Louise Kenny MB ChB hons PhD MRCOG

• Consultant Obstetrician and Gynaecologist and Professor of
• Obstetrics, The Anu Research Centre, University College Cork,
• Cork University Maternity Hospital, Cork

Other things may help including: Drink plenty of fluids if a migraine is starting Eat slow release carbohydrates (eg banana metabolic disease risk 25 mg precose with visa, biscuits diabetes type 1 and kidney stones buy precose online from canada, toast) Rest away from noise or light or any known trigger factors Menthol diabetes test fasting purchase precose 25mg amex. Using this frequently is not known to increase the risk of bringing on more migraine attacks (as happens with tablet painkillers) diabetes test edinburgh precose 25 mg on-line. Step 2 – using medications For many patients with episodic migraine blood glucose 3 month average cheap precose 50 mg with mastercard, a simple painkiller taken early in the attack may be helpful managing diabetes in the workplace discount precose 25mg with mastercard. Painkillers and anti-sickness drugs may work well if used together and early in an attack diabetes mellitus type 2 guidelines cheap precose amex. If not effective diabetes in dogs natural remedies purchase generic precose from india, then a specific migraine drug called a triptan may be considered. Antisickness drugs If there is any nausea or loss of appetite, then the following can be used up to a maximum of 2 days per week. Buccastem will not keep the stomach moving but it may be helpful to stop vomiting. It may be used occasionally 3-6mg twice daily but should be used sparingly to avoid significant side effects. Triptans If the painkillers and/or anti sickness drugs are not showing enough benefit, then it is worth adding in a triptan drug. It is worth trying one individual type of triptan in three attacks before deciding if it has been useful – if not, a different one can be tried. If attacks arise from sleep or come very quickly, especially if there is vomiting, then the triptan can be given by a different route. These medications may be prescribed as a melt or self-injection or a nasal spray (head should be tipped forward not backwards when doing this, to allow it to be absorbed by the lining of the nose). If an attack of migraine is continuing beyond two days, there is little to be gained by continuing to take painkillers and they actually be making the attack stay for longer by causing rebound worsening as the medication wears off. Step 1 (Lifestyle) the first step in most patients with significant migraine attacks is to lay down a “foundation” of lifestyle by (1) stopping all caffeine, (2) stopping or significantly limiting painkillers or triptan medications (eg to less than a few times per month at most) – stopping may be most effective. Stopping painkillers and caffeine typically causes initial worsening of migraine, sleep and other associated symptoms but this worsening is temporary. It lasts about 1-2 weeks if stopping caffeine, simple painkillers (eg paracetamol, ibuprofen) and/or triptan medications; afterwards symptoms may temporarily be a bit unsettled. During detoxification, some patients will benefit from anti-sickness medications that allow continued absorption of food and fluids. We recommend stopping these abruptly in most people but if there are other significant medical conditions such as diabetes, epilepsy, significant mental health problems or general old age / frailty, there may need to be a more gradual process under supervision of a doctor. For patients with other pain conditions, it is worth noting that migraine amplifies that pain, just as it may amplify noise, light or smell. The painkillers used to treat pain worsen migraine and this in turn amplifies pain from other medical causes. Stopping painkillers allows us to turn down the amplifier and for a majority of patients, stopping the painkillers usually only causes temporary worsening of that other pain condition. Long term painkillers are not ideal for chronic pain conditions as they rarely have true long term benefit. Many pain experts are becoming aware that pain conditions may not be helped by long term painkillers and that very few patients with chronic pain conditions truly benefit from regular painkillers. Recognising and treating migraine by stopping painkillers may be very effective in treating many patients with other long term pain conditions. There are also increasingly recognised risks of taking some long term painkillers on a regular basis. If after optimising lifestyle, sleep remains very poor or restless legs continue, this may be worth treating sleep in its own right. Treating sleep may be considered as laying down a “ground floor” on top of the “foundation” of lifestyle. This may all be potentially helpful before “building” the management further, with specific preventative treatment approaches. Step 3 (Preventative Treatments) If the headaches are still troublesome at this stage, then a preventative treatment can be started. Medications are traditionally the main first line approach and have a good chance of turning the condition off in the longer term. There are new handheld devices that include Cefaly trigeminal nerve stimulation, Gammacore vagal nerve stimulation and Eneura transcranial nerve stimulation. Injection therapies may include nerve blocks or cranial botulinum toxin injections. You may be prescribed a “preventative” medication and this should be taken on a regular basis, usually for one year. All preventative medications are slowly introduced in a stepwise fashion to a maximum tolerated dose or a dose that turns off the headache. If side effects of drowsiness or dizziness occur, the drug should be reduced back one step. If the medications however cause significant worsening of mood or of thinking and memory, they should usually be stopped. These side effects will stop the drug from working and can be very troublesome if they are seen. If no benefit is seen after being on the best tolerated dose for at least three months, it has failed and should be gradually withdrawn while the next treatment is introduced. Drugs that we commonly use for migraine prevention include: Blood pressure drugs such as Propranolol or Candesartan Tricyclic antidepressants such as Amitriptyline or Nortriptyline Anticonvulsants such as Topiramate or Zonisamide 17 1 Gabapentin is not licensed for treatment of sleep disorders, although it is commonly used to treat other conditions such as pain and epilepsy. As specialists, we may consider using this drug at low doses at bedtime, starting 100mg at night, increasing slowly by 100mg every week or two, anywhere up to 300-600mg as a single night time dose, usually for a period of 6 to 8 months before slowly withdrawing at that stage if well controlled. The preventative drugs are chosen according to their potential effectiveness and side effect profile. Women of child bearing age need to discuss the effects on a baby of they were to become pregnant and anticonvulsants are not usually recommended (especially sodium valproate which has a high chance of causing a child to be born with learning disability if taken during any stage of pregnancy). Do not be put off taking a drug that lowers blood pressure if you have low blood pressure. Low blood pressure is very common in migraine, most likely due to over-activity of the autonomic nerves. If the drug helps turn off migraine it will potentially stop the migraine pushing the blood pressure lower. This explains why the best drugs for preventing fainting are actually medications designed to lower blood pressure in those patients who have hypertension. Other drugs that may also be used include Flunarizine, Zonisamide, Sodium Valproate, or Venlafaxine. Pizotifen is not generally a very well tolerated drug as it frequently causes significant weight gain and sedation. As a general rule, it is worth avoiding drugs such as amitriptyline and other antidepressants if there is poor sleep or if restless legs occur, as these drugs will usually make these problems worse, as they disrupt the normal sleep patterns that are so important to allow a good refreshing sleep. If there has been no significant response to the above plan of treatment and a number of preventative treatments have been tried to the best tolerated dose for at least 3-4 months at that level, then your neurologist may be able to consider botulinum toxin injections treatment. This involves 31 small injections given every 3 months but it may be quite effective in a number of people. They can use this regularly for 2 months morning and night and also for acute attacks, early in the attack. The time for urgent help is if a new type of headache occurs in the context of fever; while many people will have headache with simple viral infections, any severe headache with neck stiffness and / or rash should lead to urgent assessment in casualty. Likewise, if you experience a truly sudden onset severe headache (like a “thunderclap”) that remains severe, it is worth being checked out urgently in casualty. Older patients over 60 years who develop headache with specific and exquisite tenderness in their scalp, particularly if unwell with other symptoms such as reduced appetite or muscle tenderness across the shoulders and hips should seek urgent medical advice in casualty that day and have blood tests to look for evidence of inflammation in their blood vessels. A new type of headache that is severe, especially if associated with focal neurological symptoms. If headaches are specifically brought on by coughing, sneezing or straining or transient blindness occurs on standing, it is worth being checked medically. Painkillers for other conditions It is gradually becoming apparent that long term painkillers for medical conditions is not particularly useful and may lead to harm. As the brain acts as an amplifier for pain in migraine, a patient with migraine may find the condition is amplifying their pain from other causes. Fibromyalgia, a condition characterised by widespread pains and tenderness in muscles and joints, is probably linked to migraine and caused by the same amplification processes described above. In most patients with migraine, if they stop painkillers their other bodily pains will temporarily worsen for a few weeks (up to 6-8 weeks if coming off opiates). This may reflect a turning down of the amplifier so that it no longer amplifies the pain. Other pain management approaches can be used after this and some people with complex conditions will also benefit from referral to a pain clinic, particularly to look at non-painkiller approaches to reducing the