Cross Reference Winging of the scapula Poriomania A name sometimes given to prolonged wandering as an epileptic automatism impotence herbs order viagra soft online, or a fugue state of non-convulsive status epilepticus erectile dysfunction under 35 viagra soft 50 mg lowest price. Postural and righting reflexes depend not only on the integration of labyrinthine erectile dysfunction treatment in egypt buy viagra soft uk, proprioceptive erectile dysfunction caused by high cholesterol generic viagra soft 100 mg mastercard, exteroceptive impotence of organic origin meaning discount 100mg viagra soft free shipping, and visual stimuli erectile dysfunction vacuum pump demonstration buy viagra soft 100mg amex, mostly in the brainstem but also involve the cerebral cortex best pills for erectile dysfunction yahoo generic 100mg viagra soft amex. However erectile dysfunction treatment otc buy viagra soft with american express, abnormalities in these reflexes are of relatively little diagnostic value except in infants. One exception is extrapyramidal disease (parkinsonism, Huntington’s dis ease, but not idiopathic dystonia) in which impairment or loss of postural reflexes may be observed. In the ‘pull test’ the examiner stands behind the patient, who 284 Presbyastasis P is standing comfortably, and pulls briskly on the shoulders; if balance is normal, the patient takes a step back; with impaired postural reflexes, this may provoke repetitive steps backwards (retropulsion, festination) or even en bloc falling, due to the failure of reflex muscle contraction necessary to maintain equilibrium. Pushing the patient forward may likewise provoke propulsion or festination, but this manoeuvre is less safe since the examiner will not be placed to catch the patient should they begin to topple over. Cross References Dystonia; Festinant gait, Festination; Parkinsonism; Proprioception; ‘Rocket sign’ Pourfour du Petit Syndrome Pourfour du Petit syndrome is characterized by mydriasis, widening of the palpebral fissure, exophthalmos, hyperhidrosis. Cross Reference Horner’s syndrome Pouting, Pout Reflex the pout reflex consists of a pouting movement of the lips elicited by lightly tapping orbicularis oris with a finger or tendon hammer, or by tapping a spatula placed over the lips. This myotactic stretch reflex is indicative of a bilateral upper motor neurone lesion, which may be due to cerebrovascular small vessel disease, motor neurone disease or multiple sclerosis. It differs from the snout reflex, which refers to the reflex elicited by constant pressure on the philtrum. Cross References Frontal release signs; Primitive reflexes Prayer Sign An inability to fully oppose the palmar surfaces of the digits with the hands held in the praying position, recognized causes of which include ulnar neuropa thy (main en griffe), Dupuytren’s contracture, diabetic cheiroarthropathy, and camptodactyly. Presbycusis Presbycusis is a progressive sensorineural hearing loss, especially for high fre quencies, developing with increasing age, which may reduce speech discrimina tion. Cross Reference Age-related signs Presbyopia Presbyopia is progressive far-sightedness which is increasingly common with increasing age, thought to be due to an age-related impairment of accommo dation. The eyes can be brought to the other side with the oculocephalic manoeuvre or caloric testing. In contrast, thalamic and basal gan glia haemorrhages produce forced deviation of the eyes to the side contralateral to the lesion (wrong-way eyes). There are also non neurological causes, such as haematological conditions (sickle cell anaemia, polycythaemia rubra vera) which may cause intrapenile thromboses. Primitive Reflexes Reflexes which are normally found in infancy but which disappear with brain maturation during childhood may be labelled as ‘primitive reflexes’ if they re emerge in adulthood as a consequence of pathological states. Developmental reflexes: the reappearance of foetal and neonatal reflexes in aged patients. Impairment of proprioception leads to sensory ataxia which may manifest clin ically with pseudoathetosis or pseudochoreoathetosis (also seen in useless hand of Oppenheim) and with a positive Romberg’s sign. Cross References Ataxia; Dissociated sensory loss; Myelopathy; Pseudoathetosis; Pseudochoreoathetosis; Rombergism, Romberg’s sign; Useless hand of Oppenheim; Vibration Proptosis Proptosis is forward displacement of the eyeball, an exaggerated degree of exoph thalmos. Once established, it is crucial to determine whether the proptosis is axial or non-axial. Axial proptosis reflects increased pressure within or transmitted through the cone of extraocular muscles. Middle cranial fossa tumours may cause pressure on the veins of the cavernous sinus with secondary intraorbital venous congestion causing a ‘false localizing’ proptosis. Familiar individuals may be recognized by their voices or clothing or hair; hence, the defect may be one of visually triggered episodic memory. It is impor tant to note that the defect is not limited solely to faces; it may encompass animals (‘zooagnosia’) or cars. Prosopagnosia is often found in association with a visual field defect, most often a left superior quadrantanopia or even hemianopia, although for the diag nosis of prosopagnosia to be made this should not be sufficient to produce a perceptual deficit. Unilateral non-dominant (right) hemisphere lesions have occasionally been associated with prosopagnosia, and a syndrome of progressive prosopagnosia associated with selective focal atrophy of the right temporal lobe has been reported. Involvement of the periventricular region on the left side may explain accompanying alexia, and disconnection of the inferior visual association cortex (area V4) may explain achromatopsia. Progressive prosopagnosia associ ated with selective right temporal lobe atrophy. Odour-evoked autobiographical memories: psychological investigations of Proustian phenomena. The “Petites Madeleines” phenomenon in two amnesic patients: sudden recovery of forgotten memories. Cross Reference Amnesia Proximal Limb Weakness Weakness affecting predominantly the proximal musculature (shoulder abduc tors and hip flexors) is a pattern frequently observed in myopathic and dystrophic muscle disorders and neuromuscular junction transmission disorders, much more so than predominantly distal weakness (the differential diagnosis of which encompasses myotonic dystrophy, distal myopathy of Miyoshi type, desmin myopathy, and, rarely, myasthenia gravis). Age of onset and other clinical features may help to narrow the differential diagnosis: painful muscles may suggest an inflammatory cause (polymyositis, dermatomyositis); fatiguability may suggest myasthenia gravis (although lesser degrees of fatigue may be seen in myopathic disorders); weakness elsewhere may suggest a specific diagnosis. Causes include any interruption to the anatomical pathway mediating proprioception, most often lesions in the dorsal cervical cord. Bilateral internal capsule lacunar infarctions, widespread small vessel dis ease (Binswanger’s disease);. Congenital childhood suprabulbar palsy (Worster–Drought syndrome; peri sylvian syndrome). A 22-item checklist to help differentiate pseudodementia from Alzheimer’s disease has been described, based on clinical history, behaviour, and mental status. However, it should be borne in mind that depression is sometimes the pre senting symptom of an underlying neurodegenerative dementing disorder such as Alzheimer’s disease. Psychomotor retardation in dementia syndromes may also be mistaken for depression. Longitudinal assessment may be required to differentiate between these diagnostic possibilities. Some patients with dementia with Lewy bodies certainly realize that their percepts do not correspond to external reality and similar experiences may occur with dopamine agonist treatment. Cross References Myotonia; Neuromyotonia; Woltman’s sign Pseudo-One-and-a-Half Syndrome Pseudo-one-and-a-half syndrome is the eye movement disorder of one-and-a half syndrome without a brainstem lesion. Cross Reference One-and-a-half syndrome Pseudopapilloedema Pseudopapilloedema is the name given to elevation of the optic disc that is not due to oedema. Cross Reference Ptosis Pseudoradicular Syndrome Thalamic lesions may sometimes cause contralateral sensory symptoms in an apparent radicular. If associated with perioral sensory symptoms this may be known as the cheiro-oral syndrome. Von Graefe’s sign), medial rotation of the eye, and pupillary constriction 296 Ptosis P seen on attempted downgaze or adduction of the eye. It may be confused with the akinesia of parkinsonism and with states of abulia or catato nia. Psychomotor retardation may also be a feature of the ‘subcortical’ type of dementia or of impairments of arousal (obtundation). This may be due to mechanical causes such as aponeurosis dehiscence, or neurological disease, in which case it may be congenital or acquired, partial or complete, unilateral or bilateral, fixed or variable, isolated or accompanied by other signs. A tinted coloured lens in front of the good eye can alleviate the symptom (or induce it in the normally sighted). In an eye with poor visual acuity, a relative afferent pupillary defect may be observed using the ‘swinging flashlight test’. The contralat eral (consensual) response results from fibres crossing the midline in the optic chiasm and in the posterior commissure at the level of the rostral brainstem. The afferent pathways sub serving this response are less certain than for the light reflex and may involve the occipital cortex, although the final (efferent) pathway via Edinger–Westphal nucleus and oculomotor nerve is common to both accommodation and light reflexes. In comatose patients, fixed dilated pupils may be observed with central diencephalic herniation, whereas midbrain lesions produce fixed midposition pupils. A dissociation between the light and accommodation reactions (light-near pupillary dissociation, q. There may be associated amusia, depending on the precise location of cerebral damage. Pure word deafness has been variously conceptualized as a form of auditory agnosia or a subcortical sensory aphasia. Pure word deafness is most commonly associated with bilateral lesions of the temporal cortex or subcortical lesions whose anatomical effect is to dam age the primary auditory cortex or isolate it. Very rarely pure word deafness has been associated with bilateral brainstem lesions at the level of the inferior colliculi. Pure word deafness after resection of a tectal plate glioma with preservation of wave V of brain stem auditory evoked potentials. Brain 1987; 110: 381–403 Cross References Agnosia; Amusia; Aphasia Pursuit Pursuit, or smooth pursuit, eye movements hold the image of a moving target on the fovea, or during linear self-motion, i. Parietal lobe lesions may produce inferior quadrantic defects, usually accompanied by other localiz ing signs. Cerebellar hypoplasia and quadrupedal locomotion in humans as a recessive trait mapping to chromosome 17p. No specific investigations are required, but a drug history, including over the counter medi cation, is crucial. The condition may be confused with edentulous dyskinesia, if there is accompanying tremor of the jaw and/or lip, or with tardive dyskinesia. Radiculopathy A radiculopathy is a disorder of nerve roots, causing pain in a radicular distribution, paraesthesia, sensory diminution