Physician’s assistants and nurse practitioners are midlevel practitioners, meaning that their responsibilities lie somewhere between those of a nurse and those of a physician. Midlevel practitioners assess medical problems, order tests, and recommend treatments. They work with varying degrees of independence, depending on state laws, the medical problems they care for, and their relationship with the other health care providers.     Midlevel practitioners often have specialized training in one area of medical care, including care of people with HIV infection. They are especially valuable in highly specialized areas of medical care because they have often acquired, through training and experience, an expertise not usually found among physicians who care for people with many different diseases. Many comprehensive care programs for people with HIV infection rely heavily on midlevel practitioners.     Physician’s assistants have two years of specialized training, must pass a board exam every six years, are required to have at least one hundred hours of postgraduate education every two years, and are licensed. Physician’s assistants must practice under the supervision of a physician. They may prescribe drugs in some states but not in others.     Nurse practitioners are registered nurses who have nine additional months of advanced training or have received a master’s degree in nursing. Nurse practitioners do much of what physician’s assistants do, but they are not required to serve under direct supervision of a licensed physician.*164\191\2*

It is hard to tell how common such problems are, since there are biases in all studies. Children with psycho-social problems are far more likely to be identified and included in studies than those without problems. Also, children with continuing seizures are more likely to be identified than the 80 percent whose seizures are completely controlled or outgrown.Whatever the true incidence, such problems are sufficiently common that they should be monitored. Problems with learning and even with retardation are usually caused by brain injury rather than the seizures themselves. Learning problems, as well as hyperactivity and behavioral problems, may be caused by medication. Close monitoring of your child’s school performance should be your responsibility and if you have concerns, you should discuss them with your physician.Depression is not uncommon in children. It may be hard to identify. Symptoms of depression include sleep disturbances, school problems, fatigue or listlessness, lack of enthusiasm, easy crying, and irritability, among others. Depression can be due to medication, particularly phe-nobarbital. But depression also may be a consequence of a child’s or family’s reaction to the seizures and their treatment. If you are concerned about these problems, you should discuss them with your doctor. Early identification of depression can lead to earlier help.In general, psycho-social problems are sufficiently common in children with epilepsy that families and physicians should be alert to them. Preventive discussions with members of the family and the school may avoid problems and permit early identification. Psycho-social problems should not be allowed to become a handicap.*216\208\8*

Another consequence of thrombophlebitis, especially in the deep veins of the legs, is damage of the valves in the affected veins. These valves prevent backward (downward) flow of blood in the veins when you stand up. Because veins do not have muscle in their walls to help “pump” the blood back to the heart, they are affected by gravity and the gentle squeezing provided by the surrounding skeletal muscle. To improve the flow of blood back to the heart, veins have valves. These valves work like safety cogs on mountain trains, which prevent them from rolling backward if they lose power while climbing up a steep mountain slope. In much the same way, the valves in the veins prevent the blood from “flowing back” as it is gradually pushed uphill toward the heart.When the valves in the veins do not work properly, several problems can occur. The pooling of blood can lead to ballooning of the vein, resulting in varicose veins. In some cases the pooling gets so bad that the leg swells. This condition is commonly referred to as venous insufficiency. With chronic swelling and the associated increase in pressure on the skin, discoloration called stasis pigmentation can develop in some people, and in severe cases, actual skin ulceration can develop.*210\252\8*

Finally, after you accept what you must, control whatever else you can. A friend of Steven’s felt he was being a burden to his parents and moved into a private home for people with AIDS; he liked the home particularly because he felt needed by other people there. Another friend of Steven’s had wanted to be sick at home, but after he had diarrhea and his sister had to change his sheets and wash him, he decided to go to the hospital instead.     If you cannot control your life in big ways, control it in small: you never lose control over everything. Lisa would ask her husband, “Do you want the water glass here or there? Do you want to wear your blue shirt or your white one? Do you want cocoa or coffee?” When Dean needs to go to the hospital, he routinely takes along his own lamp and radio. You can always affect the course or quality of your life somehow.     This strategy of controlling what you can extends to the social service and medical systems.
*85\191\2*

