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Doppler can be used to assess be considered in patients who are symptomatic des- pressure gradients across stenosed valves and is ex- pite angiotensin and b-blockade or who are unable to tremely sensitive in detecting valve regurgitation discount minocycline 50 mg on line. Recentstudieshavealsoshownabenet Bloodpressurelevelsshowastrongfamilialaggregation in patients with heart failure in sinus rhythm generic minocycline 50 mg with mastercard. However buy discount minocycline 50 mg line, the genetic and environmental factors ac resynchronisation therapy) eliminate the delay in contributing to hypertension are likely to be extremely activation of the left ventricle seen in many patients diverse, confounding the search for responsible genes. These include genes regurgitation and reduce septaldyskinesis (see Trials involvedinthereninangiotensinsystem,togetherwith Box 10. Reninangiotensinaldosterone system Ventricular arrythmias and A number of factors, including hypotension, hypovo- laemia and hyponatraemia, stimulate renin release sudden death from the juxtaglomerular apparatus. Aetiology Endothelins, prostacyclins and nitric oxide These are derived from the vascular endothelium. In over 90% of cases no specic cause is found and the They regulate vascular contraction and relaxation, hypertension is known as essential. Predisposing factors include: are a family of structurally related 21-amino-acid pep-. It is generated from proendothelin-1 by Hypertension may be secondary to: the action of endothelin-converting enzyme, a metal-. Ifhigh(systolic which raise intracellular calcium > 140mmHg, diastolic > 90mmHg), check in both. Papilloedema indicates the presence esters react with thiols such as cysteine and gluta- of malignant hypertension. Observe the face for evidence of Cushing syndrome Pathophysiology usually caused by corticosteroid administration. Examineforaorticcoarctationfeelbothradialsand acterised by increased cardiac output with normal measure blood pressure in both arms. As hypertension progresses radialfemoral delay, weak femoral pulses, bruits of peripheral resistance increases and cardiac output the coarctation and scapular anastomoses which returns to normal. Listen for an epigastric or paraumbilical bruit of even in mild hypertension and is associated with renal artery stenosis. Higherdosesconferlittle Routine investigation of hypertension is aimed at additional antihypertensive effect, but cause more detecting treatable disease (usually renal) and asses- marked adverse metabolic effects, including hypokal- sing cardiac and renal function. They inuence the function of cardiac proteinuria and evidence of infection, and for myocytes, the specialised conducting cells of the albumin : creatinine ratio heart, and vascular smooth-muscle cells. Dihydro- Patients should attempt to achieve an ideal weight, pyridines vary in their effects on different vascular avoid excessive alcohol and salt and take regular beds. For patients with diabetes, renal hypotension, particularly in the presence of sodium impairment or established cardiovascular disease, a depletion. In heart failure, rst doses are usually given lower target of 130/80mmHg is recommended. Side effects include hyperkalaemia (par- be eithera calcium-channel blocker or a thiazide-type ticularly in the presence of renal disease), persistent diuretic. In patients younger than 55, the rst choice dry cough, blood dyscrasias, rashes and angioedema. These include aspirin and statins b-Blockers reduce blood pressure and cardiac out- for secondary prevention of cardiovascular disease, put, block peripheral adrenoceptors and alter baro- and primary prevention in treated hypertensive receptor reex sensitivity. They are therefore relatively stimulate as well as block adrenergic receptors, and cardioselective, and less likely to provoke broncho- may cause less bradycardia and coldness of the ex- spasm. Some b-blockers have b-Blockersarenolongerrecommendedasrstline less effect on b2-(bronchial) receptors (e. Renal failure is an invariable feature of accelerated hypertension in which acute, severe hypertension is associated with gross intimal hyperplasia leading to occlusion of the lumen of small arteries and arterioles Severe hypertension withinthekidney. Very severe hypertension (diastolic > 140mmHg) or malignant hypertension (with papilloedema) should Renal disease as a cause of be treated in hospital. Calcium-channel blockers, a-blockers and although duplex ultrasonography and differential iso- b-blockers are also useful. Hypertension as a cause of renal Treatment disease Medical treatment is aimed at reducing cardiovascu- Estimates of the prevalence of chronic kidney disease lar risk with aspirin, statins and antihypertensive because of hypertension vary widely. Low-dose aspirin Stroke volume and heart rate increase during preg- (7581mg/day) is effective at preventing pre-eclamp- nancy, leading to increased cardiacoutput. Gestational hypertension occurs in women who Valvular