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Unit1 1、Some factors that may lead to the complaint:Neuron overloadPatients* high expectationsMistrust and misunderstanding between the patient and the doctor2、 Mrs. Osorios condition:A 56-year-old womanSomewhat overweightReasonably well-controlled diabetes and hypertensionCholesterol on the high side without any medications for itNot enough exercises she should takeHer bones a little thin on her last DEXA scan 3、 Good things: Blood tests done Glucose a little better Her blood pressure a little better but not so great Bad things: Cholesterol not so great Her weight a little up Her bones a little thin on her last DEXA scan 44、The situation:The author was in a moderate state of panic: juggling so many thoughts about Mrs. Osorios conditions and trying to resolve them all before the clock ran down.Mrs. Osorio made a trivial request, not so important as compared to her conditions.Mrs. Osorio seemed to care only about her “innocent and completely justified request”： the form signed by her doctor.The doctor tried to or at least pretended to pay attention to the patient while completing documentation.5、Similarities:In computer multitasking, a microprocessor actually performs only one task at a time. Like microprocessors, we human beings carft actually concentrate on two thoughts at the same exact time. Multitasking is just an illusion both in computers and human beings. Differences:The concept of multitasking originated in computer science.At best, human beings can juggle only a handful of thoughts in a multitasking manner, but computers can do much better.The more thoughts human beings juggle, the less human beings are able to attune fully to any given thought, but computers can do much better.6、7 medical issues to consider5 separate thoughts, at least, for each issue7 x 5 = 35 thoughts10 patients that afternoon35 x 10 = 350 thoughts5 residents under the authors supervision4 patients seen by each resident10 thoughts, at least, generated from each patient5 x 4 x 10 = anther 200 thoughts350 + 200 = 550 thoughts to be handled in total If the doctor does a good job juggling 98% of the time, that still leaves about 10 thoughts that might get lost in the process.7、Possible solutions:Computer-generated remindersCase managersAncillary servicesThe simplest solution: timeUnit2 1、The author implies: Peoples inadequate consciousness about the consequence of neglecting the re- emerging infectious diseases Unjustifiability of peoples complacency about the prevention and control of the infectious diseasesUnfinished war against infectious diseases2、Victory declarations:Surgeon General William Stewarts hyperbolic statement of closing “the book on infectious disease”.A string of impressive victories incurred by antibiotics and vaccinesThe thought that the war against infectious diseases was almost over What followed ever since:Appearance of new diseases such as AIDS and EbolaComeback of the old afflictions: Diphtheria in the former Soviet Union TB in urban centers like New York City Rising Group A streptococcal conditions like scarlet feverThe fear of a powerful new flu strain sweeping the world3、Elaborate on the joined battle:WHO established a new division devoted to worldwide surveillance and control of emerging disease in October 1995.CDC launched a prevention strategy in 1994.Congress raised fund from $6.7 million in 1995 to $26 million in 1997.4、 The borders are meaningless to pathogenic microbes, which can travel from one country to another remote country in a very short time.5、TB:Prisons and homeless shelters as ideal places for TB spreadEmerging of drug-resistant strain or even multi-drug-resistant strainA ride on the HIV won by attacking the immunocompromised Group A strep:A change in virulenceMutation in the exterior of the bacterium Flu:Constant changes in its coat (surface antigens) and resultant changes in its level of virulence6、Examples:Experiment in England is seeing the waning immunity because of no vaccination.Due to poor vaccination efforts, the diphtheria situation in the former Soviet Union is serious. The vaccination rates are dropping in some American cities, and it will lead to more diphtheria and whooping cough.7、The four areas of focus:The need for surveillanceUpdated science capable of dealing with discoveries in the fieldAppropriate prevention and controlStrong public health infrastructure8、The infectious diseases such as TB, flu, diphtheria and scarlet fever will never really go away, and the war against them will never end.Unit31、 Terrys life beforeShe loved practicing Tae Kwon DoShe loved the surge of adrenaline that came with the controlled combat of tournaments.She competed nationally, even won bronze medal in the trials for the Pan American Games.She attended medical school, practiced as an internal medicine resident, and became an academic general internist.She got married and got a son and a daughter.2、The symptoms of MS and autoimmune disease: Loss of stamina and strength Problems with balance Bouts of horrific facial pain Dips in visual acuity 3、Terry did the following before she self-experimented: She started injections. She adopted many pharmacotherapies. She began her own study of literature: She read articles on websites such as PubMed. She searched for articles testing new MS drugs in animal models. She turned to articles concerning neurodegeneration of all types dementia， Parkinsons disease, Huntingtons disease, and Lou Gehrigs disease. She relearned basic sciences such as cellular physiology, biochemistry, and neurophysiology.4、Approaches Terry mainly used:Self-experimentation with various nutrients to slow neurodegeneration based on literature reports on animal modelsSelf-experimentation with neuromuscular electrical stimulation which is not an approved treatment for MSOnline search to identify the sources of micronutrients and having a new dietReduction of