Mark Corson

By D. Connor. University of Massachusetts at Amherst.

Perceived stress may be greater if the relative feels that the patient should be able to control his illness or symptoms or if the relative feels helpless in controlling these phenomena order 1 mg detrol with visa. A full understanding of the seriousness and prognosis of the disorder may also increase stress cheap 1 mg detrol with mastercard. Alternative terms are parasuicide (Kreitman) cheap 1 mg detrol with visa, deliberate self- harm (Morgan) and act of self-harm (Bateman, who avoids implying intent or motive). In the real world, any psychiatric disorder may be accompanied by suicidal behaviour or self-harm. Walsh (2008) reminds us that suicides once had their remains hung from the Five Lamps in Ballybough, Dublin! In the opinion of Simon and Savarino (2007) suicide attempts are not caused by antidepressants but reflect referral patterns. Of self-harm ‘cases’ presenting to Irish emergency departments in 2007 17% were repeat visits. A toxic breakdown product of paracetamol is scavenged by glutathione; when the body runs out of glutathione (common in alcoholics) the paracetamol metabolite attaches itself to liver cells and kills them. St Valentine , Christmas Day; female admissions increased during 2-4 January in Edinburgh. Female admissions in Edinburgh increased during summer (others report spring/early summer excess). The 2000 British National Survey of Psychiatric Morbidity (Bebbington ea, 2009) found that sexual abuse is a significant antecedent of suicidal behaviour, more so for females. Also, excess alcohol may increase high- density lipoprotein levels and hence the amount of cholesterol transported peripherally, causing a lowering of the serum cholesterol. The same group (Hallahan ea, 2007) reported reduced indices of self harm in repeated self-harmers given long-chain omega-3 essential fatty acids. Low self-esteem Low socio-economic status (Taylor ea, 2004) 1466 Menstrual cycle (late luteal and follicular phases ) and premenstrual syndrome (Saunders & Hawton, 2006) 1467 Panic disorder Parental concern. Parental concern may be more accurate than clinician risk assessment in predicting repetition of self-harm. Gibbons ea, 2007b) Emergence of suicidal ideation during citalopram treatment may be associated with genetic markers within genes encoding ionotropic glutamate receptors. Episodes of self-harm, when they occurred, occurred in the first few weeks of treatment. These authors found higher risk for venlafaxine (possibly given for ‘deeper depression’) and benzodiazepines (possible disinhibition). It must be remembered that analysis of many variables is likely to ‘throw up’ results that may or may not have clinical implications as distinct from media interest. The therapist should address any underlying fantasies such as the wish to punish oneself or another person, to manipulate, or to put a stop to suffering. Has the patient internalised the capacity to contain psychic stress, does he find solace in keeping suicide as a future possibility should circumstances deteriorate, or does he harbour a wish to die simultaneously with a wish to live? Has he become calm because he is resigned to self-termination or because his depression has lifted or because his girlfriend is returning to him? The therapist must not collude with the patient who is in denial concerning the threat to his life. The person attacks him/herself instead of looking at different ways of directly changing the situation, trying to distract him/herself, avoiding or resigning him/herself to difficulties, seeking comfort from others, avoiding being preoccupied with the problem, showing annoyance with those causing the difficulty, or engaging in self-comforting thoughts. Passivity and problem avoidance, with associated lowering of self esteem, may be helped by intensive aimed at improving problem solving ability. Legally, suicide means 1472 that a person ‘acting alone’ did the act that led to death and the act was done in order to cause death, and intent at the time of the act must be shown beyond reasonable doubt. Long term follow up shows that psychiatric patients kill themselves much more often than those who do not have such a history. It is important to elicit whether suicidal thoughts are present or absent and if present if they are active (e. The Catholic Church now allows full funeral rites and a Christian burial for suicides. When reading this list one cannot escape the conclusion that one is reading a potted history of the rapid social changes that characterised the latter part of the twentieth century. This is suggested by increasing suicide rates in 1474 Russia where social and economic disintegration are important, as may gun ownership in some areas. However, according to the National