heart disease develop hypertension without proteinuria after 20 weeks of gestation. Aortic stenosis Pre-eclampsia is dened by pregnancy-induced hypertension (systolic blood pressure of 140mm Hg Aetiology or more or a diastolic blood pressure of 90mm Hg or Valvular stenosis more on two occasions at least 6h apart) and proteinuria greater than 300mg/24h or urinary Valvular stenosis is caused by calcication of a con- protein:creatinine ratio > 30mg/mmol. Pre-eclampsia affects about 5% of primiparae, but Congenital aortic stenosis (very rare) is less common in subsequent pregnancies by the Congenital aortic stenosis can be due to subvalvular same father. Mild pre-eclampsia is treated with bed rest and close maternal and fetal monitoring. Left ventricularhypertrophy(sustained and heaving Congenital bicuspid valve and infective endocarditis apex). Themurmurbecomesless marked when the stenosis is very tight because Symptoms the ow falls as the heart pump fails. Signs The pulse has a sharp rise and fall (water-hammer or Investigations collapsing) and there is a wide pulse pressure. Chest X-ray: left ventricular enlargement may not left sternal edge maximal in the left third and fourth be present, even in the presence of a prominent intercostal spaces, heard best with the patient leaning apex beat. The aorta is small and may be dilated forward and with the breath held in expiration. There is usually a systolic ow aortic valve may be calcied (best seen on lateral murmur, which does not necessarily indicate aortic chest X-ray).

Research and development of antibiotic substances continues to be the path that promises the greatest success for the effective treatment of future bacterial infections order 50mg minocycline with mastercard. Measures aimed at improving the quality of the evaluation of antibiotic resistance buy 50mg minocycline otc, including the effect of medicinal substances on the organ- ism (pharmacodynamics) and the specic growth conditions of bacteria at the site of the infection cheap minocycline 50 mg amex, are not taken into consideration. In addition, animal models using model bacteria have to be established for experiments with antibiotic therapies. The Federal Ofce for Consumer Protection and Food Safety is in charge of the national resistance monitoring of veterinary pathogens in Germany. However, these networks are not always representative, because a different number of in- stitutions are taking part in it from different countries. In the long term, it is im- portant to achieve a greater degree of representativeness and the continuous support of these networks is required. If successful, the established quality standards and experience could be transferred to other regions and other, in particular gram-negative, pathogens. Molecular epidemiology of antibiotic resistance The objective of molecular epidemiology of antibiotic resistance is to uncover the rationale of resistance development trends derived from surveillance systems and newly emerging antibiotic resistance. Resistant bacteria can be transferred to humans via food or direct contact with animals. As al- ready dened in the 2010 guidelines of the Federal Veterinary Association, an- tibiotics should generally only be used for therapeutic purposes in animals aside from a few justied exceptions rather than for prophylactic purposes. Antibiotic resistance emerging in connection with animal husbandry can im- pair the efcacy of important antibiotics in human medicine. Furthermore, it is imperative to monitor animal pathogenic bacteria and zoonotic parasites and to continue documenting resistance data such as has been done in Germany since 2001 within the scope of the national re- sistance monitoring programme GermVet conducted by the Federal Ofce for Consumer Protection and Food Safety. The awareness of antibiotic resistance and the mechanisms of their develop- ment and spread must also be heightened amongst employees in the agricultural and food industries with regular measures for continuing education. The effects of antibiotic use in animals on the development of resistance and the identication of the transmission pathways are already being discussed by a number of research networks. This indeed effectively pre- vents the breakout of the disease, but the development of antibiotic resistance is promoted. Streptomycin resistance genes were found on mobile genetic ele- ments that code for a phosphotransferase enzyme (StrA, StrB). The same genes have demonstrably been identied in 17 species of environmental bacteria and pathogenic organisms. The purpose is to create management models with the inclusion of all components, ranging from basic research and clinical interventions to healthcare-related economic evaluations. Leading European research insti- tutions have pooled their expertise in the Network of Excellence (NoE) Eu- roPathoGenomics. Within the scope of this initiative, researchers examined the biology and dy- namics of resistance, devised strategies for the prevention of resistance develop- ment and