Franklin grew up in a neighborhood where violence is a fact of daily life. He had dropped out of high school after tenth grade, and at age twenty-one he was working in a factory and living with his mother and siblings. Franklin had formed an early attachment to a girlfriend he’d met in junior high school, and by the time of his injury they had a young son. Though his girlfriend and son lived with her family, Franklin saw them daily and was very close to his little boy.Franklin was shot while walking in his neighborhood. It was a random street shooting, and Franklin thinks the teenagers who shot him were trying to “prove themselves” for gang membership or were just showing off. Franklin was shot first in the leg, then in the back. He remembers lying in the street, waiting for help. “1 had a lot of wounds and bleeding. I turned myself over and realized I couldn’t move my legs. 1 didn’t feel much pain.” But Franklin remembers feeling scared and alone. He could see some people sitting on a front porch. “I asked someone to come over and talk to me while I was lying on the ground. Someone called for help and someone came over and talked to me.” Everything seemed unreal. When the ambulance came, Franklin remembers the paramedics cutting off his pants and putting him on a board. “Police were asking my name and address, who to contact,” he recalls. “Then they put me into an ambulance.”Franklin’s memories of the immediate aftermath of the shooting are somewhat vague and jumbled. This is typical in cases of trauma. At the hospital, he recalls, “I was awake while they were pulling the bullets out of me. When they got me back to Intensive Care, that’s when I finally slept. They had to close up a lot of flesh wounds. I think I got hit in my lung – I had some tubes.” Franklin later found out that he had been shot twelve times. He had a collapsed lung, which was repaired. Fortunately the bullets had missed other vital organs, so he was able to survive the assault.The doctors told Franklin that he had a spinal cord injury at T9 (the ninth thoracic or upper back, vertebra) and that his prognosis was unclear because he had a lot of swelling around his spinal cord. Until the swelling went down, they wouldn’t know whether he would be able to walk. Franklin recalls feeling overwhelmed. He couldn’t focus on the meaning of the doctors’ words, so he told them to talk to his mother.When the doctors determined that Franklin had a complete spinal cord injury and explained the consequences, he cried a lot. He realized he would have to use a wheelchair for the rest of his life. He imagined life as a paraplegic as much worse than it turned out to be. “I was lying down the whole week I was in acute care,” he remembers, “and didn’t think I’d be able to do all the things 1 can do now. I got dizzy when I got up, didn’t want to bother with it. I thought I wouldn’t be able to deal with it.”That first week, Franklin was scared and sad. He and his family cried a lot, though he recalls that his mother, girlfriend, and siblings were always there for him and told him “everything was all right, whatever happened” to him.Franklin’s medical condition stabilized quickly and he was transferred to a rehabilitation hospital about a week or so after his injury. His mood improved immediately, as he started getting out of bed every day, became more active, started lifting weights, and “started feeling like 7 can do this’; stopped saying 7 can’t do it.’” In rehabilitation, the staff showed him how to get in and out of a chair, get dressed, and check his skin. “Once I started doing things on my own, I felt like everything was going to be all right,” he recalls. “Even if I can’t walk, I’ll still be going about life, doing the same things that I always did, just a little bit different.”Injuring your spinal cord transports you into a whole new territory. What can you expect during the “wilderness” phase? This depends on the individual. Each person’s experience, and each person’s base of knowledge, is different. And spinal cord injury affects people differently, depending on the location and type of the damage. The level of injury (where on the spinal cord the injury occurs) defines the point below which paralysis can occur. Whether the spinal cord is completely or partially damaged determines the extent of the weakness or paralysis. How quickly emergency intervention begins and the quality of medical care received also affect outcome. Franklin was young, strong, and lucky. Someone else – someone older, younger, weaker, or with a different injury or outlook – would have a very different experience.Nearly everyone with spinal cord injury requires emergency room care, acute hospitalization, and inpatient rehabilitation. In many cases, surgery is required to stabilize the spine; other people do not require surgery. Some have long hospital stays; others, short.
*3/156/5*

