Should we depend less on palpation and assessment right-sided sacroiliac joint pain purchase desloratadine without a prescription. What other tests do you use so that your clinical lumbar erectors; see descriptions of assessments in examination’s reliability can be bolstered? If treatment based on possibly unreliable assessment ture cheap desloratadine 5mg free shipping, edematous features cheap desloratadine 5mg, range of motion, etc. This would certainly assessment methods, valuable mainly for its placebo be what an osteopathically or chiropractically ori- effects? Should palpatory diagnostic ﬁndings be accepted as because we do tend to ﬁnd what we look for, the having a subjective/interpretative value similar to assessment might at times be self-fulﬁlling. A question interpretation of radiographic ﬁndings or other worth considering is whether patterns of dysfunction Chapter 5 • Assessment and Palpation: Accuracy and Reliability Issues 103 revealed in the symptomatic patient, which are inter- practiced examiners, and when used in conjunction preted as being etiological, may sometimes (often) be with other assessment methods. It is seldom the identiﬁed in symptom-free individuals if they were case that a single positive test should be relied on assessed in the same manner. The individual practi- as offering conclusive evidence in clinical tioner/therapist, whose skill relates to an ability to decision-making. This practitioner might also To some extent this will always remain an individual assess the position of the atlas, evaluate digestive matter for the naturopathically trained clinician, who function, undertake a gait analysis and perform a box – it is to be hoped – will rely on an amalgam of infor- step-up test, a toe touch drill, a lunge, a squat, a mul- mation, gathered in a variety of ways, that will be tiﬁdus activation test and a gluteus medius strength placed alongside palpation and assessment ﬁndings, test. The data would • Which tissues or areas are dysfunctional, based on then be assessed for patterns of dysfunction and, if these ﬁndings, and why are they in this state? Hence, what that practitioner is looking for is operating appropriately, and what can I do to assist different from the focus of the ﬁrst example. The depth of the second set of assessments would • Are these tissues too loose, too tight, too damaged, fall well outside the conﬁnes of a traditional 30-minute too weak (etc. This search for information, conducted before suggesting or applying • What is the appropriate initial treatment for this corrective measures, would seem to offer a more situation? The transmission of these responses to the • How do these ﬁndings equate with the evidence brain, and gathered from the Zink and Lawson (common 3. The interpretation or analysis or perception of compensatory pattern) assessment (see pages 138/139) the information. Clearly, if any aspect of these operations is distorted • What whole body, constitutional methods might be or inaccurate, the conclusions drawn from them are most suitable for this individual, rather than likely to be suspect. Numerous examples exist of poor inter-examiner reliability in use of palpation and motion assessment The following paradigm may be found to be con- detection of spinal (cervical or elsewhere) dysfunc- structive when making clinical decisions: tion. There are, however, also examples of excellent • Identifying the physiological status of the tissues assessment outcomes (Christensen et al 2002, Downey and the context in which these exist + et al 2003, Gibbons et al 2002, Mior et al 1985). Whether interpreting symptoms • Rational, effective, evidence-based treatment and signs, radiographic evidence (Aprill & Bogduk choices. Questions 1 and 2 relate to the type, location and condition of the tissues involved, and palpation is central to answering these questions. Posing questions to the body Question 3 is about identifying the process that may have led (or contributed) to, or that is maintaining, All motion testing represents the posing by the exam- this state. For example, the of tissue texture cues at rest, as well as during gentle answer to ‘Why is this knee restricted? This is detective work, physiological disturbance, or adaptation, in the tissues seeking information from witnesses that can only being palpated. This recognition will assist in making offer information in a minimalist manner – Yes? In this way skilled palpation whether appropriate answers will emerge, for clearly, and observation can contribute to improved clinical assessment of ﬂexion potential in the wrist will tell choices, and therefore of results. Chapter 5 • Assessment and Palpation: Accuracy and Reliability Issues 105 The way the question is phrased, i. Palpation and observation is a process of Authors in the ﬁeld of manual therapy claim that mining for data, not a process of proving one’s suspi- intervertebral dysfunction – known as somatic dys- cions correct. We need to use the unconscious, non- (DiGiovanna & Schiowitz 1997, Gatterman 1995, judgmental mind (more right-brain function) to gain Greenman 1996, Grieve 1981, Kappler 1997, Kuchera unbiased information, and then switch to the con- et al 1997, Leach 1994) – can be detected by skilled scious, decision-making mind (more left-brain func- manual palpation (DiGiovanna & Schiowitz 1997, tion) to interpret the data. Jull et al suggest that one reason for the often reported Given the traditional time frame for assessment ‘fair to poor’ reliability of motion palpation in the (30–60 minutes maximum), arriving at accurate neck region (DeBoer et al 1985, Mior et al 1985) is that answers to these questions may be extremely difﬁcult repeated, consecutive palpatory procedures might to achieve – particularly if the clinician has a holistic alter joint play within the cervical spine, and therefore understanding of biomechanics. This underlines the need for minimal contact when For example, watching someone do a full squat means palpating and as few repetitions of active or passive that you have multiple joints and body segments cou- movements as possible. This means that a pattern of restriction or asymmetry, sometimes employing radiographic dysfunction becomes magniﬁed by the attempted analysis to determine positional asymmetry (Leach coupling of multiple joints (this is the premise in prep- 1994). Hence there are referred to in manual therapy literature to deﬁne rafts of sports people and members of the general ‘somatic dysfunction’, biomechanical dysfunction public who manifest ‘dysfunction’, and unless cor- or ‘chiropractic subluxation’ (DeBoer et al 1985, rected it is just a matter of time before that dysfunc- Greenman 1989, Kappler 1997). Pain thresholds differ from person to person, and in the same person, depending on, among other things, How valid are these components of how worried the person is about the pain, and what dysfunction, and how accurately they meaning they ascribe to the pain (Jensen & Karoly can be assessed by palpation? A study by Jull et al (1988) concluded that manual A stomach-ache after overeating will be less worry- diagnosis, performed by an experienced manual thera- ing than a stomach-ache that has no obvious cause, pist, was as accurate at identifying symptomatic cervi- especially if someone you know has recently been cal zygapophyseal joints as diagnostic nerve blocks, diagnosed with abdominal cancer! While one person may report a muscle or joint as Whilst results for determining the inter-examiner being ‘painful’, another might report the very same reliability in detection of cervical spine dysfunction joint as ‘uncomfortable’. There are cultural as well are promising, there remains a continuing need for physiological, ethnic and gender reasons for this studies that investigate the reliability and validity of (Hong et