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The electronic ear was supposed to resolve all difficulties of communi- cation cheap 20mg cialis super active with amex erectile dysfunction vitamin deficiency, psychological problems, delays in language and social develop- ment — it was even supposed to improve the vocal performances of singers! W hile his magic ear may have seduced the public, Tomatis failed in his attempt to develop a theoretical framework, because it rested on a foundation of untruths. According to him, the right ear is preferred because it is the sensor, and he explained its preeminence by the fact that the cerebral circuits on the right side are 200 times shorter than those on the left side. One can only wonder about the value of such reasoning, since it negates anatomical facts that have been known since Ambroise Paré. In 1976, Tomatis resigned from the order of physicians (before the order had to render a ruling on his activity). But it was another 20 years before the Justice Department took an interest in the electronic 148 From Mother Ocean to the All-Embracing Mother 5 ear. Suffering from Ménière’s vertigo (a deterioration of the inner ear), she participated in 80 sessions of listening of Mozart at the Tomatis Center in Paris. Given the failure of these sessions, at full price, the Center offered her 80 additional meetings for free — with no greater success. Many filed a complaint and, eight years later, To- 6 matis was fined $10,000 in amends. The lawsuit charged that the "electronic ear" was only a cheap audiometer with no therapeutic func- tion. According to ear-nose-and-throat specialists, the Tomatis system is more like a religious pilgrimage to Lourdes than a scientific and therapeutic reality. Therefore, render unto Caesar that which is Caesar’s and to God that which is God’s. If there is any field where therapeutic delusions can be exercised without any limitation or possible control, it is that of psychiatry. The field of physical suffering has certain characteristics that con- strain the doctor and give patients some reference points by which they might judge the validity of the medical approach that is being offered. A bone fracture can be located and its progress in healing can be ana- lyzed using X-rays. You can have an electrocardiogram to obtain com- parative data, and you can take your temperature to see whether an anti-fever medication is working. W hile we might envisage some form of tests to use in the case of definite, specific pathologies like psychosis or neurosis, there is no sys- tem by which one can check the validity of everyday psychiatric prac- tices — neither in regard the diagnosis nor to the prescribed therapy. New means of research have been invented, like cerebral cartographies via technetium, but so far they are restricted to the domain of labora- tory research — fortunately — and have not yet invaded the doctors’ 151 Healing or Stealing? Given that he has no tools, the patient has no frame of reference by which to differentiate between something that is an appropriate part of reasonable — albeit sometimes ineffective — practice, and something that is more in the domain of pickpockets, quacks, and delu- sionary pseudo-therapists. My 20 years of psychiatric practice have put me in contact with quite a number of patients who had been "treated" by crystal therapy, gemmo-therapy, vedic sophrology and foot massages. In addition to the fact that we have no authentic system for chart- ing the province of the mind, the field of psychiatric therapy is vulner- able to the recruitment of supposed therapists who find it a convenient discharge system for their own problems and fantasies. Since time immemorial, mental therapy has been a field where sci- ence, magic and religion come together. In the Middle Ages, it was be- lieved that epileptics were possessed by demons, and a certain religious influence can still be detected in that arena nowadays. Hysteria, with its great spectacular crises, was and still is the preferred area of activity for people who style themselves as exorcists, who consider the episodes a sign of the evil one’s influence or even a manifestation of erotic rela- tions with a succubus. Many bridges have been built between psychiatry and certain reli- gious or philosophical doctrines. In the 1960’s, for example, psychia- trist-philosophizer Alan W atts made connections between Buddhism and psychiatry; at the same time, new movements were born that re- gard a certain religious or philosophical practice as a form of therapy. However, while these practices have a real didactic value and often rep- resent a mode of expression and psychological progression, they should not be confused with therapeutic models; they cannot really handle the critical phases that "psychiatric sufferers" endure. Mastering a relaxa- tion technique, meditation or visualization, certainly represents a posi- tive step for an individual, but it is still necessary that the subject con- 152 Psychiatry and Delusions cerned should be in good enough shape to practice it coherently and that the practice not bring on additional more problems. Cult groups and unscrupulous individuals frequently take advan- tage of the delirious or hallucinatory signs and symptoms of patients in a state of suffering. They claim the signs and symptoms are demonstra- tions of malevolent powers or evidence of the subject’s past lives. I have noticed this on several occasions, when I have been called into various courts as expert witness to assess the psychiatric after-effects of such pseudo-medical practices. A patient in need of psychological assistance or on a personal quest may thus place his fate in the hands of one of these many self- proclaimed healers, whose principle activity is selling a very personal- ized "therapy" derived from one or another psychiatric or psychoana- lytical trend.
