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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Andrew Shennan MB BS MD FRCOG
Stool consistency will depend on how much ileum was removed; the shorter the ileum medications side effects prescription drugs order 250mg flutamide with mastercard, the more liquid the stool will be treatment diffusion discount flutamide 250 mg overnight delivery. Digestive enzymes are present in the stool and will be caustic/irritating to the skin medicine x pop up 250 mg flutamide overnight delivery, if pouch leakage occurs symptoms 9 days past iui trusted 250mg flutamide. The following foods help thicken the stool: Bananas Peeled potatoes White rice, bread, unseasoned crackers, pasta Applesauce Marshmallows Creamy peanut butter For more information on ileostomy, visit A catheter (small plastic tube) is inserted into the stoma to empty the reservoir and for the purposes of irrigation/emptying. Large intestine is bypassed and/or removed resulting in decreased water and electrolyte absorption. Depending on the configuration of the internal reservoir, it is sometimes called a J or S pouch. Ileoanal reservoir (J pouch) 26 Ostomy and the Urinary System the urinary system is made up of two kidneys, the ureters, the bladder, and the urethra. Urine is made in the kidneys and transported through the ureters to the bladder where it is stored and finally leaves the body through the urethra. As blood passes through the kidneys, waste products are removed along with fluids your body no longer needs. The urinary system also regulates the volume of fluid in the body and what the fluid contains. When a person has bladder diversion surgery, the bladder is either removed or bypassed. A conduit (passage) is made from a short segment of the small intestine (the ileum). One end of the conduit is sewn closed, and the other end of the conduit is brought to the outside surface of the abdomen to create a stoma (opening). The ureters, which normally carry urine to the bladder, are disconnected from the bladder and connected to the conduit to allow urine to flow through and leave the body through the stoma and into a pouch worn over the stoma. Having an ileal conduit means that one does not have control over urine as it leaves the body. You cannot decide when to pass urine, and you do not feel when the urine passes into the pouch. Ileal conduit Continent Urinary Pouch this is a surgical procedure in which the bladder is either removed or bypassed. An internal reservoir or collection area is created by opening loops of the small or large intestines and sewing them back together to create an internal pouch or pseudo-bladder. Urine is drained on a regular basis through the stoma using a catheter (small tube). Continent urinary pouches are called different names according to how they are made by the surgeon and where they are located and include Indiana Pouch, Kock Pouch, Mitrofanoff, Miami, and Mainz. It is connected to the urethra to allow urine to leave the body in the usual manner (sitting on a toilet). After that time, you can resume a regular diet unless specific recommendations have been made by your doctor. Supplement your diet with Vitamin C, unsweetened cranberry juice, or capsules to help keep the urine more acidic or control bacterial growth in the urinary tract. Discuss these or other supplements with your doctor before using them as they may interact with other medications. Urinary crystals that cause irritation to the stoma and skin can form in the pouching system. Stay well hydrated and keep the urine acidic to decrease the formation of crystals. Rather than a burning sensation while urinating or frequency of urination, be alert to the following signs and symptoms: Discolored urine Blood in the urine Strong odor to the urine unrelated to food. For those with a urostomy, pouches are made to be odor proof, so odor may not be noticed