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As far as theatres go discount himcolin 30gm, many of the larger venues now have adapted toilets and facilities buy himcolin 30 gm mastercard. In some theatres, it may be necessary for the occupant of a wheelchair to be able to transfer into an aisle seat, with the wheelchair stowed elsewhere. In other theatres, seats can be 178 MANAGING YOUR MULTIPLE SCLEROSIS removed with advance notice to make way for a wheelchair, while in others there are specific seat-less areas where a wheelchair user will be asked to sit. If you need assistance or a specific seat as an ambulant or visually impaired disabled person, or indeed for any disability, then do ask in advance. Usually the easiest access to seats will be on the same level as any wheelchair spaces, and/or you could ask for a seat at the end of a row if this is helpful. For other popular venues such as museums, galleries or arts centres, if you are unsure about access and facilities, contact the place concerned and ask in advance of your visit. Both access and the presentation of exhibits have been improved to suit disabled visitors, and facilities, such as catering and the provision of toilets, have been upgraded as well. Some major museums and galleries are large, making it difficult to walk or wheel all the way round in a single visit. Like most visitors, you may prefer to look at a museum/gallery map before or when you arrive, so you can select some of the things of greatest interest and plan the easiest route round. Some places will have on-site wheelchairs to borrow, but check and book these in advance if they are going to be a necessity. Some arts centres are housed in modern, purpose-built buildings; others are based in old buildings such as Victorian town halls and churches that have been adapted for the purpose. Accessibility varies, but efforts have been made in recent years to cater better for disabled visitors. Many arts venues have multiple functions, and may include a cinema, theatre, concert hall, and an exhibition area. If you are in London, you may find it practical as well as interesting to visit a site or complex that has a number of such accessible possibilities within easy reach of each other, such as the South Bank or the Barbican centre. If you are going to a theatre, cinema or other venue in London, you could contact the London arts access information service, Artsline. You should also check to see whether there are any services giving similar information in your area, from DIAL (see Appendix 2 for details). Some past or present experiences may provoke you into joining one of the many local groups campaigning for better local access to public buildings and places. If you like visiting stately homes and gardens, the National Trust Handbook (see Appendix 2) gives information about the suitability of its LEISURE, SPORT AND HOLIDAYS 179 properties for people in wheelchairs, and there is a separate guide from them for properties that are particularly suitable. All give free admission to someone escorting a person in a wheelchair, and some have motorized buggies for those with mobility problems. Three other books give details of wheelchair access: • Places that care by Michael Yarrow • The National Gardens Scheme handbook, and • Historic houses, castles and gardens which list over 1300 properties of all types and gives information about access. Other possible sources of information are RADAR (the Royal Association for Disability and Rehabilitation), and local disability groups, or your local MS Society may have information about access issues to places near to you. Holidays If you plan your holiday carefully, you should have no major problems with travelling. Try and stick to a schedule that is not too demanding and, perhaps just as important, allow yourself time to rest at the other end. You might also consult your doctor when you are planning your journey to see if he or she has helpful advice. By and large most airlines are very good at providing extra help and assistance for people with disabilities, including those in wheelchairs, as long as they are notified well in advance of your requirements. If you have vision problems and you are travelling by car, you could enlarge any maps or written instructions before your journey begins. You could also use a highlighter pen on the map to mark out your journey or a magnifying glass with a light on to help you see the map. In relation to air travel make sure that you give notice on any special requirements you have (such as meals) well in advance.

