Mark Corson

By L. Murak. Mississippi University for Women.

This is the area of the city where ing codes prohibit cooking in the West Wing mariners from around the world like to spend rooms buy thorazine 50 mg amex. However buy 50mg thorazine amex, there is a small kitchenette their hard-earned money generic thorazine 100mg free shipping, and it’s only a short with a microwave and table for students to drive from Hopkins. A wash sink is adjacent to this room so For your living accommodations, the students can wash their dishes. Many frst-year students pre- Wing consists of 4-person and 8-person fer to live in Reed Hall, across from the Johns suites of rooms arranged with common living/ Hopkins Hospital, where they can get to know dining room, kitchenette and bathroom areas their classmates. The residents located in the suburbs, but can also be found of both wings must provide their own bed downtown and within walking distance of the linen and towels. If you want a home, you can look East Wing must provide dishes, silverware, at properties with pleasant lawns and trees, and utensils. You can choose to be close to the water or lounge, game room, library/conference room, nearer the countryside. Wherever you select study lounge, room with vending concession, to live, you will have chosen one of America’s self-service laundry, music room, and on-site most exciting cities. A recreational center is adjacent to Reed Rentals are $525, $565, and $600 per month Medical Residence Hall. The Johns Hopkins Women’s Medical Applications for housing and a descriptive Alumnae Association. A women’s organization in vari- Offce, Reed Medical Residence Hall, 1620 ous forms has existed at the Medical School McElderry Street, Room 1132, Baltimore, since 1904. For information regarding incorporated in 1957 to provide professional both on and off campus housing see www. You may also contact on the frst foor of the hospital near the Doc- the Housing Director, Robin Lenzo, at 410- tor’s Lounge. The University collections of over A calendar of events is mailed to women 2 million volumes are housed in the Milton S. This library acquires in excess of 9,000 The Medical and Chirurgical Faculty: The current journals and is a depository for United Medical and Chirurgical Faculty of the State States Government documents as well as for of Maryland is located at 1211 Cathedral United Nations, Atomic Energy Commission Street, Baltimore. It conducts a direct access to all library reading rooms and scientifc session each year in April and main- stack areas. The library of the Medical and Chirurgical The Baltimore City Medical Society: The Faculty of Maryland, 1211 Cathedral Street, Baltimore City Medical Society is an indepen- contains 94,500 volumes and is operated in dent society of Baltimore physicians. Their libraries of Baltimore are the Peabody and meetings are open to medical students. The the chief institutions of interest to students Bulletin is published quarterly by the Institute are the Smithsonian Institution and Nation- of the History of Medicine. It is the organ of al Museum, the Library of Congress, the the Institute and of the American Association National Library of Medicine, and the librar- for the History of Medicine. The Dome The Johns Hopkins Medical and Surgical is the monthly house organ for all students, Association: Eileen P. Shortle, Secretary-Treasurer; Diane contains feature stories on people and activi- J. News about The association is composed of graduates signifcant research, promotions, honors and of the School of Medicine, past and present award presentations also is included. Scientifc papers by medical school, former faculty and staff, and staff members and alumni are presented at current medical school students and their the biennial meetings. Over 13,000 indi- recognize the critical importance of teaching viduals receive the publication which has a at Johns Hopkins. Robert Francis Siliciano of the Depart- terly and is jointly sponsored by the School of ments of Medicine and Molecular Biology Medicine, the Hospital, and the Medical and and Genetics. Surgical Association, and is the alumni news- The Graduate Student Association Award letter for the School of Medicine. Jeremy Nathans in Teaching is awarded annually to the teach- of the Departments of Molecular Biology and ers voted by the students in the preclinical Genetics, Neuroscience, and Ophthalmology. David Weishampel of the The Dean’s Special Recognition Award Center for Functional Anatomy and Evolution. Anthony lished the Tilghman Traveling Fellowship in the Derek Sung of the Department of Medicine. The Tilghman Traveling Fellowship will The Stuart Award was established in 1969 be awarded periodically to young members following the bequest of a grateful patient, of the medical faculty, who are native-born George J. The new theories, methods and techniques in selection is made by the senior students. Mitchell Goldstein of The recipients are to be selected by a com- the Department of Pediatrics. All full time and departments in the School of Medicine shall part time members of the faculty are eligible be eligible for consideration. Selection of the awardees is proposed work during the sabbatical year made by the Professors’ Award Committee. Nisha Chandra-Strobos of the Department of Guidelines are available at http://www. Applications may be submitted at Molecular Biology and Genetics for teach- any time, but should be submitted at least 60 ing in the basic sciences, and Dr. Hueppchen of the Department of Gynecology The Shing Yuk Yau Memorial Fund: The and Obstetrics for teaching in the basic and fund was established in 1984 in memory of clinical sciences. Cowles Andrus Distinguished Profes- exchanges between the School of Medicine sorship in Cardiology [2001]: Edward K. Michael Armstrong Professorship [2000]: of Medicine indicates that a sum of money Gregg L. Michael to generate income which supports a profes- Armstrong, to support medical research, with sor in a particular department. Frances and a member of the original faculty of the Baker is a pediatrician and Dr.

