By O. Phil. The College of Saint Thomas More. 2018.

In Joe’s case he reflects just such a family attitude generic 5 mg finast with mastercard hair loss yeast infection, but his acceptance is more accurately described as ‘compliance’ order 5mg finast visa hair loss blood tests, because he is following what appears to be a family-induced form of reaction to events within and external to their functioning. He is mirroring a learnt response that confers the least resistance. Finding time for family members It is not an easy matter for parents to find sufficient time for all family members especially when one member requires special care. Such situations may lead to emotional neglect, which is possible in Joe’s 66 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES situation, mentioned above, and although he attended a support group for siblings this seemed not to fulfil his needs other than providing some outside activities. Possibly there is some guilt within Joe’s apparent isolation from friends, failure to follow up within the support group, and apparent general apathy concerning events, but it is difficult to be sure, because his reluctance to discuss matters makes assessment difficult. The evidence from other research supports the view that youngsters tend not to talk to others about having a disabled relative, particularly one as close as a brother or sister, or indeed about the amount of caring they may be obliged to do (Atkinson and Crawford 1995; Thompson 1995). Powell and Ogle (1985) suggest that, as well as support services, siblings need information about disabilities themselves or they may lose out on the many positive elements of childhood. What is very clear is that siblings, as well as family members, need support, to help clarify their own under- standing of their needs, and professional help seems always to be accepted, despite not always appearing to be welcome or fully understood. The evidence presented here suggests that professionals need to work at gaining trust within a family, and it is not acceptable to assume that because help is not requested that it is not needed. Intervention in such cir- cumstances requires a proactive worker, who will frequently return to the family and checking their needs for advice and service provision. Joe’s family will not demand help, but they clearly need it. Chapter 5 Children as Young Carers It is probably an accepted fact that most families will look to themselves in times of difficulty, to resolve problems or needs that have to be met. It is probably true that siblings will always help to bring up children within the family, but the question, ‘What is reasonable to expect? In this chapter the siblings of children with disabilities are considered as ‘young carers’. A definition of a young carer used by the Carers National Association is: Anyone under the age of 18, whose life is in some way restricted because of the need to take responsibility for the care of a person who is ill, has a disability, is experiencing mental distress, is affected by substance misuse or HIV/AIDS. The term ‘young carers’, as defined above, may also concern young people who care for a parent who is ill, has disabilities or is subject to a range of illnesses or conditions, and these are dimensions beyond siblings caring for other siblings. Siblings are considered as young carers in recognition of the help that they offer the family in caring for a disabled brother or sister, which is considered additional to that help that may be expected or assumed within 67 68 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES a family where the children are not considered to have a disability. This element of help in going beyond the norm is not merely an assertion, as I shall show, but is supported by empirical research evidence. The pheno- menon is not only common in Britain, but is also experienced in the USA and across Europe. The degree of help offered may be considered somewhat of a subjective element, because what may seem reasonable within one family may not in another: the exceptional is due the nature and type of help offered by siblings to their disabled brother and sisters, which then enables the whole family to function that bit better. This chapter will explore the nature of the additional and exceptional caring tasks before considering how the ‘locus of control’ may assist the family and professionals with assessing the support needs that arises directly from the care that is provided. I begin by considering the research on ‘young carers’ and the responsibilities they assume. Research findings Becker (2000) estimated the total numbers of family carers in Britain to be near 1 million. The number of young carers under the age of 18 years was estimated by the Loughborough University research group to be 50,000 of whom the majority were girls (Brindle 1998). Horwitz (1993) estimated that in the USA approximately one-fifth of the population do not have siblings and there the option to assist parents with the caring task is not possible, but it would seem, nevertheless, that in Britain we follow the trend in the USA, in which the majority of children with disabilities will have siblings who can offer some form of help and assistance to their parents. Myers (1978) discusses the additional responsibility that siblings of disabled brothers and sisters accept and shows that they are expected to mature more quickly than they would if they did not have a disabled sibling. A parent encountered during my own interviews said, ‘they have to grow up more quickly, don’t they,’ which seemed to reflect the view from two-thirds of those responding to the survey (40), indicating that siblings were more caring and aware of disabilities thanks to their home experience (Burke and Montgomery 2003). The point about ‘growing-up more quickly’ is repeated in the case of Fay and Michael, which is used to CHILDREN AS YOUNG CARERS / 69 illustrate the experience of Fay in the final part of this chapter. Grossman (1972) reports a similar finding, cited in Powell and Ogle (1985, p. The fact that siblings help to care for their non-disabled children is found in evidence from research across nations.

