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Though the anti-smoking lobby plays up its offensive against the tobacco industry (whose executives are now despised and demonised as though they were war criminals or child abusers) its real threat is to the status of the individual and to civil liberties cheap 10mg zetia with amex cholesterol machine. If people who smoke—more than a quarter of the adult population— are defined as being in a state of drug addiction and are considered as a result to be incapable of making rational decisions purchase zetia 10mg with visa cholesterol ratio paleo, then the state is justified in taking ever greater control over their behaviour. The dominant theme in the earlier medical literature was that cigarette smoking was merely a bad habit. That this habit could be broken by an effort of will was confirmed by the rapid response of an informed public to the revelations of the link between cigarettes and lung cancer. As we saw in Chapter 3, publicity about the dangers of smoking following the RCP’s 1962 report led to a steady decline in levels of smoking. In a chapter devoted to ‘the smoking habit’, the second edition of the RCP report acknowledged discussion of ‘pharmacological dependence’ on nicotine (RCP 1971: 112) Though it suggested that this matter required further research, its general tone was dismissive: ‘evidence that the difficulty that many smokers find in giving up the habit is due to habituation to nicotine is scanty’ (RCP 1971:41). In the course of the 1960s and 1970s a wide range of programmes, using everything from behavioural and psychodynamic therapies to hypnotism and acupuncture, were established in the effort to encourage people to quit smoking. A review of these programmes in the USA in 1982 drew gloomy conclusions: 1 No one cessation technique or approach is clearly superior to any other; 2 Most people who join cessation programmes do not quit smoking; 110 THE EXPANSION OF HEALTH 3 Of those who do quit, most do not remain off cigarettes for any substantial period of time. In the course of the 1980s, the recognition of nicotine addiction allowed for the convergence of different forms of dependence in the concept of ‘substance abuse’, or in the less judgemental term increasingly favoured in medical circles, ‘substance misuse’. This provided a useful umbrella to cover not only alcohol, heroin and nicotine, but other illicit ‘substances’—such as cannabis, solvents, cocaine/crack, amphetamines, LSD and ecstasy, and others—which were in widespread use, but for which the evidence of ‘dependency’ was weak. Indeed they needed ‘nicotine replacement therapy’, a formulation paying richly ironic homage to the use of ‘hormone replacement therapy’ in post-menopausal women. A blood nicotine assay had become available for research purposes and nicotine chewing gum came on the market. In 1988 the US Surgeon-General’s report gave official approval to nicotine addiction as a condition requiring appropriate medical treatment (Berridge 1998). In Britain, however, some medical resistance to the concept of ‘nicotine replacement therapy’ was reflected in the decision not to make it available on prescription, either in the form of chewing gum or the more ‘medical’ skin patches. It was not until 1998 that an editorial in the BMJ called for ‘nicotine replacement therapy for a healthier nation’—and proposed that it should be made available on prescription (Smeeth, Fowler 1998). This demand was issued with the full authority of a Cochrane Library ‘systematic review’ of 47 trials involving more than 23,000 patients, claiming to demonstrate its efficacy (Silagy et al. However, patients in these trials were only followed up for 6–12 months, so whether the effect is sustained remains unknown—as does whether this approach would also be effective when extended to a wider, and inevitably less motivated population. Nevertheless the nicotine replacement bandwagon was on the roll, and, following the RCP’s enthusiastic endorsement, it seems set to allow the further medicalisation of individual behaviour. The roots of this movement, the subject of a penetrating study by John Steadman Rice, lie in the ‘Twelve Step’ recovery programme popularised by Alcoholics Anonymous (founded in Ohio in 1935, AA became widely established in the USA and internationally in the post-war period) (Steadman Rice 1998). Though groups concerned with the special problems of the spouses and families of alcoholics had long run in parallel with the mainstream AA meetings, in the 1980s there was a dramatic proliferation of such groups. They now rapidly expanded to include ‘survivors’ of other forms of victimisation (domestic violence, sexual abuse) and victims of other forms of addiction, such as gambling, shopping, sex. The central claim of this movement was that ‘co-dependency’ was a disease, an addiction, characterised by dependence on a pathological relationship with another person, a substance, or any ‘processes external to the individual’ (Steadman Rice 1998). Co-dependents are believed to experience ‘a pattern of painful dependence on compulsive behaviours and on approval from others in an attempt to find safety, self worth and identity’. As Steadman Rice observes, this is a concept of ‘virtually limitless applicability’ and it was not surprising to find it extending to cover, not only familiar bad habits, but even fads about novelties such as the