Frequency of depression after stroke: a systematic review of observational studies cheap 400 mg ethambutol mastercard. Stroke is the leading cause of physical not necessarily severe enough to induce dementia disability in adults: of one million inhabitants buy genuine ethambutol line, 2400 when isolated) ethambutol 400mg without prescription. The term Even in stroke survivors who are independent order ethambutol with mastercard, slight VaD cannot be used for all patients who have had cognitive or behavioral changes may have conse- a stroke and are demented, because many of them quences for familial and professional activities [5]. Therefore, the This chapter will not cover: (i) cognitive impair- economic burden of dementia is important. The prevalence of stroke and of ably of vascular origin that occur in the absence of dementia is likely to increase in the coming years, clinical symptoms of stroke or transient ischemic because of the decline in mortality after stroke [8] attacks. Therefore, our review will focus only on and the aging of Western populations [9]. Therefore, dementia that occurs – or was already present – in the burden of stroke-related dementia is also likely to patients who have had clinical symptoms of stroke. A study where stroke was not associated between stroke onset and cognitive assessment, and with an increased risk of dementia [30] was actually criteria used for the diagnosis of dementia [5, 12]. The incidence of dementia after stroke depends on whether the study excluded Stroke doubles the risk of dementia; the attribut- patients with pre-existing cognitive decline or demen- able risk is the highest within the first year after tia or not. In a community-based study of dementia after stroke conducted over a 25-year period, the cumulative inci- Determinants of post-stroke dementia that have been dence of dementia after stroke was 7% after 1 year, found in at least two independent studies, or have 10% after 3 years, 15% after 5 years, 23% after 10 years been identified recently, are listed in Table 13. In hospital-based studies, the incidence of dementia after stroke ranged from Demographic and medical 9% [23] to 16. In the Lille Stroke/ The most important demographic predictors of Dementia cohort after exclusion of patients who were dementia after stroke, in sufficiently powered studies, demented at month 6, only 6% of survivors developed are increasing age and low education level, but not really “new-onset” dementia after 3 years [25]. The risk of dementia after stroke is higher in patients who Incidence of dementia after stroke is 7% after 1 year, 10% after 3 years, 15% after 5 years, 23% were already dependent before stroke [5]. Relative risk of dementia after stroke Diabetes mellitus, atrial fibrillation and myocar- In the Rochester study, the relative risk of dementia dial infarction were also independent risk factors for (i. Arterial by the risk of dementia in stroke-free controls) was hypertension, a risk factor for vascular dementia 8. In the Epileptic seizures [33], sepsis, cardiac arrhythmias Framingham study, the results were similar 10 years and congestive heart failure are independently associ- after stroke, after adjustment for age, gender, educa- ated with an increased risk of dementia after stroke 195 tion level and exposure to individual risk factors for [5]. However, the statistical relationship found Section 3: Diagnostics and syndromes Table 13. The same study may appear several times if several assessments were performed at different time intervals after stroke. This table between these disorders and dementia does not mean includes only determinants of dementia after stroke that have a causal relationship: it is also possible that dementia been found in at least two independent studies or identified recently. A few determinants may not have been confirmed increases the risk of such events [5]. The influence of hyperlipidemia, hyperhomocys- References to the studies cited in this table and published teinemia, alcohol consumption and cigarette smoking before 30 April 2005 can be found in Leys et al. The Demographic and medical characteristics of the patient results concerning cigarette smoking should be inter- Demographic variables preted with caution, because smoking influences mor- tality and stroke recurrence. ApoE4 genotype is Increasing age associated with an increased risk of dementia after Low education level stroke [34]. Pre-stroke dependency Risk factors for dementia after stroke include Dependency increasing age, low education level, diabetes Pre-stroke cognitive decline mellitus, atrial fibrillation, myocardial infarction, epileptic seizures, sepsis, cardiac arrhythmias and Pre-stroke cognitivedecline without dementia[32,50] congestive heart failure. Vascular risk factors Diabetes mellitus Atrial fibrillation Pre-existing silent brain lesions Myocardial infarction in stroke patients ApoE4 genotype [34] Silent infarcts, i. Their Sepsis influence is more important when the follow-up is longer: in the Lille study, silent infarcts were associ- Cardiac arrhythmias ated with dementia after stroke at year 3 [25] but not Congestive heart failure at year 2 and in the Maastricht study silent infarcts Silent brain lesions were independently related to dementia after 12 Silent infarcts months, but not after 1 or 6 months [35]. Stroke patients with associated silent infarcts seem to have Global cerebral atrophy a steeper decline in cognitive function than those Medial temporal lobe atrophy [36] without, but this decline might be confined to those Leukoaraiosis with additional silent infarcts after base-line. Global cerebral atrophy is associated with a higher Stroke characteristics risk of dementia after stroke [5]. However, the question of their influence on Stroke characteristics, such as severity of the clinical deficit or stroke localization, influence the risk of the risk of post-stroke dementia has never been sys- dementia after stroke. The risk of dementia and its severity 10 years younger than in all other studies, and patients are not influenced by the type of stroke (ischemic or who were lost to follow-up at the 3-month evaluation hemorrhagic) [5]. However, differences in survival were more cognitively impaired at the acute stage, and rates between stroke subtypes make the results diffi- in the other [21] the diagnosis of VaD was based on the cult to interpret. In other studies, the risk tia after stroke: (i) in stroke patients who are too of dementia after stroke was lower in patients with young to have Alzheimer lesions, and became demen- small-vessel disease [5]. These results are influenced ted just after stroke; (ii) when cognitive functions by the higher mortality rate in stroke subtypes associ- were normal before stroke, impaired immediately ated with more severe deficits, i. Previous stroke and stroke recurrence In many other circumstances dementia is the con- are also associated with a higher risk of dementia after sequence of the coexistence of Alzheimer and vascular stroke [5]. Supratentorial lesions, left hemispheric lesions, Even when vascular lesions or Alzheimer path- anterior and posterior cerebral artery territory ology do not lead to dementia by themselves, their infarcts, multiple infarcts and so-called “strategic association may reach the threshold of brain lesions infarcts”, i. The same study may appear several times in this table if several assessments were performed at different time intervals. The long-term mortality rate after stroke is may lead to an underestimation of the need for sec- 2–6-fold higher in patients with dementia, after ondary stroke prevention measures. The hypothesis of adjustment for demographic factors, associated car- a possible summation of lesions is supported by the diac diseases, stroke severity and stroke recurrence results of the Optima and the Nun studies, showing [27, 46–48]. This hypothesis was also risk of any nonspecific complication in patients supported by the results of the Syst-Eur dementia with dementia [5]. Frequently dementia is the consequence of the coexistence of Alzheimer and vascular lesions. Even when vascular lesions or Alzheimer pathology do Stroke recurrence not lead to dementia on their own, their summa- Dementia diagnosed 3 months after stroke is associ- tion might induce dementia. Dementia may be a marker for a more severe Influence of dementia vascular disease leading to an increased risk of recur- on stroke outcome rence [5]. Less intensive stroke prevention and lack of compliance may contribute to the increased risk of Mortality recurrence [49]. Leukoaraiosis could also be a con- Both population- and hospital-based studies have founding factor, as it is associated with an increased 199 shown that stroke patients with dementia after stroke risk of stroke recurrence [25]. Section 3: Diagnostics and syndromes the burden of dementia after stroke at the community Functional outcome level, in order to have better knowledge of the need in The few available data on the influence of dementia terms of resources and its evolution over time. Dementia is one of the major causes of dependency Dementia after stroke is associated with a 3-fold in stroke patients. In community-based studies, the increase in stroke recurrence and with higher prevalence of dementia in stroke survivors is approxi- mortality. Patient-related variables associ- in patients with dementia ated with an increased risk of dementia after stroke are increasing age, low education level, dependency There are no data in randomized