evaluated innovative treatment options. Despite these currently existing research structures, greater support is re- quired in view of the needs for urgent development of new antibiotics, involv- ing the longer-term establishment of research structures beyond national borders. In addition, the success of projects conducted in recent years should be evaluated and favourable approaches pursued further. From the academies point of view, research activities should cover a broad portfolio of topics and methods in order to combat the problem of an- tibiotic resistance from different angles. This new methodological approach has revolutionised biomed- ical sciences and is also important for the research in the eld of antibiotic re- sistance. To facilitate these advances, it is also necessary to establish powerful bio- informatics capacity. What matters most is the ability to analyse large sequence packages and address those functions playing an essential role in the analysis of changes in the genome of pathogenic microorganisms, in particular the analysis of point mutations. In this context, genome research offers direct access to the ex- ploration of virulence and resistance with respect to functional genome analysis. Gene expression under in vivo and in vitro conditions is another crucial fac- tor. This approach should be utilised for re- sistance research and for analysing the expression of resistance-relevant genes. This approach should be used more broadly to explore the spread of resistant pathogens. With re- spect to resistance research, it is necessary to track the expression of genes that are relevant for the metabolism (metabolomics) in order to evaluate new resis- tance mechanisms. Such methods can be used as basis for the development of new test systems that allow a faster and safer analysis of antibiotic resistance. This is attributed in part to poorly designed test systems and the use of low diversity substance libraries. For example, more than 25 gene clusters for the production of secondary metabolites were discovered with the genomic analysis of actinomycetes and myxobacteria. In this context, the possibility of analysing the genomes of host cells should equally be considered. Metabolic functions of the host cells could potentially represent new points of action for active ingredients. Its purpose is to replicate living processes in the laboratory and to establish (micro-) organisms with new properties. The synthesis of major metabolic determinants in the laboratory should be improved to help optimise the production of antibiotics. Examples involving the therapy of malaria (artemisinic acid) give rise to optimism with respect to the use of these methods.

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This correction is convenient for comparisons between countries because age has a powerful influence on the risk of colorectal cancer order 50 mg minocycline with amex. Such age-standardized data demonstrate that incidence of colorectal cancer is 10 to 20 times higher in countries in the top quartile (North America & Western Europe) as compared to those in the lowest quartile (India buy discount minocycline 50mg on line, Africa) generic minocycline 50 mg with amex. In general, the figures correlate well with socio-economic development but not in a strictly linear relationship. The precise pathological origin of functional dyspepsia remains unclear, although a combination of visceral hypersensitivity, gastric motor dysfunction, and psychological factors has been suggested to induce this condition (55). Complications and seriousness Functional dyspepsia is not a life-threatening disorder and has not been associated with any increase in mortality. Diet and functional dyspepsia The role of diet in functional dyspepsia has not been thoroughly studied. Republic Study) Denmark Anual Incidence 1998 National Health Insurance Meineche-Schmidt V, Krag E. Functional selected from the Campania gastrointestinal disorders in children: an region of the Italian National Italian prospective survey. Functional bowel symptoms in a general Dutch population and associations with common stimulants. Turkey 28,40% 2007 Questionnaires Data from Ege University School of Medicine, Sect Gastroenterology (Turkish Gastroenterology Association). Prevalence and interviews Consultation Behavior of Self-Reported Rectal Bleeding by Face-to-Face Interview in an Asian Community. Full- prevalence and clinical course of functional length published manuscripts dyspepsia. These figures are probably distorted by inconsistency in the definition used in the different studies. Functional constipation This functional digestive disorder is characterised by persistently difficult, infrequent, or seemingly incomplete defecation. Individuals should present at least two of the above symptoms for the last 3 months since symptom onset and at least 6 months prior to diagnosis. Complications and seriousness Chronic constipation may lead to complications including hemorrhoids, caused by continuous strain in stool