By Z. Nafalem. Minnesota State University Moorhead.

The content of your interview with your patient/client will of course depend upon his knowledge base and needs purchase 100mg dipyridamole mastercard. Working with someone just beginning to explore his sexuality can be very different to working with someone who is sexually experienced buy 100mg dipyridamole. The following areas for discussion will depend upon why he has been referred to the health adviser or has requested to see the health adviser and should be tailored to the needs of the patient buy discount dipyridamole 100 mg on line. The interview As with any patient, in order to establish trust and confidence it is first important to find out what he may already know, what he percieves his needs to be and to build on these. A key part of the health adviser role is to provide the patient with the information necessary for him to make informed choices about his sexual wellbeing. This means addressing gaps in the patient s knowledge and challenging any assumptions not based on fact or evidence. This will guide the patient towards developing a personal sexual risk reduction strategy that makes sense and is workable for him. When discussing sexual activity it is important to ascertain whether the patient ever has sex which is more risky than he would like it to be ? This can be a more helpful question for opening a discussion about risk reduction with a patient than do you ever have unsafe sex. If he voices concern about his risks then it is probable he will be open to further discussion. They can also be advised to set some ground rules about safer sex with other sexual partners 10 and to be open with each other if unsafe sex has occurred outside of the relationship. Therefore they feel they are making an informed choice about risk taking in order to enjoy genuine intimacy with other positive men, particularly regular partners. We are then in a position to have a useful dialogue with our patients and to ensure that their sexual choices and strategies are informed by the best available evidence. Sexual health surveys show that at any one time around 30% to 40% of gay men are not using condoms for anal 12 intercourse. This does not necessarily mean that 30% to 40% of gay men are always having high risk sex. They are often men who do not perceive themselves to have been at risk since their last test or who were not offered a test 13 at their last sexual health screen. If Project Sigma (Tel: 020 7737 6223) have surveyed Gay Men s sexual behaviour since 1993. It might be possible to help him reduce risk by exploring ways of changing factors in his life which impact on his sexual choices. This might involve several counselling sessions to identify potential changes that can be made. Some men feel they have failed if they cannot maintain safer sex with every partner. The health adviser should be wary of being viewed as punishing or policing around safer sex. By using positive and affirming language about the patients desire to reduce risk and by identifying factors likely to increase risky behaviour he can be encouraged to return for further discussion after risky sex occurs. Other options for men who want to reduce risk but are finding change difficult can include referral for ongoing counselling or psychology support if available. Many men have found sharing their 14 experiences with other gay men in a workshop or groupwork setting to be very useful. Some have felt judged by clinic staff around sexual practices and personal risk reduction strategies. Tel 020 7831 0330 332 ensure that in any discussion with this client group, health advisers are sensitive to and respectful of the individual needs and choices of the patient. Health advisers are in a difficult position because we have a public health as well as patient advocate role. The laudable aims of improving public health are not always easily applied to the complexities of human sexual behaviour. Helping the patient to identify and address factors in his life which affect his ability to reduce risk, is a fundamental part of developing a workable risk reduction strategy appropriate to his needs. A patient who knows that the health adviser is providing him with clear and unbiased information and is listening to and addressing his needs is probably more likely to feel able to discuss his sexual activity and to return for further advice and counselling. The patient who feels that the health adviser, irrespective of that patient s needs or concerns, is imposing an agenda and who feels judged or patronised may not be open to future discussion. Always ask the patient to clarify any terminology he uses that is new or confusing and always check that the patient understands the information you are giving him. Covering all of the above in one session may prove difficult given pressure of time. If a good working relationship has been established between the health adviser and the patient he can be encouraged to return if he feels this would be helpful.

