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Iris Publishers - Journal of Archives of Clinical Case Studies-Panchakarma – What Benefits Will I Experience?

Author by Jaisri M Lambert*

Opinion

According to classical medical thinking of Ayurvedic medicine, the body functions through various channel systems called „Srotamsi‟, containing both microscopic and macroscopic structures such as the respiratory system, lymphatic/circulatory system, reproductive system, and nervous systems, among others.

These channels function as innumerable psycho-biological processes such as enzyme production, neuro-transmitter secretion, hormonal intelligence, respiratory capacity and digestive assimilation/elimination, immune power among others. These act rhythmically and in concert with one another to perform complex decision-making regarding the supply of nutrients, filtration of toxins, excretion of wastes and much more.

If these waste materials are insufficiently metabolized, toxins or incompletely processed foods and experiences can become deposited in weak areas of the body. If unaddressed these can become a disease. Weak zones occur in the body due genetic factors or more commonly, lifestyle factors, such as unhealthy food choices, stress, or environmental influences. These toxins or unprocessed metabolic deposits can cloud the normal psycho-biological cellular intelligence.

Panchakarma Therapy of ancient Ayurveda, the world’s oldest holistic health science, is the accumulated experience of millennia to help the accumulated toxins to be expelled, thus supporting metabolic restoration and acuity.

Some benefits of Panchakarma:

• Helps restore metabolic power.

• Eliminates toxins, strengthens tissue functions.

• Helps balance all three doshas.

• Improves mental clarity, awareness, and forgiveness

• Reduces dependence on alcohol, tobacco, and drugs.

• Helps implement healthy diet and lifestyle.

• Reduces stress, improves relaxation & tolerance.

• Slows the ageing process and increases the lifespan.

• Increases the skin’s glow, luster and immunity.

• Boosts body immunity and energy level.

• Improves strength, endurance, energy and vitality.

Panchakarma therapy is both preventative for healthy people to maintain and improve excellent cellular function, and curative for those experiencing disease. It is a highly complex and sophisticated science of purification of the body/mind channel systems and is therefore best supervised/performed by a senior clinician.

The medical scriptures of Ayurveda (yes, it is a spiritual science of the soul’s human experience and not a mechanical approach to health) give the example of a diseased person’s body as a soiled cloth, unable to accurately render the dye colors. To succeed in assimilating the true color (spiritual truth or self-realization), the cloth must first become clean.

Panchakarma science describes the preparatory actions required to cleanse the body before starting a rejuvenation process, when the herbal and mineral medicines can penetrate to the deeper tissues. The detoxification process involves three main stages:

• Purvakarma - preparatory actions performed before the detoxification processes, such as dietary adjustments, pre-oleation and abhyanga (oil massage).

• Panchakarma - the main detoxifying actions, which are five in number (basti, virechan, vaman, rakta moksha, nasya). The practitioner can choose any of these detoxifying methods according to the disease, the current state of the „doshas‟ (humors) and psychological preparedness.

• Rasayana - restorative, rejuvenating measures including diet, supplements and lifestyle choices implemented following the detoxification process.

The Purvakarma steps help soften and oleate the channels and toxins, so the toxins can more easily detach and be eliminated during treatment phase, thus increasing bodily metabolic fire or „agni‟. Later, the whole body is oleated internally and externally with medicated oil or ghee, called „snehan‟.

“Administering small quantities of medicated oil or ghee internally does internal oleation. The physician determines the duration of internal olation and the quantity and type of medicated oil or ghee after analyzing the body constitution of the patient. The patient has to eat liquid food or light food on the day prior to internal olation.

After consuming the medicated oil or ghee the patient is encouraged to sip warm water frequently. When medicated oil or ghee is completely digested, the patient is advised to consume light food”, says Dr. Savitha Suri, experienced panchakarma practitioner.

Following individualized oil massage therapy, the body or body part is exposed to heat through steam bath or other heating methods according to the physician’s choice. This process of exposing body to heat is called as „swedan‟ or sudation (sweating) therapy. Both snehan and swedan help to soften the channels and unclog the toxins. Elimination of toxins becomes easy when channels are soft, and toxins are loose. Utvartana or introduction of dry herbal medicines via the skin may follow.

A strict diet and lifestyle are to be followed throughout these three stages of treatment. During the rejuvenation phase, the digestive power is brought back to normalcy. Medicines are administered to rejuvenate the body or to treat the disease. During the three phases of panchakarma, these restrictions are to be observed:

1. Avoid cold exposure internally and externally.

2. Avoid sex, bad news, loud noise, stress.

3. Avoid daytime sleeping - rest when tired, but don’t sleep.

4. Avoid suppression of natural urges such as sneezing, coughing, flatulence, etc.

5. Avoid being awake at night after 10pm.

6. Avoid indigestible foods; favor foods that balance the doshas.

7. Avoid strenuous exercise (restorative yoga in moderation at a right time is OK)

Some contra-indications for Panchakarma therapy are:

• Menstruation, pregnancy, lactation.

• HIV, AIDS, tuberculosis.

• Morbid obesity, emaciation.

• Hypertension, congestive heart disease, angina.

• Active infection, open lesions.

• Cancer of skin, lungs, testicles, lymph.

• Intense grief.

In these cases, palliation of the dosha precedes panchakarma treatment.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Frailty In Geriatrics

Author by Siniša Franjić*

Abstract

Recently, a condition called senile frailty or fragility has become more common in people over 65 years of age. The condition is also noticeable in people under the age of 65, but it is not so common. Elderly frailty is a slow decrease in the capacity of a number of organ systems. This leads to loss of muscle mass, abnormal functioning of the inflammatory and hormonal system and weakening of energy regulation. Due to the reduced capacity, the organism is no longer able to cope with excessive demands. Once senile frailty is manifested, the organism often decays rapidly. It is a condition that causes concern, above all, in family members.

Keywords: Frailty; Concept; Measurement; Geriatrics; Care

Introduction

Demographic trends show that independently of geographic regions and socioeconomic background, the absolute and relative number of older persons is increasing worldwide [1]. It has been estimated that the prevalence of persons aged 65 years and older worldwide will increase from 7.7% in 2010 to 15.6% in 2050. This trend is evident even among the subpopulation of those aged 80 years and older, which is predicted to more than double in size from 2010 to 2050 (1.6% and 4.1%, respectively).This is not exclusive to more developed countries, because similar trends have even been reported in the least developed regions of the world. The reduction of mortality risk at advanced age is largely the result of scientific advancements and improvement of life conditions. At the same time, as the aging population seeks care, simply extending current practices is threatening the sustainability of the health care system. In particular, current models of care do not sufficiently take into account the new (and still unmet) needs of the changing population. Not surprisingly, a recent alert by the Royal College of Physicians (London) indicated the necessity of “more consultants with skills in acute, general and geriatric medicine to be able to cope with the ageing population.”

One of the major challenges of health care systems is to face the severe burden imposed by disabling conditions of old age. Because disability in the older person has to be considered as an almost irreversible condition, because it is largely caused by lifelong accrual of deficits, attention must be focused on preventing the disabling cascade and on managing people in ways that aim to mitigate, or at least not add to, their level of dependence.

Frailty has long been recognized by practitioners of medicine as a syndrome of late-life, multisystem decline associated with vulnerability to adverse health outcomes, including accelerated mortality [2]. However, until very recently few investigators have attempted to identify its underlying aetiology and how it might interact with chronic diseases such as diabetes. This is in part due to the heterogeneity with which frailty and many complex diseases of late life present. Recently, several investigators have attempted to operationalize and characterize some of the clinical and biological characteristics of frailty. However, weight loss tends to be less predictive of adverse outcomes when inserted into other frailty models, and hence it is a relatively weak predictor. The Studenski model offers utility in that it is all based on objective measurements, but it has not been widely tested in other populations. The Fried model is currently the most widely utilized in both outcomes and biological research; this takes longer to complete because it incorporates two questionnaires, but these two criteria are more subjective. Most emerging definitions related to frailty have focused on the concept of weakness, fatigue, low levels of activity and the accumulation of deficits and incorporate performance measures into the examination.

Frailty generally refers to a state of diminished physiologic reserve rendering the patient more likely to decompensate from minor stressors, to suffer from geriatric syndromes, and to be more vulnerable to disability [3]. However, the term frailty has varying definitions in research and clinical care. A traditional and less specific definition refers to frailty as the result of unrelated chronic disease conditions acquired by an individual, who then crosses a functional tipping point into disability. More recently, frailty has been described as a specific syndrome (sometimes referred to as the frailty syndrome) characterized by sarcopenia (muscle wasting), poor exercise tolerance, slowed motor performance, decreased physical activity, and undernutrition. At the organ system level, the frailty syndrome is characterized by age-associated disregulation of physiologic systems that help to maintain homeostasis, such as pathologic inflammation, impaired immune function, and hormonal imbalances.

Whatever the cause of frailty, patients in this functional state will often develop and present with geriatric syndromes that pose serious risk of further functional decline and death. As such, a strategy of preventing these syndromes or their sequelae is warranted in frail older adults. The etiology of these syndromes is not confined to a single organ system or pathophysiologic process, but rather to multiple causes arising from both medical and non-medical conditions and stressors. Preventive efforts for geriatric syndromes can be primary, as in counseling older adults about accident prevention in the home; secondary, as in screening older adults for gait disorders; or tertiary, as in enrolling a patient with an injurious fall in a comprehensive falls prevention program.