pain or the impact of the pain. Migraine and dizziness / vertigo Dizziness in migraine may include dissociation (a feeling of unreality or feeling distant) or true vertigo (a sensation of movement) and unsteadiness. Migraine vertigo is very common and accounts for more than 50% of referrals seen in specialist dizziness clinics. While dissociation is probably related to generalised nerve dysfunction in the brain, true vertigo probably reflects the process of “amplification” (as discussed in early chapters). People with migraine may generally find their brains are sensitive are more likely to experience visual vertigo. This is where patients have a sense of imbalance or dizziness on looking at certain things such as stripes, patterned carpets, narrow corridors, tall buildings, blinds on windows, lighting units with metal dividing strips, motorway lanes, lines on a page, etc. Similar effects may be seen if someone is given glasses with a slightly wrong prescription. It is likely that in migraine vertigo, the nerve signals from the inner ears are giving an incorrect sense of movement. Treating migraine will typically see these non-headache symptoms disappear on crystal clear headache free days. Particular drugs that should be avoided include antiepileptic medications as they may have a higher risk of causing damage to an unborn baby, especially if taken at the beginning of the pregnancy. Sodium valproate (also known as epilim) has a very high risk of resulting in a baby with learning disability and should most likely be avoided in all women of childbearing age. Occasionally drugs such as propranolol or amitriptyline may be used to prevent migraine but we do not have a guarantee that they are safe and most women find migraine considerably improves in the second and third trimester anyhow. If migraine is problematic, a handheld nerve stimulator such as Cefaly or referral to a specialist headache clinic may be useful to consider nerve block injections. Breastfeeding It is worth discussing the treatment options that are safe in breastfeeding with your doctor or pharmacist. Some over the counter treatments can be used as preventative approaches for migraine, eg riboflavin 400mg or magnesium up to 1000mg daily. They may take up to six months to start working and work in a minority of patients. Diet and exercise in migraine There is little evidence that any form of diet helps migraine. Cutting out food triggers is usually futile in the majority of patients as it is more likely that the brain processes of a migraine attack have started before that food is consumed. Cutting out artificial food colours and additives may be reasonable in some patients. Exercise may be helpful to prevent migraine in the longer term, as may weight reduction. It is important to exercise slowly and surely to a level that doesn’t provoke attacks. Good hydration and some slow release carbohydrate may be helpful before exercising to reduce tendencies to triggering an attack. There is a particular increased risk if there have been prolonged episodes of aura. Patients with prolonged aura or with frequent headaches are advised to stop and typically it is best to stop abruptly. The risk of stroke or heart attack is related to being a smoker as opposed to the amount smoked. Stopping completely sees a gradual reduction in risk back to that of a non-smoker within two years of completely stopping. Many people worry that headache is caused by something worrying but for the vast majority of patients, it will be simply due to the way they are made. A scan may be considered if your headache disorder has been of recent onset and your doctor is concerned but scans are highly unlikely to be helpful in patients who have had more than 3 months with their current symptoms if their examination is otherwise normal. If a headache is only ever on one side and is associated prominent restlessness / agitation and with features of prominent red/runny/droopy/puffy eyes, stuffy/runny nose, flushing sweating or fullness in the ear, you may benefit from referral to a specialist headache or neurology service to see if you have a different cause of headache that involves different management. More than 90% of patients seen in hospital with headache will, however, have migraine as the cause. The following table gives some information about the differences between the most common primary headache disorders. A diary is enclosed in this information booklet (see appendix) Research the Walton Centre has a very active research unit and we are often running clinical trials related to potential new treatments. If you are interested to be considered as a volunteer for ongoing research, then you can contact the clinical research unit at migraineresearch@thewaltoncentre. Motor or sensory sx suggest a neurologic or general medical problem (“pseudoneurologic”) B. Psychological factors are key, as stressors precede onset of deficit/symptoms (a symbolic resolution that keeps psychological conflict out of conscious awareness) C. Not limited to pain or sexual dysfunction 5 Common Conversion Symptoms z Motor: Impaired coordination or balance Paralysis or localized weakness Inability to speak Difficulty swallowing or lump in throat Tremors Seizures or convulsions z Sensory: Loss of touch or pain sensation Double-vision, blindness Deafness, hallucinations “The Grief that has no vent in tears Makes other organs weep. Age 14, she saw a church play about the end of the world and became terrified of earthquakes or signs from God that the world was ending. Z (continued) z Other symptoms: paranoia, myalgias, testicular pain, fasciculations, lower back pain, shooting pains, vision change, headaches z Tx: No response to fluvoxamine(300 mgs) x 8 weeks z New onset bull’s eye rash.? Was the presence of any Personality Disorder at baseline associated with a poor treatment response? The concepts of “fatigue”, “sleepiness” and “drowsiness” are often used interchangeably. Sleepiness can be defined as the neuro biological need to sleep, resulting from physiological wake and sleep drives. Fatigue has from the beginning been associated with physical labour, or in modern terms task performance. Although the causes of fatigue and sleepiness may be different, the effects of sleepiness and fatigue are very much the same, namely a decrease in mental and physical performance capacity. The most general factors that cause fatigue are lack of sleep, bad quality sleep and sleep demands induced by the internal body clock. Besides these general factors, prolonged driving (time-on-task) can increase driver fatigue, especially when drivers do not take sufficient breaks. A small part of the general population (3-5%) has to cope with obstructive sleep apnoea, a sleeping disorder which contributes to above average day-to-day sleepiness. Fatigue leads to a deterioration of driving performance, manifesting itself in slower reaction time, diminished steering performance, lesser ability to keep distance to the car in front, and increased tendency to mentally withdraw from the driving task. The withdrawal of attention and cognitive processing capacity from the driving task is not a conscious, well-planned decision, but a semi-autonomic mental process of which drivers may be only dimly aware. Drivers may try to compensate for the influence of fatigue, for instance by either increasing the task demands. But crashes and observations of driving performance show that compensatory strategies are not sufficient to remove all excess risk. Survey research world-wide suggests that over half of all private drivers drive while being fatigued or drowsy at least once a year. Amongst young drivers, driving while fatigued is quite common due to lifestyle factors. Adolescents need more sleep than adults; fatigue may affect Project co-financed by the European Commission, Directorate-General Transport and Energy 16/10/2009 Page 4 Fatigue – Web text youngsters more than adults. Most professional drivers and shift workers have to cope with fatigued driving on a frequent basis due to work-related factors. About half of professional drivers take less than normal sleep time before a long-distance trip. A person who drives after being awake for 17 hours has a risk of crashing equivalent to being at the 0. The increased risk often results from a combination of biological, lifestyle-, and work-related factors. More scientific evidence is needed concerning the exact quantitative relationship between fatigue and risk. Driver fatigue countermeasures may be directed at drivers, transport companies, roads or vehicles. Roads may be equipped with edgelines or centrelines that provide audio-tactile feedback when crossed over. In the future, legislation concerning working and rest hours may be further improved and vehicles can be equipped with devices that detect fatigue-related decrements in driver performance. Introduction this text provides an introduction on the subject of driver fatigue, its causes, consequences, and possible countermeasures. Individual characteristics including medical conditions Information is given on how fatigue affects Driving behaviour in general, and Steering, Speed choice and Following behaviour in particular, and how Compensatory strategies to fight off the effects of fatigue are not enough. This section also explains that the Driving without awareness phenomenon should not be confused with driver fatigue and it discusses some important Individual differences. Research results are given on the prevalence of fatigued driving among: Among private drivers, Among young drivers, Among professional drivers, and Among shift workers. Descriptions are also given on how to recognise fatigue-related crashes, the frequency of these crashes, and the evidence concerning the fatigue-risk relationship. Further a focus on risks and circumstances of several driver groups who have a higher risk of driver fatigue: Young drivers, Professional and truck drivers, Shift workers and Drivers with sleep-breathing disorders. Finally, this web text closes with a discussion of possible countermeasures, such as Publicity, Infrastructural, In-vehicle detection and warning, Legislation and enforcement, Fatigue management programs and a consideration of Further need for knowledge on countermeasures. At the end of each section main, summarising conclusions are provided: Conclusions Introduction, Conclusions Behaviour, Conclusions Prevalence, Conclusions Risk groups, Conclusions Crashes, Conclusions Countermeasures. Project co-financed by the European Commission, Directorate-General Transport and Energy 16/10/2009 Page 5 Fatigue – Web text 1.

