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Chlorine test kits are available for purchase to check the concentration of your solution purchase levitra oral jelly 20 mg overnight delivery. Licensed facilities are required to use a test kit to measure the strength of the sanitizing solution quality 20 mg levitra oral jelly. However order levitra oral jelly 20 mg with amex, a common chemical name of the active ingredient is dimethyl benzyl ammonium chloride cheap levitra oral jelly 20 mg mastercard. Use the information on pg 40 to determine if the product meets the criteria for both a sanitizer and/or disinfectant. Use test kit daily to monitor the correct concentration of the product used in the food areas (200 to 400 ppm). Use separate bottles and label each clearly with its intended use with the name of product, date mixed, food/mouthed contact use, or general disinfection. The solution for use on food contact surfaces may differ from that used for general disinfection. For more information about a specific product call the distributor or the company. Scrub the area with soap or detergent and water to remove blood or body fluids and discard paper towels. Disinfect immediately using bleach solution 1 or another appropriate disinfecting product on any items and surfaces contaminated with blood and body fluids (stool, urine, vomit). Spray the area thoroughly with bleach solution 2 or another appropriate sanitizing product. Wipe the area to evenly distribute the sanitizer using single-service, disposable paper towels. Before any new group of children begins an activity at a water play table or water basin, the water play table or basin is washed, rinsed, and sanitized. Any child participating in an activity at a water play table or basin washes his or her hands before the activity. This is acceptable for soaking, cleaning, sanitizing, and disinfecting washable articles. Sink/Basin #1: wash items in hot water using detergent (bottle brushes as needed). If at the end of the cycle when the machine is opened the dishes are too hot to touch, then the items are sanitized. This interest is twofold: first is due to reports about increased allergies, sensitivities, and illness in children associated with chemical toxins in the environment and second, these products tend to cause less damage to the environment. Children are more vulnerable to chemical toxins because of their immature immune systems, rapidly developing bodies, and their natural behaviors. They play on the floor, are very tactile having much body contact with the tables, desks, or play equipment, and have oral behaviors of mouthing toys and surfaces and putting their hands in their mouths. Green sanitizers or disinfectants must be approved by your local public health agency or your childcare consultant. Germs found in the stool can be spread when the hands of caregivers or children contaminate objects, surfaces, or food. Note: The importance of using good body mechanics cannot be over emphasized when changing diapers of larger or older children, as well as infants and toddlers. Equipment Changing surface - The changing surface should be separate from other activities. Check with your childcare health consultant or school nurse to determine which handwashing procedures are appropriate for different age groups of children. Diapers High-absorbency disposable diapers are preferred because cloth diapers do not contain stool and urine as well and require more handling (the more handling, the greater chances for spread of germs). Cloth diaper considerations The outer covering and inner lining must both be changed with each diaper change. Disposable gloves Non-latex gloves without powder should be considered because of possible allergy to latex in staff and children. Disposable wipes A sufficient number of pre-moistened wipes should be dispensed before starting the diapering procedure to prevent contamination of the wipes and/or the container. Parents/guardians or healthcare providers must provide written, signed directions for their use. Plastic bags Disposable plastic bags must be used to line waste containers and to send soiled clothing or cloth diapers home. Waste containers and diaper pails A tightly covered container, preferably with a foot-operated lid, is recommended. Potty chair or commodes (not recommended) Flush toilets are recommended rather than commodes or potty chairs. However, if potty chairs or commodes are used, frames should be smooth and easy to clean. Wipe the area to distribute the sanitizer evenly using single-service, disposable paper towels. If you have questions about cleaning and sanitizing procedures, ask your childcare health consultant or school nurse for specific instructions. July 2011 44 July 2011 45 Please Post Changing Pull-ups/Toilet Learning Procedure *Note: This procedure is recommended for wet pull-ups only. Thoroughly with soap and warm running water for 15-20 seconds using posted procedure. Place pull-up directly into plastic bag, tie and place in a plastic lined waste container. Thoroughly with soap and warm running water for 15-20 seconds using posted procedure. Thoroughly with soap and warm running