passage, or fecal impaction. This occurs when dried and hard stools accumulate in the rectum and anus, preventing natural ejection. Concomitant alterations induced by fecal impaction encompass swelling of the rectum, fecal incontinence, and rectal bleeding. Diet and functional constipation A high fiber (wholegrain, fruits, vegetables) and fluid intake, regular physical exercise and maintainingoptimal weight are factors contributing to optimal digestive functions and reducing the risk of suffering from constipation. Survey Country Prevalence Type of Study Author/Source of information Date Australia 14,1 - 27,7% 2000 Questionnaire survey. George Peppas, Vangelis G Alexiou, Eleni Sometimes or often Mourtzoukou and Mattew E Falagas. Distribution and Sofia district characteristics of chronic constipation among a part of the population of Sofia District. An epidemiological survey of constipation in canada: definitions, rates, demographics, and predictors of health care seeking. An epidemiologic study of stratified and randomized functional bowel disorders in adolescents in China. Functional questionnaire gastrointestinal disorders in children: an Italian prospective survey. Ponce te al, Am J Epidemiol 2004 Spain 19% Rome I Criteria 2004 Data from Sociedad Espaola de Patologa Digestiva. Prevalence and face interviews Consultation Behavior of Self-Reported Rectal Bleeding by Face-to-Face Interview in an Asian Community. Turkey 8,90% 2008 Data from Ege University School of Medicine, Sect Gastroenterology (Turkish Gastroenterology Association). The highest prevalence detected by the current survey was 34% in children in Italy (but constipation in children is not defined as functional constipation as defined here). The change in trend and the high incidence among children in Western countries point out the need of serious concern with this issue by Public Health Care agencies. Irritable in house-to-house survey bowel syndrome in a rural community in Bangladesh: prevalence, symptons pattern, and health care seeking behavior. The prevalence, patterns random digit telephone and impact of irritable bowel syndrome: dialing an international survey of 40,000 subjects. Prevalence of random sample of irritable bowel syndrome according to population different diagnostic criteria in a nonselected adult population. Prevalence of randomly selected sample irritable bowel syndrome in Shahrekord, of the population Iran. Prevalence of Irritable a self-reported bowel Syndrome, influence of lifestyle questionnaire factors and bowel habits in Korean college Students. Prevalence of race stratified random irritable bowel syndrome in a multi-ethnic sample of population Asian population. Mexico 20%(patients that 2004 Multicentric study Data from Asociacin Mexicana de goes to a Gastroenterologa Gastroenterologist office) Netherlands 6,20% 2003 A community survey using Hungin, A. What general practitioners know General Practitioners about irritable bowel syndrome. The prevalence, symptom characteristics, and impact of irritable bowel syndrome in an Asian community. Mearin et al, Scand J Gastroenterol 2001 Switzerland 8,40% 2003 A community survey using Hungin, A. Irritable bowel syndrome in the 21st century: perspectives from Asia or South-east Asia. Irritable people in a city centre bowel syndrome prevalence in city center of Sivas.

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The key 412 months of therapy to making patient-specifc decisions regarding glycemic tar- Patients with persistent A1C elevation (>8%) with no gets goes beyond the aggregate trial fndings and involves histories of mild or moderate hypoglycemia examination of study subject characteristics and post hoc evaluations cheap 50 mg minocycline visa. The patients with no history of hypoglycemia or in those with his- intensive therapy group demonstrated an increase in mortal- tories of severe hypoglycemia requiring assistance buy discount minocycline 50mg line, it would ity buy 50 mg minocycline visa; however, the highest mortality rate within the intensive be potentially more risky to pursue an aggressive A1C goal. The excess risk occurred in intensive-group subjects the frst 412 months of treatment, the continued pursuit of an with mean on-treatment A1C of more than 7% (Riddle 2010). In addition, the excess risk was demonstrated only in partic- The timing of intervention is also important: The data seem ipants in the intensive group whose A1C did not decline or to support that even though the risk of microvascular compli- declined very little (<0. The evidence supports Not surprisingly, severe hypoglycemia (requiring third-party that such early glycemic interventions can provide lasting assistance for resuscitation) was more common in the inten- benefts (the legacy effect) even if they are not sustained sive group. Elevated blood pressure is a known risk factor for microvas- The highest incidence of severe hypoglycemia in the inten- cular and macrovascular complications in patients with sive group was in subjects with mean A1C between 7% and