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However buy discount himcolin 30gm on line, careful inter- pretation is required himcolin 30gm low cost, as a single occurrence of ventricular tachycardia during a stress test is not necessarily an indication of the onset of fatal ventricular fibrillation. Nevertheless, it should be highlighted that an individual who has experienced an episode of ventricular fibrillation (VF) that did not occur in the presence of an acute event or cardiac procedure would be considered mod- erate to high risk (AHA, 2001). Similarly ventricular arrhythmias (VA) which are uncontrolled at low to moderate workloads with medication would be con- sidered at greater risk for cardiac-related complications during exercise. Those at greatest risk of exercise-induced ventricular fibrillation are indi- viduals with significantly impaired left ventricular function: namely those who have serious/major myocardial damage, due either to a large infarct, multiple infarctions or other conditions affecting ventricular function, e. There is a lack of recent evi- dence on the incidence of arrhythmic events during CR. In a study cited by Belardinelli (2003) a programme of exercise training for heart failure patients had only one episode of cardiac arrest in 16 years, i. However, as Belardinelli (2003) suggests, the low incidence of arrhyth- mia, as with other complications, during CR is because exercise is safe if the exercise prescription is ‘tailored to the patient’s clinical picture and needs’. Left ventricular function It is generally accepted that impairment of left ventricular (LV) function is a strong predictor of prognosis, with a number of authors rating it as the most powerful predictor (Specchia, et al. LV function can be expressed as a verbal description, as an ejection fraction (%) or wall motion index. Although less common, LV function can also be assessed during angiography or perfusion scanning. Although ejection fraction as a percentage is less com- monly available to exercise practitioners, it is accepted that normal ejection fraction approximates to 60–70%. Variations exist within the literature as to clearly defined links between ejection fraction percentages, verbal descriptors Risk Stratification and Health Screening for Exercise 31 Exercise Undertaken Sinus Tachycardia Increased Oxygen Decreased Diastolic Vasoconstriction Consumption Filling Time Reduced Cardiac Output Ischaemia Electrical Instability Dyskinesis Arrhythmia Potential Sudden Death Figure 2. Possible adverse physiological consequences of exercise in presence of heart failure (Adapted from Belardinelli, 2003). Some of the risk table summary data report that only at the level of poor LV function is this considered a high risk variable (Paul- Labrador, et al. In relation to risk stratification for exercise, LV dysfunction is an indicator of increased risk of complication during exercise. This explains the link between exercise and adverse event in individuals with impaired LV function. This figure shows that the sequence of events links LV dysfunction directly to other components of risk stratification already discussed, namely, arrhyth- mic potential and exercise capacity, due to compromised cardiac output and ischaemic burden. The information the exercise professional can gather regarding LV function will be relevant for only a specific time. Predicted spontaneous recovery and pharmaceutical interventions (especially ACE inhibition) may have an effect on LV function between time of event and commencement of phase III exer- cise. Contrary to historical evidence, which suggested LV-impaired patients could not increase cardiac output sufficiently to benefit from rehabilitation, recent research shows that exercise training itself improves survival in the presence of LV dysfunction (Specchia, et al. This is mainly due to the effective pre-entry screening, knowledge and skills of the CR professionals in these patient services. Historically, CR programmes were delivered in the outpatient areas of local hospitals, but now it is common for the exercise component to be delivered in fitness centres, health centres and community halls, thus improving access. The literature indicates that low to moderate intensity exercise for low to moder- ate risk patients can be delivered safely in the community (Armstrong, et al. However, patients deemed to be high risk or undertaking high inten- sity exercise should be limited to hospital-based programmes, supervised by appropriately trained and experienced health professionals (Stone, et al. CR professionals would concur that, as far as possible, patients should not be excluded from CR and exercise prescription should be a component of that service. Suggested exclusion criteria from Balady and Donald (1991), ACSM (1995), BACR (1995) and Goble and Worcester (1999) are shown below in Table 2. Many of these patients can safely enter exercise-based CR when these exclusion criteria are stabilised. COMPONENTS OF CLINICAL ASSESSMENT The following section details key components of a pre-exercise assessment, but is by no means exhaustive. It describes the rationale for each component, including supporting evidence, and highlights links to the risk categories pre- viously detailed, i. Assessment of the patient should include not only the risk-stratification process and establishment of functional capacity; there should also be a gath- ering of further information during a subjective interview. This assessment process may take place repeatedly over the four phases of rehabilitation, with a number of factors being assessed in phase I and re- assessed over time.