water for 15-20 seconds using posted procedure. Acknowledge Toilet Learning Praise child for all attempts/successes in toilet learning process. Toileting results and any concerns to parents (rash, unusual color, odor, frequency, or consistency of stool). Handwashing Wash hands thoroughly with soap and warm running water after using the toilet, changing diapers, and before preparing or eating food. Thorough handwashing is the best way to prevent the spread of communicable diseases. Food and beverage storage, handling, preparation, and cooking guidelines Storage guidelines/rationale - Store all potentially hazardous foods (eggs, milk or milk products, meat, poultry, fish, etc. Childcare centers/schools that receive hot food entrees must hold potentially hazardous foods at 135° F or above and check food temperature with a clean, calibrated food thermometer before serving. Bacteria may grow or produce toxins if food is kept at temperatures that are not hot or cold enough. This will help to prevent the meat and poultry juices from dripping onto other foods. Never refer to medicine as “candy” as this may encourage children to eat more medicine than they should. For example, cleansers may look like powdered sugar and pine cleaners may look like apple juice. Preferably, one sink should be dedicated for food preparation and one for handwashing. This area has equipment, surfaces, and utensils that are durable, easily cleaned, and safe for food preparation. This helps remove pesticides or trace amounts of soil and stool, which might contain bacteria or viruses that may be on the produce. Cross contamination occurs when a contaminated product or its juices contacts other products and contaminates them. High concentration of sanitizer can leave high residuals on the food contact surface, which can contaminate food, make people ill, and damage surfaces or equipment. Staff knowledgeable about safe food handling practices can prevent foodborne illnesses. Use a food thermometer to achieve an internal temperature of 155° F for 15 seconds. Large quantities of hamburger may “look” cooked, but may contain “pockets” of partially cooked meat. Monitoring temperatures can ensure that all potentially hazardous foods have not been in the “danger zone” (41° - 135° F) too long, which allows for bacterial growth. The container or platter could contain harmful bacteria that could contaminate the cooked food. These items may be the source of foodborne illnesses caused by pathogens such as Campylobacter, Salmonella, E. Cooking projects in the childcare and school settings should be treated as a science project. Children could contaminate food and make other children/staff ill if they handle food during these types of projects. Monitor the children’s handwashing and supervise children so they do not eat the food. Children and parents may not understand food safety principles as well as staff at licensed food establishments. Licensed commercial kitchens are more controlled environments for preparation than private homes. If you choose to have an animal in the childcare or school setting, follow the listed guidelines to decrease the risk of spreading disease. Check with your local health department or childcare licensing agency before bringing any pets to your childcare setting or school because there may be state and/or local regulations that must be followed.

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Biol Psychiatry 74:720–726 17 The Impact of Microbiota on Brain and Behavior: Mechanisms & Therapeutic cheap levitra oral jelly 20mg. Diaz Heijtz R et al (2011) Normal gut microbiota modulates brain development and behavior cheap levitra oral jelly 20 mg otc. Nishino R et al (2013) Commensal microbiota modulate murine behaviors in a strictly contamination-free environment confirmed by culture-based methods buy 20mg levitra oral jelly fast delivery. Desbonnet L et al (2014) Microbiota is essential for social development in the mouse buy generic levitra oral jelly 20mg online. Sudo N et al (2004) Postnatal microbial colonization programs the hypothalamic-pituitary- adrenal system for stress response in mice. Antibiotic treatment during infancy and increased body mass index in boys: an international cross-sectional study. Fouhy F et al (2012) High-throughput sequencing reveals the incomplete, short-term reco- very of infant gut microbiota following parenteral antibiotic treatment with ampicillin and gentamicin. Rousseaux C et al (2007) Lactobacillus acidophilus modulates intestinal pain and induces opioid and cannabinoid receptors. Benton D, Williams C, Brown A (2007) Impact of consuming a milk drink containing a probiotic on mood and cognition. Tillisch K et al (2013) Consumption of fermented milk product with probiotic modulates brain activity. Yang J et al (2007) Epigenetic marks in cloned rhesus monkey embryos: comparison with counterparts produced in vitro. Petschow B et al (2013) Probiotics, prebiotics, and the host microbiome: the science of translation. Drakoularakou A et al (2010) A double-blind, placebo-controlled, randomized human study assessing the capacity of a novel galacto-oligosaccharide mixture in reducing