By A. Torn. Robert Morris College, Illinois. 2019.
They may see themselves as taking signiﬁcant professional risks in pursuing this line of research buy cheap kamagra oral jelly 100mg on line, and they may have sacriﬁced much time for relaxation and personal fulﬁllment to pursue this research; and consequently cheap kamagra oral jelly 100mg free shipping, their consciences may be numb to the idea that there would be anything ethically problematic about expecting that patients involved in this research would have to take some risks as well discount kamagra oral jelly generic. However, one of the most basic principles in medical ethics is what is referred to as the Kantian principle of respect for persons. In short, that principle says that it is never ethically acceptable to treat persons as if they were mere things, as if one individual could use another individual for purposes that the latter individual did not accept as his or her own. Again, the primary ethical purpose of informed consent is to permit patients to adopt/accept the medical therapies that are being offered by their physi- cian. No matter how genuinely noble the intent of that physician in providing medical care, if that competent patient has not freely consented to those interven- tions, then the outcome is ethically ignoble. As noted earlier, eliciting truly informed consent in experimental clinical cir- cumstances is much more difﬁcult and ethically risk-laden than in ordinary medical practice. Patients in these circumstances may desperately want to hear hopeful things from their physicians, which makes it easy for experimental researchers to understate the risks to which such patients might be exposing themselves. Patients are naturally inclined to trust their physicians, which means they are less likely to ask probing questions about competing interests that might motivate that researcher. That makes it all the more ethically imperative that researchers be candid with potential patients about the risks of experimental medicine and the rewards that might accrue to them as researchers. Since researchers themselves may have great difﬁculty being candid enough in these circumstances, given the genuine mixture of motives that generates such research, the ethically required course of action is that the physician who is primarily responsible for providing therapeutic care to a patient be different from the physician who is responsible for the research. In that way it is expected that the primary care physician will be better able to advise that patient in a suitably neutral fashion about where their best medical interests might lie. Finally, it is assumed that this primary care physician would have no ties at all to that clinical research, which might otherwise potentially compromise his/her ability to protect the best interests of the patient for whom they are caring. Case of Donald: Gene Therapy for Cystic Fibrosis There are a number of other ethical issues that might be raised in connection with the case of David, but we will pass over them. The case of David is not about gene therapy, but it is actually an excellent model for the sorts of clinical ethical issues that are most likely to arise. Having discussed the case of David in some depth, this portion of our discussion can be much more concise. We start by recalling an earlier observation, namely, that patients enrolled in clinical trials for serious medical disorders are often in medically desperate circumstances; they have generally exhausted all other reasonable options. But this was not true with David; and it will generally not be true for many of the early trials with different approaches to gene therapy. As in the case of David, we will assume that Donald is very bright, which is to say he is capable of rationally processing the relevant medical information. Before commenting directly on this hypothetical case, we will lay out a common ethical framework often used to address cases like this, including a sharper arti- culation of some of the ethical issues raised by this case. That prompts the ethical question: Is Donald capable of making an autonomous choice in this matter? Would we (societal representatives) have the moral right to deny all 12-year-old individuals such an option, no matter how bright or mature they were, much as we deny the right to legally consume alcohol to those below age 21? A second basic principle of health care ethics, probably the oldest of these prin- ciples, is what is referred to as the principle of nonmaleﬁcence. It is often interpreted to mean that at the very least physicians should do nothing that will cause unnec- essary harm to their patients. Surgeons will cause considerable misery to their patients because of what surgery is, but such surgery does not represent a net harm to the patient because it is conﬁdently believed that surgery will restore the patient’s health. Further, the patient has freely agreed to the surgery because he sees this as protecting his best medical interests. So surgery in these circumstances does not rep- resent a violation of this ethical principle. These are not inert substances; they are often modiﬁed viruses, which is to suggest that there is some risk of biological modiﬁca- tion of those viruses within an individual that could have serious adverse conse- quences. Again, we have David’s actual story as a reminder of the kind of risks that are associated with clinical medicine. It is expected that they will either be destroyed or that they will function