al 1996, Melzack & Katz 1999). When Since only one of these factors needs to be present for other ﬁndings are made, a pain report by the a diagnosis of dysfunction to be made (Jones 1997), patient can positively complement the practitioner’s dysfunction can be present before the advent of pain. This, then, is of greater application in preventive medi- cine, rather than just reactive work – which, of course, is where most of our time as therapists is spent. Tissue texture Most studies of athletic/sporting injury rates only Fryer et al (2004a) report that little direct evidence reﬂect the ‘tenderness’ or pain component of dysfunc- exists for the actual nature of abnormal paraspinal tion, as subjects are generally only considered ‘injured’ tissue texture detected by palpation, and note that if they miss a competitive match, miss a training palpation for tenderness is more reliable than palpa- session or report to a clinic with pain. In 1993, Cassisi et al disagreed, stating that there was The relevance of abnormally increased muscle activ- little direct evidence to support the existence, or ity to paraspinal regions that are tender, and that feel nature, of paraspinal tissue texture change that was abnormal to palpation, remains untested, but it is fea- claimed to be detected with palpation. The concept of sible – indeed probable – that increased muscle activ- segmental reﬂex paraspinal muscle contraction had ity would be detectable with palpation, and possibly not at that time been supported, they said, at least in that the act of palpation itself might provoke further association with low back pain. Ten years later the evidence has changed, and it safe Actual structural modiﬁcations may be present, as to say that their supposition was incorrect. They observed It seems that tissue texture changes and tenderness marked wasting on the symptomatic side, located at can indeed be located by palpation, if they are present, just one vertebral level. And there is clearly asym- range and quality of motion of a joint, as it is moved metry involved, and, as Fryer et al have shown, the both actively and passively. Subsequent palpation of the shortened or descriptors you give them), perceived during palpa- lengthened structures associated with such an imbal- tion of active or passive movement, is clearly at ance might reveal altered tone and/or abnormal least as important as being aware of the variables texture and/or tenderness. Does the ‘restricted, hesitant’ movement page 184) creates a level of inevitability of tissue indicate pathology? Is the end-feel: compensatory postural changes to accommodate the • normal but soft? Or is there a pathological end-feel such as help they have compensated several times from the reduced elasticity – relating perhaps to scar original ‘dysfunction’ until, eventually, their body is tissue? Like that famous end-feel because the movement has been analogy of ‘peeling an onion’, the skilled practitioner stopped by the patient, perhaps to avoid pain must now trace back through the patient’s history or because of psychological reasons (their biography) and through their biomechanics (Kaltenborn 1985, Mennell 1964)? As Myss (1997) states, ‘your biography suggest structural, neural, psychological, becomes your biology’. This suggestion, however, has no ground- achieve literacy in this subjective, interpretive skill.
There may be sexual dysfunction buy generic desloratadine 5mg online, either impotence or premature ejaculation cheap desloratadine 5mg visa, which the patient attributes to loss of semen in urine due to excessive masturbation or sexual intercourse purchase desloratadine in india. An overvalued idea may form that the urine is foul smelling and less viscous than normal. Shenkui (or shen-k’uei) occurs in China and consists of anxiety, panic, and various physical complaints (including tiredness and sexual dysfunction). The author has certainly seen anxious Irish adolescents who imagined that they have semen in the urine due to ‘damage’ induced by masturbation, so the syndrome is more widespread than India. Frigophobia, found in East Asia, involves an excessive fear of the cold (wears far too many clothes). Hwa-byung (wool-hwa-byung; ‘fiery illness’ or ‘illness of anger’) is found in Korea, mainly in women. There are an epigastric mass sensation, anorexia, anxiety, dyspnoea, and epigastric pain. It seems to be reactive to social circumstances (a way to release anger or indignation), although partial improvement with antidepressant therapy has been recorded. There is usually awareness of the attack whilst it is happening and it can be recalled later. It may represent a way of expressing feelings without incurring adverse consequences. Koro (Malaysian for “head of turtle”; rok-joo in Thailand; jinjinia bemar in Assam; also called suk-yeong by Cantonese Chinese: shrinking penis) resembles panic in symptomatology. The victim, who usually has no history of psychopathology, believes that the secondary sexual organs (penis, female genitalia, breasts) are retracting (as does a turtle’s head) into the trunk. He, or she, may take active steps to maintain the externality of breasts, penis, and so on. It is probably a non-specific symptom, especially in the West, having been described in both schizophrenia and bipolar affective disorder. Qi-gong reaction is a transient neurotic or psychotic response to practicing qi-gong177 in China. Shenjing shuairuo (Mandarin Chinese: ‘weakness of the nervous syndrome’) is known to us as neurasthenia. Shinkeishitsu, found in Japan, consists of obsessions, perfectionism, ambivalence, social withdrawal, neurasthenia, and hypochondriasis. Shin-byung is found in Korea where it is attributed to ancestral spirits: initial anxiety and somatic complaints give way to convulsive movements and anorexia. Hsieh-ping in Taiwan is somewhat similar: short-lived trance state whilst possessed by ancestral spirit who may be attempting to communicate with the family through the possessed; auditory or visual hallucinations, delirium, and tremulousness. New Zealand Whakama (shame) is expressed by Maori people when they break social taboos. Whakamomori consists of low mood, sometimes with damage to 174 Person or voice that enters and controls a person (Zulu). It may involve movement, breathing regulation, or focusing on ‘energy centres’ in or around the body. Mate Maori (Maori sickness), which different forms, is due to the spirit world responding to the breaking of rules. Rules may be broken by the patient or by others (alive or deceased) in the whanau (extended family). Early studies of mental disorders shared problems of observer bias, sampling errors, and non-standardised measuring instruments. Initial reports of a lack of depressive guilt in developing countries may not have been entirely accurate, as it has been demonstrated to exist, especially in Uganda. It has been suggested that Afro-Caribbean’s are more likely to be detained as offender patients. Psychologists Li ea (2007) discuss common difficulties in assessing, diagnosing, and treating minorities: flawed approaches to assessment (e. Bhugra & Bhui, 2001) 178 Services for ethnic minorities need to be accessible, provide trained interpreters , employ members of the minority group, and supply patient advocates. Ireland and other countries are experiencing immigration in large numbers and provision remains inadequate. This contains a language identification card, a set of 20 translated phrasebooks and a user manual. The term disorder refers to ‘a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions’. Borderline personality disorder is hesitantly included and hyperkinetic disorder was broadened. Oppositional defiant disorder appears because of its predictiveness for later conduct disorder. In Neurasthenia, or nervous debility/exhaustion, the