DIET AND CANCER

The link between diet and cancer is one of the most challenging areas of current research. Some things are known with reasonable certainty, some things will be known for certain quite soon and others remain rather speculative. We believe that the link between fibre (and perhaps starch) and cancer of the large bowel is reasonably well established. The link between fat and breast cancer may not be direct and causal. Similarly, the link between fat or meat and bowel cancer may not be a direct causative one. The link between vitamin A and carotene and prevention of lung cancer and probably other cancers is still unproven, although a lot of supportive evidence exists which may be confirmed by the results of important trials in the next five years or so. Obesity is strongly associated with a number of relatively uncommon cancers. The evidence incriminating food additives and substances produced in cooking and then eaten is relatively slender except for that relating to anatoxins from fungi, which may be important in liver cancer in the developing world. Certain nitrogen compounds in rood, especially when it is smoked or preserved, are possibly implicated in stomach cancer. So what does a practical person do about diet in order to
minimize cancer risk?
These are among the most difficult recommendations we have to make because the area is so important but so uncertain. It is sensible to think about food rather than the nutrients of which it consists since this is the choice facing the individual. It seems also sensible to think about enjoyable food because only this advice is likely to be accepted. Any changes have to be moderate, easy and cheap. Any supplement to diet must be simple, cheap and accessible.
We have been impressed by some evidence and confounded by some. The science of nutrition can be rather inexact. The International Agency for Research on Cancer in Lyon has a programme to collect the dietary facts from 350,000 Europeans in the next few years. We await their results with interest and wish them good luck – they may need it.
*65\194\4*

DIET AND CANCERThe link between diet and cancer is one of the most challenging areas of current research. Some things are known with reasonable certainty, some things will be known for certain quite soon and others remain rather speculative. We believe that the link between fibre (and perhaps starch) and cancer of the large bowel is reasonably well established. The link between fat and breast cancer may not be direct and causal. Similarly, the link between fat or meat and bowel cancer may not be a direct causative one. The link between vitamin A and carotene and prevention of lung cancer and probably other cancers is still unproven, although a lot of supportive evidence exists which may be confirmed by the results of important trials in the next five years or so. Obesity is strongly associated with a number of relatively uncommon cancers. The evidence incriminating food additives and substances produced in cooking and then eaten is relatively slender except for that relating to anatoxins from fungi, which may be important in liver cancer in the developing world. Certain nitrogen compounds in rood, especially when it is smoked or preserved, are possibly implicated in stomach cancer. So what does a practical person do about diet in order tominimize cancer risk?These are among the most difficult recommendations we have to make because the area is so important but so uncertain. It is sensible to think about food rather than the nutrients of which it consists since this is the choice facing the individual. It seems also sensible to think about enjoyable food because only this advice is likely to be accepted. Any changes have to be moderate, easy and cheap. Any supplement to diet must be simple, cheap and accessible.We have been impressed by some evidence and confounded by some. The science of nutrition can be rather inexact. The International Agency for Research on Cancer in Lyon has a programme to collect the dietary facts from 350,000 Europeans in the next few years. We await their results with interest and wish them good luck – they may need it.*65\194\4*

SECONDARY DISEASES OF THE SPINE: OLD AGE LOW BACKACHE

Ageing causes osteoarthritic changes in the facet joints of the lumbar spine. These inflamed joints (caused by wear and tear) may hurt on their own. The discs of the lower lumbar vertebrae may degenerate and dry up. This causes the vertebrae to sit one on top of the other without the cushioned disc. The absence of discs may not cause any pain as such or else everyone who has had a disc-removal surgery would complain of severe pain. What one feels is stiffness and perhaps restriction of movement around that area.
One of the commonest forms of backache in the elderly is caused by scoliosis. Due to weakening or wasting of spinal muscles, the anti-gravitational force is reduced to the very minimum, and so the spine shrinks and acquires an S-shape configuration to maintain the vertical posture. Such deformations lead to irritation of nerve roots, muscular spasms etc, which generate pain.
*212\330\8*