until you empty your pouch. Back pain Fever and chills Also be aware that a small amount of mucous in the urine may be normal as the bladder diversion is made from the intestine, which contains mucous. To get a urine sample, the doctor, nurse, or nurse practitioner will catheterize the stoma (insert a small tube). If the results show that you have an infection, your doctor will prescribe an antibiotic to treat it. Dietary Supplements (Vitamin C and Cranberry Capsules) may help to acidify urine or control bacterial growth in the urinary tract which may help with odor. You also will begin with a diet low in fiber/low in residue and focus on low spice and low-fat foods. As your bowels return to normal, you may be able to return to your regular diet and food choices, unless your surgeon has recommended alternative choices due to your medical conditions. Goals of a Healthy Diet after Surgery Promote wound healing and healing of the surgical incision, by getting enough protein. Mashed, boiled, or pureed vegetables Peeled potatoes Raw vegetables and vegetables with seeds Sauerkraut, cabbage, cauliflower, onions, corn Winter squash, broccoli, brussel sprouts, mushrooms Sweet potatoes Unpeeled potatoes Vegetables *For advice on protein or calorie supplements, consult your doctor or registered dietician 33 Allowed Fruits Cooked or canned fruit (except canned pineapple) Applesauce Bananas, plantains Avoid Prunes and prune juice Fresh or dried fruit, including berries, figs, dates, and raisins Canned pineapple Milk and Dairy Plain, low-fat milk Plain or vanilla low-fat yogurt Pudding Kefir Low-fat ice cream Full-fat milk and cheese Yogurt with whole fruit Cheese sauce or alfredo sauce Custard, sherbet, popsicles Desserts, Condiments Clear jelly Coconut Pickles Relishes Fruit preserves with seeds Marmalade Horseradish Salsa Guacamole Tips for Success Give your appetite 4-6 weeks to return. Focus on a balanced diet with a variety of fruits, vegetable, lean protein and grains. The information in this section provides basic nutritional and hydration guidelines for the first 4 to 6 weeks after ostomy surgery. However, your doctor or dietitian may want to create an individualized plan for you. Ileostomy: Specific Post-Op Guidelines Stoma Blockage If you have a new ileostomy, you are at greater risk for a stoma blockage than someone with a colostomy for several reasons. First, the stoma created from the ileum (small intestine) is smaller in diameter than one created from the colon. These particles can get stuck where the intestine comes through the abdominal wall (stoma), creating a blockage. Abdominal cramps and pain Signs of a stoma food blockage Abdominal distention Watery stools with bad odor Stool released in spurts Absence of stool output Pressure at the stoma but little or no output of stool Contact your doctor immediately if you feel you have a stoma blockage. If stool is not coming out of your stoma, it is best to call your doctor or go to the hospital immediately to determine if you have a stoma blockage related to food, or a small bowel obstruction. Also avoid the foods and liquids listed in the Preventing Dehydration chart below, which may cause high volume stool output. An ileostomy that produces 1,500 milliliters or more of stool per 24 hours Normal output is less than 1200 milliliters per 24 hours. How to measure ileostomy output: To measure your output, you can use a container from the hospital that fits on the toilet or any kind of container with a measuring guide. This way, you can calculate your output based on the number of times you empty your pouch in a day. Preventing Dehydration Avoid the Following Coffee Caffeinated tea (herbal is good) Drinks high in sugar (juices, some sports drinks, soda/colas). To Help Thicken Loose Stool Add the Following Bananas Peeled potatoes White rice, bread, pasta, unseasoned crackers Stay Hydrated Sip throughout the day.