clinical trials that before stroke, pre-stroke cognitive decline without may help in determining how acute stroke therapy dementia, diabetes mellitus, atrial fibrillation, myo- and stroke prevention should be conducted in cardial infarction, epileptic seizures, sepsis, cardiac patients who are demented before or develop demen- arrhythmias, congestive heart failure, silent cerebral tia after stroke [5]. Patients with dementia after stroke are associated with an increased risk of dementia after patients with dementia and they are also stroke stroke are severity, volume, location and recurrence. In the absence of studies specifically Dementia in stroke patients may be due to vascular designed for stroke patients with dementia, current lesions, Alzheimer pathology, white matter changes guidelines for stroke prevention should be applied, or a summation of these lesions. The proportion of patients with presumed Alzheimer’s disease amongst but we should bear in mind that the specific issue of those with dementia after stroke varies between 19% secondary prevention of stroke in patients with and 61%. Stroke patients with dementia have higher dementia (either pre-existing or new-onset dementia) mortality rates, and are more often functionally is not addressed in any guidelines. Lifetime risk of stroke and dementia: current concepts, and estimates from the Conclusions Framingham Study. Treatment and secondary tant because it indicates a worse outcome with higher prevention of stroke: evidence, costs, and effects on mortality rates, more recurrences and more func- individuals and populations. J Neurol ary stage of dementia after stroke, be much more Neurosurg Psychiatry 2007; 78:56–9. Lancet Neurol 2005; also necessary to evaluate the evolution over time of 4:752–9. Dement stroke incidence, mortality, case-fatality, severity, and Geriatr Cogn Disord 2003; 16:52–6. Zhu L, Fratiglioni L, Guo Z, Aguero-Torres H, brain infarctions predict the development of dementia Winblad B, Viitanen M.

The left ventricle is small (atrophy by inactivity) and appears as an appendage of the atrium effective ethambutol 600mg. Guide to diagnosis is lung organ chilus cheap ethambutol online amex, which is visible at the rear of the preparation buy ethambutol 600 mg without prescription. The cut surface shows that both lobes are evenly diffuse greyish with fine granular structure cheap 600mg ethambutol visa. Density creates an impression that the edges between the two cut surfaces are very well defined (stage of gray ‘hepatization’). Head brain with polished edge - the folds are broad and flat and gyri between them were shallow. By convexity there is a heavy white purulent exudate, located subarachnoidal, filling gyri and spreading on the folds. Organ diagnosis is made in view of the rear surface of the preparation, where a partially removed Glisson’s capsule shows the hepatic parenchyma. Inside, thin cystic structure with a milky color soft and friable - chitin membrane of Hydatid cyst. In the area of the apex, the heart myocardium is whitish, sealed and significantly taper - chronic aneurysm. In endocardium in this area there is mural lobular gray-brown mass with whitish stripes - thrombus. Top shows a large tumor formation - 7,5 / 6 cm, whitish, poorly demarcated, with a central fission of tissue originating from the wall of the main broncus - mostly exophytic bronhogenic cancer. In the field of small curvature, a rounded tumor formation is seen with sunken central part and raised, not better contouring soft edges. The bottom is colorful - showing necrotic areas, hemorrhage, inflammatory deposits. Part of the colon with available exophytic, nodular, tumor formation, increasing broad-based, measuring 3. The bottom was unequal, with a whitish color, and the raised edges with the color of environmental mucosa. Organ diagnosis is made by the presence of smooth fibrous capsule and preserved nodular array. In the middle of the preparation is clearly visible distinct bluish-black area with a spongy structure - a cavernous haemangioma. Material from liver, cut surface on which are visible numerous large rounded foci with dark brown to black, sharply contrasting with preserved liver parenchyma - metastatic malignant melanoma. Unicameral cystic formation with traces of ‘porridge- like’ content, , brownish in color about 1 cm in diam. The surface is uniformly as "grain" sizes are 1-2 mm which correspond to hypertrophic (regenerative) nephrons. Papillary muscles are massive, rounded and with prominant trabeculae in the cavity. The intima is a colorful and grossly unequal because of outbreaks and prominent yellowish thick whitish areas that narrow and deform lumens. Distally, there is mural thrombotic deposition (uneven dark brownish-red mass above bifurcation). Visible extensive area of irregular shape, deleted fascicular structure and clay-yellow (coagulation necrosis), with distinct peripheral dark red stripe (hyperemic-haemorrhagic area). Preparation of the heart, including incoming tract of the left ventricle, mitral valve and left ventricle. Valves layers are thickened, gray-white, with an uneven surface, deformed, shortened and fused with each other. Left Учебна програма за специалност “Медицина” 225 ventricle is significantly enlarged with hypertrophic myocardium and endocardium thickened and whitish in color. One of the sails of the aortic valve with ulceration and another with thrombotic deposits that have polypoidal appearance. The visceral pericardial sheet (epicardium) shows grayish-whitish, sometimes ‘velvet’-like coating with a thickness of 2-3 mm, covering the whole heart. Thin bodies with transparent walls, filled with air (bullae) are seen in the upper and lower lobe. The background ispale gray-pink to gray-white parenchyma showing abundant deposits of anthracotic pigment, imparting a characteristic mosaic variegation on the surface. Lung, covered with smooth, slightly dim, intense visceral pleura, showing numerous airless areas with dense grayish color and texture - lobular pneumonia. The cut surface is diffusely airless, compact, grayish, covered with small whitish nodules or fields the size of ‘millet’ grains. Lung, in which chilus a nodular tumor formation is seenwith a size about 10 cm emanating from a wall of the bronchus and sprouting into the surrounding lung tissue. Preparation of the esophagus, the upper half of which shows saccular extension of its wall, with communicating lumens – pulsating diverticulitis. Shown are several shallow ulcers with a round shape, sizes from 1 mm to 2 cm, with slightly raised edges and a smooth hollow bottom with black color. In the small gastric curvature seen ulcerative defect with irregular oval, raised, solid and well- contouring edges. Part of the stomach wall which is engaged by exophytic tumor with rounded shape, gray-whitish in color and shaped with a central ulcerative defect. Diffusely scattered nodules with a size of lentil to a pea stand out above the hepatic parenchyma. A single rounded concretion with a brownish color and uneven surface is presented in its lumen. Fragment of the trachea and part of ascending aorta with her trunk out of vessels. The two bodies are prorastnati the periphery of highly enriched, and sivkavobeleznikavi srastnali packages in lymph nodes with uniform structure. Highly enlarged spleen with a longitudinal length about 18 cm, dark brown in color. Subkapsularno and cut her face are visible off-white nodular structures (tumor infiltration) with sizes of up to lentil beans, imparting a characteristic diversity of the body. The outer surface is uneven with small retention cysts and extensive shallow depressions with grayish-brown bottom. The cut surface is dominated by theexpansion and deformation of pyelon and calices. At places, the atrophic process is particularly strong and parenchyma remained as a thin strip - significant hydronephrosis. Strongly and equally enlarged kidneys with longitudinal length about 20 cm Their color is white, the capsule is tense. The surface is very uneven because of numerous thin-walled cystic formations in size from 1 to 3-4 cm, filled with clear contents. Preparation of kidney, in which upper pole large spherical tumor is visible, well distinct from the renal parenchyma by pseudocapsule. Preparation of bladder prostate significantly larger at the expense of its three parts. The bladder has a thickened wall and mucosal rough appearance due to pathological hypertrophy of the muscles. Open bladder filled with papillary-polypotic formation of broad-based, infiltrating bladder wall. The surface of the tumor is uneven, covered with short, thick and brittle papillae. Germ-cell tumor presented in the form of nodular mass, poorly demarcated from the testis which has increased in size. Uterine cavity is filled by a mass resembling a semi-dry grapes - bubbles with sizes and lentil seeds, brownish in color, captured in thin stalk. The latter is fully covered and distorted by nodular, gray-white tumor formation with unclear boundaries. In the cut sections infiltrative growth is seen- whitish tumor strands, sprouting in myometrium and cervix. The front third of the uterine body shows exophytic tumor mass with papillae, gray-whitish in color, with fields of bleeding and necrosis originating from the endometrium and spreading to the fundus and cervix. Bilateral cystic ovarian metastases from primary tumors of the digestive system (stomach, colon), breast and others. The ovaries are highly increased in size, deformed, with a smooth, nodular surface.