This is more likely if the patient is taking diuretic medication or has poor left ventricular function buy generic thorazine 50 mg on-line. Generally thorazine 50 mg online, before starting any antidepressant in the elderly one should steer clear of any drug that 1368 might exacerbate any underlying medical illness or interact with other prescribed medication purchase 50 mg thorazine overnight delivery. The importance of psychosocial support cannot be underestimated, even when antidepressant drugs are used. Lenze ea (2003) found little effect of co-morbid anxiety on outcome of late- life depression treated with interpersonal psychotherapy. Depression in the workplace 1367 Risk of hyponatraemia and small increase in risk of falls. Recurrent brief depression This is a relatively new innovation that is said to be common and have a relapsing course. One in twelve people may be affected and the risk of deliberate self-harm may be 13% over ten years. Diagnostic criteria include 3 episodes over 3 months, depressive episode lasting less than 2 weeks, and no association with the menstrual cycle. The usual treatments for depression may be given a trial, although it may be relatively unresponsive to antidepressants (Baldwin, 2003) because episodes may be too short. Also of significance are the adequacy and appropriateness of treatment received, and the duration of the illness episode prior to starting therapy. Other conditions In 1882, the French psychiatrist Jules Cotard (1840-89), described patients with what he called délire de négation, the term Cotard’s syndrome being first used by J Seglas in 1897. Associated features include le délire d’énormité or delusion of enormous body size or a delusion that urinating will flood the world, and delusion of immortality. Cotard’s syndrome may be associated with valaciclovir (Halldén ea, 2007) or may complicate Parkinson’s disease. Lycanthropy is the belief that one is transformed into an animal, classically a wolf or werewolf. This non- specific presentation can be associated with ‘hysteria’, bipolar affective disorder, psychotic depression, schizophrenia, or organic brain disorders. Essentially, the criteria are (a) one or more episodes of depressive symptoms that fulfil the duration criterion for major depression but there are fewer symptoms and less impairment, and (b) the following diagnoses are outruled: adjustment disorder with 1370 depressed mood , depressive disorder not otherwise specified, major depressive episode, dysthymia, cyclothymic disorder, periods of normal sadness, uncomplicated bereavement, mood disorder induced by substance/general medical condition, a history of major depressive /mania/mixed episode(s), and depressive symptoms that occur exclusively during schizophrenia or schizophreniform/schizoaffective/delusional/not otherwise specified psychotic disorders. Mania may be precipitated by sleep deprivation in people who are euthymic, depressed, or who have no history of prior mania. The risk of such a switch occurring in predominantly unipolar depressives has been put at <1%. According to Vieta,(2004) quetiapine (for mania) may not be associated with treatment-emergent depression. Current or past substance use in depressed bipolar patients was not associated with longer time to recovery but may have increased risk for switching directly into mania/hypomania/mixed states in an American study. First onset mania in 1377 later life may be associated with increased vascular risk factors and relatively high current serum cholesterol levels. Women are more likely to experience depressive episodes than mania (men experience both phases with equal frequency) and rapid cycling is more common in females. Mania may be induced in vulnerable people by lack of sleep, crossing many time zones during travel, and shift work. Less common are chronic depression, chronic mania (said by some to be rare today but one report of hospitalised cases of mania 1380 found that 13% were chronic), and so-called rapid cyclers. Cycling Rapid cycling, which is more common in females, is present when there are at least 4 episodes/year 1381 Ultra-rapid cycling is when attacks occur every so many weeks to several days Ultra-ultra-rapid (ultradian cycling) is when attacks are of less than 24 hours duration (or several episodes daily) Continuous cycling when there is no sustained period of stable mood. Bipolar I disorder prospective study (Solomon ea, 2009) N = 219; median follow-up = 20 years; 1208 mood episodes Major depressive