The 3rd chapter of Charaka Samhitha Vimana sthana is Janapadoddhvamsaneeya Vimanam. It deals with the determination of the specific characteristics of epidemics. अथातो जनपदोद्ध्वंसनीयं विमानं व्याख्यास्यामः||१|| इति ह स्माह भगवानात्रेयः||२|| athāto janapadoddhvaṃsanīyaṃ vimānaṃ vyākhyāsyāmaḥ||1|| iti ha smāha bhagavānātreyaḥ||2|| We shall explore the chapter on the “Determination of the specific Characteristic of Epidemic disorders”. Thus said […]
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New guidance from the Royal College of Obstetricians and Gynaecologists adds further weight to the fact that two non-drug options – ginger and acupressure bands – can be helpful in relieving nausea.
BBC report:
These are non-drug options which are also worth considering when nausea occurs in ME/CFS.
However, whilst nausea and sickness can be a symptom of ME/CFS, it is important to exclude other possible medical explanations before doctors or patients conclude that this is ‘just another ME/CFS symptom’.
Medical information on acupressure bands:
More information on ginger (from Cancer Research UK):
Some people find ginger very helpful when feeling sick. People say it is particularly good for motion sickness. You can use ginger any way you like, for example as crystallised stem ginger. Or you can add freshly ground ginger to your favourite dishes, or to hot water or tea to make a soothing drink. You can try sipping ginger ale. Fizzy drinks sometimes help to reduce nausea too.
Researchers have been looking at using ginger alongside anti sickness medicines during chemotherapy. But the results so far have been mixed. So more research is needed.
Drug treatment options for nausea and vomiting. Source: patient information UK
* Cinnarizine, cyclizine, promethazine – these medicines belong to a group of medicines called antihistamines. The exact way that they work is not fully understood. It is thought that antihistamines block histamine 1 (H1) receptors in the area of the brain which creates nausea in response to chemicals in the body. They are thought to work well for nausea caused by a number of conditions including ear problems and motion (travel) sickness.
* Hyoscine – this medicine works by blocking a chemical in the brain called acetylcholine. It is a type of medicine called an antimuscarinic (or anticholinergic). It works well for nausea caused by ear problems and motion sickness.
* Chlorpromazine, haloperidol, perphenazine, prochlorperazine, levomepromazine– these medicines work by blocking a chemical in the brain called dopamine. They are useful for nausea that is caused by some cancers, radiation, and opiate medicines such as morphine and codeine. Prochlorperazine (or brand name Stemetil®) is one of the most used medicines for nausea. It works for many causes of nausea, including vertigo, ear problems and sickness in pregnancy.
* Metoclopramide – this medicine works directly on your gut. It eases the feelings of sickness by helping to empty the stomach and speed up how quickly food moves through the gut. It is often used for people with sickness due to gut problems or migraine. It is not usually used for more than a few days.
* Domperidone – this medicine works on the CTZ (an area of the brain known as the chemoreceptor trigger zone). It also speeds up the emptying of the gut. It is not usually used for more than a few days.
* Dexamethasone – this is a steroid medicine. It is a man-made version of a natural hormone produced by your own body. Dexamethasone has a wide range of actions on many parts of the body. The reason why it reduces nausea isn’t clear.
* Granisetron, ondansetron, and palonosetron – these medicines work by blocking a chemical called serotonin (5-HT) in the gut, and the brain. Serotonin (5-HT) has an action in the gut and the brain to cause nausea. These medicines are useful for controlling nausea and vomiting caused by chemotherapy.
* Aprepitant and fosaprepitant – these are newer medicines and work by blocking a chemical that acts on neurokinin receptors in the body to cause nausea. They are sometimes called neurokinin-1 receptor antagonists. They are usually given to people on a certain type of chemotherapy.
* Nabilone – it is still not clear how this medicine works to control nausea. It is normally prescribed for people who are having chemotherapy.
Medicines for nausea are available as tablets capsules, liquids, suppositories and skin patches. Some are given as injections into the muscle or directly into the vein.
Some of these medicines are also available as tablets that dissolve in the mouth against the gum. They are called buccal tablets. These medicines come in various different brand names.
Dr Charles Shepherd
Hon Medical Adviser, ME Association
New guidance from the Royal College of Obstetricians and Gynaecologists adds further weight to the fact that two non-drug options – ginger and acupressure bands – can be helpful in relieving nausea.
BBC report:
These are non-drug options which are also worth considering when nausea occurs in ME/CFS.
However, whilst nausea and sickness can be a symptom of ME/CFS, it is important to exclude other possible medical explanations before doctors or patients conclude that this is ‘just another ME/CFS symptom’.
Medical information on acupressure bands:
More information on ginger (from Cancer Research UK):
Some people find ginger very helpful when feeling sick. People say it is particularly good for motion sickness. You can use ginger any way you like, for example as crystallised stem ginger. Or you can add freshly ground ginger to your favourite dishes, or to hot water or tea to make a soothing drink. You can try sipping ginger ale. Fizzy drinks sometimes help to reduce nausea too.
Researchers have been looking at using ginger alongside anti sickness medicines during chemotherapy. But the results so far have been mixed. So more research is needed.
Drug treatment options for nausea and vomiting. Source: patient information UK
* Cinnarizine, cyclizine, promethazine – these medicines belong to a group of medicines called antihistamines. The exact way that they work is not fully understood. It is thought that antihistamines block histamine 1 (H1) receptors in the area of the brain which creates nausea in response to chemicals in the body. They are thought to work well for nausea caused by a number of conditions including ear problems and motion (travel) sickness.
* Hyoscine – this medicine works by blocking a chemical in the brain called acetylcholine. It is a type of medicine called an antimuscarinic (or anticholinergic). It works well for nausea caused by ear problems and motion sickness.
* Chlorpromazine, haloperidol, perphenazine, prochlorperazine, levomepromazine– these medicines work by blocking a chemical in the brain called dopamine. They are useful for nausea that is caused by some cancers, radiation, and opiate medicines such as morphine and codeine. Prochlorperazine (or brand name Stemetil®) is one of the most used medicines for nausea. It works for many causes of nausea, including vertigo, ear problems and sickness in pregnancy.
* Metoclopramide – this medicine works directly on your gut. It eases the feelings of sickness by helping to empty the stomach and speed up how quickly food moves through the gut. It is often used for people with sickness due to gut problems or migraine. It is not usually used for more than a few days.
* Domperidone – this medicine works on the CTZ (an area of the brain known as the chemoreceptor trigger zone). It also speeds up the emptying of the gut. It is not usually used for more than a few days.
* Dexamethasone – this is a steroid medicine. It is a man-made version of a natural hormone produced by your own body. Dexamethasone has a wide range of actions on many parts of the body. The reason why it reduces nausea isn’t clear.
* Granisetron, ondansetron, and palonosetron – these medicines work by blocking a chemical called serotonin (5-HT) in the gut, and the brain. Serotonin (5-HT) has an action in the gut and the brain to cause nausea. These medicines are useful for controlling nausea and vomiting caused by chemotherapy.
* Aprepitant and fosaprepitant – these are newer medicines and work by blocking a chemical that acts on neurokinin receptors in the body to cause nausea. They are sometimes called neurokinin-1 receptor antagonists. They are usually given to people on a certain type of chemotherapy.
* Nabilone – it is still not clear how this medicine works to control nausea. It is normally prescribed for people who are having chemotherapy.
Medicines for nausea are available as tablets capsules, liquids, suppositories and skin patches. Some are given as injections into the muscle or directly into the vein.
Some of these medicines are also available as tablets that dissolve in the mouth against the gum. They are called buccal tablets. These medicines come in various different brand names.
Dr Charles Shepherd
Hon Medical Adviser, ME Association
The second year of International Day of Yoga has just passed by on 21st June. With every passing year, more people are getting drawn towards practise of yoga, and this...
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From Nursing in Practice | 27 June 2016 | Article written by Dr Keith Geraghty
The ‘all in the mind’ myth of myalgic encephalomyelitis/chronic fatigue syndrome
Health professionals should be made aware that ME/CFS is not a psychological illness and in order to improve patient care, nurses need to better understand this illness and its impact on patients.