Concept

To better appreciate the heterogeneous health status of the older persons, the frailty concept was introduced in geriatric and gerontology literature about 20 years ago [1]. Frailty is now noncontroversially understood as the concept of increased vulnerability to adverse outcomes among people of the same chronologic age. It is the term used to indicate the geriatric syndrome or state characterized by a reduction of the organism’s homeostatic reserves. The lower capacity of the organism to face entropic forces (coming from endogenous and exogenous sources) exposes an individual to an increased risk of negative health-related events, including falls, hospitalizations, worsening disability, institutionalization, and mortality. In a frail individual, a clinically irrelevant endogenous or exogenous stressor may become the trigger for the initiation of the burdening disabling cascade.

Frailty has been defined by an international consensus of experts as “a multidimensional syndrome characterized by decreased reserve and diminished resistance to stressors.” A widely accepted definition of frailty was provided in Orlando, Florida, by an international consensus group in 2012. It stated that frailty is “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”

However, frailty is not all or none; grades of frailty make a difference. Still, many studies classify people simply as frail or nonfrail. In some settings, such as comparing frailty prevalence in different samples, this can be useful; however, even in this case, important information gets lost. Many clinical decisions require greater precision than a nonfrail-frail status. In addition, frailty is a dynamic process where transitions across states of frailty are common. On average, health tends to decline with age, and the population-based trajectories of frailty are consistent, showing acceleration in deficit accumulation. The frailty index increases, on average, tenfold between 20 and 90 years. Even so, individual trajectories of the frailty index are generally irregular, showing that frailty reflects a stochastic dynamic process. For an individual, most transitions are gradual, and the likelihood to change their frailty level is largely conditioned on their previous frailty level. Therefore, transitioning from a nonfrail state to a severely frail state (and vice versa) is not very common. In individuals, including older adults, frailty levels increase nonmonotonically over time; however, health status can improve, which will result in a transition from a higher to a lower frailty level state.

Biology

Frailty has been described as a phase of acceleration occurring during the aging process due to endogenous and exogenous stimuli [1]. It results from the age-related cumulative declines occurring across multiple physiologic systems. The biology of frailty has its origins in the most intimate roots of the aging process. The parallelism between aging and frailty implicitly leads to the existence of a shared pathophysiologic substrate between the aging process and frailty.

Such hypotheses can easily find support in the growing body of evidence showing that the same pathways indicated as crucial for the aging process (e.g., inflammation, oxidative damage, immune function, telomeres, natural selection) also represent key determinants in the development and maintenance of the frailty phenotypic syndrome. Furthermore, it cannot be ignored that specific innate capacities (e.g., mobility) characteristic of living beings across species (from Drosophila to humans) are strongly correlated with frailty and age-related conditions.

Based on the deficit accumulation approach, frailty arises from the accumulation of microscopic damage (cellular and subcellular deficits) that are not repaired or removed and may reach macro scopic deficits—clinical detectable deficits at the organ and system levels. As organ level deficits accumulate, they may give rise to symptoms or signs, thereby presenting as clinically evident disease. Also, damage in one organ system may predispose to damage in another organ system, showing that deficit accumulation and repair are intertwined. A recent study showed this association between the clinical macroscopic and subclinical microscopic deficit accumulation using a frailty index constructed by routine laboratory data. This supports the notion that frailty that is macroscopically detectable represents the buildup of subcellular, tissue, and organ deficits from damage that is not removed or repaired.

Condition

Frailty (or the biologic age of the individual) is a dynamic and complex condition, largely determined by endogenous and exogenous stressors experienced by individuals during their lifetime [1-3]. Thus, it is also implicitly assumed that age is a continuous variable, and the manifestations of the aging process follow dynamic and continuous patterns during the entire course of the life experience. Every positive or negative stressor experienced during the life course may differently affect health status and determine deviations from the reference status of successful aging. Thus, it is implied that through a careful evaluation of a person’s background and history, the current health status of the person should be assessed not only cross-sectionally, but also longitudinally. This also means that preventive interventions for age-related conditions should not necessarily be applied only to older adults. Age-related conditions can be successfully prevented if the modification of risk factors (e.g., poor socioeconomic conditions, unhealthy lifestyle and behaviors, little access to health care services) also involves younger adults.

In addition, there is strong evidence that exercise prescription is more beneficial than any other individual intervention for the health of frail people. This could be related to the impact of exercise across a variety of systems and its potential effect on intrinsic repair mechanisms. Multicomponent exercise interventions composed of aerobic, strength, and balance training seem to be the best strategy to improve health, treat frailty, and prevent disability in frail older adults. However, the optimal design of the exercise protocol in this population is not clear. An example of the capacity to intervene successfully in the health status of frail older adults by using exercise interventions to prevent negative health-related outcomes has recently been provided by the Lifestyle Interventions and Independence for Elderly (LIFE) trial. This multicenter study recruited 1635 community-dwelling sedentary older persons with physical limitations but able to walk 400 m. Participants were randomized in two groups, an intervention group undergoing a moderate intensity physical activity protocol and a control group receiving a health education program. Results showed that after 2.6 years of intervention, the physical activity protocol significantly reduced the onset of mobility disability compared to the health education program. Interestingly, the LIFE study (as well as secondary analyses conducted on its pilot trial) suggests that individuals with more comorbidities and lower physical performance at baseline are those who obtain most benefit from the physical exercise intervention.

Measurement

In recent years, there has been a surge of interest in frailty in the medical, surgical, and anesthetic literature [4]. In various surgical populations, frailty has been described as an independent risk factor for postoperative morbidity, mortality, prolonged hospitalization, and institutional discharge. Combining a measure of frailty (based on Fried criteria) with other preoperative risk assessment tools (e.g., American Society of Anesthesiologists [ASA] class, Lee index) increases the predictive power relating to postoperative morbidity, length of stay, and institutionalization. Furthermore, frailty is common in older surgical patients, with a quoted prevalence of between 40% and 50% in those undergoing elective surgery. This is in comparison to the cited prevalence of frailty in less than 10% of older communitydwelling individuals (aged 65 to 74 years), suggesting the relative vulnerability of the older surgical population. The cause of frailty is incompletely understood, but is thought to be related to the dysregulation of inflammatory pathways, with several inflammatory cytokines independently associated with frailty, including interleukin-6, tumor necrosis factor-α and chemokine ligand10. Many conditions that are treated surgically (e.g., neoplastic conditions, degenerative or inflammatory arthropathies, arterial pathology) also result in the dysregulation of inflammatory processes. Thus, frail older adults may be more susceptible to developing such diseases or, alternatively, patients with such inflammatory, neoplastic, or vascular-type pathology may be more likely to be frail.

Interpreting the literature examining frailty in surgical patients is hampered by inconsistent definitions of frailty and the use of different tools for measuring frailty. The measurement of frailty will depend on the intention (e.g., screening, case finding, assessment, prognostication), setting (e.g., research, clinical, community, inpatient, outpatient), and clinician (e.g., researcher, allied health care professional, geriatrician). At present, two approaches are generally used—scoring systems based on assessment across multiple domains, which include comorbidity, cognition, function, and psychosocial status (e.g., Edmonton Frail Scale, Canadian Study of Health and Aging [CSHA] Clinical Frailty Scale, Groningen Index) or surrogate single measures, such as grip strength, gait speed, or timed get-up-and-go (TGUG) test. The anesthetic literature tends to focus on the use of surrogate markers. This approach has two potential drawbacks. First the sensitivity and specificity of these surrogate markers in identifying frailty are not yet well established and second, identifying frailty to use it simply as a predictor of outcome may limit the potential to modify the perioperative risk related to frailty. The more detailed multidomain scoring systems may be more useful in this situation to identify individual components of frailty that can be modified using targeted interventions. For example, patients could be assessed using a tool such as the Edmonton Frail Scale to screen for frailty-associated perioperative risk, prompting optimization in the high-risk group using comprehensive geriatric assessment. Such an approach has yet to be evaluated.

Malnutrition

In America, where obesity is an increasing problem, undernutrition and malnutrition are significant problems for the older adult population [5]. Statistics show that a large number of older adults are at risk for malnutrition, whether they are living independently or are institutionalized. Malnutrition is defined as a disorder of nutrition resulting from unbalanced, insufficient, or excessive diet or from impaired absorption, assimilation, or use of food. The risk for developing nutritional deficiencies increases with aging, but determining nutritional status can be challenging. Older adults who appear to be healthy may have unhealthy nutritional practices. An obese older adult may be malnourished, whereas someone thin may be well nourished. Studies have shown that a majority of older Americans believe that nutrition is important for good health but that they do not always follow good nutritional practices. Information from the National Council on Aging Nutritional Assessment Self-Test reveals that older adults have a disproportionately high risk for poor nutrition, which, in turn, has a negative effect on their health. Poorly nourished older adults are more likely to experience functional impairments, fatigue, decreased muscle strength, poor tissue healing, pressure ulcers, and infections. They are likely to develop more postoperative complications, spend a longer time in the hospital, and are at increased risk for death.