or loss in the corresponding der matome, and lower motor neurone type weakness with reflex diminution or loss in the corresponding myotome. There may be concurrent myelopathy, typically of extrinsic or extramedullary type. Most radiculopathies are in the lumbosacral region (60–90%), followed by the cervical region (5–30%). Structural lesions: Compression: disc protrusion: cervical (especially C6, C7), lumbar (L5, S1) >>> thoracic; bony metastases; spondylolisthesis; fracture; infection; Root avulsion. Cross References Cauda equina syndrome; Lasègue’s sign; Myelopathy; Neuropathy; Paraesthesia; Plexopathy; Reflexes; ‘Waiter’s tip’ posture; Weakness Raynaud’s Phenomenon Raynaud’s phenomenon consists of intermittent pallor or cyanosis, with or with out suffusion and pain, of the fingers, toes, nose, ears, or jaw, in response to cold or stress. Raynaud’s phenomenon may occur in Raynaud’s disease (idiopathic, primary) or Raynaud’s syndrome (secondary, symptomatic). Recognized causes include connective tissue disease, especially systemic sclerosis: cervical rib or tho racic outlet syndromes; vibration white finger; hypothyroidism; and uraemia. Associated symptoms should be sought to ascertain whether there is an under lying connective tissue disorder. Rebound Phenomenon this is one feature of the impaired checking response seen in cerebellar disease, along with dysdiadochokinesia and macrographia. It may be demonstrated by observing an overshoot of the outstretched arms when they are released sud denly after being pressed down by the examiner or suddenly releasing the forearm flexed against resistance so that it hits the chest (Stewart–Holmes sign). Although previously attributed to hypotonia, it is more likely a reflection of asynergia between agonist and antagonist muscles. Recruitment Recruitment, or loudness recruitment, is the phenomenon of abnormally rapid growth of loudness with increase in sound intensity, which is encountered in patients with sensorineural (especially cochlear sensory) hearing loss. Cross Reference Reflexes Recurrent Utterances the recurrent utterances of global aphasia, sometimes known as verbal stereo typies, stereotyped aphasia, or monophasia, are reiterated words or syllables produced by patients with profound non-fluent aphasia. This may also occur with temporomandibular joint dysfunction and thalamic lesions. Reduplicative Paramnesia Reduplicative paramnesia is a delusion in which patients believe familiar places, objects, individuals, or events to be duplicated. The syndrome is probably het erogeneous and bears some resemblance to the Capgras delusion as described by psychiatrists. Cross References Capgras delusion; Delusion; Paramnesia Reflexes Reflex action – a sensory stimulus provoking an involuntary motor response – is a useful way of assessing the integrity of neurological function, since disease in the afferent (sensory) limb, synapse, or efferent (motor) limb of the reflex arc may lead to dysfunction, as may changes in inputs from higher centres. Reflex Root value Jaw jerk Trigeminal (V) nerve Supinator (brachioradialis, radial) C5, C6 Biceps C5, C6 Triceps C7 Finger flexion (digital) C8, T1 Abdominal T7–T12 Cremasteric L1, L2 Knee (Patellar) L3, L4 Hamstring L5, S1 Ankle (Achilles) (L5) S1 (S2) Bulbocavernosus S2, S3, S4 Anal S4, S5 Tendon reflex responses are usually graded on a five-point scale: –: absent (areflexia; as in lower motor neurone syndromes, such as peripheral nerve or anterior horn cell disorders; or acute upper motor neurone syndromes. Subjectively, patients may note that the light stimulus seems less bright in the affected eye. Although visual acuity may also be impaired in the affected eye, and the disc appears abnormal on fundoscopy, this is not necessarily the case. Venous pulsation is expected to be lost when intracranial pressure rises above venous pressure. Cross References Papilloedema; Pseudopapilloedema Retinitis Pigmentosa Retinitis pigmentosa, or tapetoretinal degeneration, is a generic name for inher ited retinal degenerations characterized clinically by typical appearances on ophthalmoscopy, with peripheral pigmentation of ‘bone-spicule’ type, arteriolar attenuation, and eventually unmasking of choroidal vessels and optic atrophy. Despite the name, there is no inflammation; the pathogenetic mechanism may be apoptotic death of photoreceptors. Hypertension: hypertensive retinopathy may cause arteriolar constriction, with the development of cotton–wool spots; and abnormal vascular per meability causing flame-shaped haemorrhages, retinal oedema, and hard exudates; around the fovea, the latter may produce a macular star. Cross References Maculopathy; Retinitis pigmentosa; Scotoma Retrocollis Retrocollis is an extended posture of the neck. Retrocollis may also be a feature of cervical dystonia (torticollis) and of kernicterus. This phenomenon does not have partic ular localizing value, since it may occur with both occipital and anterior visual pathway lesions. This may occur in association with acalculia, agraphia, and finger agnosia, collectively known as the Gerstmann syndrome. Cross References Acalculia; Agraphia; Autotopagnosia; Finger agnosia; Gerstmann syndrome Rigidity Rigidity is an increased resistance to the passive movement of a joint which is constant throughout the range of joint displacement and not related to the speed of joint movement; resistance is present in both agonist and antagonist mus cles. In other words, there is a change in the sensitivity of the spinal interneurones which control α-motor neurones due to defective supraspinal con trol. Hence rigidity is a positive or release symptom, reflecting the operation of intact suprasegmental centres. Rigidity in Parkinson’s disease may be lessened by treatment with levodopa preparations. Pathophysiology of Parkinson’s disease rigidity: role of corticospinal motor projections. Neurophysiology of Parkinson’s disease, levodopa-induced dyskinesias, dystonia, Huntington’s disease and myoclonus. Risus sardonicus may also occur in the context of dystonia, more usually symptomatic (secondary) than idiopathic (primary) dystonia. Cross References Parkinsonism; ‘Wheelchair sign’ Roger’s Sign Roger’s sign, or the numb chin syndrome, is an isolated neuropathy affecting the mental branch of the mandibular division of the trigeminal (V) nerve, causing pain, swelling, and numbness of the lower lip, chin, and mucous membrane inside the lip. Hypoaesthesia involving the cheek, upper lip, upper incisors, and gingiva, due to involvement of the infraorbital portion of the maxillary division of the trigeminal nerve (‘numb cheek syndrome’), is also often an ominous sign, result ing from recurrence of squamous cell carcinoma of the face infiltrating the nerve. Le signe du mentonnier (parasthésie et anesthésie unilatérale) révélateur d’un processus néoplasique métastatique. Before asking the patient to close his or her eyes, it is advisable to position ones arms in such a way as to be able to catch the patient should they begin to fall. Large amplitude sway without falling, due to the patient clutching hold of the physician, has been labelled ‘psychogenic Romberg’s sign’, an indicator of functional stance impairment. Heel–toe (tandem) walking along a straight line is sometimes known as the dynamic Romberg’s test. Development of numbness, pain, and paraesthesia, along with pallor of the hand, supports the diagnosis of thoracic outlet syndrome. Its presence in adults is indicative of diffuse premotor frontal disease, this being a primitive reflex or frontal release sign. These movements may be performed voluntar ily (tested clinically by asking the patient to ‘Look to your left, keeping your head still’, etc. Several types of saccadic intrusion are described, including ocular flutter, opsoclonus, and square wave jerks. Sacral sparing is explained by the lamination of fibres within the spinotha lamic tract: ventrolateral fibres (of sacral origin), the most external fibres, are involved later than the dorsomedial fibres (of cervical and thoracic ori gin) by an expanding central intramedullary lesion. The outstanding ability may be feats of memory (recalling names), calculation (especially calendar calculation), music, or artis tic skills, often in the context of autism or pervasive developmental disorder. Occasionally, skills 320 Scoliosis S such as artistic ability may emerge in the context of neurodegenerative disease (Alzheimer’s disease, frontotemporal lobar degeneration). However, cerebellar disease typically produces an ataxic dysarthria (variable intonation, interruption between syllables, ‘explosive’ speech) which is some what different from scanning speech. The examiner then places the tuning fork over his/her own mastoid, hence comparing bone conduc tion with that of the patient. In addition to the peripheral field, the cen tral field should also be tested, with the target object moved around the fixation point. Infarction of the occipital pole will produce a central visual loss, as will optic nerve inflammation. Cross References Altitudinal field defect; Angioscotoma; Blindsight; Blind spot; Central scotoma, Centrocaecal scotoma; Hemianopia; Junctional scotoma, Junctional scotoma of Traquair; Maculopathy; Papilloedema; Quadrantanopia; Retinitis pigmentosa; Retinopathy; Visual field defects Scratch Test the ‘scratch test’, or ‘direction of scratch’ test, examines perception of the direc tion (up or down) of a scratch applied to the anterior shin (for example, with the sharp margin of a paper clip). Otherwise, as for idiopathic generalized epilepsies, various antiepileptic medica tions are available. Best treated with psychologi cal approaches or drug treatment of underlying affective disorders; antiepileptic medications are best avoided. Cross References Lid retraction; Nystagmus; Parinaud’s syndrome; Stellwag’s sign Shadowing A neurobehavioural disorder, occasionally seen in patients with dementia, in which the patient follows the spouse or carer around like a shadow. Cross References Ataxia; Cerebellar syndromes; Heel–knee–shin test, Heel–shin test Sialorrhoea Sialorrhoea (drooling) is excessive salivation, possibly due to excess flow of saliva but more likely secondary to a reduced frequency of swallowing. If troublesome, treatment of sialorrhoea with anticholinergic agents may be tried (atropine, hyoscine), although they may cause confusion in Parkinson’s dis ease. Recently, the use of intraparotid injections of botulinum toxin has been found useful. Cross References Bulbar palsy; Parkinsonism Sighing Occasional deep involuntary sighs may occur in multiple system atrophy. Sudden inspiratory or expiratory sighs are said to be a feature of the hyperki netic choreiform dysarthria characteristically seen in choreiform disorders such as Huntington’s disease. Dorsal: An attentional limitation preventing more than one object being seen at a time; although superficially similar to apperceptive visual agnosia, with which it has sometimes been classified, patients with dor sal simultanagnosia can recognize objects quickly and accurately, but unattended objects are not seen. There may be inability to localize stim uli even when they are seen, manifest as visual disorientation. Dorsal simultanagnosia is associated with bilateral posterior parieto-occipital lesions and is one feature of Balint’s syndrome. This is thought to reflect damage to otolith-ocular pathways or vestibulo-ocular pathways.