sufferer complains of tiredness, depression, irritability, 182 poor concentration, and anhedonia (also found in depression and schizophrenia), an inability to derive pleasure from anything. It commonly follows or is associated with exhaustion or an infection like influenza. It has been argued that most cases of neurasthenia are actually cases of anxiety or depression. Shenjing shuairuo, in China, and 183 shinkeishitsu, in Japan, are related concepts. Hedonic tone refers to the ability to experience pleasure, its absence 185 meriting the label anhedonia. Historically, Ernst Kretschmer and William Sheldon tried to associate so-called somatotypes, or body builds, with particular psychiatric conditions. There are three basic types, each one with overdevelopment of one of the primary embryonic layers: the endomorph with large visceral cavities and a tendency to bipolar affective disorder, the mesomorph with antisocial proclivities, and the ectomorph who has a tendency to develop schizophrenia. Dress and address Patients want doctors of both sexes to dress formally, the great majority prefer to address doctors by title, but they like to be called by their own first name or they may be undecided about this (Swift ea, 2000; Gallagher ea, 2008) – when in doubt, ask! In a study by Vinjamuri ea (2009) 91% of adult psychiatric 188 outpatients across all age wished to be greeted with their first name ; most wanted their hand to be shaken 184 A French physician described Briquet’s Syndrome (St Louis Hysteria; now called somatisation disorder), a term rarely applied in Europe, in 1859. Classically, it occurs in women, starts before their thirtieth birthday, the patient persistently complains of a variety of physical symptoms, she will not accept a psychological explanation - even if one is obvious, and it is said to affect at least one in a hundred females. Management and prognosis Preparation of a management plan should include investigations, immediate management strategies and long-term interventions; in each instance one should consider social, psychological and biological interventions, and ask who will intervene, when they will do it, and where will it be carried out. We should consider both short-term (this episode) and long-term (recurrences/maintenance) prognoses; features of both illness and the individual with the disorder should be included in the discussion. This can be useful when highlighting a patient’s care and dealing with a specific problem. Psychiatrists are in a very strong position to view clinical cases as a whole because of their commendable tendency to wade through the thickest charts in liaison settings.
In The compressive effects of the water of the oceans many ways more efﬁcient than the wheel desloratadine 5 mg without prescription, the unique would have been the ﬁrst adaptive force imposed on arrangement of human biomechanics allows the body the earliest single-celled living organisms – hence to move using elastic recoil (Gracovetsky 1997 order 5 mg desloratadine, 2001) their ability to resist compression (i discount 5mg desloratadine with mastercard. A wheel, for example, would struggle to roll up manipulate their shape away from danger or toward a steep hillside laden with boulders and fallen trees, nutriment meant that radial contraction would have or to climb a tree or rock-face – yet these are not such been the most likely movement pattern to develop signiﬁcant barriers for a set of legs. Larger organisms that had a sense of desire to move Most commonly, this takes the form of an upper or a against the lateral force of ocean currents (whether for lower crossed syndrome – see ‘Muscle imbalance food, to escape predators, to stay ‘safe’ within the physiology’ and ‘Gravity patterns’ below. A dorsal ﬁn developed – Having mastered the primal dimension of radial con- like the tail wing of an airplane – to minimize pitching traction, and the three spatial dimensions of the and rolling of the body. Interestingly, their ability to frontal, sagittal and transverse planes, the next dimen- breathe (gills) and their major sense organ – the lateral sion to consider, the 4th dimension, is time. This is a manic journeying and so may very much have a place reﬂection of the extrinsic forces and adaptations to in this chapter. For an Gravitational accessible discussion of quantum aspects of the 4th Moving onto land, lateral ﬂexion was no longer the dimension, see The Field by Lynne McTaggart (2003). This meant that the next here and now, the 4th dimension of time still plays a natural transition was mastery of the sagittal plane – critical role in our understanding of etiology, treat- or ﬂexion-extension. The lateral line gradually lost its ment strategy, exercise prescription and subsequent usefulness and became redesigned as an ear. Human mechanics are built with cells, a extension of the organism (Radinski 1987). Indeed cellular system, whereas industrial mechanics are respiration itself became facilitated by, and coupled built with materials, a modular system. This is why in with, axial extension (inhalation) and axial ﬂexion biological systems the whole is greater than the sum (exhalation). Hence the primary adaptive strategy for resisting gravity was to literally meet it head-on through ﬂexion Time and tissue damage etiology and extension – as is seen in mammalia; however, there is only one species that effectively combats Cumulative trauma/gravitational strain gravity in the transverse plane – and that is the species What is commonly deﬁned as the 4th dimension – that has traveled the globe on foot and conquered time – is critical in our understanding of how joint virtually all terrains – Homo sapiens. Optimal instantaneous axis of rotation Posture When in optimal postural (biomechanical) alignment, While it has been recognized for some time that the range of motion of the joints of the body remains posture and deportment are important in preventing optimal. When additional vectors of motion are added injury, the actual process of injury has only recently to the joint (whether they are primary, secondary or been understood. Collagen is one such connective tissue osteopaths, chiropractors, naturopaths and other joint that is the predominant tissue through the body’s con- manipulators to create a ‘locking’ of the joint, meaning nective tissue matrix. Collagen is known to undergo that only a limited range of motion (low amplitude) the mechanical property called ‘creep’ when it is need be thrust through to surpass the physiological placed under load. It is essential to understand that creep is both time Therefore, if a joint has faulty posture, it has a limited dependent and load dependent. In other words, if a range of motion through which it can move – which light load is applied many times to a given biological equates to earlier stress on the passive subsystem and tissue, it can have the same effect as applying a heavier decreased range through which power may be gener- load just one or two times to that same tissue (McGill ated. Falling over onto modern living this means that sporting competition the outstretched arm might be a good example – the may be hampered, though in bygone times such loss scaphoid fracture being a relatively common outcome. Aside from sports and repetitive actions associated However, it is a little more difﬁcult to relate to the with activities of daily living, gravity – the single idea that someone typing at the computer for 20 years biggest, yet most underestimated physical stressor – is with wrists that are slightly too hyperextended may relentless (Kuchera 1997). Similar to buildings and end up with a very debilitating condition – far worse bridges, the human architecture is stressed by any prognostically than a scaphoid fracture. Yet no one slight deviation from optimal posture and, in