SECONDARY DISEASES OF THE SPINE: OLD AGE LOW BACKACHEAgeing causes osteoarthritic changes in the facet joints of the lumbar spine. These inflamed joints (caused by wear and tear) may hurt on their own. The discs of the lower lumbar vertebrae may degenerate and dry up. This causes the vertebrae to sit one on top of the other without the cushioned disc. The absence of discs may not cause any pain as such or else everyone who has had a disc-removal surgery would complain of severe pain. What one feels is stiffness and perhaps restriction of movement around that area.One of the commonest forms of backache in the elderly is caused by scoliosis. Due to weakening or wasting of spinal muscles, the anti-gravitational force is reduced to the very minimum, and so the spine shrinks and acquires an S-shape configuration to maintain the vertical posture. Such deformations lead to irritation of nerve roots, muscular spasms etc, which generate pain.*212\330\8*

IS IT RELATIVE OF BDD? SOCIAL PHOBIA: SOCIAL ANXIETY, EMBARRASSMENT, AND AVOIDANCE

BDD also has many similarities to social phobia (also know as social anxiety disorder). This anxiety disorder is characterized by an excessive fear of social or performance situations in which the person is exposed to unfamiliar people or to scrutiny by others and fears they’ll do something embarrassing or humiliating. The excessive fear may occur in most social situations (generalized type) or in specific situations, such as speaking in public or eating or writing in front of others.
Natasha had felt extremely anxious and fearful in social situations since she was a child. “I’ve always been really nervous around other people,” she said. “Even in grade school. I’d miss school on days I had to give a book report in front of the class. I’ve never gone to parties because I’m afraid I’ll do something embarrassing, like blushing or saying or doing the wrong thing.” As a result, Natasha didn’t date and had no friends. She spent most of her time alone at home.
*369\204\8*

IS IT RELATIVE OF BDD? SOCIAL PHOBIA: SOCIAL ANXIETY, EMBARRASSMENT, AND AVOIDANCEBDD also has many similarities to social phobia (also know as social anxiety disorder). This anxiety disorder is characterized by an excessive fear of social or performance situations in which the person is exposed to unfamiliar people or to scrutiny by others and fears they’ll do something embarrassing or humiliating. The excessive fear may occur in most social situations (generalized type) or in specific situations, such as speaking in public or eating or writing in front of others.    Natasha had felt extremely anxious and fearful in social situations since she was a child. “I’ve always been really nervous around other people,” she said. “Even in grade school. I’d miss school on days I had to give a book report in front of the class. I’ve never gone to parties because I’m afraid I’ll do something embarrassing, like blushing or saying or doing the wrong thing.” As a result, Natasha didn’t date and had no friends. She spent most of her time alone at home.*369\204\8*

LOW BLOOD SUGAR & IRRITABLE BOWEL SYNDROME: EATING PLAN TO KEEP BLOOD SUGAR LEVELS STABLE – PRINCIPLES OF THE DIET

If your doctor has already given you a diet to follow consult him or her before you make any changes in your eating pattern. If there at some foods here which you cannot tolerate, just exclude them and follow the main theme.
Principles of the Diet
The aim is to avoid foods and substances that are quickly absorbed in order to minimize rapid changes in the level of glucose in the blood.
Avoid or cut down to a minimum refined carbohydrates:
• Sugar, sweets, chocolate
• White bread, white flour, cakes, biscuits, pastry
• Alcohol
• Sweet drinks
• ]unk foods.
Eat non-refined carbohydrates:
• Whole grain cereals; wheat, oats, barley, rice, rye, millet.
Give up processed breakfast cereals and make your own muesli from whole oats, nuts, seeds (sunflower, pumpkin or sesame are all very nutritious) and a little dried fruit (sultanas, apricots etc). If you are used to eating ‘plastic bread’ you will love the taste of whole-grain brown bread. If you normally eat brown bread make sure it is whole grain.
Eat protein:
• Animal protein: meat, fish, poultry, cheese, eggs, milk, yoghurt.
• Vegetable protein: nuts, seeds, peas, beans, lentils and small amounts in all vegetables.
There is always a lot of argument about how much protein should be included in any diet. The early diets for low blood sugar were very high in protein. Eating this way certainly controls the blood sugar but more recent research has shown that the body does not like too much concentrated protein, and blood sugar levels can be kept steady on smaller amounts, particularly if lots of raw vegetables are included.
Eat Large Quantities of Vegetables
These will supply you with essential minerals and vitamins and provide fibre (roughage). Some people have become over-anxious about fibre, and have bran with everything. This is not a good idea, as it can irritate the bowel and hinder the absorption of some minerals. Eating vegetables is a better way to get fibre.
Eat Lots of Fresh Fruit
Although fruit contains quite a lot of sugar, it is in a different form from that in sweets (fructose rather than sucrose); it does not need insulin for its digestion and therefore is an ideal food to help slow down the pancreas.
Eat Some Fat
People tend to concentrate on low-fat diets (often dangerously low) and think this will take care of all cholesterol problems. However, there are other factors which are just as important – stress, and a diet low in raw vegetables and fruit can be just as damaging as moderate amounts of butter. Also remember that some foods actually lower cholesterol levels. They include onions, garlic, apples and olive oil. Olive oil is also wonderful for the immune system.
*104\326\8*