Estimates of the number of malnourished older adults vary depending on the screening tool used, but generally fall within the following ranges:

• Older adults in the community: 45%

• Older adults cared for at home: 45% to 51%

• Hospitalized older adults: 54% to 82%

• Older adults in residential care facilities: 84% to 100%

These data reveal the magnitude of the problem that needs to be addressed by health care providers and demonstrate greater malnutrition as one becomes more frail and dependent on others.

Symptoms of nutritional problems include unintentional weight loss, lightheadedness, disorientation, lethargy, and loss of appetite. Similar symptoms occur with a variety of illnesses, making it difficult to determine whether the primary problem is medical or nutritional in origin. Weight loss is one of the signs of frailty syndrome in older adults, a syndrome characterized by increased susceptibility to stressors that can lead to negative health outcomes and functional impairment. The associated nursing diagnosis Frail Elderly Syndrome can be used to address this complex problem. Nurses working in all health care settings must assess, plan, and implement strategies to maintain or improve the nutritional status of the older adults in their care.

CGA

CGA (comprehensive geriatric assessment) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail elderly person in order to develop a coordinated and integrated plan for treatment and long-term followup [6]. While integrating standard medical diagnostic evaluation, CGA emphasizes quality of life, functional status, prognosis, and outcome that require a workup of more depth and breadth. The hallmarks of CGA are the employment of interdisciplinary teams and the use of any number of standardized instruments to evaluate aspects of patient functioning, impairments, and social supports.

Currently, the CGA is performed in a large number of institutional and community settings. CGA plays a very important role in services such as hospital geriatric units, primary care units (as a standard medical evaluation), and also in community-based services such as programs that provide comprehensive care for frail and disabled elderly patients. The short form of the CGA is known as the Multidimensional Geriatric Assessment. This abbreviated screening approach is performed by community health professionals to help decide when a referral is needed to geriatric specialty programs for a more comprehensive evaluation and management. In patients with cancer, CGA was shown to improve emotional limitation, mental health, and bodily pain. Performing the CGA did not affect length of hospitalization or overall hospital costs. This evaluation was easily administered in an abbreviated form in the outpatient setting and was effective in identifying cognitive and functional deficits in cancer patients.

The focus of a more extensive CGA is on the elderly who are frail (i.e., at risk of loss of homeostasis and incident disability), disabled, or both. Frailty is a clinically recognized syndrome that is common in older adults. Using recently developed criteria, the prevalence of marked frailty is less than 10% in community-dwelling adults 65 years and older, with high risk of mortality over 3 and 7 years.

From its inception, geriatric medicine has recognized that frail and disabled older adults are at the highest risk for adverse outcomes and are also most likely to benefit from geriatric care. Subsequent health services and clinical research has sought to define the healthcare delivery modalities as well as specific interventions that would mitigate or even prevent frailty and its outcomes. The CGA has been central to this approach and has the objectives of improving diagnostic accuracy, optimizing medical treatment and health outcomes, improving function and quality of life, extending community tenure, reducing use of unnecessary formal services, and instituting or improving long-term care management.

PCMH

The vast changes occurring in medicine today are most prominent in ambulatory care [7]. With the Patient Protection and Affordable Care Act passed in 2010, and growing urgency to curtail the rising costs of health care, ambulatory care has seen rapid changes to practice. The patient-centered medical home (PCMH) is one of the most widely adopted models of ambulatory health care that has been disseminated across the United States in recent years. The Centers for Medicare and Medicaid Services and the Veterans Affairs (VA), have both been implementing PCMH models at community health centers and VA medical centers around the country; private insurers and health plans are also redesigning their practices into PCMH models.

Why is PCMH being so strongly promoted as the ideal model of ambulatory care? PCMH is an approach to providing comprehensive, cost-effective primary care for patients of all ages. It aims to improve the delivery and experience of care for patients and clinicians through team-based coordinated care rather than the more ubiquitous fragmented health care norm that most patients have experienced for decades. Geriatric medicine is particularly well-suited to the PCMH approach to care because the principles of geriatrics ambulatory care (such as strong patient–provider relationships that recognize the role of family and caregivers, interprofessional team-based care, and continuous care throughout life stages and health care settings) are aligned with PCMH principles. Additionally, geriatrics-trained providers have specific skills that apply to many of the processes that comprise PCMH care.

Continuous and comprehensive care carries significantly more weight for older patient populations than younger populations. Older adults have more chronic illnesses than younger adults, and are more likely to transition through multiple care settings and services (hospital and nursing home care, home health and hospice services, in addition to ambulatory clinic-based care). Geriatrics clinicians are uniquely trained in the care of patients in all of these care settings. With the increasing frailty that often accompanies aging with chronic conditions, older adults benefit from personal relationships with primary care providers who understand and can lead team care across the spectrum of settings, from enrollment in the primary care clinic through end-of-life stages. Providing coordinated transitional care, home-based, and palliative care are hallmarks of geriatrics ambulatory care which align with PCMH’s principle for continuous and comprehensive care.

Long-term Care

The term long-term care conjures up many images; few of them are felicitous [8]. This reaction may represent a profound psychological defense against death, to be sure, but its immediate effect is to place long-term care center stage in an unfavorable light. The images of long-term care are images of frailty and despair, loneliness and destitution, and above all a profound sense of loss, a loss not only of things, but of who and what we are. These attitudes undoubtedly reflect society’s perceptions of the institutions that are often thought to be the main providers of long-term care, namely, nursing homes. Anthropologists and sociologists regard nursing homes as anything but humane. They are frequently seen as places of exploitation (of staff as well as of residents). They stimulate either moral outrage or revulsion. These reactions are shaped by latent image: a blabbering, incoherent, disheveled elder strapped into a gerichair, withdrawn or beckoning for attention, but invariably ignored by staff who, without emotion, expression, or enthusiasm, perfunctorily perform the onerous tasks of daily bed and body work that are made even more difficult by the niggling demands of residents. The image is coupled with the olfactory assault of urine, excrement, and myriad other unpleasant odors that suffuse drab corridors or insipid sitting rooms where residents sit transfixed, each in his or her own world. There are also disturbing sounds of people moaning from down the hall, crying out, one elder scolding another harshly, others weeping in protest. Long-term care seems suffused with a terrifying absence, the absence of a meaningful sense of control, dignity, or identity. It is an appalling state of living death, somewhere just this side of madness.

Conclusion

Chronic frailty can occur after a certain acute illness or as an end stage of a chronic condition, such as atherosclerosis, infection, cancer, and depression. Elderly frailty takes place in several stages. In the first stage, called pre-weakness, the person has less than three characteristic signs of senile frailty. There is a possibility of developing senile frailty in full form and decay, placement in a specialized institution or death. Yet, the likelihood of some of this happening is much higher in people with developed senile frailty syndrome. In the final stage, weakness progresses, which includes functional decline, progressive apathy, decreased appetite, and death.

Acknowledgement

None.

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Iris Publishers - Journal of Archives of Clinical Case Studies-New Emerging Fields in Palliative Care

Auhtor by  Vinod kumar Gangolli

Abstract

Palliative care is a crucial part of integrated, people-centered health services. Relieving serious health-related suffering, be it physical, psychological, social, or spiritual, is a global ethical responsibility. Thus, whether the cause of suffering is cardiovascular disease, cancer, major organ failure, drug-resistant tuberculosis, severe burns, end-stage chronic illness, acute trauma, extreme birth prematurity or extreme frailty of old age, palliative care may be needed and has to be available at all levels of care [1,2].

Introduction

Palliative care is a crucial part of integrated, people-centered health services. Relieving serious health-related suffering, be it physical, psychological, social, or spiritual, is a global ethical responsibility. Thus, whether the cause of suffering is cardiovascular disease, cancer, major organ failure, drug-resistant tuberculosis, severe burns, end-stage chronic illness, acute trauma, extreme birth prematurity or extreme frailty of old age, palliative care may be needed and has to be available at all levels of care [1,2].

The World Health Organization defines palliative care as an approach which improves the quality of life of patients and their families facing life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems [1,2].

While palliative care has historically been associated with cancer and therefore, over the decades evolved to cater to the needs of cancer patients and their families, there is growing body of international evidence and literature advocating the need for palliative care for non-cancer conditions like dementia, stroke, cardiac failure, chronic hepatic failure, chronic kidney disease and other chronic life limiting conditions associated with distressing symptoms and caregiver burden. Sandra McKinnon describes her experience of what happens to people dying of non-cancer diagnosis and states in her article that even though the illness may eventually lead to death, people will live, on average, much longer with any medical diagnosis other than cancer [3].She justifies the need of palliative care services for non-cancer patients stating that each of these illnesses is characterized by exacerbations and remissions with an eventual terminal phase requiring support for patients and families. The support required by people dying from any of the medical conditions is not different from the support needed by someone dying from cancer [3]. In a review of 14 studies Luddington L et al also summarized that some patients dying of non-cancer conditions have needs comparable with those dying of cancer [4].