travellers’ diarrhoea. Hornig M (2013) The role of microbes and autoimmunity in the pathogenesis of neuro- psychiatric illness. Timoveyev L et al (2002) Stability to sound stress and changeability in intestinal microflora. Eur Psychiatry 17(Suppl 1):200 17 The Impact of Microbiota on Brain and Behavior: Mechanisms & Therapeutic. Suzuki K et al (1983) Effects of crowding and heat stress on intestinal flora, body weight gain, and feed efficiency of growing rats and chicks. Barrett E et al (2012) Bifidobacterium breve with alpha-linolenic acid and linoleic acid alters fatty acid metabolism in the maternal separation model of irritable bowel syndrome. Wall R et al (2010) Impact of administered Bifidobacterium on murine host fatty acid composition. Krogius-Kurikka L et al (2009) Microbial community analysis reveals high level phylo- genetic alterations in the overall gastrointestinal microbiota of diarrhoea-predominant irri- table bowel syndrome sufferers. Tana C et al (2010) Altered profiles of intestinal microbiota and organic acids may be the origin of symptoms in irritable bowel syndrome. Craft N, Li H (2013) Response to the commentaries on the paper: Propionibacterium acnes strain populations in the human skin microbiome associated with acne. Codling C et al (2010) A molecular analysis of fecal and mucosal bacterial communities in irritable bowel syndrome. Clarke G et al (2012) Review article: probiotics for the treatment of irritable bowel syndrome–focus on lactic acid bacteria. Moayyedi P et al (2010) The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Pimentel M, Lezcano S (2007) Irritable bowel syndrome: bacterial overgrowth—what’s known and what to do. Happe F et al (2006) Executive function deficits in autism spectrum disorders and attention- deficit/hyperactivity disorder: examining profiles across domains and ages. Fombonne E (2005) Epidemiology of autistic disorder and other pervasive developmental disorders. Nolen-Hoeksema S, Larson J, Grayson C (1999) Explaining the gender difference in depres- sive symptoms. Biol Psychiatry 61(4):521–537 17 The Impact of Microbiota on Brain and Behavior: Mechanisms & Therapeutic. Physiol Behav 96(4–5):557–567 Chapter 18 Neuroimaging the icrobiome-Gut–Brain Axis Kirsten Tillisch and Jennifer S. Labus Abstract The brain is the most complex organ in the human body, interacting with every other major organ system to continuously maintain homeostasis. Thus it is not surprising that the brain also interacts with our microbiota, the trillions of bacteria and other organisms inhabiting the ecosystem of the human being. As we gather knowledge about the way that our microbiota interact with their local environments, there is also increasing interest in their communication with the brain. Labus Introduction The brain is the most complex organ in the human body, interacting with every other major organ system to continuously maintain homeostasis. Thus it is not surprising that the brain also interacts with our microbiota, the trillions of bacteria and other organisms inhabiting the ecosystem of the human being. As we gather knowledge about the way that our microbiota interact with their local environ- ments, there is also increasing interest in their communication with the brain. Brain-Gut Communication Bidirectional communication between the brain and gut has been well described (Fig. The brain communicates with the gut via the autonomic nervous system (particularly the vagus nerve) and the hypothalamic-pituitary adrenal axis. Descending monoaminergic pathways also act on the dorsal horn and can regulate gut-related sensations. Gastrointestinal motility, secretion, local blood flow, and immune regulation are modulated by the brain, generating stereotypic patterns of gut response which are context specific, such as the classic gastrointestinal stress response of nausea and/or fecal urgency. Thus the local environment of gastroin- testinal microbes is continuously adjusted by central influences. These interactions provide a partial explanation for the differences in gut bacterial populations between healthy persons and those with gastrointestinal illness [5–7] or prolonged psychological stress [8]. Similarly, preclinical studies have identified altered fecal bacteria after experimental pre and post-natal stress [9–12]. Completing the bidirectional loop, the brain receives afferent input from the gut, likely from a variety of pathways, as described below. With a surface area far exceeding that of the skin, the gut is the largest interface between the body and the external environment, and contains the body’s most numerous population of microbes. The gut also has a vast immune system and complex nervous system through which the microbiota can communicate with the brain. Additionally, organisms can stimulate the release of these compounds by gut enterochromaffin cells, leading to central signaling and clini- cally apparent symptoms [16]. An example of this is the central nausea induced at the nucleus tractus solitarius after rotavirus-stimulated gastrointestinal serotonin release [17]. An alternate pathway by which information may reach the brain from the gut is