food allergies and toxic load5、Cases mentioned in the text:Increased mercury stores in the brains of people with dental fillingsHigh levels of the herbicide atrazine in private wells in IowaThe strong association between pesticide exposure and neurodegenerationThe association of single nucleotide polymorphisms involving metabolism of sulfur and/or B vitaminsInefficient clearing of toxins6、 With 70% to 90% of the risk for diabetes, heart disease, cancer, and autoimmunity being due to environmental factors other than the genes, we can take many health problems and the health care crisis under our control, for example, optimizing our nutrition and reducing our toxic load.Unit41、Two concepts: Complementary medicine refers to the use of conventional therapies together with alternative treatments such as using acupuncture in addition to usual care to help lessen pain. Complementary and alternative medicine is shortened as CAM.Alternative medicine refers to healing treatments that are not part of conventional therapies like acupuncture, massage therapy, or herbal medicine. They are called so because people used to consider practices like these outside the mainstream.2TCM does not require advanced, complicated, and in most cases, expensive facilities.TCM employs needles, cups, coins, to mention but a few.Most procedures and operations of TCM are noninvasive.The substances used as medicine are raw herbs or abstracts from them, and they are indeed all natural, from nature.TCM has been practiced as long as the Chinese history, so the efficiency is proven and ensured.Ongoing research around the world on acupuncture, herbs, massage and Tai Chi have shed light on some of the theories and practices of TCM3、It may be used as an adjunct treatment, an alternative, or part of a comprehensive management program for a number of conditions: post-operative and chemotherapy induced nausea and vomiting, post-operative dental pain, addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma.4、A well-justified NO:More intense research to uncover additional areas for the use of acupunctureHigher adoption of acupuncture as a common therapeutic modality not only in treatment but also in prevention of disease and promotion of wellnessExploration and perfection of innovative methods of acupuncture point stimulation with technological advancementImproved understanding of neuroscience and other aspects of human physiology and function by basic research on acupunctureGreater interest by stakeholdersAn increasing number of physician acupuncturists5、Appropriate uses of herbs depend on proper guidance: Proper TCM diagnosis of the zheng of the patient Correct selection of the corresponding therapeutic strategies and principles that guide the choice of herbs and herbal formulasDigression from either of the above guidence will lead to misuses of herbs, and will result in complications in patient6、Randomized controlled trials Advantages: Elimination of the potential bias in the allocation of participants to the intervention group or control group Tendency to produce comparable groups Guaranteed validity of statistical tests of significance Limitations: Difficulty in generalizing the results obtained from the selected sampling to the population as a whole A poor choice for research where temporal factors are an issue Extremely heavy resources, requiring very large sample groups Quasi-experiments Advantages: Control group comparisons possible Reduced threats to external validity as natural environments do not suffer the same problems of artificiality as compared to a well-controlled laboratory setting. Generalizations of the findings to be made about population since quasiexperiments are natural experiments Limitations： Potential for non-equivalent groups as quasi-experimental designs do not use random sampling in constructing experimental and control groups. Potential for low internal validity as a result of not using random sampling methods to construct the experimental and control groups Cohort studies Advantages: Clear indication of the temporal sequence between exposure and outcome Particular use for evaluating the effects of rare or unusual exposure Ability to examine multiple outcomes of a single risk factorLimitations: Larger, longer, and more expensive Prone to certain types of bias Not practical for rare outcomes Case-control studies Advantages: The only feasible method in the case of rare diseases and those with long periods between exposure and outcome Time and cost effective with relatively fewer subjects as compared to other observational methodsLimitations： Unable to provide the same level of evidence as randomized controlled trials as it is observational in nature Difficult to establish the timeline of exposure to disease outcome “N=1” trials Advantages Easy to manage Inexpensive Limitations： Findings difficult to be generalized to the whole population Weakest evidence due to the number of the subject7、 Synthesis of evidence is completely dependent on: The completeness of the literature search (unavailable for foreign studies) The accuracy of evaluation There are situations in which no answer can be found for the questions of interest in RCTs and database analyses.Theres the requirement of using less stringent information rather than “hard data”8、Assessment of the intrinsic value of traditional medicine in societyResearch and educationPolitical, economic, and social factorsUnit51、Dis-ease refers to the imbalance arising from： Continuous stress Pain HardshipsDisease is a health crisis ascribable to various dis-eases.Prompting elimination of dis-eases can alleviate some diseases.2、Wellness is a state involving every aspect of our being: body, mind and spirit.Manifestations of a healthy person: Energy and vitality A certain zip in gait A warm feeling of peace of heart seen through behavior3、 Constant messages, positive and negative，are sent to our mind about the