Parasuicide Registry,(Allen, 2005) in 2001 the percentages of male and female 1475 suicides employing drowning or hanging were not dissimilar (see Hawton ea, 2008 ), and the figures for overdoses among parasuicides for 2002 did not support large differences between the sexes. Additionally, Värnik ea (2008) examined suicide methods in Europe and hanging was the most common method among males (except in Switzerland where firearms was more common) and, in eight countries only (including Ireland) among females; firearms was the second most frequent method in five countries but it was the least common method in Scotland; and women were more likely to drown themselves than were men (except in Luxembourg). European female suicide methods (Värnik ea, 2008) Hanging – most common method in 8 countries Poisoning with drugs - most common method in 5 countries Jumping from a height - most common method in 3 countries According to Brendel ea (2008, p. This was associated with an increase in hanging and poisoning with vehicle exhaust gas. The author suggested that psychosocial factors played a role in this worrying trend. In fact, self-burning is commonest in schizophrenic patients and in 1479 Asian women. Tobacco growers in parts of Brazil (which has a relatively low reported suicide rate: Mello-Santos ea, 2006) often employ organophosphate pesticides to commit suicide whereas in Sri Lanka oleander seeds are often used for the same purpose.

Carbamazepine is less effective than either Lithium or Valproate and is a liver enzyme inducer 4 mg detrol visa, therefore it interferes with the metabolism of other drugs buy detrol 1mg line. It has a worse side effect profile than Valproate with potential to cause agranulocytosis order detrol 1 mg without a prescription, cardiotoxicity and neurotoxicity. Antipsychotics like Olanzapine, Risperidone, Quetiapine and Aripiprazole appear to be effective in treating mania but their use in the elderly manic patients is limited by side effects such as extrapyramidal with potential for worsening of parkinsonism, hypotension, sedation, weight gain and diabetes and precipitation of depressive symptoms. Quetiapine seems to have lesser potential for inducing extrapyramidal side effects. Benzodiazepines are effective in lessening agitation and behavioural disturbances. However, in the elderly their use should be restricted to severe cases because of adverse effects such as sedation, hypotension, falls and paradoxical agitation and confusion. Antidepressants are effective in alleviating depressive episodes but caution should be exercised because of their potential to induce mania. The protective effect of a mood stabilizer is required before using an antidepressant and as soon as the depressive episode resolves, the antidepressant is usually withdrawn. Prognosis 961 After accounting for some confounding factors like brain disease, evidence suggests that 34-50% of elderly manic patient will die on long term follow up as against 20% of elderly patients with unipolar depression. Also, 32% will suffer significant cognitive decline, as measured by a score of less than 24 on Mini-Mental State Examination. This suggests that mania has a poorer prognosis and represents a more severe disruption of the central nervous system function. Summary and recommendations of a report of a working party of the Royal College of Physicians. Anxiety Disorders Oliaku Eneh Definition The psychological symptoms of anxiety comprise of fear, worry, nervousness, tension, apprehension, irritability, difficulty concentrating and insomnia. The physical symptoms include increased heart rate resulting in palpitations, breathlessness, light headedness and dizziness, nausea, tremor, dry mouth, sweating, abdominal discomfort that may progress to diarrhoea and frequent micturition. Patients may have a tendency to alleviate their symptoms by abusing alcohol and prescribed medications, especially benzodiazepines. Most psychiatric disorders in the elderly have co-morbid anxiety and many elderly people get very anxious about the multiple health conditions they are faced with, resulting in the under-recognition and under-treatment of primary anxiety disorders. Epidemiology The prevalence of most anxiety disorders falls with age and is higher in women than in men. This gender difference is less pronounced in the elderly and the majority of cases are longstanding with onset in young adulthood and middle age. Overall prevalence in the elderly ranges from 5-10%, the highest rates are found in the community with phobic disorders presenting the most while panic disorders present the least. Aetiology As with other psychiatric disorders, many factors come to play in the development of anxiety disorders in the elderly. Physical illness- there is an association between