its observed what happened. The patient blames a lumbar tures (P Beach, Lecturer, British College of Naturopa- disc herniation on bending over to tie a shoelace – as thy & Osteopathy, personal communication, 1994) this is when he or she ‘felt it go’. The fact that this and instinctive sleep postures (Tetley 2000, M Tetley, Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 335 Rate Genetic potential Figure 9. If rate of repair is good (gray line) throughout life, and the rate of cumulative microtrauma (black line) is kept mimimal through optimal mechanics, the rate of repair will exceed the rate of damage and the tissue, or organism, will fulﬁl its genetic potential. If the rate of repair is suboptimal (white dotted line) due to poor nutrition and lifestyle habits, and/or the rate of cumulative microtrauma is increased due to poor mechanics, the rate of damage will exceed the rate of repair earlier in life, and the tissue, or the organism, will fail before genetic potential is reached. If biomechanics are suboptimal, the rate of cumulative microtrauma will increase (black dotted line), surpassing the rate of healing at an earlier stage in life, and resulting in early tissue failure for orthopedic consultation have an idiopathic onset to their pain condition. What this implies is that since most of these pain presentations were not brought on Figure 9. Top, by a clear, traumatic event, it is likely they can be optimal pull from muscles in ‘balance’ with each other results in no disruption of the instantaneous axis of rotation and therefore no attributed to a cumulative microtrauma mechanism signiﬁcant trauma to the joint. For example: arrow) results in compressive stress to one side of the joint, and distractive stress on the opposite side of the joint • typing with poor (hyperextended) wrist posture personal communication, 2004; see below under ‘Bio- • sitting with a ﬂexed lumbar spine 8 hours per mechanical attractors’) – that it regularly adopts to day for 25 years avoid too much stress on any one speciﬁc structure. This rhythm means that during its The implication for naturopaths, manual therapists waking hours the organism is predominantly in a and bodyworkers is that if 85% of patients presenting breakdown, catabolic state, and when it sleeps it in orthopedic surgery clinics have cumulative micro- should be predominantly in a growth and repair, ana- trauma as part of the etiological matrix, then the per- bolic state (Chek 2003). We can deduce that in as a bad tackle in a football or rugby match which clinical practice, cumulative microtrauma is the etiol- results in a rupture of a major ligament – may have ogy of most pain conditions we see. Chek (2002) and been predisposed by previous microtrauma to the Vleeming (2003) state that 85% of patients attending ruptured tissue (Fig. Adapted from McGill (2000) Hence, we can conﬁdently state that, in most cases, ing of the spine and therefore minimizing potential a dysfunction in the primal (radial – to include breath- trauma to the tissues surrounding it. Stiffness is little consequence, but when in the context of the 4th deﬁned as the change in tension per unit of change in dimension (time) the impact may be profound. The spine, when used to its This view is wholly naturopathic since it highlights maximum functional capability, is stretched through- both the need for minimization of biomechanical out its full range of motion. Stiffness of the spine, loading through avoidance of cumulative micro- therefore, may at ﬁrst appear contradictory to full per- trauma, in concert with the need for maximization of formance; however, the provision of stiffness by the tissue repair in the form of nutrition and lifestyle inner unit will presumably be generated at the exact factors. An integral component of a muscle’s capacity Clinical importance of the dimensional to generate stiffness is its number of sarcomeres in par- model allel (as opposed to in series). Since each myosin ﬁla- Current models of rehabilitation have correctly identi- ment within the sarcomere has six titin proteins (titin ﬁed the deep intrinsic muscles of the spine and those being the primary intramuscular connective tissue), the muscles intrinsically involved in compartmental pres- more there are arranged in parallel, the more stiffness sure regulation (radial ﬁeld mastery) as those requir- the muscle will have (Sahrmann 2002). While metabolic fatigue is unlikely to occur in into subsequent dimensional mastery (see ‘Visceroso- an inner unit muscle due to its preponderance of slow matic reﬂexes’ below). Hodges rationalized that the pre-contraction (or Hunter (2005) goes on to state that of eight feed-forward mechanism) of the inner unit – described players who had recurrent hamstring strain, six had as a ‘visceral cylinder’ (see Fig. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 337 the fact that this motion is known to be most likely to Table 9. Studying the applied anatomy of the abdominal wall Dimension Example of intervention and pelvis provides another suggestion. Firstly, the Radial Nutritional intervention three layers of the abdominal wall – transversus Breath-based exercises abdominis, internal oblique and external oblique – are Singing/voice work fashioned in such a way that they can slide over one Prone transversus activation with another (Rizk 1980). Of course, the obliques, having biofeedback cuff the greatest lever arm of all trunk rotators and a higher 4-point transversus activation ratio of fast twitch ﬁbers, are prime movers in explo- Frontal Reptilian crawl sive rotation movements. Supine hip extension: If the applied anatomy of the abdominal wall is scru- • On ground tinized, then the internal oblique is observed to insert • Feet on Swiss ball • Back on Swiss ball into the deep lamina of the posterior layer of the tho- Squat racolumbar fascia (see Vleeming et al 1997, p. The biceps femoris also attaches into this same Transverse Rolling exercises (à la Feldenkrais) lamina.
LifeBridge Health & Fitness is a to receive instruction on the clinical services national model for hospital-sponsored well- of the departments of Medicine order genuine desloratadine on-line, Obstetrics- ness centers order 5mg desloratadine with visa. Gynecology 5mg desloratadine sale, Pediatrics, Rehabilitation Medi- The Medical Staff of Sinai Hospital num- cine, and Surgery. Students at any level bers over 1,023 full-time and private practicing of training are eligible to participate in the physicians. One half-day per week is The curriculum is organized to allow each of our devoted to a precepted clinical experience, graduates to achieve the eleven educational the Longitudinal Clerkship, which provides objectives noted in the Mission and Education further training in patient-centered inter- Program Objectives for the Johns Hopkins Uni- viewing, physical diagnosis, and health care versity School of Medicine (page 9 ). Students able beginning in Quarter 4 of the Second will have a variety of lecture and small group Year. Elective courses are described in the discussions supplemented by experiential programs of the various departments in the and skill learning in each intersession. In the section under Departments and Divisions, afternoons of these intersessions students Centers, Institutes and Subjects of Instruc- will be attending a Scholarly Concentration tion. This information is supplemented by course in one of fve concentrations: Basic an elective book which is updated annually. Science Research, Clinical Research, Public Selected students may interrupt the regular and Community Health, History of Medicine, curriculum for one or more years in order to and Medicine and the Arts. These Renal, Cardiovascular, Gastroenterology, courses are intended to introduce students Reproductive Health and Endocrinology, and to the basic language and concepts of bio- Rheumatology. 