In 2010, the major contributions to diseases requiring palliative care in India were from non-communicable diseases that accounted for 53% of all deaths. Among them, cancers constituted only 6%, whereas cardiovascular diseases contributed to 24% followed by respiratory diseases (11%), injuries (10%) and diabetes (2%) [5]. The right to a pain free and dignified life cannot be denied to people suffering from conditions considered less serious than cancer. Especially when the numbers of such chronic noncommunicable diseases are on an increasing trend in India. Nearly 3.6 crore cases of coronary heart disease and 3.1 crore cases of diabetes was estimated for the year 2005 and was expected to have risen to nearly 6.1 crore and 4.6 crore cases respectively in 2015. Hypertension prevalence among adults ≥ 20 years was 159.46 per thousand. In addition to these non-communicable diseases, wide availability of anti-retro viral therapy has made HIV to be a chronic condition requiring palliative care; around 2.7 million people are living with HIV and about 1.89 million suffer from pain requiring palliative care [6].The need for palliative care is further increased in India because of rising life expectancy and increasing proportion of elderly in the population [6].It is known that only less than 2% of those who need it have access to any type of palliative care in India [7] given that the total number who need palliative care is estimated to be 6 million people a year [8].

The guiding principles as rightly suggested by the Expert Group for the Proposal of Strategies for Palliative Care in India is to deliver palliative care at all levels of the health delivery systems, from primary to tertiary levels [6].The Global Atlas has described Palliative care to be provided at three different levels: i) through a ‘palliative care approach’ adopted by all healthcare professionals, provided they are educated and skilled through appropriate training ii) ‘general palliative care’ provided by primary care professionals and those treating patients with life-threatening diseases, with a good basic knowledge of palliative care, and iii) ‘specialist palliative care’ provided by specialized teams for patients with complex problems [9].

To improve the scenario and for successfully implementing the first of the three strategies given by Global Atlas i.e., ‘palliative care approach’ for all healthcare professionals, all doctors and nurses have to be trained in skills of delivering palliative care services. If such training is given, the second strategy of ‘general palliative care’ can also happen. This can happen only when it is introduced as a must-know area into the graduate curriculum for medical and nursing courses. In the Proposal of Strategies for Palliative Care in India, the recommendations for tertiary care centers focus on providing palliative care to mainly cancer patients in the Tertiary Cancer Centers (TCC) Scheme [3]. But tertiary care centers can be a good point of access to all non-cancer patients requiring palliative care and if the treating physicians and nurses are oriented and skilled to provide palliative care, the outcomes of treatment can improve. The care can be part of the continuum that the patients would receive also in the community. So, when planning for the palliative care services in the country through integration into the public health, the oft neglected non-cancer diseases should remain in focus of our policy makers and the large network of tertiary hospitals should also be in the service delivery of palliative care.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Gitelman Syndrome in Maternity Ward an Uncommon Entity

Author by S. Chhabra

Abstract

Gitelman syndrome (GS), familial hypokalaemia -hypomagnesemia, is an autosomal recessive salt-losing renal tubulopathy that is characterised by hypomagnesemia, hypocalciuric and secondary aldosteronism, which is responsible hypokalaemia and metabolic alkalosis. The prevalence is estimated at 25 million [1].

In the majority of cases, symptoms do not appear before the age of six years and the disease is usually diagnosed during adolescence or adulthood. Transient periods of muscle weakness and tetany, sometimes accompanied by abdominal pain, vomiting and fever are often seen in GS patients. Paraesthesia, especially in the face, frequently occur. Chondrocalcinosis can be present in some patient.

GS is transmitted as an autosomal recessive trait. Mutations in the solute carrier family12, member 3 gene, SLC12A3, which encodes the thiazide sensitive NaCl cotransporter (NCC)is present. At present, more than 140 different NCC mutations exist. mutations in the CLCNKB gene, encoding the chloride channel ClC-Kb have been identified [2].

Diagnosis is based on the clinical symptoms and biochemical abnormalities (hypokalaemia, metabolic alkalosis, hypomagnesemia and hypercalciuria) [3].

Reaching to diagnosis was difficult, as it was not thought but was due to persistent hypokalaemia in patient, further analysis was done, then Gitelman Syndrome was diagnosed.

Keywords:Gitelman Syndrome, hypokalaemia, hypocalciuria,hypomagnesemia

Case Summary

21 years old primi gravida admitted at around 34weeks with severe anaemia with gestational hypertension. Antihypertensive were started and blood transfusion was given. In spite of giving antihypertensive, blood pressure was not controlled. Her renal function was progressively deteriorating. So, emergency caesarean section was done under spinal analgesia. There were no Intraoperative problem and female child was born. Baby was taken into neonatal intensive care unit in view of low birth weight and preterm birth. Post operatively anti hypertensives were given.

Her hypokalaemia persisted in spite of potassium supplements. On day11 post caesarean section, pt. developed tingling sensation & weakness in both distal extremities of lower limb and upper limb and positive Trousseau sign was present, suggestive of tetany. On work up she had hypocalcaemia, hypokalaemia, hypocalciuric, hypophosphatemia and electrocardiogram were suggestive of hypokalaemia changes and metabolic alkalosis. Based on association of hypokalaemia, hypomagnesemia, hypophosphatemia, hypocalciuric and metabolic alkalosis the diagnosis of Gitelman Syndrome was established.

Comments

GS is often not diagnosed until late childhood or even adulthood. Clinical manifestations are similar to the prolonged administration of thiazide diuretics like of a salt-losing renal tubulopathy that causes hypokalaemia and metabolic alkalosis [4,5]. To sum up, pregnancy with Gitelman syndrome presents with challenges of electrolyte imbalance, which may require a multidisciplinary approach with obstetricians, endocrinologists, anaesthetists, neonatologists and geneticists for good obstetric and neonatal outcomes.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Wishing You A Happy Thanksgiving Day!!!

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Iris Publishers - Journal of Archives of Clinical Case Studies-The Resurgence of Mucormycosis in the Covid-19 Era – A Review

Author by Kratika Mishra

Abstract

Mucormycosis (MCM) is a life-threatening infection that carries high mortality rates with devastating disease symptoms and diverse clinical manifestations. This article briefly explains clinical manifestations and risk factors and focuses on putative virulence traits associated with mucormycosis, mainly in the group of diabetic ketoacidotic patients, immunocompromised patients. The diagnosis requires the combination of various clinical data and the isolation in culture of the fungus from clinical samples. Treatment of mucormycosis requires a rapid diagnosis, correction of predisposing factors, surgical resection, debridement and appropriate antifungal therapy. The overall rate of mortality of mucormycosis is approximately 40%.

Keywords:Amphotericin B, emerging, Mucorales, mucormycosis, zygomycetes

Introduction

Mucormycosis is defined as an opportunistic infection, affecting patients with diabetes mellitus (DM), neutropenia, malignancy, chronic renal failure, and acquired immunodeficiency syndrome and those who have received organ or hematopoietic stem cell transplants, it can affect immunocompetent hosts as well (such as trauma patients) [1,2]. It is third invasive mycosis after candidiasis and aspergillosis which is caused by several species of different genera [3] (Table 1).Table 1: Classification of the aetiological agents responsible for mucormycosis.

This mucormycosis infection is caused by Mucorales. Zygomycetes is the class that is divided into two orders i.e., mucorales and entomophthorales. Mucormycosis is a fulminant disease with high rates of mortality and morbidity that mainly affects the immunocompromised patients.

This disease is characterised by host tissue infarction and necrosis. Tissue necrosis due to blood vessels invasion and subsequent thrombosis are the hallmarks of invasive mucormycosis. In a French study, mucormycosis incidence increased by 7.3% per year in neutopenic patients [4].

Routes of Transmission

The most common route of transmission is inhalation of spongiosprores. Other routes are direct implantation into injured skin like burns, intra-venous drugs administration, exposure or trauma with contaminated soil. It is rapid progressive disease extending into neighbouring tissues, including orbit and brain involvement in more severe cases.

Classification of Mucormycosis is based on the involvement of anatomic sites of infection reflecting in part the portals of their entrance in the humans. The spores enter through different routes of transmission the disease may present as rhino-orbitalcerebral, pulmonary, cutaneous, subcutaneous, gastrointestinal and disseminated form [5,6].

Discussion

The mortality rate of mucormycosis is approximately 40%, but this rate depends on the clinical presentation of the disease, the underlying disease, surgery, and the extent of the infection [7,8,9,10].

Mucormycosis occurs in patients with diabetes mellitus and ketoacidosis, haematological malignancies [11,12,13,14] like neutropenia [12,15] or graft vs. host disease, in solid-organ transplant patients [11,19,20,18–33] and in patients receiving high doses of corticosteroids [34].It is infrequent in immunocompetent patients like those patients that are without any risk factors,HIVinfected patients and patients with solid organ tumors [35,36].

Mucormycosis most commonly occurs in the sinuses (39%), lungs (24%), skin (19%), brain (9%), and gastrointestinal tract (7%), in the form of disseminated disease (6%), and in other sites (6%) [37]. With the exception of rhino-cerebral and cutaneous mucormycosis, the clinical diagnosis of mucormycosis is difficult, and is often made at a late stage of the disease or post-mortem [38].

Diagnosis includes tests using cultures of clinical samples, sputum analysis, histopathological testing and it requires the combination of various clinical data and the isolation in culture of the fungus from clinical samples. Other techniques involve computed tomography scans, magnetic resonance imaging. Magnetic resonance imaging is technique of choice when intracranial structures are affected. Molecular biology advances would greatly improve diagnosis in such deadly disease.