in such a way that they produce the proteins with which they are normally associated. Again, it is not expected that these genes will somehow insert themselves into normal cells and disrupt the normal function- ing of the genetic machinery. We think we know enough about how things work at that level that it is extremely unlikely that something like that would happen. For any sort of major surgery patients are assuming signiﬁcant enough risk of harm. We know in general the risks of anesthesia; and we know in general the risks of infection after surgery. In cases where that surgery is medically necessary (90% occluded coronary arteries), the risk of harm is ethically justiﬁed by the conﬁdently expected medical beneﬁt. In the case of Donald, however, we cannot talk about “conﬁdently expected medical beneﬁt. Further, there is some legitimate concern about unknown risks that could be very serious, again a reason why we describe these interventions as experimental. Facts like that would seem to undermine the ethical warrant for exposing this patient to almost any level of experimental risk. However, that should be taken as nothing more than a tentative conclusion at this point. There is a third ethical principle that needs to be considered at this point, what is usually referred to as the principle of beneﬁcence. One formulation of this prin- ciple would say that physicians always ought to act in such a way as to advance the best medical interests of their patients. We saw in our discussion of the David case how this principle might be violated by allowing third-party interests, or the physi- cian’s own self-interests, to compromise inappropriately the patient’s interests. It is a common practice today to pay physicians a fee for “recruiting” patients for clinical trials. The fee is intended to cover the cost of that physician’s time in discussing with a patient the nature of the trial and why he might wish to consider it. It is reasonable to ask whether there is anything ethically suspect about this practice. If, on the other hand, the fee is very generous, and it is really intended as a strong incentive for that physician to persuade patients to participate in these trials, then it is prima facie ethically suspect. If he were reluctant to do so, that suggests the practice is potentially ethically corruptive. Sound ethical judgments are always capable of standing the light of day, that is, public scrutiny. There are at least two other construals of that principle that need to be considered in relation to the case of Donald. First, we might take the principle to mean that physicians ought always act in such a way as to maximize the best interests of their patient from the point of view of their best medical judgment.
Adrenal gland synsacrum may be identified buy discount kamagra oral jelly 100mg online, removed en bloc and enlargement may be observed in chronically stressed fixed in formalin solution order kamagra oral jelly with visa. These tissue sections can be processed and Specimens of skin cheap kamagra oral jelly 100 mg, feather follicles and feathers may examined microscopically to evaluate nervoustissue, be taken for histopathology if they have not already bone and attached soft tissues. The parathyroid case, hydropericardium was associated glands are present at the caudal pole of the with avian viral serositis in a Blue and Gold thyroid gland but are normally minuscule. The parasites were identified as a vessels were partially calcified and the his- new species of filariid worms,Chandlerella tologic diagnosis was atherosclerosis. The bird the left and right hepatic peritoneal mem- was provided cuttlebone that was seldom branes (open arrows). The bird flew into a wall and caudal thoracic air sac is also clearly visible sustained multiple fractures. Radiographs through the transparent, contiguous wall of the indicated metabolic bone disease and egg- cranial thoracic and caudal thoracic air sacs. A mature Moluccan Cockatoo was pre- The normal syringeal muscles (s), trachea sented for an acute onset of lethargy, dysp- (t), thyroid (th) and thoracic esophagus (e) nea and weakness. Note how the thoracic large quantity of blood was noted in the esophagus passes dorsally to the syrinx at right axillary and neck region. The Pericarditis can be caused by many bacte- pale heart is shown resting in an increased rial, fungal or viral pathogens. The hemorrhage can be an indication of septice- bird died shortly after presentation. His- Note the syringeal bulla (arrows) that is an topathologic changes included extension of the trachea found in some male atherosclerosis and myocardial fibrosis. Auditory evoke poten- Lobules of normal thymic tissue (arrows) tials indicated a centralized inflammatory within fascial planes adjacent to the cervi- disease. Necropsy indicated an internal cal musculature in a young cockatoo (cour- and external bacterial ear infection with tesy of Ken Latimer). The nematode burrows into cutaneous tissue (open arrow) associated the koilin layer of the ventriculus, causing with the area where the bird had been vac- hypertrophy (arrows). These “turkish towel”- there is no accumulation of fluid (courtesy type lesions can be caused by candidiasis or of Kenneth Latimer). Severe con- sues in the small intestines of a duck with gestion and hemorrhage in the brain were duck virus enteritis (courtesy of John H. Brachial Plexus severe nephritis or renal neoplasia where compres- The brachial plexus lies lateral to the thyroid gland sion or