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The first species is responsible for abdominal angiostrongyliasis; the second for eosinophilic meningitis or meningoencephalitis; and the third buy kamagra polo 100 mg lowest price impotence versus erectile dysfunction, A kamagra polo 100 mg free shipping impotence with prostate cancer. Some 12 other rat species have been found to be infected; coatis (Nasua arica) kamagra polo 100mg fast delivery erectile dysfunction treatment center, monkeys (Saguinus mystax), and dogs can be exper- imentally infected. The female lays eggs in those arteries; the eggs are then carried by the bloodstream and form emboli in the arterioles and capillaries of the intestinal wall. The eggs mature and form a first-stage larva which hatches, penetrates the intestinal wall to the lumen, and is carried with the fecal matter to the exterior, where it begins to appear around the twenty-fourth day of the prepatent period of the infec- tion. In order to continue their development, the first-stage larvae have to actively penetrate the foot of a slug of the family Veronicellidae (particularly Vaginulus ple- beius) or be ingested by it. In Brazil, four species of Veronicellidae slug were found to be infected: Phyllocaulis variegatus, Bradybaena similaris, Belocaulus angustipes, and Phyllocaulis soleiformis (Rambo et al. In the slug, the lar- vae mature and change successively into second- and third-stage larvae in approxi- mately 18 days. The third-stage larva, which is infective for the definitive host, is eliminated with the slug’s mucous or slime, and contaminates the soil and plants around it (Mojon, 1994). When the definitive host ingests the infective larva in the free state or inside the mollusk, the larva migrates to the ileocecal region, penetrates the intestinal wall, and invades the lymphatic vessels. In this location the larvae undergo two molts before migrating to their final habitat: the mesenteric arteries of the cecal region. The parasite can complete the life cycle in man, an accidental host, reaching sexual maturity and producing eggs, but the eggs usually degenerate, caus- ing a granulomatous reaction in the intestinal wall of the host. The intermediate hosts are various species of land, amphibian, or aquatic gastropods, e. The definitive hosts can become infected by ingesting the infective third-stage larvae, either with infected mollusks or with plants or water contaminated with the larvae that abandon the mollusk. In addition, infection can occur as a result of consuming transfer hosts (paratenic hosts), such as crustaceans, fish, amphibians, and reptiles, which in turn have eaten infected mol- lusks or free larvae. When a definitive host ingests an infected mollusk or infective larvae, the larvae penetrate the intestine and are carried by the bloodstream to the brain, where they undergo two additional changes to become juvenile parasites 2 mm long. From the cerebral parenchyma, they migrate to the surface of the organ, where they remain for a time in the subarachnoid space and later migrate to the pul- monary arteries, where they reach sexual maturity and begin oviposition. The eggs hatch in the pulmonary arterioles or their branches, releasing the first-stage larva, which penetrates the pulmonary alveoli and migrates through the airways to the pharynx; there it is swallowed and is eliminated with the feces starting six weeks after infection. Snails or slugs, which are the intermediate hosts, become infected when they ingest the feces of infected rodents. The third-stage infective larva forms in the mollusk in 17 or 18 days and can remain there for some time or be expelled and contaminate the envi- ronment. A large number of paratenic or transport hosts, such as crustaceans, fish, amphibians, or reptiles, may become infected with these larvae and, in turn, infect rats or human beings. The adult parasite has been found in rats, and its larva infects the snail Biomphalaria glabrata, although not as easily as it infects A. It has been