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Topical treatment with antifungal creams is recom- mended order nizagara uk erectile dysfunction organic causes, with attention to any underlying stress fac- Histoplasmosis tors buy nizagara australia erectile dysfunction after prostate surgery. Trichophyton gallinae is a zoonotic disease and Histoplasmosis is similar to cryptococcosis in many has been described as a pruritic nizagara 100mg for sale erectile dysfunction is often associated with, scaly lesion of the scalp. Histo- plasma capsulatum is an infectious but not conta- Mucormycosis is a term that includes a variety of gious disease of the reticuloendothelial system. The6 lomas of the gut and ventriculus were found in a organism has been associated with or found in the group of canaries that were being fed sprouted seed; feces of chickens, blackbirds, pigeons and gulls. Surveys of aviary soil are bers of the phycomycetales (zygomycota) can some- needed to determine the incidence of this organism. Granulomatous inflammation involv- Diagnosis of histoplasmosis is based on culture of the ing the liver, myocardium and lung was associated organism (mycelial phase may sometimes be recov- 50 with Trichosporon beigelii. Penicillium griseo- ered on Sabouraud’s agar) and histopathology (peri- fulvum is another rare fungal isolate that caused a odic acid-Schiff, Bauer’s and Gridley stains). Nocardiosis (Nocardia asteroides) involving the lungs and air sacs of two Pesquet Parrots has been reported. It has been docu- Uncommon Fungal Diseases mented in ducks and geese but not in Psittaciformes or Passeriformes. It also occurs in man and the dog, and in most species it can take the form of an erythe- matous nasal polyp. Mycetomas in are of some interest to the avian practitioner because man are eruptions of the extremities that usually of their role in skin and feather abnormalities. Rahway, Merck & Co, 1991, cockatiel nestlings and mucormy- Assoc Avian Vet, 1990, pp 432-459. Vet Med Assoc 181(11):1389-1390, Clinical Avian Medicine and Sur- Today 2(4):202, 1988. Quesenberry K, et al: Roundtable dis- Vet Med Sm Anim Clin 78(2):249- and medicine. Proc Assoc Avian Vet, 1986, zoonoses: Proven and potential dis- in an African grey parrot. Parasitic life cycles may be direct or complex indirect cycles re- quiring various arthropod or animal hosts. Some species of parasites can infect nearly every organ system, although individual genera will inhabit spe- cific organs or tissues. For example, mature tape- 36 worms (Cestoda) and spiny-headed worms (Acantho- cephala) are restricted to the small intestines. Mature flukes (Trematoda) occur in the intestines, liver, kidney, air sacs, oviducts, blood vessels and on the surface of the eyes. Adult roundworms (Nema- toda) parasitize the crop, proventriculus, ventricu- lus, intestines, ceca, body cavities, brain, surface and periorbital tissues of the eyes, heart and subcutane- ous tissues. Sin- gle-celled organisms with discrete nuclei (Protozoa) may be found in the lumen of the intestinal tract, extracellularly in the blood or within cells of many tissues. Long-term symbiotic parasite-host relationships are usually characterized by benign infections compared with parasites that have been recently introduced to a new host. The fact that companion and aviary birds from widely varying geographic regions are combined creates an opportu- nity for exposure of a naive host to parasitic organ- isms that may cause few problems in their natural host. Parasites that are apathogenic in endemic avi- fauna can cause chronic disease or rapid death in unnatural hosts. Diagnostic stages of most avian parasites have infections are most common in birds that are recently not been matched to the adults of the same species imported or that have access to the ground. Some and thus characterization is usually limited to order parasites are host-specific, while others can infect a or superfamily. Free-ranging birds by cooperation among aviculturists, avian veteri- should be restricted from an aviary to prevent them narians and parasitologists. Parasitic prob- lems are best managed by designing facilities that restrict a bird’s access to infectious stages of a para- site and by practicing sound hygiene. Birds main- tained indoors or in suspended welded wire enclo- sures are unlikely to have parasites that have an Diagnosis of Parasites indirect transmission cycle. In contrast, parasitic in- fections are common in countries where birds are maintained in walk-in type aviaries with access to the ground. Parasitic infections in birds may be diagnosed through examining samples from living birds