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Extension or eve- gible for the fnancial aid program from Johns ning courses taken in fulfllment of premedi- Hopkins University School of Medicine due cal course requirements are not acceptable to federal restrictions on the use of a large unless they are identical to courses offered in percentage of the loan funds which support the college’s regular academic program. Because of these limitations, aration in foreign universities, in most cases, qualifed students will be issued conditional must be supplemented by a year or more of acceptances into the School of Medicine course work in an accredited United States under the following terms: on or before July 1 university. Each appli- dent must provide an escrow account or a four cant must have received the B. A list of major United States bank in the favor of Johns specifc pre-medical course requirements Hopkins University. In order to assess fcient to meet all tuition, mandatory fees and the classroom performance of an applicant, living expenses for the anticipated period of the Committee on Admission requires that all enrollment. The current escrow requirement of the coursework submitted in fulfllment of is $270,000. In the event of tuition increases admission requirements must be evaluated for future years, accepted students will be on the basis of a traditional grading system. Details of fnancial requirements will be bers or letters to indicate the comparative included in letters of acceptance. Following receipt received a grade of Pass/Credit for any of the of all required credentials, the committee on specifed premedical course requirements, admission will review applications and make the instructor must supply, in writing, a state- interview decisions. Applicants selected for ment evaluating the student’s performance in interview will be notifed by the committee. Students admit- the applicant lives at some distance from Bal- ted to the School of Medicine on a conditional timore. The student should attain a basic understanding of the structure and function of the mammalian cell. Individuals who have completed their studies in biology more than 4 years prior to their application are strongly advised to take a one semester advanced mammalian biology course. The student should have knowledge of chemi- cal equilibrium and thermodynamics, acid/base chemistry, the nature of ions in solution and redox reactions, the structure of molecules with special emphasis on bioorganic compounds, reaction rates, binding coeffcients, and reaction mechanisms involved in enzyme kinetics. Also important is a basic understanding of the structure of nucleic acids including how they store and transfer information. Applicants with advanced placement in general chemistry must take one additional semester of advanced chemistry with lab. Effective communication skills are essential and candidates must be profcient in spo- ken and written English and be able to communicate well. Advanced Placement credit for calculus, acceptable to the student’s undergraduate college, may be used in fulfllment of the math requirement.
This is reflected in an At the same time best desloratadine 5 mg, the brains of substance-using individual pathologically pursuing reward and/or individuals may adapt to the unnaturally high relief by substance use and other behaviors buy cheapest desloratadine. Compared to non-substance users cheap desloratadine express, the addiction often involves cycles of relapse and brains of chronic substance users appear to have remission. Without treatment or engagement in lower baseline levels of dopamine, making it recovery activities, addiction is progressive and difficult for them to achieve feelings of pleasure 24 can result in disability or premature death. The cognitive control of an motivated or directed actions such as attaining addictive substances and also influences dopamine ‡ levels in the brain. Although certain when he or she wants to cut down or stop using specific genetic factors predispose an individual 37 an addictive substance, it becomes extremely to addiction involving a particular substance, 30 difficult to do so. Advances in genetic research have enabled People may choose to take drugs, but no one chooses to be an addict. Genetic variations may affect a person’s ability The Risk Factors for Addiction 41 to metabolize an addictive substance or to 42 tolerate it. Studies have found that genetics Genetic factors play a major role in the account for between half and three quarters of development of addiction as do individual † 43 the risk for addiction. Genetic factors appear biological and psychological characteristics and to be stronger drivers than environmental factors 31 44 environmental conditions. A factor influences them to have a higher tolerance for that is particularly predictive of risk, however, is alcohol are at increased risk of developing the age of first use; almost all cases of addiction begin with substance use before the age of 21, 35 when the brain is still developing. Genetic Risks * Twin and adoption studies confirm a genetic role in the likelihood of substance use and the from environmental similarities. Identical twins are genetically identical and fraternal twins share an * These studies help distinguish the roles of genetics average of 50 percent of their genes, but both types of and environment in the development of addiction. Adopted children with biological tendency toward heightened dopamine response parents who have addiction involving alcohol also are at increased risk because of their are at least twice as likely as are adopted enhanced or above average experience of reward 56 children without such parents to develop or pleasure from engaging in substance use. Individuals Other biological risks may involve damage or † whose genetic makeup produces involuntary deficits in the regions of the brain responsible 57 skin flushing and other unpleasant reactions to for decision making and impulse control. Psychological Risks It’s theoretically possible to take kids before Clinical mental health disorders such as they first drink, find out whether they have any depression and anxiety and psychotic disorders gene variations, and say to them, ‘If you choose such as schizophrenia, as well as behavioral to be a drinker, then be careful because it’s very disorders such as conduct disorder and attention- likely that you’ll need to drink more to have the 58 50 deficit/hyperactivity disorder --and sub-clinical same effect. Individuals whose brain University of California, San Diego development has been altered by stress are more sensitive to the effects of addictive substances and more vulnerable to the development of Other Drugs. Twin military duty, are at increased risk of developing studies have found genetic risks for 62 addiction. People who have risk-taking or hallucinogen, opioid, sedative and stimulant use 63 impulsive personality traits or who have low 53 64 and addiction. Expectations play a role in substance use as well, since people who expect that using In addition to genetic variations, certain addictive substances will be a positive and individuals have neurological, structural or rewarding experience--in terms of physical functional differences that make them more effects, mood or behavior--are likelier to smoke, 54 susceptible to addictive substances. This is in drink alcohol or use other drugs than are those part due to individual differences in how the 67 with more balanced or negative expectations. Some research indicates that individuals with a Environmental Risks naturally low level of dopamine response to addictive substances are at increased risk of Many factors within an individual’s family, engaging in substance use in order to achieve