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Always speak with your physician or other healthcare professional before taking any medication or nutritional treatment x time interaction flutamide 250mg with visa, herbal or homeopathic supplement treatment of diabetes cheap 250 mg flutamide free shipping, or using any treatment for a health problem medicine 7 discount flutamide 250mg on-line. If you have or suspect that you have a medical problem medicine zocor purchase flutamide 250mg without a prescription, contact your health care provider promptly. The education and information presented herein is intended for a general audience and does not purport to be, nor should it be construed as, specific advice tailored to any individual. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease. No part of this document or the related files may be reproduced or transmitted in any form, by any means (electronic, photocopying, recording, or otherwise) without the prior written permission of the publisher. Nearly 80% of your immune system is in the gut, and the gut is also where 95% of your serotonin, the "feel good" hormone, is produced. So if you want to be happy and healthy, healing your gut is the first place to start! Leaky gut is a condition I see every day in my medical clinic, and it is one of the primary root causes of autoimmune and thyroid diseases. If your gut has become leaky it means the the tight junctions that usually hold the walls of your intestines together have become loose, allowing undigested food particles, microbes, toxins, and more to escape your gut and enter your bloodstream. Teeny tiny boats (micronutrients in food) that are meant to travel back and forth are able to go under the bridge without a problem. Once they enter your bloodstream, your immune system tags them as invaders and attacks them, causing a huge rise in inflammation. These constant attacks can manifest in a huge range of symptoms, including the ones listed. Over the next few days, I will be sending you more information about several of these health issues to help you pinpoint the root cause of your own leaky gut. As your immune system becomes more stressed, it is less able to attack pathogens and invaders with precision. Instead, it begins indiscriminately sending wave after wave of attack in a desperate attempt to fight off the invaders. I have witnessed dramatic reversal of chronic and inflammatory illnesses in a very short period of time by utilizing this simple approach. Inflammatory foods including gluten, dairy, corn, soy, eggs and sugar can lead to food sensitivities. Removing the infections may require treatment with herbs, anti-parasite medication, anti-fungal medication, anti-fungal supplements or even antibiotics. This includes digestive enzymes, hydrochloric acid and bile acids that are required for proper digestion. Other key nutrients include zinc, omega 3 fish oils, vitamin A, C, E as well as herbs such as slippery elm and aloe vera. Add back in the essential ingredients for proper digestion and absorption 3 Reinoculate with beneficial bacteria to re-establish a healthy balance of good bacteria. This 4 Repair your gut by providing the nutrients necessary to help the gut heal itself. It is a two-part process that includes removing the toxic and inflammatory foods that caused your gut to become leaky, and adding in the nutrients that will help it heal. Each of these recipes is free of gluten, grains, dairy, legumes, nuts and seeds, nightshades, eggs, sugar and caffeine. They are also full of gut-healing nutrients your body needs to heal your gut and improve your health, such as zinc, sulfur, collagen, L-glutamine, medium chain triglycerides, fatty acids, vitamins A and D, enzymes, selenium. L-Glutamine L-Glutamine is an amino acid that is fundamental to the well-being of the digestive and immune systems. Glutamine is great for repairing damage to the gut, helping the gut lining to regrow and repair, undoing the damage caused by leaky gut, and reducing sugar cravings. Arabinogalactan contains polysaccharide that provides support for the gut microflora and can increase beneficial short-chain fatty acid production. After going gluten free and taking this product, I was able to get off my Prilosec for good and it was worth it. It also support joint and bone health, and gives you glowing skin, strong nails, and healthy hair. This includes digestive enzymes, hydrochloric acid and beneficial bacteria that are required for proper digestion. Probiotic Our gut is full of "good"and friendly bacteria that help us properly break down and digest our food. Unfortunately, these friendly bacteria can be depleted and disrupted by taking antibiotics, steroids, acid-blocking medications, eating a poor diet, and many other factors. Taking a highly concentrated dose (25-100 billion units a day) of probiotics on a daily basis can help you regain a healthy balance of bacteria in your gut. Digestive Enzymes Digestive enzymes are plant or microbial-based supplements that support the breakdown, absorption, and utilization of macronutrients. It helps you break down and digest proteins, minerals, and other nutrients such as vitamin B12. I recommend for everyone with an autoimmune or thyroid condition go gluten-free for good. I recommend that everyone else give up gluten for 30 days to see how you feel before adding it back in. Patients are often amazed that the symptoms they thought of as "just a part of life" disappear after a short time off of gluten. Gluten is a protein