or Treatment for parasitic infections should include ap- through necropsy of affected individuals or repre- propriate anthelmintics (when available) and man- sentatives of flocks. Relatively apathogenic parasites may cause It is important to determine which parasites are pre- severe clinical disease in birds that are immunosup- sent because: 1) related parasite/host systems may pressed or stressed or have concomitant infections. Some nematode eggs will larvate if allowed to age, produc- flotation medium is saturated sodium nitrate (568 g ing atypical eggs or larvae that are difficult to identify. Sheather’s sugar parasitic forms (trophozoites of Giardia for example) are solution (500 g table sugar, 320 ml water and 6. Collect feces per cloaca or from nonabsorbent cage lining such as waxed paper or aluminum foil. Using nonabsorbent sulfate/ 1000 ml water) is best for concentrating cysts material to collect feces provides a moist sample of greater of Giardia and may be better for detecting spiruroid volume when compared to scraping a sample off newsprint eggs than sodium nitrate. Samples collected from corn cob, wood shavings or cat litter should not be considered diagnostic. Conduct the test that specifically demonstrates the parasite of flotation medium and passing the mixture through a that is most likely to be causing the clinical changes. Trophozoites of piece of double-layer gauze or cheesecloth placed on top Giardia and Trichomonas will be destroyed if placed into of a vertical tube. The tube should be filled until a slight saturated salt or sugar flotation solutions. A coverslip is placed on top tes die in tap water and are best identified by using warm saline or lactated Ringer’s solution as a diluent. The low power objective (10x) should be used for gauze pad on top of a 15 ml centrifuge tube and washed scanning. Scan the coverslip be- then centrifuged at 1200 to 1500 rpm for ten minutes ginning at one corner and traversing the length of the coverslip, then move the slide to the next field of view and and the sediment is mixed in the appropriate flotation reverse the field of movement. The coverslip from either method is then until the entire coverslip has been viewed will provide a examined microscopically. Examine the entire slide and do not stop when eggs of one kind have been identified. If a diagnostic technique is not standardized, Hexamita, Giardia, Fresh direct mount with warm the results are of limited value. Comparing egg counts between treated and un- Giardia, spiruroid eggs Flotation - Zinc sulfate treated birds may provide some information on the effect of Nematodes, cestodes, Flotation - Sodium nitrate an anthelmintic. The supernatant is gently removed and cell, morula or larvae) and type of larva present in the tube is refilled with soapy water and allowed to the egg (nematode larva, hexacanth larva, mi- stand for another five minutes. It The diagnostic stage of most avian helminths is an can also be used in place of flotation to detect eggs and egg that is detected in the feces by either flotation or cysts but is more time-consuming and may not be as sedimentation. The proper density of the preparation is achieved when newsprint can be easily read through the preparation.

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Europ Symp Bird Diseases purchase 25 mg nizagara free shipping testosterone associations with erectile dysfunction diabetes and the metabolic syndrome, 1987 discount nizagara 25 mg otc erectile dysfunction new drug, paction associated with nonsuppura- genesis of duck viral hepatitis order nizagara 100 mg free shipping erectile dysfunction pump images. Ames, like conjunctivitis in Australian Tagung Vogelkrht, München, 1988, Avian Pathol 17:391-401, 1988. Ames, Iowa tion antibodies against an adenovirus pesvirus from a bald eagle nestling. J Zoo Wildlife Med 23:103-107, State University Press, 1991, pp 684- (virus 127) in white Pekin ducks in Avian Dis 27:1162-1165, 1983. Dorrestein G, et al: Einige Befunde isolated from a nestling cormorant liosis in Japanese quail. In like agent from young budgerigars (Phoenicopterus ruber) and a pied im- infection in hand-fed parrots: Virus Gylstorff I, Grimm F: Vogelkrank- with feather abnormalities. Ames, Iowa State University isolated from black storks (Ciconia tions in captive birds. Ianconescu M, et al: Reticuloendothe- strigum und andere Krankheiten der “wasting macaw” complex. Heffels U, et al: Serologische Unter- liosis and lymphoproliferative disease Greifvogel und Eulen. Greenacre C, et al: Psittacine beak al: Krankheiten des Wirtschaftsge- Press, 1991, pp 674-679, 1991. In Gylstorff “Tauben-Paramyxovirus” sowie