anxiety disorders and increased mortality and physical morbidity from cardiovascular, respiratory and gastrointestinal complaints. This is further confounded by the physical symptoms of anxiety with some important physical disorders presenting with anxiety symptoms and vice versa. In the majority of elderly people, the investigations and treatment of physical illness is frightening and may provoke anxiety disorder in vulnerable individuals. Psychosocial stressors- evidence shows that anxiety is associated with low socioeconomic status. Adverse life events especially if they are threatening in nature are known to precipitate anxiety. In addition, individuals may also develop late life vulnerability to anxiety when faced with challenges if they were previously exposed to early adverse experience such as parental loss. In contrast to late life depression, phobic disorders in the elderly are not associated with the lack of confiding relationships; rather it is believed that in some cases the presence of close relationships may maintain phobic avoidance (Lindesay, 1996) because in a bid to protect and support the patient, families and other home based services invariably encourage the housebound approach and may thereby worsen the situation. Drug induced- A variety of drugs have been implicated in the onset of anxiety symptoms. They include: - Thyroxine - Antidepressants - Anticholinergics - Sympathomimetics 963 - Steroids - Alcohol - Caffeine In addition, withdrawal symptoms from psychotropic medications can also precipitate anxiety symptoms (Rodda ea, 2008). Co-morbidity with other psychiatric illness- - High levels of anxiety are often found in elderly patients in the early stages of dementia. Recent studies revealed that different genes showed evidence for association with specific types of anxiety disorders, such as panic disorder, social phobias or generalised anxiety disorder (Academy of Finland, 2008). Specific anxiety disorders and their clinical features Phobic disorder Phobia occurs commonly in the elderly with increasing frailty and prevalence ranges from 0. These disorders provoke clinically significant levels of distress and disability due to high levels of anxiety. They are usually heralded by a traumatic event usually of a physical nature and may have had a public manifestation. However, in spite of the complete resolution of the physical event, the psychological impairment persists. There are 3 main types of phobia: Agoraphobia- prevalence in the elderly is estimated to range from 1. These individuals may be rendered housebound because many are terrified by the thought of collapsing and being left helpless in public. It can occur with or without panic attacks but always causes anxiety symptoms during the situation. This fear may spiral out of control if there is no obvious escape route and embarrassment is perceived. Consequently the individual learns to avoid these situations and this avoidance in turn reinforces the fear. Fear can also occur merely in anticipation of the anxiety-provoking situation and symptoms are not better explained by another mental or physical disorder.

The shoulder joint in hemiplegia is sensitive Section 4: Therapeutic strategies and neurorehabilitation to traumatization of various structures and inferior incapable of driving purchase 2 mg detrol overnight delivery, e buy detrol 1 mg on-line. It is impor- whereas pure motor deficits can often be solved by tant to keep the shoulder correctly positioned to car adaptation purchase 1 mg detrol mastercard. Hemi- The extent of further evaluation ranges from plegic shoulder pain in stroke may be due to adhesive screening tests, specific neuropsychological assess- capsulitis (50%), shoulder subluxation (44%), rotator ments and simulator tests to full road tests. If a post- cuff tears (22%), and shoulder-hand syndrome (16%) stroke patient is evaluated as not capable of driving, a [121]. The etiology of shoulder-hand syndrome with reassessment in the further course of rehabilitation pain of the shoulder or arm and edema of the hand with appropriate therapies can be a goal. It has also and arm is controversial; many authors consider been shown that simulator-based driving training it a form of reflex sympathetic dystrophy/complex improved driving ability, especially for well-educated regional pain syndrome, probably initiated by and less disabled stroke patients [126]. Management includes Partnership and sexual functioning: partnership is positioning, orthotic management, physical therapy in many cases affected by the post-stroke condition, including steps for reduction of edema, and analgetics. Summarized in a review [127], observa- due to varying definitions, populations, exclusion cri- tional studies suggest that the frequency and range teria and the