naturally found in white and wheat flour, as well as other grains like barley, rye, spelt, kamut, semolina, and einkorn. Gluten causes leaky gut When you eat gluten, it travels through your stomach and arrives in your small intestine, where we know from Dr. Zonulin is a chemical that signals the tight junctions of your intestinal wall to open up, creating leaky gut. It causes inflammation It is estimated that one in 30 people have a gluten sensitivity - meaning eating gluten causes inflammation every time they eat it. They are so similar in fact, that when you eat gluten-containing foods your immune system goes to attack the gluten but inadvertently attacks your own tissues in a case of mistaken identity. Homemade broths contain gelatin which heals the mucosal lining of the digestive tract and helps aid in the digestion of nutrients. Gelatin is also a potent helper for hair, skin, nails, and joints because it replenishes the collagen that we lose as we age or due to malabsorption. Studies also show that eating chicken soup during a respiratory infection reduces the number of white blood cells, which are the cells that cause flu and cold symptoms. Think of bone broth as a healer for the immune system, bones, connective tissue, and gut. To modify the recipes below, either boil ingredients for one hour or less, or use a device like an InstaPot to allow the flavors to meld rather quickly without increasing the amines. If water evaporates, add enough water to top off the crock pot so it remains full. Place the drumstick meat into a separate container and pull off of the bone for use in other recipes. It will "gel" once refrigerated for a few hours - this is a good sign and indicates a high gelatin content. So bone broth improves the taste of other foods as well as adding in gut-healing gelatin. Use bone broth any time you mash root vegetables or cauliflower, use in soups, make sauces and gravies, or stew meats in broth. Or, use it in recipes for savory baked goods that traditionally call for water or milk. A few ounces and I know my body will be able to better handle whatever the day brings. This is my favorite because it contains a probiotic powder to add in the good bacteria to the gut, collagen to seal up a leaky gut, coconut milk for healthy fat, and berries and kale to provide polyphenols and antioxidants to reduce inflammation. Turmeric is used to give a deep color, but is also naturally anti-inflammatory for the gut lining and full of sulfur to promote glutathione cycling. Basil and mint are anti-inflammatory and full of essential oils that kill bad gut bugs. The basil is full of magnesium, and the pineapple is full of enzymes to help you digest food well.
The therapists use their knowledge of anatomy and physiology along with different manual techniques including but not limited to cross-fiber massage medicine quotes doctor flutamide 250mg free shipping, friction massage symptoms 7 weeks pregnant buy flutamide 250mg fast delivery, myofascial release medicine 4 you pharma pvt ltd buy flutamide 250mg amex, and trigger point therapy medicine 7767 purchase 250mg flutamide with visa. Soft tissue mobilization is a form of manual physical therapy where the physical therapist uses hands-on techniques on the muscles, ligaments and fascia with the goal of breaking adhesions. This procedure is commonly applied to the musculature surrounding the spine and consists of rhythmic stretching and deep pressure. Myofascial Release is a hands-on technique that involves applying gentle sustained pressure into American Chronic Pain Association Copyright 2019 40 the myofascial connective tissue to release restrictions. Myofascial Release Treatment is performed directly on skin without oils, creams or machinery. This enables the therapist to accurately detect fascial restrictions and apply the appropriate amount of sustained pressure to facilitate release of the fascia. While most therapists will use only their hands, tools or instruments can be used with therapeutic massage. The Graston Technique is when a tool is used to perform a specialized form of massage/scraping of the skin. The provider uses his or her hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments and nerves. It can also help push joint fluid throughout the body and stimulate the lymphatic system, which helps lower inflammation. Ultrasound Ultrasound therapy is using ultrasonic waves or sound waves of a high frequency to stimulate tissues in the body. The ultrasonic waves are caused by the vibration of crystals within the head of the wand/probe. The sound waves that pass through the skin cause a vibration of the local tissues. Ultrasound gel is used in order to reduce friction and assist in the transmission of the ultrasonic waves. Ultrasound is thought to improve healing through increases in tissue relaxation, local blood flow, and scar tissue breakdown. The medication gel is applied to the skin, and then the ultrasonic energy forces the medication through the skin. Although ultrasound is a common modality used in physical therapy treatment, the evidence does not support the use of ultrasound as an effective treatment for pain. Iontophoresis Iontophoresis is a method of delivering medication using electrical stimulation. Iontophoresis is thought to decrease inflammation, decrease pain, decrease muscle spasm, decrease swelling and edema, reduce calcium deposits in the body and manage scar tissue. Iontophoresis is administered in a physical therapy clinic or the patient wears a small battery-operated