episodes = 30. Nwulia ea (2008) found the best predictors of rapid cycling in familial cases of bipolar disorder to be earlier onset of symptoms (18 v 21 years), comorbid anxiety (47% v 26%), and antidepressant-induced mood switching. Persistence of depressive symptoms increased significantly in the 2 youngest groups. Earlier ages at onset were associated higher depressive morbidity throughout 20 years of follow-up but did not predict changes in symptom persistence. The proportion of weeks spent in episodes of either pole (depression or mania) correlated across follow-up period in all age groups, although correlations were stronger for depressive symptoms and shorter intervals. Bipolar spectrum disorders are associated with an increased premature mortality rate due to general medical illnesses, a consequence perhaps of unhealthy lifestyle, medication, biology, and disparities in health care. Adolescent-onset is associated with substance abuse, anxiety, and an episodic course. Both groups, in contrast to adult cases, have elation, mixed episodes, longer episodes, and poor inter-episode recovery. Forty ea (2008) compared major depression and bipolar disorder patients and found psychosis, diurnal mood varian, hypersomnia during depression, and more frequent short episodes of depression to predict bipolarity. Depression and cancer If a person becomes depressed in middle age, especially if it is for the first time and if no precipitant can be found, should be rigorously investigated to exclude physical disease. Affective disorders may be an early precursor of clinical cancer, especially with cancer of the pancreas (more than with gastric cancer). Other criticisms include the inclusion of mildly depressed outpatients, the difficulties of establishing an adequate placebo group, low numbers in light therapy studies, lack of comparison with established treatments, uncontrolled studies, apparent seasonality (non-seasonal episodes on follow-up), and the finding of peaks in all seasons, including spring-summer depression. Classically the patient becomes depressed in autumn or winter and the condition remits by the following spring or summer over at least two years (reversed in the Southern Hemisphere). Schlager ea (1993) found that healthy women, but not men, had more symptoms (anxiety, somatisation, depression) in the two weeks before testing in winter than at other times. According to one relatively small 420 study, recent negative life events and poor social support may increase seasonality in mood disorder. It may also simply be an exaggeration of normal familial seasonal changes in mood.

Treatment increases the amount of neurotransmitter acutely but the effect of this over time is to desensitise (downregulate) receptors purchase thorazine 100 mg amex. Bupropion purchase thorazine 100 mg without prescription, amineptine buy thorazine 100 mg lowest price, and 1282 nomifensine are the main dopaminergic antidepressants. Pramipexole (Mirapexin), used for Parkinson’s disease, is a D2/3 agonist with preferential D3 binding affinity. Whiskey and Taylor (2004) reviewed the literature on the use of pramipexole in depression (unipolar and bipolar) and concluded that whilst the data appear promising further research is required. Perhaps old-age depression with cognitive impairment might be due to cortisol-induced neuronal damage, although this is still controversial. It has also been 1285 suggested that change in peptides (that are involved in stress adaptation) in brain areas linked to emotional responses like the amygdala may precipitate depressive illness. It has been asserted that the reason for developing psychotic features in the context of a depressive episode may be enhancement of dopaminergic activity by glucocorticoids. Also, animal studies suggest that corticosteroid administration 1287 causes hippocampal cell loss. Sheline ea (2003) found that hippocampal volume decreased as the number of days of untreated depression increased. However, Lloyd ea (2004) found that smaller hippocampi were associated with late-onset depression only and not with lifetime duration of depression. The authors admit that the latter is difficult to measure accurately and all the patients were on medication. Kronmüller ea (2008) found that smaller hippocampi were associated with relapse of major depression and Chen ea (2010) found that girls at high familial risk of developing depression had small hippocampi compared to those at low risk, i. Fiedoronicz ea (2010) conducted a