internet, mobile phones and the National Lottery (all of which were linked with media scare stories about new forms of addiction in the late 1990s). The inevitable result was inflated estimates of the numbers of victims of various addictions: one (US) estimate reckoned that co-dependency afflicted ‘approximately 96 per cent of the population’ (Steadman Rice 1998) Lest this be thought to be a preoccupation peculiar to Americans, the British advocacy group Action on Addiction claims that ‘almost every one of us has either experienced some form of addiction or knows someone who has’ (AOA 1997). With typically British modesty it settles for the assertion that ‘in fact, one in three adults suffer from some form of addiction’. While co-dependency expanded the concept of addiction to cover diverse personal and social problems, there was also a surge in the popularity of biological theories of addiction. Developments in genetics (not only a ‘gene for alcoholism’, but also a ‘promiscuity 112 THE EXPANSION OF HEALTH gene’), advances in the study of neurotransmitters (endorphins, serotonin, dopamine) and the speculations of evolutionary psychologists were all recruited to explain the remarkable grip of compulsions and addictions on individuals in modern society (James 1997). The crude biological determinism apparent in such attempts to establish a direct link of causality that extends from embryonic DNA, through the structure and function of the brain to the individual personality and social behaviour reflects the profoundly fatalistic outlook that underlies the concept of addiction. If human behaviour is ‘hard wired’ into our genes and hormones, then the scope for individual autonomy and self-control is drastically curtailed.

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This phrase refers to questions which could embarrass or force respondents into giving a false answer purchase 10 mg zetia free shipping cholesterol ratio hdl ldl. They might do this if they do not want to look ‘bad’ in front of the researcher discount 10mg zetia visa cholesterol chart mg/dl, or they might do it because it is expected behaviour. Questions about income or educational qualifications might illicit this type of response, so you need to be careful about how you try to obtain this information. X Some issues may be very sensitive and you might be bet- ter asking an indirect question rather than a direct ques- tion. Promising confidentiality and anonymity may 90 / PRACTICAL RESEARCH METHODS help, but many respondents can, understandably, be sceptical about these promises. If you ask an indirect question in which respondents can relate their answer to other people, they may be more willing to answer the question. Using closed-ended questions If you are constructing a closed-ended question, try to make sure that all possible answers are covered. This is particularly important for time and frequency questions such as ‘how often do you. Also, you want to make sure that you don’t artificially create opinions by asking someone a question about which they don’t know, or don’t care. You need to make sure that you include a ‘don’t know’ category in this case. Firstly, it assumes that the respondent has a car and secondly, it assumes the respondent washes his car. Would a respondent feel bad if they didn’t have a car and therefore would tick ‘four times a week’ anyway? Would they feel bad if they don’t ever wash their car but feel the researcher expects them to? If you need to ask this question, you should ask a filter question first to find out whether the respondent actually owned a car. Then you would need to ask: ‘If you wash your car, HOW TO CONSTRUCT QUESTIONNAIRES/ 91 how many times a year? Have a look at Exercise 2 which will help you to think about some of the issues involved in the wording and structuring of questions. EXERCISE 2 Read the following questions and decide what is wrong with them. What do you think about the Green Peace attempt to blackmail the Government? What is wrong with the young people of today and what can we do about it? The problem with this question is in the categories supplied for the answer. Everybody has a different idea as to what words such as ‘sometimes’ and ‘fre- quently’ mean. Instead, give specific time frames such as ‘twice a year’ or ‘once a month’. Also, the order of answers should follow a logical sequence – in the example above, they do not. It assumes that Green Peace is blackmailing the Government and assumes that someone knows about the issues and would be able to answer. A filter question would have to be used in this case and the word ‘blackmail’ changed. The word ‘wrong’ is emotive and sug- gests there is something not normal about the young people of today. It asks the respondent to distance themselves and comment from the moral high ground. This question may contain prestige bias – would peo- ple be more likely to say they have read plenty of books when they might not have read any? Also, the categories for the answers need modification – which box would you tick for someone who answered ‘20’? This question assumes knowledge and could only be asked of someone who has the figures to hand. It also asks for what could be confidential information which a respondent might be reluctant to give. The word ‘profit’ has different meanings for different people, especially if the question is asked by an inter- viewer, rather than read by the respondent.