infiltration of the nerve occurs. Although the plexus commonly is inspected Ischiatic (Sciatic) Nerve at necropsy, dissection and collection of tissues is In instances of pelvic limb paresis or paralysis, the limited except in cases of suspected neurologic dam- ischiatic nerve should be examined grossly and his- age from penetrating wounds, inflammation, neo- tologically. The ischiatic nerve can be found beneath plasia or trauma resulting in avulsion of the plexus. The sacral nerve plexus should be examined care- Removal of the Eyes fully in instances where pelvic limb paresis or paraly- If intraocular disease is present, the eye(s) should be sis has been noted (see Anatomy Overlay). The eyeball is in the midportion of the kidney just anterior to the removed by sharp and blunt dissection of orbital soft ischiatic artery (Figure 14. Collection of Bone and Bone Marrow Detailed examination of portions of the skeletal sys- tem may be necessary in instances of fractures, me- tabolic bone disease, osteomyelitis, arthritis or synovitis and anemia or blood cell dyscrasia. Collec- tion of various skeletal tissues ultimately may be essential for a definitive diagnosis. In the case of fractures, osteomyelitis and arthritis or synovitis, the tissues of interest may be localized with the assistance of survey radiographs. Callus formation, if present, should be noted and specimens for culture or cytology can be taken after the site is exposed by dissection. Cytology preparations will be useful to characterize inflamma- tory infiltrates, identify pathogens or identify urate crystals. Articular surfaces should be examined for erosions of cartilage, eburnation of sub- chondral bone, tags of fibrin or the presence of exudates or hemorrhage. Rongeurs or a small dove- tail saw can be used to excise portions of bone en bloc for histopathologic examination. The sacral plexus and lumbosacral spinal gross necropsy examination (pale liver and kidneys column should be submitted for histopathology in these cases as well as those with clinical changes suggestive of neuropathic gas- suggest anemia) or has a blood cell dyscrasia, bone tric dilatation. The right kidney (k) row examination is necessary, it should be collected and ureter (double arrow) are in their normal anatomic locations lateral to the spine (s). Because many bones of the bird are pneumatized (including those of Other Cranial and Skeletal Tissues the thoracic girdle, humerus, sternum, sternal ribs The nares, cere, beak, choanal slit, infraorbital sinus and occasionally femur), the tibiotarsus or vertebral and ears should be examined. Articular surfaces should be off-white, tibiotarsal marrow, the integument over the tibiotar- smooth and glistening. If exudates are present, ap- sus is plucked and the skin is incised and reflected. The cortex is cracked and urate crystals can be confirmed by microscopic ex- small amounts of marrow are teased or gently amination of cytologic preparations (under polarized squeezed from the marrow cavity. Urate crystals will appear as re- preparations of bone marrow are made for cytologic fractile needles. The cortex should be cracked to promote rapid penetration of fixative into the tissues. Skin (including Crop Pancreas feathers, follicles) Proventriculus Ovary and oviduct Trachea Ventriculus (female) Lung Small intestine Testis (male) Whole Carcass Submission Air sac Large intestine Pectoral muscle Heart Ceca (if present) Bone marrow In instances where the entire carcass is extremely Kidneys Cloaca Cloacal bursa small, such as embryos, nestlings or very small adult Thyroid glands Spleen Thymus Parathyroid glands Liver Brain birds, the entire carcass may be submitted for his- Adrenal glands Gall bladder Ischiatic (sciatic) tologic examination. This is best accomplished by Esophagus (if present) nerve opening the thoracoabdominal cavity, gently separat- Selection of additional tissues will depend upon gross lesions observed at ing the viscera and fixing the entire carcass in for- necropsy. Exces- sively thick (one cm thickness) tissue slices or tissues that float (gas-filled intestine, fatty liver, lung) when immersed in formalin solution often do not fix and Specimen Collection become autolytic. Representative tissue specimens from all organ systems should be collected (Table for Ancillary Testing 14. When specific lesions are observed at necropsy, the tissue specimen collected should include a small margin of normal tissue adjacent to the lesion. Ancillary testing often is essential to confirm or es- Specimens should be shipped to the laboratory in tablish a definitive diagnosis. To de- should be collected routinely for histopathologic crease shipping weight, tissues that have been fixed evaluation; however, additional specimens (eg, swabs in formalin solution for at least 24 hours can be for bacterial culture, fresh tissues for bacterial cul- wrapped in a formalin-soaked gauze square that is ture and virus isolation, crop contents for toxicologic placed into a sealable plastic bag for shipment. In the analysis) are obtained as necessary based upon his- authors’ experience, a complete set of necropsy tis- torical, clinical and necropsy findings. Because specimens can be submitted along with the formalin- cost is often a consideration when submitting his- fixed tissues if the need for additional laboratory topathologic specimens to the laboratory, the practi- testing is obvious or they may be held under appro- tioner should consult a veterinary pathologist con- priate conditions for later submission if required. It cerning the tissues to be submitted in a particular is better to have taken specimens for ancillary testing case. The remaining fixed tissues can be held for and not need them, than to need the specimens and additional study if needed. The following information is designed to expedite specimen procurement and han- Hematologic and Cytologic Specimens dling to maximize the results obtained.