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Walker (1991) reported that women in professional jobs drink more than women in unskilled positions ethambutol 800 mg for sale. Cheapness generic ethambutol 600mg fast delivery, a relative characteristic order ethambutol now, of alcohol is associated with increased consumption ethambutol 600mg low cost. A low-risk environment, such as not experiencing excess alcohol use by the family, may reduce the effect of high genetic loading. There is evidence that twins living together are more likely to be concordant in their normal drinking habits than when they live apart. No such receptors have been found Therefore, does alcohol work by changing membrane fluidity (and thereby alter receptors/channels? Taxonomy: Alcohol abusers tend to remain alcohol abusers and alcohol dependent patients tend to remain alcohol dependent. Alcoholism can be divided into Alcohol related problems - social, psychological or physical Alcohol dependence - manifested similarly to any other physical dependence: Secretiveness Buying extra rounds Gulping drinks Drinking alone Stocking up Giving other activities up 2525 People who start smoking often experience disconcerting nausea, cough, and dizziness and yet, if social pressure is strong enough, may persist with the habit to the point of dependence. Performance impairment, often subtle, is greater in older people than can be 2529 accounted for by blood alcohol concentration. Non-intoxication in the presence of a blood alcohol level in excess of 200 mg/dL is pathognomonic of alcoholism. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking? The scores are not shown to the user in the form in which the questionnaire is used in practice, but they are given here for convenience sake. Have you ever had a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover? One unit of alcohol equals a half-pint glass of beer, lager or stout, a glass of wine or sherry, or a single measure of spirits. Having excess drink on each occasion of drinking (say > 5 drinks) is as important as the overall intake when it comes to social and personal complications. The annual cost of alcohol misuse in Britain for 1990 was estimated at stg £2 bn if one includes ill health, crime, accidents and absenteeism. Treatment of illnesses and injuries due to alcohol costs the British Government in the early twenty-first century up to £176 bn annually, total costs (absenteeism, crime, etc) reaching as high as £20 bn. This takes no account of the effects on health, relationships, and child development. About 25% of acute male admissions to medical wards, and an even higher percentage in the case of acute surgical emergency admissions, are related to alcohol misuse. If someone looks sober with a high blood alcohol level this suggests a regular heavy alcohol intake - the 2536 levels can still be high 24 hours after the drinking has stopped. Reasons for misdiagnosis of excess alcohol consumption in the elderly (O’Connell ea, 2003) Non-disclosure Low index of clinical suspicion Low referral rate because seen as understandable (poor health and life changes) and untreatable Atypical (falls, confusion, depression) or masked (comorbid physical or psychiatric disorders) presentation Non-applicability of ‘sensible limits’ (metabolic changes, ill health, increased sensitivity to alcohol) Lack of consequences (social, legal, occupational) Focus on recent (rather than lifetime) intake by diagnostic criteria and screening instruments Self-disclosure of alcohol intake by elderly Irish interviewed in their homes showed a significant positive association between consumption and being male and widowed. It was held that 6- 20% of alcoholics commited suicide, although the accepted figure has dropped below the lower of these 2537 two figures in recent years. The alcoholic who was seen as at the highest risk for suicide was older, socially isolated, male, had made previous suicide attempts of serious intent, was physically ill and had a 2533 Gamma glutamyl transpeptidase levels are also elevated with hepatic disease, obesity, and a number of drugs (e. He also believes that 25% of suicides are solely due to alcohol (alcohol is present in the bodies of 58% of Irish suicides). Elder abuse is usually related to chronic stress and low support, but a minority is associated with drug and alcohol abuse, sociopathy, intellectual disability, and various psychiatric disorders in the abuser, e. Wrigley, 1991) Depression in alcohol misusers is often secondary to alcohol, although it may be primary in some cases (bipolar > unipolar depression). Opinion differs on how long a period of sobriety is required before an (alcohol-) independent diagnosis of depression can be made. Alcoholics are at high risk for marital breakdown, unemployment, accidents, doing physical or psychological harm to others, becoming involved in unwise sexual encounters, and of imprisonment. It may also causes gradual coarsening of the personality and the emergency of sociopathic traits. Syndromes associated with alcohol Alcoholic dementia: Lishman (1987) suggested that this condition might account for at least 10% of all end-stage dementias. Radiological studies revealed decreases in brain volume in many chronic alcoholics. This is at least partially and very slowly reversible with prolonged abstinence: it is debated as to whether reversal is due to rehydration of the brain or repair of neurones or myelin. In both cortical areas there was evidence that alcoholics had smaller, shrunken neurones than controls. Possible causes of cognitive disorders in alcoholics include premorbid intellectual deficit, direct ethanol neurotoxicity, neurological complications of alcohol (e. Korsakoff’s), thiamine or nicotinic acid deficiency, recurrent head trauma, and hepatocerebral degeneration. There is controversial evidence that light to moderate drinking may reduce the chances of developing dementia, even when other variables like smoking are controlled for. Most cases clear up quickly after drinking is stopped although hallucinations may return if drinking restarts. The patient may become paranoid, hostile or suicidal as a result, or he/she may take flight or hide. Treatment includes detoxification from alcohol and neuroleptics for hallucinations. Features include intense fear, restlessness, 2540 2541 illusions, delusions, visual hallucinations , tremulousness, ataxia, vestibular dysfunction , hypertension, tachycardia, leucocytosis, impaired hepatic function, and pyrexia. Fever may be part of the core syndrome or due to a complication such as aspiration pneumonia. High blood pressure, tachycardia, and tremor may be obscured by medication that the patient is taking, e. Death can be due to 2543 2544 cardiovascular collapse, infection, and self-injury when restless. Subdural haematoma, pneumonia, and meningitis should be considered in the disorientated alcoholic. Fluids should be replaced sparingly because alcoholics have a reduced ability to excrete water and a tendency to cerebral oedema. Black-outs: This refers to memory lapses (‘memory blackouts’) following a heavy bout of drinking despite observers not noting any significant change in level of consciousness. It is more likely to be abnormal if it occurs frequently or if the episodes of amnesia last for days. The drinker cannot remember where he left his car, who was with him at the time, and so on. Hypoglycaemia: Factors responsible include malnourishment (low hepatic stores of glycogen) and inhibition of hepatic gluconeogenesis by alcohol. Children who take alcohol (not necessarily in large quantity), binge drinkers, and chronic alcoholics have relatively little glycogen reserve in their livers and may present in a comatose state with hypothermia. Hypertension: About a quarter of alcoholics have systemic hypertension, often resolving (to various degrees) with abstention. Retrobulbar neuritis and optic atrophy: These are classically associated with methanol but can occur with ethanol. The retrobulbar neuritis usually comes on insidiously and causes central loss of vision, typically red-green blindness. Neuropathy: This is usually a polyneuropathy, with sensory, motor and autonomic signs: numbness, paraesthesiae, burning dysesthesia, pain, weakness, muscle cramps, gait ataxia, loss of tendon reflexes (including ankle jerks), defective perception of touch and vibration sensation. Treatment: if the patient stops drinking and if nutrition is improved the prognosis should be good. Myopathy: This is more common than one would think from the number of cases diagnosed in clinical practice. There are a variety of possible causes, such as a direct toxic effect of alcohol or hypokalaemia. The acute form may occur during an alcoholic binge, when the patient develops weakness, tenderness, and swelling of the affected musculature. The chronic form is more common and pain is less prominent - there are muscle weakness and atrophy, especially affecting the hip and shoulder girdles.