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The usual procedure to get up is to put your feet slightly apart and flat on the floor discount 30 gm himcolin amex, and then to pull them back a little towards the chair cheap 30 gm himcolin otc. Place both hands on the chair arms, and then ease yourself forward so that your bottom is near the front of the chair. You should then push down on your hands and heels, and straighten your hips and knees. When you move from a standing to a sitting position, the procedure is rather simpler, and involves turning round, so that you can feel the chair with the back of your legs. Of course, if you are getting in and out of a wheelchair, ensure that the chair is stable and that the wheelchair brakes are on! There are inflatable and portable cushions to help you rise from a chair, and there are also a number of mechanical aids, usually incorporated into the chairs themselves, that hydraulically assist the actions of sitting and standing – although these can be expensive. Bathroom aids Baths and showers Ensure that getting in and out of the bath is as safe and easy as possible and that, when you are in the bath, you can relax without worrying. Working out how to clean yourself properly is often a relatively minor problem compared to getting in and out of the bath! The siting of these is very important – consult your occupational therapist or other skilled person, to make sure that they can really help you. With a hand-held, temperature-controlled shower attachment, you should have a reasonably enjoyable experience, even if it isn’t quite the same for some people as a bath! Toilet aids Toiletting aids are important for, traditionally in our society, going to the toilet yourself is an indication of independence. Continuing to go to the toilet completely by yourself for as long as possible is an issue that many people feel strongly about, even between partners who have known each other for many years. Although having other people to assist you is a problem for both sexes, many men in particular are not so used to helping others with such issues on an everyday basis, such as young children or older parents, or indeed their partners. For men, one of the first things that you could do, if you have difficulties in controlling finger movement, is to readjust your type of clothing, to enable you to urinate from a standing position, or to take off or loosen your trousers and underwear. Buttons on trousers are not often not easy to manage, so a zip is usually slightly more user friendly; if zips are difficult to operate, Velcro fastenings will still look good and fasten well; they can be used on underwear as well. If you have limited movement, or are a bit unsteady, you will need to be very careful in lowering yourself on to the toilet. You need to check where your arms and feet are, and stand directly in front of the seat, then bend your knees until you can touch the sides of the seat with your hands, and lower yourself down slowly. Check that the toilet seat is secure before embarking on lowering or raising yourself! As far as the toilet itself is concerned, there are a range of adaptations which may be of help: • Grab bars can be placed on adjacent walls if they are near enough. The number of different adaptations in this area is increasing rapidly, so consult your occupational therapist, and look at other sources of information about such products. One of the most trying problems for people with MS is using toilet paper, for the manoeuvre involves considerable movement and dexterity. You might find a wet cloth more useful than toilet paper, or you might consider using a squeezy bottle full of (warm! A bidet might be easier, although this may well not fit into your toilet area, can be rather expensive to install, and would need fitting to your water supply. Recently a portable toilet/bidet has been launched that might help people who are worried about travelling and having to deal with conventional, and therefore problematic, toilets elsewhere. You may find a toilet that automatically washes and dries you where you are – this is the kind of development that could help many people with MS considerably. Finally, when you are out and about, you can obtain a special key from RADAR for public toilets for disabled people. Dressing aids The problem with dressing, or undressing for that matter, if you have limited movement and dexterity, is not just the difficulty but also the time 114 MANAGING YOUR MULTIPLE SCLEROSIS involved in doing them. Although you may be able to accomplish dressing now, in due course it can become such a frustrating and time- consuming process, that you have got little energy left to do anything else.

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I weaved in and out of the traffic on my bicycle discount 30gm himcolin amex, and within two minutes I was at the police cordon discount 30gm himcolin with amex. There were five commuters lying on the ground, each white with fear, shivering, although it was not cold. I felt as if I was on autopilot, driven by all the procedures that I had been taught and all the duty that had been ingrained in me. He was obviously in pain with a deformed broken lower *Taken from BMJ 1999;319:1079. It was soon emptied and we had to wait for the next fleet of ambulances for more bags. He was stabilised and put into an ambulance, all the while thanking those around him. The coordinator told me that it was unlikely that anyone else would be brought out alive from the wreckage. I grabbed my bike and sped down the main road still feeling as if some kind of compelling force was driving me. I had read the major incident plan two years before and remember being impressed by the precision and detail. What struck me was that there seemed to be order, there seemed to be a plan—and it was working. I was allotted a patient to look after and immediately recognised her as the woman I had attended at the scene. Now, like all the other patients, she had a number and I would be responsible for her. Never had I imagined a major incident running so efficiently, especially with the horrific severity of injuries. I glimpsed the sight of patients with major burns being whisked away for emergency surgery. My duty was to stay with my patient to continually assess her condition, anticipate potential problems, investigate and repair her wounds and be her friend. My main concern after establishing that her airway, breathing, and circulation were stable was to recognise that she might have a skull fracture and underlying serious head injury. It is funny how little things impress on your mind—hearing about members of the public ringing to donate blood, the catering department sending down sandwiches and drinks for exhausted staff, the gratitude of patients. Some were dreadfully burned, others had fractured limbs, ruptured spleens, or head injuries. Suddenly the department was quiet and then the debriefing—lots of emotion, satisfaction, and pride on all sides for the sheer professionalism shown not just by the medical and nursing staff but by the porters, receptionists, police, security, and caterers. FI 135 Appendices Appendix 1 The core outcomes of basic medical education The principles of professional practice The principles of professional practice set out in Good Medical Practice must form the basis of medical education. Doctors must practise good standards of clinical care, practise within the limits of their competence, and make sure that patients are not put at unnecessary risk. Doctors must keep up to date with developments in their field and maintain their skills. If doctors have teaching responsibilities, they must develop the skills, attitudes, and practices of a competent teacher. All curricula must include curricular outcomes that are consistent with those set out below. Maintaining good medical practice (a) Be able to gain, assess, apply, and integrate new knowledge and have the ability to adapt to changing circumstances throughout their professional life. Working with colleagues (a) Know about, understand and respect the roles and expertise of other health and social care professionals. Probity Graduates must demonstrate honesty in all areas of their professional work. Health Graduates must be aware of the importance of their own health, and its effect on their ability to practise as a doctor. Appendix 2 The aims of the Preregistration House Officer (PRHO) year ("general clinical training") • When universities grant a registrable degree, they are certifying that their graduates have attained the goals of undergraduate medical education, as set out in the GMC’s Recommendations on Undergraduate Medical Education, Tomorrow’s Doctors, and that they have demonstrated competence in their published list of procedures.

