure to the isocyanates for 10 years. J Allergy Clin Immunol 2002; 110:381–387 inhaled corticosteroid use in asthma: collaboration This study shows that hay fever and asthma were less com- of American College of Chest Physicians, American mon in participants who were seropositive for hepatitis A, Academy of Allergy, Asthma, and Immunology, and Toxoplasma gondii, and herpes simplex virus 1 compared American College of Allergy, Asthma, and Immunol- with seronegative participants. Transient early wheezers (ie, children who wheeze occur include subepithelial fibrosis, smooth-muscle hyper- during early life but who were not wheezing at age 6 years) plasia and hypertrophy myofibroblast hyperplasia, epithelial were no more likely to wheeze after age 6 years than healthy hypertrophy, and mucus gland and goblet-cell hyperplasia. This might result in an exaggerated narrowing of The study also showed that deficits in lung function that are the airway after a bronchoconstricting stimulus. It has observed in children with asthma are not the consequence been argued that some aspects of remodeling have beneficial of ongoing disease, but rather are due to changes before the effects: stiffening the airway may result in decreased com- age of 6 years. Although the transient wheezers have lower pressibility allowing the airways to better resist dynamic lung function that is present as early as the first 3 months compression; and extra connective tissue, surrounding of life, they do not have the elevations in serum IgE levels, the smooth-muscle cells may provide a radial constraint to eosinophilia, and skin test reactivity to aeroallergens that are maximal shortening. Asthma exac- Clin Immunol 2005; 5:85–90 erbations during pregnancy: incidence and associa- Chronic inflammation in asthma can lead to airway remod- tion with adverse pregnancy outcomes. Develop- A controlled trial of environmental intervention to reduce ment of the asthma control test: a survey for assess- allergies and environmental smoke that included the reduc- ing asthma control. This asthma control test asthma and wheezing in the first 6 years of life: follow- presents a scoring system for asthma control that includes up through adolescence. These 2005; 172:1253–1258 include asthma symptoms, the use of rescue medications, The authors found that in children who start having asthma- and questions regarding the impact of asthma on everyday like symptoms before the preschool years, the prevalence of functioning. This updated report (Expert Panel tutes of Health, August 2007 Report 3) continues to emphasize that the most effective This guideline should be on the bookshelf of every pulmon- medications for long-term therapy are those shown to have ologist. The Salme- asthma for most patients begins early in life, with the pattern terol Multicenter Asthma Research Trial: a comparison of disease persistence determined by early, recognizable risk of usual pharmacotherapy for asthma or usual phar- factors, including atopic disease, recurrent wheezing, and a macotherapy plus salmeterol. The patients were used for the written asthma action plan, although in some predominantly women and had a misdiagnosis of asthma for studies cited, investigators may have used a variation of this an average of almost 5 years. An in-depth discussion of 2005; 5:161–166 antigen sensitization and the subsequent cytokine response This article is a review of more recent articles on the rela- is provided. The pulmonary physician in immune mechanisms involved in the phenotypic expression critical care: acute severe asthma in the intensive care of allergic diseases, including the allergen-specific T-helper unit. Other modalities, including the Care Med 2005; 171:129–136 use of helium, magnesium sulfate, and inhalation anesthetic This group hypothesized that the conditions of patients agents, also are discussed. In a double- This review discusses recent advances in our understanding blind randomized study of 2,760 patients with asthma, of the pathophysiology, diagnosis, and treatment of near- the budesonide/formoterol maintenance therapy plus relief fatal asthma medication prolonged the time to first exacerbations and Ringdal N, Chuchalin A, Chovan L, et al. The a randomised, double-blind comparison of Seretide therapy also improved symptoms, nighttime awakenings, (50/250 microg bd Diskus vs formoterol (12 microg and lung function. Salmeterol plus fluticasone was at least as airway responsiveness are useful in making a diagnosis of effective as formoterol plus budesonide in improving pulmo- asthma, especially when symptoms are present and there is nary function despite a lower corticosteroid dose. The anti-inflam- The airway smooth muscle is a major effector cell of asthma matory effects of leukotriene-modifying drugs and that is responsible for bronchomotor tone. Am J Respir Crit 5:185–193 Care Med 2005; 172:453–459 This article reviews the relationship between obesity and Patients with asthma symptoms who had not previously asthma. A number of prospective studies have shown that received a diagnosis of asthma were studied to determine weight gain can antedate the development of asthma. Curr Opin Allergy However, it also takes a closer inspection of the literature Clin Immunol 2005; 5:49–56 and reveals significant overlaps between the two conditions. In this study, more than airway hyperresponsiveness as an additional guide to one in four children