Instead diabetes type 2 questions purchase 50 mg precose fast delivery, the tive impairment diabetic diet basics discount precose 25 mg without a prescription, manifested as a difculty to concentrate focus became a symptom-based assessment diabetic promotions order 50mg precose mastercard. However diabetes diet coke generic precose 25mg otc, Family history appears to be a risk factor for fbromy another set of diagnostic criteria has been developed since algia blood sugar count purchase precose with mastercard, as does female sex diabetes mellitus is a disease characterized by order cheap precose on line. The later factor is controversial then and is used to assess pain location and symptom because the incidence is similar between sexes when newer impact blood sugar insulin chart buy 25 mg precose visa. Evaluation of these criteria report Note the number of areas in which the Points sensitivity of 81% diabetes in dogs how to tell purchase 25 mg precose, specifcity of 80%, and correct classif patient has had pain over the last week. Shoulder girdle, lef The Fibromyalgia Diagnostic Screen has been devel Shoulder girdle, right oped specifcally for use by primary care providers and Upper arm, lef combines clinical assessment with patient-reported data. Five Upper leg, lef supplemental models have also been developed, some of Upper leg, right which address confounding factors such as elevated eryth Lower leg, lef rocyte sedimentation rate, thyroid-stimulating hormone Lower leg, right levels, and joint swelling. Further studies are Upper back warranted to evaluate the accuracy and value of this tool Lower back in primary care practice. Questions relate to physical function, pain level, fatigue, sleep disturbance, anxiety, and depression. Symptoms Severity Scale can be obtained and then compared with subsequent Score is the sum of the severity of the three symptoms scores afer treatments are initiated. Patients may feel stig 0 = no symptoms matized by the medical and nonmedical community alike, 1 = few symptoms especially given that treatment centers on symptom relief 2 = a moderate number of symptoms rather than management of a disease process. Because many patients with fbro be diagnosed if a patient had at least one severe somatic myalgia likely meet these criteria, concern arose that these symptom. Some clinicians think that the term fbromyalgia about the seriousness of one’s symptoms; persistently high should be abandoned altogether in favor of alternative level of anxiety about health or symptoms; or excessive diagnosis as a somatic symptom disorder (Bass 2014). Conficting results were shown in regard to from each guideline is presented in Table 1-1. Of note, the frst improvements in fatigue and various scales for symptom drug to have a labeled indication for fbromyalgia gained the severity. Both dosing strate gies signifcantly reduced pain as measured by a standard Pregabalin 0–10 rating scale and caused similar rates of adverse Pregabalin’s efects on the release of excitatory neu efects. Simply from a convenience standpoint, once rotransmiters such as glutamate, norepinephrine, and nightly dosing of pregabalin may be preferable, although substance P may contribute to pain reduction in patients adherence rates in the study were similar (Nasser 2014). The manufacturer-recommended starting dosage is 75 mg twice daily, eventually titrated Duloxetine and Milnacipran to 225 mg twice daily. Varying dose adjustments are e exact mechanism is unknown, but it is theorized that required for patients with a CrCl less than 60 mL/minute. Benefts may also gabalin 300 mg, 450 mg, or 600 mg daily were signifcantly occur because of their efcacy in improving the anxiety and more likely to respond to treatment than patients taking depression that commonly accompanies fbromyalgia pain. The three randomized controlled trials included For both agents, dosages that improve fbromyalgia symp 1890 patients, and response was defned as a greater toms are generally lower than those needed to provide than 30% decrease in the main pain score from baseline. Amitriptyline is recommended by all treatment hypothesis has not been proven clinically. A systematic review of According to manufacturer recommendations, mil 10 randomized controlled trials evaluated amitripty nacipran should be started at a dosage of 12. Six of the 10 trials used 25 mg daily, adjustments are needed for patients with severe kidney which signifcantly improved pain, sleep disturbances, impairment (CrCl 5–29 mL/minute). In a 15-week ran and fatigue, and both patient and physician global assess domized double-blind trial comparing milnacipran with ments. Amitriptyline 50 mg daily did not show a beneft placebo, milnacipran demonstrated signifcant improve over placebo, possibly because of a large adverse event-re ments in the Patient’s Global Impression of Change scale, lated drop out rate. A 6-month dry mouth, somnolence, gastrointestinal disturbances, trial showed that milnacipran was more likely to reduce and weight gain. No dosage adjustments are required for pain and fatigue than placebo (Mease 2009). Sustained Cyclobenzaprine efects of milnacipran were evaluated in an open-la Structurally similar to tricyclic antidepressants, bel, fexible-dosing study. Five trials were included in a meta-analy component score were maintained over the study dura sis comparing cyclobenzaprine, at dosages of 10–30 mg tion of up to 3. Sleep and pain symptoms improved The recommended starting dosage of duloxetine for for three times the number of patients taking cycloben fbromyalgia is 30 mg once daily, titrated afer 1 week to zaprine versus placebo (Toferi 2004). Use of duloxetine is not recommended points did not improve with cyclobenzaprine, and 85% for patients with CrCl less than 30 mL/minute. In a study of the patients taking cyclobenzaprine reported adverse of duloxetine versus placebo for fbromyalgia, statistically efects. Data are limited regarding the role of gabapentin in Adverse efects of duloxetine include dry mouth, fatigue the treatment of fbromyalgia. Short Form and showed signifcant diference in response A systematic review compared their efcacy using stud rates (Arnold 2007). In general, all drugs including an assessment of sleep, showed benefts with were superior to placebo. Dizziness, weight for fatigue, similar to milnacipran for sleep disturbances, and gain, and sedation were noted with gabapentin. Symptom reduction difered among the drugs, with duloxe Venlafaxine tine and pregabalin superior to milnacipran for pain reduction Two small open-label studies with venlafaxine have and improvements in sleep disturbance; duloxetine superior been conducted, one using immediate release venlafaxine to pregabalin and milnacipran for reducing depressed mood, 37. Adverse efect profles were similar, although head from baseline using a visual scale and pain questionnaire ache and nausea were more common with duloxetine and (Dwight 1993, Sayar 2003). Of-label Drug T erapies Selective Serotonin Reuptake Inhibitors Tricyclic Antidepressants Fluoxetine, paroxetine, and citalopram have been stud Tricyclic antidepressants have long been the mainstay ied for the treatment of fbromyalgia. In a small 14-week Beyond Pharmacotherapy trial of 60 patients initiated on treatment with pramipex ole, 42% of patients had a 50% or more reduction in their Given the modest benefts of most drugs, many patients pain score using a visual analog scale, compared with 14% may use nonpharmacologic approaches. A trial of rop ing showed 91% of patients with fbromyalgia were using inirole found no beneft; however, the discontinuation nonpharmacologic therapies to manage symptoms, with rate was high (63%) for both intolerance and lack of ef two-thirds using more than one complimentary therapy cacy (Holman 2003). Pain Medications Nonpharmacologic T erapy Although pain is a characteristic feature of fbromyal Cognitive Behavior T erapy gia, analgesics are ofen of limited clinical value. This For those patients who can tolerate its adverse efects, therapy is ofen employed as a treatment for depression tramadol may be benefcial in reducing the severity of and anxiety. Of those 69 patients, 35 of pain in fbromyalgia (Creamer 2000, Hadhazy 2000, were randomized to tramadol in the double-blind place Nielson 1992, Singh 1998, White 1995). A careful consideration of adverse efects and the A meta-analysis of mindfulness-based stress reduction abuse potential should be considered before tramadol is used in chronic pain and stress disorders for fbromyalgia used for fbromyalgia pain relief. Opioids are not recommended for fbromyalgia because these drugs may actually worsen symptoms such as fatigue Exercise and cognitive impairment. A 1-year observational study Exercise as a therapy for fbromyalgia may appear para evaluated the use of opioids in 1700 adults with fbromyal doxical given the syndrome’s classic symptoms of pain and gia and found that patients taking nonopioid pain relievers fatigue. However, strong evidence supports exercise as an demonstrated greater improvements in assessments such efective treatment. A review of 16 trials that focused on exercise as Other Pain Medications a treatment for fbromyalgia divided exercise interventions Nonsteroidal anti-infammatory drugs and acetamino into categories of single exercise (aerobic training, strength phen act peripherally and are therefore less likely to be of training, fexibility training) or more than one type of exer beneft for the centrally mediated pain mechanisms that cise (mixed training). The newer criteria as well-being, physical function, pain reporting, tenderness, modifed in 2011 may capture more patients with fbro and muscle strength, thereby supporting a role for resis myalgia than the original 1990 criteria. Lifestyle physical activity is ofen Other Complementary Modalities recommended and may be more appealing than a struc Music has been suggested to help provide an analge tured exercise program to many patients with fbromyalgia. Evidence also suggests that into the day by increasing walking or using the stairs did not hydrotherapy may be of beneft for the treatment of fbro show sustained beneft (Fontaine 2011); therefore a struc myalgia in regards to pain, health status, and tender point tured exercise program is recommended. A review of nine randomized be counseled to seek professional help when atempting an controlled trials found patients with fbromyalgia had sig exercise program for fbromyalgia in order to avoid injury. Manual ther Vitamin D apy, which includes massage therapy and joint (spinal and Evidence is conficting regarding the role of vitamin D in extremity) manipulation or mobilization, has been