LOW BLOOD SUGAR & IRRITABLE BOWEL SYNDROME: EATING PLAN TO KEEP BLOOD SUGAR LEVELS STABLE – PRINCIPLES OF THE DIETIf your doctor has already given you a diet to follow consult him or her before you make any changes in your eating pattern. If there at some foods here which you cannot tolerate, just exclude them and follow the main theme.Principles of the DietThe aim is to avoid foods and substances that are quickly absorbed in order to minimize rapid changes in the level of glucose in the blood.Avoid or cut down to a minimum refined carbohydrates:• Sugar, sweets, chocolate• White bread, white flour, cakes, biscuits, pastry• Alcohol• Sweet drinks• ]unk foods.Eat non-refined carbohydrates:• Whole grain cereals; wheat, oats, barley, rice, rye, millet.Give up processed breakfast cereals and make your own muesli from whole oats, nuts, seeds (sunflower, pumpkin or sesame are all very nutritious) and a little dried fruit (sultanas, apricots etc). If you are used to eating ‘plastic bread’ you will love the taste of whole-grain brown bread. If you normally eat brown bread make sure it is whole grain.Eat protein:• Animal protein: meat, fish, poultry, cheese, eggs, milk, yoghurt.• Vegetable protein: nuts, seeds, peas, beans, lentils and small amounts in all vegetables.There is always a lot of argument about how much protein should be included in any diet. The early diets for low blood sugar were very high in protein. Eating this way certainly controls the blood sugar but more recent research has shown that the body does not like too much concentrated protein, and blood sugar levels can be kept steady on smaller amounts, particularly if lots of raw vegetables are included.Eat Large Quantities of VegetablesThese will supply you with essential minerals and vitamins and provide fibre (roughage). Some people have become over-anxious about fibre, and have bran with everything. This is not a good idea, as it can irritate the bowel and hinder the absorption of some minerals. Eating vegetables is a better way to get fibre.Eat Lots of Fresh FruitAlthough fruit contains quite a lot of sugar, it is in a different form from that in sweets (fructose rather than sucrose); it does not need insulin for its digestion and therefore is an ideal food to help slow down the pancreas.Eat Some FatPeople tend to concentrate on low-fat diets (often dangerously low) and think this will take care of all cholesterol problems. However, there are other factors which are just as important – stress, and a diet low in raw vegetables and fruit can be just as damaging as moderate amounts of butter. Also remember that some foods actually lower cholesterol levels. They include onions, garlic, apples and olive oil. Olive oil is also wonderful for the immune system.*104\326\8*