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Current treatments for melasma include broad-spectrum sunscreens proven finast 5 mg hair loss in male guinea pigs, hydro- quinone formulations generic finast 5mg hair loss normal, azelaic acid, kojic acid, α-hydroxy acid products, retinoic acid, retinol, superficial chemical peels, and microdermabrasion. Although all these therapies improve melasma, none are curative. It is essential for patients to adhere to a regimen of daily sun protection. A lentigo is a well-circumscribed, brown-black macule that appears at birth or early childhood. Postinflammatory hyperpigmentation is characterized by an acquired increase in cutaneous pigmentation secondary to an inflammatory process; there is no such history in this patient. Vitiligo is a common skin disorder characterized by one or more patches of depigmented skin. A 16-year-old white male comes to your clinic for evaluation of skin pigmentation. For the past 6 weeks, he has been experiencing progressive dark pigmentation in both arms. The patient has acne, which was first diagnosed 2 years ago. He says he is not taking any medications except for an “acne pill. The patient also has hyperpigmented skin in both arms. No other skin lesions are present; the rest of the examina- tion is normal. Which of the following is the most likely diagnosis for this patient? Drug-induced hyperpigmentation Key Concept/Objective: To recognize hyperpigmentation as a possible side effect of different medications Medications are a common cause of cutaneous hyperpigmentation. Medications can also cause hyperpigmentation of the oral mucosa and 36 BOARD REVIEW nails. Medications causing drug-induced hyperpigmentation include oral contraceptives, hormone replacement therapies, antibiotics, antidepressants, antiviral agents, antimalari- als, antihypertensives, and chemotherapeutic agents. This patient has acne, for which he is taking medication. This medication could be minocycline or tetracycline—antibiotics that are commonly used for treatment of acne and that can cause hyperpigmentation. This makes drug-induced hyperpigmentation the most likely etiology. Postinflammatory hy- perpigmentation can be a sequela of several dermatologic conditions, including acne; however, the hyperpigmentation in this patient is not located where the acne lesions are. Addison disease can cause hyperpigmentation on the skin and mucosal surfaces; however, this patient has no other signs and symptoms of this disorder. Erythema dyschromicum perstans is an acquired benign condition characterized by the presence of slate-gray to vio- laceous macules. The lesions are usually symmetrically distributed and vary in size from small macules to very large patches. Common sites of involvement include the face, neck, trunk, and upper extremities. This patient’s clinical picture is not consistent with this dis- order. A 40-year-old African-American woman with a history of hypertension comes to your clinic for a follow- up visit. Physical exam- ination reveals an area of hypopigmented skin measuring 5 × 7 cm on her right foot. Which of the following is the most likely diagnosis for this patient, and what further workup is indicated?