follow-up (median 20 years, max 25 years) of patients who had a fasting total cholesterol evaluation at intake: low cholesterol among bipolar patients (N = 65) predicted a higher proportion of follow-up weeks with manic but not depressive symptoms and cholesterol did not predict depressive symptom burden among unipolar depressives (N = 66). Also, there is evidence that antidepressants induce neurogenesis,(Santarelli ea, 2003) although this may be a chronic rather than acute effect. Cotter and Pariante (2002) suggest that the pathological changes reported in schizophrenia, bipolar disorder 1293 1294 and major depressive disorder differ only quantitatively rather than qualitatively. They suggest that the common cause may be (stress-related) glucocorticoid-induced damage. They point out that the reduction in hippocampal volume reduction seen in cases of Cushing’s disease is reversible after normalisation of cortisol levels and express the hope that neuroprotective therapies may be developed for the psychiatric disorders under consideration. Whilst autoimmune thyroiditis occurs in about 15% of depression it may occur in up to 50% of cases of rapid cycling bipolars. This could conceivably lead to atrophy and perhaps to apoptosis in hippocampal neurones. In animals antidepressant drugs increase neuronal turnover and sprouting of synapses. Early reports suggested that opiates might relieve depression (Weber & Emrich, 1988), but hard evidence is lacking. Also, there is some evidence that variation in the mu-opioid receptor gene may influence rates of response to antidepressant drugs (Garriock ea, 2010), although this effect could be either via a placebo or pharmacological action. T1) expression in the frontal cortex of a subpopulation of suicide completers that was associated with the methylation state of the promoter region. Thus: (a) ↑ kynurenine in depression → quinolinate (neurotoxic) in microglia → astrocyte and then neurone death (b) Kynurenine → kynurenate (neuroprotective) is ↓ in depression There is a suggestion that deficiency of orexins/hypocretins might have a role in causing depression. Looking at patients with ‘major affective disorder’, Machón ea(1997) of Helsinki found an increased likelihood of exposure to an epidemic of influenza (A2/Singapore virus) during the second trimester compared to controls. Cotter ea (2001) found a reduction in reduced neuronal size and glial cell density in the anterior cingulate cortex of major depressives at postmortem. Relatively small cingulate volumes in children and adolescents with bipolar disorder have been reported,(Kaur ea, 2005) suggesting that such may be the case from early in the illness course. Geomagnetic storms have been suggested as a cause of depression in susceptible individuals. They might 1300 desynchronise pineal circadian rhythms or they might disrupt pineal melatonin synthesis via actions on serotonergic or adrenergic systems. Such storms could, according to the theory, act on cell membrane permeability, cause increased calcium channel activity, or the retinal rods could act as magnetoreceptors. Melatonin secretion is fairly contant within individuals but varies widely between individuals. Also, light therapy may be useful in the treatment of depression lasting more than two years. Neuroticism did not predict amount of mood change following acute tryptophan depletion in healthy volunteers (but it did moderate performance on a verbal fluency test). Tryptophan hydroxylase A779 allele more common among deliberate self-harm subjects v controls. Beta-arrestin-1 levels reduced in white blood cells in depressives and elevated in rat brain by antidepressants. Presence of lifetime history of depression in Alzheimer’s disease corresponds to increased Alzheimer-related neuropathological changes in the hippocampus – more pronounced if depression occurs early during the disease process. A number of studies suggested that the closer the lesion is to the frontal pole on the dominant side, and the further away from the pole on the opposite side, the more likely is the person to be depressed. However, Carson ea (2000) found no support for a link between the site of a lesion and risk of depression. The authors point out that the areas affected are involved in emotion processing and regulation of stress. Such hypertrophy has been found in depressives post mortem and in completed suicides. Represents functional/reversible problem) whereas no real improvement in bilateral medial/dorsolateral/parietal (?