LIVING WITH EPILEPSY/SCHOOL: LEARNING AND BEHAVIOR – ATTENTION DEFICIT DISORDER

A cause that has received much attention is a condition called “organic hyperactivity” or more recently “ADD,” Attention Deficit Disorder. Although this condition is common, we know surprisingly little about its source. It may or may not be associated with physical hyperactivity. ADD is more common (or more easily recognized) in boys, where over-activity is a more common accompanying symptom and more likely to draw attention to the child. Attention Deficit Disorders are not uncommon in children during the early school years; they are perhaps even more common in children with epilepsy. They are also frequently associated with “immaturity” of the nervous system and with the learning disorders described above.
While its cause is unknown, we like to think of ADD as a “filtering” problem. Everyone is constantly bombarded by multiple different stimuli. As you are reading this chapter there may be children playing in the room, the TV may be playing, the clock ticking, and someone else talking. And yet you are able to filter all of these other stimuli out and concentrate, pay attention to what you are reading. We do not know exactly how this filtering takes place, but it seems to be partly a learned skill and partly a result of maturity of the nervous system. Infants and young children are easily distracted by the many stimuli around them; they have difficulty paying attention (except to TV). As they get older, they can attend better. Some children mature faster in this respect than others. Some have far more difficulty paying attention than others and are diagnosed as having Attention Deficit Disorders when the problem interferes with their work in school.
*246\208\8*

LIVING WITH EPILEPSY/SCHOOL: LEARNING AND BEHAVIOR – ATTENTION DEFICIT DISORDERA cause that has received much attention is a condition called “organic hyperactivity” or more recently “ADD,” Attention Deficit Disorder. Although this condition is common, we know surprisingly little about its source. It may or may not be associated with physical hyperactivity. ADD is more common (or more easily recognized) in boys, where over-activity is a more common accompanying symptom and more likely to draw attention to the child. Attention Deficit Disorders are not uncommon in children during the early school years; they are perhaps even more common in children with epilepsy. They are also frequently associated with “immaturity” of the nervous system and with the learning disorders described above.While its cause is unknown, we like to think of ADD as a “filtering” problem. Everyone is constantly bombarded by multiple different stimuli. As you are reading this chapter there may be children playing in the room, the TV may be playing, the clock ticking, and someone else talking. And yet you are able to filter all of these other stimuli out and concentrate, pay attention to what you are reading. We do not know exactly how this filtering takes place, but it seems to be partly a learned skill and partly a result of maturity of the nervous system. Infants and young children are easily distracted by the many stimuli around them; they have difficulty paying attention (except to TV). As they get older, they can attend better. Some children mature faster in this respect than others. Some have far more difficulty paying attention than others and are diagnosed as having Attention Deficit Disorders when the problem interferes with their work in school.*246\208\8*

HELPING YOUR CHILD COPE WITH EPILEPSY: ABSENCE SEIZURES – YOUR CHILD’S PROBLEMS SOLVING

You need to give your child the opportunity to let you know he’s missing things in school—for example, instructions or the end of a story. We know of one child who assumed that life was just a series of blank spaces. His class was making a movie about a train going by, and he wanted to cut out frames of the film. When asked why, he told his teacher that’s how he saw it—with short blank spots between the pictures. It was then that his teacher became aware that there were frequent, very brief, gaps in his attention and that the diagnosis of absence seizures was eventually made.
These simple absence seizures can usually be brought completely under control with medication, although it may take several weeks to gain control. Until then, the child’s activities should be more carefully supervised, with caution and concern but without over-protectiveness or panic.
Teachers are a very important, perhaps even crucial part of the evaluation and treatment of a child who has absence seizures. There are few other times when a child is consistently under observation and when brief lapses in attention can be readily recognized. It is not uncommon for the teacher to be the first to recognize these lapses of attention. Some parents feel guilty because they did not notice these lapses themselves, but in the structured atmosphere of the classroom, they are often easier to see and recognize than in the more informal atmosphere of a family. And once they are recognized the teacher can be your child’s best ally by noting spells and possible side effects of medication.
On the other hand, because of the myths about epilepsy, an uninformed or biased teacher may now treat your child as if he has a learning problem or is dumb. Normal daydreaming may be misperceived as staring spells. A child who is daydreaming may or may not respond if called, but will certainly respond if the teacher goes over and touches him. When a child does not respond he is more likely to be experiencing absence seizures.
*184\208\8*