In economically developing the frequency of the most common cancer diagnoses and deaths countries erectile dysfunction treatment in lucknow cheap viagra soft 50mg fast delivery, the three most commonly diagnosed cancers were also varies by geographic areas (Table 3) xatral impotence order viagra soft american express. For example erectile dysfunction causes cancer discount 50mg viagra soft with visa, among lung impotence urban dictionary order viagra soft 100mg without prescription, stomach erectile dysfunction treatment malaysia order viagra soft 100mg on line, and liver in men erectile dysfunction funny images generic viagra soft 50 mg amex, and breast erectile dysfunction doctor kolkata order viagra soft 100mg mastercard, cervix uteri erectile dysfunction injections australia discount viagra soft 50mg otc, and women breast cancer was the most common cause of cancer lung in women. In both economically developed and developing death in 10 out of the 21 world areas, while cervical and lung countries, the three most common cancer sites were also the cancers were the leading causes of cancer death in the remaining three leading causes of cancer death (Figure 1). Further variations in the most frequently diagnosed cancers are observed by examining individual countries world Is There Geographic Variation in Cancer wide. Factors that contribute to regional differences in the types or Lung cancer predominated as the top cancer site in most of burden of cancer include regional variations in the prevalence Eastern Europe and Asia. The greatest variation among males of major risk factors, availability and use of medical practices was observed in Africa, where the most common cancers included such as cancer screening, availability and quality of treatment, prostate, lung, liver, esophagus, bladder, Kaposi sarcoma, and and age structure. Among females worldwide the most men (stomach and liver) and women (cervix and stomach) in common cancer sites were either breast or cervical cancer, with developing countries were related to infection. Stomach can the exception of China (lung), South Korea (thyroid), and Mongolia cer continued to be the most common infection-related cancer and Vietnam (liver) (Figure 3). The geographic variations in a worldwide, followed closely by liver and cervix (Figure 1). This percentage is about three times higher in developing countries (26%) than in developed countries (8%) (Figure 2). It is estimated that more than half of all cancer cases and deaths worldwide are potentially preventable (Figure 2). Estimated Number of New Cancer Cases and Deaths by World Area, 2008* Cases Deaths Male Female Overall Male Female Overall Eastern Africa 100,800 120,200 221,100 85,400 88,300 173,700 Middle Africa 29,500 37,400 66,900 25,600 27,600 53,200 Northern Africa 81,500 82,900 164,400 65,400 55,400 120,800 Southern Africa 40,600 38,600 79,200 29,300 25,500 54,800 Western Africa 72,500 111,600 184,100 61,300 78,000 139,300 Eastern Asia 2,135,300 1,585,400 3,720,700 1,511,800 928,600 2,440,400 South-Central Asia 651,100 772,000 1,423,100 496,800 483,200 979,900 South-Eastern Asia 336,700 388,800 725,600 258,600 242,400 501,000 Western Asia 118,500 104,800 223,300 86,700 64,400 151,200 Caribbean 42,800 36,500 79,300 26,300 21,500 47,800 Central America 84,000 92,600 176,600 52,500 55,800 108,300 Northern America 831,800 772,100 1,603,900 332,500 305,900 638,300 South America 318,000 332,100 650,100 200,600 185,300 385,900 Central and Eastern Europe 494,600 490,600 985,200 351,700 283,000 634,800 Northern Europe 248,400 231,800 480,200 126,400 116,300 242,700 Southern Europe 398,800 315,000 713,900 225,000 155,500 380,500 Western Europe 569,600 464,700 1,034,300 258,900 204,900 463,800 Australia/New Zealand 70,300 56,700 127,000 27,600 21,400 49,100 Melanesia 3,300 3,700 7,000 2,600 2,500 5,100 Micronesia 300 400 700 200 200 400 Polynesia 600 600 1,100 300 200 600 * Excludes nonmelanoma skin cancer. Estimated New Cancer Cases and Deaths Worldwide for Leading Cancer Sites by Level of Economic Development, 2008 Estimated New Cases Estimated Deaths Male Female Male Female Worldwide Lung & bronchus Breast Lung & bronchus Breast 1,095,200 1,383,500 951,000 458,400 Prostate Colon & rectum Liver Lung & bronchus 903,500 570,100 478,300 427,400 Colon & rectum Cervix Uteri Stomach Colon & rectum 663,600 529,800 464,400 288,100 Stomach Lung & bronchus Colon & rectum Cervix uteri 640,600 513,600 320,600 275,100 Liver Stomach Esophagus Stomach 522,400 349,000 276,100 273,600 Esophagus Corpus uteri Prostate Liver 326,600 287,100 258,400 217,600 Urinary bladder Liver Leukemia Ovary 297,300 225,900 143,700 140,200 Non-Hodgkin lymphoma Ovary Pancreas Esophagus 199,600 225,500 138,100 130,700 Leukemia Thyroid Urinary bladder Pancreas 195,900 163,000 112,300 127,900 Oral cavity Non-Hodgkin lymphoma Non-Hodgkin lymphoma Leukemia 170,900 156,300 109,500 113,800 All sites but skin All sites but skin All sites but skin All sites but skin 6,629,100 6,038,400 4,225,700 3,345,800 Male Female Male Female Developed Prostate Breast Lung & bronchus Breast Countries 648,400 692,200 412,000 189,500 Lung & bronchus Colon & rectum Colon & rectum Lung & bronchus 482,600 337,700 166,200 188,400 Colon & rectum Lung & bronchus Prostate Colon & rectum 389,700 241,700 136,500 153,900 Urinary bladder Corpus uteri Stomach Pancreas 177,800 142,200 110,900 79,100 Stomach Stomach Pancreas Stomach 173,700 102,000 82,700 70,800 Kidney Ovary Liver Ovary 111,100 100,300 75,400 64,500 Non-Hodgkin lymphoma Non-Hodgkin lymphoma Urinary bladder Liver 95,700 84,800 55,000 39,900 Melanoma of skin Melanoma of the skin Esophagus Leukemia 85,300 81,600 53,100 38,700 Pancreas Pancreas Leukemia Non-Hodgkin lymphoma 84,200 80,900 48,600 33,500 Liver Cervix uteri Kidney Corpus uteri 81,700 76,500 43,000 33,200 All sites but skin All sites but skin All sites but skin All sites but skin 2,975,200 2,584,800 1,528,200 1,223,200 Male Female Male Female Developing Lung & bronchus Breast Lung & bronchus Breast 612,500 691,300 539,000 268,900 Countries Stomach Cervix uteri Liver Cervix uteri 466,900 453,300 402,900 242,000 Liver Lung & bronchus Stomach Lung & bronchus 440,700 272,000 353,500 239,000 Colon & rectum Stomach Esophagus Stomach 274,000 247,000 223,000 202,900 Esophagus Colon & rectum Colon & rectum Liver 262,600 232,400 154,400 177,700 Prostate Liver Prostate Colon & rectum 255,000 186,000 121,900 134,100 Urinary bladder Corpus uteri Leukemia Esophagus 119,500 144,900 95,100 115,900 Leukemia Esophagus Non-Hodgkin lymphoma Ovary 116,500 137,900 71,600 75,700 Oral cavity Ovary Brain, nervous system Leukemia 107,700 125,200 63,700 75,100 Non-Hodgkin lymphoma Leukemia Oral cavity Brain, nervous system 103,800 93,400 61,200 50,300 All sites but skin All sites but skin All sites but skin All sites but skin 3,654,000 3,453,600 2,697,500 2,122,600 Source: Globocan 2008. Proportion of Cancer Causes by Major Risk Factors and Level of Economic Development Developed Countries Developing Countries Occupational exposures 5% Diet or Diet or nutrition Environmental nutrition 30% pollution 2% 20% Infections 8% Infections 26% Other Other 44% 39% Tobacco 16% Tobacco 10% Source: Cancer Atlas, 2006. Some All cancers involve the malfunction of genes that control cell cancers (colorectal and cervix) can be avoided by detection and growth, division, and death. However, most of the genetic removal of precancerous lesions through regular screening abnormalities that affect cancer risk are not hereditary (inherited examinations by a health care professional. Early detection of from parents), but instead result from damage to genes (muta cancer is important because it provides a greater chance that tions) that occur throughout a person’s lifetime. Cancers that can be detected at an genes may be due to internal factors, such as hormones or the early stage through screening include breast, cervix, colorectum, 4 metabolism of nutrients within cells, or external factors, such as prostate, oral cavity, and skin. These nonhereditary mutations proven to be effective in reducing the mortality for only breast, are called somatic mutations. Most cancers evolve through for most of these cancers are not available in developing countries multiple changes resulting from a combination of hereditary because of limited resources. However, the risk of being diagnosed Cancer survival is usually measured as the proportion of cancer with cancer increases substantially with age. In economically patients who are still alive five years after diagnosis relative to developed countries, 78% of all newly diagnosed cancer cases the 5-year survival of people in the general population who are of occur at age 55 and older, compared to 58% in developing coun the same age and sex. The difference is largely due to variations in age structure affected by a number of factors, most importantly, the types of of the populations. The populations of developing countries are cancer that occur, the stages at which cancers are diagnosed, younger and have a smaller proportion of older individuals in and whether treatment is available (Table 5). Table 4 shows the estimated are affected by screening and/or treatment, such as female breast, age-standardized incidence and mortality rates (per 100,000) for colorectal and certain childhood cancers, there are large survival various types of cancers by sex and level of economic development differences between economically developed and developing in 2008. For example, five-year survival rates for breast cancer more developed countries compared to less developed countries in the United States are approximately 84%, compared to 39% in in both men (300. In contrast, the mortality rate for all cancers combined 4 Global Cancer Facts & Figures 2nd Edition Table 3. The Two Most Common Types of New Cancer Cases and Deaths by World Area, 2008 Cancer Cases Males Females First Second First Second Eastern Africa Kaposi sarcoma 15. Estimated Age-standardized Incidence and Mortality Rates (per 100,000) by Sex, Cancer Site, and Level of Economic Development, 2008 Males Females Developed countries Developing countries Developed countries Developing countries Site Incidence Mortality Incidence Mortality Incidence Mortality Incidence Mortality Bladder 16. In addition to differences regional, and distant) is the most simplistic way to categorize in screening and treatment, international differences in cancer how far a cancer has spread from its point of origin. It is useful for survival rates are also affected by differences in detection historical descriptive and statistical analysis of tumor registry practice, awareness, and data quality. If cancer cells are present only in the layer of cells where they originated and have not penetrated the basement membrane How Is Cancer Staged? Stage is categorized as local if cancer cells are confined to the organ of Staging describes the extent or spread of the disease at the time origin, regional if the cells have spread beyond their original of diagnosis. It is essential in determining the choice of therapy (primary) site to nearby lymph nodes or tissues, and distant if and in assessing prognosis. Stage is based on the primary tumor’s they have spread from the primary site to distant organs or size and location and whether it has spread to other areas of the distant lymph nodes. A number of different staging systems are used to classify cancer have become better understood, prognostic models have tumors. Once the T, N, and M are determined, Global Cancer Facts & Figures 2nd Edition 7 Table 5. Five-year Relative Survival Rates*(%) for Selected Cancers among Individuals† Aged 15 and Older in Select Countries United States England Demark Austria Poland Belgium Germany (1999-2006) (1995-1999) (1995-1999) (1995-1999) (1995-1999) (1995-1999) (1995-1999) Brain 26. Variations in survival rates across countries reflect differences in detection practice, availability of treatment, and data quality. Stage Distribution (%) for Cervical Cancer diagnosis for cancer of the uterine cervix among patients in in Selected Countries among Patients Treated in 1999-2001 cancer hospitals in different cities around the world. Recent research has shown that 26th Annual Report on the Results of Treatment in Gynecological Cancer. However, portions of the