patch for 24 hours. American Chronic Pain Association Copyright 2019 41 Paraffin (wax) A paraffin treatment uses warm oil-based wax most commonly used on the hands, elbows and feet to provide deep heat therapy. The affected body part is dipped into the paraffin and then removed to allow the paraffin to harden. Paraffin provides the benefits of heat including increased blood flow, increased muscle flexibility and decreasing joint stiffness. Home units are available although one should always use paraffin wax heater which has automatic heat controller to maintain appropriate temperatures. Infrared Light Therapy Infrared Light therapy delivers light energy safely through the skin. Light at longer wavelengths are no longer visible to the human eye and are called infrared. Infrared Light therapy is thought to increase blood circulation, stimulate healing and reduce inflammation. Spinal Traction & Spinal Decompression Spinal Traction simply means providing a pulling force that provides a stretch to the spine. Traction is thought to decrease the intradiscal pressure to promote retraction of the herniated disc which would decrease the pressure on the adjacent nerve. However, muscles surrounding this area can contract as the body attempts to protect itself against the stretch, eliminating the benefit. Spinal decompression claims to use computercontrolled force to achieve gradual and calculated increases in traction forces and angles to the spine that creates a vacuum action within the disc. The computerized decompression table continuously monitors spinal resistance and adjusts forces accordingly. The goal of treatment is to create a negative intradiscal pressure to promote repositioning of the herniated disc material and to cause an influx of healing nutrients and other substances into the disc. Spinal Traction and Spinal Decompression have not been proven effective in treatment of pain. There is moderate evidence that home-based patient-controlled traction may be a noninvasive conservative option, if used along with other evidence-based conservative care. Kinesiotape is made up of cotton fibers with polymer elastic strands and is lightweight with heat-sensitive acrylic adhesive. Clinicians that use the tape believe that it can improve blood and lymph flow, provide soft tissue and muscle support, allow for beneficial muscle activation and provide joint protection. Kinesiotape can be American Chronic Pain Association Copyright 2019 42 applied in a variety of patterns on different body parts. Despite the fact that the brightly colored Kinesiotape has been widely seen on Olympic and professional athletes, the scientific evidence for its use remains low. Kinesiotape may have a small beneficial role in improving strength, range of motion and fluid circulation in certain injured individuals, but multiple systematic reviews have found insufficient evidence to support the use of Kinesiotape for those following injury or those with chronic musculoskeletal pain. Non-Elastic or Corrective Taping, often called McConnell Taping technique named after physical therapist Jenny McConnell who developed it, is characterized by tape with a combination of minimal elasticity and a high adhesive. Due to the highly adhesive backing of the tape (usually called Leukotape), a protective tape (usually called cover roll tape) is applied on the skin first. This type of taping technique is much more rigid and is used for structural support or alignment. McConnell taping is most frequently used for taping of the knee however the research is inconclusive for its benefit. Spinal manipulation is a historically recognized therapeutic intervention that has been employed in various cultures for thousands of years. Chiropractors prefer the term "adjustment" whereas physical therapists apply the word "mobilization. Manipulation and mobilization are two types of manual (hands-on) therapies that include a wide array of different techniques and schools of thought. In general, mobilization involves assisted low force, low velocity movement often directed to one or more compromised vertebral segments and typically uses long lever arms to deliver the force. The effects of spinal manipulation include relief of acute and chronic back pain, improved spinal motion, and affecting the nervous system mostly at the local spinal level. Overall, studies have shown that spinal manipulation can provide relief from acute and chronic low back and neck pain. In 2007 Guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care. Electrical Stimulation Devices (external) Electrotherapy represents the therapeutic use of electricity and is another modality that can be used in the treatment of pain. Transcutaneous electrotherapy is the most common form of electrotherapy in which electrical stimulation is applied to the surface of the skin. Interferential current is proposed to produce less impedance in the tissue, and the intensity provided is supposed to be more comfortable. Because there is minimal skin resistance with the interferential current therapy, a maximum amount of energy goes deeper into the tissue. This crisscrossing is postulated to be more effective because it serves to confuse the nerve endings, preventing the treated area from adjusting to the current. All cells produce electromagnetic fields and every organ in the body produces its own signature bioelectromagnetic field. As low frequency pulsed electromagnetic current passes through the body, it stimulates the electrical and chemical processes in the tissues.