shown the pathophysiology of fbromyalgia. In one study, patients to be benefcial for fbromyalgia symptoms, but with sex with fbromyalgia and vitamin D defciency, defned as a diferences in response. Manual therapy improved qual vitamin D level less than 32 ng/mL, were randomized to ity of sleep and tender point count in men and women, cholecalciferol or placebo. Cholecalciferol dosages were although women showed a greater reduction in pain and adjusted to achieve a target serum calcifediol concentration of perceived impact of fbromyalgia symptoms and men 32 to 48 ng/mL. Given the small study size and lack of supporting studies, more evidence is needed to routinely rec Patient Education and Resources ommend vitamin D supplementation for fbromyalgia. Education provided to patients about the chronic and Complementary Medicine waxing/waning nature of fbromyalgia symptoms has Tai Chi been shown to lead to fewer symptoms reported and Originally a Chinese martial art, tai chi is a mind-body decreased symptom intensity (Huynh 2008). T erefore practice that combines meditation, slow movements, and patient education plays a vital role in fbromyalgia man deep breathing. Interventions with more support Benefts seen at 12 weeks were sustained at 24 weeks. Tai ing evidence, such as aerobic and/or resistance exercise, chi adapted as pool-based therapy— with the thought that cognitive behavior therapy, and tai chi were not listed the warm pool water and increased buoyancy would help by patients on the survey. Signifcant improvements were also aged to identify stressors that worsen symptoms and to try seen in Pitsburgh Sleep Quality Index scores in those approaches to lessen these stressors. Counseling on proper who participated in pool-based tai chi but not for those sleep hygiene can assist patients with improving sleep-re doing stretching exercises in the pool. The National Fibromyalgia Association ofers many free resources for patients, including online Acupuncture support forums, a digital magazine, and information Acupuncture, defned as the stimulation of specifc about local support groups. A review of nine trials concluded acupuncture had no beter Despite developments in research, fbromyalgia remains efect for pain relief than sham acupuncture, suggesting a a challenging condition for many clinicians and patients. J Womens should be patient-specifc and should be focused on symp Health 2012;21:231-9. A 3-year, open-label, fexible-dosing study of milnacipran for the treatment of fbro myalgia. Practice Points In determining the optimal pharmacotherapy for the Bass C, Henderson M. Fibromyalgia: an unhelpful diagnosis treatment of fbromyalgia, practitioners should consider the for patients and doctors. An internet survey of most bothersome symptom(s) and the adverse efect 2596 people with fbromyalgia. Treatment of fbromy Efects of pool-based exercise in fbromyalgia symptomatol algia syndrome: recommendations of recent evidence-based ogy and sleep quality: a prospective randomized comparison interdisciplinary guidelines with special emphasis on comple between stretching and Tai Chi. Diagnostic and Statistical gia: a systematic review of randomized controlled trials. Research to encourage exer evidence-based recommendations for the management of cise for fbromyalgia: use of motivational interviewing, fbromyalgia syndrome. A double-blind, mul Protocol on Pain, Physical Function, Quality of Sleep, ticenter trial comparing duloxetine with placebo in the Depressive symptoms and Pressure Sensitivity in Women and treatment of fbromyalgia patients with or without major Men with Fibromyalgia Syndrome: A Randomized Controlled depressive disorder. J Clin Psychiatry treatment of fbromyalgia in adults: a 15-week, multicenter, 2006;67:1219-25. Arthritis Rheum improvement produced by nonpharmacologic intervention 2007;56:1336-44. Comparative efcacy and of print harms of duloxetine, milnacipran, and pregabalin in fbromyal gia syndrome. Efcacy and safety of duloxetine for treatment of fbromyalgia in patients with or Lauche R, Cramer H, Dobos G, et al. A systematic review and without major depressive disorder: results form a six-month, meta-analysis of mindfulness-based stress reduction for the randomized, double-blind, placebo-controlled, fxed-dose fbromyalgia syndrome. Altern T er Health Med a systematic review and meta-analysis of randomized con 1998;4:67-70. Evaluation of the fbromy in fbromyalgia syndrome: relationship to somatic and psycho algia diagnostic screen in clinical practice. Living with the unex gabalin in the treatment of fbromyalgia: a systematic review plained: coping, distress, and depression among women with and a meta-analysis. J Rheumatol ria and severity scales for clinical and epidemiological studies: 1995;22:717-21. Arthritis of rheumatology 1990 criteria for classifcation of fbromyal Care Res 2010;62:600-10. A 49-year-old man with fbromyalgia has been treated with 20% of the 35 matched controls who did not with pregabalin 225 mg twice daily for 4 weeks. Which one of the following best patient is pleased with how his symptoms of pain have describes the number needed to treat for this new improved. Which one of the following is best to recommend for sleep quality as her most bothersome symptom. A 38-year-old woman who received a diagnosis of fbromyalgia 1 year ago presents to your clinic. Which one of the following best justifes establishing pain related to her fbromyalgia is well controlled on this new service in the AllFam clinic? Education is recommended as part of a treatment with her cognitive abilities and thinks she has “fbro regimen for fbromyalgia. Education will ensure the patient’s safe use of the following is best to recommend for this patient? Which of the following is most consistent with crit icism surrounding the use of “tender points” in the A. It may mask the true incidence of fbromyalgia in everyone with fbromyalgia for symptom men. It takes a specially-trained clinician to relief if she is defcient, but frst she should have administer the examination. A patient with fbromyalgia has her pain symptoms well controlled on pregabalin and reports minimal Questions 15–17 pertain to the following case. The patient is switching jobs and will be without insurance coverage for 6 months. She presents one of the following is best to recommend for this with complaints of sleep disturbances, fatigue, and pain; patient? Discontinue pregabalin until insurance benefts throughout the day on most days of the week. Replace pregabalin with cognitive behavior She has not noticed cognitive symptoms related to her lack therapy. A patient with newly diagnosed fbromyalgia inquires about complementary and alternative medicine 16. Based upon available diagnostic criteria for fbromy algia, which one of the following criteria is P. You have just completed motivational interviewing training and decide to try this communication tech nique with a patient with fbromyalgia. Which of the following statements would be most appropriate in a dialogue promoting patient self-care? For the past 2 years her fbromyalgia symptoms have been well controlled with pregabalin 300 mg daily and a regular exercise program. In the past 3 months she has had to deal with several life stressors and now feels her fbromyal gia symptoms (namely pain and cognitive symptoms) have worsened. Which one of the following patients with fbromyalgia is most likely to beneft from milnacipran? A 38-year-old man with a new diagnosis of fbromyalgia and a primary complaint of sleep disturbances. A 47-year-old woman who had fatigue symptom relief from duloxetine but could not tolerate the drug’s adverse efects. A 44-year-old man who has most of his symptoms relieved through exercise but complains of depressed mood. As you take the postest for this chapter, also evaluate the Use the 5-point scale to indicate whether this chapter pre material’s quality and usefulness, as well as the achieve pared you to accomplish the following learning objectives: ment of learning objectives. Demonstrate an understanding of the epidemiology of fbromyalgia, its impact on patient health, and the. Do people sometimes have difficulty understanding how your symptoms such as extreme fatigue, dizziness, pain, and cognitive impairments can be so debilitating to you but can even be met with hostility by society at large People with some kinds of invisible disabilities, such as chronic pain or some kind of sleep disorder, are often accused of faking or imagining their disabilities. These symptoms can occur due to chronic illness, chronic pain, injury, birth disorders, etc. These people do not use an assistive device and most look and act perfectly healthy. Generally seeing a person in a wheelchair, wearing a hearing aid, or carrying a white cane tells us a person may be disabled. But what about invisible disabilities that make daily living a bit more. For example there are people with visual or auditory impairments who do not wear hearing aids or eye glasses so they may not seem to be obviously impaired. Those with joint conditions or problems who suffer chronic pain may not use any type of mobility aids on good days, or ever. Another example is Fibromyalgia which is now understood to be the most common cause of chronic musculoskeletal pain. Sources estimate between 3 and 26 million Americans suffer from this hidden condition. Other Types of Invisible Disabilities: Chronic Pain: A variety of conditions may cause chronic pain. A few of those reasons may be back problems, bone disease, physical injuries, and any number of other reasons. Chronic pain may not be noticeable to people who do not understand the victims specific medical condition. Chronic Fatigue: this type of disability refers to an individual who constantly feels tired. This can be extremely debilitating and affect every aspect of a persons every day life. Mental Illness: There are many mental illnesses that do qualify for disability benefits. Some examples are depression, attention deficit disorder, schizophrenia, agoraphobia, and many others. These diseases can also be completely debilitating to the victim, and can make performing everyday tasks extremely difficult, if not impossible. Chronic Dizziness: Often associated with problems of the inner ear, chronic dizziness can lead to impairment when walking, driving, working, sleeping, and other common tasks. People with psychiatric disabilities make up a large segment of the invisibly­disabled population covered under the Americans with Disabilities Act of 1990. Invisible disabilities can also include chronic illnesses such as renal failure, diabetes, and sleep disorders if those diseases significantly impair normal activities of daily living.