The most common cancer affecting the uterine lining is the ‘endometrioid adenocarcinoma’. This means that the tissue looks like the endometrium (‘endometrioid’) and is a glandular cancer (‘adenocarcinoma’) that is, it arises in the glands of the uterine lining. There are three types of endometrioid adenocarcinoma. The first is most commonly seen in oestrogen-driven tumours, i.e. the ‘well-differentiated’ endometrioid adenocarcinoma, which looks similar to the normal uterine lining and has a high cure rate. In contrast, the ‘poorly-differentiated’ endometrioid adenocarcinoma looks highly malignant under the microscope and the cure rate is lower. The third type is in between this well- and poorly differentiated situation, i.e. a ‘moderately well-differentiated endometrioid adenocarcinoma’.'Adenosquamous’ cancers contain both the glandular tissue seen in the lining of the uterus and the squamous tissue seen covering the surface of the cervix.The ‘papillary serous’ and ‘clear cell’ cancers look very similar to those cancers seen in the ovary and often act like ovarian cancers in the way they spread. They tend to invade deeply into the muscle and to have spread beyond the uterus at the time of diagnosis. The endometrioid adenocarcinoma is more likely to be localized within the uterus itself. They are the most malignant and challenging of all cancers affecting the uterus.Endometrial cancers first of all invade into the muscular wall of the uterus (the myometrium) and are most likely to be confined there. They can spread down to the cervix, either along the surface of the lining of the cervix or into the substance of the cervix itself, so that occasionally it is difficult to work out where the tumour started.The spread of the cancer along the fallopian tubes to the ovaries and lymph glands within the pelvic and abdominal cavities occurs in about 15% of cases at the time of diagnosis.It is clear that once the cancer has spread, successful treatment is less likely. There are currently no screening tests available for endometrial cancer but a number are currently under development and provide us with some hope that in the future, more of these cancers will be diagnosed when they are confined to the uterus itself.As the cancer grows and spreads, the most common problem is bleeding which, although rare, can become very heavy indeed and possibly life threatening. Radiation therapy can stop the bleeding, or rarely, the blood vessels to the uterus can be blocked (‘uterine artery embolisation).It is rare for the cancer to invade through the front wall, but if it does then the bladder can develop a hole and urine will leak through the vagina (‘urinary fistula’). Surgery is required to repair the bladder because the leakage of urine is constant, sometimes occurring at night, and is associated with chafing of the vulva area and the inner thighs. This can be uncomfortable and painful.If the cancer invades through the back wall, then the rectum can be involved and a hole (fistula) from the rectum to the vagina occurs. This also requires surgery because faeces and gas (flatus) can then leak through the vagina with obvious discomfort, foul smelling odour and great mental stress for the woman.If the cancer is untreated and spreads outside the uterus, then the common sites for it to go to are the lungs, bones and liver. If the disease spreads to the lungs, then breathlessness, pain on breathing and cough can develop, whereas if it goes to the liver then usually this is painless. If the liver surface is stretched then pain underneath the side of the diaphragm can occur. Secondary cancers in bones are always painful and can cause fractures. However they respond well to radiation treatment in most cases.*2/144/5*

When you hit the wrong nailFingers often get smashed, pinched or jammed during daily activities. Most finger injuries are not serious. Although they may be quite painful and inconvenient, these injuries heal well with self-care at home. Serious injuries with possible bone fractures, severe bleeding or severed parts require professional medical help.
What you can do Immediately apply an ice pack or insert finger into ice-cold water to decrease the pain and reduce swelling. For protection, place a washcloth between bare skin and ice.Apply ice pack for 10 to 15 minutes every hour for two hours, then leave ice off for two hours. Repeat this cycle for 48 hours or until swelling is gone. Do not use heat as long as there is swelling.Remove any jewelry if you can do so without causing additional pain.If skin is broken, gently wash with soap, then dry. Apply soft, clean dressing.Splint and support injured finger by taping it to a nearby healthy one.Rest and elevate hand for 24 to 48 hours. Immobilize hand in a sling or use hand as little as possible.Take aspirin or ibuprofen to reduce swelling and pain. NEVER give aspirin to children/teenagers. It can cause Reye’s syndrome, a rare but often fatal condition.When swelling is gone, apply warm compresses at intervals for comfort.Resume full range of motion as soon as swelling is gone. Gentle bending and movement will stretch the muscle tissue and prevent limited movement later.Stop any activity that causes pain to the finger.
Dislocated fingernailsTrim the part of the nail that is still attached to avoid catching it on anything. It is not necessary to remove the nail.Keep area clean and watch for signs of infection.Protect the tip of the finger with a soft cloth or covering. A new nail will take one to two months to grow back.
Blood under a nailApply ice as soon as possible. For protection, place a washcloth between bare skin and ice.Make a hole in the nail to relieve pressure and pain:
Straighten a paper clip and hold it with a pair of pliers in a flame until it is red hot.Place the tip of the paper clip on the nail and let it melt through. You need not push. A thick nail may take several tries. As soon as the hole is complete, blood will escape and the pain and pressure will ease.
If the blood and pressure build up again, repeat the procedure using the same hole.Soak the finger three times a day for 15 minutes in a solution of equal parts water and hydrogen peroxide.*18\303\2*