total costs of cancer have been estimated to be as high as Primary prevention. Primary prevention offers the greatest public health potential and the most cost-effective, long-term method of cancer control. Once a diagnosis is confirmed, it is necessary to main objectives of the strategy are: 1) Reduce risk factors for determine cancer stage, where the main goals are to aid in the chronic diseases that stem from unhealthy diet and physical choice of therapy, to determine prognosis, and to standardize the inactivity through public health actions. The primary modalities and understanding of the influences of diet and physical activity of cancer treatment are surgery, chemotherapy, and radiotherapy; on health and the positive impact of preventive interventions. There is increasing Develop, strengthen, and implement global, regional, national emphasis worldwide on the development of specialized cancer policies and action plans to improve diets and increase physical centers that apply evidence-based multimodal therapies and activity that are sustainable, comprehensive, and actively engage provide rehabilitation and palliative care. In most parts of the world, the majority of cancer can be treated most effectively. Early detection is only valuable if patients are diagnosed with advanced-stage disease. The most basic approach to palliative care for opportunistic screening requested sporadically by a physician terminally ill cancer patients, especially in low-resource settings, or an individual or 2) organized screening in which a defined involves using inexpensive oral pain medications ranging from population is contacted and invited to be screened at regular aspirin to opiates, depending on individual patient needs. In practice, many cancer screening programs have 15 Unfortunately, sufficient supplies of opioid drugs for use in elements of each of these approaches. Cancers that have proven palliative care are often not available in developing countries early detection methods include cervix, colon and rectum, and because of regulatory or pricing obstacles, lack of knowledge, or breast. The Institute of Medicine of the National steps comprise a sequential approach according to the individual Academies recommends that low-resource countries that cannot pain intensity, which begins with non-opioid analgesics and afford the infrastructure required for organized screening progresses to opioids for moderate pain and then for severe pain. In developing countries, cervical countries, cancer pain management is also limited by geographical cancer is one of the most important health problems for women. About half of these cases occured in economically devel than 140% in the Miyagi registry during the time period 1973 oping countries. Female breast cancer incidence rates varied 1977 through 1998-2002, and India, where rates increased 40% internationally by more than 13-fold in 2008, ranging from 8. This may in part reflect low screening rates likely reflect changes in reproductive patterns, obesity, physical and incomplete reporting in developing countries. Although generally high in North America, Australia, and Northern and breast cancer incidence rates continued to increase through the Western Europe; intermediate in Eastern Europe; and low in late 1990s, breast cancer mortality over the past 25 years has been large parts of Africa and Asia (with the exception of Israel). Breast cancer is the leading cause of cancer detection through mammography and improved treatment. International Variation in Age-standardized Breast Cancer Incidence Rates, 2008 Rate per 100,000 ≥ 72. When breast cancer has grown to a size diagnosis of breast cancer for postmenopausal women. Breast that it can be felt, the most common physical sign is a painless feeding, moderate or vigorous physical activity, and maintaining mass. Less common signs and symptoms include breast pain and a healthy body weight are all associated with a lower risk of persistent changes to the breast, such as thickening, swelling, breast cancer. All reduce the risk of developing breast cancer is to reduce known women should become familiar with both the appearance and risk factors as much as possible by maintaining a healthy body feel of their breasts so they can promptly report any changes to a 36 weight, increasing physical activity, and minimizing alcohol doctor or nurse. Methods for early detection of breast cancer include Risk factors: Aside from being female, age is the most important screening by mammography and clinical breast examination. Numerous studies have shown that early breast tissue density (a mammographic measure of the amount detection saves lives and increases treatment options. However, of glandular tissue relative to fatty tissue in the breast), biopsy implementation of population-based, organized mammography confirmed hyperplasia of breast tissue (especially atypical screening programs may be cost prohibitive in many developing hyperplasia), and high-dose radiation to the chest as a result of countries and is only recommended for countries with good health medical procedures. Reproductive and middle-income countries are awareness of early signs and factors that increase risk include a long menstrual history symptoms and screening by clinical breast examination. Effective breast cancer in mortality rates are still occurring in countries that have more treatment for women in low and middle-income countries may limited resources, including Mexico and Brazil in South America be limited by the small numbers of trained medical personnel, and Romania and Russia in Eastern Europe. Advanced disease may cause rectal bleeding, Survival: the five-year survival rate from breast cancer among blood in the stool, a change in bowel habits, and cramping pain women age 15 and older is 89% in the United States, 82% in in the lower abdomen. In some cases, blood loss from the cancer Switzerland, and 80% in Spain (Table 5). Breast cancer survival leads to anemia (low red blood cells), causing symptoms such as rates in developing countries are generally lower than in Europe weakness and excessive fatigue. The stage In developed countries, more than 90% of cases are diagnosed at diagnosis is the most important prognostic variable. However, lifestyle factors are also important Colon and Rectum determinants of colorectal cancer risk. Modifiable factors New cases: Colorectal cancer is the third most common cancer associated with increased risk of colorectal cancer are obesity, in men and the second in women. Studies indicate that men incidence rates were in North America, Australia, New Zealand, and women who are overweight are more likely to develop and Europe, and Japan (Figures 6a and 6b). Deaths: About 608,700 deaths from colorectal cancer occured in However, these drugs are not recommended for the prevention 2008 worldwide, accounting for 8% of all cancer deaths. Global trends: the incidence of colorectal cancer is increasing 46 Prevention and early detection: Screening can prevent colorectal in certain countries where risk was historically low (Japan). In cancer through the detection and removal of precancerous high-risk/high-income countries, trends are either gradually lesions. Screening can also detect colorectal cancer at an early increasing (Finland, Norway), stabilizing (France, Australia), or stage. The current recommendation for colorectal cancer declining (United States) with time. The greatest increases in screening in most countries is to begin screening at age 50 for the incidence of colorectal cancer are in Asia (Japan, Kuwait, men and women who are at average risk for developing colorectal Israel) and Eastern Europe (Czech Republic, Slovakia, Slovenia). Persons at higher risk should begin screening at a In fact, rates among males in the Czech Republic, Slovakia, and younger age and may need to be tested more frequently. Japan have not only exceeded the peak rates observed in long standing developed countries such as the United States, Canada, There are several accepted colorectal cancer screening methods, and Australia but they continue to increase. While colonoscopy is countries, relatively large increases have been observed in Spain, a highly sensitive test, it requires a skilled examiner, involves which may be related to the increasing prevalence of obesity in greater cost, and is less convenient and has more risk for the recent years in that country. While some countries have implemented Global Cancer Facts & Figures 2nd Edition 13 Figure 6a. International Variation in Age-standardized Colorectal Cancer Incidence Rates among Males, 2008 Rate per 100,000 ≥ 28. International Variation in Age-standardized Colorectal Cancer Incidence Rates among Females, 2008 Rate per 100,000 ≥ 28. Despite colorectal cancer screening initiatives consist of recommenda a lower prevalence of smoking, lung cancer rates in Chinese tions and/or guidelines with opportunistic screening available. In contrast, in countries where the Treatment: Surgery is the most common treatment for colorectal epidemic has been established more recently and smoking has cancer. For cancers that have not spread, surgical removal may just peaked or continues to increase, such as China, Korea, and be curative. A permanent colostomy (creation of an abdominal several countries in Africa, lung cancer rates are increasing and opening for elimination of body wastes) is very rarely needed for are likely to continue to increase at least for the next few decades, colon cancer and is infrequently required for rectal cancer. For barring interventions to accelerate smoking cessation and rectal cancer, chemotherapy alone, or in combination with reduce initiation. Signs and symptoms: Symptoms may include persistent cough, For colon cancer, chemotherapy is most often used after surgery sputum streaked with blood, chest pain, voice change, and for cancers that have spread to lymph nodes and may also be recurrent pneumonia or bronchitis. Risk factors: Cigarette smoking is the most important risk Survival: Five-year relative survival rates for colorectal cancer factor for lung cancer, accounting for about 80% of lung cancer vary worldwide. In the United States the overall five-year survival 7 45 cases in men and 50% in women worldwide. Cigar cancers are detected at an early stage, the five-year survival rate and pipe smoking also increase risk. Other risk factors include increases to 90%; however, only 39% of colorectal cancers are secondhand smoke, occupational or environmental exposures diagnosed at this stage, mainly due to underuse of screening. In to radon and asbestos (particularly among smokers), certain Europe survival rates range from 38. High five-year relative survival rates are also 64-65 especially in those who develop the disease at a younger age. Most lung cancers could be prevented by countries – China, India, the Philippines, and Thailand – ranged reducing smoking initiation among adolescents and increasing from 28% to 42%. In the United States, comprehensive 2008, accounting for about 13% of total cancer diagnoses. In men, tobacco control programs in many states have markedly the highest lung cancer incidence rates were in North America, decreased smoking rates and accelerated the reduction in lung Europe, Eastern Asia, Argentina, and Uruguay and the lowest cancer occurrence, particularly in California. International Variation in Age-standardized Lung Cancer Incidence Rates among Males, 2008 Rate per 100,000 ≥ 33. International Variation in Age-standardized Lung Cancer Incidence Rates among Females, 2008 Rate per 100,000 ≥ 33. Screening for early lung cancer detection has not yet been proven Treatments include surgery, radiation therapy, chemotherapy, to reduce mortality. For localized cancers, surgery is usually fiber-optic examination of the bronchial passages have shown the treatment of choice. Recent studies indicate that survival limited effectiveness in reducing lung cancer mortality. Because the disease has usually and molecular markers in sputum, have produced promising spread by the time it is discovered, radiation therapy and Global Cancer Facts & Figures 2nd Edition 17 chemotherapy are often used, sometimes in combination with Canada, Finland, France, Israel, Italy, the Netherlands, Norway, surgery. Chemotherapy alone or combined with radiation is the