via neurochemicals secreted into the portal venous system, as is seen in hepatic encephalopathy [18, 19]. Interoceptive (internal) signals of body 18 Neuroimaging the Microbiome-Gut–Brain Axis 407 Fig. The gastrointestinal microbiota communicate with the brain via enteric nervous system and via metabolic products. It has been proposed that interoceptive input has relevance beyond merely reporting the homeostatic “status” of the body. In the model proposed by Craig and others, interoceptive signals appear to be integrated with emotional and cognitive input primarily in the anterior insula. This combined input is used continuously to create a sense of momentary “self” which can be consciously interpreted as happy, sad, healthy, ill, etc. Since visceral feedback from the gut and other body sites contributes to our conscious state of wellbeing, it then follows that the gut’s luminal organisms also have the opportunity to influence mood states like anxiety or depression [26, 27]. During an experimental task, when a brain region is more active compared to a baseline or control task, blood flow increases and thus a higher proportion of oxygenated hemoglobin is observed in that area. Alterations in resting brain function have also been described in patients with functional gastrointestinal disorders, which are believed to involve brain-gut axis dysfunction [36–38]. Whether these resting brain signal changes represent ongoing gastrointestinal input to the brain or persistent changes in the function of neural circuitry due to chronic disease is not yet known. Only one study to date has described functional brain changes in response to a probiotic intervention [29]. In this study healthy, normal weight women without any gastrointestinal symptoms, pain or psychiatric disorder, were randomized to treatment with a probiotic, a placebo dairy product or no treatment. This difference in brain activity was not correlated to any subject reports of mood or gastrointestinal symptoms. Evaluation of the microbiota in that study confirmed that the experimental probiotic could be identified in the stool of the probiotic ingesting subjects but did not show group specific changes in the overall architecture of the microbiota. This is consistent with other studies and suggests that microbial metabolites rather than overall microbial configuration may be the salient result of probiotic ingestion [42]. This initial study suggests that subtle changes in the gut contents can lead to measureable changes in brain function, even in the absence of a conscious awareness of the change. Differences in both white matter and gray matter have been identified in irritable bowel syndrome and functional dyspepsia, both of which are considered to be disorders of the brain- gut axis and which likely are accompanied by alterations in the gut microbiota [43– 51]. High resolution structural brain images can be used to produce global (whole- brain), regional, and voxel-level indices of gray matter density and volume as well as cortical thickness, surface area and mean curvature (Fig. Network analysis from graph theory has recently been applied to gray matter morphometry to demonstrate alterations in regional topology, providing strong evidence for exten- sive structural reorganization of cortical and subcortical regions previously impli- cated in altered brain responses to visceral pain stimuli and their expectation [43]. The biological substrate underlying grey matter changes may involve increased or decreased glial cells, changes in dendritic spines or synapses or less likely, neural degeneration. The next inner four rings depict the gray matter volume, surface area, cortical thickness, and degree of connectivity.

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Oxidized low-density lipoprotein is a major risk factor for coronary heart disease order levitra oral jelly 20 mg otc. Chapter 1 / The Science of Nutritional Medicine 5 The fundamental virtue of the reductionist approach is that it tends to clarify cause-effect relationships discount levitra oral jelly 20 mg with amex. It can be used to detect factors that predis- pose to disease and to identify interventions that alter the course of disease cheap 20mg levitra oral jelly overnight delivery. Although randomized 20 mg levitra oral jelly with amex, double-blind, placebo-controlled clinical trials are the most scientifically sound approach to establishing cause-effect relation- ships, other research designs can be used to ascertain the likelihood of such a relationship. Although the probability of a cause-effect relationship is greatest when substantiating evidence can be obtained from studies in humans, other strategies that identify a correlation between dietary choices and wellness or disease have been developed. Animal studies and other lab- oratory investigations meet a number of the criteria required to establish a cause-effect relationship. Biologic plausibility is an important criterion that should be met in any postulated cause-effect relationship. The biologic plausibility of using nutri- ents to influence pathophysiologic processes is well established. The role of nutrients