Treatment depends on early diagnosis, correction of predisposing factors, anti fungal therapy, surgical debridement and resection. Patients with diabetic ketoacidosis should be addressed and suppression of corticosteroids should be done. The best treatment of mucormycosis is rapid and complete surgery. Surgery combined with use of antifungal therapy is best choice of treatment [39,40,41]. Current studies suggest that point to high dose liposomal amphotericin B has shown variable activity in vitro against agents responsible for mucormycosis. Other drugs of choice includes itraconazole, voriconazole, posaconaazole, ravuconazole [42]. Other therapeutic alternatives include cytokines such as gamma interferons or granulocyte-macrophage colony stimulating factors for treatment of mucormycosis [43,44].

Conclusion

This life-threatening fungal infection is characterised by host tissue infarction and necrosis that occurs in immunocompromised patients with high rates of mortality. Further studies are required to analyse and better optimise induction and consolidation treatment. The clinical outcomes of patients with mucormycosis are poor especially in patients with uncontrolled diabetes and age is negative prognostic factors.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Cranial Electrotherapy Stimulation as A Treatment with Three Violent Jail Inmates and One Violent Tourette’s Subject

Author by Ronald R Mellen

Abstract

The present article reviews three previously published single case studies of violent jail inmates and one violent Tourette’s subject. The treatment utilized a cranial electrotherapy stimulation device (Alpha-Stim) to reduce violent behaviors and clinical symptoms in the four subjects. The studies were completed between 2009 and 2018. In each of the inmates studied, positive changes in clinical measures and reductions in aggressive behaviors were found. In the Tourette’s subject improvements were also noted through self-assessments of clinical issues and tics. Important changes were also noted in improvements in daily life activities.

Keywords:Clinical; Detention; Electrotherapy

Introduction

There are multiple types of aggressive inmates including the predatorial, and those whose violent behaviors are responses to environmental cues. A third group are those suffering with neurodevelopmental disorders (NDD) such as individuals experiencing advanced stage Tourette’s.

The three inmates in the reviewed studies were recommended by either the County Sheriff or the Director of the Jail/Detention Center. The principal investigator’s request, each time, was for the most physically violent inmate in custody. One of the most common descriptors of the recommended inmates was “He is always involved in every fight.” The NDD subject was referred by his wife.

Treatment

The treatment variable, the Alpha-Stim SCS, was the same for each of the inmate/subjects. It is a handheld device that uses a 9 V battery to produce a proprietary electric current. The device uses clips that attach to the earlobes. It is simple to use, yet frequently produces significant positive changes in the behaviors of inmates. It accomplishes this by encouraging the brain to produce higher levels of the neurotransmitter serotonin. The increased serotonin leads to a calming on the inmate’s brain functioning and reduces the frequency of their engaging in violent behavior. The treatment also reduces cholinergic activity in the thalamo-cortical circuit (anxiety & stress). Increasing serotonin levels and, at the same time, reducing cholinergic activity in the inmate’s brain produces a brainmodulation effect which also increases positive decision-making. There are over 100 published studies Kirsh [1] that successfully used the Alpha-Stim as its treatment for psychological dysfunctions & pain management.

Methodology

The four single case studies all followed the same basic research design. Each study used the Alpha-Stim as the treatment variable. The dependent variables were administered pre- and post-treatments to assess possible effects of the Alpha-Stim. The dependent variables measured changes in personality traits, clinical symptoms, and executive functioning. Self-Assessments & assessments-by-others were sometimes completed. In one study qEEG readings were taken pre-and post-treatment. INMATE RR [2] RR’s demographics are presented below in greater detail than the other inmates since all were found to have personal histories reflecting significant difficult family & early life experiences. The Tourette’s subject had a positive personal history.

The subject, RR, was a 19-year-old Caucasian of average height and weight with no physical or apparent cognitive disabilities. He reported never having been married but that he had a 14-monthold daughter who lived overseas. The subject’s family was composed of biological parents, two stepparents, two sisters and two stepsisters. His ordinal position was third. During his childhood he lived with his mother and step-father. He described his mother as an intermittent recovering alcoholic and his stepfather as a chronic marijuana abuser. His biological father had a history of methamphetamine abuse and had at least one criminal conviction. The inmate reported an extensive history of fistfights with his biological father. RR described his childhood as unhappy, painful, hard to remember, and that he, himself, was active, aggressive, irresponsible, rebellious, and stubborn. He had problems getting along with others and experienced frequent nightmares. He also reported an intense fear of failure and a fear of falling that began in childhood.

When he was 13 years old, while living in Chicago, Illinois, he was brutally initiated into a gang. He was sentenced to boot camp for gang activity but was kicked out of the camp for fighting and he eventually went AWOL. He fought on the streets especially where drugs were involved. His nose has been broken twice and he stated that he has had “more black-eyes than he can count”. A history of head trauma can be important in understanding the behaviors of many violent inmates. Subject RR reported two serious instances of head trauma. The first was at the age of four years when the horse kicked him in the head. The injury required 48 stitches to the left eyebrow area. The injured area was near the orbitofrontal cortex, which is involved with controlling emotions. The second injury to the head also required many stitches. This injury occurred when he was 17 years old and a passenger in a serious car wreck.

While his drug history included marijuana, cocaine, pills, opiates, and barbiturates, he began using crack cocaine and methamphetamines at the age of 17 years. Most recently he was using meth intravenously. At the time this research was carried out inmate RR had been court ordered to complete the detention center’s Substance Abuse Treatment Program. If he failed to complete the program, he was court-ordered to be sent immediately to the state prison system. If he successfully completed the program, he would be sent home.

The Director of the Detention Center related RR’s experiences in the treatment program prior to starting the Alpha-Stim treatment. He noted that in this program inmates resided in pods with a population of 8 to10 inmates. During the first week RR was involved in a physical altercation. As a result, he was assigned to Administrative Segregation (Ad Seg) for 40 days in order “to think things over.” Upon release he was involved in a second fight and received 40 additional days in Ad Seg. He was again released from Ad Seg at which time he attacked a jail security officer and threatened the officer’s wife. The director liked the young inmate, but the sequence of events had exhausted his patience with RR. The director told the inmate that this would be his last Ad Seg. If he engaged in any aggressive behavior, he would be sent immediately to state prison. The inmate stated he did not care if he went to prison, and the prognosis was extremely poor indeed. Inmate RR volunteered for the Alpha-Stim treatment which began immediately upon his being was released from Ad Seg.

Treatment Program

The inmate completed 15 treatments with the Alpha-Stim each lasting 40 minutes. All treatments were completed within a 45- day treatment period. The daily treatment amperage, which was chosen by the inmate based on comfort with the device, ranged between 300 and 400 uA. The dependent variables included the 16 Personality Factors Inventory and personal self-assessments by the inmate as well as behavioral assessments by the Substance Abuse Program leader.

Results

Post treatment results from the 16 Personality Factors Inventory indicated support for the following changes: increases in warmth, emotional stability, spontaneity, social boldness, openness to change, affiliativeness, and self-discipline. Decreases were observed in threat sensitivity, tension, and apprehensiveness.

A weekly assessment of the inmate was completed by the substance abuse program leader who noted that prior to the third treatment session the inmate stated he felt “more natural”, rather than feeling agitated. He was found to share his thoughts with other members in his pod. On the fourth day of treatment, he reported increase ability to concentrate while on the fifth day he reported he felt less negative toward other people. In summary the inmate was found to show improvement in his ability to address issues with Pod family members.

On the eighth day of treatment the subject volunteered to be a part of a new inmate suicide watch. The program staff saw a sufficient number of positive changes in the subject that the Director of the Detention Center promoted RR to pod leader. RR’s self-assessment provided measures on the following issues: anger, anger control, calmness, anxiety, coping skills, and patience. The range was from a score of one which indicated serious trouble with the issue being addressed to a score of 10 which indicated no trouble with that issue. His beginning daily mean was 3.6 and his average at the completion of treatment was 7.1 INMATE DH [3].

The subject was a 31-year-old male Caucasian with a long history of drug use, as well as aggressive and violent behavior. His current charge was attempted capital murder of a deputy sheriff. His father died of a heroin overdose at the age of 36 years and his mother died in a motorcycle accident. The inmate stated his jail incarcerations were too numerous to count.

Methodology

The treatment variable was the Alpha-Stim. The dependent variables were the BRIEF-A (executive functioning), the Brief Symptom Inventory (clinical symptoms), the 16 PF (personality factors), and the Mini-Q EEG (a measure of electrical activity in the brain). Inmate DH received 12 treatment sessions with the Alpha- Stim over 20 days. Each session lasted 45 minutes. The Mini-Q EEG along with the other dependent measures were administered in the traditional pre-post treatment paradigm.

Findings

The calming effects of the Alpha-Stim treatment were apparent in the qEEG readings. As expected, there was a positive global modulation effect is demonstrated by the following bandwidths readings: Delta dropped 40%, Theta was reduced by 25%, Alpha was reduced by 17% and beta dropped 12%. The BRIEF-A results showed reductions from the clinical range to normal functioning in four domains related to executive functioning: ability to selfinhibit, increased cognitive flexibility, ability to control emotions and ability to self monitor. DH’s scores on the16PF show positive changes with reductions in tension, vigilance and his need for privateness. His results also indicated a willingness to trust others. His scores included an increase in liveliness, emotional stability, and social boldness. The inmate’s Brief Symptom Inventory’s nine clinical measures were initially all in the extreme negative range (64-80). Under normal circumstances two scores in the clinical range would call for a full psychological assessment. DH’s scores suggested serious emotional and cortical difficulties.

