During this century there have been striking trends in the incidence of certain important cancers, while others have remained fairly steady. Lung cancer mortality has risen dramatically in the last fifty to sixty years. Colorectal cancer (cancer of the large intestine and rectum) increased in most of the Western world in the 1930s and 1940s but has been steady for the last thirty years. There seems to have been an increase in cancer of the prostate gland in men between 1930 and 1950 but this may reflect improved diagnosis. Melanoma incidence has risen rapidly in the last twenty years and continues to rise, reflecting changes in exposure to sunlight. There has been some good
news. Stomach cancer has been falling steadily for sixty years and continues to do so, and some kinds of gynaecological cancer affecting the uterus in women are now less frequent than they were in the 1940s and 1950s.
The extent to which we can predict future trends by looking at cancer incidence in young people. These trends provide important clues about the cause of cancer, the most obvious one being the parallel between lung cancer and smoking.
*25\194\4*

After the physical examination, the physician will develop a differential diagnosis. This consists of a list of possible causes of your specific symptoms. The physician will order specific laboratory tests to rule out certain of the diagnoses and other tests to confirm the proper diagnosis (these tests are described in detail below).
Blood tests and x-rays are seldom helpful in diagnosing R A in the very earliest stage. For this reason, your tests may not uncover any specific abnormalities. On the one hand, you’ll probably be happy that the test results are normal; on the other hand, there’s the frustration of knowing that something is wrong and not having a test result to prove it. Your physician may temporarily have to make an experienced best guess of the diagnosis in this case. Effective treatment can be initiated before test results are diagnostically significant, however.
What Makes RA So Difficult to Diagnose?
RA is the most common of the inflammatory forms of arthritis, and yet it is often difficult to make an accurate diagnosis of it. For this reason, your physician may have initially diagnosed your RA as another type of inflammatory arthritis, such as ankylosing spondylitis, Reiter’s disease, arthritis associated with psoriasis or colitis, gout, pseudo-gout, or systemic lupus erythematosus (SLE). The symptoms of these forms of arthritis are similar to the symptoms of RA, and many excellent doctors initially misdiagnose RA as being another form of inflammatory arthritis (and vice versa). As mentioned above, RA also is often diagnosed incorrectly as the most common form of arthritis, osteoarthritis.
A good clinical history, a thorough physical examination, some laboratory tests, and a good measure of time and patience are required to diagnose RA. A physician who is well acquainted with the pattern of joint involvement in RA is likely to have an easier time making an accurate diagnosis. Board-certified rheumatologists are specifically trained and experienced in making these difficult early diagnoses.
*17/209/5*

So genius and wisdom, and by extension talent and competence, do not always travel together, and in fact they often don’t. Most people seem to recognize the difference between these highly desirable traits. Sternberg has studied how people from various walks of life perceive the relationship between creativity and wisdom. It turns out that most of his subjects viewed these traits as being positively but very weakly linked, and in some instances even as being negatively, inversely linked. Interestingly, the same study shows that both “wisdom” and “creativity” were viewed by the subjects as being better correlated with “intelligence” than with each other. This suggests to me that the very construct of “intelligence” is, in the minds of most people, an attempt to capture a sum total of many aspects of the mind, rather than a particular, distinctive aspect of the mind.
The belief that novelty-seeking is the attribute of youth and that wisdom is the attribute of old age seems to be shared by a lot of people. Psychologists J. Heckhausen, R. Dixon, and P. Baltes conducted a fascinating experiment in which they asked their subjects which human attributes appear at what age. Most subjects believed that curiosity and the ability to think clearly become dominant attributes for people in their twenties and that wisdom becomes a dominant attribute for people in their fifties. When asked to rank various attributes in terms of their desirability, wisdom was ranked among the most desirable traits. In a similar study, Marion Perlmutter and her colleagues found that most people associate wisdom with advanced age more than with anything else. This amounts to an interesting syllogism: If people believe that wisdom is the privilege of old age arid also regard wisdom as one of the most desirable traits, then they also must believe that aging has its benefits, its positive side, and its unique and valuable assets.
In the minds of most people competence, like wisdom, is also the fruit of maturity. Understanding wisdom as an extreme degree of competence is consonant with the approach taken by psychologists Paul Baltes and Jacqui Smith, who define wisdom as “expert knowledge,” a highly developed ability to deal with the “fundamental pragmatics of life” involving “important but uncertain matters of life.” They place “rich factual knowledge” and “rich procedural knowledge” among the important prerequisites of wisdom and point out that the accumulation of such knowledge by definition requires a long life.
Following Sternberg’s prudent (and wise!) admonition, I will refrain from discussing the concept of wisdom in all its richness. I will forgo the existential, self-actualizing, and moral aspects of wisdom, so cogently considered by Erikson, Jung, Kohut, and others. I will limit the scope of this book to one aspect of wisdom: the enhanced capacity for problem-solving. This admittedly narrow, morally agnostic approach allows a few villains into the book, along with many heroes. While realizing the limitations of this approach, I feel that it is a big enough slice of an infinitely rich concept to tackle in one book. Problem-solving is the one aspect of wisdom that we are most prepared to explore through neuroscience.
If wisdom and competence (or expertise) increase with age in all their aspects, then how does one reconcile this with the common assumption that one’s mental powers decline with age? Or, to turn it around, if our memory and mental focus decline with age, then how is it possible that our wisdom and competence grow? What sets wisdom and competence apart from other manifestations of the mind and allows them to survive the ravages of aging?
*16\302\2*