HELPING YOUR CHILD COPE WITH EPILEPSY: ABSENCE SEIZURES – YOUR CHILD’S PROBLEMS SOLVING You need to give your child the opportunity to let you know he’s missing things in school—for example, instructions or the end of a story. We know of one child who assumed that life was just a series of blank spaces. His class was making a movie about a train going by, and he wanted to cut out frames of the film. When asked why, he told his teacher that’s how he saw it—with short blank spots between the pictures. It was then that his teacher became aware that there were frequent, very brief, gaps in his attention and that the diagnosis of absence seizures was eventually made.These simple absence seizures can usually be brought completely under control with medication, although it may take several weeks to gain control. Until then, the child’s activities should be more carefully supervised, with caution and concern but without over-protectiveness or panic.Teachers are a very important, perhaps even crucial part of the evaluation and treatment of a child who has absence seizures. There are few other times when a child is consistently under observation and when brief lapses in attention can be readily recognized. It is not uncommon for the teacher to be the first to recognize these lapses of attention. Some parents feel guilty because they did not notice these lapses themselves, but in the structured atmosphere of the classroom, they are often easier to see and recognize than in the more informal atmosphere of a family. And once they are recognized the teacher can be your child’s best ally by noting spells and possible side effects of medication.On the other hand, because of the myths about epilepsy, an uninformed or biased teacher may now treat your child as if he has a learning problem or is dumb. Normal daydreaming may be misperceived as staring spells. A child who is daydreaming may or may not respond if called, but will certainly respond if the teacher goes over and touches him. When a child does not respond he is more likely to be experiencing absence seizures.*184\208\8*

DANGERS OF ANTIHYPERTENSIVE DRUGS: DIURETICS AND BETA-BLOCKERS MAY INCREASE RISK OF SUDDEN DEATH

According to a 1995 study published in the Annals of Internal Medicine, non-potassium-sparing diuretics and beta-blockers may increase the risk of sudden cardiac death. Researchers from Erasmus University Medical Center in Rotterdam, the Netherlands, examined the medical records of 257 patients who had died suddenly while taking drugs for high blood pressure and compared them with those of 257 living patients also taking antihypertensive drugs. They discovered that patients taking thiazide or loop diuretics had double the risk of sudden death compared with those taking potassium-sparing diuretics. The research team also found that patients taking beta-blockers were 1.7 times as likely to succumb to sudden cardiac death as patients taking other blood-pressure-lowering medications. They concluded that this increased risk of death may offset the benefits of these drugs.
*55/313/5*

DANGERS OF ANTIHYPERTENSIVE DRUGS: DIURETICS AND BETA-BLOCKERS MAY INCREASE RISK OF SUDDEN DEATHAccording to a 1995 study published in the Annals of Internal Medicine, non-potassium-sparing diuretics and beta-blockers may increase the risk of sudden cardiac death. Researchers from Erasmus University Medical Center in Rotterdam, the Netherlands, examined the medical records of 257 patients who had died suddenly while taking drugs for high blood pressure and compared them with those of 257 living patients also taking antihypertensive drugs. They discovered that patients taking thiazide or loop diuretics had double the risk of sudden death compared with those taking potassium-sparing diuretics. The research team also found that patients taking beta-blockers were 1.7 times as likely to succumb to sudden cardiac death as patients taking other blood-pressure-lowering medications. They concluded that this increased risk of death may offset the benefits of these drugs.*55/313/5*

UNDERSTANDING TESTS FOR HIV

In 1983, the virus that came to be called the human immunodeficiency virus (HIV) was discovered in human blood samples. Two years later, researchers developed a test to detect HIV in the blood. At that time, the best use of the test was to screen people who wanted to donate blood so that blood transfusions and the blood supply would be free of HIV.
Medical researchers, however, were reluctant to use the screening test to identify people with HIV infection. First, although the test was one of the most accurate tests of its kind, occasional errors in its results created a lot of anxiety. Someone whose test result was positive might not have HIV, while someone whose test result was negative couldn’t be certain that HIV was not present. Second, at that time, the public was not ready to accept people with HIV infection, and the newspapers were full of stories of discrimination against these people. This public response was partly due to fear and partly to our uncertainty about how the virus was transmitted. The third reason, and the most important, was that physicians had little to offer anyone who tested positive. As a result, recommendations from the medical profession and from others concerned with the epidemic about whether to get tested for HIV were ambiguous. That is, no one knew whether testing for HIV made sense or not.
Since these early times, the accuracy of the test has improved substantially, public understanding has progressed somewhat, and medical research has made a gigantic leap forward in the treatment of HIV infection. Recommendations have changed accordingly. The purpose of this article is to discuss the tests themselves and their accuracy, make recommendations about who should be tested, discuss the confidentiality of the tests, and help interpret the results.
*252\191\2*