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For example zetia 10 mg discount cholesterol foods to eat & not eat, if the cause is a medication or other toxin purchase zetia 10 mg with amex cholesterol levels requiring medication, the best course is to eliminate that agent. If available, specific treat- ment for the underlying metabolic disturbance should be employed. In cases where there is no known primary treatment or when symptoms persist despite treatment of the underlying cause, symptomatic treatment can be employed. There are relatively few data on the efficacy of various agents in the treatment of secondary dystonia. The medications described above for primary dystonia may be effective in secondary dystonias. Empirical treatment with carbidopa=levodopa, trihexyphenidyl, baclofen, carbamazepine, or a combination should be considered. In the case of tardive dystonia, dopamine depletors such as reserpine or tetra- benazine can be effective. Reserpine should be started at a dose of 20 mg=kg daily and increased gradually until benefit is achieved or side effects occur. The most common side effects are sedation, depression, orthostatic hypotension, and parkinsonism. Tertrabenazine is also effect in tardive dystonia, but is not available in the United States. The dose should be increased gradually until there is benefit or side effects occur. The effective maintenance dose varies widely from 25 to 200 mg per day divided three times daily. Perhaps the most common secondary dystonia is the acute dystonia reaction that typically occurs in response to a dopamine antagonist. Anticholinergic medica- tions are the most effective; benztropine and diphenhydramine are the most com- monly used agents to treat acute dystonia reactions. After occurrence of an acute dystonia reaction, re-exposure to a dopamine antagonist should be avoided if possible. The prognosis for DRD is excellent with life-long benefit from low doses of carbidopa=levodopa. Often, the symptoms diminish in the 3rd decade of life and it may be possible to decrease the levodopa dose. Primary dystonia is typically progressive to a point at which point there is usually a plateau. DBS is promising and may confer long-lasting benefit, but there are insufficient data at this time. The prognosis for secondary dystonia depends entirely on the cause and availability of primary treatment for the underlying etiol- ogy. Symptomatic treatment of secondary dystonia is not expected to alter the natural history of the underlying disease. Some forms of dystonia, such as DRD, are readily treated with complete benefit expected. Because the symptoms of DRD respond entirely in most cases, it is important to always consider this diagnostic possibility. Other forms of dystonia are more difficult to treat and may require empirical trials of multiple medications to achieve maximum benefit. Many medications are tolerated at higher doses in children than in adults, so dosing is usually guided by degree of benefit and severity of side effects. Stereotaxic surgical treatments are promising, particularly for primary dystonia due to the DYT1 mutation. Torsion dystonia: a double-blind, prospective trial of high-dosage trihexyphenidyl. Dure, IV Division of Pediatric Neurology, Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, U. INTRODUCTION Tremor in childhood, although considered rare, is frequently seen among patients referred to pediatric neurologists. In a series of 684 children with movement disor- ders, the incidence of tics was 39%, dystonia 24%, tremor 10%, chorea 5%, myoclo- nus 2%, akinetic-rigid syndromes 2%, and mixed disorders 8%. Although not generalizable data, it is of interest that there is very little published regarding this entity in childhood. DIAGNOSIS=CLINICAL FEATURES Tremor is defined as an involuntary rhythmical reciprocal oscillatory movement of a body part, typically around a joint.