timing of assessments [123]. In underdiagnosed because of overlapping symptoms addition to the direct consequences of stroke, psycho- with the stroke itself. It manifests itself in subtle social issues and depression are likely to contribute to signs, such as refusal to participate in treatments. As the problems are often choice; in addition studies suggest adaptations of complex, treatment suggestions have to be compre- cognitive-behavioral therapy techniques and brief hensive. Erectile dysfunctioning can be treated with supportive therapy to be beneficial [3]. In a Cochrane phosphodiesterase type 5 inhibitors or intracaverno- review, however, there was no evidence for impro- sal prostaglandin E-1 injections. Social coun- (n ¼ 4448) the diagnosis “previous stroke” was only seling is therefore mandatory in the course of stroke a nearly significant risk [124]. There is no doubt that rehabilitation, which includes, for example, informa- driving ability in the post-stroke period needs assess- tion about social security systems, social services, self- ment, and a study [125] shows that patients are in help and stroke groups. As a first step there are certain Acknowledgement 300 medical and neurological conditions where clinical The authors would like to thank Serafin Beer for judgement will confirm stroke patients as being helpful discussion and comments on the manuscript. Chapter 20: Neurorehabilitation Chapter Summary and others were found to be beneficial for motor recovery, while others, e. Neuroplasticity is the dynamic potential of the brain to reorganize itself during ontogeny and learning, or Speech disorders need intense training because following damage. Newer adult human being has an astounding potential for studies with therapies taking place daily for several regeneration and adaptability, which can be select- hours correct the former uncertainty regarding the ively supported and used for rehabilitation. Brain stimulation Several mechanisms of neuronal plasticity can be techniques and medication might add additional identified: benefit. Vicariation describes the hypothesis that func- Dysphagia occurs in the acute state of stroke in tions of damaged areas can be taken over by more than 50% of patients, probably leading to different regions of the brain. In the central nervous system of the ventions, for example modification of bolus volume adult, however, this mechanism is reduced, but and viscosity, and rehabilitative techniques, such as not absent. Diaschisis describes the phenomenon that a focal Patients admitted with tracheostomy often also need lesion may also lead to changes in brain func- intense dysphagia management. Spasticity can be treated with physiotherapy, nursing care and occupational therapy. If physical Neuroplasticity can be supported by: treatment reaches a limit, oral agents, intrathecal A multidisciplinary team in a structured setting. Treatment in a stroke unit has been shown to For the treatment of spatial neglect, perception improve the outcome significantly (number via the affected side is enforced as much as possible needed to treat 7 for thrombolysis versus 9 for and additional alertness training as well as visual and stroke unit treatment). Only team of medical, nursing and therapy staff, opti- a few pilot studies have been published to evaluate mal timing and early initiation (i. Pharmacological interventions: in preliminary studies, some medications such as levodopa 5. Brain plasticity: from pathophysiological mechanism for recovery and rehabilitative training. Mechanisms for recovery of motor function interaction, and physical activity as determinants of following cortical damage. Curr Opin Neurobiol 2006; functional outcome after cerebral infarction in the rat. Noninvasive cortical representations in primary motor cortex following stimulation in neurorehabilitation: a review. Pattern-specific role of the current orientation used Use-dependent alterations of movement to deliver theta burst stimulation. Clin Neurophysiol representations in primary motor cortex of adult 2007; 118(8):1815–23. Influence of Training-induced changes of motor cortex somatosensory input on motor function in patients representations in stroke patients. Vicarious function within the human stroke survivors with severe motor loss of the upper primary motor cortex? Functional neuroimaging studies of motor recovery after stroke in adults: a review. Brain 2003; Inactive and alone: physical activity within the first 126(Pt 6):1430–48. The Immediate constraint-induced movement therapy Rivermead Mobility Index: a further development of causes local hyperthermia that exacerbates cerebral the Rivermead Motor Assessment. Balance in elderly exacerbate brain damage after focal brain ischemia in patients: the “get-up and go” test.