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Semin Spine Surg 1997 generic finast 5 mg overnight delivery hair loss with menopause;9:38 Khan I order finast 5 mg with amex hair loss cure just like heaven, Vaccaro AR, Zlotolow DA. Management of verte- bral diskitis and osteomyelitis. Orthopaedics 1999; 22:758 ©2002 CRC Press LLC 8 Spinal surgery Many of the destructive and compression lesions in Figure 8. In recent years, there has been a rapid expansion in the number and complexity of available surgical options. The surgical techniques can be divided into three basic categories. The first includes the minimally invasive tech- niques in which the vertebral structure being oper- ated on is approached using either needles or catheters to inject proteolytic chemicals into the disc, steroids or analgesics into the facets and paraspinal soft tissue structures, or a thermal needle into the disc to ablate the discal tissues. These methods, however, can only be used in well-localized lesions that can be accessed percutaneously. This is the more common procedure, as many lesions of the lumbar spine require removal of a mass lesion, such as a disc protrusion, tumor or abscess, through a surgical incision. This requires dissection of the skin and musculature to reach the lesion, followed by the surgical removal of the offending lesion. The spinal structures can be approached surgically from the back through the posterior spinal musculature, through the ribcage via a flank incision, or anteriorly through the neck or abdomen. The third category of surgical procedures are those which attempt to reduce mobility in the spine by fusing two or more segments. Such fusion can be achieved by approaching the spine either posteriorly Longitudinal section through the lumbar spine shows surgical or anteriorly. The surgeon may elect to place corti- bone graft fusion of the posterior elements of L3 to the sacrum, cal or cancellous bone grafts across two or more with narrowing of the L2–L3 disc and canal at this level due to new bone formation above the fusion vertebrae in order to create a bony fusion through ©2002 CRC Press LLC Figure 8. Alternatively, the between the vertebral bodies and allowing for fusion. The vertebral bodies of C4–C5 show complete union of the bones. There are degenerative changes in the form of narrowing of the disc space and osteophyte formation. The fusion is thought to present additional stressors on adjacent vertebrae which can aggravate the degenerative changes ©2002 CRC Press LLC Figure 8. The peritoneum is not opened ©2002 CRC Press LLC Figure 8. The peritoneum is opened and the bowel is retracted to expose the lumbo-sacral junction. Goodwin Graham Hughes AUTISM: THE FACTS MISCARRIAGE: THE FACTS Simon Baron-Cohen and Patrick Bolton (second edition) Gillian C. Lachelin BACK AND NECK PAIN: THE MULTIPLE SCLEROSIS: THE FACTS FACTS (fourth edition) Bryan Matthews and Loïc Burn Margaret Rice-Oxley CANCER: THE FACTS MUSCULAR DYSTROPHY: THE (second edition) Michael Whitehouse FACTS and Maurice Slevin (second edition) Alan E. Emery CHILDHOOD LEUKAEMIA: THE OBSESSIVE-COMPULSIVE FACTS DISORDER: THE FACTS (second edition) John S. Lilleyman (second edition) Padmal de Silva and Stanley Rachman CHRONIC FATIGUE SYNDROME (CFS/ME): THE FACTS PANIC DISORDER: THE FACTS Frankie Campling and Michael Sharpe Stanley Rachman and Padmal de Silva CYSTIC FIBROSIS: THE FACTS SCHIZOPHRENIA: THE FACTS (third edition) Ann Harris and Maurice (second edition) Ming T. Faraone DOWN SYNDROME: THE FACTS THYROID DISEASE: THE FACTS Mark Selikowitz (third edition) R. Tunbridge EATING DISORDERS: THE FACTS (third edition) Suzanne Abraham and TOURETTE SYNDROME: THE Derek Llewellyn-Jones FACTS (second edition) Mary Robertson and ECZEMA IN CHILDHOOD: THE Simon Baron-Cohen FACTS David J. Atherton EPILEPSY: THE FACTS ALSO FROM OXFORD (second edition) Anthony Hopkins and UNIVERSITY PRESS Richard Appleton FORBIDDEN DRUGS: HEAD INJURY: THE FACTS UNDERSTANDING DRUGS AND (second edition) Dorothy Gronwall, WHY PEOPLE TAKE THEM Philip Wrightson and Peter Waddell (second edition) Philip Robson A BLOKE’S DIAGNOSE IT HUNTINGDON’S DISEASE: THE YOURSELF GUIDE TO HEALTH FACTS Keith Hopcroft and Alistair Moulds Oliver Quarrell KIDNEY FAILURE: THE FACTS Stewart Cameron AS-Pre(i-xii) 5/29/02 5:40 PM Page iii ANKYLOSING SPONDYLITIS thefacts Muhammad Asim Khan MD FACP FRCP Professor of Medicine Case Western Reserve University School of Medicine, Cleveland, Ohio, USA 1 AS-Pre(i-xii) 5/29/02 5:40 PM Page iv 3 Great Clarendon Street, Oxford, OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the university’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Bangkok Buenos Aires Cape Town Chennai Dares Salaam Delhi Hong Kong Istanbul Karachi Kolkata Kuala Lumpur Madrid Melbourne Mexico City Mumbai Nairobi Paris São Paulo Shanghai Taipei Tokyo Toronto and an associated company in Berlin Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer A catalogue