Some little “critters” carry a big wallop
Most insect bites and stings are minor and the reaction is localized. Often an insect injects a substance with its bite that causes a painful, stinging sensation. More serious problems may arise if you’re bitten by a poisonous insect — such as a black widow or brown recluse spider — or if you experience an allergic reaction
What you can do
If emergency care is required
Until emergency care can be obtained:
Apply ice or cold water to the bite for five minutes. For protection, place a washcloth between bare skin and ice.
If the bite is on a hand or foot, keep the limb snugly bandaged above the bite for five minutes (but make sure there is still circulation to the limb). Do not apply a tourniquet.
Keep the limb below the level of the heart.

When emergency care is not required
Scrape out or flick out any stinger that may be left in the skin by scraping it out with your fingernail. Avoid squeezing the stinger.
Use calamine lotion or over-the-counter (OTC) hydrocortisone cream to reduce itching and inflammation.
Apply ice. For protection, place a washcloth between bare skin and ice.
If itching becomes severe, try an over-the-counter (OTC) oral antihistamine such as Benadryl or Chlor-Trimeton.
Prevention
General precautions
Avoid wearing perfume if you’ll be spending time outdoors — it attracts bees.
Get reliable instructions before trying to remove a beehive or nest. Follow directions on commercial products.
If known to be allergic to bees, always carry an anaphylactic kit. You can get one with a prescription from your doctor.
*13\303\2*

The Centers for Disease Control and Prevention, a division of the U.S. Public Health Service, strongly recommends that certain people be vaccinated against influenza every year before the flu season begins. Children twelve years of age and younger should be given only the so-called split-virus vaccine. Children under nine years of age who have not been previously vaccinated should get two doses of split-virus vaccine, with a one-month gap between them and with the second dose given before December. Although the best time for vaccination is between October 15 and November 15, high-risk individuals who were not previously immunized may still benefit from vaccination even after a flu outbreak has begun in their communities.
Charges for a flu shot are now fully reimbursable for everyone covered by Medicare. The vaccine is also offered for a minimal fee at many public health clinics and health maintenance organizations (HMOs) and it is increasingly being offered free of charge to employees of large companies. Check with your local health department or your company’s medical department or benefits office. The vaccine is also available for a fee from many private physicians.
The current U.S. Public Health Service recommendations for flu vaccination are as follows:
Groups at High Risk for Serious Influenza Complications
Every person aged 65 and older.
Infants over 6 months of age and all children and adults with chronic heart or lung disease, cystic fibrosis, a chronic metabolic disorder like diabetes, kidney disease, anemia, or severe asthma.
People of any age with cancer or an immunological disorder (in-eluding HIV infection) or those on medications that suppress immunity and lower the body’s resistance to infection.
All residents of nursing homes and other chronic-care facilities, particularly those with long-term health problems.
Children and teenagers (aged 6 months to 18 years) who are on long-term aspirin therapy (they may be at risk of developing a life-threatening condition called Reye’s syndrome should they get the flu while taking aspirin).
Groups That Can Transmit Influenza to
High-Risk Persons
Physicians, nurses, and other personnel who work in a hospital, outpatient facility, nursing home, or chronic-care facility and have contact with high-risk patients in all age groups, including infants.
Health-care workers and volunteers who provide in-home care to high-risk persons.
Household members, including children, of anyone who is at high risk for serious flu complications.
Other Groups
While they are not covered by official public health recommendations, other people who might consider taking an annual flu shot include:
People like the police and firefighters who provide essential community services.
Students, teachers, day-care personnel, and others who work in institutional settings.
Pregnant women who have other medical conditions that might increase their risk of flu complications. If possible, the vaccine should be administered after the first 3 months of pregnancy. However, vaccination of high-risk women should not be delayed if they will still be in the first trimester when the flu season begins.
Foreign travelers who expect to be in tropics at any time of the year or in the southern hemisphere during April through September, when the flu season hits there. Pretravel vaccination with the previous season’s vaccine is especially important for those in high-risk categories.
Any person who wants to reduce his or her chances of getting the flu. Only cost and vaccine availability limit the ability of every young, healthy person to take an annual flu shot.
Who Should Not Be Vaccinated
People with extreme allergic reactions to eggs, since the virus used in the vaccine is grown in eggs and the vaccine can contain minute amounts of egg protein. • People with fever-causing illnesses, who should wait until they recover to take a flu shot.
*20\296\2*

