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Sometimes one professional person is appointed to liaise with you buy kamagra oral jelly 100mg fast delivery erectile dysfunction pump walgreens, as the first point of contact buy kamagra oral jelly 100 mg fast delivery impotence lack of sleep. Teams may involve the neurologist, a nurse, a physiotherapist, a speech therapist, an occupational therapist, a counsellor, an MS Specialist Nurse and possibly others. In general, the move to a team approach has been helpful for people with MS, but problems of coordination between the professions still continue to exist, especially in the community. Sometimes you may be somewhat confused by the large number of professional staff you come into contact with. If you can establish one main person for contact – no matter what their professional discipline – it is very helpful. Note that many hospitals are still underfunded, and the team approach in itself will not lead to a change in that aspect, but they might be used more efficiently. In addition, there are often coordination problems between social services departments and other non-health-based support sources. Visiting your GP/neurologist/MS Specialist Nurse Getting the most out of your visit • Ask for an explanation of any words that you don’t understand – including illnesses, medicines, symptoms or treatments. Increasingly, some doctors are now happy to allow you to tape record your discussions to jog your memory of what he or she said. Research has shown that having such a recording is a great help to yourself, and your family, in following a doctor’s observations or advice. Seeing your GP notes Under recent legislation all patients have the right to see their complete medical notes, and to request corrections to, or deletions of, any inaccurate material – particularly regarding comments on a patient’s attitude or state of mind. The doctor is fully entitled to either sit with you whilst you examine the notes or recover reasonable costs of providing copies (including administration costs). However, you can be refused access to notes when there is a reasonable concern that the contents may have an adverse effect on your welfare. Having a check-up The purpose of the traditional neurological check-up, for which people with MS are asked to return every 6 months or year, is gradually changing. Previously, because there was no real therapy to slow down the course of the disease, the check-up was used to monitor the speed of its progression, and to offer symptomatic and appropriate advice. Many people found this a frustrating system, for often their symptoms were as well controlled as they were likely to be, given the modest resources available, and the consultations following a routine examination frequently appeared cursory, focusing on further decline (or any newly acquired neurological problems) since the last check-up. However, this approach is changing, as neurologists now turn their attention far more towards assisting people to manage MS medically over the longer term, rather than largely focusing on getting the diagnosis right and seeking confirmation of that through monitoring the disease. All this is changing the ‘check-up’ process, making it more likely to be of value to you. Often you will be seen by other specialists – perhaps specially trained nurses – as well as the neurologist; thus the increasing use of MS clinics of the drop- in variety is beginning to make the problematic ‘check-up’ experience of old a matter of the past. However, there are still areas of the country where the old system prevails, and in this case it is very important that you ensure that your questions and concerns are addressed in the consultation with your neurologist – after all it is a two-way discussion. It is important anyway that some periodic monitoring of your MS is undertaken, to give you further information about likely developments in the disease, and to assess your eligibility for newer drugs, or possibly trials of experimental drugs, that is if you wish to participate. In this case a neurological examination will determine, over the course of time, how many episodes of MS have occurred, how many individual areas of the nervous system have been affected, and the rate at which new areas are being affected. You may also have an MRI scan, which records similar information about changes in plaques, plaque location and severity, but which may, from your point of view, be little related to your symptoms. Your clinical history is also vital when your neurologist is dealing with any new episode of MS that occurs. Other support Many people with MS will need professional support services and assistance at some time, to manage the changes in their lifestyles, and to monitor effects of any new drugs. Depending on the precise nature of your MS and its effects, such services may include nursing, physiotherapy, occupational therapy, speech therapy, psychological assessment and support, counselling and advice on housing, employment, financial and other similar issues (see later chapters). Such professional support services for all the many consequences of MS have not previously been adequate, in fact often woefully inadequate and ill coordinated. Despite serious financial constraints, there are now many attempts underway locally to provide better coordinated services and support. MEDICAL MANAGEMENT OF MS 29 Rehabilitation ‘Rehabilitation’ is perhaps the new watchword of longer term care in MS. Regional Rehabilitation Units have been created in recent years for the support of people with many conditions, but there are also an increasing number of more specialist MS rehabilitation units or programmes.