It is recommended that patients withhold taking short-acting bronchodilators for Maximum Voluntary Ventilation at least 4 h before testing and any long-acting or sustained-release bronchodilators for at least 12 h The maximum voluntary ventilation is the before testing purchase 4mg detrol with mastercard. There are a variety of available techniques Body Plethysmography Technique in the pulmonary function laboratory that may be used to measure absolute lung volumes buy discount detrol 2mg on line, including The term thoracic gas volume refers to the body plethysmography buy generic detrol 4mg on line, nitrogen washout, and plethysmographic measurement of intrathoracic inhaled inert gas dilution. During the inspiratory phase of the pant, thoracic volume increases slightly, Gas Dilution Techniques decompressing the volume of air in the lungs while slightly compressing the volume of air in the box. Gas dilution techniques measure the gas vol- Conversely, during the expiratory phase of the ume in the lungs that communicates via the air- pant, thoracic volume decreases slightly, compress- ways by use of a mass balance approach. Using tracer gas concentration and the final tracer con- Boyle’s law, where at a given temperature, the centration to calculate the volume in the patient’s product of gas volume and pressure is constant: lungs at the moment the tracer gas breathing (1) V P V P began. Pressure and volume at the end of would cause lung volumes to be underestimated, the inspiratory phase of the pant are P2 (P1 P) whereas use of a soluble gas would lead cause lung and V2 (V1 V). These include the volume number of physiologic conditions, specifically and distribution of ventilation, mixing and diffu- sion, the composition of the gas, characteristics of the alveolar membrane and lung parenchyma, the volume of alveolar capillary plasma, the concentra- Table 7. An alveolar sample of the exhaled Exercise 2 Supine position gas is considered after anatomic and mechanical Obesity dead space gas is discarded from the collected gas Decreased fraction of inspired O2 (∼0. It is therefore recommended that no adjusting the predicted Dlco in adolescents and more than five repeated measurements be under- adult men is as follows14: taken at any sitting. The recommended equation for adjusting the Dlco for lung volume is also confusing because the predicted Dlco in a subject on supplemental in some instances the relationship is proportional, O2, and assuming a room air Pao2 at sea level of whereas in other settings it is unpredictable and 100 mm Hg is: varied. Values decrease with age, and are approxi- helpful in the diagnosis of respiratory muscle mately one third lower in women when com- weakness, in assessing the severity of respiratory pared with men. Nonselective stimuli can be either direct strong negative predictive value, and therefore (for example, methacholine and histamine) or functions best when normal to rule out current indirect (for example, exercise, eucapnic voluntary asthma. Thus, the use of the tidal Most patients with exercise-associated bron- breathing method or a modified dosimeter method choconstriction (which when clinically occurring is now recommended. The suggested The key principles for diagnosing common abnor- time periods these agents should be withheld before mal ventilatory disorders are listed in Table 9. The specificity of direct Typical examples of commonly encountered flow- (ie, methacholine and histamine) challenge testing volume curves are shown in Figure 7. Quantitative evi- the specificity of the methacholine challenge, but it dence is often inferred by a reduction in expiratory does not directly influence the sensitivity. Serial testing is routinely undertaken in clinical The use of severity classification systems is practice to monitor results over time, and to evalu- currently fraught with difficulty and frustration ate change following intervention(s). First, none have been standing of test variability is required before one specifically validated—as stated by others, “the can conclude that any observed change relates to number of categories and exact cut-off points are the underlying process or to an intervention. Canadian ducibility of twitch mouth pressure, sniff nasal thoracic society recommendations for management inspiratory pressure, and maximal inspiratory of chronic obstructive pulmonary disease—2007 pressure. With the miniaturization of elec- procedures tronic devices, the first video bronchoscope was • Review the procedures available to the interventional introduced in 1987. This development allowed pulmonologist • Stress the need for specific training in advanced proce- endoscopic pictures to be printed out and shared dures and, even more