Portugal, Sweden, the United Kingdom, and the United States. The five-year relative increased consumption of animal fat, obesity, and physical survival rate for all stages combined is about 16% in the United 69 inactivity. The five-year survival rate is 53% for cases detected when the disease is still localized, but only 15% of lung cancers Signs and symptoms: Early prostate cancer usually has no are diagnosed at this early stage. With more advanced disease, individuals may expe rates are generally similar to those in the United States, ranging rience weak or interrupted urine flow; inability to urinate or from 7. Continual pain in the lower back, pelvis, or upper thighs may be an indication of spread of the disease to New cases: Prostate cancer is the second most frequently the bones. Many of these symptoms, however, are similar to those diagnosed cancer in men, with 903,500 new cases estimated to caused by benign conditions. Nearly three-quarters of these cases were diagnosed in economically developed countries. Incidence rates Risk factors: the only well-established risk factors for prostate of prostate cancer vary by more than 70-fold worldwide. The cancer are older age, race (black), and family history of the highest rates are recorded primarily in the developed countries disease. About 62% of all prostate cancer cases in the United of Europe, North America, and Oceania, largely because prostate States are diagnosed in men 65 and older. Deaths: With an estimated 258,400 deaths in 2008, prostate cancer was the sixth leading cause of cancer death in men Prevention and early detection: Although modifiable risk factors worldwide. The reason for the high prostate cancer animal fat and high in fruits and vegetables. International Variation in Age-standardized Prostate Cancer Incidence Rates, 2008 Rate per 100,000 ≥ 66. Treatment: Treatment options vary depending on age, stage, and Stomach grade of the cancer, as well as other medical conditions. Surgery New cases: Stomach cancer was the fourth most common (open, laparoscopic, or robotic-assisted), external beam radiation, malignancy in the world in 2008, with an estimated 989,600 new or radioactive seed implants (brachytherapy) may be used to cases. Generally, stomach cancer rates are about twice as radiation (or combinations of these treatments) are used for high in men as in women. Stomach cancer incidence rates vary metastatic disease and as a supplemental or additional therapy widely across countries, ranging from less than 1 case (per for early stage disease. Hormone treatment may control prostate 100,000) in areas such as Botswana to about 62 in Korea for men cancer for long periods by shrinking the size or limiting the and from less than 1 in Botswana to about 26 in Guatemala for growth of the cancer, thus relieving pain and other symptoms. In general, the highest incidence Careful observation (“watchful waiting” or “active surveillance”) rates are in Asia (particularly in Korea, Japan, and China) and rather than immediate treatment may be appropriate for some many parts of South America, and the lowest rates are in North men with less aggressive tumors, especially older men with America and most parts of Africa with the exception of Mali and limited life expectancy and/or other health considerations. Survival: Over the past 25 years, a dramatic improvement in Deaths: Stomach cancer is the third leading cause of cancer survival has been observed, partly attributable to earlier diagnosis death in men and the fifth leading cause in women. About of asymptomatic cancers (some of which would never have 738,000 people worldwide died from stomach cancer in 2008.
To facilitate a single bolus swallow causes of erectile dysfunction in 40 year old purchase 50 mg viagra soft otc, the entire bowl of a dry spoon can be placed on the tongue applying downward pressure to encourage the tongue to make a bowl then move back to initiate a swallow erectile dysfunction protocol real reviews safe viagra soft 100 mg. If the child does not close his lips around the spoon erectile dysfunction hypogonadism purchase on line viagra soft, he is asked to and/or his lips are closed around the spoon to learn the correct sequence (Chigira erectile dysfunction at age of 20 purchase 100 mg viagra soft with amex, Omoto erectile dysfunction humor buy viagra soft 100 mg on-line, Mukai impotence 16 year old buy viagra soft uk, & Kaneko erectile dysfunction treatment in sri lanka cheap viagra soft 100mg amex, 1994) erectile dysfunction treatment edmonton buy viagra soft 50mg cheap. All presentations of the spoon should be done with the child’s head in a neutral position and with him facing forward. Since there is no food on the spoon and no threat of aspiration, he is learning the correct sequence of movement for a single bolus swallow in a safe manner using the utensil that is used for feeding. As he becomes more proficient with this pattern, a small amount of food is placed on the spoon. The amount of food on the spoon is increased gradually until he can accept a level spoonful of food while always ensuring that he is continuing to exhibit the appropriate oral-motor pattern. Some children have difficulty grading the amount of mouth opening and closing needed for a variety of foods. When a child demonstrates wide jaw excursions, he will have difficulty using his tongue to manage the food. Providing jaw stability by placing your hand under the jaw will help the child to take bites and to keep the mouth closed while the tongue does the work of manipulating the food. As the child practices, thinner foods can be placed between the molars to chew using minimal jaw excursions. Empirical Support for Oral Stimulation and Oral-Motor Therapy Oral-Motor Therapy While the majority of published studies report on the efficacy of oral-motor therapy for high-risk infants born prematurely or children with neuromotor difficulties, a few case studies suggest the promising use of oral-motor treatment techniques for children with low muscle tone (Kumin, Von Hagel, & Bahr, 2001) and retardation/autism (Larrington, 1987). Using a two-group design, Gaebler and Hanzlik (1996) compared 5 minutes of pre-feeding stroking to 5 minutes of pre-feeding stroking and introral prefeeding stimulation in a sample of 18 premature infants. Assessments occurred on days 1, 3 and 5; the group that received oral stimulation fed significantly better than the control group on day 3 only. In addition, infants in the experimental group demonstrated greater overall intake, rate of milk transfer, and amplitude of the expression component of sucking. In contrast, there were no differences between experimental and control infants on sucking stage maturation, sucking frequency, amplitude of the suction component of sucking or endurance of sucking. An elegant series of studies investigating sensorimotor intervention on eating skills of children with cerebral palsy (average age ~ 5 years) has been conducted by Gisel and colleagues (Gisel, 1994; Gisel, Applegate-Ferrante, Benson, & Bosma, 1995, 1996). Oral-motor therapy, which was designed to increase tongue lateralization, lip control, and vigor of chewing, was delivered before the lunch meal for 5-7 minutes/day, 5 days/week for 10-20 weeks. Using a between subject experimental design, children’s spoon feeding, biting, and chewing improved with oral-motor therapy (Gisel, 1994). Using a within-subject design, spoon feeding, chewing, and swallowing improved after oral-motor therapy (Gisel et al. In addition, more children advanced food texture with oral motor therapy (Gisel et al. These functional changes in feeding skills appear to be a function of jaw stabilization. Behavioral Interventions Targeting Oral-Motor Problems Within the field of applied behavior analysis, several researchers have designed interventions using behavioral principles to improve specific oral-motor problems, such as swallowing dysfunction (Hagopian, Farrell, & Amari, 1996; Hoch, Babbitt, Coe, Duncan, & Trusty, 1995; Lamm & Greer, 1988), cup drinking (Patel, Piazza, Kelly, Ochsner, & Santana, 2001), and failure to advance texture (Luiselli & Gleason, 1987; Shore, Babbitt, Williams, Coe, & Snyder, 1998). The hallmark of all these interventions is 1) analyzing the “task” into small, discrete steps, 2) manipulating the antecedent condition by presenting food or liquid in a way that allows the child to complete the behavior expected successfully, and 3) clear consequences for completing or not completing the task. For example, in the swallowing induction procedures, swallowing was broken down into its component steps from food entering the mouth to the initiation of the swallowing reflex at the faucal arches. The researchers used forward or backward chaining with prompts (verbal and physical prompts on the tongue) to initiate swallowing. Although the data suggest that the intervention is promising (Kerwin, 1999), the technique assumes competent oral-motor tongue and jaw movements. Although the children had increased swallow frequency, increased food acceptance and increased quantity of food consumed orally, it is unclear from the study results if the oral-motor pattern acquired indirectly would allow the child to continue advancing oral-motor skills with other food textures. The current research literature suggests that a more expedient intervention might be direct targeting of the oral-motor movements. The behavior analyst can be instrumental in assisting members of other disciplines in teaching children these skills. Because behavior analysts are skilled in task analyses, they can also help members of the other disciplines task analyze their interventions and learn to look for and document specific responses that they expect from each procedure (see Kumin et al. Perhaps an ideal avenue for future investigation is combining the best of both approaches together to maximize the child’s benefit from systematic, gradual steps with clear instruction and consequences in the context of meaningful oral motor facilitation and therapy (Bailey & Angell, 2005). Peterson and Ottenbacher (1986) demonstrated this combined approach in teaching lip closure to three children with mental retardation. Conclusion Children requiring early, intensive intervention often have complex feeding and swallowing issues that requires a team approach in order to fully evaluate and treat the underlying issues. Low tone, abnormal sensory processing, altered postural alignment and movement patterns are often present in these populations. These issues place them at risk for having abnormal postural alignment of the pelvis, trunk, shoulder girdle, which leads to a forward head posture. This alters the biomechanics of breathing and swallowing and the corresponding sensory input. With altered sensory perception the child may have difficulty motor planning postural alignment and control for acquisition and mastery of feeding and swallowing behaviors. Once medical stability and postural alignment have been obtained, oral stimulation can be an effective adjunct to feeding treatment. Oral stimulation should provide the child with the necessary sensory and movement input to adequately prepare the child for controlled practice with food. The use of varying foods in multiple therapeutic practice situations a day is the key to increasing the frequency of positive practice and thus increasing the acceptance of variety and volume of foods consumed in children exhibiting oral-motor difficulties. Dysphagia in infants and children with oral-motor deficits: Assessment and management. A preliminary investigation of oromotor function in young verbal and nonverbal children with autism. The development of normal feeding and swallowing: Showa University study of feeding function. Relationship between feeding difficulties, medical complexity, and gestational age. Effect of an oral stimulation program on sucking skill maturation of preterm infants. Oral-motor skills following sensorimotor intervention in the moderately eating impaired child with cerebral palsy. Effect of oral sensorimotor treatment on measures of growth, eating efficiency, and aspiration in the dysphagic child with cerebral palsy. Oral-motor skills following sensorimotor therapy in two groups of moderately dysphagic children with cerebral palsy: Aspiration vs. Impact of oral