a social circle and community, as well as the greater experience of reward. Other research larger cultural climate, increase the likelihood suggests that individuals with a biological that an individual will use addictive substances and develop addiction. The of cases, addiction originates with substance use 82 nature of the parent-child relationship is key; before the age of 21. Because the parts of the people who come from families with high levels brain responsible for judgment, decision- of parent-child conflict, poor communication, making, emotion and impulse control are not weak family bonds and other indicators of an fully developed until early adulthood, unhealthy parent-child relationship are at adolescents are more likely than adults to take 69 increased risk of substance use and addiction. At the same time, because these or convey approval of such use are at increased regions of the brain are still developing, they are 70 risk as well. Homes where liquor and combination of early initiation of use and medicine cabinets are open to teens increase the genetic, biological, psychological or 73 chances that teens will use these substances. Widespread access to controlled prescription drugs contributes to the misuse of these … [addiction] is not simply a disease of the 75 substances and increased access to marijuana brain, but it is a developmental disorder, and it 71 marketed as medicine is linked to increased begins early in life--during adolescence. Community tolerance of high levels of substance use or of experimenting with and --Nora D. Risky Use and Addiction Exposure to advertising and marketing messages Frequently Co-occur with Other that promote or glamorize smoking and drinking Health Conditions increases the chances that these substances will 78 be used and misused. Direct-to-consumer marketing of controlled prescription drugs may Individuals with addiction are likely to have co- 87 encourage substance use by conveying the occurring health conditions. Smoking causes 79 bladder, esophageal, laryngeal, lung and oral message that there is a pill for every ill. From 2000-2004, the top three causes Environmental influences can exacerbate of smoking-attributable death were lung cancer, existing genetic, biological and psychological risks for substance use, further increasing the * As is true of much of health research, the research chances that an individual will engage in risky on the neurological effects of addictive substances on substance use, sometimes to the point of 80 the adolescent brain primarily has been conducted on addiction. Alcohol consumption chronic disease--like heart disease, hypertension, contributes to diseases that are among the top diabetes and asthma--defined as having a clear causes of death, including heart disease, cancer biological basis, a behavioral component, 90 and stroke. Addiction involving alcohol is environmental influences, unique and linked to cirrhosis, alcoholic hepatitis, chronic identifiable signs and symptoms, a predictable pancreatitis, cardiomyopathy, heart arrhythmias, course and outcome and the need for continued 104 stroke and neoplasms of the liver, pancreas and management following treatment. Heavy alcohol use and addiction involving alcohol are associated with the Like any other chronic condition, addiction 92 incidence and re-infection of tuberculosis. The incidence of various forms of other chronic conditions, individuals with 94 95 cancer, heart disease and sexually-transmitted addiction can have symptom-free periods and 96 105 diseases are higher among those with addiction periods of relapse. In fact, Risky use and addiction also have high rates of addiction frequently is characterized as a disease co-occurrence with many mental health where relapse is virtually inevitable. Yet, this problems including depression, anxiety, post- conception of addiction might be due to the traumatic stress disorder, bipolar disorder, focus of research studies on those with the most schizophrenia and other neuropsychiatric severe manifestations of addiction, who disorders such as attention deficit/hyperactivity experience multiple episodes of symptom disorder, conduct disorder and eating relapse and co-existing health and social 98 disorders. The association between addiction problems over the course of many years or even 107 and co-occurring health conditions can result a lifetime. Substance use may addiction actually receive adequate, effective, 108 precipitate the onset of other conditions such as evidence-based treatment. Other times, high rates of relapse may be due, at least in the health conditions may precede the onset of part, to inadequate or ineffective interventions 109 addiction, as often occurs with mood disorders and treatments. It doesn’t mean types of conditions also may co-occur as a that the treatment doesn’t work, it just means function of an underlying psychological or 97 that you need to continue treatment. Boston University School of Medicine Addiction Can Be a Chronic Disease Once an individual develops addiction, changes in the brain’s reward circuitry may remain even 103 after cessation of substance use. These changes leave addicted individuals vulnerable to * physiological and environmental cues that they Relapse rates for those with addiction are have associated with substance use, increasing comparable to relapse rates for those with other chronic diseases. This approach has contributed to the critical because it influences how individuals concern that viewing addiction as a disease with addiction are treated in society and guides might: the nature of the services provided to address the 110 disease. The current model of addiction 111 Release the individual from personal recognizes that it is a complex brain disease responsibility and the need for self- and that multiple determinants and systems 119 control, and influence substance use and its progression to 112 addiction. Although this model is based on a Engender feelings of hopelessness with large and growing body of scientific evidence, regard to effective treatment and the treatment practice and public attitudes still 120 possibility of recovery. These concerns, however, rarely are raised in 113 relation to other health problems and appear, at Since the 1700s, with few exceptions, two least in part, to be reflective of the moral model different models have dominated society’s views of addiction. Addiction The moral model of addiction framed addiction primarily as a failure of personal responsibility America’s approach to addressing substance use or morality. It asserted that addiction could be and addiction has been filled with contradiction. This approach has to effective marketing by the tobacco industry, contributed to: that view was replaced by one of tobacco use as 122 glamorous and even healthful, only to be The stigma associated with addiction, supplanted in the mid-1960s by a growing attaching blame to the individual, creating understanding that cigarette smoking is a shame and embarrassment, increasing the significant contributor to poor health and 123 likelihood of discrimination and decreasing disease. Physicians prescribed marijuana and cocaine for th a variety of ailments in the late part of the 19 Restrictions in benefits for addicted century only to scale back in the first decades of th individuals.