importantly, physicians no longer needed to look through an eyepiece. Instead, the Key words: airway obstruction; bronchoscopy; hemoptysis; interventional pulmonology; laser; lung cancer; pleuroscopy; endoscopic image could be projected onto moni- stent; thoracoscopy tors, allowing everyone in the room to see what was happening in the airway. By convention, as viewed from into the treatment of choice in these patients, with the operator’s perspective, the camera is at 9:00, a clinical success rate 98%. He went airways because the bronchoscope may need to be on to develop bronchoscopes, laryngoscopes, and rotated to visualize or sample the intended target. In 1966, Shigeto expert in airway and thoracic anatomy, including Ikeda presented the first prototype flexible fiber- knowledge of the nasopharnyx and oropharynx optic bronchoscope at the Ninth International in addition to the bronchial tree and mediastinal Congress on Diseases of the Chest in Copenhagen. If appropriate staging is to be performed, thoracic vessels and lymph nodes, as well as their biopsy of the lesion that will place the patient in relationship to endobronchial landmarks. If a diag- nosis was not obtained from 4R, station 7 should be Diagnostic Bronchoscopy sampled next because this would be considered an N2 node if involved with cancer. Electrocautery snare forceps is an Cancer Diagnosis and Staging excellent tool for the removal of a pedunculated airway lesion because it can open the airway and Lung cancer is the leading cause of cancer also provide excellent tissue for the pathologist. However, data support the use of the is estimated that there were 215,020 new cases of combination of techniques to improve diagnostic lung cancer in 2008, and the incidence and num- yield, as opposed to using them in isolation. The sonographic characteris- of peripheral nodules has been shown to have tics of peripheral nodules also have been shown to a greater diagnostic yield than other sampling correlate well with histology findings. Another important indication for bron- diagnostic or when it has been shown to signifi- choscopy in patients with community-acquired cantly increase the diagnostic yield as compared pneumonia is the ruling out of an obstructing with less-invasive means include lymphangitic endobronchial lesion. Obviously, it is crucial to carcinomatosis, sarcoidosis, rejection after lung avoid contamination with upper airway secre- transplantation, hypersensitivity pneumonitis tions when performing bronchoscopy in patients and, sometimes, mycobacterial and invasive fun- with pneumonia. Neutrophil predominance suggests bacterial infection, acute interstitial pneumonia, By using the techniques of evidence-based and may also be found in patients with asbestosis medicine to guide their recommendations, or usual interstitial pneumonitis. Eosinophils are the American Thoracic Society and Infectious seen in patients with eosinophilic pneumonias, Diseases Society of America have recently reviewed these topics in great detail. The alveolar ics, the use of semiquantitative or quantitative macrophages are filled with pulmonary alveolar culture data, and the use of negative culture data proteinosis-positive material, and lamellar bodies to discontinue antibiotics in patients who have not can be seen with electron microscopy. Additionally, it is impor- that the use of bronchoscopy can often aid in the tant to note that multiple diagnoses often can be diagnosis of a radiographic occult neoplasm in a present simultaneously in these patients64 and that patient who presents with hemoptysis, a broncho- noninfectious conditions may have a similar pre- scopic diagnosis of malignancy is made in 5%. Bronchoscopy is an excellent method who present with hemoptysis and normal chest of evaluating these patients because the use of imaging if they are 40 years of age, are male, less-invasive techniques can miss the diagnosis in and have a 40 pack-year smoking history. Although the appropriate Helmers and Pisani30 suggest three broad cat- timing for bronchoscopy is controversial, there egories of immunocompromised patients: those is a greater likelihood of identifying the bleeding who are pharmacologically immunosuppressed, source when performed within the first 48 h of those with hematologic malignancy/malfunction, symptoms. Cryptococcus sp, Histoplasma sp, and Although many advanced techniques can be viruses such as cytomegalovirus are seen in patients performed with flexible bronchoscopy, the rigid with defects in cell-mediated immunity. By using a approximately 2 to 3 mm and, hence, the risk of definition of 500 mL/24 h, Hirshberg et al74 found airway perforation is less when compared with that 14% of 208 patients presenting with hemop- lasers.