Über- dystrophy and necrosis in cockatoos. J Am Jagdfalken - Klinik, pathomorpholo- Stuttgart, Eugen Ulmer, 1987, pp schiedener Newcastle-Disease- Vet Med Assoc 189:999-1005, 1986. Ames, Iowa State I, Grimm F: Vogelkrankheiten, Magen/Darmbereich bei Großpa- fection in white-masked lovebirds University Press, 1991, pp 471-484. Stuttgart, Verlag Eugen Ulmer, 1987, pageien (wasting macaw complex, in- (Agapornis personata). Prakt Tier- Stuttgart, Verlag Eugen Ulmer, 1987, ton, Kluwer Academic Publ, 1988, pp arzt 61:952-954, 1980. Mustaffa-Babjee A, et al: Acute enteri- Impfung gegen die Paramyxovirose aetiology. Mustaffa-Babjee A, et al: A patho- Langzeitversüches unter Laborbedin- ated outbreaks in domestic poultry in 264. Logemann K, et al: Comparative stud- noviruses and reoviruses from avian fection in normal and antibody defi- Oklahoma (reservoir of a virus that ies for the characterization of avian species other than domestic fowl. Kraft V, et al: Nachweis eines Pocken- Stuttgart, Gustav Fischer Verlag Poultry 9th ed. Ames, Iowa State Uni- logical characterization of influenza virus bei Zwergpapageien (Agapornis Jena, 1992, pp 695-770. McOrist S, et al: Psittacine beak and undulatus): Clinical and aetiological feather dystrophy in wild sulphur- al: Krankheiten des Wirtschaftsge- studies. Landowska-Plazewska E, et al: Aus- anemia virus associated with Plasmo- Pathol 20:531-539, 1991. Exp Parasitol 31:29- Discordance between neutralizing an- Pinguinen im Warschauer Zoo. Proc Assoc four cockatoos with psittacine beak egg drop syndrome 1976 virus in do- Comp Pathol 93:127-134, 1983. Malkinson M: An outbreak of an acterization of rotavirus from feral pi- puffinus). In: Francki cons (as vectors of the disease to poul- West Poult Dis Conf, 1982, p 110. Ottis K, et al: Isolation and charac- the bursa of Fabricius of herring cies of fowl and waterfowl. Study of terization of ortho- and paramyxovir- gulls (Larus argentatus pontoppidan) immunity afforded by Reovirus vac- In Heider, et al: Krankheiten des us from feral birds in Europe. Müller H, et al: A polyoma-like virus associated with acute disease of fledg- 302. Proc Assoc Wellensittiche, eines aviaren guineafowl: Characterization on two Proc 34th West Poult Dis Conf, 1985, Avian Vet, 1988, pp 27-30. Avian Pathol 16:623-633, myelosis in conures, the “hemor- Charakterisierung von aviären Vet Pract 15:55-60, 1985. Proc Intl Conf Avian tischen und detuschen Haustauben of psittacine beak and feather dis- tis in a tawny frogmouth (Podargus Med, 1984, pp 213-228. J Gen Virol 50:410- nologic relationship of quail and my- Newcastle disease in Egypt. Schemera B et al: A paramyxovirus of tralian cockatoos Cacatua galerita beim Geflügel. Sironi G: Concurrent papavirus-like Cockatoo, Cacatua roseicapilla geese in Saskatchewan. Am J Vet fication of a papovavirus in a Moluc- beak disease: A cluster of cases in a article 2:329 (No 329), 1975. Pfister R: Zur Verträglichkeit und tion inhibition for detection of anti- Probleme der Influenzavirusinfek- waterfowl of Michigan (Possible Wirksamkeit einiger Adjuvantien in bodies against the virus. J As- Virusinfektion bei Prachtfinken bei Enten, Gänsen und Graureihern: 513, 1989. Assoc Avian Vet Today 1:152- pesvirus der Hepatosplenitis infec- avian species for neutralizing anti- versity Press, 1991, pp 621-627. Aust Eulen (Sträges) mit Ausnahme der birds in the spread of influenza vi- Vet J 63:337-338, 1986. Woods L: Case report: Papova-like vi- subgenus within the polyomavirus ge- cockatiels. Vindevogel H, et al: Comparaison de Krankheiten des Wirtschaftsge- feather disease/French molt. Winteroll G, et al: Schwere durch Her- characteristics of an agent inducing 18:133-139, 1982. Waddell G, et al: Genetic variability des Respirationsapparates bei Ama- 385, 1979. J Am Vet Med Assoc 50:1466- akuten Form der Nephro-Enteritis Zbl Vet Med B 13:215-218, 1966. Proc Assoc Avian hemorrhagic syndrome and a chronic versity Press, 1991, pp 439-456. Tumova B, et al: A further member of Conf Zool & Avian Med, 1984, pp 15- schiedener Desinfektionsmittel and the Yucaipa group isolated from the 19. Avian bacteriology is further complicated by the fact that bacteria that are as yet taxonomically undescribed can be isolated from a variety of avian species. Some of these bacterial strains have been erroneously classified as taxons (eg, Pasteurella haemolytica, Alcaligenes faecalis). In general, bacte- 33 rial adaption to an avian host minimizes cross-spe- cies transmission from birds to mammals. Non-host- adapted transmission usually requires large numbers of organisms, repeated exposures, specific susceptibility or immunosuppression.