iden- tified in children in Costa Rica since 1952, and more than 130 human cases had been diagnosed when Morera and Cespedes described the parasite in 1971. Morera (1991) indicated that about 300 cases a year were diagnosed in Costa Rica alone. In 1992, two cases were discovered in children on the French island of Guadeloupe in the Caribbean (Juminer et al. The first known epidemic occurred in 1994–1995 in Guatemala and affected 22 persons (Kramer et al. With respect to the animal definitive hosts, 15% of Rattus norvegicus and 6% of R. In Panama, the adult parasite was found in five species of rodents belonging to three different families. It is highly probable that the parasitosis is much more wide- spread than is currently recognized. In 1992, 27 cases had been reported in Japan, the majority in the prefecture of Okinawa. It is believed that the parasite was introduced to the island some years ago by rats from a ship from Asia. Since 1950, cases have been identified in Indonesia (island of Sumatra), Philippines, Taiwan, and even Tahiti. It subsequently appeared in Australia, mainland China, India, and Japan (Okinawa). The Disease in Man: The clinical manifestations of abdominal angiostrongylia- sis caused by A. Leukocytosis is characteristic (20,000 to 50,000 per mm3), with marked eosinophilia (11% to 82%). Lesions are located primarily in the ileocecal region, the ascending colon, appendix, and regional ganglia. Granulomatous inflammation of the intestinal wall can cause partial or complete obstruction. Out of 116 children with intestinal eosinophilic granulomas studied from 1966 to 1975 in the National Children’s Hospital in Costa Rica, 90 had surgery (appendectomy, ileocolonic resection, and hemicolectomy). Ectopic localizations may occur, such as those found in the livers of Costa Rican patients with visceral larva migrans-like syndrome (Morera et al. In Taiwan, the disease occurs mainly in children, but in other endemic areas it occurs in adults. A study of 82 children found that the incubation period was 13 days, shorter than the average of 16. The symptoma- tology of meningitis and eosinophilic meningoencephalitis was studied in 1968 and 1969 in 125 patients from southern Taiwan. Most patients had a mild or moderate symptomatology, and only a few suffered serious manifestations; four of the patients died and another three had permanent sequelae. In 78% of the patients, the disease had a sudden onset, with intense headache, vomiting, and moderate intermittent fever. More than 50% of the patients experienced coughing, anorexia, malaise, constipation, and somnolence, and less than half had stiffness in the neck. Pleocytosis in the cerebrospinal fluid was particularly pronounced in the second and third weeks of the disease. The percent- age of eosinophils was generally high and was directly related to the number of leukocytes in the cerebrospinal fluid. While there are no effective anthelminthic and the headaches and weakness can last a few weeks, as a general rule the patient recovers without sequelae. The reason for the different clinical pictures is not known, but the severe cases may be due to the higher number of parasites present (intensity of infection). Eosinophilic meningitis usually occurs after the ingestion of paratenic hosts or contaminated vegetables containing few larvae; the most serious forms of the disease are due to direct consumption of highly infected intermediate hosts (Kliks et al. In American Samoa, an out- break of radiculomyeloencephalitis was described in 16 fishermen who had con- sumed raw or undercooked Achatina fulica (giant African snail), an intermediate host of A. In addition to eosinophilia in the spinal fluid and the blood, the disease was characterized by acute abdominal pain, generalized pruritus, and later by pain, weakness, and paresthesia in the legs, and dysfunction of the bladder (urinary retention or incontinence) and the intestine. Half of the patients suffered transitory hypertension or lethargy; three entered a coma and one died.