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Practitioner stands in front and supports patient’s restriction head and neck with cephalad hand and forearm discount ethambutol 400 mg on line. The patient’s tableside hand/arm should be flexed at of the side-lying patient generic ethambutol 400mg free shipping, firmly compressing the shoulder and elbow buy ethambutol american express, while the other arm is in scapula and clavicle to the thorax buy 800 mg ethambutol with visa, while the patient’s extension and adduction, resting on the lateral flexed elbow is held in the practitioner’s caudad thoracic cage. If the restriction involves an inability of C7 on T1 to be sensed, indicating the beginning of the end of fully flex, side-bend and rotate, the hand supporting range of that movement. At that ‘first sign of resistance’ barrier the patient is that the hand in contact with T1 becomes aware of instructed to push the elbow towards the feet, or forces building at that level as the barrier of free anteriorly, or to push further towards the direction of motion is reached (at C7 on T1). When the barrier has been engaged this should be strength, building up force slowly. The range of motion is repeated, and the barrier re- after 7–10 seconds the patient is instructed to slowly engaged rhythmically, with pauses at the barrier for cease the effort. Spencer treatment of shoulder flexion restriction abduction, internal and external rotation, as well as 1. The patient has the same starting position as in A, circumduction movements (Chaitow 2006). The practitioner stands at chest level, half-facing The example is given by Patriquin & Jones (1997) of an cephalad. The practitioner’s non-tableside hand individual with viral pneumonia with a resistant chest grasps the patient’s forearm while the tableside hand wall in which all ribs are restricted in their range in both holds the clavicle and scapula firmly to the chest inhalation and exhalation. The practitioner stands at the head of the bed and shoulder, and by the hand/arm moving the patient’s reaches down under the patient’s back, palms arm toward the direction being assessed), the patient upwards so that the flexed fingertips can engage is instructed to pull the elbow towards the feet, or to an upper pair of ribs (2nd ideally, or 3rd) as close direct it posteriorly, or to push further towards the to the angles on each side of the midline as direction of flexion – utilizing no more than 20% of possible. This effort is firmly resisted by the practitioner, and mobilize the costotransverse and costovertebral after 7–10 seconds the patient is instructed to slowly articulations, and to stretch both the intercostals cease the effort. The tension should be held for at least 10 practitioner moves the shoulder further into flexion, to seconds and then slowly released. A degree of active patient participation in the possible, once the cephalad tension has been movement towards the new barrier may be helpful. The same procedure is repeated on the same pair introducing articulatory shoulder adduction and of ribs, until a sense is gained that no further freedom of movement can be achieved. The next pair of ribs is then engaged and the with the effort being maintained for not less than process repeated. The non-tableside hand is placed under the the patient should be asked to inhale as deeply as patient, so that the slightly flexed fingertips can possible. The process should be repeated until a suitable to the angle of the ribs (one side treated at a time degree of improved mobility/articulation has been when the patient is supine). If performed rapidly this creates • Mobilization of joints controlled microtrauma of the contracting • Preparation for the stretching/lengthening of muscle (breaking minute adhesions, fibrosis – shortened muscles, or for reducing tone in known as an isolytic contraction), whereas if hypertonic muscles performed slowly this produces a toning of the • Introduction of controlled microtrauma in contracting muscle and a simultaneous (slight) cases of fibrosis inhibition of its antagonist(s), followed by a • Toning inhibited/weakened muscles reduction in sensitivity to stretching (Liebenson • As part of an integrated sequence for 2006). For example, Klein et al muscle energy technique – described later in this (2002) examined the effect of a 10-week flexibility chapter) (Ruddy 1962). If lengthening shortened soft tissues is the objec- contraction (there is usually at least 10 seconds tive, myofascial release and other stretching methods of refractory muscle tone release during which offer alternatives. The practitioner must be careful to use enough, but not too much, effort, and to • Aneurysm ease off at the same time as the patient. For obvious reasons the disease characterized by exercise intolerance, shorthand term ‘pulsed muscle energy technique’ is myalgia and stiffness) now applied to Ruddy’s method (Chaitow 2001). Occasionally some muscle stiffness The application of this ‘conditioning’ approach and soreness after treatment. If the area being involves contractions which are ‘short, rapid and treated is not localised well or if too much contractive rhythmic, gradually increasing the amplitude and force is used pain may be increased. Sometimes the degree of resistance, thus conditioning the proprio- patient is in too much pain to contract a muscle or ceptive system by rapid movements’ (Ruddy 1962). Chaitow L 2006 Muscle energy techniques, 3rd its rhythmic pulsing (see below) or isotonic concentric edn. Churchill Livingstone, Edinburgh modes, to assist in facilitating rehabilitation of injured 2. Williams & Wilkins, naturopathic care since it is capable of being used to Baltimore remove obstacles to optimal adaptation, as well as 3. DiGiovanna E, Schiowitz S (eds) 1991 An encouraging enhanced functionality and self- osteopathic approach to diagnosis and regulating processes. Mitchell F Jr, Moran P, Pruzzo N 1979 An Ruddy (1962) developed a method of rapid pulsating evaluation of osteopathic muscle energy contractions against resistance which he termed ‘rapid procedures. Pruzzo, Valley Park, Missouri Chapter 7 • Modalities, Methods and Techniques 233 Box 7. The restriction barrier should be engaged and, following a 5- to 7-second isometric contraction involving no more than 20% of available strength, an attempt should be made to passively move to a new barrier, without force or stretching. Unlike the period required to hold soft tissues at stretch (see next exercise), in order to achieve increased extensibility, no such feature is part of the protocol for treating joints. Once a new barrier is reached, having taken out available slack without force after the isometric contraction, a subsequent contraction is called for and the process is repeated. A variety of directions of resisted effort may prove useful (or, put differently, a range of different muscles should be contracted isometrically) when attempting to achieve release and mobilization of a restricted joint, including Figure 7. Reproduced with permission from Chaitow (2006) the joint, such as the sacroiliac, sternoclavicular and acromioclavicular joints. Patient-directed isometric efforts towards the restriction is introduced at this ‘bind’ barrier (if acute) or a little barrier, as well as away from it, and using a