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Abnormalities were classified as (a) attrib- nondiabetic population to around 50% among diabetic utable to a disease or an isolated abnormality; and (b) patients older than 60 years) order himcolin 30gm online, but the presence of disease buy himcolin 30gm with visa, more common with increasing age or not. Abnor- References malities attributable to disease and more common with increasing age simply reflect diseases that are more 1. Illness behavior in common in older persons and have nervous system find- the aged, implications for clinicians. New York: Free age are most likely individual variations not attributable Press; 1978. Health and illness progression occurs following changes that developed behaviors in elder veterans. Analysis of previous reports of abnormal neurologic Cambridge: Harvard University Press; 1984. Differences in the Most studies include subjects screened inadequately or appraisal of health between aged and middle-aged adults. On the other hand, the consid- vival of a cohort of very old Canadians: results from the erable prevalence of neurologic abnormalities in older second wave of the Canadian Study of Health and Aging. For health in persons aged 85 and over: results from the example, frontal release signs (also called "primitive" Canadian Study of Health and Aging. Can J Public Health reflexes)—snout, palmomental, root, suck, grasp, glabel- 1996;87(1):28–31. The Prevention of Illness in the Elderly:The dementia118–120 or with Parkinson’s disease. Proceed- ings of a conference held at the Royal College of Physi- signs appear in 10% to 35% of older adults screened to 117,121,122 cians of London. Old people at home: these signs as identifiers of disease, at least in older their unreported needs. Cambridge: otherwise healthy older persons, turn out to be just a bit Harvard University Press; 1961. Tomorrow and tomorrow and tomorrow: rologic hammer rather than a lightweight, red triangu- toward squaring the suffering curve. Aging 2000: Our Health Care Destiny, It appears that reports of loss of ankle jerk with age may II. Sugges- reports and general practitioner information on the tive of functionally significant neuropathy are absent heel presence of chronic diseases in community-dwelling reflexes, reduced vibratory sense, impaired position sense elderly. A study on the accuracy of patients’ self-reports at the great toe, and inability to maintain unipedal stance and on determinants of inaccuracy. Instruments for the of elderly and younger patients with out-of-hospital chest functional assessment of older patients. Diagnosis and treatment of depression in late aging modify pulmonary tuberculosis? Hyperosmolar nonketotic coma in the elderly plementary and alternative medicine among African- diabetic. Consensus Development atric assessments for elderly people living in the commu- Conference Statement: geriatric assessment methods for nity. Comprehensive Functional Assessment for geriatric assessment: a meta-analysis of controlled trials. Alcoholism medical history taking as part of a population based survey screening questionnaires: are they valid in elderly in subjects aged 85 and over. Smoking effects of the presence of a third person on the physician- cessation and decreased risk of stroke in women. A short native medicine use in the United States, 1990: results of physical performance battery assessing lower extremity a follow-up national survey. Population- in the aged: the index of ADL, a standardized measure based study of social and productive activities as pre- of biological and psychosocial function. Why do physicians fail to recognize and treat ambulatory elderly: clinical confirmation of a screening malnutrition in older persons? Patterns of ortho- level and physical disability as predictors of mortality in static blood pressure change and their clinical correlates older persons. The management of chronic pain in alcoholism screening questionnaires in elderly veterans.

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