HistoryA complete and thorough history is essential in the initial evaluation of a patient with acute diarrhea. The physician should elicit a detailed description of the diarrheal syndrome, including length of symptoms, quantity and quality of stool, presence of fever, and abdominal symptoms. The history should address recent travel to underdeveloped countries, potential exposures to raw or undercooked food, sick contacts, contact with children, and employment in health care facilities. A sexual history may elicit risk factors for herpes simplex, Chlamydia, Neisseria gonorrhoeae, or Treponema pallidum proctitits.Establishing the immune status of the host is essential. Patients with immune deficiencies due to organ transplant, HIV, and certain drugs (particularly steroids, chemotherapeutic agents, and immunosuppressants) can be more susceptible to less typical gastrointestinal pathogens. Such patients may also exhibit more severe symptoms and experience a more fulminant course, lowering the threshold for antimicrobial therapy and hospitalization.Recent hospitalization or antimicrobial therapy increases the likelihood of C. difficile infection or antibiotic-associated diarrhea. Other medications may cause diarrhea or other adverse gastrointestinal effects.Patients presenting with diarrhea after international travel often are infected with bacteria or parasites, most frequently enterotoxigenic E. coli. Recent camping, travel to mountainous areas, or a prolonged diarrheal illness lasting more than 14 days suggests Giardia infection.
Physical ExaminationPhysical examination should concentrate on assessment of volume status with particular attention to heart rate, blood pressure, and mental status, especially in the very young and elderly. A directed examination of the abdomen may qualify the illness, but sensitivity and specificity for agents of infectious diarrhea is extremely low. A rectal examination may reveal hemoccult or grossly positive blood or mucus and may elicit tenderness, indicating proctitis.*72/348/5*

Sunlight is, of course, a splendid tonic for the skin, and a healthy skin should be well pigmented; but it should not be forgotten that the sun can do harm if a skin untrained to its influences is forced to undergo excessive sun-bathing. No matter how tanned the skin may be, it should never be exposed for very long periods to the direct rays when the summer sun is at its height.In many ways the air-bath is more important than the sun-bath, because it stimulates the functions of the skin without causing the least amount of harm, and it can be practiced all the year round. It is not necessary for the air-bath to be taken in the open air, although this is highly desirable when the weather is opportune.   The air-bath is of great value when it is taken indoors provided that the room has been carefully aired and is warm enough to prevent shivering. As the body gets accustomed to exposure the shivering reaction will decrease, and the body will be able to stand a much lower temperature.The air-bath is of great value in keeping the skin in good tone, and if practiced regularly it will contribute to the general health of the body. The habit should be inculcated in the child, who should be taught that it is just as important as washing the skin; then by the time adulthood is reached the air-bath will be taken as a matter of course. It is well known by those who practice this method of toning up the skin that it is preventive of coughs and colds, and it is a significant thing that when we tend to wear heavy clothes and completely cover the skin we are much more liable to suffer from these ailments.When taking the air-bath it is a very good thing to stimulate the circulation through the skin by some kind of friction. This can be done by rubbing the surface of the body with the palms of the hands, or, if preferred, with a fairly rough towel. Exposing the skin to the air and quickening the circulation through it not only stimulates the whole nervous system, but is actually far more cleansing than many people imagine.
*15/154/5*

The most striking difference between natural therapy and conventional medicine is the length of time you will spend in consultation with your therapist. A first consultation with a natural therapist is likely to take at least an hour and much of the time will be spent in finding out about you and your life. Further consultations are unlikely to be as long as the first but will still be longer than you would spend with a family doctor.Treatments are different too. Often, after the initial symptoms have cleared, you will continue to receive some form of therapy aimed at restoring your body’s natural healing ability. For this reason treatments may take longer than those used in conventional medicine. They may also take longer to work.In addition to specific treatments you will usually be advised to make changes to your lifestyle – for example, a change of diet, sleeping habits, stress management, and exercise may all be recommended to help you back to good health.You will not be a passive recipient of healthcare. A natural therapist will encourage you to take more responsibility for your own health.*54\120\4*