had wheezing that persisted from childhood long-term treatment. The factors pre- 159:1043–1051 dicting persistence or relapse were sensitization to house dust This group of investigators explored whether a treatment mites, airway hyperresponsiveness, female sex, smoking, and strategy aimed at reducing airway hyperresponsiveness early age at onset. These findings, together with persistently added to the strategies used in the asthma guidelines would low lung function, suggest that outcomes in adult patients provide more effective control of asthma and greater improve- with asthma may be determined primarily in early childhood. This implies that the monitoring of airway This interesting article discusses a theory of why a paradoxi- hyperresponsiveness (by repeated bronchial inhalation chal- cal response sometimes develops in asthmatic patients who lenge) may improve the long-term management of asthma. Sudden-onset fatal was written by a panel of experts, including allergists, pulm- asthma: a distinct entity with few eosinophils and rela- onologists, and occupational medicine physicians, The Con- tively more neutrophils in the airway submucosa? Am sensus Document defined work-related asthma to include Rev Respir Dis 1993; 148:713–719 occupational asthma (ie, asthma induced by sensitizer or This study determined the histologic differences in the air- irritant work exposures) and work-exacerbated asthma (ie, ways of patients who died of sudden-onset asthma ( 1 h) preexisting or concurrent asthma worsened by work factors). Patients with slow-onset asthma had more agement (including diagnostic tests, and work and compen- eosinophils and fewer neutrophils than patients with sudden- sation issues), as well as preventive measures. The relationship asthma is immunohistologically distinct from the slow-onset between infant airway function, childhood airway type because of these differences in eosinophilic and neutro- responsiveness and asthma. They raise the possibility that the Med 2004; 169:921–927 mechanisms involved in these two distinct forms of asthma This study sought to determine whether there are early life are different. The presence of This article reviews the basic and clinical science that impli- wheezing at age 11 years was associated with lower lung func- cates the atypical bacterial pathogens M pneumoniae and tion during infancy and was independent of increased airway Chlamydophila (formerly Chlamydia) pneumoniae responsiveness and atopy at a younger age. Although their that intrinsic disturbances in lung function, possibly related exact contribution to asthma development and/or persistence to lung development, maternal factors, and/or environmental remains to be determined, evidence links them to new-onset factors close to the time of birth, have a role in the later devel- asthma and asthma exacerbations. It concludes Recent investigations have highlighted that endogenous that aspirin-induced asthma runs a protracted course even if antiinflammatory mediators and immune-regulating mecha- therapy with cyclooxygenase-1 inhibitors is avoided. Risk fac- diagnostic methods has shown that rhinovirus is the most tors associated with the presence of irreversible airflow common cause but coinfection is frequent. Viruses provoke limitation and reduced transfer coefficient in patients asthma attacks by additive or synergistic interactions with with asthma after 26 years of follow up.

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They are common genetic diseases present in 1:500 men and is increasing in inci- with a high carrier frequency in specifc popu- dence for undetermined reasons plaquenil 200mg free shipping arthritis medication diabetes. Accessing the target a proportion of men with azoospermia purchase plaquenil 200mg with visa rheumatoid arthritis physical exam, but the population remains a challenge as on average cause of the infertility may then be passed on 200 mg plaquenil arthritis medication weight loss. The majority of myotonic dystrophy should be carefully coun- Marfan’s syndrome has a prevalence of improve during the pregnancy only to affected patients have mild learning diffcul- seled regarding their own health and the risk 1–5:10 purchase plaquenil 200mg on-line arthritis fingers,000, the major physical features being deteriorate postnatally. Maternal age for frst pregnancy is increas- 21 span 10% more than the height, high arched festations and possibly leiomyomata of the counseling is strongly recommended. The patient may wish to undergo inva- ness in pregnancy that is rare in younger complications are lens dislocation and dissect- sive prenatal diagnosis in view of the approxi- women, such as coronary artery disease. There may be no previous family Marfan’s syndrome may be identifed in the These rarely cause fetal/neonatal compromise All autosomal dominant diseases that affect history of the disease. Two genes have been fetus on ultrasound but normally this is the and disappear over the frst year of life but one parent have a 50:50 chance of being passed on to the fetus. The majority are inher- Ehlers Danlos syndrome type I however, many women may be taking beta- Many women with successfully repaired con- ited as an autosomal dominant trait, and the blockers and a few will have implantable car- genital heart disease are now becoming preg- penetrance is highly variable. Conotruncal and careful assessment needs to be undertaken are not