in diverse biochemical pathways is well documented in numerous laboratory studies. A logical extrapolation of the proven ability of nutrients to affect biologic processes in the test tube is to postulate their use in clinical care. However, laboratory evidence does not constitute proof that nutrient intervention is effective in clinical practice. For example, genistein inhibits thrombin formation and platelet activation in vitro, yet dietary supplemen- tation with soy protein isolates rich in isoflavones has no significant effect in vivo. Animal experiments lend themselves to mechanistic exploration, and analogous situations can be identified but are seriously limited by questions about cross-species validity. Epidemiologic studies have species relevance but are quasi-experimental and rely on statistical methods for control. Because each approach has its own limitations, epidemiologic studies rely on a variety of research meth- ods. Criteria used to establish a cause-effect relationship that may be tested by means of epidemiologic studies include the following: consistency between different studies supporting a relationship between intervention and out- come, an appropriate temporal relationship (i. Data to meet these criteria can be collected from analytic epidemio- logic trials in which cohort or prospective longitudinal studies are done; from descriptive studies based on prevalence, survey, or cross-sectional studies; and from case studies and case reports, the weakest source of evi- dence (see Box 1-1). Analytic epidemiology provides good descriptions and suggests useful diet-disease inferences. Case-control studies provide useful clues but low-level exposures, confounding and methodologic errors can cause researchers to overlook both protective and harmful repercussions of nutritional intervention. Contradictions become apparent when data from different research methods are compared. They attempt to correct for known confounding variables, but selection bias is a problem. Cohort studies follow persons: ● Who have been exposed to risk factors and control subjects who have no known exposure ● Longitudinally over time (i. Chapter 1 / The Science of Nutritional Medicine 7 suggest fat restriction decreases breast cancer; descriptive epidemiologic studies support an inverse relationship, but case-control studies show little effect and cohort studies show few associations. An eclectic approach is often used to enhance the reliability and validity of conclusions. For example, in the case of functional foods, it has been suggested that before particular benefits are claimed, evidence should be obtained from diverse sources and weighted as follows: epidemiologic studies (25%), intervention studies (35%), animal models (25%), and mechanism of action (15%). In contrast to the biomedical model, which supposes that outcomes are predictable, the holistic infomedical model accepts that clinical outcomes are unpredictable and that uncertainty is the rule rather than the exception. The infomedical model accepts discrepancies explaining the inexplicable as an inherent feature of the circular cybernetic of interacting information sys- tems characteristic of living organisms. The infomedical model seemingly provides a framework in which dietary choices and the interaction between nutrition and health or disease triggers can be better accommodated. However, the infomedical model has yet to clarify the rules of a research design for investigating nutritional medicine. A template that accommo- dates the diverse and interacting influences of behavioral choices and dietary complexity, while permitting objective measurement of clinical out- comes, is needed. The biomedical model abhors uncertainty and seeks to limit clinical unpredictability by withholding unproven therapy. The infomedical model advocates interventions that have yet to achieve scientific validation. Such discrepancies in the use of nutritional information have resulted in two schools of nutritional “medicine. The alternative school, consistent with its focus on maximizing wellness in individual patients, may serve as a source of nutritional misinformation. When faced with conflicting results, the conservative school withholds potentially beneficial therapy until it meets rigorous scientific standards. In the absence of such trials, postulates supported by biologically plausible mech- anisms need to be treated with skepticism. This is done because conven- tional nutritional medicine recognizes that the side effects of a therapy with uncertain efficacy approximate infinity. Although the medical profession hesitates to advocate routine nutritional supplementation for patients, one study showed that half the female physicians surveyed in the United States took a multivitamin- mineral supplement. Descriptive stud- ies suggest that fat is associated with an increased risk for this disease. However, a meta-analysis that included 13 case-control studies suggested that total energy intake, rather than the intake of fat, correlated with the risk of colon cancer. On the other hand, case-control studies suggest that animal, but not vegetable, fat corre- lates