Nurses often witness close-up the impact of acute and chronic illness on patients. Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) is one illness that nurses may encounter that causes profound life changes for many sufferers. This controversial illness is sometimes presented as a psychosomatic disorder that requires psychological treatment. However, there is no compelling evidence that ME/CFS is a mental health condition and increasing evidence shows it is a biological disease with a range of complex symptoms. This article discusses how the ‘all in the mind’ myth of ME/CFS has permeated both medical discourse and popular culture, with negative consequences for patients living with this poorly understood condition.
In a recent Nursing in Practice article, Roberts (2016)1 suggests that ME/CFS is a psychosomatic disorder, best treated with psychotherapy and mindfulness. The erroneous idea that mindfulness is an optimum treatment masks a hidden and more important story; that very little is understood about ME/CFS and many health professionals are skeptical about whether ME/CFS is even a real illness. For example, NICE guidelines do not mention mindfulness.2 A GP once exclaimed to me that ‘all these patients need is anti-depressants and a good pair of running shoes’. While discussing my ME/CFS research at a hospital in Leicester a nurse offered me a similar opinion by suggesting that ‘ME/CFS patients would get out of bed if you paid them £5000 per day’. Such negative views among doctors and nurses are not uncommon and are perhaps fueled by misinformation about the illness being psychological.
In a recent book, All in Your Head: True Stories of Imaginary Illness,3 Dr Suzanne O’Sullivan, a London-based consultant neurologist, includes a chapter on ME/CFS. O’Sullivan argues ME/CFS is strongly associated with psychological complaints and illness beliefs. In contrast, a growing body of scientific evidence suggests that ME/CFS is not an imagined illness, nor is it a psychological condition, but a complex biological disease that is often triggered by an infection that causes observable neuro-immune dysfunction. Far from being ‘all in the mind’, sufferers often experience life-changing and disabling physical symptoms and physiological abnormalities (see Table 1).
Table 1: Biological abnormalities observed in ME/CFS
· Alterations in grey and white brain matter.
· Muscle cell dysfunction.
· Immune cell abnormalities.
· Raised inflammatory markers.
· Cellular and oxidative stress.
· Autonomic irregularities.
· Cardiovascular deficiencies.
· Orthostatic intolerance.
The World Health Organization (WHO) classifies ME as a neurological disorder in the International Classification of Diseases (ICD-10: G 93.3; WHO, 1992).4
The US Institute of Medicine (2015) conducted an extensive review of the evidence and concluded that ME/CFS is ‘a serious, chronic, complex, systemic disease’.5
The US National Institutes for Health confirmed ME/CFS as a disabling physical illness and stated that the medical profession has been responsible for causing distress to patients with ME/CFS by ignoring patients’ calls for medical help and failing to adequately research the disease.6
Psychiatrists have long been interested in attempting to explain the medically unexplained. Sigmund Freud, the father of modern psychiatry, explored the connection between the mind and health. The famous French neurologist J. Charcot believed traumatic life events may bring about a form of hysteria or paralysis in patients; while George Beard put forward the theory of neurasthenia (exhaustion of energy within the nervous system).7 These theories continue to influence how doctors perceive medically unexplained illnesses, particularly ME/CFS.
A brief time-line of how ME (nuero-immune disease) became CFS (a psychosomatic fatigue syndrome)
· 1955: Melvin Ramsay describes a viral outbreak illness among staff at the Royal Free Hospital in London as a post-infectious disease affecting brain, nerves and muscle tissue (Myalgic Encephalomyelitis).
· 1970s: UK psychiatrists McEvedy and Beard state that ME is nothing more than a case of ‘mass hysteria’.
· 1980s: A London newspaper runs a story about ME being ‘Yuppie Flu’. Since then, ME has been indelibly linked with stressed-out professionals complaining about exhaustion.
· 1988: The US Centers for Disease Control recommend replacing ME with a new syndrome (Chronic Fatigue Syndrome).
· 1990s: UK psychiatrist Simon Wessely argues ME (now CFS) is a biopsychosocial syndrome, partly created by social trends and maintained by patients’ illness beliefs and behaviours.
· 2000s: Colleagues of Wessely, including nurse/researcher Professor Trudie Chalder, conduct clinical trials of psychotherapy to treat CFS, including the £5 million PACE trial testing cognitive behavioural therapy and graded exercise therapy.8
· 2007: The UK National Institute for Health and Care Excellence (NICE) conducts a review and recommends CBT and GET for the treatment of ME/CFS.2 This decision is criticised by ME/CFS patient groups who deem CBT and GET inappropriate treatments. In particular, GET attracts much criticism.
· 2015: A large patient survey finds CBT has little impact on the condition: 74% of patients report that GET makes their symptoms worse, while simple pacing is preferred by patients.9 Such concerns are echoed in scientific studies that suggest exercise therapy may be harmful, given biological abnormalities found in ME/CFS.10
The answer to this question is rather complex. ME/CFS is an umbrella term often used for patients with ongoing unexplained fatigue. Hooper (2006) points out that ‘Amorphous definitions and diagnostic symptom criteria have contaminated study cohorts and corrupted research data’.11 Essentially, it may be difficult to differentiate patients with ME/CFS from patients with fatigue or depression, given the generality of the diagnostic criteria for CFS: patients are often lumped together in studies, with depressed patients responding better to CBT compared with ME/CFS patients.12 In addition, CBT may help with the secondary depression or anxiety that occurs in most illness states. Clinical trials of CBT and GET tend to recruit mild to moderately unwell CFS patients, as more severe cases are too unwell to take part. Yet, even if we accept these research biases, the evidence for the success of psychological or exercise therapies in ME/CFS is unconvincing:
· Cochrane review:A meta-analysis found that while CBT and/or GET may benefit some patients with ME/CFS in the short term, the benefits are short-lived and have little impact on restoring physical function over the long term.13
· PACE trial:The largest clinical trial of CBT and GET for CFS reported that 22% of patients recovered following CBT/GET added to standard care, while only 7% did after standard care alone.14 However, ‘recovery’ here did not mean a return to normal physical function. A patient could be deemed recovered with a SF-36 (quality of life) score of 60/100 or higher,8 even though a score of 65/100 indicates severe disability with 57/100 being a score of patients with Class II congestive heart failure.15 At follow-up, two years after treatment, there was no clear benefit of adding CBT or GET to standard medical care.8
· FINE trial:A study of nurse-provided community-based CBT and GET for 296 CFS patients failed to find any evidence for the long-term effectiveness of these therapies.16FINE stood for ‘Fatigue Intervention by Nurses Evaluation’. CBT-GET was compared against a supportive listening treatment. The FINE investigators found no statistically significant benefits to either pragmatic rehabilitation (CBT-GET) or supportive listening at 70 weeks. The authors concluded that the community setting was inappropriate, rather than the psychotherapy treatment.
In a recent Centers for Disease Control ‘Grand Rounds’ event (2016) discussing ME/CFS research, Professor Anthony Komaroff of Harvard University stated that the medical profession were wrong to adopt the name Chronic Fatigue Syndrome in 1988, as this term led to inaccurate perceptions of the illness. Komaroff points out that that there are thousands of published articles on biological dysfunction in ME/CFS, with no compelling evidence to suggest the illness is psychogenic (an illness of the mind).16
Many ME/CFS sufferers and advocacy groups are deeply concerned about the portrayal of the disorder as a psychological illness in medical publications and the wider media. Misinformation may negatively impact patients. Patient surveys consistently reveal that many ME/CFS patients experience medical scepticism, difficult interactions with health professionals and poor care quality (AfME, 2001).17 Sufferers report finding it difficult accessing benefits and social care and often have to fend off accusations of laziness and hypochondria – perhaps a consequence of the perception that the illness is a self-generated psychological illness.
The 25% ME Group, a charity that supports the most severely ill sufferers, state that the medical establishment has largely ignored these ME/CFS patients.18 Many are housebound or bedbound, with family members as full-time care-givers.