Fever
If an infection is localized, pus formation, redness, swelling, and irritation often occur. These symptoms indicate that the invading organisms are being fought systematically. Another indication is the development of a fever, or a rise in body temperature above the norm of 98.6°E Fever is frequently caused by toxins secreted by pathogens that interfere with the control of body temperature. Although this elevated temperature is often harmful to the body, it is also believed to act as a form of protection. Elevations of body temperature by even 1 or 2 degrees provide an environment that destroys some types of disease-causing organisms. Also, as body temperature rises, the body is stimulated to produce more white blood cells, which destroy more invaders.

Pain
Although pain is not usually thought of as a defense mechanism, it is a response to injury, and it plays a valuable role in the body’s response to invasion. Pain may be either direct, caused by the stimulation of nerve endings in an affected area, or referred, meaning it is present in one place although the source is elsewhere. An example of referred pain is the pain in the arm or jaw often experienced by someone having a heart attack. Regardless of the cause of pain, most pain responses are accompanied by inflammation. Pain tends to be the earliest sign that an injury has occurred and often causes the person to slow down or stop the activity that was aggravating the injury, thereby protecting against further damage. Because it is often one of the first warnings of disease, persistent pain should not be overlooked or masked with short-term pain relievers.
*20/277/5*

What’s more, study of EEG tracings can help us monitor the way a patient is responding to treatment. Many antidepressant medications serve to suppress REM sleep—in fact, REM suppression may be one of the mechanisms by which such drugs work. (Interestingly, depressed patients also show improvement when they are deprived of REM sleep merely by being awakened at those points in the sleep cycle.) A patient who experiences REM sleep immediately after dropping off is thought to be responding poorly to antidepressants and may need to try a combination of drugs. Similarly, some patients who may respond better to electroshock therapy tend to show much shorter onset of REM sleep than others. Perhaps in the not-too-distant future physicians will be able to diagnose and categorize a patient’s illness and prescribe appropriate therapy primarily on the basis of EEG sleep records.
*116\226\8*