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One might have experimented with its calibrations buy cheap kamagra polo 100mg line erectile dysfunction treatment hypnosis, but the device itself was irreplaceable order kamagra polo 100 mg amex erectile dysfunction endovascular treatment. In 2002 buy kamagra polo 100 mg otc erectile dysfunction at the age of 21, a number of organizations—the Fogarty The review generated findings about the comparative cost- International Center of the U. National Institutes of Health, effectiveness of interventions for most diseases important in the World Bank, the World Health Organization, and the Bill & developing countries. This consistency constraint led to downward one dealing with deaths and the disease burden by cause and revision of the estimates of deaths from many diseases. In addition, the because health system activities, including the choice of inter- World Bank invested in generating improved estimates of ventions, depend partly on the magnitude of health problems, deaths and the disease burden by age, cause, and region for and because assessment of the burden of diseases, injuries, and 1990. Results of this initial assessment of the global burden of risk factors includes important methodological and empirical disease appeared both in the World Development Report 1993 dimensions. Organization has also invested in improving the conceptual, During 1999–2004, the authors of this volume and many methodological, and empirical basis of burden of disease collaborators from around the world worked intensively to assessments and the assessment of the disease and injury assemble an updated, comprehensive assessment of the global xvii burden of disease and its causes. New York: Oxford University conditions of the world’s population at the beginning of Press. Quantification of Health Risks: The Global and Regional Burden of New York: Oxford University Press. Prior to joining the World Health Organization health and Head of the School of Population Health at the in 2000, he worked for the Australian Institute of Health and University of Queensland, Australia. Prior to joining the uni- Welfare for 13 years in technical and senior managerial posts. Mathers has published widely on population health Health Organization in Geneva, where he held a series of tech- and mortality analysis; on inequalities in health, health nical and senior managerial posts, including chief epidemiolo- expectancies, and burden of disease; and on health system gist in the Tobacco Control Program (1992–5), manager of costs and performance. He developed the first set of the Program on Substance Abuse (1996–8), director of the Australian health accounts mapping health expenditures by Epidemiology and Burden of Disease Unit (1999–2001), and age, sex, and disease and injury causes (1998) and carried out senior science adviser to the director-general (2002). At the World Health Organization, he played a key role and causes of death, including the impact of the global tobacco in the development of comparable estimates of healthy life epidemic, and on the global descriptive epidemiology of major expectancy for 192 countries, in the reassessment of the global diseases, injuries, and risk factors. He is the coauthor of the burden of disease for the years 2000–2, and in the develop- seminal Global Burden of Disease Study (1996), which has ment of software tools to support burden of disease analysis at greatly influenced debates about priority setting and resource the country level. He has been awarded major research global, regional, and country mortality and burden of disease grants in epidemiology, health services research, and popula- from 2002 to 2030. Mathers graduated with an honors degree and university Queensland; and is a member of Australia’s Medical Services medal in physics from the University of Sydney in 1975 and was Advisory Committee. His principal research interests are the measure- ematics from the University of Western Australia in 1973 and a ment and reporting of population health and its determinants, master of science degree in statistics from Purdue University in burden of disease methods and applications, measurement of the United States. His He has collaborated with leading researchers throughout the principal research interests are analysis of mortality data; bur- world on issues relating to the development and applications of den of disease methods and applications; and quantification of summary measures of population health. He has collaborated extensively with leading researchers Majid Ezzati is an assistant professor of international health at throughout the world on these issues, particularly at Harvard the Harvard School of Public Health. He holds bachelor’s and and Oxford universities, and he holds an adjunct appointment master’s degrees in engineering from McMaster and McGill at Harvard University as professor of population and interna- Universities and a Ph. Ezzati’s research interests center around understanding the causal determinants Colin D. Mathers is a senior scientist in the Evidence and of health and disease, especially as they change in the process of Information for Policy Cluster at the World Health social and economic development and as a result of technolog- Organization in Geneva. World Health Organization’s Epidemiology and Burden of xix His current research focuses on two main areas. Murray is the Richard Saltonstall professor of area is the relationship among energy, air pollution, and health public policy, professor of social medicine, and director of the in developing countries, on which he conducts field research