UNDERSTANDING TESTS FOR HIVIn 1983, the virus that came to be called the human immunodeficiency virus (HIV) was discovered in human blood samples. Two years later, researchers developed a test to detect HIV in the blood. At that time, the best use of the test was to screen people who wanted to donate blood so that blood transfusions and the blood supply would be free of HIV.     Medical researchers, however, were reluctant to use the screening test to identify people with HIV infection. First, although the test was one of the most accurate tests of its kind, occasional errors in its results created a lot of anxiety. Someone whose test result was positive might not have HIV, while someone whose test result was negative couldn’t be certain that HIV was not present. Second, at that time, the public was not ready to accept people with HIV infection, and the newspapers were full of stories of discrimination against these people. This public response was partly due to fear and partly to our uncertainty about how the virus was transmitted. The third reason, and the most important, was that physicians had little to offer anyone who tested positive. As a result, recommendations from the medical profession and from others concerned with the epidemic about whether to get tested for HIV were ambiguous. That is, no one knew whether testing for HIV made sense or not.     Since these early times, the accuracy of the test has improved substantially, public understanding has progressed somewhat, and medical research has made a gigantic leap forward in the treatment of HIV infection. Recommendations have changed accordingly. The purpose of this article is to discuss the tests themselves and their accuracy, make recommendations about who should be tested, discuss the confidentiality of the tests, and help interpret the results.*252\191\2*

HIV: PRACTICAL MATTERS-PUTTING YOUR AFFAIRS IN ORDER: LIVING WILLS

A living will is a legal document outlining your decisions about treatment to sustain your life should you be unconscious or incompetent. The living will is somewhat different from the durable power of attorney for health care: the person with your durable power of attorney for health care, when faced with the decision of whether to prolong your life, will usually decide to prolong life. The living will provides that person with your specific instructions for making this decision. The person with your durable power of attorney for health care can also make decisions that may not have been foreseen in your living will.
Living wills, unlike regular wills, apply only to medical treatments. The actual form and scope of a living will is established by state laws. In general, living wills specify which types of treatment you wish to have or wish not to have. Living wills also specify the physical and mental states in which you do or do not want these treatments. These treatments include transfusions, support on a respirator, operations, and resuscitation. Some states have no provision for living wills. Other states that do provide for living wills do not allow any restrictions on food and water. In any case, a living will applies only after the person becomes incompetent and has a terminal condition.
A living will might be written as follows:
In the event that I have an incurable disease that is certified to be a terminal condition by two physicians who have personally examined me—including one who shall be my attending physician—and these physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are used; and where application of such procedures would serve only to artificially prolong the dying process, I direct that these procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, food, and water, and any additional procedure necessary to give comfort and alleviate pain. In the absence of my ability to give directions regarding the use of such
life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right to control my medical care and treatment.
To make a living will, obtain a sample document from your lawyer, from a hospital legal office, or from a social worker. The content of the living will may be discussed with your physician to assure the use of proper terms and to include likely decisions. The living will must be dated and signed by you and by two witnesses. You must be at least eighteen years old and competent. The witnesses must be at least eighteen years old, must not be related to you, must not be financially responsible for your care, and may not be your health care provider or connected with the facility providing your care. You or your representative should give your physician a copy of the living will. You may revoke the will at any time, preferably by a written statement, but also by destroying the living will and notifying any persons—including the physician—who retain copies.
*218\191\2*