Many measures have been used in or- thopaedics and rheumatology to assess outcome in all forms of intervention (1 discount 100 mg kamagra oral jelly otc, 3) discount kamagra oral jelly 100 mg with visa. This paper reviews the literature and discusses cheap kamagra oral jelly online amex, in particular, the ma- jor issues regarding measures of physical function (e. The most common formats (1-4) used for measurement (alone or in combination) are: a) observation/examination – when health profession- als (or others) make a judgement and rate some parameters on the basis of subjective evidence and with minimal input from the patient; b) patient report – in the form of a structured interview or, more often, of a self-com- pletion questionnaire in which the client is asked to report, with minimal influence from other persons, experienced phenomena (such as pain, dis- tress, fatigue and so on), or give a relativistic evaluation correlated to his/her perspectives/expectations (e. Sometimes, a proxy/caregiver account is collected when the client cannot self-report or when the examiner is interested also in alternative information. The concept of interest can be measured by a single question, rating or item (summary item) or – more often – by a series of them. When the component ratings are presented separately for each di- mension, a “profile” is formed. Contributions from the component scores may be combined to create a new single expression (an arithmetical over- all score), termed “index”, only when the items measure a single underly- ing construct (a construct, such as functional status or health-related quality of life, is a complex phenomenon containing multiple intangible attributes that cannot be easily isolated) (2-4). In choosing measurement instruments of physical function and health status, a common distinction is drawn between generic and specif- ic measures (1): the first provide a broad picture of health status across a range of conditions, whereas the latter are more sensitive to the disorder under consideration and are therefore more likely to reflect clinically im- portant changes. Where necessary, these scales can be supplemented with specialised domain-specific scales (for the assessment of psychological well-being, social role functioning, etc. Even if it is gen- erally recognised that in this field the outcome of treatment is multidi- mensional, it is important in clinical practice to avoid using a long se- quence of instruments with many overlapping items, as this is tiresome to respondents and expensive to administer and analyse. Generally, no- tions of quality of life are not specified but are considered to be implicit in the measure used, i. Nonethe- less there seems to be acceptance that health-related quality of life is “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expec- tations, standards, and concerns. It is a broad-ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient fea- tures of their environment” (9). Health status measures over the last two decades have gradually broadened their sphere of interest to embrace a wide spectrum of con- cepts including “quality of life”. Generic health-status measures purport to be broadly applicable across different types and severities of disease, medical treatments or health interventions, and in a wide range of demo- graphic and cultural sub-groups. They should also be able to measure the burden of illness of populations suffering from chronic conditions as compared with normals (11). Their use permits the comparison of differ- ent impairments, illnesses, populations, and programs, one of the most important objectives for policy analysis and decision making. A concern with generic instruments is that they are sensitive to any changes in health. So, if the primary interest is of a specific nature, other changes in general health will potentially act as interference obscuring the particular outcome of interest. Moreover, in a generic measure a num- ber of questions may be inappropriate or irrelevant for a particular prob- lem while, on the contrary, there may be too few items tapping a specific area (this, to ensure a reasonable length of the generic questionnaire). The most popular generic measures in rheumatology are: the Medical Outcomes Study 36-Item Short-Form Health Survey, the Sickness Impact Profile, and the Nottingham Health Profile (Table 1). Physical functioning (10 items) – extent to which health limits activities such as self-care, walking, climbing stairs, bending, lifting, and other moderate and vigorous activities; 2. Social functioning (2 items) – extent to which physical health or emotional prob- lems interfere with normal social activities; 3. Physical role functioning (4 items) – extent to which physical health interferes with work or other dai- ly activities (patients accomplish less than they wanted, are limited in kinds of activities they can do, etc. Emotional role functioning (3 items) – extent to which emotional problems interfere with work or other daily activities (including decreased time spent, accomplishing less than wanted, not