When older adults cannot meet the adult guide older lines diabetes jock itch purchase precose 25 mg without a prescription, they should be as physically active as their abilities and conditions will allow diabetic diet help order precose 50 mg free shipping. Moderate-intensity physical activity: Aerobic activity that increases a person’s heart rate and breathing to some extent metabolic disease syndrome x generic precose 25 mg overnight delivery. On a scale relative to a person’s capacity diabetic banana bread order precose 50mg visa, moderate-intensity activity is usually a 5 or 6 on a 0 to 10 scale diabetes diet tracker app order genuine precose line. Vigorous-intensity physical activity: Aerobic activity that greatly increases a person’s heart rate and breathing blood glucose units conversion table generic 25 mg precose with amex. On a scale relative to a person’s capacity diabetes type 2 good foods generic 50 mg precose free shipping, vigorous-intensity activity is usually a 7 or 8 on a 0 to 10 scale diabetes test equipment reviews buy generic precose on line. Jogging, singles tennis, swimming continuous laps, or bicycling uphill are examples. Muscle-strengthening activity: Physical activity, including exercise, that increases skeletal muscle strength, power, endurance, and mass. It includes strength training, resistance training, and muscular strength and endurance exercises. Bone-strengthening activity: Physical activity that produces an impact or tension force on bones, which promotes bone growth and strength. The behaviors with the strongest evidence Research has investigated additional principles that related to body weight include: may promote calorie balance and weight manage ment. Consuming an eating pattern low in reduced intake of solid foods, which can lead to calorie density may help to reduce calorie intake and higher total calorie intake. The sweeteners may reduce calorie intake in the short Nutrition Facts label found on food packaging pro term, yet questions remain about their effectiveness vides calorie information for each serving of food as a weight management strategy. Other behaviors or beverage and can assist consumers in monitor have been studied, such as snacking and frequency ing their intake. Also, monitoring body weight and of eating, but there is currently not enough evidence physical activity can help to support a specific recommendation for these prevent weight gain and behaviors to help manage body weight. When possible, order a in calorie balance—calories consumed and calories small-sized option, share a meal, or take home part expended. Review the calorie content of foods and ing and maintaining an appropriate body weight beverages offered and choose lower-calorie options. Prepare, serve, and consume smaller portions conditions, it is not the only lifestyle-related public of foods and beverages, especially those high health problem confronting the Nation. Individuals eat and drink more when terns that are high in calories, but low in nutrients provided larger portions. Not eating and costly health problems in the United States, breakfast has been associated with excess body particularly heart disease and its risk factors and weight, especially among children and adolescents. Similarly, a sedentary lifestyle Consuming breakfast also has been associated increases risk of these diseases. Improved eat with weight loss and weight loss maintenance, as ing patterns and increased physical activity have well as improved nutrient intake. Improved nutrition, appropriate eating behaviors, and Children and adolescents are encouraged to spend increased physical activity have tremendous potential no more than 1 to 2 hours each day watching televi to decrease the prevalence of overweight and obesity, sion, playing electronic games, or using the computer enhance the public’s health, reduce morbidity and (other than for homework). Many Americans are overweight or based advice to promote health and reduce the risk obese, and are at higher risk of chronic diseases, of major chronic diseases through diet and physical such as cardiovascular disease, diabetes, and certain activity. Even in the absence of overweight diets that meet Dietary Guideline recommenda or obesity, consuming too much sodium, solid fats, tions. This chapter focuses on certain foods and saturated and trans fatty acids, cholesterol, added food components that are consumed in excessive sugars, and alcohol increases the risk of some of amounts and may increase the risk of certain chronic the most common chronic diseases in the United diseases. Discussing solid fats in addition to saturated sources of saturated and trans fatty acids), added and trans fatty acids is important because, apart sugars, and refined grains. These food components from the effects of saturated and trans fatty acids on are consumed in excess by children, adolescents, cardiovascular disease risk, solid fats are abundant adults, and older adults. In addition, the diets of most in the diets of Americans and contribute signifi men exceed the recommendation for cholesterol. An important underlying principle is the need to control calorie intake to manage body weight and limit the intake of food components that increase the risk of certain chronic diseases. This goal can be achieved by consuming fewer foods that are high in sodium, solid fats, added sugars, and refined grains and, for those who drink, consuming alcohol in moderation. Sodium Sodium is an essential nutrient and is needed by the body in relatively small quantities, provided that substantial sweating does not occur. On average, the higher an individual’s sodium intake, the higher the individual’s blood pressure. A strong body of evidence in adults documents that as sodium intake decreases, so does blood pressure. Moder ate evidence in children also has documented that as sodium intake decreases, so does blood pressure. Keeping blood pressure in the normal range reduces an individual’s risk of cardiovascular disease, conges tive heart failure, and kidney disease. The estimated average intake of sodium for all Americans ages 2 years and older is approxi mately 3,400 mg per day (Figure 3-1). As a food ingredient, salt has multiple uses, such as in curing meat, baking, masking off flavors, retaining moisture, and enhancing flavor (including the flavor of other ingredients). Many types of processed foods contrib ute to the high intake of sodium (Figure 3-2). One drink is defined as 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of Some sodium-containing foods are high in sodium, wine (12% alcohol), or 1. Includes white bread or rolls, mixed-grain bread, flavored bread, whole-wheat bread or rolls, bagels, flat breads, croissants, and English muffins. Risk into 97 categories and ranked according to sodium contribution to the Factor Monitoring and Methods, Cancer Control and Population Sciences. Some of the ensures that recommended intake levels for other sources discussed here and in the following sec nutrients can be met. Includes macaroni and cheese, spaghetti and other pasta with or without sauces, filled pastas. The average achieved levels of sodium intake, as reflected by urinary sodium excretion, was 2,500 and 1,500 mg/day. Americans should reduce their sodium intake to less than 2,300 mg or 1,500 mg per day depend the types of fatty acids consumed are more impor ing on age and other individual characteristics. Animal diabetes, or chronic kidney disease and individuals fats tend to have a higher proportion of saturated ages 51 and older, comprise about half of the U. While nearly everyone and plant foods tend to have a higher proportion of benefits from reducing their sodium intake, the monounsaturated and/or polyunsaturated fatty acids blood pressure of these individuals tends to be (coconut oil, palm kernel oil, and palm oil being the even more responsive to the blood pressure-raising exceptions) (Figure 3-3). Most fats with a high percentage of saturated or Additional dietary modifications may be needed trans fatty acids are solid at room temperature and for people of all ages with hypertension, diabetes, are referred to as “solid fats,” while those with more or chronic kidney disease, and they are advised unsaturated fatty acids are usually liquid at room to consult a health care professional. Total fat intake contributes an average of benefits of foods that sodium intake to less 34 percent of calories. Saturated fatty acids Fats the body uses some saturated fatty acids for Dietary fats are found in both plant and animal physiological and structural functions, but it makes foods. Fats supply calories and essential fatty acids, more than enough to meet those needs. People and help in the absorption of the fat-soluble vita therefore have no dietary requirement for saturated mins A, D, E, and K. Total fat intake should fall within saturated fatty acids and replacing them with these ranges. Fats contain Lowering the percentage of calories from dietary a mixture of these different kinds of fatty acids. Trans saturated fatty acids even more, to 7 percent of fatty acids are unsaturated fatty acids. Fatty Acid Profiles of Common Fats and Oils Saturated fat Monounsaturated fat Polyunsaturated fat 100 90 80 70 60 50 40 30 20 10 0 Solid fats Oils a. The primary ingredient in soft margarine with no trans fats is liquid come from plants. Most stick margarines contain partially hydrogenated vegetable oil, a Reference, Release 22, 2009. Saturated fatty acids contribute an average of of the major food sources of saturated fatty acids can 11 percent of calories to the diet, which is higher than be purchased or prepared in ways that help reduce recommended. Major sources of saturated fatty acids the consumption of saturated fatty acids. Oils that are rich in monounsaturated fatty based desserts48 (6%); dairy-based desserts49 (6%); acids include canola, olive, and safflower oils. Oils chicken and chicken mixed dishes (6%); and sausage, that are good sources of polyunsaturated fatty acids franks, bacon, and ribs (5%) (Figure 3-4). To reduce the intake of saturated fatty acids, many Trans fatty acids Americans should limit their consumption of the Trans fatty acids are found naturally in some foods and major sources that are high in saturated fatty acids are formed during food processing; they are not essen and replace them with foods that are rich in mono tial in the diet. For association between increased trans fatty acid intake example, when preparing foods at home, solid fats and increased risk of cardiovascular disease. Because natural trans fatty acids but not all, unsaturated fatty acids are converted to are present in meat, milk, and milk products,50 their saturated fatty acids; some of the unsaturated fatty elimination is not recommended because this could acids are changed from a cis to trans configuration. Trans fatty acids produced this way are referred to as “synthetic” or “industrial” trans fatty acids. Synthetic Cholesterol trans fatty acids are found in the partially hydroge the body uses cholesterol for physiological and nated oils used in some margarines, snack foods, and structural functions, but it makes more than enough prepared desserts