However the post-treatment results showed eight of his clinical scores were now within the normal range: insomnia went from 78 down to 50; obsessive-compulsive 74 to 50; depression 80 to 50; anxiety 80 to 54; hostility 80 to 52; phobia 74 to 50; paranoia 76 to 63; psychesthenia 80 to 58.DH’s post-treatment debriefing remarks included” my legs don’t bounce up and down all the time like they used to”, “I’m less agitated,” “even though my brain used to be more active, I now get more things accomplished.”

Five years after completing the Alpha-Stim treatment the principal investigator received the following missive from inmate DH. This was a spontaneous communication from the inmate and had not been solicited by the Principal Investigator.

Dr. Mellen. Don’t know if you’ll remember me but I participated in a research study between 2006-11. I have the exact date if you need. It was at the AA County Detention Center while I was in the substance abuse prevention program. Dr. BB offered me that opportunity and many more.

The reason I wanted to email you was for you to see the aftereffects. When I look back it seems surreal. Here is a link to an article that portrays me then. And now things are drastically different. I can be found 5 years almost to the day later in a positive light from the same newspaper. Since my release I have sole legal and physical custody of my 9 year old daughter, have a daughter turning 1 in May, married to a wonderful woman who has started an organization to help people suffering, I am the compliance officer at a court ordered non profit, I work full time as an optician at a practice where all my talents and abilities are utilized ( I am able to manage the optical department, develop the web presence, administer the network, service the high tech optical equipment, plus much more. As well I am the resident maintenance technician at a very nice apartment complex. And in my spare time I like to Garden

My wife is holding a 4.0 at University of North Alabama with a major in psychology and minor in criminal justice. So, she is obviously interested in what happened. But to tell you the truth I don’t even know. All I know is that sometimes I look back and it is amazing. You can find me on facebook, linkedin, and google plus. Additionally, my contact information should be at the bottom of the page. Thank you for your time Inmate DT [4]. The volunteer subject was a 22-year-old Caucasian male who has never married. He had a serious drug problem and frequently engaged in violent behavior which had contributed to his frequent encounters with law enforcement. He also stated he has lost count of how many times he had been in jail. However, he was proud of the fact that he only been to prison once. When asked about his important life goals he stated he wanted to have a family, get his GED and the college education. The things he wanted to change the most were his habits which included smoking, drug and alcohol abuse but most of all he wanted to stay out of jail. The present subject was chosen because of an extensive history of aggressive and violent behavior which continued while retained in the county jail. It was noted the by the jail security staff that he was a participant in every fight that occurred in the jail.

Independent variable: the independent variable was the same in this study as in the above reviewed studies: The Alpha-Stim.

The dependent variables were:

*Brief Symptom Inventory: A measure of nine clinical symptoms and three general levels of stress.

*BRIEF-A: A measure of frontal lobe executive functioning.

*Trauma Symptom Checklist

* Emotion Identification Scale

*Inmate self-assessment, daily

Treatment Application

The final decision on the micro-amp range was chosen by the inmate and based on the subject’s comfort level. The treatment was administered by two students, one a college undergraduate and the other an ABD psychology/neurology student. The student assistants were supervised by the Principal Investigator. The treatment sessions were applied in an observation room at the jail. The safety of the inmate and research staff was provided by jail security staff. The inmate received 10 Alpha-Stim treatments which lasted 40 minutes each. The inmate was cooperative during prepost assessment sessions and the treatment sessions.

Results

posttreatment changes in the dependent variables were examined for main effects. DT’s results showed positive changes in four of the BSI’s Clinical Scales: Reduced Somatization (bodily complaints), Obsessive-Compulsive thinking, reduced Depression and Hostility. His results also showed improved Interpersonal- Sensitivity,

On his BRIEF-A the inmate showed significant improvement in his ability to inhibit his behaviors, his ability to shift his thinking (flexibility in thinking), and working memory, His Emotion Identification Scale was seven out of 10. Most individuals score 10 out of 10 while inmates tend to score between five and seven.

DT’s scores on the Trauma Symptom Checklist fell within the normal range and on the suicide assessment he showed no evidence of suicidal thoughts. The jail security officers overall assessment of the inmate stated he was a person who had experienced positive changes and no longer created trouble in the jail. There was one behavioral anecdote. The day before the inmate was to be released a fight broke out and instead of joining in the altercation, his usual behavior, the subject stopped the fight by stepping between the three inmates in the fight and said, “Come on fellows and don’t hurt this old man”. The jail security staffs, and fellow inmates were shocked by this change his behavior.

Such improvements in psychological functioning and general cooperation, when combined with the anecdotal evidence of stopping fights rather than engaging in them strongly suggests that this device can sometimes make the daily job experience for jail security officers and inmates safer.

A Violent Tourette’s Subject

The subject was a 21-year-old Caucasian male. His Tourette’s symptoms began in childhood and in the seventh grade he had to shift to home schooling due to harassment from students and some staff. He did graduate with his GED [5]. Prior to beginning the Alpha-Stim treatment his symptoms had proven refractory to psychological, pharmacological and behavior treatments. He had difficulty going out in public, such as to the grocery store, and applying for jobs. His job history was one of strictly menial work.

Experimental Design

The subject was allowed to choose the uA level and frequency of application during the programmed 10-day treatment period. He completed eight 20-minute sessions the first day of treatment and set the uA current level at 300uA, however he quickly moved to the top level of 500uA which he used for all remaining treatments. The subject, with the Principal Investigator’s permission, continued for an additional 10 days of treatment (days 11-20).

His daily Self-Assessment Scale ratings addressed the following: Tics, General Anxiety, Social Anxiety, Depression, Insomnia, Pain, Anger, Nicotine Dependence & Alcohol Dependence. The lower the scores the greater the pain and discomfort for the subject. Conversely higher scores indicated reductions in pain and discomfort with the scores ranging from 0 to 10. A rating of 10 meant the subject was symptom-free. The subject did not have access to his earlier assessments as he filled out his current daily self-assessment form.

Self-Assessment

The following are the subject’s mean scores on assessed symptoms. These ratings are for Pretreatment Day and days 10 and 20. Anecdotal notes: The subject’s wife reported that he continues to use the Alpha-Stim device once a day, twice a week. She also provided quotes from the client that he repeated frequently as treatments progressed. These included “I don’t hate anything anymore. except Communists”, “I feel like a completely new me”, “Life changing.” Finally, she reported that after four months of treatment he was employed as an aircraft serviceman and that he has plans to become an A&P mechanic.

Summary

While the above summaries are from single case studies treatments using a cranial electrotherapy stimulation device (Alpha-Stim) produced significant change in the emotions and behaviors in the three inmates and one violent NDD subject.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Cardiotoxicity: An Unusual Case of Methotrexate Overdose

Author by R Nhiri,

Abstract

The methotrexate (MTX) is an antimetabolite, whose dosages vary according to indication. It is used in the treatment of tumoral pathologies, as acute lymphoblastic leukaemias and in rheumatology, in the rheumatoid polyarthritis (RP) and other chronic inflammatory rheumatisms. The methotrexate belongs to the group of antifolates: it inhibits purine and pyrimidine synthesis, which accounts for its efficacy in the therapy of cancer as well as for some of its toxicities. Relative or absolute overdoses in low-dose methotrexate treatments for non-oncological diseases are regularly reported, either in isolated cases or in small series. The bone marrow toxicity with thrombocytopenia and leuconeutropenia is most often the first sign of general involvement. The cardiotoxicity of methotrexate is very rare, in this article we report the observation of pancytopenia associated with cardiotoxicity in a woman treated for RA, for whom the etiological investigation revealed inadvertent methotrexate intoxication by mistake of dosage.

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Iris Publishers - Open Acces Journal of Archives of Clinical Case Studies-Is High Intensity Exercise Safe for the Chronic Thoracic Aortic Dissection Patient?

Author by Donald C DeFabio,

Abstract

Exercise parameters for the chronic aortic dissection patient are broad and research detailing specific exercise protocols is limited. Nevertheless, for clinicians interested in designing a tailored exercise routine for physically active patients, the available literature on physical rehabilitation for patients with chronic aortic disease may be referenced. Moreover, it is of upmost importance that when developing an exercise program that a patient’s particular cardiovascular pathology, including the distribution of the lesion, along with an understanding of hemodynamic principles, relative to the aorta, be respected. With these concepts applied, patients may safely return to recreational sport through the guidance of a thoughtful, clinically based, individualized exercise program.

Keywords: Chronic aortic dissection; Cardiovascular exercise; Physical rehabilitation

Abbreviations: Newborn; Gastric ulcers; Gastroduodenal ulcers; Digestive bleeding; Endoscopy Stanford Type A Dissection: TAD; Stanford Type B Dissection: TBD; Abdominal Aortic Aneurysm: AAA; Relative Perceived Exertion: RPE; High Intensity Training: HIT.