positively with colon cancer. To complicate matters, cohort studies, after controlling for energy, showed no association with fat but suggested that red meat, especially beef, was associated with a risk for colon cancer. Animal experimentation has added a further dimension, suggesting that genetically distinct colon cancers respond discretely to nutritional intervention. High consumption of monounsaturated fats, mostly derived from olive oil, was associated with a statistically significant decrease in the risk of cancer with wild-type Ki-ras genotype but not in the risk of Ki-ras–mutated cancers. Contradictory findings do not lend themselves to confident clinical interven- tion. Although it is desirable to provide unambiguous dietary advice, it is even more important to justify prescription of nutritional supplements. Appropriate dietary advice and nutrient prescriptions are most likely to arise when cause-effect or food/nutrient-health relationships are established. Difficulties associated with identifying causal associations between diet and disease make safe, effective, and timely nutritional intervention prob- lematic. Variables making intervention equivocal for conventional practi- tioners of nutritional medicine include the following. This uniqueness is of sufficient significance for authorities to maintain that although it is possible to enunciate recommended daily allowances to prevent nutrient deficiencies, it precludes community prescription of optimal intake levels. A further repercussion of metabolic individuality Chapter 1 / The Science of Nutritional Medicine 9 is the indeterminate relationship of blood nutrient levels to dietary intake because of the complexity of metabolic interactions. Colorectal cancer represents three diseases: can- cer of the proximal colon, the distal colon, and the rectum. Results from epidemiologic studies, active pharmacologic principles identified in traditional plants, and the role of natural antioxidants in maintaining food quality would seem to support this construct. Attempts to adopt a reductionist approach in nutritional epidemiology are clouded both by the propensity for individual micronutrients to be present in numerous food sources and the impact of the physical characteristics of a food on physiologic responses. Nutrient interactions and the diversity of nutrients in any one food make it difficult to predict the effect of supplementation with single nutrients. Data from two cohort studies, one in males older than 10 years and one in females older than 12 years, suggested that several carotenoids may reduce the risk of lung cancer. Supplementation with lycopene, the most powerful carotenoid antioxi- dant, may be advisable if the protection afforded is the result of singlet oxygen quenching. However, if the benefit results from the propensity of vitamin A and retinenes to regulate epithelial cell differentiation and maintenance, then lycopene supplementation is a poor choice. Nutrient interaction may also influence bioavailability as demonstrated by feeding tocopherol with and without vitamin A. Furthermore, it is recognized that overweight and obese persons increasingly underreport their total energy intake and, presumably, their total fat consumption. Concerns about the accuracy of dietary self- reporting caused by measurement error biases have even led to the sug- gestion that current reporting instruments may be inadequate for analytic epidemiologic studies of dietary fat and disease risk. In contrast to conventional reductionist thinking, alternative medicine prac- titioners work within a holisitic model that accepts uncertainty as inevitable. Rather than finding virtue in delaying the use of potentially useful therapy until scientifically sound advice can be given, alternative medicine practi- tioners may require only that a therapeutic regimen be biologically plausible and supported by personal clinical experience accumulated from individual case studies. Attribution of a particular outcome to a natural intervention based on its likely impact on pathophysiologic processes is potentially fraught with danger. Individual behavioral differences can distort biochem- ical, not to mention clinical, outcomes. Daily oral supplementation with 30 mg of beta-carotene significantly raises serum beta-carotene levels. Daily supplementation with 30 mg of beta-carotene successfully prevents the serum-depleting effect of steroid contraceptive use but fails to prevent serum depletion of beta-carotene induced by cigarette smoking. Pathophysiologic reality can- not be assumed in the clinical context, and it certainly cannot alone be anticipated to confer clinical effectiveness. Thus biologic plausibility is a desirable but inadequate justification for intervention. A multitude of variables may confound the extrapolation of in vitro find- ings to in vivo situations. Some, but not all, prospective epidemiologic studies have shown that the intake of flavonols (e. Quercetin, like other flavonoids, has been shown in vitro and in animal studies to modify eicosanoid biosynthesis, pro- Chapter 1 / The Science of Nutritional Medicine 11 tect low-density lipoprotein from oxidation, inhibit platelet aggregation, and promote relaxation of cardiovascular smooth muscle.