Harvard Initiative for Global Health. This research has led to university, for five years he led the World Health Organization’s the identification and design of technological interventions for Evidence and Information for Policy Cluster, which was dedi- reducing exposure to indoor air pollution from household cated to building the evidence base and fostering a culture of evi- energy use. His second area of research is major health risk fac- dence to inform health decision making. The cluster was respon- tors and their role in the current and future disease burden sible for work on epidemiology and the burden of disease, the globally and in specific countries and regions. His research on World Health Survey,cost-effectiveness analysis,national health risk factors focuses on environmental risks, smoking, and accounts, catastrophic health spending, responsiveness, health nutritional risks. He was the lead scientist for the World Health financing policy, human resources for health systems, coverage Organization’s Comparative Risk Assessment Project, which of health interventions, quality of care and patient safety, stew- was reported in the World Health Report 2002: Reducing Health, ardship of health systems,assessment of health system perform- Promoting Healthy Life. He is currently studying the role of ance,health research policy,and a range of efforts to manage and major risk factors in health inequalities. Jamison is a professor of health economics in the School focused on tuberculosis control and the development with of Medicine at the University of California, San Francisco Alan D. Jamison concurrently serves as an Adjunct Professor in both metric for comparing deaths and disabilities caused by various the Peking University Guanghua School of Management and diseases and the contribution of risk factors to the overall bur- in the University of Queensland School of Population Health. Jamison was on the faculty of the neering effort has been hailed as a major landmark in public University of California, Los Angeles, and also spent a number health and an important foundation for policy formulation of years at the World Bank, where he was a senior economist and priority setting. Murray has contributed to in the research department, division chief for education the development of a range of new methods and empirical policy, and division chief for population, health, and nutri- studies for strengthening the basis for population health meas- tion. In 1992–93 he temporarily rejoined the World Bank to urement and cost-effectiveness analysis. A main thrust of his serve as Director of the World Development Report Office work has been the conceptualization, measurement, and appli- and as lead author for the Bank’s 1993 World Development cation of approaches to understanding the inputs, organiza- Report: Investing in Health. His publications are in the areas of tion, outputs, and outcomes of health systems. Jamison or edited eight books, many book chapters, and more than 90 studied at Stanford (B. National Academies, Gainesville, Florida, United States Perla Santos Ocampo President, National Academy of Science and Thechnology, San Guy de Thé, Co-chair Juan, Philippines Research Director and Professor Emeritus, Institut Pasteur, Paris, France G. Academy of Medical Sciences, Cambridge, Gates Foundation, Seattle, Washington, United States United Kingdom xxi Misael Uribe Witold Zatonski President, National Academy of Medicine of Mexico, Mexico Professor, Health Promotion Foundation, Warsaw, Poland City, Mexico Zhengguo Wang Professor, Chinese Academy of Engineering, Daping, China xxii | Advisory Committee to the Editors Contributors Stephen J. Murray World Bank Harvard University Initiative for Global Health; Harvard School of Public Health Goodarz Danaei Harvard School of Public Health; Harvard University Anthony Rodgers Initiative for Global Health University of Auckland Majid Ezzati Joshua Salomon Harvard School of Public Health; Harvard University Harvard School of Public Health Initiative for Global Health Sonbol A. Jamison Population Reference Bureau; Disease Control Priorities University of California, San Francisco; Disease Control Project Priorities Project Stephen Robert Vander Hoorn Julian Jamison University of Auckland University of California, Berkeley Jelka Zupan Joy E. Lopez University of Queensland; Harvard School of Public Health xxiii Disease Control Priorities Project Partners The Disease Control Priorities Project is a joint enterprise of billion to $22 billion each year in loans to its client countries, the Fogarty International Center of the National Institutes provided $1. The World Bank is working in more than 100 developing and the Population Reference Bureau. For 75 years, the The World Health Organization is the United Nations’ spe- bureau has analyzed complex data and research results to cialized agency for health. Its objective, as set out in its consti- provide objective and timely information in a format easily tution, is the attainment by all peoples of the highest possible understood by advocates, journalists, and decision makers; level of health, with health defined as a state of complete phys- conducted workshops around the world to give key audiences ical, mental, and social well-being and not merely the absence the tools they need to understand and communicate effec- of disease or infirmity. Breman, Mariam Claeson, tutions and individuals spanning a period of more than David B. Richard Suzman of the National Institute on from the contributions of those institutions and the efforts of Aging provided invaluable support and critical reactions.