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Iris Publishers - Journal of Archives of Clinical Case Studies-Allergic Reactions Associated with Ingestion of Protein Supplements

Author by  Andrew Rorie 

Abstract

IgE-mediated food allergy is a significant public health concern of which there is growing evidence the prevalence is increasing [1]. We present a case series of new-onset food allergy associated with ingestion of supplemental cow’s milk protein products. Discussion Patient #1 was 34-year-old male without history of food allergy. He drank an EAS whey protein shake and within 75 minutes he developed facial angioedema. The symptoms progressed to include generalized abdominal pain with cramps, explosive defecation, worsening periorbital and orolabial angioedema, chest tightness, shortness of breath, and pre-syncope. He was taken to the ER and received intramuscular epinephrine with immediate improvement in symptoms. After this reaction and prior to allergy consultation he tolerated traditional cow’s milk products (i.e. milk with cereal) on numerous occasions. He demonstrated sensitization to the EAS protein shake by skin prick testing (Figure 1A, Table 1). Patient #2 was a 13-year-old male without history of food allergy. He drank a Vanilla Body Fortress whey protein shake and within 45 minutes he developed rhinorrhea, profuse sneezing, flushing with dermal pruritus, periorbital angioedema, diffuse urticaria and shortness of breath. The school nurse administered diphenhydramine with improvement in the symptoms. He subsequently tolerated cow’s milk on multiple occasions after this reaction occurred. He was skin tested to the Body Fortress protein shake which demonstrated sensitization (Figure 1B, Table 2).

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Iris Publishers - Journal of Archives of Clinical Case Studies-Myofascial TMD, Multifactorial Ethiology with Multidisciplinary Approach- A Case Report

Author by  Marefat MahparehAbstract

Temporomandibular disorder (TMD) is a broad term refers to pathophysiology related to the temporomandibular joint (TMJ), masticatory muscles and associated head and neck structures. It may present wide spectrum oral manifestations, such as abnormal tooth wear, soft and hard tissue injuries and facial pain [1]. It has been a great challenge to clinically diagnose and to effectively manage this condition because of incomplete understanding and multifactorial etiology. A comprehensive examination following Diagnostic Criteria (DC/TMD) helps the clinicians with more proper clinical assessment of TMD patients [2]. This indicates a multidisciplinary approach including dental treatment, oral orthotic device(s), pharmacotherapy, physical medicine and proper referrals to other health care providers including pain specialists.

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Iris Publishers - Open Access Journal of Archives of Pharmacy & Pharmacology Research | Wishing you a Happy Independence Day

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Iris Publishers - Open Access Journal of Archives of Clinical Case Studies | Wishing you a Happy Independence Day

Hope this festive season will bring good luck and good health for you and your family. Wishing you a Happy Independence Day

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Iris Publishers - Open Access Journal of Archives of Clinical Case Studies-Covid 19 Pandemic Notes from Tri-counties: Palm Beach, Broward and Miami Dade of Florida

Authored by KV Venkatachalam

Abstract

SARS-CoV-2 is a beta corona virus that contains positive strand RNA genome. It has various structural proteins and nonstructural nuclear proteins (NSP) (Figures 1&2) [1]. The virus binds to ACE2 receptors that are located on lung cell membrane and enters the cells for example of lung alveolus by endocytosis. In lung cells the virus un coats itself, undergoes translation to generate RNA dependent RNA polymerase (RdRp) and the viral genome gets multiplied by RdRp to produce several copies of RNA genome. The NSP’s are involved in RNA 5’ cap formation. For example, NSP16 along with NSP 10 forms Cap-1 structure from Cap-0. Cap1 of the viral RNA confers stability as well as evasion from host immune response by stopping the interferon (IFN) production by innate immune system [2]. Each RNA genome is packaged into viral particles through a complicated process that involves ER and Golgi bodies [2]. Finally, each viral particle exits by exocytosis (Figure 2) [1] and could enter another body through air borne close contacts, touch etc. The Covid-19 situation in Palm Beach, Broward and Miami-Dade Counties accounts ~50% of total cases from the state of Florida, USA [3]. The monster that originated across the continent from Asia has spread all way to Florida, USA, a spanning distance that is way too higher than the seasonal forceful wind the hurricane. Here are some data on Covid-19 of South Florida. On May 26, 2020, the state of Florida reported an estimate of 51,746 positive cases, out of which more than 50% of the cases were found in the most populated tri counties [3]. Table 1 describes the details of this CoVid-19 situation. Data from the month of May-July shows an increase in both numbers of positive cases and deaths (Table 1) [3,4]. However, in July the number cases increased tremendously (Figure 3) but then the infection fatality rate in July was significantly lot less (Table 1). A slight decrease in the infection fatality rate in Broward and Palm Beach could perhaps be attributed to multiple reasons. The median ages of the population was Miami-Dade 48, Broward 47, and Palm Beach was 45 [4]. Table 2 describes the number of hospitals and average number of patients/hospitals in the three counties of study [4].

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Article on Covid-19 related issue in Iris Publishers

COVID-19 pandemic is having many life-altering short and likely long-term effects. The COVID-19 pandemic has had a major impact on number of economical, ethical, legal, health services and social issues arise because of the virus rapidly spreading worldwide.  Most people infected with the COVID-19 virus will experience mild to moderate respiratory illness and recover without requiring special treatment.  Older people, and those with underlying medical problems like cardiovascular disease, diabetes, chronic respiratory disease, and cancer are more likely to develop serious illness. The best way to prevent and slow down transmission of covid-19 is protecting yourself by wearing mask and others from infection by washing your hands frequently and not touching your face. Most of the people recover from the acute phase of the disease. However, some people continue to experience a range of effects for months after recovery and damage to organs has been observed. Multi-year studies are underway to further investigate the long-term effects of the disease.  

 Iris Publishers have focused and started a special issue on Covid-19 (Corona Virus). This issue mainly covers Quarantine measures, vaccine development during pandemic, Vaccination Side Effects, Immunity Simulation, Measuring the Covid-19 Pandemic, changing in Nursing Practice, Surgery during Covid-19, Global Impact of the Pandemic (COVID-19) on Construction Industry and so on, it is freely accessible to all the readers from the globe. The aim of this issue is to summarize the ethical information related to Covid-19 as we are going through coronavirus pandemic, and to estimate what we have seen thus far in view of this new knowledge. Iris Publishers strictly follows double bind peer review process by the Editors for better quality and relevance. We welcome all the authors from the globe to submit their original research articles, reviews, opinion, minireview, short communication and commentaries on Covid-19 (Corona Virus).

For more information: https://irispublishers.com/COVID-19.php

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Hospital Discharge Strategy at a Governmental Hospital in Qatar| Iris Publishers

Authored by Almunzer Zakaria*

Abstract

Preparing a patient for hospital discharge takes time, especially when complicated by medication preparation and reconciliation, patient education, and discharge summary documentation. Therefore, the healthcare managers and administrators should have tangible policies for discharging patients to avoid unnecessary readmissions linked to wasteful hospital expenditures. A single case study design was applied to investigate the varied inputs from different administrators within one setting and obtained information related to optimal patient discharge practices bounded by time and place. The hospital had six departments, the departments including pediatrics, obstetrics and gynecology, surgery, burns, medicine, and an intensive care unit. One toolkit designed to reduce readmission rates is the Re-Engineered Discharge (RED) toolkit. This strategy is an evidenced based approach with the three-fold aim of ensuring that patients understand how to care for themselves, reducing emergency visits and readmissions, and improving patient satisfaction. As for implementing RED, several specific indicators could be used depending on the context specific to the hospital. These indicators should be meaningful, credible, feasible, and timely. As a result of this study, both patient educations, planning for outpatient appointments and telephone follow-up by clerical or nursing staff were shown to have successfully reduced readmission rates for patients discharged to home. The hospital setting involved in the study introduced the admission-discharge lounge that helps, first, to accommodate patients that are already discharged in the inpatient but are not yet ready to leave the hospital for personal reasons. This prompts the process of clearing bed spaces for other admissions. Second, is by transferring the patient to the admission-discharge lounge, giving the patient and families time to support the discharge instruction education because now patients receive the instructions twice, once from the inpatient, and also from the lounge.

Keywords:Hospital Discharge; RED Toolkit; Readmissions; Admission-discharge lounge

Abbreviations:RED toolkit: Re-Engineered Discharged toolkit; AHRQ: The Agency for Health Research and Quality

Introduction

Preparing a patient for hospital discharge takes time, especially when complicated by medication preparation and reconciliation, patient education, and discharge summary documentation [1- 3]. Discharge preparation differs for each patient due to unique admitting history, a physical examination, and detailed medical education. A good hospital discharge transition is as vital as a thorough admission evaluation [4]. Reasons for readmissions may vary, but may include a lack of information at discharge from hospital and a clinical preventive action, such as preparing the patients with proper care planning while at the hospital [5] .Therefore, the healthcare managers and administrators should have tangible policies for discharging patients to avoid unnecessary readmissions linked to wasteful hospital expenditures [6].

Materials and Methods

A qualitative method was used to explore phenomena in which limited previous understanding existed; thus, the findings may produce new insights and practices. A single case study design was applied to investigate the varied inputs from different administrators within one setting and obtained information related to optimal patient discharge practices bounded by time and place. A variety of data collection techniques were used, including an interview protocol, semi-structured interviews, document review, and data analysis. Methodological triangulation helped to strengthen the research and gain data from the facility’s Health Information Management Office. The data analysis process included coding and clustering the interview data and identifying common trends in the findings; and generating themes that aligned with the central research question and conceptual framework.