working as carefully as usual); 5. Vitality (4 items) – feeling en- ergetic and full of pep versus tired and worn out; 7. Bodily pain (5 items) – intensity of pain and effect of pain on normal work, both inside and out- side the house; 8. General health perceptions (5 items) – personal evalua- tion of health, including current health, health outlook, and resistance to illness. These eight scales, weighted according to normative algorithm, are scored from 0 to 100, with higher scores reflecting better quality of life (13). Unfortunately, many older adults and patients describe difficulty in doing so and prefer the standard interview. With the possible exception of the summary scales, the instru- ment seems more relevant to groups with lower impairment because of the potential “floor” effect. Each item is weighted depending on the relative severity of dysfunction implied by each statement. For each dimension, the scores are summed and expressed as a percentage of the maximum score possi- ble. Three summary scores are also calculated: total score (includes all do- mains), a physical score (ambulation, body care and movement, and mo- bility), and a psychosocial score (social interaction, emotional behaviour, alertness, and communication) (19). The questionnaire consisted of two parts, but only part I is now used: it contains 38 yes/no items that can be grouped into 6 domains (physical mobility, pain, sleep, social isolation, emotional reactions, and energy level) with each question weighted for severity. The sum of all weighted values in a given domain represents a continuum between 0 (best health) and 100 (worst health) (22). A second major category of generic measurements is represented by the functional disability indicators. All the above generic disease measures do not capture the individual value that a given respondent may assign to a particular health state, and two individuals may rate differently the same health state depending on the value they assign to a symptom or impairment and their willingness to accept trade-offs between benefits and risks. In the context of health- related quality of life evaluation, preference-based (or utility) measures are specifically designed to assess the value or desirability of a particular health status/outcome. They provide a final score on a 0-1 scale where 0 is the worst possible imaginable state (or death) and 1 is perfect health. Rating can be elicited from different groups of individuals such as pa- tients, health professionals, or the general public. These ratings can hence be used as quality of life adjustment weights to calculate, for example, quality-adjusted life years and similar measures, which can then be used in economic evaluations (27). The first is to classify pa- tients into categories based on their responses to questions about their functional status (preference-classification systems). Combining these categories or dimensions results in descriptions of patients’ overall health states. The European Quality of Life Measure (EuroQol) and the Health Utility Index are based on this approach. The European Quality of Life Questionnaire (EuroQol) (28) is a stan- dardised, self-administered questionnaire that classifies the patient into one of 243 health states. EuroQol is self-completed by respondents and ideally suit- ed for use in postal surveys, clinics and face to face interviews (Table 1). The system measures 8 attributes: vision, hearing, speech, physical mobility, dexterity, cognition, pain and discomfort, and emotion. The second approach to utility measurement is to ask patients di- rectly to assign a value to their overall health. The first option is the certainty of living for the rest of one’s life in a particular health condition; the other option is a gamble with two possible outcomes, living for the rest of one’s life in perfect health or immediate death. The changes in the gamble are varied to de- termine the point at which a respondent is indifferent to the choice be- tween the certain option and the gamble.
The most signiﬁcant source is probably drinking water buy 100 mg kamagra oral jelly mastercard, as the aluminum in water is in a more bioavailable and thus potentially toxic form discount kamagra oral jelly 100mg without a prescription. Researchers measuring the absorption of aluminum from tap water added a small amount of soluble aluminum in a radioactive form to the stomachs of animals cheap kamagra oral jelly 100mg with mastercard. They discovered that the trace amounts of aluminum from this single exposure immediately entered the animals’ brain tissue. The frightening news is that aluminum in water not only occurs naturally but also is added (in the form of alum) to treat some water supplies. In addition, citric acid and calcium citrate supplements appear to increase the efﬁciency of absorption of aluminum (but not lead) from water and food. Nutritional Considerations Nutritional status is directly related to mental function in the elderly. These results appear to be signiﬁcantly better than those achieved with vitamin C, vitamin E, and beta-carotene either alone or in combination without the minerals. It is entirely possible (and very likely) that vitamin E, vitamin C, and beta-carotene may simply be markers of increased phytochemical antioxidant intake and do not play a signiﬁcant role on their own. Often researchers make the mistake of thinking that the antioxidant activity of a particular fruit or vegetable is due solely to its vitamin C, vitamin E, or beta-carotene