We must consider the harrowing case of Miss Sophia Mirza, a young ME sufferer forcibly removed from her home and sectioned under the Mental Health Act to impose psychiatric treatment on her. Miss Mirza died in 2005 and is one of the first patients in the UK to have ME as the official cause of death. The reality that ME/CFS kills some patients and dramatically shortens life expectancy is rarely reported in the media. In addition, ME/CFS sufferers are six times more likely to commit suicide compared to the general population;19 most likely as the result of having to deal with debilitating symptoms, such as chronic pain and sleep deprivation, but perhaps also having to deal with feelings of social isolation and poor medical treatment.
Many nurses will encounter ME/CFS patients, particularly in primary care. Nurses often have the capacity to form close therapeutic relationships with patients. Offering empathy and understanding to patients experiencing distressing symptoms is a central part of the nursing role. In the absence of a cure for ME/CFS, nurses are well placed to provide supportive care. By understanding the symptoms generated by the illness, nurses may be able to offer patients better care. ME/CFS severity varies from mild to severe and patients experience the illness in different ways. Some sufferers may be able to continue work on a limited basis, while others may be bed-bound, reliant on family and carers. Retired nurse Greg Crowhurst, a care-giver to a wife with severe ME/CFS, writes eloquently about how nurses may support patients with the illness.19
Practical tips for nursing practice are as follows:
· Sufferers experience profound fatigue – nurses may be able to ensure patients are not left in waiting areas for long periods of time.
· Sufferers experience cognitive problems – nurses may assist patients in medical consultations, perhaps asking whether the patient understands the information provided.
· Sufferers experience sensory overload – nurses may ask patients if they require a quiet area or darkened room, or on home visits, nurses may avoid causing sensory distress by speaking quietly and ensuring mobile phones are turned off.
· Sufferers symptoms vary and fluctuate – nurses should liaise with family members or care-givers to get a personalised account of the patient’s health status and care needs.
· Sufferers often feel disbelieved and anxious – nurses may reassure patients, particularly if they convey empathy and knowledge of the illness to the patient.
Nurses also have an another important role as advocates for ME/CFS patients, helping to liaise between the patient and doctor and also helping to promote the patient voice in the public domain. However, to fulfill this important role, nurses need to better understand the illness and to understand that ME/CFS is by no means ‘all-in-then-mind’.
Most people feel fatigued following illness, stressful events, or after working long hours. This is quite different from the severe fatigue and the range of symptoms that patients with ME/CFS endure, including: unrelenting painful joints and muscles; cognitive dysfunction, including memory problems; gastrointestinal complaints; transient paralysis; hypersensitivity to light, noise and touch; unrefreshing sleep; post-exertional malaise after minimal effort; and the inability to maintain an upright posture for any significant period. Overwhelming evidence shows that these symptoms are not psychosomatic. Nurses have a valuable role to play in assisting and supporting patients with ME/CFS. Nurses should not underestimate the power and importance of the nursing position to relieve suffering, prevent harm and promote better care for ME/CFS patients.
1. Roberts D. Diagnosing and managing chronic fatigue syndrome. Nursing in Practice 2016, 89.
2. NICE. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) – Diagnosis and management of CFS/ME in adults and children. NICE 2007, 53. http://ift.tt/290yAFQ.
3. O’Sullivan S. All in Your Head: True Stories of Imaginary Illness, 2016.
4. WHO. International Classification of Diseases, Tenth Revision (ICD-10). WHO 1992; G93.3.
5. IOM (Institute of Medicine). Beyond myalgic encephalomyelitis/chronic fatigue syndrome: redefining an illness. Washington, DC; 2015. ISBN: 978-0-309-31689-7.
6. Green CR, Cowan P, Elk R, O’Neil KM, Rasmussen AL. National Institutes of Health pathways to prevention workshop: Advancing the research on Myalgic Encephalomyelitis/chronic fatigue syndrome. Annals of Internal Medicine 2015;16;162(12):860-865.
7. Beard G. Neurasthenia, or nervous exhaustion. The Boston Medical and Surgical Journal 1869;217-221.
8. White PD, Goldsmith KA, Johnson AL et al. Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine 2013;43(10):2227-2235.
9. ME Association. ‘ME/CFS Illness Management Survey Results: No decisions about me without me’. Patient Survey, May 2015. http://ift.tt/1H0nHkL
10. Twisk F, Geraghty K. Deviant Cellular and Physiological Responses to Exercise in Myalgic Encephalomyelitis and Chronic Fatigue Syndrome. Jacobs Journal of Physiology 2015;1(2):007, 2015.
11. Hooper M. Gibson Inquiry – Day 1 April 18th 2006 – Group Testimonies, Comments by Professor Malcolm Hooper 21st April, 2006. http://ift.tt/290yMoK.
12. Jason LA, Torres-Harding S, Brown M et al. Predictors of change following participation in non-pharmacologic interventions for CFS. Tropical Medicine and Health 2008;36(1):23-32. DOI: 10.2149/tmh.36.23.
13. Price JR, Mitchel E, Tidy E, Hunot V. Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database of Systematic Reviews 2008, Issue 3.
14. Sharpe M, Goldsmith KA, Johnson AL, Chalder T, Walker J, White PD. Rehabilitative treatments for chronic fatigue syndrome: long-term follow-up from the PACE trial. The Lancet Psychiatry 2015a;2(12):1067-1074.
15. Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, Haass M. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart 2002;87(3):235-241. http://ift.tt/29jDSen
16. Wearden A, Dowrick C, Chew-Graham C et al. Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial. British Medical Journal 2010;340:c1777.
16. Komaroff AL. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Real Illness. Annals of Internal Medicine 2015;162:871-872.
17. Action for ME. ‘Severely neglected’. Patient Survey, 2001.
18. 25% ME Group. Stakeholder Response to NICE CG53 Three Yearly Review, Nov, 2010. http://ift.tt/290yrm0(accessed January 2016).
19. Roberts E, Wessely S, Chalder T et al. Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register, Lancet, (published online Feb 9.), 2016.
20. Crowhurst G. Supporting people with severe myalgic encephalomyelitis. Nursing Standard 2005;19(21):38-43
About the Author
Dr Keith Geraghty
Honorary Research Fellow, Centre for Primary Care, University of Manchester
From Nursing in Practice | 27 June 2016 | Article written by Dr Keith Geraghty
The ‘all in the mind’ myth of myalgic encephalomyelitis/chronic fatigue syndrome
Health professionals should be made aware that ME/CFS is not a psychological illness and in order to improve patient care, nurses need to better understand this illness and its impact on patients.
Nurses often witness close-up the impact of acute and chronic illness on patients. Myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS) is one illness that nurses may encounter that causes profound life changes for many sufferers. This controversial illness is sometimes presented as a psychosomatic disorder that requires psychological treatment. However, there is no compelling evidence that ME/CFS is a mental health condition and increasing evidence shows it is a biological disease with a range of complex symptoms. This article discusses how the ‘all in the mind’ myth of ME/CFS has permeated both medical discourse and popular culture, with negative consequences for patients living with this poorly understood condition.
In a recent Nursing in Practice article, Roberts (2016)1 suggests that ME/CFS is a psychosomatic disorder, best treated with psychotherapy and mindfulness. The erroneous idea that mindfulness is an optimum treatment masks a hidden and more important story; that very little is understood about ME/CFS and many health professionals are skeptical about whether ME/CFS is even a real illness. For example, NICE guidelines do not mention mindfulness.2 A GP once exclaimed to me that ‘all these patients need is anti-depressants and a good pair of running shoes’. While discussing my ME/CFS research at a hospital in Leicester a nurse offered me a similar opinion by suggesting that ‘ME/CFS patients would get out of bed if you paid them £5000 per day’. Such negative views among doctors and nurses are not uncommon and are perhaps fueled by misinformation about the illness being psychological.