Salivon & Polina (2005) carried out a comparative Sheldon (1940) order 50 mg thorazine amex, whose classification is the clearest and analysis of anthropometric indices order thorazine 100mg fast delivery, matching these to most applicable to assessing patients for physical cardiovascular vegetative regulation purchase 50 mg thorazine amex. The researchers interventions, stated that the constitution ‘refers to those observed typological specificity of organism reactivity to aspects of the individual which are relatively more fixed unfavorable geochemical situations in young males and and unchanging – morphology, endocrine function, etc. His system was developed deficiencies in the soil (‘vital macro- and micro-elements from a study of over 4000 students whom he in soils and drinkable water’). Individuals of The endomorphic constitution has a predominance of robust physique (high endomorphic and mesomorphic soft roundness in which the digestive organs dominate components) showed higher mean values of systolic and the body economy. The researchers note that their predominance of muscles, bone and connective tissue. The Figures in the lower quintile, or below the range, contrasts of hydrotherapy applications can be greater, suggest degrees of hypotonia and weakness (Priest soft tissue procedures may need to be stronger and 1959). The ectomorphic types, or those of tending towards sympathicotonia, as suggested by slim build, on the other hand, require lighter, shorter iridological findings. Mesomorphs are more sturdy and athletic Iris diagnosis in build and can usually tolerate reasonably strong A further guide to the vital reserve of the patient is stimuli. The Somatotype has also been shown to have correlations overall color and texture of the irids is considered to be with aerobic trainability, adaptability and blood pressure. Observation may be made with a hand lens tests and measures of ventilatory capacity on subjects and penlight although, for more detailed analysis, a divided into four somatotype groups – endo- desktop ophthalmoscope or camera designed for close mesomorphs, mesomorphs, meso-ectomorphs and imaging of the iris is preferable. Turner 2000) has described as ‘symbolic topography’ Continued 90 Naturopathic Physical Medicine Box 4. Nevertheless, empirical tightness of the autonomic wreath, a radial zone lying evidence suggests that the tightness or otherwise of the outside the pupil, as well as the dilation of the pupil structure of the iris can give a good indication of the itself (Kriege 1969). This There exist several approaches to constitutional method identified chemical elements that predominated diagnosis in naturopathic medicine. Based on characteristic physical, was initially advocated by Kuhne (1902) in his widely mental and emotional patterns, individuals could be influential work. Havard further elaborated on the cranial categorized and therapeutic interventions designed. While Kuhne’s diagnosis Verbon (1948), Shanklin (1950) and Jensen (1983) focused upon identification of the pattern of advocated and expanded upon Rocine’s approach. Rank categorization incorporated some facial and fingernail diagnosis as based upon the relative size of the occipital, parietal or well. The later taxonomy of Deck (1965) has certain temporal lobes, as evidenced visually in the similarities; however, the focus is upon the iris. This corresponding cranial structures, allowed a ranking of approach is gaining greater international acceptance the digestive, genitourinary or cardiopulmonary systems, and is advocated as a basic identification model by the respectively. The genetically allow prediction of healing crises, in the secondary determined iris color is thought to identify the primary strength during adulthood, and in the weakest organ constitution, the overarching structural pattern of the system at childhood. Pathological derangement of the fibers the secondary disposition, and finally tertiary strongest organ system was considered a poor categorization is determined by accumulation patterns. This method was referred to as ‘basic Upon this basic constitutional classification further iris diagnosis’ and Lindlahr advocated a combination of this diagnosis is then elaborated. Similarly, the neurogenic understanding of the model of the iridological disposition, characterized by a relatively tight and taut constitutions. For example, the connective tissue iris fiber pattern, has increased expression of genotype weakness disposition, characterized by a general laxity associated with hypertension (Um et al 2005). Fascia is one component tissue, which has major implications for manual/ of connective tissue in the body, which includes fascia, physical therapies. These tissues have particular charting method for location of the connective tissue (fascial) planes, acupuncture points and acupuncture characteristics that influence their function – they meridians of the arm, they note that ‘overall, more than have parallel collagen fibers, various degrees of undu- 80% of acupuncture points and 50% of meridian lations and are low in elastin. This category of tissue intersections of the arm appeared to coincide with has many functions (Manheim 