Diseases
It is perceived not only as a sensation described with words such as burning symptoms questionnaire purchase flutamide 250 mg without a prescription, pressing medications emt can administer flutamide 250mg, stabbing medications that cause constipation flutamide 250 mg on-line, or cutting treatment centers for drug addiction buy 250 mg flutamide overnight delivery, but also as an emotional experience (feeling) with words such as agonizing, cruel, terrible, and excruciating. This tendency leads to a vicious circle of pain, lack of activity, fear, depression, and more pain. Conversely, patients with clear somatic symptoms often do not receive adequate psychological care: pain-related anxiety and depressive moods, unfavorable illness-related behavior, and psychopathological comorbidities may be neglected. From a psychological perspective, it is assumed that chronic pain disorders are caused by somatic processes (physical pathology) or by significant stress levels. This leads to unfavorable patient assumptions, such as (1) pain always has somatic causes and you just have to keep looking for them, (2) pain without any pathological causes must be psychogenic, and (3) psychogenic means psychopathological. This obsolete dichotomization must be addressed within the context of holistic pain therapy. Psychologically oriented pain therapists cannot have a naive attitude toward the pain and neglect somatic causes, because otherwise, patients with mental disorders. Interdisciplinary teams, with a biopsychosocial treatment concept, do not distinguish between somatic and the psychological factors, but treat both simultaneously within their individual specialties and through consultation with one another. Psychological pain therapy Psychological interventions play a well-established role in pain therapy. Patients with chronic pain often feel incapable of doing something about their pain themselves. Behavioral processes are geared toward changing obvious behaviors such as taking medication and using the health care system, as well as other aspects relating to general professional, private, and leisure activities. This step is accompanied by extensive education initiatives that help reduce anxiety and increase motivation to successfully complete this phase. The therapy begins with the development of a list of objectives that specify what the patient wants to achieve. It does not make sense to encourage a patient to return to work and to make this an objective if this is unlikely, due to the conditions on the job market. The support patients receive in therapy makes it more likely that they will continue 22 Table 1 Psychological interventions and therapy targets Intervention Patient training Therapeutic Targets Treatment Context Harald C. Cognitive-emotional modification strategies, on the other hand, predominantly focus on changing thought processes (convictions, attitudes, expectations, patterns, and "automatic" thoughts). Patients are taught, for example, how to identify thoughts that trigger and sustain pain, how to perceive situational characteristics, and how to develop alternative coping strategies. One of the goals of therapy is for patients to learn to monitor the function of expressing symptoms (something patients are usually not aware of ) to be able to better manage and manipulate their social environment. At the same time, detailed information is collected on the effects of the behavior and the functions the behavior might have. Fearful assumptions regarding the presence of a serious illness have negative behavioral consequences and foster passive pain behavior. To reduce this uncertainty, patients should be provided with information and knowledge using written or graphic materials as well as videos. In a group setting, the standardized process works better due to the expected differences between the patients. Biofeedback Biofeedback therapy involves physiological learning by measuring physiological pain components such as muscle activity, vascular responses, or arousal of the autonomic nervous system and providing visual or acoustic feedback to the patient. Several different methods are used for migraines, such as handwarming techniques and vascular constriction training (targeting the temporalis artery). The patient is asked to increase the blood supply to the hand (and thereby reduce vasodilatation in the arteries of the head). In autogenic feedback training, the hand warming is supported by the development of formula-type intentions from autogenic training (heat exercises). And finally, the patient is asked to increase the temperature of the hand without any direct feedback, and is told subsequently if he or she was successful. Due to learning theory considerations pertaining to the "enhancement character" of pain behavior, the pain itself is basically pushed out of the therapeutic focus. The physical therapy components usually include an increase in Psychological Factors in Chronic Pain overall fitness level, improvement