In a recent book, All in Your Head: True Stories of Imaginary Illness,3 Dr Suzanne O’Sullivan, a London-based consultant neurologist, includes a chapter on ME/CFS. O’Sullivan argues ME/CFS is strongly associated with psychological complaints and illness beliefs. In contrast, a growing body of scientific evidence suggests that ME/CFS is not an imagined illness, nor is it a psychological condition, but a complex biological disease that is often triggered by an infection that causes observable neuro-immune dysfunction. Far from being ‘all in the mind’, sufferers often experience life-changing and disabling physical symptoms and physiological abnormalities (see Table 1).
Table 1: Biological abnormalities observed in ME/CFS
· Alterations in grey and white brain matter.
· Muscle cell dysfunction.
· Immune cell abnormalities.
· Raised inflammatory markers.
· Cellular and oxidative stress.
· Autonomic irregularities.
· Cardiovascular deficiencies.
· Orthostatic intolerance.
The World Health Organization (WHO) classifies ME as a neurological disorder in the International Classification of Diseases (ICD-10: G 93.3; WHO, 1992).4
The US Institute of Medicine (2015) conducted an extensive review of the evidence and concluded that ME/CFS is ‘a serious, chronic, complex, systemic disease’.5
The US National Institutes for Health confirmed ME/CFS as a disabling physical illness and stated that the medical profession has been responsible for causing distress to patients with ME/CFS by ignoring patients’ calls for medical help and failing to adequately research the disease.6
Psychiatrists have long been interested in attempting to explain the medically unexplained. Sigmund Freud, the father of modern psychiatry, explored the connection between the mind and health. The famous French neurologist J. Charcot believed traumatic life events may bring about a form of hysteria or paralysis in patients; while George Beard put forward the theory of neurasthenia (exhaustion of energy within the nervous system).7 These theories continue to influence how doctors perceive medically unexplained illnesses, particularly ME/CFS.
A brief time-line of how ME (nuero-immune disease) became CFS (a psychosomatic fatigue syndrome)
· 1955: Melvin Ramsay describes a viral outbreak illness among staff at the Royal Free Hospital in London as a post-infectious disease affecting brain, nerves and muscle tissue (Myalgic Encephalomyelitis).
· 1970s: UK psychiatrists McEvedy and Beard state that ME is nothing more than a case of ‘mass hysteria’.
· 1980s: A London newspaper runs a story about ME being ‘Yuppie Flu’. Since then, ME has been indelibly linked with stressed-out professionals complaining about exhaustion.
· 1988: The US Centers for Disease Control recommend replacing ME with a new syndrome (Chronic Fatigue Syndrome).
· 1990s: UK psychiatrist Simon Wessely argues ME (now CFS) is a biopsychosocial syndrome, partly created by social trends and maintained by patients’ illness beliefs and behaviours.
· 2000s: Colleagues of Wessely, including nurse/researcher Professor Trudie Chalder, conduct clinical trials of psychotherapy to treat CFS, including the £5 million PACE trial testing cognitive behavioural therapy and graded exercise therapy.8
· 2007: The UK National Institute for Health and Care Excellence (NICE) conducts a review and recommends CBT and GET for the treatment of ME/CFS.2 This decision is criticised by ME/CFS patient groups who deem CBT and GET inappropriate treatments. In particular, GET attracts much criticism.
· 2015: A large patient survey finds CBT has little impact on the condition: 74% of patients report that GET makes their symptoms worse, while simple pacing is preferred by patients.9 Such concerns are echoed in scientific studies that suggest exercise therapy may be harmful, given biological abnormalities found in ME/CFS.10
The answer to this question is rather complex. ME/CFS is an umbrella term often used for patients with ongoing unexplained fatigue. Hooper (2006) points out that ‘Amorphous definitions and diagnostic symptom criteria have contaminated study cohorts and corrupted research data’.11 Essentially, it may be difficult to differentiate patients with ME/CFS from patients with fatigue or depression, given the generality of the diagnostic criteria for CFS: patients are often lumped together in studies, with depressed patients responding better to CBT compared with ME/CFS patients.12 In addition, CBT may help with the secondary depression or anxiety that occurs in most illness states. Clinical trials of CBT and GET tend to recruit mild to moderately unwell CFS patients, as more severe cases are too unwell to take part. Yet, even if we accept these research biases, the evidence for the success of psychological or exercise therapies in ME/CFS is unconvincing:
· Cochrane review:A meta-analysis found that while CBT and/or GET may benefit some patients with ME/CFS in the short term, the benefits are short-lived and have little impact on restoring physical function over the long term.13
· PACE trial:The largest clinical trial of CBT and GET for CFS reported that 22% of patients recovered following CBT/GET added to standard care, while only 7% did after standard care alone.14 However, ‘recovery’ here did not mean a return to normal physical function. A patient could be deemed recovered with a SF-36 (quality of life) score of 60/100 or higher,8 even though a score of 65/100 indicates severe disability with 57/100 being a score of patients with Class II congestive heart failure.15 At follow-up, two years after treatment, there was no clear benefit of adding CBT or GET to standard medical care.8
· FINE trial:A study of nurse-provided community-based CBT and GET for 296 CFS patients failed to find any evidence for the long-term effectiveness of these therapies.16FINE stood for ‘Fatigue Intervention by Nurses Evaluation’. CBT-GET was compared against a supportive listening treatment. The FINE investigators found no statistically significant benefits to either pragmatic rehabilitation (CBT-GET) or supportive listening at 70 weeks. The authors concluded that the community setting was inappropriate, rather than the psychotherapy treatment.
In a recent Centers for Disease Control ‘Grand Rounds’ event (2016) discussing ME/CFS research, Professor Anthony Komaroff of Harvard University stated that the medical profession were wrong to adopt the name Chronic Fatigue Syndrome in 1988, as this term led to inaccurate perceptions of the illness. Komaroff points out that that there are thousands of published articles on biological dysfunction in ME/CFS, with no compelling evidence to suggest the illness is psychogenic (an illness of the mind).16
Many ME/CFS sufferers and advocacy groups are deeply concerned about the portrayal of the disorder as a psychological illness in medical publications and the wider media. Misinformation may negatively impact patients. Patient surveys consistently reveal that many ME/CFS patients experience medical scepticism, difficult interactions with health professionals and poor care quality (AfME, 2001).17 Sufferers report finding it difficult accessing benefits and social care and often have to fend off accusations of laziness and hypochondria – perhaps a consequence of the perception that the illness is a self-generated psychological illness.
The 25% ME Group, a charity that supports the most severely ill sufferers, state that the medical establishment has largely ignored these ME/CFS patients.18 Many are housebound or bedbound, with family members as full-time care-givers.
We must consider the harrowing case of Miss Sophia Mirza, a young ME sufferer forcibly removed from her home and sectioned under the Mental Health Act to impose psychiatric treatment on her. Miss Mirza died in 2005 and is one of the first patients in the UK to have ME as the official cause of death. The reality that ME/CFS kills some patients and dramatically shortens life expectancy is rarely reported in the media. In addition, ME/CFS sufferers are six times more likely to commit suicide compared to the general population;19 most likely as the result of having to deal with debilitating symptoms, such as chronic pain and sleep deprivation, but perhaps also having to deal with feelings of social isolation and poor medical treatment.
Many nurses will encounter ME/CFS patients, particularly in primary care. Nurses often have the capacity to form close therapeutic relationships with patients. Offering empathy and understanding to patients experiencing distressing symptoms is a central part of the nursing role. In the absence of a cure for ME/CFS, nurses are well placed to provide supportive care. By understanding the symptoms generated by the illness, nurses may be able to offer patients better care. ME/CFS severity varies from mild to severe and patients experience the illness in different ways. Some sufferers may be able to continue work on a limited basis, while others may be bed-bound, reliant on family and carers. Retired nurse Greg Crowhurst, a care-giver to a wife with severe ME/CFS, writes eloquently about how nurses may support patients with the illness.19
Practical tips for nursing practice are as follows:
· Sufferers experience profound fatigue – nurses may be able to ensure patients are not left in waiting areas for long periods of time.
· Sufferers experience cognitive problems – nurses may assist patients in medical consultations, perhaps asking whether the patient understands the information provided.