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A combination of changes develop when Chelsea and her new beau (a dentist cheap kamagra oral jelly 100 mg without a prescription does erectile dysfunction cause infertility, whom Norman goads and insults) leave his son for Ethel and Norman to look after 100mg kamagra oral jelly sale erectile dysfunction caused by spinal stenosis. In To Dance with the White Dog (1993), Robert Samuel Peek (Hume Cronyn) is a pecan grower who has been married to Cora (Jessica Tandy) for 57 years when she dies. Sam’s outlook veers to loneliness until he befriends a stray white dog that no one else can see. His dialogues have some insight into loss and preserving relationship memories and loyalty (what the psychodynamic therapists call object rela- tions). The movie shows a touching connection of personal hope in an un- usual example of mourning and preserving love. Moving on, an important perspective in looking at couples’ interactions may be the quote, "Some things are too important to be taken seriously. On the other hand, consider some humor on sex and love: It’s okay to laugh in the bedroom as long as you don’t point. Therapy with Older Couples: Love Stories 89 When choosing between two evils, I always like to take the one I’ve never tried before. Nancy Peske and Beverly West have written a funny and insightful book using popular movies to capture the ups and downs of relationships. A short sampling of their approach should open some minds and mouths with laughter. Then, family psychiatrist, Frank Pittman (who writes a column for the Family Therapy Networker magazine) examines popular movies and the vi- cissitudes of lives in transition, stagnation, tragedy, and health. His lively and insightful columns probe, decipher, and guide couples and the thera- pists who treat them. I had wrapped her in that rug, and she was going to kill me if I didn’t let her out. Friedan goes on to ask whether the problem is really that men die too young, seek younger women, and most women are therefore doomed to lives alone or lives with- out intimacy. Her suggestion is that the problem is not a sexual imbalance, but the fear and denial of age; which reaches its high water mark in sex. Many women and men (married, widowed, single, divorced) fail to move past the youthful sexual measures (with their masks, fears, and shames). She does not denounce the sexual, but uncovers the pos- sibilities of a deeper connection. Friedan argues convincingly that this is new territory, but a territory with much to recommend it. She also references Butler and Lewis (1988) who write about their research on love and sex after 60. In the vein of women’s themes, there is an entertaining and enlightening popular book: Cinematherapy: The Girl’s Guide to Movies for Every Mood (1999). Just as a sample of their humor, enjoy Nancy Peske and Beverly West’s chap- ter headings on such timeless topics as: 1. When Men Were Men and Women Were Wicked Recently, the TV network OXYGEN (which offers themes of particular interest to women) has given Peske and West a regular program to keep current on movies of interest. The authors discuss countless movie recom- mendations to capture themes, dreams, and nightmares. Frank Pittman is a highly respected family psychiatrist, and a writer on families and the nature of men and their possibilities and peculiarities. Mag- gie Scarf in her review called it "delightfully readable, compassionate, and awfully funny at the same time. The magazine for its for- mative years was called the Family Therapy Networker, and more recently: the Psychotherapy Networker. A sampling of Pittman’s reviews shows keen insight into a wide range of issues in society, families, couples, and gender contrasts. Some of his per- spectives and movie reviews fit well in working with couples of any age. The venue of the silver screen has rarely been explained so well in showing us our themes and blunders, strivings, and self-deceptions, but also the possibilities and paths of loving couples. Therapy with Older Couples: Love Stories 91 One of Pittman’s columns "Rebels Without a Clue" (Family Therapy Net- worker, August, 1995), compared Marlon Brando, James Dean, Montgomery Clift, and Paul Newman. He saw each of them as alienated in their own lives and adept at portraying that experience in powerful films that shaped our culture. Brando, diagnosed with Attention Deficit Disorder and labeled "unedu- cable," was said to wander around unbathed, seeking love and food for his unquenchable appetites.