combination short of it (if chronic). Note: These refinements as to of forces, often of a ‘spiral’ nature, may be experimented position in relation to the barrier are not universally with if a joint does not release using the most obvious agreed and are based on the teaching of Janda directions of contraction. Level 4 is the same as the previous description the stretching/lengthening of shortened, contracted but the patient actively moves the tissues or fibrosed soft tissues, or for reducing tone in hyper- through the fullest possible range of motion, tonic muscles. Because of its contiguous nature, and digital pressure to the involved tissue in a direction its virtually universal presence in association with proximal to distal while the patient actively moves the every muscle, vessel and organ, the potential influ- muscle through its range of motion in both eccentric ences of fascia are profound if shortening, adhesions, and concentric contraction phases. John Barnes (1996) writes: ‘Studies suggest that It can be seen from the descriptions offered that fascia, an embryological tissue, reorganizes along the there are different models of myofascial release, some lines of tension imposed on the body, adding support to taking tissue to the elastic barrier and waiting for a misalignment and contracting to protect tissues from release mechanism to operate and others in which further trauma. Barriers of resistance are engaged load (pressure) are required when treating fascia and these are forced to retreat but by virtue of the because of its collagenous structure. In this way the physiological tive way of lengthening (‘releasing’) fascia rapidly responses of creep and hysteresis are produced, (Hammer 1999). This is a non-violent, direct approach that has little potential for causing damage. When active or passive movements are combined Methodology with the basic methodology, caution is required, Myofascial release is a hands-on soft tissue technique depending on the status of the patient and the tissues, that facilitates a stretch into the restricted fascia. For example, enthesitis sustained pressure is applied into the tissue barrier; could occur if localized repetitive stretching combined after 90 to 120 seconds the tissue will undergo with compression were applied close to an attachment histological length changes allowing the first release to (Simons et al 1999). The practitioner’s contact (which could involve thumb, finger, knuckle Alternatives or elbow) moves longitudinally along muscle Since myofascial release is utilized to lengthen short- fibers, distal to proximal, with the patient ened soft tissues, all other methods that have this passive. Any • Phlebitis dehydration of the ground substance will decrease the • Recent scar tissue free gliding of the collagen fibers. Applying pressure to • Syphilitic articular or peri-articular lesions any crystalline lattice increases its electrical potential, • Uncontrolled diabetic neuropathy attracting water molecules, thus hydrating the area. This is the piezoelectric effect of manual connective Naturopathic perspectives tissue therapy. As fascial tissues distort in Further reading response to pressure, the process is known by the 1. Shea M 1993 Myofascial release – a manual for shorthand term ‘creep’ (Twomey & Taylor 1982). Shea Educational Hysteresis is the process of heat and energy exchange Group, Juno Beach, Florida by the tissues as they deform (Dorland’s Medical 2. The tissue creep results in loss of Indications/description energy (hysteresis), and repetition of loading before the tissue has recovered will result in greater deformation Joint restrictions, or pain on movement involving a (Norkin & Levangie 1992). Significant resting Cautions symptoms are usually associated with a degree of • Acute arthritis and other inflammatory underlying pathology far beyond that of relatively conditions (contraindicated during acute minor biomechanical abnormalities (Wilson 2007). In the cervical spine the direction of translation (48% increase in pain-free grip strength). In some instances, as well as actively moving improves talocrural dorsiflexion, a major the head and neck toward the direction of impairment following ankle sprain, and restriction while the practitioner maintains the relieves pain in subacute populations.

Brain best ethambutol 400mg, Behavior and Immunity Ernst E 2001 Prospective investigations into the safety 19(4 Suppl 1):e15 of spinal manipulation order ethambutol master card. Journal of Pain and Symptom DiCarlo L buy ethambutol 600 mg overnight delivery, Sparling P order genuine ethambutol, Hinson B et al 1995 Management 21(3):238–242 Cardiovascular, metabolic, and perceptual responses to Ernst E 2004 Musculoskeletal conditions and hatha yoga standing poses. Best Practice and Nutrition and Health 4:107–112 Research Clinical Rheumatology 18(4):539–556 Dickey J 1989 Postoperative osteopathic manipulative Ernst E, Canter P 2006 A systematic review of management of median sternotomy patients. Journal of the American Osteopathic Association 89(10):1309–1322 the Royal Society of Medicine 99:189–193 Diegelmann R, Evans M 2004 Wound healing: an Escalona A, Field T, Singer-Strunk R et al 2001 overview of acute, fibrotic and delayed healing. Frontiers in Bioscience 9:283–289 Journal of Autism and Developmental Disorders Diego M, Field T, Hernandez-Reif M 2002 Aggressive 31:513–516 adolescents benefit from massage therapy. DiGiovanna E, Schiowitz S (eds) An osteopathic Electroencephalography and Clinical Neurophysiology approach to diagnosis and treatment. Lippincott, 63(2):174–179 Philadelphia Evans D 2002 Mechanisms and effects of spinal high- DiGiovanna E, Schiowitz S 1991 An osteopathic velocity low-amplitude thrust manipulation. Lippincott, Manipulative and Physiological Therapeutics Philadelphia 25(4):251–262 Chapter 7 • Modalities, Methods and Techniques 285 Faling L 1986 Pulmonary rehabilitation physical Field T, Grizzle N, Scafidi F et al 1996 Massage and modalities. Clinical Chest Medicine 7:599–618 relaxation therapies’ effects on depressed adolescent mothers. Adolescence 31:903–911 Fallon J 1997 The role of chiropractic adjustment in the care and treatment of 332 children with otitis media. Field T, Henteleff T, Hernandez-Reif M 1997a Children Journal of Clinical Chiropractic Pediatrics 2:167 with asthma have improved pulmonary functions after massage therapy. Journal of Pediatrics 132:854–858 Fallon J, Lok B 1994 Assessing efficacy of chiropractic care in pediatric cases of pyloric stenosis. Field T, Hernandez-Reif M, LaGreca A et al 1997c Harper & Row, New York Massage therapy lowers blood glucose levels in children with diabetes mellitus. Diabetes Spectrum Ferber R, Gravelle D, Osternig L 2002a Effect of 10:237–239 proprioceptive neuromuscular facilitation stretch techniques on trained and untrained older adults. Field T, Schanberg S, Kuhn C et al 1998 Bulimic Journal of Aging and Physical Activity 10:132–142 adolescents benefit from massage therapy. Journal Kinesiology 12:391–397 of Bodywork and Movement Therapies 5:271–274 Ferezy J 1988 Neural ischemia and cervical Field T, Diego M, Cullen C et al 2002 Fibromyalgia pain manipulation: an acceptable risk. Journal of Clinical Rheumatology 8:72–76 Fernández-de-las-Peñas C, del Cerrob L-P, Carneroa J 2005 Manual treatment of