· Sufferers experience sensory overload – nurses may ask patients if they require a quiet area or darkened room, or on home visits, nurses may avoid causing sensory distress by speaking quietly and ensuring mobile phones are turned off.
· Sufferers symptoms vary and fluctuate – nurses should liaise with family members or care-givers to get a personalised account of the patient’s health status and care needs.
· Sufferers often feel disbelieved and anxious – nurses may reassure patients, particularly if they convey empathy and knowledge of the illness to the patient.
Nurses also have an another important role as advocates for ME/CFS patients, helping to liaise between the patient and doctor and also helping to promote the patient voice in the public domain. However, to fulfill this important role, nurses need to better understand the illness and to understand that ME/CFS is by no means ‘all-in-then-mind’.
Most people feel fatigued following illness, stressful events, or after working long hours. This is quite different from the severe fatigue and the range of symptoms that patients with ME/CFS endure, including: unrelenting painful joints and muscles; cognitive dysfunction, including memory problems; gastrointestinal complaints; transient paralysis; hypersensitivity to light, noise and touch; unrefreshing sleep; post-exertional malaise after minimal effort; and the inability to maintain an upright posture for any significant period. Overwhelming evidence shows that these symptoms are not psychosomatic. Nurses have a valuable role to play in assisting and supporting patients with ME/CFS. Nurses should not underestimate the power and importance of the nursing position to relieve suffering, prevent harm and promote better care for ME/CFS patients.
1. Roberts D. Diagnosing and managing chronic fatigue syndrome. Nursing in Practice 2016, 89.
2. NICE. Chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) – Diagnosis and management of CFS/ME in adults and children. NICE 2007, 53. http://ift.tt/290yAFQ.
3. O’Sullivan S. All in Your Head: True Stories of Imaginary Illness, 2016.
4. WHO. International Classification of Diseases, Tenth Revision (ICD-10). WHO 1992; G93.3.
5. IOM (Institute of Medicine). Beyond myalgic encephalomyelitis/chronic fatigue syndrome: redefining an illness. Washington, DC; 2015. ISBN: 978-0-309-31689-7.
6. Green CR, Cowan P, Elk R, O’Neil KM, Rasmussen AL. National Institutes of Health pathways to prevention workshop: Advancing the research on Myalgic Encephalomyelitis/chronic fatigue syndrome. Annals of Internal Medicine 2015;16;162(12):860-865.
7. Beard G. Neurasthenia, or nervous exhaustion. The Boston Medical and Surgical Journal 1869;217-221.
8. White PD, Goldsmith KA, Johnson AL et al. Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychological Medicine 2013;43(10):2227-2235.
9. ME Association. ‘ME/CFS Illness Management Survey Results: No decisions about me without me’. Patient Survey, May 2015. http://ift.tt/1H0nHkL
10. Twisk F, Geraghty K. Deviant Cellular and Physiological Responses to Exercise in Myalgic Encephalomyelitis and Chronic Fatigue Syndrome. Jacobs Journal of Physiology 2015;1(2):007, 2015.
11. Hooper M. Gibson Inquiry – Day 1 April 18th 2006 – Group Testimonies, Comments by Professor Malcolm Hooper 21st April, 2006. http://ift.tt/290yMoK.
12. Jason LA, Torres-Harding S, Brown M et al. Predictors of change following participation in non-pharmacologic interventions for CFS. Tropical Medicine and Health 2008;36(1):23-32. DOI: 10.2149/tmh.36.23.
13. Price JR, Mitchel E, Tidy E, Hunot V. Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database of Systematic Reviews 2008, Issue 3.
14. Sharpe M, Goldsmith KA, Johnson AL, Chalder T, Walker J, White PD. Rehabilitative treatments for chronic fatigue syndrome: long-term follow-up from the PACE trial. The Lancet Psychiatry 2015a;2(12):1067-1074.
15. Juenger J, Schellberg D, Kraemer S, Haunstetter A, Zugck C, Herzog W, Haass M. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. Heart 2002;87(3):235-241. http://ift.tt/29jDSen
16. Wearden A, Dowrick C, Chew-Graham C et al. Nurse led, home based self help treatment for patients in primary care with chronic fatigue syndrome: randomised controlled trial. British Medical Journal 2010;340:c1777.
16. Komaroff AL. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Real Illness. Annals of Internal Medicine 2015;162:871-872.
17. Action for ME. ‘Severely neglected’. Patient Survey, 2001.
18. 25% ME Group. Stakeholder Response to NICE CG53 Three Yearly Review, Nov, 2010. http://ift.tt/290yrm0(accessed January 2016).
19. Roberts E, Wessely S, Chalder T et al. Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register, Lancet, (published online Feb 9.), 2016.
20. Crowhurst G. Supporting people with severe myalgic encephalomyelitis. Nursing Standard 2005;19(21):38-43
About the Author
Dr Keith Geraghty
Honorary Research Fellow, Centre for Primary Care, University of Manchester
Article by Prof. MS Krishnamurthy MD (Ayu), PhD. In this era of fashion even though the crazy of gold and silver is slightly decreased, significant inclination is found towards artificial ornaments. Artificial ornaments or jewelries are sold in the names like-fashion jewelry , artificial jewelry, antique jewelry, trinkets, junk jewelry, fake jewelry, fine jewels, copper jewels, […]
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The 2nd chapter of Charaka Vimana sthana is called Trividha Kukshiya Vimana. It deals with the determination of specific characteristics of the stomach capacity together with its 3 parts. Specific Characteristics of Stomach Capacity: अथातस्त्रिविधकुक्षीयं विमानं व्याख्यास्यामः||१|| इति ह स्माह भगवानात्रेयः||२|| athātastrividhakukṣīyaṃ vimānaṃ vyākhyāsyāmaḥ||1|| iti ha smāha bhagavānātreyaḥ||2|| We shall now explore the chapter on […]
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Article by Prof. MS Krishnamurthy MD (Ayu), PhD. Quite commonly we get the patients who are complaining of one or other simple skin problem repeatedly. They complain of burning, itching, numbness, discoloration, pain, irritation etc. Many a time it does not need any medicine. Whereas in few conditions immediate medicines are to be taken or […]
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By Ms Usha Shinde. “There is a limit to cure, But there is no limit to care” This is the philosophy of Hospice. What is a hospice? “A place where the terminally ill patients are kept for symptom control and pain management.” But the answer is not complete yet. Hospice is a place where terminally ill […]
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Following discussion with ME North East, who were going to host this year’s MEA Question TIme meeting in Durham on Saturday September 17, we have reluctantly decided to cancel the meeting this year.
The main reason for doing so is the decision by the General Medical Council (GMC) to suspend Dr Nigel Speight from taking part in clinical or any other medical activities involving ME/CFS.
In addition, we have been unable to find a local paediatrician with the necessary knowledge and experience of ME/CFS who could take Nigel’s place.
Jane Colby, from The Tymes Trust, is also unable to get to Durham this year.
The ME Association regards input and information on children and adolescents with ME/CFS to be a vital component of these meetings. Consequently, we felt we had no option but to cancel the meeting on this occasion. We are sorry for any disappointment that this will cause.
We intend to resume normal MEA Question Time service in 2017 – when we hope that Dr Nigel Speight will be able to return to his role as paediatric adviser to the MEA as well as being able to resume helping children and adolescents with ME/CFS.
We are currently discussing the possibility of holding the 2017 meeting in Yorkshire.
Dr Charles Shepherd
Hon Medical Adviser, ME Association
Following discussion with ME North East, who were going to host this year’s MEA Question TIme meeting in Durham on Saturday September 17, we have reluctantly decided to cancel the meeting this year.
The main reason for doing so is the decision by the General Medical Council (GMC) to suspend Dr Nigel Speight from taking part in clinical or any other medical activities involving ME/CFS.
In addition, we have been unable to find a local paediatrician with the necessary knowledge and experience of ME/CFS who could take Nigel’s place.
Jane Colby, from The Tymes Trust, is also unable to get to Durham this year.