Both Lorraine and her husband were surprised at the highly specialised treatment Samantha was given at the Breakspear discount desloratadine master card. She was treated for almost everything she might come into contact with generic desloratadine 5 mg overnight delivery, everything which she might eat — some 76 antigens discount desloratadine line, which were tested under her tongue. Pesticides, artificial colourings, and chemical residues in foods such as pork, chicken and beef, appeared to be a big problem. Unfortunately, Lorraine had been introduced to the benefits of this work at the very time others were setting out to destroy it. She felt that the treatment she received from Dr Monro was of such a high quality and so comprehensive, that she would, she says, have paid, even if it meant selling their house, something, she adds hastily, she and her husband never had to consider. She had seen children going into the Breakspear with conditions like chronic asthma, hardly able to walk through the doors, and she had seen them a few weeks later, running round the hospital garden. Lorraine Hoskin was soon to learn that the attacks upon Dr Monro had absolutely nothing to do with her abilities as a doctor, nor the effectiveness of her treatments. There was no hint of common sense in the sudden and insistent clamouring to have the Breakspear shut down. Throughout the first six months of 1990, Wood researched the programme, approaching a number of people who had been patients of Dr Monro and Dr Monro herself. Because the real programme was being made covertly, Wood never told any of the people he approached that the idea was to refute Clinical Ecology or to attack Dr Monro. In fact, Dr Monro, all too happy to be involved in a television programme she thought was about environmental medicine, gave full co-operation, in the early stages, to Wood and Granada. Initially, Wood had extensive information on Dr Jean Monro, and the Breakspear Hospital, which he had probably been given by Caroline Richmond and Duncan Campbell. This was information garnered by health-fraud activists, pharmaceutical companies and insurance companies, since 1985. The hundreds of complaints against the programme, following its transmission, included some from people who had been approached by Wood but had refused to be interviewed. One woman, who had consistently refused Wood an interview, had after rejecting him, been rung up by members of HealthWatch who tried to convince her that she should take part in the programme. Despite the death of her son, Maureen Rudd was completely committed to the treatments and the practices of Dr Monro. On the first occasion that Rudd met Barry Wood, he told her that he was researching a programme on environmental medicine. Until he became ill in 1979, he had been a very fit person: six foot five, a rugby player who was interested in music and played the viola. In 1979, at the age of twenty, he developed glandular fever from which he never properly recovered. The history of his pre-Breakspear treatment is reminiscent of that received by Samantha Hoskin. When William Rudd found Dr Monro, he was so enthusiastic about her treatments, that he suggested the rest of the Rudd family also went to her for consultation. Maureen Rudd had always suspected that she and her family had allergic responses, she was often affected by swellings after eating certain foods and her husband suffered from asthma. For the first time in five years, he was able to take some exercise without becoming immediately tired. He never did feel as ill again after treatment with Dr Monro, and he was gradually able to take a 23 bit more exercise and do more. Living for periods in this caravan also aided his recovery, and up to a year before his death the prognosis for his return to health was good. William fell and shattered his knee-cap, the operation to repair it necessitated a stay in hospital and a general anaesthetic. He gritted his teeth and ran every day for a year in the hopes of being able to get back to Cardiff University, where he had to give up his course, but in fact he was completely ruined by that, his muscles were damaged and he kept falling from then on and had worse and worse falls, until he eventually shattered a knee-cap. Following the treatment on his knee and throughout the long winter, the Rudd family, who live on a farm in Dorset, were often snowed in. All these factors precipitated a relapse, which William was emotionally unable to contend with. Finally in February 1988, the day after he suffered a most serious, but quite separate, emotional set-back, William Rudd committed suicide. She then went on to make clear that she did not consider this cost to have been excessive. It is an expensive treatment because it involves one nurse to one patient, and the actual testing at the beginning is time consuming, and we quite understood that. Although she herself was seeing Dr Monro, it was her child, Jade, who was receiving the most focused treatment at the Breakspear. Blanche Panton was, at the time of her interview with Barry Wood, completely committed to the Breakspear and to Dr Monro. This put Blanche Panton in an impossibly sensitive position, with regard to any television programme critical of Dr Monro. She had nausea and pains in her abdomen from irritable bowel syndrome, and she had an often continuous cold. At her worst she was unable to walk up and down stairs without getting out of breath and her speech became slurred. When she finally got to see Dr Monro, in January 1989, both she and Jade were admitted to the Breakspear. Because of the poor state of her immune system, Blanche had become allergic to a wide range of substances. Dr Monro took Blanche and Jade into the Breakspear for a second stay, even though she had no insurance cover and no money at that time to pay for her treatment. During the second stay at the Breakspear it became apparent to Blanche Panton that she was too ill to look after Jade. Her ex-husband, with his parents, who were Christian Scientists, decided that, especially as she was undergoing medical treatment with which they did not agree, they should take Jade away from her. On that first visit, Wood stayed for an hour or so discussing her condition, and the treatment which she had received from Dr Monro. Blanche Panton did not hear from Wood for a month after that first meeting, until the early autumn, when he called again. Then, he told her that they were still working on the programme even though it had been delayed. Blanche Panton next received a phone call from Wood to confirm the time and date of a filmed interview. On the day agreed, a film crew arrived at her home with Wood and another man who seemed to be senior to him. While the film crew set up the cameras for the interview, Blanche Panton went into another room with Wood, where they discussed the interview. Blanche stressed the point that in her opinion the things which were being said about Jean Monro were essentially political. Blanche says that she was calm when the interview was filmed, telling Wood about the treatment which she and Jade had received, and about how that treatment had benefited her. As the interview went on, Blanche began to realise that it was changing direction.