post-whiplash injury. Journal Fielder S, Pyott W 1955 The science and art of of Bodywork and Movement Therapies 9:109–119 manipulative surgery. Spine 27:2835–2843 Journal of Bodywork and Movement Therapies 10:3–9 Foldi M, Strossenreuther R 2003 Foundations of manual Ferrandez J, Laroche J, Serin D 1996 lymph drainage, 3rd edn. Folweiler D, Lynch O 1995 Nasal specific technique as Journal des Maladies Vasculaires 5:283–289 part of a chiropractic approach to chronic sinusitis and Ferreira M, Ferreira P, Latimer J et al 2003 Efficacy of sinus headaches. Journal of Manipulative and spinal manipulative therapy for low back pain of less Physiological Therapeutics 18(1):38–41 than three months’ duration. Cancer Nursing based on clinical practice guidelines for patients with 16:93–101 acute low back pain: a randomized clinical trial. Fritz J, Whitman J, Flynn T et al 2004 Factors related to Panminerva Medica 40(1):48–50 the inability of individuals with low back pain to Field T 2000 Touch therapy. Physical Therapy Edinburgh 84:173–190 Field T, Hernandez-Reif M 1997 Juvenile rheumatoid Fryer G 2006 Muscle energy technique: efficacy and arthritis benefits from massage therapy. In: Chaitow L (ed) Muscle energy techniques, Pediatric Psychology 22:607–617 3rd edn. Journal of Neurology, Neurosurgery and Galantino M, Boothroyd C, Lucci C 2003 Psychiatry 57(11):1443 Complementary and alternative medicine interventions Giudice M 1990 Effects of continuous passive motion for the orthopedic patient: a review of the literature. American Journal of Occupational Therapy Galantino M, Bzdewka T, Eissler-Russo J et al 2004 The 48(5):914–921 impact of modified hatha yoga on chronic low back Glossary Review Committee 2005 Sponsored by pain: a pilot study. Stroke 32:714–718 immediate effects of soft tissue mobilisation with Gamber R, Shores J, Russo D et al 2002 Osteopathic proprioceptive neuromuscular facilitation on manipulative treatment in conjunction with medication glenohumeral external rotation and overhead reach. Journal of Orthopaedic and Sports Physical Therapy Results of a randomized clinical pilot study. Journal Wilkins, Baltimore, p 55–57 of the American Medical Association 1997; 277: 1775–1781 Gatterman M 1990b Chiropractic management of spine related disorders: disorders of the pelvic ring. Lippincott Williams & Wilkins, Baltimore, p 115 Williams & Wilkins, Baltimore Gemmell H, Jacobson B 1989 Chiropractic management Greenman P 1996 Principles of manual medicine, 2nd of enuresis: a time-series descriptive design. Williams & Wilkins, Baltimore Manipulative and Physiological Therapeutics 12:386 Guiney P, Chou R, Vianna A et al 2005 Effects of Gerber R 1988 Vibrational medicine. Bear, Santa Fe, osteopathic manipulative treatment on pediatric New Mexico, p 128, 130, 131 patients with asthma: a randomized controlled trial. Gibbons P, Tehan P 1998 Muscle energy concepts and Journal of the American Osteopathic Association coupled motion of the spine. Manual Therapy 105(1):7–12 3(2):95–101 Guyton A, Hall J 1997 Inflammation and function of Gibbons P, Tehan P 2000a Manipulation of the spine, neutrophils and macrophages. Perth, Australia, 9–10 November, and tendon relaxation treated by prolotherapy, 5th edn. Journal of Psychosomatic Research 41(5):481–493 Hackett G, Hemwall G, Montgomery G 2002f Ligament and tendon relaxation treated by prolotherapy, 5th edn. Canadian Henderson D, Cassidy J 1988 Vertebral artery Medical Association Journal 165(7):905–906 syndrome. Williams & Haldeman S, Kohlbeck F, McGregor M 2002a Wilkins, Baltimore, p 195–222 Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of Hernandez-Reif M, Field T, Theakston H 1998 Multiple sixty-four cases after cervical spine manipulation. Journal of Psychosomatic Medicine and Science in Sports and Exercise Research 57(1):45–52 30(10):1543–1547 Herzog S 2002 Internal forces sustained by the vertebral Ikimi F, Hunt J, Hanna G et al 1996 Interstitial fluid artery during spinal manipulative therapy. Journal of plasma protein, colloid, and leukocyte uptake into Manipulative and Physiological Therapeutics 8:504–510 initial lymphatics. Journal of Applied Physiology Herzog W 2002 Testimony at Lewis Inquest, Coroner’s 81(5):2060–2067 Court, Toronto, November 26, 2002 Ironson G, Field T, Scafidi F et al 1996 Massage therapy Hill M 2003 Cervical artery dissection, imaging, trauma associated with enhancement of immune systems and causal inference. International Journal of Sciences 30:302–303 Neuroscience 84:205–217 Hoag J 1969 Osteopathic medicine. Journal of the American Osteopathic Evaluation of transvaginal Theile massage as a Association 89(8):1037–1045 therapeutic intervention for women with interstitial cystitis. Williams Hooper R, Ding M 2004 Retrospective case series on & Wilkins, Baltimore patients with chronic spinal pain treated with dextrose Janse J, Houser R, Wells B 1947 Chiropractic principles prolotherapy. Manual Therapy 7(2):103–107 Improvement of cardiac autonomic regulation Hou C-R, Tsai L-C, Cheng K-F 2002 Immediate effects following spinal manipulative therapy. In: Cleveland C, of various physical therapeutic modalities on cervical Haldeman S (eds) Conference Proceedings of myofascial pain and trigger-point sensitivity. Archives Chiropractic Centennial Foundation, Davenport, Iowa, of Physical and Medical Rehabilitation 83:1406–1414 p 359 Hovind H, Nielsen S 1974 Effect of massage on blood Jaskoviak P 1980 Complications arising from flow in skeletal muscle. Journal of Rehabilitation Medicine 6:74–77 Manipulative and Physiological Therapeutics Hoyland J, Freemont A, Jayson M 1989 Intervertebral 3:213–219 foramen venous obstruction. Spine 14(6):558–568 Jayson M, Sim-Williams H, Young S et al 1981 Hunt A 1978 Electronic evidence of auras, chakras in Mobilization and manipulation for low-back pain. Brain/Mind Bulletin 3:9 Spine 6:409–416 Hurwitz E, Haldeman S 2004 Manual therapy including Jensen K 2004 University of Wisconsin, Department of manipulation for acute and chronic neck pain. Presented at the Hackett Hemwall Foundation Annual American Academy of Orthopedic Surgeons, Rosemont, Prolotherapy Conference 2004. Spine Johnson A 1939 Principles and practice of drugless 30:1477–1484 therapeutics. Straube, Los Angeles Chapter 7 • Modalities, Methods and Techniques 289 Johnson A 1977 Chiropractic physiological therapeutics. In: Twomey L, Taylor J (eds) Physical Klougart N, Leboeuf-Yde C, Rasmussen L 1996 Safety therapy for the low back. Part 1: The occurrence of Churchill Livingstone, New York cerebrovascular accidents after manipulation to the neck in Denmark from 1978–1988. Churchill Livingstone, Edinburgh Bantam, New York Keating J Jr 1992 Toward a philosophy of the science of Knebl J 2002 The Spencer sequence. Journal of the 31(2):452–458 American Osteopathic Association 70:570–592 Konstantinou K, Foster N, Rushton A et al 2002 The use Kenna C, Murtagh J 1989 Back pain and spinal and reported effects of mobilization with movement manipulation, 2nd edn. Butterworth-Heinemann, techniques in low back pain management; a cross- Oxford sectional descriptive survey of physiotherapists in Kent P, Marks D, Pearson W et al 2005 Does clinician Britain. Journal of Vertebral Subluxation Research Korr I 1981 Axonal transport and neurotrophic function 2(1):43–49 in relation to somatic dysfunction.