The documents reviewed were monthly data on the percentage of discharges from January 2018 to April 2019. Documentation supplemented the qualitative interviews and helped to provide a deeper understanding of the scope of the phenomenon. The hospital had a capacity of 326 beds and an average of 50 discharges and 65 admissions per day, in Qatar. The hospital had six departments, the departments including pediatrics, obstetrics and gynecology, surgery, burns, medicine, and an intensive care unit. which provided the setting for this study. Understanding that procedures and patient outcomes varied between departments, all six departments provided significant inputs to conduct the investigation. Interviews were conducted with four hospital administrators and included reviews of relevant documentation offered by the administrators [7]. The administrators were asked about strategies that were used upon discharge to assist the patient to continue the recovery process to avoid readmissions and learn about the different services available in the hospital to support patients post-discharge.

Results and Discussion

Efforts to improve how the discharge plan is prepared were notable. Aside from interviews, data from the Health Information Management Office indicated that the discharge rates, from January 2018 to March 2019, were fluctuating. The trends of discharge depend on the specific units in the hospitals. Dramatic drops occurred in the obstetrics/gynecology unit and burn units. The pediatric unit, surgical unit, medical unit, and intensive care unit showed almost similar trends in discharge rates; however, there was no dramatic drop or increase noticeable. All units’ performance showed that the discharge rate for March 2018 was similar to the baseline taken in January 2018.

One toolkit designed to reduce readmission rates is the Re- Engineered Discharge (RED) toolkit. This strategy is an evidencedbased approach with the three-fold aim of ensuring that patients understand how to care for themselves, reducing emergency visits and readmissions, and improving patient satisfaction. To structure and fully operationalize the RED into the patient care system, may take at least six months. The RED was prepared by the Boston University Medical Center, in cooperation with the Agency for Health Research and Quality (AHRQ). The RED has 12 components, which are:

1) Ascertain the need for and obtain language assistance

2) Make appointments for follow-up care

3) Plan for the follow-up of results from tests or labs that are pending at discharge

4) Organize post-discharge outpatient services and medical equipment

5) Identify the correct medicines and a plan for the patient to obtain them

6) Reconcile the discharge plan with national guidelines

7) Teach a written discharge plan the patient can understand

8) Educate the patient about his/her diagnosis and medicines

9) Review with the patient what to do if a problem arises

10) Assess the degree of the patient’s understanding of the discharge plan

11) Expedite transmission of the discharge summary to clinicians accepting care of the patient and

12) Provide telephone reinforcement of the discharge plan [8].

As for implementing RED, several specific indicators could be used depending on the context specific to the hospital. These indicators should be meaningful, credible, feasible, and timely. Furthermore, Implementation should measure whether RED was delivered to target patients, whether the correct information was collected, whether evidence-based care was delivered, whether appropriate follow-up care was arranged, whether patients were prepared for discharge, and whether patients received postdischarge care [8]. Once the patient returns home following a hospitalization, the RED captures key junctions in which the discharge plan failed; for instance, when the discharge education was not properly given or if the patient or family did not understand what the patient needed to do once home. If this occurs, patients will most likely not follow the medication schedules which in turn will make their recovery slower, sometimes making their condition worse than when patients were discharged from the hospital, forcing them to return to the emergency department within a few days. Poor patient education can also lead to problems in medication instructions. Sometimes, incomplete patient education is given to the patient before the patient was discharged, and that includes improper medicine reconciliation. Alternatively, the education was complete, but the patient didn’t understand the instructions completely because of the language barrier. As a result of this study, the hospital introduced the admission-discharge lounge that helps nursing staff to clear bed spaces for the pending admissions in the emergency departments and reinforces the discharge instruction education to the patients and families. The nursing staffs are encouraged to make sure that the discharge plan is completed 24 hours prior to discharge. Early preparation gives time for the patients to fully understand the education provided and gives the patient time to think of possible questions to ask the staff regarding parts of the plan that patients and families didn’t understand.

Conclusion

As a result of this study, both patient education, planning for outpatient appointments and telephone follow-up by clerical or nursing staff were shown to have successfully reduced readmission rates for patients discharged to home [9]. The RED program was introduced to streamline the patient discharge process and to decrease the readmissions at hospitals. The RED program is comprised of 12 components which included discharge planning and patient teaching [10]. Client teaching, for instance, included teaching patients a written discharge plan in terms that client. Education related to the clients’ diagnosis and medicines must be provided at discharge to ensure the client is well-prepared to continue a successful healing process at home. The discharge plan must include telephone reinforcement, expediting the transmission of the discharge summary to patients. In summarizing the effectiveness of RED, there was a wide variability in the fidelity of the interventions, engaged leadership and multidisciplinary implementation teams as keys to success, and some challenges such as timely follow-up appointments, transmitting discharge summaries to outpatient clinicians, and leveraging information technology. The RED showed improvement in 30-day readmission rates.

As mentioned, the hospital setting involved in the study introduced the admission-discharge lounge that helps, first, to accommodate patients that are already discharged in the inpatient but are not yet ready to leave the hospital for personal reasons. This prompts the process of clearing bed spaces for other admissions. Second, is by transferring the patient to the admission-discharge lounge, giving the patient and families time to support the discharge instruction education because now patients receive the instructions twice, once from the inpatient, and from the lounge. If patients and families did not understand any instructions during the first time, both have another chance to gain clarity, or ask further questions. The final key advantage is the availability and set up of home care.

Moreover, the discharge plan is completed 24 hours prior to discharge. By doing so, medical staff are relieved from the pressure and time to finish the plan on the day of discharge. This arrangement helps the patient to perceive the discharge instructions and gives time to clarify any point in the plan that the patient and families didn’t understand. Hospitals require more protocols and guidelines for the effective treatment and release of the patient. If hospital staffs effectively treat the patient, the patient will not return, and therefore, hospitals will have more empty beds for other patients which will have a positive impact on pending patients in the emergency department.

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ABCD…Airway, Breathing, Circulation (and don’t forget Differentials) |Iris Publishers

Authored by Ashok Handa*

Abstract

Male patients over the age of 65, presenting with acute abdominal pain should be managed as a potential ruptured abdominal aortic aneurysm (AAA), until proven otherwise. Ruptured AAA is a commonly missed life-threatening diagnosis. This paper aims to recap over the diagnosis and management to aid doctors in training in their decision making.

Keywords:AAA; Aneurysm; Rupture; Epigastric pain; Collapse

Main Text

History

A 69-year old man presented to the emergency department with a three-week history of general malaise and diarrhoea, on a background of chronic kidney disease (baseline creatinine 250 μmol/L) and an abdominal aortic aneurysm (AAA;5cm). He was admitted with acute kidney injury (creatinine 1500 μmol/L) presumed to be secondary to severe hypovolemia, and commenced emergently on hemofiltration requiring heparinization, as well as aggressive fluid resuscitation. A few days later, he developed sudden onset of epigastric pain and syncope, with increasing abdominal girth and decreasing haemoglobin. Surgical review found a tender abdomen with a pulsatile epigastric mass, however he continued to be hydrated and anti-coagulated, as definitive diagnostic imaging and vascular referral was delayed until the following morning, some 5 hours later.

Computed tomography angiography (CTA) of the abdomen showed a large infrarenal AAA, measuring 7.5 cm in maximal anterior-posterior diameter (Figures 1 & 2). Typical features of an aortic aneurysm include the calcified intimal layer of the arterial wall and the eccentric thrombus lining of the arterial lumen.

Of greater concern is the presence of an apparent contained rupture indicated by the presence of a significant retroperitoneal swelling due to a large contained haematoma, in this case unusually bilaterally and anteriorly displacing the posterior peritoneum; this can be verified by indicative Hounsfield’s units [1]. Quite remarkably, contrast can also be seen jetting from the intraluminal space into the haematoma anteriorly. The former is sufficient to demonstrate a ruptured aneurysm that has subsequently tamponaded, however the latter suggests ongoing bleeding into the retroperitoneal space.

Key Points

This case demonstrates that a high index of suspicion must always be exercised when patients over 65-years present with a history of epigastric pain and collapse. Certainly, a ruptured aneurysm constitutes one of several important differentials that must always be suspected and rapidly excluded (Table 1). In this case, a ruptured AAA could have been seen using a bedside ultrasound, including a FAST (focused assessment with sonography for trauma) scan [2]. Otherwise, in the setting of such severe acute renal failure, even a non-contrast CT would have sufficient features to suggest the diagnosis.

Management

Management of ruptured aneurysms includes early assessment and management with subsequent rapid access to definitive treatment (Table 2). If suspected or confirmed, all patients should have adequate vascular access, and “permissive hypotension” is key, such that low systolic blood pressures (>90mmHg) are tolerated as long as the Glasgow Coma Scale remains 15 and ST-T segment remains unchanged on electrocardiography. If the patient becomes haemodynamically unstable, volume resuscitation should be implemented cautiously with packed red blood cells, either previously cross-matched or O-negative if a crossmatch is not available. Simultaneously, early referral and rapid transfer to the nearest Vascular Unit should be facilitated [3].

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