The ME Association regards input and information on children and adolescents with ME/CFS to be a vital component of these meetings. Consequently, we felt we had no option but to cancel the meeting on this occasion. We are sorry for any disappointment that this will cause.
We intend to resume normal MEA Question Time service in 2017 – when we hope that Dr Nigel Speight will be able to return to his role as paediatric adviser to the MEA as well as being able to resume helping children and adolescents with ME/CFS.
We are currently discussing the possibility of holding the 2017 meeting in Yorkshire.
Dr Charles Shepherd
Hon Medical Adviser, ME Association
Foot on the gas – An angry, agitated, or “fight” stress response. You’re heated, keyed up, overly emotional, and unable to sit still.
Foot on the brake – A withdrawn, depressed, or “flight” stress response. You shut down, pull away, space out, and show very little energy or emotion.
Foot on both – A tense or “freeze” stress response. You become frozen under pressure and can’t do anything. You look paralyzed, but under the surface you’re extremely agitated.
Foot on the gas – An angry, agitated, or “fight” stress response. You’re heated, keyed up, overly emotional, and unable to sit still.
Foot on the brake – A withdrawn, depressed, or “flight” stress response. You shut down, pull away, space out, and show very little energy or emotion.
Foot on both – A tense or “freeze” stress response. You become frozen under pressure and can’t do anything. You look paralyzed, but under the surface you’re extremely agitated.
From The Cornell Chronicle (Cornell University website) | 24 June 2016 | story by Krishna Ramanujan.
Physicians have been mystified by chronic fatigue syndrome, a condition where normal exertion leads to debilitating fatigue that isn’t alleviated by rest. There are no known triggers, and diagnosis requires lengthy tests administered by an expert.
Due to this lack of information, some people have even suggested the disease may be psychosomatic.
Now, for the first time, Cornell researchers report they have identified biological markers of the disease in gut bacteria and inflammatory microbial agents in the blood.
In a study published June 23 in the journal Microbiome, the team describes how they correctly diagnosed myalgic encephalomyeletis/chronic fatigue syndrome (ME/CFS) in 83 percent of patients through stool samples and blood work, offering a noninvasive diagnosis and a step toward understanding the cause of the disease.
“Our work demonstrates that the gut bacterial microbiome in ME/CFS patients isn’t normal, perhaps leading to gastrointestinal and inflammatory symptoms in victims of the disease,” said Maureen Hanson, the Liberty Hyde Bailey Professor in the Department of Molecular Biology and Genetics and the paper’s senior author. “Furthermore, our detection of a biological abnormality provides further evidence against the ridiculous concept that the disease is psychological in origin,”
Ruth Ley, associate professor in the Departments of Molecular Biology and Genetics and Microbiology, is a co-author.
“In the future, we could see this technique as a complement to other noninvasive diagnoses, but if we have a better idea of what is going on with these gut microbes and patients, maybe clinicians could consider changing diets, using prebiotics such as dietary fibers or probiotics to help treat the disease,” said Ludovic Giloteaux, a postdoctoral researcher in both Hanson’s and Ley’s labs and first author of the study.
Researchers have evidence that an overactive immune system plays a role in chronic fatigue. Symptoms include fatigue even after sleep, muscle and joint pain, migraines and gastrointestinal distress. One hallmark of the condition is post-exertional malaise, meaning patients may take weeks to recover from minor exertion. To test for ME/CFS, clinicians may give patients a cardio-pulmonary exercise test where they ride a bike until they become fatigued. If the test is repeated the following day, ME/CFS patients usually cannot reproduce their performance from the first day..
“That’s very typical and specific of people with ME/CFS, because healthy people, or even people who have heart disease, can reproduce the exercise on the second day, but these people cannot,” Giloteaux said.
In the study, Ithaca campus researchers collaborated with Dr. Susan Levine, an ME/CFS specialist in New York City, who recruited 48 people diagnosed with ME/CFS and 39 healthy controls to provide stool and blood samples.
The researchers sequenced regions of microbial DNA from the stool samples to identify different types of bacteria. Overall, the diversity of types of bacteria was greatly reduced and there were fewer bacterial species known to be anti-inflammatory in ME/CFS patients compared with healthy people, an observation also seen in people with Crohn’s disease and ulcerative colitis.
At the same time, the researchers discovered specific markers of inflammation in the blood, likely due to a leaky gut from intestinal problems that allow bacteria to enter the blood, Giloteaux said.
Bacteria in the blood will trigger an immune response, which could worsen symptoms.
The researchers have no evidence to distinguish whether the altered gut microbiome is a cause or a whether it is a consequence of disease, Giloteaux added.
In the future, the research team will look for evidence of viruses and fungi in the gut, to see whether one of these or an association of these along with bacteria may be causing or contributing to the illness.
Co-authors include Julia Goodrich, a doctoral student, and William Walters, a postdoctoral researcher, both in Ley’s lab.
The study was funded by the National Institutes of Health.
From The Cornell Chronicle (Cornell University website) | 24 June 2016 | story by Krishna Ramanujan.
Physicians have been mystified by chronic fatigue syndrome, a condition where normal exertion leads to debilitating fatigue that isn’t alleviated by rest. There are no known triggers, and diagnosis requires lengthy tests administered by an expert.
Due to this lack of information, some people have even suggested the disease may be psychosomatic.
Now, for the first time, Cornell researchers report they have identified biological markers of the disease in gut bacteria and inflammatory microbial agents in the blood.
In a study published June 23 in the journal Microbiome, the team describes how they correctly diagnosed myalgic encephalomyeletis/chronic fatigue syndrome (ME/CFS) in 83 percent of patients through stool samples and blood work, offering a noninvasive diagnosis and a step toward understanding the cause of the disease.
“Our work demonstrates that the gut bacterial microbiome in ME/CFS patients isn’t normal, perhaps leading to gastrointestinal and inflammatory symptoms in victims of the disease,” said Maureen Hanson, the Liberty Hyde Bailey Professor in the Department of Molecular Biology and Genetics and the paper’s senior author. “Furthermore, our detection of a biological abnormality provides further evidence against the ridiculous concept that the disease is psychological in origin,”
Ruth Ley, associate professor in the Departments of Molecular Biology and Genetics and Microbiology, is a co-author.
“In the future, we could see this technique as a complement to other noninvasive diagnoses, but if we have a better idea of what is going on with these gut microbes and patients, maybe clinicians could consider changing diets, using prebiotics such as dietary fibers or probiotics to help treat the disease,” said Ludovic Giloteaux, a postdoctoral researcher in both Hanson’s and Ley’s labs and first author of the study.
Researchers have evidence that an overactive immune system plays a role in chronic fatigue. Symptoms include fatigue even after sleep, muscle and joint pain, migraines and gastrointestinal distress. One hallmark of the condition is post-exertional malaise, meaning patients may take weeks to recover from minor exertion. To test for ME/CFS, clinicians may give patients a cardio-pulmonary exercise test where they ride a bike until they become fatigued. If the test is repeated the following day, ME/CFS patients usually cannot reproduce their performance from the first day..
“That’s very typical and specific of people with ME/CFS, because healthy people, or even people who have heart disease, can reproduce the exercise on the second day, but these people cannot,” Giloteaux said.
In the study, Ithaca campus researchers collaborated with Dr. Susan Levine, an ME/CFS specialist in New York City, who recruited 48 people diagnosed with ME/CFS and 39 healthy controls to provide stool and blood samples.
The researchers sequenced regions of microbial DNA from the stool samples to identify different types of bacteria. Overall, the diversity of types of bacteria was greatly reduced and there were fewer bacterial species known to be anti-inflammatory in ME/CFS patients compared with healthy people, an observation also seen in people with Crohn’s disease and ulcerative colitis.
At the same time, the researchers discovered specific markers of inflammation in the blood, likely due to a leaky gut from intestinal problems that allow bacteria to enter the blood, Giloteaux said.
Bacteria in the blood will trigger an immune response, which could worsen symptoms.