I’ve also found that some insomniacs use their disorder as a mechanism to avoid certain issues or obligations in their personal lives. One of my patients, a thirty-six-year-old man I’ll call Jim, had experienced difficulty falling asleep for nearly ten out of the twelve years he had been married. While his wife usually went to bed by 11:30, Jim would stay up for hours, finding a number of tasks, such as balancing the checkbook, that had to be done before he could turn in. He was convinced that he suffered from some kind of “chemical imbalance” that simply prevented him from enjoying normal sleep patterns; he believed that a prescription for sleeping pills was all he needed.
During one discussion, however, Jim made a casual remark to the effect that the birth control method he used was celibacy. To my surprise, I discovered that he had intercourse with his wife no more than half a dozen times a year. On further probing I learned that Jim suffered from deep-seated fears about his sexual performance, which apparently stemmed from some thoughtlessly facetious remarks his wife had made shortly after they were married. Eventually, it seems, his fears were transformed into a behavior pattern that kept him from going to bed at the same time as his wife, in order to avoid confronting the issue of sex and exposing himself to the risk of what he perceived as “further ridicule.” After some encouragement and therapy Jim discussed these feelings with his wife, who, I am happy to say, cooperated by reassuring him about his sexual desirability and performance. At last report Jim’s sleep pattern—as well as his sex life—has returned to nearly normal.
As you can see from this example, Jim subconsciously used his insomnia as a means of avoiding sexual confrontation. Similarly, other patients blame sleeplessness for poor performance at work or use it to minimize expectations people might have of them or to avoid risk of failure. Still others find they can avoid family or social obligations by using their chronic fatigue as a constant excuse.
In some cases, of course, DIMS stems not from psychological causes but from a true organic abnormality, such as a disruption in the nervous system responsible for controlling breathing. Complicating matters is the fact that such organic insomnia  often mimics the symptoms of psychological insomnia, especially when the problem is one of interrupted sleep. Organic sleep disturbance seldom results in premature morning waking—an example of why a detailed understanding of an individual’s sleep pattern is so important in diagnosis. To reiterate, however, a psychological element will be found in most cases of insomnia.
*109\226\8*

Waste products excreted by these mites, which are mainly proteins, are the main substances to which allergic people react. Each mite excretes about 20 of these pellets every day.
These pellets, minute in size, continue to cause allergic symptoms even after the mite is dead. A female mite lays 25 to 50 eggs and a new generation is produced every three weeks.
There is a direct relationship between the number of mites in the house dust, the degree of allergy and the symptoms of asthma. Tests done with extracts made from the laboratory cultivated mite (D. pteronyssimus), showed that all individuals who had positive reactions to the mites also reacted to house dust extract. “We have not yet seen a case in which a patient reacted to house dust and not to this particular species of mite or vice-versa,” says Dr Voorhorst, the researcher who discovered mite as the cause of house dust allergy.
*22\260\8*

These sprays or inhaled powders are cortisone-like medicines that are inhaled directly into the lungs. They act as anti-inflammatory drugs and help reduce bronchial sensitivity over a period of time. If asthma is present, these medications should be taken after using a bronchodilator. The most commonly used topical steroids are Aldecin, Becloforte, Becotide and Pulmicort.
Pulmicort (budesonide) has just been released on the Australian market. It is taken through a metered dose inhaler called a Turbuhaler, which is breath activated and contains no chlorofluorocarbons (CFCs), fillers or additives. The Turbuhaler is preloaded with 200 doses of pure medication, and it contains an indicator to warn users when they have reached the last 20 doses.
Recently there have been concerns among doctors worldwide that beta-agonists, such as Ventolin, are being used too often by some patients, particularly chronic asthmatics. There is a current trend among many doctors to change their prescribing patterns by recommending that patients on regular doses of beta-agonists should switch to preventive therapy with topical steroids. The steroids repress the bronchial inflammation and sensitivity of the lungs as well as relieve symptoms. Under this medication regime, beta-agonists would be used to relieve any attacks that break through.
Topical steroids do not bring instant relief and can take one to four weeks to become effective. While waiting for preventive medicines to take effect, patients should continue with metered doses of bronchodilators. The bronchodilatots can be reduced once maximum lung function is reached. Doctors report that patients should be able to significantly reduce their use of bronchodilators and still maintain good lung function after using preventive medicines over a period of time.
SIDE EFFECTS OF INHALED STEROIDS
The side effects from inhaled steroids are minimal. Even in high doses, they do not have the side effects associated with steroid tablets. This is because the dose is so small that the drug acts only on the lungs and is not absorbed into the body. Some people experience a slightly hoarse voice or sore throat after use. Others develop a fungal infection in the throat or mouth, but such a condition generally responds quickly to treatment. The patient’s mouth should be rinsed out immediately after each dose is administered to prevent these side effects. Inhaled steroids should be used with a spacer, such as a Nebuhaler or Volumatic.
*21\148\2*