appliance therapy: Are oral skills and growth maintained one year after termination of therapy? Feeding skills and growth after one year of intraoral appliance therapy in moderately dysphagic children with cerebral palsy. Neuro-Developmental Treatment Approach: Theoretical Foundations and Principles of Clinical Practice. Behavioral and postural changes observed with use of adaptive seating by clients with multiple handicaps. The critical or sensitive period, with special reference to certain feeding problems in infants and children. Effectiveness of Innsbruck Sensorimotor Activator and Regulator in improving saliva control in children with cerebral palsy. Empirically supported treatments in pediatric psychology: Severe feeding problems. Behavioral interventions and prevention of feeding difficulties in infants and children. Patterns of feeding, eating, and drinking in young children with Down Syndrome with oral motor concerns. An effective oral motor intervention protocol for infants and toddlers with low muscle tone. Positioning improves the oral and pharyngeal swallowing function in children with cerebral palsy. A sensory integration based program with a severely retarded/autistic teenager: An occupational therapy case report. Combining sensory reinforcement and texture fading procedures to overcome chronic food refusal. Tongue lip and jaw differentiation and its relationship to orofacial myofunctional treatment. Assessment and treatment of sensory versus motor-based feeding problems in very young children. Using a fading procedure to increase fluid consumption in a child with feeding problems. Use of applied behavioral techniques and an adaptive device to teach lip closure to severely handicapped children. Effects of consistent food presentation on oral-motor skill acquisition in children with severe neurological impairment. Infant sucking ability, non organic failure to thrive, maternal characteristics, and feeding practices: A prospective cohort study. Assessment of sensorial oral stimulation in infants with suck feeding disabilities. Pediatric Clinics of North America: Pediatric Gastroenterology and Nutrition, 49, 97-112. Developmental and age-related changes in reflexes of the human jaw-closing system. Prevalence and severity of feeding and nutritional problems in children with neurological impairments: Oxford Feeding Study. Development of perioroal muscle activity during suckling in infants: A cross-sectional and follow-up study. Kerwin, Department of Psychology, Rowan University Correspondence concerning this article should be addressed to: MaryLouise Kerwin Department of Psychology Rowan University 201 Mullica Hill Road Glassboro, New Jersey 08028 E-mail: kerwin@rowan. Materials A writing utensil for each participant Needed A “Math Test” and the Billy Goats Gruff story for each participant A bag of kosher marshmallows Program Explain to the group that you are going to do a few simulations to help understand Description what having a disability might at times feel like. Simulations are tricky because we can never, in a short simulation, really understand someone else lifelong challenges. If someone in the group has disabilities and is willing to share, their personal reflection can provide valuable depth and understanding. Depending on the group, choose which and how many of these simulation activities to do (activities can be done in any order and each relates to a specific disability): Math Test (meant to simulate a learning disability) 1. Hand out the math tests and ask everyone to keep them face down until ready to start. Point out that they were able to do the math test when they came up with strategies to complete it. Having a learning disability means having to continuously use a strategy as opposed to many of us who would complete those problems directly. Reading Time (meant to simulate dyslexia, visual processing and depth perception issues) 1. Pass out the story and tell the group you are going to call on people to read and that there will be a quick reading comprehension quiz at the end. Do not tell the group that this is a story of Little Red Ridinghood written out with letters reversed, words crooked, etc. Point out that not all individuals with dyslexia actually “see” words that look different but the frustration and pace of being to ask to read something this challenging is a common experience for many. Talk about how someone might act in class if this is what a written page looked like every Simulation 101 – Page 1 time they open a book. Discuss how a student may joke or otherwise purposely draw attention away from the fact that reading is challenging. Also discuss how visual processing disorders go beyond school and can affect participation in sports (depth perception and ball sports, etc. Marshmallow activity (meant to simulate articulation disorders that might go along with cerebral palsy). Call for a volunteer (who is not allergic to eggs as marshmallows contain egg whites) to come up and read. Ask the volunteer to fill his/her mouth with marshmallows until their tongue is immobilized. Discuss that we sometimes want to pretend that we understand what person is saying to make things more comfortable. But what if the person is saying "I feel sick and I want to go to the nurse” Remind group that the person generally knows that their speech is difficult to understand and they just want to hear the message that you are going to take the time to listen and try to understand. Talk about strategies asking yes or no questions, asking if they can write it down, asking another person to come over and see if they can understand, etc. Story with an "N" (meant to simulate a language processing/expressive language disorder) 1. Tell them they are going to tell a progressive story starting with "Today I woke up" (or any other starting sentence) and each person has to add a sentence or two to the story. Discuss the experience of telling both stories, which story was easier to tell, which story included more details, maybe more drama, how telling each felt, etc. Point out that it took longer and was more difficult to have a conversation when not using words with the letter N because everyone had to think of they wanted to say and everyone had to choose specific words. This is what that people with language processing/expressive language disorder have to do. Talk about being patient and not rushing people who have expressive language difficulties. Simulation 101 – Page 2 A Children’s Story: Simulation 101 – Page 3 A Simple Math Test Simulation 101 – Page 4. J Pediatric Orthopaedics (2001) 20 Obligatory Co-activation Quads & Gastrocnemius contributes to Toe-walking & Loss of Selective Motor Control in Cerebral Palsy 21 Muscle Pathology in Spastic Cerebral Palsy Rose et al. J Orthopaedic Research (1994) Increased proportion of type-1: type-2 muscle fibers Increased fiber size variation Type-1 fiber proportion vs. In Australia, the current systems which attempt to support people with disabilities, their families and carers, are inadequate, inequitable and crisis driven. This submission from Cerebral Palsy Australia does not attempt to address all the questions in the Australian Productivity Commission Issues Paper (May 2010). Rather, this submission wishes to support the submissions of our Member Organisations (in which most of these questions are addressed) and to emphasise particular issues relevant to children and adults with Cerebral Palsy, their families and carers. Cerebral Palsy is the most common cause of physical disability affecting children in Australia and most developed countries (Howard, Soo, Kerr Graham, Boyd, Reid, Lanigan, Wolfe and Reddihough: 2005). An estimated 30% of people with Cerebral Palsy have severe forms and are non-ambulant and at increased risk of pain and poorer health (Donnelly, Parkes, McDowell and Duffy: 2007). Cerebral Palsy is a condition which may result in an individual having multiple impairments and significant lifestyle limitations (Odding, Roebroeck and Stam: 2006). To place this submission in context, the following is a statement from the Canadian Paediatric Society (2000): “The World Health Organization defines a child with multiple impairments as a child with a significant disability combined with a sensory and/or cognitive disability. Such a child places tremendous stress on a family because of the many associated issues and the fact that, in most cases, the child has a chronic condition with no cure. Ongoing support is crucial to these families; they incur increased expenses, which are aggravated frequently by the loss of income. The Member Organisations of Cerebral Palsy Australia include diverse organisations from each state and territory. The combined operational budget of all Cerebral Palsy Australia Member Organisations is well in excess of $300 million. The Member Organisations provide services to children and adults with Cerebral Palsy and similar disabilities. Services include accommodation, respite, day options, employment, therapy, equipment prescription and manufacture, community access and community development. Many of our Member Organisations also undertake specific projects, carry out research and conduct training. Some foster the development of services for people with Cerebral Palsy and similar disabilities in countries such as East Timor, Fiji, India, Thailand, Cambodia and the Marshall Islands. Membership of Cerebral Palsy Australia enables organisations to formally participate, directly or indirectly, in a national body working to enhance people’s lives. Member Organisations benefit from being linked to a network committed to mutual support and information sharing through regular updates, meetings and conferences. This change is in response to the increasingly challenging and complex environment in which Cerebral Palsy Australia functions. This move to a Company Limited by Guarantee will ensure that Cerebral Palsy Australia is well positioned to support our Member Organisations across Australia in their work for children and adults with Cerebral Palsy, their families and carers. Since being established in 1952 Cerebral Palsy Australia has worked to promote and advance the rights, welfare and social inclusion of people with Cerebral Palsy. Our key purposes are: 2 Cerebral Palsy Australia Submission Disability Care and Support Inquiry Australian Productivity Commission. Taking into account the purposes of Cerebral Palsy Australia, all our Member Organisations welcome this opportunity to provide a submission to the 2010-2011 Inquiry of the Australian Government Productivity Commission relating to Disability Care and Support. It should be noted that most of our Member Organisations have forwarded a submission to the current Australian Productivity Committee Inquiry and / or have contributed to other submissions. Guiding Principles of a Reformed System Cerebral Palsy Australia is supportive of the concept of a National Disability Care and Support Scheme. The current system is inadequate and, to quote the submission of our Member Organisation, Northcott Disability Services (2010): “Despite significant progress, improvements and initiatives to address issues in the system, there are still insufficient resources to meet needs and gaps in services; there also remains inequity in access to services, and people with a disability have limited control and choice in planning their own supports and having certainty about their future and how their needs will be met. Demographic change and the anticipated decline in the availability of informal care are expected to place further pressure on the existing system over the coming decades. Cerebral Palsy Australia commends to the Inquiry the proposed Guiding Principles of a Reformed System included in the submission of our Member Organisation, Cerebral Palsy League of Queensland. These Principles are: 1 Universal access all Australians with a disability eligible to access the system will have access to appropriate supports and services to meet their level of support need and “no wrong door”. A National Disability Insurance Scheme will be enshrined in the National Disability Strategy, signed by all levels of government in Australia. At times requiring less support and able to “relinquish” hours knowing that in future times when more may be required it will be there.