In the hospitalized past two decades for all age groups cialis super active 20 mg with mastercard erectile dysfunction treatment washington dc, since the in- elderly longitudinal project (HELP), a prospective troduction of the prospective payment system and cohort study of seriously ill patients age 80 years and Medicare/managed care programs, the proportion of older, major variables predictive of 2-year mortality hospitalized patients who are age 65 years and older is included weight loss, cognitive dysfunction, impaired increasing. In nonfederal acute hospitals, elderly patients functional status, chronic disease class, and adult physiol- account for 37% of all discharges and 47% of inpatient ogy score (from the Acute Physiology and Chronic days of care. The oldest patients have those 75 years and older—are admitted to the hospital longer hospitalizations, higher mortality rates, and higher from the emergency department. A small portion of older patients nursing home discharges will continue to be greater in the consistently make extensive use of hospital services. Fewer than 5% had consistently higher rates of hospitalization, averaging one or more admis- Functional Decline sions annually. A prospective cohort study identified eight independent variables that are risk factors for Hospitalization for an acute illness often results in an repeated hospital admission among people age 70 years older patient’s loss of independent self-care (functional 133 134 R. A study of functional morbidity in hospitalized older patients with a mean age of 84 years found that 65% of patients experienced a decline in mobility scores between baseline and day 2 of hospitalization. Recent prospective cohort studies found that 20% to 32% of patients admit- ted to general medical units lose independence in their ability to perform one or more basic activities of daily living (ADL) at discharge. In a study of more than 1200 community-dwelling patients aged 70 years and older hospitalized with acute medical illnesses, 31% lost independence in one or more of five basic ADLs when compared to their baseline status 2 weeks before admission. Functional decline occurred more frequently in patients who were over 75 years of age, had some disability in the performance of an instrumental ADL before admission, and had lower mental status scores on admission. These elements can interact with depressed dictors of mortality and contribute prognostic ability mood, negative expectations, and physical impairments to beyond that obtained with combined measures of disease result in a dysfunctional older person. Identification of comorbidity, severity, disease staging, and diagnosis- patients at risk for functional decline begins with the related groups. Virtually any class of Medical Errors medication can cause an adverse event, but antibiotics and cardiovascular drugs have been most commonly Medical errors, which have recently received widespread implicated in studies of hospitalized patients. The attention, also appear to be more common in elderly hos- increased risk for adverse drug events is also attributable pitalized patients. For example, in one study, patients over to alterations in drug disposition and tissue sensitivity age 65 had twice the chance of sustaining injury during associated with usual aging and to drug–drug interactions hospitalization as younger patients, with most events being judged as potentially preventable. Nosocomial (hospital-acquired) infec- tions are common complications of hospitalization. Colonization or infection with resistant or Medical errors can contribute to death or injury of hos- opportunistic infections may complicate hospitalization. Iatrogenic problem Common reasons Keys to prevention Adverse drug effects Polypharmacy; drug–drug interactions; Rational drug prescribing: review all medications taken before admission; altered drug disposition and tissue use lower-than-usual maintenance doses when geriatric dose is sensitivity with aging unknown; limit the addition of psychoactive drugs; avoid whenever possible multiple drugs that inhibit or induce cytochrome P-450 hepatic metabolism or are highly albumin bound Falls/immobility Weakness of leg muscles; postural Assess falls risk at admission (multiple chronic diseases, cognitive hypotension; deconditioning due to dysfunction, neuromuscular dysfunction, multiple sensory impairments); prolonged bed rest; cognitive avoid physical restraints; order physical therapy for transfer-dependent impairment; sensory impairment and gait-impaired patients; prescribe assistive devices (e. Palmer Errors leading to adverse drug events are the most medically necessary and less restrictive measures have commonly recognized medical error in hospitalized been deemed ineffective. The use of computerized and other support To enhance patient mobility, physical therapy or systems is advocated to reduce the rate of errors. For patients with impaired independence in gait or assisted decision support programs, using practice bed transfers, physical therapy consultation and bedside guidelines, can improve antibiotic use, reduce associated therapy should be considered. Exercises should include costs, and appear to limit the emergence of antibiotic- passive and active range of motion exercises to enhance resistant pathogens. Ideally, patients associated with an increased risk for injury resulting should be allowed free movement to reduce the risk of from adverse drug events. Patients often need decreases the rate of nonintercepted serious medication encouragement to sit up or to get out of bed even when errors, thereby providing evidence that information they prefer bed rest. The impor- tance of undernutrition is underscored by prospective studies that link protein-energy malnutrition evident at Geriatric Comorbid Problems admission to increased hospital and posthospital mortal- Common geriatric problems often complicate the medical ity. In one study, the prevalence of malnutrition at admis- management of acute illness during hospitalization. Physical restraints weight loss of 5% to 10% of their body weight over a 6- include vest, belt, mitten, jacket, wrist, and ankle month period and physical signs of malnutrition such as restraints. The laboratory evaluation of malnutri- and full rails are also often classified as mechanical tion is confounded by the effects of inflammation and restraints. Mechanical restraints and drugs SGA combines elements of the patient’s nutrition history used as restraints should be avoided unless they are (weight loss in previous 6 months) and physical exami- 13.