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Zack started to avoid a number of situations such as having blood drawn generic 20 mg levitra oral jelly visa, watching medical shows on television 20mg levitra oral jelly otc, visit- ing hospitals buy 20mg levitra oral jelly with mastercard, talking about medical procedures levitra oral jelly 20 mg generic, and han- dling raw meat. Although he rarely had to encounter these situations, his life was about to change. He had recently been accepted into medical school and was decidingwhethertoaccepttheofferorturnitdown because of his fear. If he could overcome his fear before school started (about three months from the time he started treatment), he would accept the offer to study medicine. Zack’s first session began with an assessment, after which an exposure hierarchy was developed. Items near the top of his hierarchy included having blood drawn, seeing someone else bleeding, and watching surgery (live or on video). Moderately difficult items included watch- ing others have blood drawn, holding tubes of blood, and looking at bags of blood. Easier items included looking at tubes of blood from a distance and cutting up raw beef for a stir-fry. Because of Zack’s history of fainting, his thera- pist recommended including the applied tension exercises 90 overcoming medical phobias (described in chapter 6). Zack and his therapist spent a few minutes at the end of the session reviewing instruc- tions for the applied tension procedures. The following week, Zack and his therapist had scheduled a two-hour exposure session. Because Zack was willing to start with some of the more difficult items on his hierarchy, they skipped some of the easier practices. The session began with Zack watching as his therapist used a finger prick blood test kit (the type that someone with diabetes might use to check blood sugar) to draw blood from her own finger. Initially, Zack was able to use the applied tension exercises to control his feelings of faintness. Although Zack was unwilling to practice any exposure homework over the next week, he agreed to continue practicing the tension exercises. Hewasdiscouragedaboutwhathadhappenedat the last session and was thinking about discontinuing his treatment. His therapist encouraged Zack to keep his appointment, offering reassurance that Zack would not be forced to do anything before he was ready. At the next session, his therapist suggested that they begin with some easier items from Zack’s hierarchy. He was then ready to once again watch his therapist prick her finger while he used the tension exercises. His therapist then pricked several more fingertips and encouraged Zack to watch the blood on her fingers. Although his anxiety level was quite high, he was suc- cessfully able to prevent himself from fainting. In the remaining hour of the session, Zack practiced pricking his own finger and then practiced let- ting his therapist prick his finger. At one point he felt as though he might faint, but the feeling passed after he lay down for a few minutes. Once the faintness passed, he resumed the exposure exercises until his anxiety decreased. For homework over the coming week, Zack practiced the finger prick tests daily with the help of his parents and his girlfriend. The following week, Zack and his therapist prac- ticed watching several surgery videos, at first using the applied tension exercises, and later watching them with- out tensing. At the end of the two hours, Zack was able to watch videos depicting cardiac surgery, removal of a facial mole, and a patient receiving stitches, all with only minimal anxiety. In the end, Zack was quite happy with his progress, and he was glad he had stuck with the treatment. Although he was still nervous about watching live 92 overcoming medical phobias surgery, he decided to work on that fear on his own, after starting medical school. Jacob—dentists Jacob had been fearful of the dentist for as long as he could remember. As soon as he became an adult, he stopped going on a regular basis and only saw a dentist if he had a problem that was causing him pain (which happened about every five years). When he did see the dentist, he insisted on being knocked out with a general anesthetic. His main concern was that the experi- ence would be painful; he remembered having a number of uncomfortable visits to the dentist as a child. By the time Jacob decided to seek treatment at age forty, he had several cavities that needed to be filled and his teeth hadn’t been cleaned for years. His children were aware of his fear, and he worried that some of his fear might rub off on them. When he made the appointment, he had a choice of several hygienists, so he requested to see the one with the reputation for being the most gentle. He had several teeth to fill and one that was likely to require a root canal and crown. When he made his first appointment, Jacob asked whether the dentist and hygienist could begin with less frightening procedures, such as examining his teeth and taking X-rays, and save more difficult