HIV: PRACTICAL MATTERS-PUTTING YOUR AFFAIRS IN ORDER: LIVING WILLSA living will is a legal document outlining your decisions about treatment to sustain your life should you be unconscious or incompetent. The living will is somewhat different from the durable power of attorney for health care: the person with your durable power of attorney for health care, when faced with the decision of whether to prolong your life, will usually decide to prolong life. The living will provides that person with your specific instructions for making this decision. The person with your durable power of attorney for health care can also make decisions that may not have been foreseen in your living will.     Living wills, unlike regular wills, apply only to medical treatments. The actual form and scope of a living will is established by state laws. In general, living wills specify which types of treatment you wish to have or wish not to have. Living wills also specify the physical and mental states in which you do or do not want these treatments. These treatments include transfusions, support on a respirator, operations, and resuscitation. Some states have no provision for living wills. Other states that do provide for living wills do not allow any restrictions on food and water. In any case, a living will applies only after the person becomes incompetent and has a terminal condition.     A living will might be written as follows:     In the event that I have an incurable disease that is certified to be a terminal condition by two physicians who have personally examined me—including one who shall be my attending physician—and these physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are used; and where application of such procedures would serve only to artificially prolong the dying process, I direct that these procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, food, and water, and any additional procedure necessary to give comfort and alleviate pain. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right to control my medical care and treatment.     To make a living will, obtain a sample document from your lawyer, from a hospital legal office, or from a social worker. The content of the living will may be discussed with your physician to assure the use of proper terms and to include likely decisions. The living will must be dated and signed by you and by two witnesses. You must be at least eighteen years old and competent. The witnesses must be at least eighteen years old, must not be related to you, must not be financially responsible for your care, and may not be your health care provider or connected with the facility providing your care. You or your representative should give your physician a copy of the living will. You may revoke the will at any time, preferably by a written statement, but also by destroying the living will and notifying any persons—including the physician—who retain copies.*218\191\2*

IMMUNIZATIONS FOR TRAVEL HEALTHY SAFETY: MENINGOCOCCAL VACCINATION

Meningococcal vaccination may benefit travelers to areas where Neisseria meningitidis is endemic or where there is an outbreak, especially if extended contact with local persons is anticipated. Up to 10% of the population of countries with endemic meningococcal disease might be asymptomatic carriers. In sub-Saharan Africa, epidemics of serogroups A or С meningococcal disease occur frequently during the dry season (December through June), particularly in the savannah areas extending from Senegal to Ethiopia in the so-called “meningitis belt”. Meningococcal vaccine is recommended for travel to this area. The vaccine is required for pilgrims entering Mecca, Saudi Arabia during the Hajj. Epidemics of meningococcal disease have occasionally been reported in Kenya, Tanzania, Burundi, and Mongolia. The CDC web site can provide updated information about recent epidemics and review the geographic areas for which vaccine is recommended.
The currently available meningococcal vaccine (Menomune, Aventis Pasteur) is effective only against serogroups A, C, Y, and W-135. Primary immunization in persons 2 years and older consists of a single 0.5 mL dose given by subcutaneous injection, and this confers immunity for at least 3 years. Protective levels of antibody are achieved in 7 to 10 days. Pain at the injection site is the most commonly reported adverse reaction. Vaccination is not contraindicated in pregnancy. Revaccination may be considered within 3 to 5 years for continued exposure.
*187/348/5*

IMMUNIZATIONS FOR TRAVEL HEALTHY SAFETY: MENINGOCOCCAL VACCINATIONMeningococcal vaccination may benefit travelers to areas where Neisseria meningitidis is endemic or where there is an outbreak, especially if extended contact with local persons is anticipated. Up to 10% of the population of countries with endemic meningococcal disease might be asymptomatic carriers. In sub-Saharan Africa, epidemics of serogroups A or С meningococcal disease occur frequently during the dry season (December through June), particularly in the savannah areas extending from Senegal to Ethiopia in the so-called “meningitis belt”. Meningococcal vaccine is recommended for travel to this area. The vaccine is required for pilgrims entering Mecca, Saudi Arabia during the Hajj. Epidemics of meningococcal disease have occasionally been reported in Kenya, Tanzania, Burundi, and Mongolia. The CDC web site can provide updated information about recent epidemics and review the geographic areas for which vaccine is recommended.The currently available meningococcal vaccine (Menomune, Aventis Pasteur) is effective only against serogroups A, C, Y, and W-135. Primary immunization in persons 2 years and older consists of a single 0.5 mL dose given by subcutaneous injection, and this confers immunity for at least 3 years. Protective levels of antibody are achieved in 7 to 10 days. Pain at the injection site is the most commonly reported adverse reaction. Vaccination is not contraindicated in pregnancy. Revaccination may be considered within 3 to 5 years for continued exposure.*187/348/5*