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It is important that your bladder is as empty as possible after you have urinated purchase kamagra oral jelly 100 mg fast delivery erectile dysfunction treatment portland oregon, not least to try and avoid an infection cheap 100mg kamagra oral jelly with mastercard erectile dysfunction treatment duration. If you need further advice, make an appointment to see your doctor or, if possible, your neurologist or continence nurse/advisor. Urinary tract infection If urination is painful or associated with a burning sensation, and even more so if it smells unpleasant and is cloudy, the chances are that you have a urinary infection. Kidney infections are particularly worrying in MS: they may be asso- ciated with both abdominal pain and a high fever, and require a tougher drug approach, perhaps with intravenous antibiotics. The problem is that, once infections get a hold in the kidneys, there is a substantial risk that they pass unchecked into the bloodstream, and cause major, even on occasions life-threatening, difficulties. On the other hand some urinary infections in MS can be almost symptomless, and thus periodically – and especially if you feel that you suffer from some prob- lems of urine retention – ask your doctor if you could have a urine test for infections just to make sure. For people who seem particularly liable to urinary tract infections, a long-term low-dose antibiotic might be given occasionally to eliminate or suppress bacteria. It is also a wise precaution to empty your bladder both before and after sexual intercourse. Indwelling catheterization When urinary difficulties become a real problem, a permanent catheter can be fitted. Although some may think this is more convenient, it is not an easy step to take for many others; some actually think of it as the hidden equivalent of being in a wheelchair. Furthermore, medically, it is best if some other way can be found to manage urinary problems. An indwelling catheter opens up the inside of the body to the continual possibility of infections from which it is normally protected, even during ISC, and it can be particularly dangerous if you have a weakened immune system. Therefore, in principle, the less time that people with MS use an indwelling catheter, the better. If the MS becomes more severe, there may be no option, particularly when you cannot undertake ISC, or when drugs or other strategies do not appear to deal with the problem. An indwelling catheter can be inserted through the urethra (like ISC), or through a specially constructed surgical opening in the lower abdomen, above the pubic bones (‘suprapubic catheterization’). Through the other end, on the outside of the body, urine is continuously drained into a collection bag. Increasingly, the medical preference is to insert the catheter through the special opening in the lower abdomen. This is because a permanent catheter through the urethra may enlarge, change or disrupt the urethral opening, and make it difficult to maintain control of the urine. An indwelling catheter like this can cause problems with sexual activity and we deal with this elsewhere in Chapter 5. Even if a catheter is inserted through the lower abdomen, there are still likely to be some problems: PROBLEMS WITH URINATION AND BOWELS 53 • Infection can occur around the site of the insertion. An indwelling catheter can be used on a temporary basis, or for particular occasions when other means of urinary control are difficult, but you need to discuss all this with your doctor or continence nurse. Each insertion runs a risk of introducing infection and it has to be undertaken as meticulously as possible. Surgery and urinary problems in MS Surgery is very rarely performed to ensure urinary control in MS – indeed it seems to offer no major improvement in such control. Several procedures are possible, but are only undertaken on rare occasions when almost all else has failed, and a more or less intractable problem remains. There is another factor here: MS, over time, is a progressive disease, and it is possible that once you have undergone some surgery, other surgical procedures may then be needed later, to manage further problems that might arise. Other management techniques In addition to trials of further drugs that may be of value to people with MS, some other procedures or techniques may help. Research has suggested that bladder training – involving working out a schedule of regular urination on the basis of ultrasound assessments – together with ISC, may be helpful. Because of the association between CNS control of leg function and urinary function, an appropriate exercise regime may help the urinary function indirectly. Bladder training generally involves a series of educational and training exercises.

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