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Anterior-posterior limits of stability are decreased in elderly com- pared to young subjects (10) discount 25mg nizagara with visa reflexology erectile dysfunction treatment. The decrease in voluntary inclination might be accounted for by the known reduction of the so-called ‘ankle strategy’ occurring with age (11) purchase nizagara 25mg with amex erectile dysfunction jelly. Postural sway increases linearly with age purchase nizagara no prescription buying erectile dysfunction pills online, but the relative contribu- tions of the sensory systems to balance do not change with age (12). Medio-lateral measures of balance are predictive of elderly community- dwelling fallers (13). Balance decrements are greatest for elderly subjects when visual and proprioceptive cues are diminished (14-16). It has been hypothesised that the differences may reflect an increase in the net stiff- ness of the muscoloskeletal system via increased muscular activity in the elderly. This increased stiffness would provide an improved ability to re- sist and correct for transient perturbations (compared to less stiff sys- tems). This would occur at the expense of increased short-term fluctua- tion across the joints and higher levels of short-term postural sway, i. Elderly subjects have difficulties adapting to new sensory conditions, and are more affected by reduced or conflicting sensory conditions than are young subjects. The peak-to-peak amplitude of sway and root-mean- square energy of sway are significantly greater in healthy elderly subjects than young subjects, both during quiet stance and during visual pertur- bation (19). Sev- eral investigators have suggested that these postural deficits may be due to reduced peripheral visual sensitivity, although this view is not always accepted. According to the authors, these results suggest that poorer central in- tegrative mechanisms, rather than decreased peripheral proprioceptive information, are the culprit for the elderly’s difficulty in reconfiguring the postural set following sensory perturbation. An alternate, but not mutually exclusive hypothesis, is that ageing slows cen- tral synaptic transmission. Healthy adults demonstrate different step recovery characteristics when compared to young adults. Healthy elders are more likely to take multiple steps than young adults and more likely to grasp a hand rail (28, 29). From a clinical standpoint, balance-impaired elders take multiple steps than do healthy elderlys (30). Laboratory studies have found that when pulled forwards, elderly fallers stepped more frequently at a low perturbation level (31). Body segment co-ordination during dynamic equilibrium on a mov- ing platform has been assessed in elderly subjects (32). Ageing is associated with greater head stabilization, and a looser coupling between head and hip. Ageing is associated with re- duced head stabilization, and a stronger coupling between head and hip. Periodical shift of the support base may be a valid protocol to test the ability to control balance in the elderly, and may be a useful tool to assess age-related changes of the sensorimotor mechanisms underlying dynamic equilibrium. Thirty to seventy percent of falls in elders are the result of trips, slips and misteps (2,33, 34). For those suffering from de- generative neurological disorders such as Parkinson’s disease, the prob- lem appears even more substantial (35). As a consequence, a great deal of studies have been devoted to the study of posture and balance alterations in elderly subjects and patients affected by neurological diseases. These deficits include a postural instability with falling, slowness of gait initiation along with short steps and a freezing phenomenon which makes gait initiation extremely difficult or no longer possible (37-42). Disorders of movement function related to posture, bal- ance, and gait are common occurrences for many persons with Parkin- son’s disease. Numerous studies have identified a broad variety and het- erogeneous distribution of postural and locomotor changes (43). In pa- tients with Parkinson’s disease there is reduced load sensitivity and de- creased leg extensor activation, which might contribute to the movement disorder in gait (44, 45). The main impairment occurs in the lateral plane (48), where the stability depends mainly on the hip joint control (49); the balance control becomes more dependent on ankle dorsiflexors’ activity and on vision (50, 51). The deficit does not result mainly from a miscalculation by the sensory input monitoring balance (52) or an inap- propriate perception of their balance (8) but rather on difficulty in accu- rately controlling the output stage, at which many dysfunctions have been reported to occur (51). As far as the stretch-related responses to postur- al perturbation are concerned, little evidence exists that the disease sig- nificantly affects these responses. On the contrary, quadriceps antagonist latencies are earlier than normal, resulting in coac- tivation at the knee not present in control subjects. The reduced sensitivity of the gastrocne- mius muscle to stretch correlates with an inability to compensate for the perturbations (51). In the patients, the