content. However, these nutrient antioxidants often account for a very small fraction of a food’s antioxidant effect—for example, only about 0. The overwhelming antioxidant activity of fruit and vegetables comes from phytochemicals such as ﬂavonoids, phenols, polyphenols, and other carotenoids. In an attempt to gauge the prevalence of thiamine deﬁciency in the geriatric population, 30 people visiting a university outpatient clinic in Tampa, Florida, were tested for thiamine levels. Depending on the thiamine measurement (plasma or red blood cell thiamine), low levels were found in 57% and 33%, respectively, of the people studied. Speciﬁcally, it both potentiates and mimics acetylcholine, an important neurotransmitter involved in memory. These results highlight the growing body of evidence that a signiﬁcant percentage of the geriatric population is deﬁcient in one or more of the B vitamins. Given the essential role of thiamine and other B vitamins in normal human physiology, especially cardiovascular and brain function, routine B vitamin supplementation appears to be worthwhile in this age group. Several investigators have found that the level of vitamin B12 declines with age (probably due to gastric atrophy) and that vitamin B12 deﬁciency is found in 3% to 42% of people 65 and older. One way to determine whether there is a deﬁciency is by measuring the level of cobalamin in the blood. In one study of 100 geriatric outpatients who were seen in ofﬁce-based settings for various acute and chronic medical illnesses, 11 had serum cobalamin levels of 148 pmol/l or below, 30 had levels between 148 and 295 pmol/l, and 59 patients had levels above 296 pmol/l. The patients with cobalamin levels below 148 pmol/l were treated and not included in the analysis of declining cobalamin levels. The average annual decline in serum cobalamin level was 18 pmol/l for patients who had higher initial serum cobalamin levels (224 to 292 pmol/l). For patients with lower initial cobalamin levels, the average annual decline was much higher, 28 pmol/l. These results indicate that screening for vitamin B12 deﬁciency appears to be indicated in the elderly given the positive cost- beneﬁt ratio. When individuals with low cobalamin levels were supplemented with vitamin B12, signiﬁcant clinical improvements were noted. In other studies, supplementation has shown tremendous beneﬁt in reversing impaired mental function when there are low levels of vitamin B. Several studies have shown that the best clinical responders are those who have been showing signs of impaired mental function for less than six months. Only those patients who had had symptoms for less than one year showed improvement. The most common form is cyanocobalamin; however, vitamin B12 is active in the human body in only two forms, methylcobalamin and adenosylcobalamin. Although methylcobalamin and adenosylcobalamin are active immediately upon absorption, cyanocobalamin must be converted to either methylcobalamin or adenosylcobalamin. The body’s ability to make this conversion may decline with aging and may be another factor responsible for the vitamin B12 disturbances noted in the elderly population. Finally, the damaging effects of low vitamin B12 levels are aggravated by high levels of folic acid that mask a vitamin B12 deﬁciency. While the addition of folic acid to the food supply in 1998 helped decrease neural tube defects in infants, it may also have worsened the problems caused by low vitamin B12. With insufﬁcient zinc, the end result could be the destruction of nerve cells and the formation of neuroﬁbrillary tangles and plaques. Only two patients failed to show improvement in memory, understanding, communication, and social contact. In one 79-year-old patient, the response was labeled “unbelievable” by both the medical staff and the family. There is ambivalence in recent medical literature about zinc because in vitro, zinc accelerates the formation of insoluble beta-amyloid peptide. A possible explanation is that the higher localized levels of zinc result in increased amyloid formation when the free-radical-scavenging mechanisms have been inadequate. This enzyme combines choline (as provided by phosphatidylcholine) with an acetyl molecule to form acetylcholine, the neurotransmitter. Studies have shown inconsistent improvements in memory from choline supplementation in both normal and Alzheimer patients. If there is no noticeable improvement within the 90-day time frame, supplementation should be discontinued. Low levels of phosphatidylserine in the brain are associated with impaired mental function and depression in the elderly. Statistically signiﬁcant improvements were noted in mental function, mood, and behavior for the phosphatidylserine group. It is not likely to be of beneﬁt in those with satisfactory levels for their age and sex. Melatonin and Bright Light Therapy Test tube studies have shown that melatonin protects brain cells from heavy metal damage. For example, melatonin treatment prevented oxidative damage and beta-amyloid release caused by cobalt. Circadian rhythm affects body functions such as sleep cycles, temperature, alertness, and hormone production. If natural sunlight exposure is not possible for at least an hour in the morning, light boxes are available that can simulate sunlight. Full-spectrum lightbulbs are available that can replace conventional bulbs as well. Even this may be in doubt, as in several double-blind studies no beneﬁt over a placebo was observed in halting cognitive decline.