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Consistent with a minor vagal influence cheap kamagra polo 100 mg overnight delivery erectile dysfunction diabetes, structural and functional investigations of nerve circuits in the small intestine indicate that there is a predominance of local connections made with enteric neurons [27] cheap 100mg kamagra polo mastercard erectile dysfunction nutrition. In contrast cheap kamagra polo amex doctor for erectile dysfunction in ahmedabad, vagal pre-enteric neurons innervate all intrinsic neurons in the bladder [28]. The exocrine pancreas has a strong reliance on vagal control [29], suggesting that here also there are pre-enteric inputs to a high proportion of pancreatic neurons. The greater splanchnic nerve that supplies the upper abdomen contains about 3,000–4,000 afferent fibers and the lumbar splanchnic nerves contain about 4,000–5,000 afferent 46 J. A high proportion of the afferent neuron endings is around arterioles in the gut wall [7]. The axons of spinal afferent neurons also provide a sparse network of varicose axons in the myenteric ganglia [30, 33]. Thoracolumbar afferent endings also branch within the lamina propria of the mucosa throughout the gastrointestinal tract, although their branching patterns have not been defined [7]. As they pass through sympathetic prevertebral ganglia, the axons of spinal afferent neurons provide collaterals that form synapses with cell bodies of postganglionic neurons [34]. In fact, it seems remarkably insensitive to stimuli, such as cutting, that would cause pain elsewhere. Gastrointestinal pain is associated with inflammation, and post- inflammatory disorders [35, 36]. Experimental studies indicate that inflammation causes long term changes in the properties of spinal afferents, that causes unresponsive neurons to become sensitive and responsive neurons to become hypersensitive [37, 38]. The sympathetic efferent pathways have four primary targets: myenteric ganglia, submucosal ganglia, blood vessels and sphincter muscle (Fig. The preganglionic sympathetic neurons have their cell bodies in the intermediolateral columns of the spinal cord. Postganglionic neurons of vasoconstrictor pathways are in sympathetic chain and prevertebral ganglia. Postganglionic (pre-enteric) neurons with cell bodies in prevertebral ganglia provide a dense innervation of myenteric and submucosal ganglia. In both cases these are inhibitory; the sympathetic inner- vation of myenteric ganglia inhibits excitatory effects of enteric neurons on the muscle of the stomach and intestine, thus slowing passage of the contents of the gastrointestinal tract [39]. The innervation of submucosal ganglia inhibits secretomotor neuron activity (see later section “Neural Control of Fluid Movement: Secretomotor and Vasomotor Reflexes”). Sympathetic post-ganglionic neurons contract the sphincters of the gastrointestinal tract, which, like the innervation of myenteric ganglia, inhibits transit of contents. Pelvic Innervation The distal colon and rectum are provided with afferent and efferent innervation via the pelvic nerves and sacral plexuses. The pelvic nerves are commonly regarded as providing an innervation to the distal gut similar to that provided by the vagus to the proximal gut. However, unlike the vagal afferent nerves, the pelvic afferents include pain fibers [40]. This diagram illustrates the inner- vation pathways for the non-sphincter regions of the stomach, small and large intestines. The densest innervation is of the myenteric ganglia throughout these regions, the submucosal ganglia of the small and large intestines, and intramural arteries. Few sympathetic fibers innervate the muscle of non-sphincter regions, whereas the sphincter muscle is densely innervated. The post- ganglionic neurons that innervate gut effectors have noradrenaline as their primary transmitter. The participation of the sympathetic innervation of the gastrointestinal tract in disease states. It is established that the pelvic nerves carry afferent information from low threshold mechanoreceptors. Mucosal mechanoreceptors in the large intestine are similar to those in the stomach and proximal small intestine, in that they respond to mild stroking of the mucosa, but not to distension or contraction of the colon [45]. The efferent pathways in pelvic nerves provide innervation to enteric ganglia of the distal colon and rectum [46]. Retrograde tracing indicates that nerve cells in the sacral spinal cord project directly to the colon, and that there are also nerve cells that project from the pelvic ganglia to the colon [47], suggesting that pre-enteric neurons are in both the spinal cord and in pelvic ganglia (Fig. For motility control, the innervation of enteric ganglia comes from the defecation centers that are in the lumbosacral spinal cord, between L5 and S3 (the levels being slightly different between species) [48]. In the rat the center is located primarily at L6-S1 [49–51] and in the guinea-pig at S1–S2 [47]. Reflexes through this center can be initiated by irritation or distension of the rectum; they persist after transection of the more rostral spinal cord, but are eliminated by section of the sacral outflows or the pelvic nerves [48, 52, 53]. In healthy individuals, the propulsive reflexes of the distal colon and rectum