diabetes. The relationship is linear, with increasing risk mir- 8%, again implicating those unable to achieve a lower A1C. Though a large pool of data Additional analysis indicated that participants with more exists for the evaluation and comparison of various therapeu- nonsevere hypoglycemia (serum glucose <70 mg/dL, no tic agents in the treatment of hypertension for patients with assistance required) during the trial had lower risk of death. The typical physiologic response to hypoglyce- 140/90 mm Hg, with initiation of pharmacotherapy at the sys- mia includes the release of counterregulatory catecholamines tolic threshold of 140 mm Hg and lifestyle interventions at resulting in increased platelet adhesion, increased heart rate, 120 mm Hg. Which A1C goal would be most 58 units subcutaneously daily, metformin 1000 mg orally appropriate for this patient? Overall, the risks of a stringent A1C goal outweigh duration of diabetes, which supports a less-stringent A1C the risks in this patient. Therefore, the evidence supports goal because patients with the greatest evidence-based a less-stringent goal (i. Effects of intensive blood This patient has had a persistently elevated A1C (more pressure control in type 2 diabetes mellitus. Those factors also support a less-stringent A1C intensive glucose lowering in type 2 diabetes. The patients vascular complications action to control cardiovascular risk in diabetes study represent another reason to consider a less-stringent A1C group. There were no signifcant between-group 8090 mm Hg) on microvascular and macrovascular out- differences in the primary outcome. Multiple observational studies support an associa- reduction in total coronary events. Current Kidney Disease: Improving Global Outcomes guide- Cerebrovascular events did not differ between groups. Scrutiny of that assumption, as a basis for guideline rec- strated on microvascular and macrovascular outcomes. A patient with treated hypertension and current blood After the original trial ended, blood pressure differences pressure less than 130/80 mm Hg without adverse between groups were attenuated within 6 months, and levels drug events remained similar for the rest of the post-trial period (mean end 2. Signifcant differences in (prior stroke or transient ischemic attack, multiple macrovascular outcomes, including all-cause mortality and stroke risk factors beyond hypertension and diabetes) 3. A patient with any signifcant degree of albuminuria ings indicate the potential presence of a legacy effect in the treatment of blood pressure in patients with diabetes. The Fenofbrate goal; mean dose about 20mg) alone or in combination with Intervention and Event Lowering in Diabetes investigation blinded fenofbrate 160mg (renally adjusted) for about 4. Though many barriers to therapy increases patient risks, including hepatic damage patient-centered care continue to exist, system-level strat- and rhabdomyolysis. Knowledge of that evidence leads to knowledge and the application of key components such integration with patient-specifc factors that in turn lead as patient as person, biopsychosocial perspective, shared to collaborative determinationwith the patient and other decision-making, and patient-provider relationship. Those members of the health care teamof the most appropriate components can be enhanced by a thorough assessment of glycemic and nonglycemic goals of therapy. Clinical practice guidelines for developing a Diabetes Mellitus comprehensive care plan2015. National lipid association recommendations for patient-centered management of dyslipidemia: part 1 executive summary. Health literacy four major concepts of patient-centered care (patient as per- and health outcomes in diabetes;a systematic review. Standards of medical care sive patient assessment that includes health literacy, patient in diabetes - 2015. Cochrane behavioral review of systems, and routine use of decision Database of Systematic Reviews 2013;10:1-45 aids can improve the patient centeredness of care. The association A1C goal for patients with new diagnoses or short disease between symptomatic, severe hypoglycaemia and mor- durations. Effect of diuretic-based Effects of intensive blood pressure control in type 2 diabe- antihypertensive treatment on cardiovascular disease tes mellitus. Intensive blood glucose control and vascular out- Dewalt D, Berkman N, Sheridan S, et al. Diabetes in primary care: tion of perindopril and indapamide on macrovascular and prospective associations between depression, nonad- microvascular outcomes in patients with type 2 diabetes herence and glycemic control. Collaborative Research Group: Major outcomes in Duckworth W, Abraira C, Moritz T, et al. Glucose control and high-risk hypertensive patients randomized to angi- vascular complications in veterans with type 2 diabetes. N otensin-converting enzyme inhibitor or calcium channel Engl J Med 2009;360:129-139. Crossing the Quality Chasm: A New and cardiovascular disease in patients with type 2 diabe- Health System for the 21st Century.