Müller-Spahn and Hock (1994) listed the most frequent problems in this vulnerable group as social isolation discount desloratadine 5 mg visa, loss of important support systems order 5mg desloratadine free shipping, loss of autonomy due to psychiatric and physical illness and physical disability order 5 mg desloratadine with visa, inactivity consequent upon retirement, loss of reputation and finances, residence relocation, and severe insomnia. Older people are likely to be taking many different medications, and some of these (e. Depressed patients with heart disease are less likely to adhere to diet, exercise, and prescribed medication. However, in the elderly depressed there is a reduced white matter response to acetazolamide, i. Tiemeier ea, (2004) in a cross-sectional population-based Rotterdam study, found that atherosclerosis and depression are associated in the elderly. The more severe was extra-coronary atherosclerosis the higher was the prevalence of depression. There was a strong relationship of severe coronary and aortic calcifications with depressive disorders. White matter changes predate and are associated with late-life depressive symptoms. The consequences of missing the diagnosis (Müller-Spahn and Hock, 1994) are loss of quality of life, social isolation, increased mortality (suicide), increased vulnerability to certain diseases, admission to a nursing home, and a large financial burden. Depression is common in nursing homes, factors contributing to this being loss of independence and familiar surroundings, reduced contact with family and enjoyed activities, and physical disorders. In an Irish community dwelling sample of people aged 65 years and older Gallagher ea (2009) found that, compared to early-onset depression, among those with depression commencing at age 60 years or more (late onset) there was less likely to be a positive family history of depression, less reporting of prior hospital admission for depression, greater cognitive impairment, less feelings of guilt, and less thoughts that life was not worth living. Nevertheless, the authors could find no distinct profile of depressive symptoms that helped to distinguish early versus late onset cases at an individual level. Saez-Fonseca ea (2007) found that depressive pseudodementia in the elderly may be a harbinger of dementia with most cases having an established dementia 5 years later! A Dutch study of depression in people aged 55 years or more (Licht-Strunk ea, 2009) found a median duration of major depressive episode of 18 months; 35% recovered within a year, 60% within two years, and 68% within three years; and poor outcome was associated baseline depression severity, a family history of depression, and poorer physical functioning (the latter only improved if the patient recovered from depression). Elderly depressives spend significantly longer as in-patients than do their younger counterparts, they take longer to respond to treatment, and relapse is common. This is more likely if the patient is taking diuretic medication or has poor left ventricular function. Generally, before starting any antidepressant in the elderly one should steer clear of any drug that 1368 might exacerbate any underlying medical illness or interact with other prescribed medication. The importance of psychosocial support cannot be underestimated, even when antidepressant drugs are used. Lenze ea (2003) found little effect of co-morbid anxiety on outcome of late- life depression treated with interpersonal psychotherapy. Depression in the workplace 1367 Risk of hyponatraemia and small increase in risk of falls. Recurrent brief depression This is a relatively new innovation that is said to be common and have a relapsing course. One in twelve people may be affected and the risk of deliberate self-harm may be 13% over ten years. Diagnostic criteria include 3 episodes over 3 months, depressive episode lasting less than 2 weeks, and no association with the menstrual cycle. The usual treatments for depression may be given a trial, although it may be relatively unresponsive to antidepressants (Baldwin, 2003) because episodes may be too short. Also of significance are the adequacy and appropriateness of treatment received, and the duration of the illness episode prior to starting therapy. Other conditions In 1882, the French psychiatrist Jules Cotard (1840-89), described patients with what he called délire de négation, the term Cotard’s syndrome being first used by J Seglas in 1897. Associated features include le délire d’énormité or delusion of enormous body size or a delusion that urinating will flood the world, and delusion of immortality. Cotard’s syndrome may be associated with valaciclovir (Halldén ea, 2007) or may complicate Parkinson’s disease. Lycanthropy is the belief that one is transformed into an animal, classically a wolf or werewolf. This non- specific presentation can be associated with ‘hysteria’, bipolar affective disorder, psychotic depression, schizophrenia, or organic brain disorders. Essentially, the criteria are (a) one or more episodes of depressive symptoms that fulfil the duration criterion for major depression but there are fewer symptoms and less impairment, and (b) the following diagnoses are outruled: adjustment disorder with 1370 depressed mood , depressive disorder not otherwise specified, major depressive episode, dysthymia, cyclothymic disorder, periods of normal sadness, uncomplicated bereavement, mood disorder induced by substance/general medical condition, a history of major depressive /mania/mixed episode(s), and depressive symptoms that occur exclusively during schizophrenia or schizophreniform/schizoaffective/delusional/not otherwise specified psychotic disorders. Mania may be precipitated by sleep deprivation in people who are euthymic, depressed, or who have no history of prior mania. The risk of such a switch occurring in predominantly unipolar depressives has been put at <1%. According to Vieta,(2004) quetiapine (for mania) may not be associated with treatment-emergent depression. Current or past substance use in depressed bipolar patients was not associated with longer time to recovery but may have increased risk for switching directly into mania/hypomania/mixed states in an American study. First onset mania in 1377 later life may be associated with increased vascular risk factors and relatively high current serum cholesterol levels. Women are more likely to experience depressive episodes than mania (men experience both phases with equal frequency) and rapid cycling is more common in females. Mania may be induced in vulnerable people by lack of sleep, crossing many time zones during travel, and shift work. Less common are chronic depression, chronic mania (said by some to be rare today but one report of hospitalised cases of mania 1380 found that 13% were chronic), and so-called rapid cyclers. Cycling Rapid cycling, which is more common in females, is present when there are at least 4 episodes/year 1381 Ultra-rapid cycling is when attacks occur every so many weeks to several days Ultra-ultra-rapid (ultradian cycling) is when attacks are of less than 24 hours duration (or several episodes daily) Continuous cycling when there is no sustained period of stable mood. Bipolar I disorder prospective study (Solomon ea, 2009) N = 219; median follow-up = 20 years; 1208 mood episodes Major depressive episodes = 30. Nwulia ea (2008) found the best predictors of rapid cycling in familial cases of bipolar disorder to be earlier onset of symptoms (18 v 21 years), comorbid anxiety (47% v 26%), and antidepressant-induced mood switching. Persistence of depressive symptoms increased significantly in the 2 youngest groups. Earlier ages at onset were associated higher depressive morbidity throughout 20 years of follow-up but did not predict changes in symptom persistence. The proportion of weeks spent in episodes of either pole (depression or mania) correlated across follow-up period in all age groups, although correlations were stronger for depressive symptoms and shorter intervals. Bipolar spectrum disorders are associated with an increased premature mortality rate due to general medical illnesses, a consequence perhaps of unhealthy lifestyle, medication, biology, and disparities in health care. Adolescent-onset is associated with substance abuse, anxiety, and an episodic course. Both groups, in contrast to adult cases, have elation, mixed episodes, longer episodes, and poor inter-episode recovery. Forty ea (2008) compared major depression and bipolar disorder patients and found psychosis, diurnal mood varian, hypersomnia during depression, and more frequent short episodes of depression to predict bipolarity. Depression and cancer If a person becomes depressed in middle age, especially if it is for the first time and if no precipitant can be found, should be rigorously investigated to exclude physical disease.