Syndromes
Easy bleeding
Trouble sleeping or sleeping too much
Side effects of medications
Injury to the recurrent laryngeal nerve
Drinking excess alcohol
Coma, respiratory depression, and death in high doses
Do not put plastic or rubber pants over the diaper. They do not allow enough air to pass through.
Umbilical stump bleeding
14 to 26 mg per kg of body mass per day for men
Sprue
One large United States study ate concerns about smoking erectile dysfunction doctor manila buy cheap viagra soft 50mg line, and nate the market in many countries erectile dysfunction treatment surgery viagra soft 100 mg discount. Large harm reduction option is electronic by smoke-free air laws was correlat graphic warnings are the most ef cigarettes (e-cigarettes) impotence word meaning order viagra soft 100 mg mastercard, also re ed with a decreased odds of suscep fective impotence and high blood pressure buy viagra soft now. This prod and established smoking in young for most people and erectile dysfunction medication new purchase cheapest viagra soft and viagra soft, even taking uct is designed to deliver nicotine people [33] erectile dysfunction medication for high blood pressure cheap viagra soft online american express. Comprehensive smoke the Internet into account erectile dysfunction treatment austin tx order 100mg viagra soft amex, remain to the lungs without combustion pump for erectile dysfunction generic viagra soft 100mg online. The mass media convey and promote e-cigarettes as low tary interventions such as smoking new information and remind people harm alternatives to smoking. The bans in private homes, which reduce about knowledge they already pos safety and effcacy of this product exposure of children to second sess but have forgotten or are ig as a cessation aid is under study. Regular more attention is paid to tobacco in tential role of e-cigarettes in reduc efforts are needed to remind the the mass media, the more quitting ing smoking is unclear [30], but population of the health benefts of related activity occurs [36]. The Chinese government owns the and expanded laws for the control China has weak text-only package world’s largest tobacco company. China is the largest producer and tection of minors, and bans on to Very cheap brands discourage consumer of tobacco, with about bacco promotion, and have issued smokers from attempting to quit. In 1997, Beijing Despite some bans on direct tobac One third of all cigarettes smoked hosted the 10th World Conference co advertising, there is heavy expo in the world are smoked in China. More than bacco monopoly, coupled with an tobacco control is included in both 70% of the population are regularly effective taxation policy. Smoking puts great pressures on common to most countries, and in gov/gtssdata/Ancillary/DataReports. International Tobacco Control Policy costs of tobacco use in China co monopoly has jurisdiction over Evaluation Project (2012). Television advertise programmes that these groups tend the profle of the issue and make ments can convey a much more to view, and is at least as effective the harms more personally relevant, engaging message than compa in infuencing these groups as in thus encouraging smokers to quit rable pack warnings, but smokers infuencing smokers in more socio and others not to start or resume are exposed to them far less often. Part of the preven Although advertising is expensive, it Smokers in less-advantaged socio tive effect seems to stem from dis can reach large numbers of people economic groups may also require gust associated with the unattractive quite cheaply per person infuenced, more intensive assistance if they and disfguring aspects of disease so it is very cost-effective. Having linked to smoking, rather than from the mass media are effective the issue of smoking prominent in anxiety about future harms. Anti in reaching smokers in lower socio the mass media can also motivate smoking advertisements appear to economic groups, especially when health professionals by making have their effects by essentially the the advertising is both designed to them more aware and also more Chapter 4. As and the success rates increase with noted above, reference to smoking increased involvement, up to sev behaviour in the media drives peo eral sessions [40,42]. The effective ple to seek help, as does product ness of such interventions is direct specifc advertising. To achieve the ly related to their intensity, typically highest cessation rates requires measured by the amount of sup a population of smokers who are port, at least up to about four sub motivated to quit, who are prepared stantial sessions, but beyond that, to use the best possible help, and who are able to access aids that will there is little evidence that even maximize success. Uptake of help, more intensive interventions are ef particularly advice-based help, re fective. Intensive advice-based pro mains low, even when services are grammes are increasingly delivered subsidized or free. This is probably via the telephone rather than face due to a combination of beliefs that to-face. Use of automated advice “I should be able to do this by my programmes, consisting of tailored self” and deep ambivalence about personalized advice on the Internet change in relation to tobacco use and/or short, frequent advice mes and other dependencies. Use of sages to mobile phones, is mark services is also infuenced by the edly increasing. For likely to raise the issue with their tomated intelligent programmes are example, in the United Kingdom, clients. Combining advice-based there is much greater use of face which includes the Internet and mo programmes with medication gives to-face services than there is of a bile telephony, provides both huge the best results as the two seem to well-organized and readily avail challenges and opportunities for have largely independent effects able network of other services. There is no evidence of re However, in most other countries come from the diffculty of regulat duced relapse associated with any that have systems to provide help, ing any pro-smoking activity. If so, different strategies are quired if signifcant progress is to be Cessation aids needed to help those who survive made in tobacco control [2]. There There is now a range of effec the diffcult early weeks to maintain are huge challenges. In low and tive medications for smoking ces cessation in the long term, which middle-income countries, govern sation when used for periods of is the ultimate challenge. These this aspect is rarely subject to sometimes lack the infrastructure medications, which include nico specifc investigation, population to support policy. In high-income tine itself (as nicotine replacement based studies indicate that a small countries, smoking is increasingly therapy) plus three other drugs (bu percentage of ex-smokers continue concentrated among less-advan propion, varenicline, and cytisine, to use nicotine replacement therapy taged socioeconomic groups, fur which impinge on different aspects in the long term. Much of the brain’s reward system), are all rently hold the most promise of be remains to be done, but progress is demonstrably effective. Nicotine Tob Res, 14:1382– on smokers’ beliefs about ‘light/mild’ on Tobacco Advertising, Promotion and 1390. A comprehensive examination cessation outcomes (data from the the Case for Abolition. Understanding Hard store concentration on individual level to Maintain Behaviour Change: A Dual 34. Global Tobacco Surveillance System Science, Policy, and Public Health, 2nd Collaborating Group (2005). Pharmacological interventions for smoking and their success in adult general. Middleton Isabelle Romieu (reviewer) Earlier chapters in this Report (see signifcantly larger reductions in dia Summary Chapter 2. In trials, weight loss and in obesity and physical inactivity may than 3000 overweight or obese in creased physical activity have re be related to the development of dividuals with impaired glucose tol duced the risk of diabetes among some forms of cancer (see “Energy erance were randomly assigned to participants. The goals of ment programmes typically epidemiological studies suggest that the lifestyle intervention included produce weight losses of about physical activity and weight loss can weight loss of at least 7% of initial 7–10% of initial body weight after lower breast cancer risk and improve body weight (by decreasing dietary 6–12 months of treatment, and survival, evidence that researchers fat intake, reducing total caloric in increasingly include extended have suggested warrants further clini take, and increasing physical activ care sessions. To develop such studies, it these goals, a 16-session core cur clude reducing caloric intake by is important to understand the basic riculum was delivered to participants approximately 500–1000 kcal strategies that might be used to help individually over the frst 6 months of (2000–4000 kJ) per day and in individuals change their weight and/ the study, with continuing contact (at creasing participation in moder or their physical activity, and the type least once every 2 months) during the ate-intensity physical activity to of results that can be achieved. Behavioural weight management Outcomes of behavioural early (after an average of 3. The strongest evidence Of participants in this arm, 49% ed guidelines are being evaluat comes from the Diabetes Prevention achieved the 7% weight loss goal ed in relation to reduced cancer Program, a multicentre randomized at 6 months and 37% at the fnal incidence in relevant trials. On average, physical activity that behavioural weight loss led to increased to 224 minutes per week Chapter 4. An 8-year-old girl from the Rayerbazar area of Dhaka, Bangladesh, breaks cardiovascular risk factors were through the ribbon during a race. Positive experiences and attitudes to physical activity greater in the intensive lifestyle in may lead to long-term benefits in relation to diabetes and cancer. Indications of possible cancer related benefts of behavioural weight loss programmes have been evi dent for more than a decade. Thus, a randomized trial of a physical activity-based weight management programme in breast cancer survi vors (n = 68) demonstrated larger weight losses in the treatment group compared with the control group (5. Furthermore, within participants assigned to the treatment group, par 74% of participants at week 24 and intensive lifestyle intervention or the ticipation in physical activity was sig 67% at the fnal visit. The lifestyle inter nifcantly associated with favourable Although they are relatively mod vention was similar to that used in changes in interleukin-6 levels. Weight loss was meal replacement products were pro Behaviour-based weight loss pro the dominant predictor of the reduced vided to increase adherence to the grammes, such as those used in incidence of diabetes. These programmes focus on were still apparent, although there 6 months, seen 3 times per month helping individuals make long-term were no longer any differences in for months 7–12, and then seen or changes in both their eating and weight loss between the three arms. This to be an independent predictor of style intervention arm had lost an av approach assumes that providing in cancer mortality (beyond body mass erage of 8. Rather, it is these trials may be benefcial for low sive lifestyle intervention group had important to help people understand ering cancer mortality. Behavioural efts, have been confrmed recently control group at both 1 year and treatment programmes then focus in another clinical trial, called Look 4 years. Nature, 489:318– of 30% non-signifcantly reduced and have markedly lower cancer 321. This extended intake relative to caloric expendi and ultimately their body weight. Thus, behavioural interven been shown to improve long-term tions typically focus on lower Format of behavioural weight outcomes [8]. Groups are typically ing caloric intake – typically by loss programmes led by a multidisciplinary team of approximately 500–1000 kcal Typically, behavioural weight loss nutritionists, exercise physiologists, (2000–4000 kJ) per day – while programmes are offered in group set and behavioural therapists. Participants Self-monitoring, a key step in evaluat typically vary by baseline body are encouraged to work up to these ing progress towards goal achieve weight [9]. Individuals who weigh goals by gradually adding 10 minutes ment, may involve keeping records 200 pounds (90 kg) or less at base per week above baseline. In addition, of body weight, caloric intake (as indi line are given calorie goals of approx participants typically track