given to affected women as they may Respiratory disease cardiac defects are the commonest type of prior to pregnancy. All couples where larly carefully monitored, and anticoagulation may make patients more vulnerable to arrhyth- Cystic fbrosis one parent is affected should be offered either may be required. It is advisable that the partner tion, may become hypocalcemia if the mother and beyond the scope of this chapter, includ- it is a diffcult diagnosis to confrm in the is tested for cystic fbrosis. Referral to a cardiologist spe- mutations in the northern European popula- Cardiomyopathy cializing in inherited cardiac disease is advis- tion, 90% can be screened. Valproic acid embryopathy: report Phenylketonuria Increased osteopenia may occur during the Periconceptional counseling in of two siblings with further expansion of the postnatal period. Spinal anesthesia is unlikely to be contra- normal antenatal services and equally impor- Neurology 2005;64:961–5 phenylalanine diet needs to be followed pre- indicated but may be technically challenging. It Systemic lupus erythematosus Growth until puberty after in utero exposure syndrome may have partial expression in a girl, is a urea cycle defect resulting in hyperam- to coumarins. Treatment consists of Diabetes mellitus (diabetic embryopathy) a baby, and family discussions and involvement 2008;11:324–30 a low protein diet and arginine supplementa- Diabetes mellitus is the most common chronic of social services are entirely appropriate. The partner tions der(13;14): frequencies of reproductive ceptional counseling for diabetic mothers is may also have learning diffculties and details outcomes and infertility in 101 pedigrees. Am J Women with skeletal dysplasia are not at well recognized and does not need to be reiter- of the cause of his problems may also need to Med Genet A 2008;146A:2611–6 high risk during pregnancy, and no par- ated in this chapter (see Chapters 5 and 32). When published their frst reports regarding the these environmental conditions change rap- association between reduced fetal growth idly, the fetus who later becomes an adult is and a number of conditions occurring later in exposed to a different environment than the life. At the beginning of Low birth weight obviously may serve as an the 21st century, Bateson and Barker pub- indicator of a disrupted intrauterine environ- lished their ‘developmental plasticity theory’5. This indicates that small morbidity in offspring, one should try to look well as by changing the secretion of several been recognized for decades and thoroughly Indian babies have small abdominal viscera into the assumed mechanism by which this investigated, as noted above. This may affect fetal ing frst and second trimester of pregnancy) ity, and that low maternal intake of B12 but to illustrate how cell differentiation (i. Such fndings highlight onstrated that maternal diet during preg- fnding is now thought to be an indicator of 8 (diabetes and osteoporosis) in adult life. It draws upon its genetic milieu the offspring, although sharing the same coat- mother, such as fetal gender or ethnic back- folate14,15 may be associated with increased for continued development and growth. There sitive indicator of the timing, extent and dura- In a similar sense, over-exposure to harmful the embryo/fetus develops is much more than is some indication from plants that epigenetic tion of exposure to nutritional deprivation. It is an interactive vessel that may dic- The growing fetus shows a remarkable abil- supplements (protein or caloric) on birth may infuence prenatal and childhood out- tate the expression of the genes, and may cre- ity to assume different sizes and discrete func- weight9, whereas others demonstrate only a come. Later life obe- can be extracted from experimental and animal sity is potentiated by alterations in appetite Maternal nutrition Transplacental transfer studies. Simple growth failure: a reduction in size likely by alterations in renal and blood ves- and number of cells in specifc tissues, for sel development, while diabetes is associated example, a reduction in pancreatic beta cell Fetal genome epigenetic changes with alterations in cellular insulin signaling mass or in the number of renal nephrons. Fetal growth patterns are not the sole the scope of this discussion to encompass the contributor to the development of type 2 full range of the various maternal manipula- diabetes. It is may have a crucial role in the rapidly ris- Type 2 diabetes suffcient to state that fetal growth and devel- ing prevalence of type 2 diabetes worldwide. Animal models ability of food, reduced physical activity and Hypertension Insulin resistance show that fetal growth can be restricted by increases in obesity). This effect has also been nutritional transition is more apparent, mani- demonstrated in humans – mainly in the so 26 23 fest the greatest rise in incidence of diabetes. This effect is partly Those who were born small for age and later disease explained by simple defciency of ‘building become overweight are at the highest risk for materials’, such as the observed low bone 27–31 type 2 diabetes. They were not, however, over- deral index, was associated with increased and 2 years of age, a young age at adiposity nancy , but it is clear that more subtle aspects weight as neonates, rather, they became overweight plasma glucose and insulin concentrations, rebound (as defned by the age