The researchers have no evidence to distinguish whether the altered gut microbiome is a cause or a whether it is a consequence of disease, Giloteaux added.
In the future, the research team will look for evidence of viruses and fungi in the gut, to see whether one of these or an association of these along with bacteria may be causing or contributing to the illness.
Co-authors include Julia Goodrich, a doctoral student, and William Walters, a postdoctoral researcher, both in Ley’s lab.
The study was funded by the National Institutes of Health.
From Physiotherapy Practice and Research, 4 June 2016.
A study of UK physiotherapists’ knowledge and training needs in hypermobility and hypermobility syndrome
Lyell, M.J.(a)*, Simmonds, J.V.(b,c), Deane,J.A.(d)
(a) University of Hertfordshire, School of Health and Human Social Work, Hatfield, UK
(b) University College London, Institute of Child Health, London, UK
(c) Hospital of St John and St Elizabeth, Hypermobility Unit, London
(d) Imperial College London, MSK Lab, School of Medicine, London, UK
Correspondence: [*] Corresponding author: M.J. Lyell, SCAS Office, Cumbria Villa, Chase Farm Hospital, 127 The Ridgeway, Enfield, Middlesex, EN2 8JL, UK. E-mail: miranda.lyell@beh-mht.nhs.uk.
Abstract
BACKGROUND
Physiotherapists play a fundamental role in managing adults with hypermobility and hypermobility syndrome (HMS). Access to training and its influence on the physiotherapy treatment of hypermobile adults is unknown.
OBJECTIVES
The purpose of this study was to: i) Explore UK physiotherapists’ knowledge of hypermobility and HMS in adults. ii) Establish the relationship between knowledge and training or experience. iii) Investigate the future training preferences of physiotherapists in this area.
DESIGN
A nationwide online survey
METHODS
A cross-sectional survey design collected quantitative and qualitative data. A validated hypermobility questionnaire was adapted and distributed as a self-administered electronic survey. A panel of expert practitioners confirmed face validity.
PARTICIPANTS
UK physiotherapists, experienced in treating adults with musculoskeletal conditions were invited to participate via purposive and snowball sampling of relevant professional networks and clinical interest groups
ANALYSIS
Microsoft Excel and SPSS were used to analyse data. Chi-squared analysis was used to explore relevant associations. Thematic coding of qualitative data was quantitatively analysed.
RESULTS
244 Physiotherapists participated. A significant association was found between training and knowledge of HMS (P < 0.001). Furthermore, training was associated with increased clinical confidence in both assessment (P < 0.001), and management (P < 0.001) of the condition. However, 51% of physiotherapists reported having no training in hypermobility, only 10% had undergone training in hypermobility at undergraduate level and 95% requested further training. CONCLUSION There are significant gaps in training received by UK physiotherapists’ in the assessment and management of HMS, despite the significant association observed between training and the degree of clinical confidence and knowledge reported.
From Social Science and Medicine, 18 June 2016
“You get to know the people and whether they’re talking sense or not”: Negotiating trust on health-related forums
Ellen Brady, Julia Segar, Caroline Sanders
University of Manchester, United Kingdom
Highlights
• The use of online forums by individuals with LTCs is a complex and nuanced process.
• Participants trust those with similar experiences and perspectives as themselves.
• Users can access a personalised form of support based on the experiences of peers.
• Role of digital literacy in developing online relationships must be acknowledged.
Abstract
The internet is increasingly being used as a source of health advice and information by individuals with long term conditions (LTCs). Specifically, online forums allow people to interact with others with similar conditions. However, it is not clear how online health information is assessed by those with LTCs.
This study aims to address this gap by exploring how individuals with contested and uncontested LTCs utilise internet forums. Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis.
Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups.
The findings indicate that the use of online forums was a complex and nuanced process and was influenced by a number of individual and illness-specific factors. Participants trusted those with similar experiences and perspectives as themselves, while also valuing conventional biomedical information and advice.
By accessing support online, forum users were able to draw on a personalised form of support based on the lived experiences of their peers. However, the role of digital literacy in developing and maintaining online relationships must be acknowledged.
From Physiotherapy Practice and Research, 4 June 2016.
A study of UK physiotherapists’ knowledge and training needs in hypermobility and hypermobility syndrome
Lyell, M.J.(a)*, Simmonds, J.V.(b,c), Deane,J.A.(d)
(a) University of Hertfordshire, School of Health and Human Social Work, Hatfield, UK
(b) University College London, Institute of Child Health, London, UK
(c) Hospital of St John and St Elizabeth, Hypermobility Unit, London
(d) Imperial College London, MSK Lab, School of Medicine, London, UK
Correspondence: [*] Corresponding author: M.J. Lyell, SCAS Office, Cumbria Villa, Chase Farm Hospital, 127 The Ridgeway, Enfield, Middlesex, EN2 8JL, UK. E-mail: miranda.lyell@beh-mht.nhs.uk.
Abstract
BACKGROUND
Physiotherapists play a fundamental role in managing adults with hypermobility and hypermobility syndrome (HMS). Access to training and its influence on the physiotherapy treatment of hypermobile adults is unknown.
OBJECTIVES
The purpose of this study was to: i) Explore UK physiotherapists’ knowledge of hypermobility and HMS in adults. ii) Establish the relationship between knowledge and training or experience. iii) Investigate the future training preferences of physiotherapists in this area.
DESIGN
A nationwide online survey
METHODS
A cross-sectional survey design collected quantitative and qualitative data. A validated hypermobility questionnaire was adapted and distributed as a self-administered electronic survey. A panel of expert practitioners confirmed face validity.
PARTICIPANTS
UK physiotherapists, experienced in treating adults with musculoskeletal conditions were invited to participate via purposive and snowball sampling of relevant professional networks and clinical interest groups
ANALYSIS
Microsoft Excel and SPSS were used to analyse data. Chi-squared analysis was used to explore relevant associations. Thematic coding of qualitative data was quantitatively analysed.
RESULTS
244 Physiotherapists participated. A significant association was found between training and knowledge of HMS (P < 0.001). Furthermore, training was associated with increased clinical confidence in both assessment (P < 0.001), and management (P < 0.001) of the condition. However, 51% of physiotherapists reported having no training in hypermobility, only 10% had undergone training in hypermobility at undergraduate level and 95% requested further training. CONCLUSION There are significant gaps in training received by UK physiotherapists’ in the assessment and management of HMS, despite the significant association observed between training and the degree of clinical confidence and knowledge reported.
From Social Science and Medicine, 18 June 2016
“You get to know the people and whether they’re talking sense or not”: Negotiating trust on health-related forums
Ellen Brady, Julia Segar, Caroline Sanders
University of Manchester, United Kingdom
Highlights
• The use of online forums by individuals with LTCs is a complex and nuanced process.
• Participants trust those with similar experiences and perspectives as themselves.
• Users can access a personalised form of support based on the experiences of peers.
• Role of digital literacy in developing online relationships must be acknowledged.
Abstract
The internet is increasingly being used as a source of health advice and information by individuals with long term conditions (LTCs). Specifically, online forums allow people to interact with others with similar conditions. However, it is not clear how online health information is assessed by those with LTCs.
This study aims to address this gap by exploring how individuals with contested and uncontested LTCs utilise internet forums. Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis.
Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups.
The findings indicate that the use of online forums was a complex and nuanced process and was influenced by a number of individual and illness-specific factors. Participants trusted those with similar experiences and perspectives as themselves, while also valuing conventional biomedical information and advice.
By accessing support online, forum users were able to draw on a personalised form of support based on the lived experiences of their peers. However, the role of digital literacy in developing and maintaining online relationships must be acknowledged.
Padmaka- Prunus cerasoides, is an Ayurvedic herb used for the treatment of skin diseases, increasing the complexion and used as uterine tonic. It is also known as Wild Himalayan Cherry. Latin Name- Prunus puddum Roxb. (Prunus cerasoides Don.) Family- Rosaceae Padmaka is a medium to a tall growing tree growing naturally in the Himalayan belt […]
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For some folks, eating a low carb, high fat diet can be the key to transforming their health for the better. But as with most things, it depends on the individual, and there is no one-size-fits-all approach to eating “right”. In this post, Jacyln helps us to understand how to know if you’ve gone too […]
The post Low Carb? How to Know if You’ve Gone Too Far appeared first on Holistic Squid.