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This problem upsets me and or interferes with my life 0----------------2-------------------4------------------6-----------------8 not at slightly sometimes much all the all time Problem 1 discount 50 mg minocycline with amex. Time 1 Time 2 Time 3 Problem 2 minocycline 50mg low price. Time 1 Time 2 Time 3 9 Now you have defined your problems 50 mg minocycline with visa, you can decide what you want out of your programme. Goals will help you to: keep focussed on the problem; be clear about what you want to achieve; and get feedback on your progress. You may want to feel better or to feel less anxious but ask yourself what feeling better means you will be able to do. Examples of goals might be: to go and play badminton once a week and enjoy it; to get to sleep in 30 minutes on 6 occasions weekly; and to be able to concentrate and enjoy reading a book regularly. Working with too many goals can be confusing so we would suggest that you work with between 1 and 3 goals. After you have worked on your problem re rate the goal at time 2 to see what progress you have made. In a few months re rate the goals to ensure that you are maintaining your progress. My progress towards achieving each goal regularly without difficulty is: 0----------------2-------------------4------------------6-----------------8 complete 75% 50% 25% 0% success success success success success Goal 1. Time 1 Time 2 Time 3 Goal 2. Time 1 Time 2 Time 3 Goal 3. The strategies aim to change thoughts, physical symptoms or behaviour, and because they each affect one another, a change in one area will lead to changes in the other areas. All the strategies have been studied in research trials and have been shown to help people with anxiety and depression. It is suggested that you read through the following interventions and choose the one that you think is best for you. If you are depressed and finding it difficult to motivate yourself it is often helpful to begin with behavioural activation and then using cognitive restructuring. If you have a specific fear or phobia exposure will probably be the best way of overcoming your problem. If you were suffering from more general anxiety and stress we would suggest that you use problem solving and some relaxation techniques. This will lead to more helpful thoughts such as I have achieved something today and found it pleasurable. Changing your thoughts and behaviour will also lead to positive changes in your physical symptoms. This is to make sure that you can do what you set out to do and that you do not become physically exhausted. Ask yourself if it was because something happened that was outside your control or if it was because you set yourself an unrealistic schedule. Many studies have shown behavioural activation to be helpful when it is used with other treatments such as cognitive therapy. However there is also evidence that this treatment alone is successful in reducing mild and moderate depression. On completing each activity score your feeling of achievement and pleasure using the following scales: Achievement (the sense of achievement you felt) 0----------------2-------------------4------------------6-----------------8 None moderate complete Pleasure (the amount of pleasure you gained) 0----------------2-------------------4------------------6-----------------8 None moderate complete 15 Example of using behavioural activation Anne is 35 and works as a receptionist 3 days a week in a dental surgery. A year ago a long-term relationship had broken down and since then has felt depressed. As result of the death of her mother and loss of relationship, and subsequent depression she has lost contact with many friends and rarely meets other people or socialises other than at work. Consequently she no longer engages in any of her previously enjoyed activities such as going to the cinema, days out at the weekends and going for a drink in the local pub. Anne said that in the evenings and at weekends she does very little except watch television, she used to enjoy gardening but says I just do not seem to be able to get going. Anne also did not do many other things she had stopped reading the daily paper and did not have it delivered any more. She used to go to the local library at least once a week and read 2-3 books weekly. Anne defined her problems and goals as: Problem 1 Feeling depressed and miserable for the last year and I have not been able to motivate myself to do the things I used to enjoy doing. Ringing her friend was the task that she achieved most pleasure as her friend had asked to meet up with her the following week. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9-10 Work Work Work Read paper Read paper Read paper Read paper for 30 for 30 mins for 30 mins for 30 mins minutes A = 5 A = 5 A = 5 A = 5 P = 3 P = 4 P = 4 P = 3 10-11 Work Work Work Library A = 5 P = 5 11-12 Work Work Work 12-1 Work Work Work 1-2 Work Work Work 2-3 Work Work Work 3-4 Work Work Work 4-5 Work Work Work 5-6 Ring a friend A = 6 P = 6 6-7 7-8 8-9 17 Anne slowly increased her levels of activity and looking at her diary 6 weeks later shows the amount of progress that Anne made. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 9-10 Work Work Work Read paper Read paper Read paper Coach outing for 30 mins for 30 mins for 30 mins with friend A = 4 A =4 A = 5 all day P = 4 P = 4 P = 4 10-11 Work Work Work As above 11-12 Work Work Work Shopping As above A= 3 P= 2 12-1 Work Work Work As above 1-2 Work Work Work As above 2-3 Work Work Work Library Inquired re As above A= 6 nightschool P= 5 A= 8 P= 8 3-4 Work Work Work Gardening As above 4-5 Work Work Work Gardening As above 5-6 Read paper Read paper Read paper Read novel Gardening As above A = 4 A = 4 A = 4 A= 6 A= 6 A = 7 P = 4 P = 4 P = 4 P= 5 P= 7 P = 7 6-7 Cinema Read novel A= 6 P= 5 7-8 Cinema 8-9 Cinema A= 7 P = 7 By about week 12 Anne was beginning to feel like her normal self. She felt it had been difficult to do some of the tasks she set herself, particularly in the first 4 weeks but very much worthwhile the effort. We are not very good at taking time out for ourselves, but we always feel better when we do. There are a number of ways of relaxing and you need to choose a way that works for you. Progressive relaxation Use the rating scale on page 17 to rate the level of relaxation you feel before you begin a relaxation exercise. You need to become aware of the feelings you get in your body when you tense and release muscles. There are 16 muscle groups to tense and release and it takes 20 to 30 minutes to go through it all.

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