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M1 may stop taking drugs either because she is mindful of her duty and does not wish to harm her baby discount 800 mg ethambutol with visa, or because she is reluctantly goaded into stopping generic 800 mg ethambutol mastercard. When a mother wishes to do the best for her baby 600 mg ethambutol amex, the result Restricting the freedom of pregnant women 141 of this oVer corresponds to one part of her will and her interests 600mg ethambutol with visa. The existence of a future punishment is in itself a present threat, but if it is in society’s armamentar- ium, it acts as a threat to all pregnant women. A drug addict who reacts to falling levels or shortage of supply with feelings of severe discomfort (withdrawal syndrome) has no choice but to respond with the reasonable and purposive action of buying or Wnding more drugs. The only way to stop her taking drugs is by force, for example, by incarceration to (hopefully) cut oV her supply of drugs, an external coercion corresponding to the inner compulsion to take drugs. Some soft cheeses contain the listeriosis bacterium, which can cause miscarriage, fatal intra-uterine infections and premature labour (with all its consequent com- plications). If eating soft blue cheese and taking heroin had the same adverse eVects on fetuses, but an addict’s discomfort on stopping heroin was marked- ly worse, then the mother who continues to eat gorgonzola would be more culpable than the woman who continues to take heroin. To avoid suVering severe discomfort, by withdrawal of the drug M2 craves and is compelled to take, the rational and reasonable action is to avoid giving a sample of urine, or miss the clinic. Antenatal care, even in the presence of drug-taking, is of beneWt for picking up other diseases of pregnancy, such as diabetes, pre-eclampsia and growth retardation, and it 142 S. Indeed, the policy of British antenatal care and drug maintenance programmes is to stabilize registered addicts on drugs prescribed by licensed doctors. If the woman attends the antenatal clinic at the same time, two potential improvements to her baby’s health are made even before drug reduction (De Swiet, 1989). The complexity of judging and influencing maternal behaviour With this complex model in mind, the drug-taking pregnancy can be viewed not merely as a grave danger to the fetus due to maternal failing, but as an opportunity to oVer intervention and improve fetal health. The pregnant drug addict may be harmed, or even die, as a consequence of her drug-taking, and thus the incentive to improve her own health may be added to fetal incentives. If her will is in conXict, as described earlier, she has the opportunity to identify more strongly with that part that wishes to do the best for her fetus, or wishes not to be a drug addict, and thus become more truly an autonomous person. If, without drug treatment programmes for pregnant women (Chavkin, 1990), she misses this opportunity, society fails both to aid her fetus and to help her realize her autonomy and potential. Strategies that threaten her, or that through fear or interaction with her compulsion diminish rational and reXective self-evaluation, reduce her autonomy (already reduced by addiction). Other incentives that might encourage M2 to minimize harm to her fetus, such as public education, free and conWdential health care, non-judgemental attitudes and access to social service help, will get drug-takers into clinics. Widening the scope Several more qualiWcations still have to be considered before limiting preg- nant women’s freedom: (1) there should be a real and serious risk to a particular fetus; (2) as a woman’s freedom is increasingly interfered with, so the justiWcation for the limitation should become stronger; (3) there has to be no less drastic method for achieving the same end; (4) the harm prevented should not be less than any harm caused; and (5) if freedom is limited, women are harmed by interference with their basic right of liberty (albeit justiWably, and thus not wronged) and there is a case for compensation. If the risk is very remote – for example, every millionth pregnant woman walking on icy pavements falls over and suVers a stillbirth – that would not seem to justify keeping pregnant women indoors all winter. If the risk is of trivial harm – let us say that listening to commercial radio made babies respond by smiling to advertising jingles – that would not justify banning pregnant women from listening to the radio. Increasing restrictions on liberty, increasing justification An example of justiWable limitation on freedom might be long-distance air travel close to delivery. It seems reasonable to balance the small risk of premature delivery and a great limitation on freedom if women could not travel at all against a higher chance at term and less limitation on freedom. Bewley (embryo-deforming) poison gas dioxin blowing towards a city, a justiWcation of forcibly rounding up the pregnant women to transport them away could be based on avoiding harm to their fetuses. If preventing fetal harm overrides women’s rights to freedom, or bodily integrity, it can also be used to override their wishes regarding the continuing of the pregnancy. The arguments can boomerang back to argue for enforced abortions (if abortion is justiWed as the killing of a being without full moral status), when an abortion is a lesser wrong than allowing the continuance of a pregnancy that will lead to a life of suVering. Only the most draconian measures (such as screening the entire female population for pregnancy) would be able to identify those women whose behaviour in early pregnancy is an avoidable source of harm. If a woman cannot work in certain jobs there should be no penalty, such as dismissal, as this would act as a strong disincentive to tell the truth, or even as a pressure towards termination. There are good reasons to doubt the eYcacy of threats when a mother is addicted to drugs, and it is wrong to punish her for behaviour that is compulsive. One comprehensive strategy might be to have a ‘hands-oV,oVers only’ system which should not deter those women who cannot stop drug-taking from seeking health care, but does not tackle indiVerent women who only stop under threat. Collins and others, ex parte S, 1998)and have not been prosecuted for drug-taking in pregnancy or the resulting harms, although children can be taken into care after birth. On the other hand, a threat strategy (such as antenatal urine test results being revealed to the police, jailing for drug-taking in pregnancy and separation on the basis of neonatal testing) may stop drug-taking in women who are not compelled to take drugs, although it risks alienating others who are so compelled from antenatal care altogether. It is wrong to limit pregnant, drug-taking women’s freedom, in the ways described, especially in the absence of having unsuccessfully tried morally preferable methods. Indeed some Scandinavian countries have either altered their legislation or professional codes of practice recently in order to limit embryo transfer to one or two embryos per cycle and to decrease the rate of multiple pregnancies. Then there is the question of what responsibilities we owe to the children of assisted conception (an issue discussed by Christine Overall in Chapter 19). As for the even newer issues related to technological advances, such as ovarian tissue freezing or reproductive cloning, their practical application is probably still quite distant. Shenfield All these ‘micoethical’ issues should also be seen in the larger ‘macroethi- cal’ context, including issues of social justice such as equal access to fertility treatment. However, although we know that health expenses are increasing worldwide, the problem of eYcacious spending on health is a political and ethical matter beyond the scope of this chapter. In passing, however, it is still puzzling to observe that in our wealthier countries huge sums of money are spent at the end of life, whilst objectors to the whole Weld of life-creating fertility treatment are still arguing that it is money misspent on a ‘non-medical matter’ (ShenWeld, 1997). In the Wnal section of this chapter I shall move on to ethical issues in reproductive and therapeutic human cloning, brieXy drawing on arguments about diVerence and identity from the French psychoanalytical feminist Julia Kristeva (1991). As shown in a three-day meeting held in December 1996 at the Council of Europe on the protection of the human embryo, this essential question is still central. The meeting was held a month after the Committee of Ministers of the Council of Europe had approved the text of the Convention for the Protection of Human Rights and Dignity of the