as a replacement for saturated for these purposes. Cholesterol is grazing animals, and small quantities are therefore found only in animal foods. There is egg mixed dishes (25% of total cholesterol intake),51 limited evidence to conclude whether synthetic chicken and chicken mixed dishes (12%), beef and and natural trans fatty acids differ in their metabolic beef mixed dishes (6%), and all types of beef burg effects and health outcomes. Includes scrambled eggs, omelets, fried eggs, egg breakfast sandwiches/biscuits, boiled and poached eggs, egg salad, deviled eggs, quiche, and egg substitutes. Beef and beef mixed dishes and all types of beef burgers would collectively contribute 11% of total cholesterol intake. Data are drawn from analyses of usual dietary intake conducted by the Source: National Cancer Institute. Risk into 97 categories and ranked according to the saturated fat contribution Factor Monitoring and Methods. Cholesterol intake by men averages total calories in American diets, but few essential about 350 mg per day, which exceeds the recom nutrients and no dietary fiber. Average of solid fats in the American diet are grain-based des cholesterol intake by women is 240 mg per day. However, this effect is reduced when saturated fatty acid intake is In addition to being a major contributor of solid fats, low, and the potential negative effects of dietary cho moderate evidence suggests an association between lesterol are relatively small compared to those of satu the increased intake of processed meats. Moderate evidence shows sausage, and bacon) and increased risk of colorectal a relationship between higher intake of cholesterol cancer and cardiovascular disease. Independent intake of solid fats, most Americans should limit their of other dietary factors, evidence suggests that one intake of those sources that are high in solid fats and/ egg. Consuming excess solid fats in the diet will result in reduced intake less than 300 mg per day of cholesterol can help of saturated fatty acids, trans fatty acids, and calories. Consuming less than 200 mg per day can further help individuals Added sugars at high risk of cardiovascular disease. Sugars are found naturally in fruits (fructose) and fluid milk and milk products (lactose). The majority Calories from Solid Fats and Added Sugars of sugars in typical American diets are sugars added to foods during processing, preparation, or at the Solid fats table. These “added sugars” sweeten the flavor of As noted previously, fats contain a mixture of foods and beverages and improve their palatability. Most fats with a high percentage of saturated and/ Although the body’s response to sugars does not or trans fatty acids are solid at room temperature depend on whether they are naturally present in food and are referred to as “solid fats” (Figure 3-3). The fat in fluid milk also is consid that contain added sugars often supply calories, but ered to be solid fat; milk fat (butter) is solid at room few or no essential nutrients and no dietary fiber. Although saturated and trans fatty acids are compo Added sugars contribute an average of 16 percent nents of many foods, solid fats are foods themselves of the total calories in American diets. The purpose for discussing sugar, brown sugar, corn syrup, corn syrup solids, solid fats in addition to saturated and trans fatty raw sugar, malt syrup, maple syrup, pancake syrup, acids is that, apart from the effects of saturated and fructose sweetener, liquid fructose, honey, molasses, trans fatty acids on cardiovascular disease risk, solid anhydrous dextrose, and crystal dextrose. Foods containing solid fats and added sugars (36% of added sugar intake), grain-based desserts are no more likely to contribute to weight gain than (13%), sugar-sweetened fruit drinks54 (10%), dairy any other source of calories in an eating pattern based desserts (6%), and candy (6%) (Figure 3-6). However, as the amount of solid fats and/or added sugars increases in the Reducing the consumption of these sources of added diet, it becomes more difficult to also eat foods with sugars will lower the calorie content of the diet, with sufficient dietary fiber and essential vitamins and out compromising its nutrient adequacy. For most foods and beverages can be replaced with those that people, no more than about 5 to 15 percent of calories have no or are low in added sugars. For example, from solid fats and added sugars can be reasonably sweetened beverages can be replaced with water accommodated in the and unsweetened beverages. Solid fats and added sugars are consumed in excessive amounts, and their intake should be limited. Together, Reducing the consumption of solid fats and added they contribute a substantial portion of the calories sugars allows for increased intake of nutrient-dense consumed by Americans—35 percent on average, or foods without exceeding overall calorie needs. Because nearly 800 calories per day—without contributing solid fats and added sugars are added to foods and 54. Risk Factor into 97 categories and ranked according to solid fat contribution to the Monitoring and Methods. Limit the amount of solid fats and added sugars provides detailed guidance that can help when cooking or eating. Refined grains the refining of whole grains involves a process that results in the loss of vitamins, minerals, and dietary fiber. Risk into 97 categories and ranked according to added sugars contribution to Factor Monitoring and Methods. Risk into 97 categories and ranked according to refined grain contribution to Factor Monitoring and Methods. Refined grains should be fiber and some vitamins and minerals that are pres replaced with whole grains, such that at least half ent in whole grains are not routinely added back to of all grains eaten are whole grains. Unlike solid fats and added sugars, refined grain products that also are high in solid fats enriched refined grain products have a positive role and/or added sugars, such as cakes, cookies, donuts, in providing some vitamins and minerals. Major when consumed beyond recommended levels, sources of refined grains in the diets of Americans they commonly provide excess calories, especially are yeast breads (26% of total refined grain intake); because many refined pizza (11%); grain-based desserts (10%); and torti grain products also are llas, burritos, and tacos (8%) (Figure 3-7). In the United States, approximately 50 percent of adults are current regular drinkers and 14 percent On average, Americans consume 6. Folic acid is added to enriched refined grains to a level that doubles the amount lost during the refining process. One ounce-equivalent of grain is 1 one-ounce slice bread; 1 ounce uncooked pasta or rice; ½ cup cooked rice, pasta, or cereal; 1 tortilla (6" diameter); 1 pancake (5" diameter); 1 ounce ready-to-eat cereal (about 1 cup cereal flakes). Alternatively, she may express harmful effects, depending on the amount con breast milk before consuming the drink and feed the sumed, age, and other characteristics of the person expressed milk to her infant later. Alcohol consumption may have beneficial effects when consumed in modera Excessive. Strong evidence from observational studies has no benefits, and the hazards of heavy alcohol has shown that moderate alcohol consumption intake are well known. Excessive drinking increases is associated with a lower risk of cardiovascular the risk of cirrhosis of the liver, hypertension, stroke, disease. Moderate alcohol consumption also is type 2 diabetes, cancer of the upper gastrointesti associated with reduced risk of all-cause mortality nal tract and colon, injury, and violence. Excessive among middle-aged and older adults and may help drinking over time is associated with increased body to keep cognitive function intact with age. However, weight and can impair short and long-term cogni it is not recommended that anyone begin drinking tive function. For the growing percentage of the or drink more frequently on the basis of potential population with elevated blood pressure, reducing health benefits because moderate alcohol intake also alcohol intake can effectively lower blood pres is associated with increased risk of breast cancer, sure, although this is most effective when paired violence, drowning, and injuries from falls and motor with changes in diet and physical activity patterns. Excessive alcohol consumption is responsible for an average of 79,000 deaths in the United States Because of the substantial evidence clearly dem each year. More than half of these deaths are due to onstrating the health benefits of breastfeeding, binge drinking. Binge drinking also is associated with a wide range of other health and social problems, including sexually transmitted diseases, unintended pregnancy, and violent crime. Moderate alcohol consumption is defined as up to 1 drink per day for women and up to 2 drinks. Besides being illegal, alcohol consumption increases the risk of drowning, car accidents, and What is heavy or high-risk drinking? Heavy or traumatic injury, which are common causes of high-risk drinking is the consumption of more death in children and adolescents. Drinking during pregnancy, especially in the day or more than 14 per week for men. No safe level of alcohol consumption consumption within 2 hours of 4 or more drinks during pregnancy has been established. For people who or take part in other activities that require atten drink, alcohol should be consumed in moderation. Appendix 4 discusses how food labels can help On average, American men, women, and children consumers evaluate and compare the nutritional consume too much sodium, solid fats (the major content and/or ingredients of products, and assist source of saturated and trans fatty acids), added them in purchasing foods that contain relatively sugars, and refined grains. Men consume too much lower amounts of certain undesirable nutrients and cholesterol, which also is found in some solid fats. In ingredients, such as sodium, saturated and trans addition, some people consume too much alcohol. In the United States, within the context of an information about suggest intakes of vegetables, fruits, whole grains, milk and overall healthy eating ed healthy eating patterns milk products,57 and oils are lower than recommended. Several other nutrients also are of con choices for a healthy eating pattern generally groups cern for specific population groups, such as folic acid foods based on commonalities in nutrients provided for women who are capable of becoming pregnant. The following recommendations provide advice this chapter describes food choices that should about making choices from all food groups while be emphasized to help Americans close nutrient balancing calorie needs. Fortified soy beverages have been marketed as “soymilk,” a product name consumers could see in supermarkets and consumer materials. Therefore, in this document, the term “fortified soy beverage” includes products that may be marketed as soymilk. An important underly beans, black beans, garbanzo beans ing principle is the need to control calories to manage (chickpeas), lima beans, black-eyed peas, body weight while making choices to support these split peas, and lentils.