health of our body.Physical symptoms are suppressed by people who go through life on automatic pilot.Being well equals to being disease- or illness-free in the minds of them.They confused wellness with an absence of symptoms.4、Peoples minds are infected by spin: Half-truth Fearful fictions Blatant deceit: some as a form of self-deceitSpin is a result of unconscious living.The kind of falseness is pandemic.5Our body intelligence is suppressed or dormant from a lack of use.There are tremendous amount of stress on a daily basis.Our bodies are easily ignored for years because of a lack of recreation time.Limiting, self-defeating and even self-destructive behaviors undermine our wellbeing and keep them from achieving our full potential.6We grow more reluctant to take risks.We lose the ability to feel and acknowledge our deepest feelings and the courage to speak our truth.We continue to deny and repress our feelings to protect ourselves.Fear, denial and disconnection from our bodies and feelings become anunconscious, self-protective habit, a kind of default response to life.7A multi-faceted process: Looking for roots of and resolutions for the issues in different dimensions Building our wellness toolbox slowly Picturing our whole state of beingAttention to the little stuff: Examining our lives honestly and setting clear intentions to change Striving to maintain a balance of our mind, body and spirit Taking small steps in the way to perceive and resolve conflict8Try to awaken and evolve in order to live more consciously.Get in touch with our genuine feelings and emotions.Come to terms with the toxic emotionsUnit61、 In the past, most people died at home. But now, more and more people are cared in hospitals and nursing homes at their end of life, which of course brings a new set of questions to consider.2、Sixty-four years old with a history of congestive heart failureDeciding to do everything medically possible to extend his lifeAvailability of around-the-clock medical services and a full range of treatment choices, tests, and other medical care Relaxed visiting hours, and personal items from home3、 Availability of around-the-clock medical resources, including doctors, nurses, and facility.4、Taking on a job which is big physically, emotionally, and financiallyHiring a home nurse for additional helpArranging for services (such as visiting nurses) and special equipment (like a hospital bed or bedside commode)5、Health insurancePlanning by a professional, such as a hospital discharge plaimer or a social workerHelp from local governmental agenciesDoctors supervision at home6、Traditionally, it is only about symptom care.Recently, it is a comprehensive approach to improving the quality of life for people who are living with potentially fatal diseases.7、Stopping treatment specifically aimed at curing an illness equals discontinuing all treatment.Choosing a hospice is a permanent decision.Unit71、A dying patientDecision whether to withdraw life-support machines and medication and start comfort measuresThe familys refusal to make any decision or withdraw any treatments2、The doctor as exclusive decision-makerThe patient as participant with little say in the final choice3、Respect for the patient, especially the patient s autonomyPatient-centered careThe patient as decision-maker based on the information provided by the doctor4、Patients are forced to make decisions they never want to.Patients, at least a large majority of them, prefer their doctors to make final decisions.Shifting responsibility of decision-making to patients will bring about more stress to patients and their families, especially when the best option for the patient is uncertain.5、 Doctors are very much cautious about committing some kind of ethical transgression.6、Shouldering responsibility together with the patient may be better than having the patient make decisions on their own.Balancing between paternalism and respect for patients autonomy constitutes a large part of medical practice.Unit81、Research: An activity to test hypothesis, to permit conclusions to be drawn, and thereby to develop or contribute to generalizable knowledgePractice: Interventions solely to enhance the well-being of an individual patient or client and that have a reasonable expectation of successBlurred distinction: Cooccurrence of research and practice like in research designed to evaluate a therapy Notable departures from standard practice being called “experimental” with the terms “experimental” and “research” carelessly defined2、Autonomy： Individuals treated as autonomous agents .Protection:Persons with diminished autonomy entitled to protectionA case in point:Prisoners involved in research 3“Do no harm” as the primary principle Maximization of possible benefits and minimization of possible harms . Balance between benefits and potential risks involved in every step of seeding the benefits4、“Do no harm” as a fundamental principle of medical ethicsExtension of it to the realm of research by Claude BernardBenefits and risks as a set “duet” in both medical practice and research5、Unreasonable denial of entitled benefit and unduly imposed burden：Enrolment of patients in new drug trial: Who should be enrolled and who should not?Equal treatment of equals:Determining factors of equality: age, sex, severity of the condition, financial status, social status6、 Definition:The opportunity to choose what shall or shall not happen to themApplication: A process rather than signing a written form Adequate information as the premise A well-informed decision as the expected result7、Requirements for consent as entailed by the principle of respect for personsRisk/benefit assessment as entailed by the principle of beneficenceMore requirements of fairness as entailed by the principle of justice: At the individual level: fairness At the social level: distinction between classes
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