We must labelled psychogenic if there seems to be a back- always remember the triad of headache order 25mg dipyridamole overnight delivery, vomit- ground of stress buy 25mg dipyridamole overnight delivery. The implication is that the suf- ing and papilloedema in this respect purchase dipyridamole 25 mg without a prescription, especially ferer is perhaps exaggerating mild symptoms in as the vomiting might not be accompanied order to gain sympathy from his or her spouse, by nausea, and is not necessarily mentioned or even perhaps the doctor. The family history should also be extremely cautious about not accepting be noted, especially where there is a history symptoms at their face value, and certainly of migraine. If the psychogenic headache is the com- monest, then the headache caused by raised Classication intracranial pressure and a space-occupying lesion must be the most important. Between When considering the different common causes these two,the whole spectrum of causes must be of headache, an anatomical classication is a considered. The rise a permanent checklist in order that obvious following should be considered by the causes are not omitted. Cerebrospinal Fluid History A rise or fall from normal of the cerebrospinal Often the history is the total disease in the uid pressure is associated with headache. When the acutely raised, a severe headache may ensue, rise of intracranial pressure is caused by a accompanied by blurring of vision. Any adults space-occupying lesion, signs of focal brain with headaches should have their blood pres- damage can also be present. Another form of headache associated with abnormality of the blood Blood Vessels vessels is that caused by an intracranial aneurysm of the internal carotid artery or one A variety of diseases involving the blood vessels of its branches. The commonest is prob- throbbing in nature and there might be other ably migraine. Classical migraine is thought to signs of a space-occupying lesion at the apex of be caused by an initial spasm followed by dilata- the orbit, for example a cranial nerve palsy or a tion of the meningeal arteries. In the case of a family history of the same problem showing elderly patients, the possibility of giant cell dominant inheritance, and attacks can some- arteritis must always be kept in mind. This is an times be precipitated by stress or taking certain inammation of the walls of many of the foods, such as cheese. Before the headache medium-sized arteries in the body, but it tends begins, there is usually a visual aura charac- to affect the temporal arteries preferentially. The that is centred above the eye and is described headache is made particularly bad by brushing as a boring pain. The headache lasts for any time the hair and other systemic symptoms include between 1 h and 24 h and then disperses. Migraine can begin quite early in childhood and continue at regular inter- vals for many years. Migraines are more common in women and tend to improve at the time of the menopause. The visual aura might appear by itself or the migraine attack might be accompanied by gastrointestinal symptoms or by ophthalmople- gia. The attack might be preceded by oliguria and uid retention and be followed by a diuresis. Cross-section of the temporal artery from patient the original diagnosis must be reviewed care- with temporal arteritis. Of some importance is the fact that a the large number of giant cells (with acknowledgement to history of migraine increases the risk of devel- Dr J. Headache 73 importance of this type of headache rests on the merges with cluster headache, being described fact that the eye is involved in about 60% of as severe ocular pain associated with meiosis cases and the patient can suddenly go blind in and ptosis. Trigeminal neuralgia can be easily one eye and then a short time later go blind in distinguished from these other forms of the other. A touching a part of the cheek or by chewing and temporal artery biopsy is helpful in specic sit- swallowing. The pain is so severe that the patient uations to assist with the diagnosis, particularly can become suicidal,and surgical division of the in those with indeterminate clinical ndings. Steroid people after an attack of trigeminal herpes treatment is effective in preventing blindness zoster. The pain seems to be more severe in the and is required usually for a 12 18-month elderly and it can persist for many years. Once instituted, the response to treat- cause of the headache is usually evident when ment and the side effects should be very care- one inspects the skin of the forehead, which is fully monitored, preferably in co-operation with slightly whitened and scarred from the previous a general physician with regular measurement attack of herpes zoster. It is easy to forget that Bones anaemic patients often have headaches, which can be cured by treating the anaemia. Likewise, In Paget s disease of bone, the bones of the head patients with polycythaemia might also com- enlarge and grow abnormally, the abnormal plain of headache. Hypoglycaemia is another growth being associated with headache and, recognised cause; here, the symptoms occur incidentally, an increase in hat size. The eyes after strenuous exercise or insulin excess in a themselves might show optic atrophy, and close diabetic patient. Oxycephaly is a congenital defect of the skull caused by premature closure of the In many respects, cluster headache resembles sutures; patients sometimes complain of migraine,although it is more common in men in headache, as well as visual loss because of optic the third or fourth decade.