The proportion of children among new cases of leprosy in the African Region ranged from 38 diabetes prevention management trusted precose 50 mg. The trends from 2005 to 2011 for new cases with grade-2 disabilities and rates/100 000 population are shown in Table 3 diabetes symptoms type 2 diabetes precose 50mg amex. Also during 2011 diabetes insipidus dilute urine generic precose 50 mg, a total of 12 225 new cases with grade-2 disabilities was detected diabete ezy precose 50 mg without prescription, a slight reduction compared with 2010 (13 275 cases) diabetic diet for dogs discount 50 mg precose mastercard. The number of relapsed cases reported in 2011 (2921) exceeded that reported in 2010 (2113) diabetes type 2 ursachen buy 50 mg precose otc. The strategy aims to reduce the global rate of new cases with grade-2 disabilities per 1 million population by at least 35% by the end of 2015; the baseline for comparison is the end of 2010 diabetes mellitus canine order precose 25 mg on line. This approach underlines the importance of detecting cases early diabetes diet restrictions order precose 25mg mastercard, providing multidrug therapy early, and ensuring a high standard of care in a setting of integrated services. Reducing the burden of disease at subnational levels by 2015 (at least 50% of new cases and at least 35% of new cases with disabilities). Countries have agreed to implement the principles of the United Nations resolution on the elimination of stigma and discrimination against persons affected by leprosy and their families (4). This will be achieved by encouraging collaboration among relevant ministries, including social services, education and justice, as well as with other partners to expand welfare and development programmes for people affected by leprosy, by engaging in regular advocacy and encouraging the goodwill ambassador for leprosy elimination to regularly visit affected countries; 5. Intensifying research by investing in the development of diagnostics and treatment, and working to prevent neuritis. Additionally, coordinating operational research should help to increase early diagnosis and the quality of leprosy services. Transmission to humans usually occurs through (i) contact with faeces of vector insects (triatomine bugs), including the ingestion of contaminated food, (ii) transfusion of infected blood, (iii) congenital transmission, (iv) organ transplantation or (v) laboratory accidents (1). These two chronic infections met in the 1980s following population movement and urbanization (5). Vector control –mainly spraying homes with insecticides that leave residues (residual insecticides) – also involves making improvements to dwellings, improving hygiene in houses to prevent insect infestation. Key measures to control vector-related transmission also include improving sanitation, implementing personal control measures (such as using bednets) and practising good hygiene when preparing, transporting, storing and consuming food. Screening blood from donors and organ donors are also fundamental methods to interrupt transmission. W ithout prompt diagnosis and treatment, the disease is usually fatal: the parasites multiply in the body, cross the blood–brain barrier and invade the central nervous system. The number of cases reported annually is considered to be a fraction of the real number of infected individuals. According to the latest 2011 estimates (1), the incidence could be around 20 000 cases a year. D uring 2009, 2010 and 2011, Benin, Burkina Faso, Ghana, M ali and Togo continued reporting zero cases. Cameroon, the Congo, Côte d’Ivoire, Equatorial Guinea, Gabon, Guinea, Nigeria and Uganda reported fewer than 100 new cases annually; Angola, the Central African Republic, Chad and South Sudan reported between 100 and 1000 new cases annually. The D emocratic Republic of the Congo is the only country that has reported more than 1000 new cases annually, and it accounts for 84% of the cases reported in 2011. Botswana, Namibia and Swaziland, considered to be endemic, have not reported any cases in the past 20 years; in these countries, the vector appears to be no longer present. Kenya and Zimbabwe have reported sporadic cases; M alawi, the United Republic of Tanzania and Zambia have reported fewer than 100 new cases annually; Uganda has reported between 100 and less than 200 new cases annually. M ore detailed information about the distribution of the disease is available in W H O ’s atlas of human African trypanosomiasis (2). Advances in controlling the disease made during the past decade have achieved an important decrease in its burden, but control and research efforts must continue and be based on sustainable public-health objectives, not only on the actual burden of the disease. The use of toxic melarsoprol has declined markedly; by 2010, 88% of cases were treated with melarsoprol-free therapy. Because use of this new treatment was based on limited experience, a reinforced pharmacovigilance system was introduced in 2010. This burden might render treatment unsustainable in the future; thus it is important that research continues to look for safe and effective medicines that are simpler to administer and cheaper than those currently available. As the number of new cases declines, new cost-effective approaches to integrate control and surveillance for the disease into health-care systems have been developed and are being tested in Benin and Togo. The control and surveillance system depends on the serological screening of selected patients who attend referral hospitals located in known foci of the disease. Positive samples are referred to W H O ’s collaborating centres for further analysis. This approach has been in place for 2 years, and there has been successful follow up and evaluation of it. The atlas maps control activities and cases reported at village level during 2000–2009. The 36 endemic countries have completed their mapping, including 175 576 cases and 19 828 geographical sites (7). The atlas is a powerful tool that can help endemic countries prepare control strategies, carry out interventions, monitor their impact, and sustain progress through surveillance. Using the data in the atlas and population layers, a methodology has been developed to calculate at-risk populations (8). The H uman African Trypanosomiasis Control and Surveillance Programme of the W orld H ealth O rganization 2000–2009: the way forward. The atlas of human African trypanosomiasis: a contribution to global mapping of neglected tropical diseases. Visceral Leishmaniasis, also known as kala-azar, is usually fatal within 2 years if left untreated. Cutaneous Leishmaniasis is the most prevalent form, causing ulcers that heal spontaneously. The mucocutaneous form invades the mucous membranes of the upper respiratory tract, causing gross mutilation by destroying soft tissues in the nose, mouth and throat. The distribution of the Leishmaniases has expanded since 1993, and there has been an increase in the number of cases recorded (3). Since reporting is mandatory in only 33/98 affected countries, the true increase in cases remains unknown. The spread of the Leishmaniases is mostly caused by movement of populations that expose nonimmune people to transmission (4). In South Sudan, an epidemic of visceral Leishmaniasis that lasted from 2009 to 2011 involved more than 25 000 cases and caused more than 700 deaths. In northern Ethiopia, the rate of coinfected patients increased from 19% during 1998–1999 to 34% during 2006–2007 (5). In 2011, more than 30 000 cases of cutaneous disease were reported from all endemic areas in the country. In East Africa, particularly in South Sudan and Sudan, epidemics of visceral disease, which has a high case-fatality rate, are frequent (7). The health burden of cutaneous Leishmaniasis remains largely unknown, partly because those who are most affected live in remote areas and often do not seek medical attention. M others with cutaneous disease may refrain or be prohibited from touching their children; young women with scars are unable to marry (6); and the disease may provide the pretext for a husband to abandon a wife. M ost studies examine only the immediate impacts of the disease and the expenditures associated with treatment and patient care. In M arch 2010, the W H O Expert Committee on the Control of the Leishmaniases met to develop guidelines for controlling these diseases (1). This meeting was followed by the publication of epidemiological information and an update on access to medicines (2). This work provides a secure base from which to reach the target of eliminating anthroponotic visceral Leishmaniasis on the Indian subcontinent by 2020. In D ecember 2011, W H O signed an agreement for the donation of 445 000 vials of liposomal amphotericin B to treat visceral Leishmaniasis. The donation will provide treatment for more than 50 000 patients over 5 years in countries in South-East Asia and East Africa. Support provided by the British and Spanish governments and the pharmaceutical industry helps sustain national efforts in endemic countries to control and eliminate the disease. W here the infection affects only humans, transmission can be reduced by implementing a combination of active case-detection, early treatment, vector control and social mobilization. In 2005, a memorandum of understanding was signed by Bangladesh, India and Nepal to overcome anthroponotic visceral Leishmaniasis by reducing the incidence of the disease to <1 case/10 000 population by 2015 (12). Combination therapy has reduced the duration and cost of treatment, improved patients’ adherence, and is expected to delay or even prevent drug resistance. To control cutaneous Leishmaniasis, W H O ’s Eastern M editerranean Region, which has the highest burden of the disease, has developed a 5-year strategic plan and case-management guidelines in consultation with other countries where the disease is endemic. Controlling vectors and reservoir