2001): intermuscular or intramuscular connective tissue • Supports matrix planes’. The tension placed on the • Sites for muscle attachment connective tissue as a result of further movements of the needle delivers a mechanical stimulus at • Stores fat – conserves heat the cellular level. They note that changes in the • Fibroblastic activity – scar formation extracellular matrix ‘. In 2005, Langevin et al observed that: ‘The dynamic, cytoskeleton-dependent responses of fibroblasts to The principles that guide attention to fascia in physi- changes in tissue length have important implications cal medicine are based on the knowledge that fascia for our understanding of normal movement and covers, separates, attaches to and gives cohesion to all posture, as well as therapies using mechanical organs, muscles and other bodily tissues, so that there stimulation of connective tissue, including physical is true structural interdependence between all regions therapy, massage and acupuncture. As noted below – see influences of fascia extend beyond the obvious biome- notes on the work of Langevin (Box 4. He showed that also recruit neuromuscular adaptive activity, and as cells deform when gravity is removed or reduced, naturopathic practitioners – as well as other holistic the behavior of cells changes to the extent that, professions – consider that a detailed analysis of the irrespective of how good the overall nutritional state, or neuromuscular system is vital in making a coherent how much exercise (static cycling in space) is taking and complete diagnosis (Kuchera 1997). Some ele- place, when they are distorted, individual cells cannot process nutrients normally, and problems such as ments of such assessment are to be found in Chapter decalcification emerge. This research is a confirmation, were any needed, that structure is the governing feature of function, a Most commonly this aspect of understanding the validation in naturopathic medicine of the essential role interdependency in human function is faced with the of manual and other physical modalities that have the patient in pain, especially when caused by trauma potential to beneficially modify structural components and/or postural imbalance. As romuscular adaptation has occurred, in which tissues, noted in Chapter 2, the corollary to this relationship is, and a strategy of assisting in the optimal outcome of of course, that functional factors such as overuse and balanced movement, stability and muscle function, is misuse imposed on tissues will modify their structure one focus of naturopathic physical medicine. Additional discussion is to be found in Chapter 2, where adaptation pro- cesses are dealt with in depth. Body–mind Physiological The link between the body and the mind has been well established in the literature over the past three Neuromuscular system decades, and confirms the traditional naturopathic Neuromuscular activity in human physiology is a and holistic view that these two realms of the indi- major adaptive system that facilitates and controls vidual cannot be separated in their functions. Movement can be disturbed by icine, as early nature cure physicians such as Alfred unexpected events, as well as by the normal activities Brauchle instituted what he called ‘naturopathic psy- of life, and the level of stability in the system can be chotherapy’ as early as 1934, and included a chapter defined as the ability of a system to return to its origi- titled ‘Psychological Nature Cure’ in his 1937 book nal state after any adaptive challenge, evident in the History of Nature Cure in Biographies (Kirchfeld & Boyle process of homeostasis. The technique was based mostly on suggestion the ability to return to a desired movement pattern and hypnosis, although he also believed in the clinical after such a demand or disturbance. Sensory systems in the body, such as the propriocep- European naturopaths have also demonstrated a tive, visual and equilibrium systems, monitor struc- wide interest in this area of health care, most notably tural, postural and other changes, demands and the British naturopathic practitioner Milton Powell disturbances, and send informational feedback signals who for many years contributed a series of articles on to the central control cortex, which in turn adapts its naturopathic psychotherapy to the British Naturopathic output to the musculoskeletal system to compensate, Journal & Osteopathic Review. This type of feedback discussing the topic of phobia, his naturopathic per- control – which is clearly dependent on accurate infor- spective involved, among other aspects of care, Chapter 4 • Naturopathic Physical Medicine 93 Box 4. There is evidence that deeper muscles (also described as ‘inner unit’, or ‘stabilizer’ or ‘local’ As adaptive changes take place in the musculoskeletal muscles) contain proportionately greater numbers of system, and as decompensation progresses toward slow twitch (postural) fibers, whereas superficial more compromised degrees of dysfunction, structural muscles (also described as ‘outer unit’, or ‘mobilizer’ or modifications appear and whole-body, regional and local ‘global’ muscles; Norris 1998) are dominated by faster postural changes emerge.