after infancy at of this issue await future investigation. Despite these uterine exposure to diabetes per se conveys a high tion and nutrient sensing in fetal liver and skel- genes, and enhanced susceptibility to adult seemingly related fndings, it remains unclear risk for the development of diabetes and obesity in etal muscle. Indian J Med Res hood and early adulthood during which exces- sive weight gain increases most the risk for strated high prevalence of type 2 diabetes or hyperfunction in early life and failure with age. The nutritional basis of the concern, not only as a healthcare burden on More than 20% of offspring born to mothers betes in middle age: the dutch hunger winter fetal origins of adult disease. Maternal protein-energy supplementation mass in Indian children; relationships to ment carries grave short- and long-term conse- betes/pre-diabetes were increased eight- and does not affect adolescent blood pressure in the maternal nutritional status and diet during fourfold, respectively42. Fetal nutrition and cardiovascular tion of serial changes in childhood body mass gies inficted upon the offspring of a diabetic then become the basis of fetal programming. Effect of lin concentrations in Indian children: rela- treatment of gestational diabetes mellitus on tionships to maternal glucose and insulin obesity in the next generation. At there is a role for every healthcare professional the same time, the infants of women with type who comes into contact with any woman of 1 diabetes who attend multidisciplinary pre- childbearing age to provide appropriate infor- pregnancy counseling show signifcantly fewer mation, support and care that relates to the major congenital malformations compared to specifc needs and desires of the woman. Women routinely fol- lowed up in the adult secondary care diabetes It is well known that women with type 1 services should be receiving general precon- and type 2 diabetes have an increased risk of ceptional advice when they attend for regular adverse pregnancy outcomes, including mis- review of their diabetes and be referred for more carriage, fetal congenital anomaly and perina- detailed preconceptional counseling and care tal death1 (see Chapter 5). These guidelines contain rec- recognize that the majority of pregnancies are due to obesity), and such women may be being developed and is the only one that publishes ommendations that, although they are not unplanned. In data on virtually all practices from every part technically mandatory for implementation, do and ‘unplanned’ pregnancy is a concept widely fact, in some areas of the world there are as of the country. The reason that it is ‘prob- betes, a huge difference from the situation 20 providing data at national, regional, primary entire chapter on preconceptional care with an lematic’ is the fact that this arbitrary and con- or so years ago, when pregnancy in diabetes care trust and practice level. The study Primary care is in contact with women with incentivizing primary care to deliver defned use should be documented at each contact concluded that formal preconception clinic pre-existing medical conditions who will ben- process and intermediate outcomes. Given with their diabetes care team sessions are unlikely to have an impact on eft from preconception information, advice these facts, it may therefore be possible to most pregnancies for women, as attendance and care, through the provision of contracep- encourage primary care to take on a role in • Guideline Recommendation 1. In the qualitative study be used to reinforce important preconception posed for consideration (Dornhorst A, Pierce The guideline also lists information about how cited above, three women (out of the 15 with information. It is important to have enough M, Gadsby R, personal communication August diabetes affects pregnancy and how pregnancy type 1 diabetes interviewed) described attend- time in the consultation to give important pre- 2010). This is valuable information ing preconceptional counseling and the anxi- conception messages and to realize that it is women of childbearing age who are living with that needs to be conveyed to women with dia- ety it provoked. Becom- care professional consultation with such ing pregnant: exploring the perspectives of women should be used to convey preconcep- women living with diabetes. Nevertheless, there is no doubt that these pro- active patient representative groups have changed forever the role of the patient in the development of diseases or to health areas considered today an therapeutics and of healthcare within society. Typical examples specializes within medicine in overseeing the pro- will be, on the one hand, an increased focus on cess of developing new therapeutics to improve the quality of life or on the effects of aging (such as standard of health and the quality of life within cognitive dysfunction, the menopause, osteopor- society. An integral part of and, on the other hand, disorders such as obesity, all progress in healthcare is evaluating the needs of attention deficit, hyperactivity, and even anorexia/ patients and society and the gaps in the present bulimia. The speciality should cover As members of the public become generally more all pharmacologically active treatments, all disease and more informed, it is inevitable that they will preventions and all health maintenance modalities.

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