For some folks, eating a low carb, high fat diet can be the key to transforming their health for the better. But as with most things, it depends on the individual, and there is no one-size-fits-all approach to eating “right”. In this post, Jacyln helps us to understand how to know if you’ve gone too […]
The post Low Carb? How to Know if You’ve Gone Too Far appeared first on Holistic Squid.
From The Times, 21 June 2016. Story by Kaya Burgess.
The BBC journalist Caroline Wyatt says that having multiple sclerosis diagnosed has made her regret putting her career before family.
Wyatt, 49, was the BBC religious affairs correspondent until last week, when she announced that she would be stepping down. She hopes to return to radio presenting in the autumn.
In her first interview about her condition Wyatt revealed her acute fear of going blind and said that she was committed to putting family life and friends before work.
“I realise now that I did live incredibly selfishly. I pursued my career because it was interesting,” she told Radio Times. “I wasn’t there for my ex-boyfriend’s birthday. I wasn’t there for Christmases and many other significant events. It’s made me realise that the really, really important things are your family and your close friends, so to a large degree it is reshaping my view of what really matters.”
Wyatt, who was BBC defence correspondent for seven years until 2014, had been treated for the chronic fatigue condition myalgic encephalomyelitis (ME) and scanned for a possible brain tumour before her condition was identified in July.
Describing her lowest moment since the diagnosis, she said:
“When I woke up with double vision about four weeks ago I sat on the edge of the bed and thought, ‘Good grief, if I don’t save my sight and do something fairly radical about the way that I’m living then it is entirely possible I will lose my sight and… I won’t be able to do all the other things I want to do in life. It was really quite a bleak moment.
Wyatt has been suffering from undiagnosed symptoms for about 25 years.
She has been using a stick to aid her walking and said: “
Neither my vision nor my balance are particularly good at the moment, so I am a bit cooped up at home. I don’t know what the future holds but I am determined to make the most of my life.”
From The Times, 21 June 2016. Story by Kaya Burgess.
The BBC journalist Caroline Wyatt says that having multiple sclerosis diagnosed has made her regret putting her career before family.
Wyatt, 49, was the BBC religious affairs correspondent until last week, when she announced that she would be stepping down. She hopes to return to radio presenting in the autumn.
In her first interview about her condition Wyatt revealed her acute fear of going blind and said that she was committed to putting family life and friends before work.
“I realise now that I did live incredibly selfishly. I pursued my career because it was interesting,” she told Radio Times. “I wasn’t there for my ex-boyfriend’s birthday. I wasn’t there for Christmases and many other significant events. It’s made me realise that the really, really important things are your family and your close friends, so to a large degree it is reshaping my view of what really matters.”
Wyatt, who was BBC defence correspondent for seven years until 2014, had been treated for the chronic fatigue condition myalgic encephalomyelitis (ME) and scanned for a possible brain tumour before her condition was identified in July.
Describing her lowest moment since the diagnosis, she said:
“When I woke up with double vision about four weeks ago I sat on the edge of the bed and thought, ‘Good grief, if I don’t save my sight and do something fairly radical about the way that I’m living then it is entirely possible I will lose my sight and… I won’t be able to do all the other things I want to do in life. It was really quite a bleak moment.
Wyatt has been suffering from undiagnosed symptoms for about 25 years.
She has been using a stick to aid her walking and said: “
Neither my vision nor my balance are particularly good at the moment, so I am a bit cooped up at home. I don’t know what the future holds but I am determined to make the most of my life.”
First Chapter of Charaka Samhitha Vimana Sthana is called Rasa Vimana. It deals with the knowledge of specific attributes of Rasa (taste), diet rules, three things that should not be taken for long periods of time etc. अथातो रसविमानं व्याख्यास्यामः||१|| इति ह स्माह भगवानात्रेयः||२|| athāto rasavimānaṃ vyākhyāsyāmaḥ||1|| iti ha smāha bhagavānātreyaḥ||2|| We shall now explore the […]
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I enjoy living. Not just living, but being an active participant in it. Of feeling the warmth on my skin from a summer sun, sensing the cool air gliding across my face as the temperature drops before a storm, witnessing flowers change a dull landscape to a beautiful one, engaging in thought-provoking conversations, revisiting experiences of yesterdays, dreaming of tomorrows, having my pets soak-up my blues and restoring some happiness within me, and experiencing the stories of others providing me the human connection that I cannot and do not want to live without.low-volume metastatic disease with limited number and size of metastatic lesions (up to 5, and not necessarily in the same organ), potentially amenable to local treatment, with the aim of achieving complete remission. Definition from Medscape article by Linda Brookes, MSc, April 28, 2016, Mastectomies: Local Approaches to Breast Cancer. www.medscape.com
I enjoy living. Not just living, but being an active participant in it. Of feeling the warmth on my skin from a summer sun, sensing the cool air gliding across my face as the temperature drops before a storm, witnessing flowers change a dull landscape to a beautiful one, engaging in thought-provoking conversations, revisiting experiences of yesterdays, dreaming of tomorrows, having my pets soak-up my blues and restoring some happiness within me, and experiencing the stories of others providing me the human connection that I cannot and do not want to live without.low-volume metastatic disease with limited number and size of metastatic lesions (up to 5, and not necessarily in the same organ), potentially amenable to local treatment, with the aim of achieving complete remission. Definition from Medscape article by Linda Brookes, MSc, April 28, 2016, Mastectomies: Local Approaches to Breast Cancer. www.medscape.com
Mercola.com is the world's #1 natural health website. Doctor Mercola's motivation is to "make you as healthy as you can possibly be" by providing the most up-to-date natural health information and resources. He also exposes corporate, government, and mass media hype that diverts you from what is best for your health and often leads straight into an early grave. The New York Times best-selling author states his passion is to transform the traditional medical paradigm in the United States.
The Food Revolution Network
Chris Wark is the young man behind this powerful website: chrisbeatcancer.com Chris found himself Mercola.com is the world's #1 natural health website. Doctor Mercola's motivation is to "make you as healthy as you can possibly be" by providing the most up-to-date natural health information and resources. He also exposes corporate, government, and mass media hype that diverts you from what is best for your health and often leads straight into an early grave. The New York Times best-selling author states his passion is to transform the traditional medical paradigm in the United States.The Food Revolution NetworkChris Wark is the young man behind this powerful website: chrisbeatcancer.com Chris found himself 
Surviving cancer is a tremendous accomplishment, and at this year's 16th annual Legacy Chase at Shawan Downs, GBMC is celebrating survivors by going big: a mile and a half long to be exact! With help from survivors and their families and friends, we will attempt to break the Guinness World Record for the longest awareness ribbon, as a demonstration of GBMC's commitment to the fight against all cancers.
Surviving cancer is a tremendous accomplishment, and at this year's 16th annual Legacy Chase at Shawan Downs, GBMC is celebrating survivors by going big: a mile and a half long to be exact! With help from survivors and their families and friends, we will attempt to break the Guinness World Record for the longest awareness ribbon, as a demonstration of GBMC's commitment to the fight against all cancers.
Ingredients
1 cup tomato sauce
1 cup grilled, boneless, skinless chicken breast, diced (about 2 small breasts)
1 cup broccoli, rinsed, chopped and cooked
2 tbsp grated parmesan cheese
1 tbsp fresh basil, rinsed, dried and chopped
4 (6 ½-inch) whole-wheat pitas
Directions
Preheat oven or toaster oven to 450°F.
For each pizza, spread ¼ cup tomato sauce on a pita and top with ¼ cup chicken, ¼ cup broccoli, ½ tablespoon parmesan cheese and ¼ tablespoon chopped basil.
Place pitas on a nonstick baking sheet and bake for about 5-8 minutes until golden brown and chicken is heated through. Serve immediately