hosts is important for controlling the Leishmaniases. Countries should regularly monitor and assess the effectiveness of different strategies being used for vector control, including indoor residual spraying with insecticides and the use of treated bednets. The economic impact of visceral leishmaniasis in rural households in one endemic district of Bihar, India. The presence of the adult tapeworm in the intestine causes taeniasis, a mildly pathogenic disease. Conversely, cysticercosis is a severe disease that results when humans ingest the tapeworm’s eggs, and larvae (cysticerci) develop in their tissues. Taeniasis and cysticercosis are closely interrelated: cysticercosis can infect pigs, and consumption of infected pork is responsible for taeniasis in humans. The intermittent release of tapeworm eggs in the faeces of humans with taeniasis contaminates the environment and exposes humans and pigs to the risk of infection with cystercercosis. H igh prevalences of human cysticercosis occur in various foci in Burkina Faso, the D emocratic Republic of the Congo, M ozambique, Senegal, South Africa, the United Republic of Tanzania and Zambia. In Asia, new reports of cases of neurocysticercosis have been received from Bangladesh, M alaysia and Singapore, mainly in migrant workers. Among people with epilepsy in endemic countries, the proportion who had neurocysticercosis has been estimated to be 29% (1). W H O estimates that at least 50 million people worldwide have epilepsy, and that about one third of all cases occur in regions where T. The annual proportion of deaths caused by epilepsy associated with neurocysticercosis has been estimated to be 6. The symptoms of cysticercosis cause two thirds of wage-earners to lose their jobs, and only 61% are able to again engage in wage-earning activities (8). The vaccine prevents new larval infection in pigs but does not affect established cysticerci, hence the need to treat with oxfendazole to eliminate them from muscles, which produces a positive impact on human health. A commercial process for producing the vaccine has been developed, and registration trials are continuing. Simultaneous safety and bioequivalence studies are in progress to provide formulations of oxfendazole that will be registered for use in pigs. M edium-term and long-term needs include validating a strategy for controlling and eliminating T. W H O and its partners are committed to attaining these milestones by improving tools for control, and formulating best-practice guidelines for interrupting transmission; the guidelines and tools will be pilot tested in selected endemic areas. Intervention studies in H onduras and Peru have shown that transmission can be interrupted and that an important cause of epilepsy can be reduced in resource constrained, endemic countries (14,15). Elimination will require (i) improvements in chemotherapy for humans and pigs, (ii) routine vaccination of pigs in endemic areas, (iii) better management of pig farms and pork production practices, (iv) improved sanitation, and (v) health education. A systematic review of the frequency of neurocyticercosis with a focus on people with epilepsy. Tendência da mortalidade relacionada à cisticercose no Estado de São Paulo, Brasil, 1985 a 2004: estudo usando causas múltiplas de morte [Cysticercosis-related mortality in the State of São Paulo, Brazil, 1985–2004: a study using multiple causes of death]. Reduction in rate of epilepsy from neurocysticercosis by community interventions: the Salamá, H onduras study. The disease results from infection with the nematode Dracunculus medinensis, the guinea worm. People become infected by drinking water containing infected cyclopoid copepods (Crustacea). No medicine or vaccine is effective in curing or preventing the disease: eradication is being achieved by implementing public-health measures. In 1989, a total of 892 055 cases in 13 682 villages were reported from the 15 countries that submitted reports from the village level (2). By the end of 2012, dracunculiasis was limited to four countries where the disease is endemic and a total of 542 cases in 271 villages; 521 (96%) of these cases were reported in 254 villages in South Sudan, 10 cases were reported in Chad, and 4 each in Ethiopia and M ali Fig. The eradication of dracunculiasis is estimated to lead to a 29% increase in economic return for the agricultural sector of countries where the disease is no longer endemic (6). In Chad, 10 cases were reported in 2010, another 10 cases in 2011 and 10 new cases in 2012 reverting to endemic country status. By 2011, the reward was associated with the reporting of 21/30 cases outside of South Sudan, with 10/10 cases in Chad, with 6/ 8 in Ethiopia, and with 5/12 in M ali. In 2010, rewards were paid for the reporting of 73/ 88 cases outside of southern Sudan, 10/10 in Chad, 18/21 in Ethiopia, and 45/57 in M ali. The reasons why cases occurred in Chad and certain areas of M ali are not yet understood. Similarly, the Ethiopian dracunculiasis eradication programme is reinforcing surveillance in areas bordering South Sudan. The intermediate hosts, which harbour the larval stages of the parasite, are a number of farm animals and wild ungulates, rodents, and other small mammals. The incubation period can last many years, with signs and symptoms depending on the location of the cyst, or cysts, and the pressure exerted on the surrounding tissues and organs. Alveolar echinococcosis is characterized by an asymptomatic incubation period of 5–15 years. Larval metastases may form in organs adjacent to the liver or in distant locations following dissemination of the parasite by the haematogenous or lymphatic route. Highly endemic areas are mostly found in the eastern part of the M editerranean region, northern Africa, southern and eastern Europe, at the southern tip of South America, in Central Asia, Siberia and western China. Both diseases are considered to be underreported; however, data indicate that echinococcosis is re emerging as an important public health problem. There are more than 1 million people worldwide affected with these diseases at any one time (4,5). Treatment for cystic echinococcosis and alveolar echinococcosis often includes surgery. In regions where cystic echinococcosis is endemic, the incidence in humans can exceed 50/100 000 person-years; prevalences as high as 5–10% may occur in parts of Argentina, Central Asia, China, East Africa and Peru (6). In livestock, the rate of cystic echinococcosis found in slaughterhouses in hyperendemic areas of Latin America varies from 20% to 95% of slaughtered animals. Validated strategies for controlling the disease, and integrated control packages for major dog-related zoonoses (rabies and echinococcosis), will be available in 2018. Large-scale interventions for controlling and eliminating cystic echinococcosis as a public-health problem in selected countries will be initiated on that basis and will be continued through 2020. W H O ’s informal working group on echinococcosis has developed consensus about treating human cystic echinococcosis and alveolar echinococcosis (3). In endemic areas, the health sector often takes the lead in initiating echinococcosis-control measures, but it is dependent on the veterinary sector for animal-related interventions. A programme combining the vaccination of lambs, treatment of dogs, and culling of older sheep could lead to disease elimination in humans in less than 10 years (8). Regular deworming of domestic carnivores that have access to wild rodents should help reduce the risk of infection to humans. Expert consensus for the diagnosis and treatment of cystic and alveolar echinococcosis in humans. The diseases of most public-health importance are clonorchiasis (caused by infection with Clonorchis sinensis), opisthorchiasis (infection with Opisthorchis viverrini or O. Information on the epidemiological status of foodborne trematodes in Africa is limited, but paragonimiasis is known to be transmitted in the central and western parts of the continent. Estimates limited to 17 countries indicate that in 2005 there were more than 56 million infected individuals, 7. The economic burden of foodborne trematodes is mainly linked to the expanding livestock and aquaculture industries. Losses in animal production and trade are likely to indirectly affect human welfare. Its mainstay is treatment of the human host, with the aim of controlling morbidity and ultimately preventing associated mortality. The objective is to ensure that medicines are available to treat those who need them. Praziquantel is the treatment of choice for clonorchiasis and opisthorchiasis, and triclabendazole for fascioliasis; either medicine can also be used to treat paragonimiasis. Treatment strategies vary, from individual case-management to the mass delivery of preventive chemotherapy. In 2012, the number of affected individuals exceeded 6 million; most of those affected live in the north-eastern provinces (6). M ore than 5000 new cases of cholangiocarcinoma, most of which are fatal, are diagnosed annually in Thailand (7). In the Lao People’s D emocratic Republic, about 2 million people are estimated to have opisthorchiasis (6). Preventive chemotherapy with praziquantel started in 2007, and in 2011 approximately 325 000 children and adults were treated. In Viet Nam, preventive chemotherapy with praziquantel started in 2006, and in 2011 more than 128 000 people were treated for clonorchiasis. In the Republic of Korea, in 2011 approximately 4000 people were treated for clonorchiasis in the remaining endemic areas. In Cambodia, mapping continues in an effort to identify areas where foodborne trematodes are transmitted. In South America, the Plurinational State of Bolivia is engaged in the largest fascioliasis-control programme worldwide. The population requiring preventive chemotherapy is estimated to be 250 000 children and adults.

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