record for this title is available from the British Library Library of Congress Cataloging in Publication Data (Data available) ISBN 0 19 263282 5 10987654321 Typeset by EXPO Holdings, Malaysia Printed in Great Britain on acid-free paper by Biddles Ltd, Guildford & King’s Lynn AS-Pre(i-xii) 5/29/02 5:40 PM Page v Dedication I dedicate this book to my family (my parents, Umar and Hameeda, my wife, Mastoora, and my sons Ali and Raza), and above all to all the people like me who suffer from ankylosing spondylitis, and to their families, as well as to their healthcare providers. AS-Pre(i-xii) 5/29/02 5:40 PM Page vi This page intentionally left blank AS-Pre(i-xii) 5/29/02 5:40 PM Page vii Preface This book is primarily intended for people with anky- losing spondylitis (AS), their family members and friends.

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Deficiency of the 21-hydroxylase and adrenal cortical and dehydroepiandrosterone sulfate (DHEAS) are the ini- hyperplasia should also be considered effective 5 mg finast hair loss 22. Any abnormality needs an endocrinologic can also be confused with cephalic pustulosis due to mal- evaluation buy generic finast 5 mg hair loss medication causes. Clinical- Infantile acne must be differentiated from acneiform ly the lesions are very similar to acne and are a conse- eruptions due to topical skin care products (greasy oint- quence of an overgrowth of these lipophilic yeasts (on a memts, creams, pomades, oils) applied by the parents (po- neonate with high sebum production) that leads to an made acne); due to steroids (topical, oral, inhaled) and inflammatory reaction and poral or follicular occlusion. Perioral dermatitis can mimic an IA, papules and pustules The treatment of neonatal acne begins with reassu- are present mainly periorally (95%) and occasionally at rance of parents. Topical treatments for comedones in- the periocular area (44%). It can be associated to kerato- clude retinoids such as tretinoin (cream 0. A family history is present inflammatory lesions, topical antibiotics (erythromycin in 20% of cases. The main diffi- culties are the treatment of inflammatory lesions, deep papules and nodules that can persist for weeks or months. Infantile Acne The oral antibiotics restricted to this age are erythromycin in doses of 125–250 mg twice daily and trimethoprim Infantile acne (IA) usually starts later than neonatal 100 mg twice daily in patients with shown resistance of acne, generally between 6 and 9 months (range 6–16 Propionibacterium acnes to erythromycin [16, 17]. A large survey on IA has been recently there is no response or nodular acne develops, which can published showing that IA was mainly moderate in 62% lead to scarring, oral isotretinoin can be used. The doses of cases and mild and severe in 24% and 17% of cases, proportionately are similar to adult (0. In addition to open and closed comedones, 5 months). Monitoring of complete and differential blood there were 59% of cases with inflammatory lesions and counts, liver function tests, cholesterol, triglyceride levels 17% with scars. Occasional cases of conglobate acne and a follow-up of skeletal involvement should be per- can be seen; they occur primarily on the face and the clini- formed [22, 23]. Parents have to be informed that the treatment is a The course is variable. Some cases disappear in 1 to 2 long-term one with possibilities of reappearance of acne at years but others are persistent and resolve at the age of puberty. Infantile acne, especially conglobate infantile acne, may be related with severe forms of the disease in adoles- Mid-Childhood Acne cence. A family history of severe acne can be present. This type of acne occurs between 1 and 7 years of age. There is one case Acne is very rare in this group and when it occurs should described with elevated levels of LH, follicle-stimulating be evaluated for hyperandrogenemia. Evaluation should be Acne in Infancy and Acne Genetics Dermatology 2003;206:24–28 25 done with a bone age measurement, growth chart and lab- present a statistically significantly earlier menarche (12. They also concluded that the num- hydroxyprogesterone. Occasional reports of acne at this ber of comedones were predictive for the severity of late age because of D-actinomycin are available in the litera- inflammatory acne. This group also showed higher levels of keratosis pilaris of the cheeks and with keratin cysts (mil- DHEAS early in life. A correlation between DHEAS, ia) particularly when they get inflamed. Both lesions are sebum production and free testosterone was found in common in atopics [3, 16]. They evaluated acne versus hormone lev- Prepubertal Acne els at various ages before and after menarche. They were able to conclude that there were no ethnic differences in Increasing number of early onset acne before obvious acne or hormone levels in the groups studied that in- signs of puberty is a recognized phenomenon associated cluded black and white girls.