Halliwell and Gutteridge later suggested to rename this free radical theory of aging as the oxidative damage theory of aging [22] purchase 100mg dipyridamole otc, since aging and diseases are caused not only by free radicals purchase 25mg dipyridamole with amex, but also by other reactive oxygen and ni trogen species order dipyridamole 25 mg with mastercard. Increases in mitochondrial energy production at the cellular level might have beneficial and/or deleterious effects [23]. On the other hand, enhanced mitochondrial activity may increase the pro duction of superoxide, thereby aggravating the oxidative stress and further burdening the antioxidant defence system. The mitochondria are the major source of toxic oxidants, which have the potential of reacting with and destroying cell constituents and which accumulate with age. The result of this destructive activity is lowererd energy production and a body that more readily displays signs of age (e. Damaged mitochondria can cause the energy crisis in the cell, leading to senescence and aging of tissue. The gradual loss of energy experienced with age is paralleled by a decrease in a number of mitochondria per cell, as well as energy- producing efficiency of remaining mitochondria. How 334 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants ever, whether this damage affects mitochondrial function or significantly modulates the physiology of aging has remained controversial [27, 28]. As already mentioned, free radicals can damage the mitochondrial inner membrane, creating a positive feedback-loop for in creased free-radical creation. Oxidative stress from endogenous or exogenous sources can trigger the chain reaction, which leads to accel erated aging process of cells and organisms. But the efficiency of autophagy to consume mal functioning mitochondria also declines with age, resulting in more mitochondria producing higher levels of superoxide [30]. Mitochondria of older organisms are fewer in number, larg er in size and less efficient (produce less energy and more superoxide). Free radicals could also be involved in signalling responses, which subsequently stimu late pathways related to cell senescence and death, and in pro-inflammatory gene expres sion. Other theories of aging Apart from the free radical theory, the aging is explained by many other theories: The Telomere shortening hypothesis (also described as "replicative senescence," the "Hay flick phenomenon" or Hayflick limit) is based on the fact that telomeres shorten with each successive cell division. The telomere shortening hypothesis cannot explain the aging of the non-dividing cells, e. The Reproductive-cell cycle theory states that aging is regulated by reproductive hor mones, which act in an antagonistic pleiotropic manner through cell cycle signaling. This promotes growth and development early in life in order to achieve reproduction, howev er later in life, in a futile attempt to maintain reproduction, become dysregulated and drive senescence [32]. The Wear and tear theory of aging is based on the idea that changes associated with aging result from damage by chance that accumulates over time [32]. The wear-and-tear theories describe aging as an accumulation of damage and garbage that eventually overwhelms our ability to function. Similar are Error accumulation and Accumulative waste theories; Error accumulation theory explains aging as the results from chance events that escape proofread ing mechanisms of genetic code [32], according to Accumulative waste theory the aging re sults from build-up of cell waste products in time because of defective repair-removal processes. Terman, [33] believes that the process of aging derives from imperfect clearance of oxidatively damaged, relatively indigestible material, the accumulation of which further hinders cellular catabolic and anabolic functions (e. It describes beneficial ac tions resulting from the response of an organism to a low-intensity stressor. It has been known since the 1930s that restricting calories while maintaining adequate amounts of other nutrients can extend the lifespan in laboratory animals. Additionally, the Disposable soma theory was proposed [36, 37], which postulated a special class of gene mutations with the following antagonistic pleiotropic effects: these hypotheti cal mutations save energy for reproduction (positive effect) by partially disabling molecular proofreading and other accuracy promoting devices in somatic cells (negative effect). The 336 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants Evolutionary theory of aging is based on life history theory and is constituted of a set of ideas that themselves require further elaboration and validation [38]. Evidence implies that an important theme linking several different kinds of cellular damage is the consequence of exposure to reactive oxygen species [5, 39]. None of the theories explain the ag ing process, as it may be too complex to be covered by only one theory. Perhaps there is no single mechanism responsible for aging in all living organisms [42]. In essence, aging is progressive accumulation through life of many random molecular defects that build up within the cells and tissues. For this reason, only one magic bullet will never be able to prevent or reverse the complex and multicaus al process of aging. The Role of Oxidative Stress on the General Aging Process In order to understand strategies to reduce oxidative stress and aging, it is first important to briefly explain reasons for oxidative stress formation. The most important endogenous sources of oxi dants are mitochondrial electron transport chain and nitric oxide synthase reaction, and the non-mitochondrial soruces: Fenton reaction, reactions involving cytochromes P450 in micro somes, peroxisomal beta - oxidation and respiratory burst of phagocytic cells [6]. Free radi cal reactions have been implicated also as the consequence of exposure to many environmental pollutants, e. Oxidative stress is the direct consequence of an increased generation of free radicals and/or reduced physiological activity of antioxidant defenses against free radi cals. The degree of oxidative stress is proportional to the concentration of free radicals, which depends on their formation and quenching. Causes of increased free-radical production include [43]: Endogenous elevation in O concentration2 increased mitochondrial leakage inflammation increased respiration others Exogenous environment (pollution, pesticides, radiation, etc.