unstruc cated by food consumed), and physi imately 1200 kcal (5000 kJ) per day, tured, lifestyle physical activity using cal activity (by using a pedometer or whereas those who weigh more than pedometers or accelerometers and accelerometer). Self-monitoring al 200 pounds (90 kg) are given goals of aim to gradually increase their activ lows individuals to assess their prog 1500–1800 kcal (6250–7500 kJ) per ity to reach a goal of 10 000 steps ress towards goals and to receive day. Adherence 500–1000 kcal (2000–4000 kJ) per to self-monitoring has been demon Key components of weight strated to be signifcantly associated day, which are associated with a management programmes with success in both weight loss and weight loss of 1–2 pounds (0. In addition, participants are recommended to decrease their fat about diet and physical activity, other [12]. These key components are dis Typically, problem-solving includes gest may be associated with obesity, cussed below. An ex such as sugar-sweetened beverages ample of a problem-solving partici and high-fat snack foods [10]. Self-regulation is generally viewed as the fve-step problem-solving model Physical activity an internal process that involves goal is generally viewed as an iterative Participants in behavioural weight setting, self-monitoring, and evalu process, and if the chosen solution loss programmes are encouraged ation of success or failure of goal does not adequately address the not only to decrease their caloric in achievement. Setting clear goals barrier, individuals are encouraged take but also to increase their level for caloric intake and physical activ to cycle back to steps 3 and 4 to try of participation in physical activity. This is often approached in two ways: Individuals are encouraged to set (i) by increasing participation in goals that are short-term (typically a Changing behavioural moderate-intensity physical activ weekly weight loss goal vs a “goal antecedents ity and (ii) by increasing overall life weight”), measurable. The American apple as a snack on three days dur cedents – events that happen before College of Sports Medicine [11] ing the week vs “eating more fruit”), the given behaviour – and by conse recommends 150–200 minutes per and attainable. Solution implementation the view that problems are a nor Individuals brainstorm potential so and verifcation. Individuals clearly describe the bar Participants evaluate decisions to rier to change in objective, concrete decide which would be the best so terms. Thus, manipulating the consequences of behaviour can lead to positive behaviour change. In general, individuals are encouraged to use non-food rewards, such as stickers, positive notes, buying new clothing, and so on. Increasing social support for behaviour change and use of programmatic incentives have also been demonstrated to lead to positive behaviour change. Social support A group format for lifestyle weight management interventions has been used to invoke social support for in dividual behaviour change. Group cohesion has been shown to en hance the effectiveness of weight management treatment, even for people who indicate before interven be affected by their environment, and tion that they would prefer individual of overeating or avoiding planned specifcally the availability of nearby treatment. The process of cogni restaurants, and by thoughts and haviour change with the group can tive restructuring involves identify feelings (such as cravings, or feeling elicit positive support, acting as a ing maladaptive thoughts, labelling stressed or upset). For ex participants to assist with health be Incentives ample, the thought “I’ll never be able haviour change, as discussed below. The use of incentives in weight to lose weight” can be replaced with management stems from literature the thought “I may have had a chal Stimulus control in behavioural economics, which has lenging week, but I’ve lost 15 pounds Environmental factors have been demonstrated that people tend to so far and can recover from this slip. This applies to Changing behavioural weight management in that long For example, the easy availability of consequences term benefts of improved dietary and high-calorie, highly palatable “junk In addition to changing behavioural activity behaviours, including weight food” can increase caloric intake, antecedents, the consequences of loss and improvements in metabolic and lack of recreation facilities, safe behaviour can be modifed to affect risk factors, can be less motivat walking areas, or sidewalks can de future behaviour. Individuals will be ing than short-term benefts such crease participation in physical ac more likely to engage in a behaviour as the pleasure of eating or being tivity. Individuals have some control over their environments and can often enact positive environmental change at home and work. Changing cognitions Thoughts and feelings can also rep resent the antecedents in Fig. According to the cognitive behav ioural model of behaviour, an individ ual’s thoughts affect their feelings, which can then affect behaviour. Thus, a person having the thought “I’ll never be able to lose weight” is likely to feel upset, frustrated, or an gry, which may lead to the behaviour Chapter 4. Increasing successful at maintaining weight intake of fresh fruits and vegetables and avoiding bringing high-fat snack foods into the loss tend to continue to consume home can lead to health benefits. Dissemination and novel interventions While behavioural weight manage ment programmes have demonstrat ed effcacy and effectiveness, dis semination remains a barrier to wide access to treatment. Cost and avail ability of trained staff often limit the reach of these programmes, espe cially the high-intensity programmes most often delivered in research settings: typically 3–6 months of weekly groups, followed by several months of extended-care groups, meeting every 2 weeks and then monthly. Interventions using newer self or deposit contracts, where partici In addition, individual factors monitoring technologies, including pants deposit money that is returned that promote long-term mainte activity monitors and smartphone only if they meet programme goals, nance have been investigated. Maintenance of weight loss Long-term maintenance of weight loss has remained a substantial Fig. The National Health Service in the United Kingdom has a website on healthy challenge [15,16]. The “Eat well” section of the website enables people to plan tion ends, individuals tend to regain healthy meals. Research has focused on identifying factors that improve the long-term maintenance of weight loss; to date, one of the most successful factors has been the provision of extended care. A recent review of the literature on maintenance of weight loss sug gested that the provision of extended care leads to the maintenance of an additional 3. It was shown that Participants completed ques spoke biorepository of its size individual components of meta tionnaires on diet and lifestyle in the world. The range of data as individual components of the syn prospective study to collect and well as biological samples that drome, namely abnormal glucose Fig. This paradox was ing individuals at increased risk of often described as a J-shaped References colorectal cancer. Int J Cancer, being very slim (body mass index mature death, that having a slim 121:368–376. Paradoxically, sport shown on television may play a role in determining cess body weight and low levels sedentary behaviour. Behavioural weight loss pro grammes are effective in helping participants lose 7–10% of their ini tial body weight; these weight losses produce numerous health benefts and should be evaluated further for cancer prevention and survival. A current randomized controlled trial, including 962 patients in 40 centres, is investigating the impact of physi cal activity on disease outcome in colon cancer survivors [19]. Data relating to cancer out comes affected by adherence to with no history of breast cancer. Future trials will investigate ence to World Cancer Research and intake of plant foods, was as the role of weight loss and/or in Fund recommendations were moni sociated with reduced breast cancer creased physical activity in primary tored among approximately 30 000 incidence [20]. Annu Rev Nutr, 21:323– control, and breast cancer risk and survival: Bouchard C, eds. Four-year change in cardiores physical activity in breast and colorectal piratory ftness and infuence on glycemic 14. While campaigns should be Campaigns in cancer preven Summary sensitive to local cultural fac tion are often conceived and fund tors, there is evidence that many ed by public health authorities as. Population-wide campaigns can campaigns can be successfully time-limited operations, whereas be an effective and effcient way re-used or adapted for use in dif in reality their objectives can rarely to modify cancer risk in popu ferent countries. A cancer prevention nication and infuence are not campaign is better thought of as a feasible. Such campaigns invari intrapersonal determinants of behaviour in members of a defned ably make use of mass media, of those behaviours. It is not concerned with ten through carefully planned paid cancer “awareness-raising” cam-. Indeed, such campaigns are for change in individuals should taneous communication and policy of questionable public health value. Campaigns would Sometimes awareness-raising cam will help focus the interventions not normally be considered for rare paigns can do harm, as when pros that make up the campaign as tumours or those concentrated in tate cancer awareness leads to inap well as defning measures of subpopulations, such as in certain propriate screening for the disease outcome that will demonstrate occupations or locations, or for in and to harms that at least arguably and explain effects. Campaign messages need to almost certainly other more effec a substitute for potentially effective take into account psychological tive and effcient alternative ways to public health policy and regulation. Series of images from a video used by Australia’s National Tobacco Campaign tion is more limited. This particular advertisement highlighted how smoking causes arteries to ary prevention depends principally become blocked, graphically emphasizing that “every cigarette is doing you damage”. Contacting individuals directly with invitation letters is far more ef fective than public advertising of a service alone [3], so a campaign is not likely to be a major element in secondary prevention. In addition, unless the relevant health services are equally available to all members of a target population, population wide campaigns would generate de mand that could not be met. Thus, the norm is for incremental change, it is said – is at the core of campaign when screening services are intro at best, in population rates of a ha planning. Judicious application of duced into a population in stages, it bitual target behaviour, whereas psychological knowledge is helpful, makes little sense to use mass me participation rates approaching if not essential. However, as 50% may rapidly follow the introduc campaign planners are explicit about suming that all required services are tion of a screening or vaccination the way in which their message is ready, there may be a limited role service that was supported by direct expected to infuence the receiver, in the early stages for mass com invitations and media publicity [5,6]. In the case of oratory studies have investigated the the programme’s life, there may also tobacco at least, the diffculties of underlying nature of effective health be a role for mass media in refresh reversing a habit are further com messages – for instance, the rela ing public interest should participa plicated by the addictive qualities of tive merits of gain or loss-framed tion rates start to fall [4]. Nevertheless, campaigns wording [9] – but the applicability mass media campaigns alone are have been shown to be effective of results obtained to population unlikely to achieve desired participa in changing population risk behav wide communications is uncertain. It is notewor explored message characteristics thy that small percentage changes as they apply to broadcast cancer in risk factor behaviours equate to prevention campaigns [10]. Habitual and non-habitual large numbers of people when a risk A common issue is when, and behaviours factor is common, and that where when not, to use confronting, shock There is a fundamental distinction relative risks are large, the potential ing, or “scary” message content [11].
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