procedures such as cleanings, injections, and fillings for subsequent appoint- ments. In fact, the dentist offered to spend an entire appointment just helping Jacob get used to the feeling of having various dental instruments (mirror, probe, scaler, suction tube, and so forth) in his mouth. First, he decided to focus just on the procedures he would have done at each appointment, rather than thinking about all the dental work he needed to have done. He also thought about how his wife, coworkers, and friends often told him that the discomfort they experience at the dentist is always manageable, and how the procedures used during dental treatment have changed since he was younger. Finally, he asked the dentist and hygienist to describe to him what procedures would be done, what they were likely to feel like, and how long they would take. Although the first visit was frighten- ing, he was reassured because he knew he wouldn’t have any dental work done that day. After having his teeth cleaned and his cav- ities filled, he decided to get his root canal and crown done. Although terrified of the procedure, he was 94 overcoming medical phobias reassured when his dentist said that the discomfort would be no worse than that he experienced during the other procedures. In the end, he felt almost no pain despite the reputation root canals have for being painful. Ella—doctors and hospitals Ella had been afraid of visiting doctors and hospitals since she was a teenager, though she was unsure what ini- tially triggered the fear. She was uncomfortable being examined and undergoing tests and, to some extent, was afraid she might find out she had a problem that she didn’t know she had. She wasn’t sure why she didn’t like hospitals, but she avoided them at all costs, even if it meant not visiting friends and relatives in the hospital. Now, at age fifty-five, Ella had become increasingly con- cerned about her phobia. She was at an age when it seemed more important than ever to have regular medical checkups. Also, her parents were older, and she worried that they might soon need to spend time in a hospital and thatshewouldn’tbeabletovisitthem. Shefinally decided to seek treatment when her husband was sched- uled to have his hip replaced. Ella’s treatment began with developing two hierar- chies—one for doctor visits and the other for hospitals. The hierarchy took into account the variables confronting your fear 95 that contributed to her fear, including the sex of the doc- tor (female doctors were easier than males), the age of the doctor (doctors younger than forty and older than sixty made her more anxious), the type of procedure being done (she was most nervous about procedures used to detect cancer, such as a mammogram), and the type of doctor (family doctors were easier than specialists). The hospital hierarchy included items ranging in difficulty from relatively easy (for example, spending time in the lobby or cafeteria of a hospital) to more difficult (for example, walking through the halls in the emergency room or visiting someone in a hospital room). She made appointments for physical exams three times per week over a two-week period. The next four exams were with other doctors (recommended by her family doctor), starting with female physicians and working up to male physicians. Ella also arranged to have a number of tests done, including blood work, a mammogram, and a colonoscopy. Over the course of these two weeks, her fear of doctors decreased to a mod- erate level. Ella decided to continue her exposure prac- tices with doctors about once per week over the next month while also starting to confront her fear of hospitals. During the next few weeks, Ella made a point of vis- iting hospitals about four times per week for an hour or two, usually on her way home from work. She visited the hospital where her husband was scheduled to have his 96 overcoming medical phobias surgery, as well as several others. She began with the eas- ier items on her hierarchy (for example, visiting her fam- ily doctor, who was a woman in her early fifties) and worked her way up to the more difficult items (for exam- ple, seeing a young male dermatology resident for a spe- cialist appointment). Eventually, she had practiced all of the items on her hierarchy except for visiting a loved one in the hospital; at the time, she had no friends or rela- tives who were hospital patients. However, when her hus- band had his surgery, she was able to visit him daily with only minimal anxiety. It requires time and patience, as well as a willingness to feel uncomfortable, at least temporarily. Unlike some of the other exercises in this book, this is not an exercise you can complete in a few minutes. Instead, you’ll need to practice for several hours over the course of a few days or a few weeks to complete this exercise. If you have a history of fainting upon encountering blood, needles, or related situations, don’t complete this exercise until you have read chapter 6. For those who faint or even just feel faint, we recommend only confronting your fear 97 completing this exercise in conjunction with the applied tension techniques described in chapter 6.