are kept in check to maintain fecal continence by central control centers that relay in the spinal defection center, and when defecation is appropriate it is triggered by central commands that impinge on the defecation center. Voluntary control of defecation (both inhibition and facilitation) is lost if cortico-spinal connections to the defecation centers are severed by spinal injury [55]. The pelvic pathways also carry pathways that cause vasodilation in the colorectum [57]. Cervical Spinal Afferents Although the gut does not receive efferent inputs from the cervical spinal cord, afferent neurons that supply the upper, striated muscle, part of the esophagus do make connections at this level [58]. Under these circum- stances, no propulsive activity occurs in the aganglionic bowel, and the newborn child will die if this region is not removed. Similar absence of enteric neurons in the distal bowel is also lethal in other species, including horse (lethal white syndrome), rats and mice [60]. Degeneration of colonic enteric neurons in Chagas’ disease, precipitated by infection with the protozoan Trypanosoma cruzi, causes colorectal propulsion to fail and megacolon to develop in the adult, similar to the problems 3 The Enteric Nervous System and Gastrointestinal Innervation: Integrated. Other enteric neuropathies that have significant effects on the motor functions of the digestive tract include esophageal achalasia, gastroparesis and hypertrophic pyloric stenosis [62]. The control of fluid movement between the intestinal lumen and body fluid compartments (discussed below) is also subject to pathological, life threatening, influences. The fluid movement is controlled by enteric secretomotor neurons that are abnormally activated by certain infective agents or their products. These pathogens, including cholera toxin and rotavirus, act directly on the secretomotor neurons and on the mucosal epithelial cells to cause life-threatening fluid loss [63]. Pavlov achieved a complete vagal denervation of the abdominal organs in dogs: these animals showed no evidence of ill-health, although responses to sham feed- ing, which are vagally mediated, were lost [64]. In humans, total abdominal or selective vagotomy has been used as a treatment for tens of thousands of peptic ulcer patients, without any indication of significant morbidity due to the vagotomy itself [65]. Complete removal of the sympathetic chains in cats left the animals in good health for many months after the surgery, although they became very sensitive to a cold environment [66]. Likewise, in humans in which sympathetic innervation of the gastrointestinal tract is removed for vascular disease or pain, there is no significant morbidity [67, 68]. Denervation of the gut by destructive lesions of the pelvic nerves or sacral plexus does not significantly disturb colorectal function, but it does compromise voluntary control of defecation and it can cause fecal incontinence [55, 69]. Large numbers of neurons are contained in the enteric nervous system, about 200–600 million in human [27]. This is more than the total numbers of neurons of all sympathetic and parasympathetic ganglia combined and about the same number of neurons that are in the spinal cord.

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Your dentist may have training videos that show dental work being done that you could borrow discount kamagra polo online american express impotence vacuum pump. Or buy genuine kamagra polo online erectile dysfunction doctors austin texas, instructional videos may be available from a dental school or a school for dental hygiene if one exists in your area order kamagra polo 100mg online erectile dysfunction doctor in philadelphia. In addition, there are Web sites that have brief videos of dental work (such as www. For photos of dental items and situations, search Google’s images site (http://images. You could also look at a library, dental school library, or bookstore for textbooks and journals with a dental theme. You can also look in your yellow pages for dental supply stores or search the Internet for businesses that sell dental supplies and equipment. Finally, your dentist may be able to recommend places where you can purchase dental supplies. These include dentists’ offices (and dentists’ chairs), dentists’ waiting rooms, and possibly a clinic at a dental or dental hygienists’ school. Many dental schools have a museum where various dental objects may be dis- played. If you let your dentist know about your fear, you could ask if it would be possible to have a visit without getting any work done, just so you could have an oppor- tunity to sit in the dentist’s chair and have a look at some of the instruments that dentists use. Dentists may also be able to spread out dental work over a few appointments, allowing you more of an opportunity for gradual exposure. Your dentist and dental hygienist may be happy to go at your pace, explaining things as they go along. Some of our clients with dental fears have found that the sound of an electric toothbrush replicates the sound or experience of a den- tist’s drill fairly closely. If you plug your ears with earplugs when using an electric toothbrush, the experience may be even more realistic. There are also Web sites that have sound libraries available to download, including