gastrocnemius response is fol- lowed by enhanced activation of the tibialis anterior muscle. The angular rotation at the ankle joint induced during faster backward-directed dis- placements is slower than that in normal subjects, despite identical amounts of gastrocnemius electromyographic activity (51). This decreased capability corre- lates significantly with the increased severity of the disease as assessed through the Webster rating scale. In fact, patients with demen- tia of the Alzheimer type, though having abnormalities in the basal gan- glia, have no difficulty in changing postural set in response to altered sup- port conditions (63). Spasticity Hemiparetic patients often stand asymmetrically and with broader stance than normals; further, sway during quiet stance is larger than in normal subjects (72). Further, the normal sequence of activation first in the distal and then in the proximal muscles in response to a postural per- turbation is lost. In fact, in hemiparetic patients the proximal and distal muscles of the affected limb are coactivated, whilst on the so-called healthy side the timing of muscle activation is normal (75). Peripheral neuropathy Eliminating vision does not necessarily increase postural sway in qui- et stance, nor does it result in longer latencies to postural perturbations suggesting that vision is not as critical as somatosensory information for postural control (82-84). Nevertheless, vision can be an important substi- tute for loss of somatosensory or vestibular function (83, 85). Sway dur- ing stance on a firm surface is larger than normal in subjects with so- matosensory loss due to diabetic peripheral neuropathy (86-92). Diabetic patients with loss of somatosensory information due to pe- ripheral neuropathy have significantly delayed latencies of postural re- sponses to surface displacements (92, 93). As a matter of fact, patients with peripheral neuropathy have an approximately 23 times higher risk of falling than do healthy control subjects (94, 95). This finding has implications for understanding how patients with peripheral neuropathy may benefit from a cane for postural stability in stance (96). Patients with other types of sensory loss, as tabes dorsalis (97) or Friedreich’s ataxia (98,99), show increased power spectrum of body sway during quiet stance with a peak around 1 Hz. Conversely, diabetic patients may develop sensorimotor dis- tal symmetric polyneuropathy involving both large and small afferent fi- bres (102). This suggests that the signal coming from the length-sensitive spindle secondaries is better suited than that from the spindle primaries in detecting the slow changes in length of the leg muscles due to the displacements of the body centre of mass during quiet stance.

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Melatonin supplementation appears to be most effective in treating insomnia in the elderly generic nizagara 50 mg overnight delivery erectile dysfunction instrumental, in whom low melatonin levels are quite common buy nizagara 50 mg lowest price erectile dysfunction drugs after prostate surgery. Although there was no discernible difference in sleep onset and sleep efficiency (time asleep as a percentage of total time in bed) between the two forms generic nizagara 25 mg fast delivery impotence nutrition, the slow-release form yielded better effects on sleep maintenance. In one study, a dosage of 8 mg per day for only four days resulted in significant alterations in hormone secretions. Restless legs syndrome occurs when the patient is awake and is characterized by an irresistible urge to move the legs. The patient is normally unaware of the myoclonus and complains only of either frequent nocturnal awakenings or excessive daytime sleepiness, but questioning of the sleep partner often reveals the myoclonus. If there is a family history of restless legs syndrome (such a history is present in about one-third of all cases of the syndrome), high-dose folic acid, 35 to 60 mg per day, can be helpful. Restless legs syndrome is also a common finding in patients with malabsorption syndromes. The association between low iron levels and restless legs syndrome was documented in clinical studies more than 30 years ago. A later study reproduced these observations, finding serum ferritin levels to be lower in 18 patients with restless legs syndrome than in 18 control subjects. However, serum ferritin levels were inversely correlated with the severity of symptoms. Fifteen of the patients with the syndrome were treated with iron (ferrous sulfate) at a dosage of 200 mg three times per day for two months. The severity of restless legs syndrome decreased by an average of 4 points in sixteen patients with an initial ferritin level lower than 18 mg/l, by 3 points in four patients with ferritin levels between 18 and 45 mg/l, and by 1 point in five patients with ferritin levels between 45 and 100 mg/l. In addition to restless legs syndrome, low serum ferritin levels have been found in psychiatric patients experiencing a condition called akathisia, a drug-induced state of agitation (the name comes from the Greek and means “cannot sit down”). The drugs that most commonly produce akathisia are antidepressant drugs, such as fluoxetine (Paxil, Prozac) and sertraline (Zoloft). Anyone suffering from drug-induced akathisia should ask a physician to perform a serum ferritin assessment. If serum ferritin levels are below 35 mg/l, take 30 mg iron bound to either succinate or fumarate twice per day between meals. If this recommendation causes abdominal discomfort, try 30 mg with meals three times per day. Plants commonly prescribed as aids in promoting sleep include: Valerian (Valeriana officinalis) Passionflower (Passiflora incarnata) Hops (Humulus lupulus) Skullcap (Scutellaria lateriflora) Chamomile (Matricaria chamomilla) Of the herbs listed, the one on which the most clinical research has been done is valerian. More than 20 double-blind clinical studies have now substantiated valerian’s ability to improve sleep quality and relieve insomnia. The studies, which were usually performed under strict laboratory conditions, demonstrated quite clearly that valerian is as effective at bringing on sleep as small doses of barbiturates or benzodiazepines. However, although these latter compounds also increase morning sleepiness, valerian usually reduces morning sleepiness. Examples include: Alprazolam (Alprazolam, Xanax) Chlordiazepoxide (Librium) Diazepam (Valium) Eszopiclone (Lunesta) Flurazepam (Dalmane) Quazepam (Doral) Ramelteon (Rozerem) Temazepam (Restoril) Triazolam (Halcion) Zaleplon (Sonata) Zolpidem (Ambien) All of these drugs are associated with significant risks. Common side effects include dizziness, drowsiness, and impaired coordination; it is important not to drive or engage in any potentially dangerous activities while on these drugs. The most serious side effects of the conventional antianxiety drugs relate to their effects on memory and behavior. Because these drugs have a powerful effect on brain chemistry, significant changes in brain function and behavior can occur. Severe memory impairment and amnesia, nervousness, confusion, hallucinations, bizarre behavior, and extreme irritability and aggressiveness may result. They have also been shown to increase feelings of depression, including suicidal thinking. The most shocking of his findings was that people who take sleeping pills die sooner than people who do not use sleeping pills. Kripke examined data from a very large study known as the Cancer Prevention Study I. In this study, American Cancer Society volunteers gave questionnaires to more than 1 million Americans and then followed up six years later. Kripke and his colleagues found that 50% more of those who said that they often took sleeping pills had died, compared with participants of the same age, sex, and reported health status who never took sleeping pills. Those who reported taking sleeping pills 30 or more times per month had 25% higher mortality than those who said that they took no sleeping pills. Those that who took sleeping pills just a few times per month showed a 10% to 15% increase in mortality, compared with those who took no sleeping pills. Deaths from common causes such as heart disease, cancer, and stroke were all increased among sleeping pill users. Four of these studies specifically found that use of sleeping pills predicted increased risk of death from cancer. Kripke’s team obtained medical records for 10,529 people who were prescribed hypnotic sleeping pills and for 23,676 matched patients who were never prescribed sleeping pills. Based on these findings, Kripke and colleagues estimate that sleeping pills are linked to 320,000 to 507,000 U. They may mean that the use of sleeping pills is just an indicator of stress, anxiety, insomnia, and depression. In other words, maybe these people were taking sleeping pills because they were really stressed out or depressed, and it was actually the stress or depression that did them in. For example, it is possible that the drugs interfere with normal sleep repair mechanisms as well as promote depression. The bottom line is that it is clear that the risks of taking the drugs far outweigh any benefits. In addition to psychological support if needed, the foremost component of treatment is the control of any factors known to disrupt normal sleep patterns, such as the following: • Stimulants (e. Once a normal sleep pattern has been established, the recommended supplements and botanicals should be slowly decreased. If there is a family history of restless legs syndrome, high-dose folic acid, 35 to 60 mg per day, can be helpful but requires a prescription. If there is no family history, ask for a serum ferritin test to rule out iron deficiency. Exercise Engage in a regular exercise program that elevates heart rate to 60 to 75% of maximum for at least 20 minutes a day (but do not exercise right before going to bed). Diet The guidelines given in the chapter “A Health-Promoting Diet” can be helpful. Especially important to preventing sleep maintenance insomnia is eating a lowglycemic-load diet to reduce blood sugar volatility. For additional information on how to stabilize blood sugar levels, see the chapter “Hypoglycemia. Determining the true frequency is virtually impossible, as many sufferers never seek medical attention. Dietary Fiber The treatment of irritable bowel syndrome through an increase in dietary fiber has a long history of success.