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They have a hard job pumping and purifying hundreds of gallons of blood each day buy finast 5 mg amex hormonal hair loss cure, breaking down raw food into digestible energy finast 5mg cheap hair loss cure home remedies, cleansing toxic substances and storing our emotional tensions. By smiling into your organs you’ve made their day a cheerful one. Smile down into your mouth and swish your tongue around to collect saliva. When your mouth is filled with saliva, put the tip of your tongue to your palate, tighten your neck muscles, and swallow hard and quickly, making a gulp- ing sound as you do. With your inner smile follow the saliva down your esophagus, through your internal tract and to your navel. Your saliva is a lubricating nectar that holds vital energy which is dis- persed throughout the body from the navel center. Smile away the nervous energy in your stomach, and you will eat better food and find it easier to digest. Relax the smiling energy into your small intestine, large intestine, and rectum. Back Line: Spine Now bring your focus back to your eyes. Smile into your eyes, your tongue, then begin to smile down the inside of your spinal column. Make sure your posture is straight with shoulders slightly rounded forward. Descend one vertebra at a time, smiling into each until - 48 - Chapter III you have reached the coccyx. The spinal column protects your central nervous system and is crucial in increasing your chi circu- lation. Starting from the neck there are seven cervical vertebrae, twelve thoracic vertebrae, and five lumbar vertebrae plus the sacrum and coccyx. You should experience a feeling of great ease, warmth, and comfort in each vertebra. When the lumbar, coccyxal, and pubic areas are relaxed, power is released and flows more easily up through the back. With practice the entire smiling meditation can be done in just min- utes, although at first it may take you longer to really feel the smile. When you end the meditation you do not want to have energy cir- culating around in the higher centers such as the head or the heart. The best place for energy storage in the body is the area of the navel, since it can easily handle the increased body heat. Most ill side effects of meditation are caused by excess energy in the head, but this is easily avoidable. Men spiral first clockwise; women spiral counter clockwise. Important Note: You do NOT collect the energy at the navel after “smiling down” if you intend to immediately circulate chi in the mi- crocosmic orbit as taught in the following chapter. You would cir- culate the orbit and then close by collecting the energy at the na- vel. Practice the Inner Smile in Daily Life Although the inner smile is used primarily to help you to relax prior to practicing the microcosmic orbit, it is powerful as a meditation in its own right. Simply smiling the inner smile in your daily life can bring tremendous results. If you are constantly aware of your inner smile, it will transform your life. She knew her boss was tight with money and would put up a fight, so she approached the grumpy boss with an inner smile as well as her outer smile. Such positivity reduced her boss’ resistance, and they ended on good terms, with both of them smil- ing. Another student’s self-image changed radically from smiling down. Before his self-esteem was low, and he was continually fight- ing with himself, telling himself he wasn’t up to par. After frequently practicing the inner smile he made good friends with himself, and began to realize potential hidden by his negative self deprecations. If you master an inner smile you may well feel like the turtle, entering the unknown sea with his protective shell snugly encased about him.

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