sounds found in a den- tist’s office. Alternatively, consider asking your dentist if you could get a tape recording of a dental procedure; or, if a friend is going to the dentist, he or she may be able to get permission from an understanding dentist to make a brief audiotape (or even a videotape) of the experience. Here are some ideas for images, items, and set- tings you might use for your exposures. There are also many video games now available that have fairly realistic scenes involving blood that you could consider using as an expo- sure item. For example, go with a friend when he or she donates blood or has a blood test done. As you try to generate ideas, consider exposures to real blood (buy a steak and drain off the blood or prick your finger with a lancet, available in pharmacies) or to theatrical blood (available at joke shops, theatrical stores, costume shops, and Halloween supply stores). These 66 overcoming medical phobias places will often also supply other blood-related items and materials to create fake cuts and wounds. Consider filling a syringe or some other small container with theatrical blood to carry around with you. There are Internet sites that supply recipes for making very realistic-looking fake blood. Wiped onto a cloth or article of clothing, this theatrical blood looks very realistic. Consider renting one of these movies and repeatedly watching only the injec- tion scenes until your anxiety lessens. Your pharmacy or local diabetes clinic may have educational videos avail- able to teach people how to give insulin injections. You may also want to consider movies or videos that involve subjects like tattooing, piercing, or acupuncture. You may be able to receive immunizations for various infections such as hepatitis A or B. Your doctor may be able to supply you 68 overcoming medical phobias with a few needles that you could take home and use as exposure items. Go along and watch when your helper or a friend visits the doctor for a vaccination or a flu shot. Or, go along and watch when your helper or a friend has blood taken or gets a piercing. If you know someone who has a condition that requires regular injections (such as insulin for diabetes), ask if you could watch the injection process. You may find that once treatment is under way, some items you initially thought would be helpful become less so. You may also find the opposite is true—as you progress with your exposure exercises, you discover new ideas, situ- ations, or objects that cause fear. Because tracking down items, images, and settings for your exposure practice will require you to encounter things and situations that may cause you great distress, you should consider having your helper preparing for treatment 69 assist in this process. You should go over your hierarchy and your list of needed items with your helper and discuss who will get what, leaving some of the more anxiety- provoking items for your helper to screen ahead of time. This is why it’s important to have a helper who doesn’t have the same fear you do. In fact, reading through this chapter may have been a bit of an exposure exercise in itself. Remem- ber, too, that often these exercises can leave you feeling drained, tired, tearful, or irritable. Some people find they feel more tense afterward and have to deal with head- aches or muscle stiffness. To help cope with these poten- tial reactions, plan to reward yourself after each exposure exercise. Make a point of going for a walk, getting together with friends, listening to some of your favorite music, or soaking in a warm bath. Consider buying your- selfatreat,suchasanewoutfitordinneratagreatres- taurant, to reward yourself for a job well done after tackling a really tough step on your hierarchy. In this chapter, we discussed the potential benefits of enlisting a helper, who may be a friend, a family member, or a professional therapist. We also reviewed the importance of gathering materials to use in your exposure practices and suggested a number of resources available to that end. Following the guidelines and suggestions in this chapter will help you lay the foun- dation for successful treatment. The drive to be comfortable leads people to take medication for a headache, run cold water over a burn, eat when hungry, sleep when tired, or have a glass of wine when feeling shy at a party. Therefore, one of the most noticeable fea- tures of any phobia is the tendency to avoid feared situa- tions or to find ways of protecting oneself from feeling overly anxious or frightened in these situations. For example, although many sleep medi- cations are effective for improving sleep on any particular night, discontinuing these medications after a period of regular use is often associated with “rebound” insomnia caused by withdrawal from the medication. In other words, these medications offer a short-term solution to insomnia that may actually increase the problem in the future, when the person stops taking the medication. In the same way, avoiding or escaping from a feared situation leads to immediate relief but makes it more likely that you’ll continue to have fear when you encounter the situa- tion in the future. As we discuss in chapter 7, fear and anxiety are often triggered by negative predictions and assumptions that a situation is dangerous in some way.