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The first two objectives require information of an intellectual kind for their achievement and may be classified as knowledge objectives purchase 10mg zetia with mastercard cholesterol medication when to start. The third and fourth objectives refer to skills of a practical kind and are thus described as a skill objectives buy zetia 10mg overnight delivery what cholesterol medication has the least side effects. The fifth objective suggests an attitude of mind and is therefore classified as an attitudinal objective. The three broad divisions – knowledge, skills and attitudes – are often used in grouping objectives but you may come across several refinements of each division in the 97 literature. The most common of these refinements is the taxonomy developed by Bloom and his colleagues. They call the three divisions ‘domains’: cognitive (knowledge and intellectual skills), psychomotor (physical skills) and affective (feelings and attitudes). These domains have been further subdivided to provide hierarchies of objectives of increasing complexity. Knowledge objectives (the cognitive domain): it is in this area that Bloom’s taxonomy has been most widely applied. He proposes six levels: knowledge; comprehension; application; analysis; synthesis; and evaluation. The reason for keeping different levels in mind when writing objectives is that courses sometimes pay undue attention to one level (usually the recall of information). Skill objectives (the psychomotor domain): in many medical courses, teachers need to pay a great deal of attention to developing skill objectives. Such objectives may be improved if the condition under which the performance is to occur, and the criteria of acceptable performance, can be indicated. You might find it useful to specify the expected level of competent performance. For example there will be some skills with which one would expect students to show a high degree of competence and others with which one might only expect familiarity. Attitudinal objectives (the affective domain): writing objectives in the affective area is very difficult, which possibly explains whey they are so often ignored. This is unfortunate because, implicity or explicitly, there are many attitudinal qualities we hope to see in our graduating students. One way of doing so is to attempt to define the starting attitudes of the students and match these with more desirable attitudes towards which you would hope they would move. For example, you might start by assuming 98 that the students had a stereotyped attitude. You would then wish to move them away from this towards an attitude which demonstrated understanding and acceptance of other views. The advantage of this method is that it recognises that not all students will develop the desired attitude nor will they all necessarily start a course with the same attitudes. The way to express objectives using this approach is to state ‘Away from … (a particular attitude), towards … (a desirable attitude)’. Writing objectives is not simply a process of sitting, pen in hand, waiting for inspiration, although original thinking is certainly encouraged. Objectives will come from a careful consideration of the subject matter, what you and your colleagues know about the students, and about the subject. These include: an analysis of your own and colleagues’ knowledge, skills and attitudes; ways of thinking and problem-solving to be devel- oped; students’ interests, needs and characteristics; subject matter, as reflected in the published literature (especially in suitable textbooks); the needs of patients and the community; the requirements of professional certifying authorities; the objectives of the department or school. The answer depends on the purposes for which the objectives are to be used. In designing a course, the objectives will be more general than the objectives for a particular teaching session within the course. As objective writing can become tedious, trivial and time-consuming it is best to keep your objectives simple, unambiguous and broad enough to convey clearly your intentions. To illustrate from our own field of teaching, the objectives for a six-week clinical skills course, conducted for groups of 9-10 students, are shown below. Though quite broad, these objectives have proved detailed enough for course planning purposes and for making the intentions of the programme clear to students. If your orientation is primarily the transmission of content, it is likely that your teaching methods will be dominated by lectures, assigned reading of books and electronically 100 based materials, and set problem-solving exercises.

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