Human Being With Regard to the Application of Biology and Medicine (Convention of Human Rights and Biomedicine; (Council of Europe, 1996)). Controversy over embryo research has been heightened since then by the growing commercial importance of stem cells derived from embryonic and fetal tissue (see Chapter 15). Using the term ‘pre-embryo’ to refer to ‘the stage of the conceptus for the interval from the completion of the process of fertilisa- tion until the establishment of biologic individuation’ (Jones and Schrader, 1992) aroused suspicion that the embryo’s supposed human essence was deliberately ignored or lessened by adding the preWx (Seve, 1994). Even if this utilitarian argument were accepted as uncontroversial – which it is patently not – two further problems arise: the source of embryos, and their fate. If non-viable embryos are to be preferred on the grounds that no harm is done, less good may result – the results may not be easily applicable to viable embryos. In English law any couple cryopreserving surplus embryos must give consent and choose their fate (donation, research or destruction) when the legal time limit for cryopreservation has elapsed. In most cases embryos used for research will in fact be destroyed, as the safety of the potential child who might ensue cannot be assured, and it can actually be argued that it would be unethical to replace such embryos in utero. The availability of cryopreservation makes the creation of embryos purely for research purposes even more controversial, but perhaps more necessary – surplus or supernumerary embryos may be frozen for possible later use, and might only be given for research once the couple have become parents. Shenfield behalf of children below the standards of ‘Gillick competence’ (Gillick v West Norfolk and Wisbech Area Health Authority, 1985), but rather because its destruction is necessarily planned, distancing the embryo from full human status. Where parental consent is recognized, the parent is expected to decide in the best interests of the incompetent child; deciding to destroy the embryo is ipso facto not in its best interests. This leads us to consider the indications for pre-implantation diagnosis, and the notion of ‘severe handicap’, already used in the terminology of legal termina- tion of pregnancy. The most complex ethical question is in fact not so much the current practice of pre-implantation diagnosis, but rather what might be the consequences of its evolving techniques. The questions for consultation centre around, but do not actually mention, the distinction between positive and negative eugenics, perhaps because the terms are so historically tainted (Missa, 1999). No legislation that allows termination of pregnancy on the grounds of a ‘serious’ disorder has actually drawn up a list of the conditions that would qualify. It is thus understandable that the more classical approach (prenatal diagnosis, possibly followed by therapeutic termination of pregnancy) may sometimes be prefer- red by patients. Studies have shown diVerent preferences according to the past experience of the couples concerned and the gender of the potential parent (Chamayou et al. In practice, it is for the time being a matter of rather restricted choice, as the number of units available worldwide for this technique is extremely limited, making it available only to a few prospective parents. The need for long-term surveillance of this particularly ‘precious’ oVspring in turn entails recording the births and follow-up of the children with their speciWc dilemmas already described in detail (Milliez and Sureau, 1997). Another concern in pre-implantation diagnosis is the dilemma between the fundamental principle of conWdentiality for the couple and the right to privacy of the potential child, together with the psychological consequences of intrusion for the children. The problem of conWdentiality with regards to the child sometimes seems insoluble, as it entails a parental, if not sometimes a state, decision, as is the case with non-anonymity of gamete donors in Sweden. In this context it is useful to stress the responsibility that the adults involved, carers as well as putative parents, have towards the vulnerable future third party – the child to be. Fifteen years after implementation of the law in Sweden, 89 per cent of the parents of sperm donor children still have not informed them of their origins (Gottlieb et al.

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 order ethambutol 600 mg with mastercard, delirium purchase ethambutol 800mg online, and tremulousness buy discount ethambutol. New Zealand Whakama (shame) is expressed by Maori people when they break social taboos buy ethambutol cheap online. 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. Records should be completed contemporaneously with note taken of event and recording times on the 24 hour clock. Recording frequency must be sufficient to give an accurate picture of the patient at all times. Late entries should generally be avoided and, if essential, should not be squeezed into the record. All healthcare professionals should be encouraged to read each other’s entries when there is a need to know. Emphasis should be placed on a factual record: subjective comments should be avoided - if deemed necessary they should be explained. All entries must be signed off and the writer should be clearly identifiable by name and status. Be systematic by keeping all patients records together and having the patient’s name and record number on every page of the record. One London survey (Mistry & Sauer, 2009) found that psychiatrists of various levels of experience (only 56% of consultants responded) experienced technical difficulties, confidentiality issues, extra workload and impact on clinical activity when using this system but that most would not return to using paper. Clinical audit This refers to the regular, systematic study and critical analysis of patient care by clinicians (Garden ea, 1989; Kelly, 2009), e. Clinical governance (quality control) This continuing process aims to increase quality and reduce risk in clinical work. Essential components include evidence-based practice, good acess to clinical information and other necessary knowledge, audit, checks on quality of practice and outcome, research, practice development, and adherence to guidelines. The College of Psychiatry of Ireland is assigned the responsibility of elaborating on the competencies required in psychiatry. A doctor must 189 The individual care and treatment plan consists of recorded goals that were developed by the patient and his/her multidisciplinary team. The plan describes the treatment and support to be offered, the resources required, and the hoped-for outcomes. Examples of competencies are relating to patients, other interpersonal skills, collaboration and teamwork, management (including self-management), scholarship, professionalism, and clinical skills. Boundaries Do not treat people you socialise or work with with (dual-roling) and ensure that a patient is formally referred. Chaperones should 190 be used when circumstances dictate that it would be safer to employ them. Family members who speak a patient’s language are poor substitutes for a neutral translator (see box) who will not interfere with the dynamics of the clinical interaction. Inappropriate self-disclosure must be avoided (‘I remember when my husband left me.... Avoid treating patients in your own home and treat in your workplace and during normal working hours when at all possible. Uber eine eigenartige Erkrankung der Hirnrinde (about a peculiar disease of the cerebral cortex. The graver the decision the wider should the clinician consult and the final decision must always be in the patient’s best interests and be the least restrictive alternative. Legally, an unwise or unconventional decision made by a patient does not mean that he/she lacks capacity. Relatives may talk for the patient instead of facilitating free expression by the patient. Use trained interpreters who are fluent in the languages of therapist and patient and who will give literal translations and can with authority inform the therapist about the weight to be attached to beliefs about illness and use of metaphor in the patient’s culture. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Clinical Governance in Mental Health and Learning Disability Services: a Practical Guide. Mental Health and Addiction Services and the Management of Dual Diagnosis in Ireland. Code of Practice: Guidance for Persons Working in Mental Health Services with People with Intellectual Disabilities. Treatment of schizophrenia is more than the treatment of delusions and hallucinations.

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