Anterior – anterior longitudinal ligament 20mg cialis super active visa erectile dysfunction statistics, anterior annulus fibrosus and anterior part of the vertebral body; middle – posterior longitudinal ligament and posterior annulus fibrosus on each side; posterior – neural arch and posterior longitudinal ligamentous complex including the interspinuos ligament. The articular processes project superiorly and inferiorly from the junction of the pedicle and lamina. Regarding the intervertebral disc: (a) The intervertebral disc forms a secondary cartilaginous joint between adjacent vertebrae. In the spine: (a) The internuclear cleft develops during fetal life to differentiate into the central nucleus pulposus and the peripheral annulus fibrosus. Concerning ligaments of the vertebral column: (a) The anterior longitudinal ligament extends from the basiocciput to the anterior surface of the upper sacrum. With increasing age, the disc undergoes progressive dehydration with loss of height and is replaced by fibrocartilage by 80 years of age. The anterior longitudinal ligament is attached firmly to the vertebral bodies and less firmly to the discs. Above C7 it continues as ligamentum nuchae and inserts into the external occipital protuberance. Regarding vertebral venous plexuses: (a) The internal venous plexus runs in the body of the vertebra. Regarding the vertebrae: (a) The ossification centres appear at the eighth week of gestation. In the thoracic and lumbar regions they are orientated laterally, and lateral radiographs are appropriate to demonstrate them. On axial section at the level of the facet joint the superior articular facet is anterior to the joint. The other cervical vertebrae are supplied by segmental branches from the costocervical, thyrocervical trunks and vertebral arteries. The thoracic and lumbar parts of the vertebral column are supplied by segmental aortic branches. The basivertebral vein runs in the body of the vertebra and drains into the internal plexus. Failure of one-half of this ossification centre to develop results in a hemivertebra. When the first edition of this book was published in 1986, disease management was only dreamed about, and the backbone of managing MS was symptom management. Now, only 16 years later, these treatments are equal- ly important in attempting to gain control of this seemingly uncon- trollable disease. As I have always emphasized, there is a person behind the MS who has needs that go beyond disease and symptom management, and these must also be addressed in any compre- hensive management program. This book remains a guide to managing the symptoms of MS, but also focuses on disease and personal management strategies. It is based on the management program developed at the oldest com- prehensive MS Center in the United States, The Fairview MS Center in Minneapolis, Minnesota, USA. With all that has happened in health care delivery in the past decade, it is even more important for people with MS to take charge of their destiny as much as pos- sible. This book provides ammunition in that fight by suggesting ways to manage the issues that accompany MS. In this new edition, the disease management section has been expanded to reflect the growth of our knowledge in this area. We have also reorganized the book to better reflect the three areas of management—management of the disease, manage- ment of its symptoms, and management of issues relating to lifestyle and general wellness. It is our hope that all who use this book will be empowered to do as much as they can with what they have, and to live their lives as fully as possible. Multiple sclerosis (MS) is one of a broad category of demyelinating diseases that affect the central nervous system (CNS)—the brain and spinal cord. Myelin is a fatty material that insulates nerves, act- ing like the covering of an electrical wire and allowing the nerve to transmit its impulses rapidly. It is the speed and efficiency with which these impulses are conducted that permits smooth, rapid, and coordinated movements that are performed with little con- scious effort.
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