in cardiovascular and pulmonary capacity, coordination and body perception, and an improved capacity to handle stress. The psychotherapeutic interventions try to change adverse emotional effects (antidepressive therapy). The therapy is highly somatically oriented, but the psychological effects of the training are just as important as the changes achieved in terms of muscle strength, endurance, and coordination. Physical training machinery can be used during the training (the patient feels safe due to the guided, limited movements), but they constitute "artificial" conditions and thus hinder the necessary transfer to daily life. Several meta-analytical studies have shown that about two out of three chronic patients were able to return to work after having undergone cognitive-behavioral pain therapy. The effect itself has been proven without a doubt, but it is much less clear why and in which combination the interventions are effective. It becomes more severe if the patient does not know the causes or the significance of the pain, which, in turn, leads to anxiety and increased pain levels. The results of many years of psychological pain research provide important insights for this process. Repeatedly, high hopes of curing pain are raised by the medical system, and usually dashed in careful long-term studies. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial. Coping with chronic pain: flexible goal adjustment as an interactive buffer against pain-related distress. Given the fact that this doctor is the only one available at that time, how is he going to handle the problem? These are common clinical problems seen by primary care physicians as well as pain clinics and are examples of how cultural and ethnic background affects pain perception, expression, and interactions with health care providers. Culture involves styles of thought and behavior that are learned and shared within the social structure of our personal world. The latter refers specifically to the sense of belonging in a particular social group within a larger cultural environment. In another experimental study, when Jewish and Protestant women were told that their own religious group had not performed well compared with others in an experiment with electric shocks, only Jewish women were able to tolerate a higher level of shock. Since their cultural background was such that they easily complained of pain, they had "more room to move" in terms of additional shock stimulus. On the other hand, in a clinical study of six ethnic groups of pain patients (including "old" American, Hispanic, Irish, Italian, French Canadian, and Polish pain patients), the Hispanics specifically reported the highest pain levels. Such a finding indeed supports the long-held belief that Latino cultures are more reactive to pain. In studies among patients with cancer, Hispanics reported much worse pain and quality of life outcomes than Caucasians or African Americans. All these studies and the ones Angela Mailis-Gagnon below are summarized by Mailis Gagnon and Israelson in their popular science book, Beyond Pain [3]. In certain parts of the world such as India, the Middle and Far East, Africa, some countries of Europe, and among North American First Nations, ability to endure pain is considered a proof of special access or relationship to the gods, a proof of faith, or readiness to "become an adult" during "initiations" or "rituals. The subjects seemed to stare far away and at no time did they seem to feel pain; as a matter of fact, they were in a "state of exaltation. Larbig was also fascinated by the amazing things that fakirs do and investigated a 48-year-old Mongolian fakir. As a matter of fact, the fakir was "somewhere else" in space and time, not aware of his surroundings. However, when he finished his performance, he would return quickly to a normal state of consciousness. Hypnosis makes the person more prone to suggestions, modifies both perception and memory, and may produce changes in functions that are not normally under conscious control, such as sweating or the tone of blood vessels. However, the physical differences between people of different cultures are less important than set beliefs and behaviors that influence the thoughts and actions of the members of a given cultural/ethnic group. Furthermore, the way patients report pain is shaped to a certain degree by what is supposed to be the norm in their own culture. Health providers must then be able to recognize that different cultures have different beliefs and attitudes toward: (a) authority, such as the physician or persons in position of power; (b) physical contact, as during physical examination; (c) communication style in regard to the verbal or body language with which people communicate their feelings; (d) men or women health providers; and (e) expressing sexual or other issues. Furthermore, women in a deprived socioeconomic situation run a higher risk for pain.
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