Abdominal Trauma, Blunt

The care of the trauma patient is demanding and requires speed and efficiency. Evaluating patients who have sustained blunt abdominal trauma remains one of the most challenging and resource-intensive aspects of acute trauma care.

Missed intra-abdominal injuries and concealed hemorrhage are frequent causes of increased morbidity and mortality, especially in patients who survive the initial phase after an injury.

Physical examination findings are notoriously unreliable for several reasons; a few examples are the presence of distracting injuries, an altered mental state, and drug and alcohol intoxication in the patient.

Coordinating a trauma resuscitation demands a thorough understanding of the pathophysiology of trauma and shock, excellent clinical and diagnostic acumen, skill with complex procedures, compassion, and the ability to think rationally in a chaotic milieu.

Blunt abdominal trauma usually results from motor vehicle collisions, assaults, recreational accidents, or falls. The most commonly injured organs are the spleen, liver, retroperitoneum, small bowel, kidneys, bladder, colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often than women.
Frequency


United States

By nearly every measure, injury ranks as one of this nation's most pressing health issues. More than 150,000 people die each year as a result of injuries, such as motor vehicle crashes, fires, falls, drowning, poisoning, suicide, and homicide. Injuries are the leading cause of death and disability for US children and young adults.

According to the 2000 statistics from the National Center for Injury Prevention and Control, trauma (unintentional and intentional) was the leading cause of death in persons aged 1-44 years. Further review of the data reveals that in those aged 15-25 years, 14,113 persons died from unintentional injuries, 73% of which were related to vehicular trauma. In individuals aged 25-34 years, 57% of the 11,769 deaths reported were from motor vehicle collisions.

In 2001, approximately 30 million people visited emergency departments for the treatment of nonfatal injuries and more than 72,000 people were disabled by injuries. Injury imposes exceptional costs, both in health care dollars and in human losses, to society.

International

In 1990, approximately 5 million people died worldwide as a result of injury. The risk of death from injury varied strongly by region, age, and sex. Approximately 2 male deaths due to violence were reported for every female death. Injuries accounted for approximately 12.5% of all male deaths, compared with 7.4% of female deaths.

Globally, injury accounts for 10% of all deaths; however, injuries in sub-Saharan Africa are far more destructive than in other areas. In sub-Saharan Africa, the risk of death from trauma is highest in those aged 15-60 years, and the proportion of such deaths from trauma is higher than in any other region of the world. In South Africa, for instance, the traffic death rate per unit of distance traveled is only surpassed by Korea, Kenya, and Morocco.

Estimates indicate that by 2020, 8.4 million people will die yearly from injury, and injuries from traffic collisions will be the third most common cause of disability worldwide and the second most common cause in the developing world.
Pathophysiology

Vehicular trauma is by far the leading cause of blunt abdominal trauma in the civilian population. Auto-to-auto and auto-to-pedestrian collisions have been cited as causes in 50-75% of cases. Rare causes of blunt abdominal injuries include iatrogenic trauma during cardiopulmonary resuscitation, manual thrusts to clear an airway, and the Heimlich maneuver.

Intra-abdominal injuries secondary to blunt force are attributed to collisions between the injured person and the external environment and to acceleration or deceleration forces acting on the person's internal organs. Blunt force injuries to the abdomen can generally be explained by 3 mechanisms.

The first is when rapid deceleration causes differential movement among adjacent structures. As a result, shear forces are created and cause hollow, solid, visceral organs and vascular pedicles to tear, especially at relatively fixed points of attachment. For example, the distal aorta is attached to the thoracic spine and decelerates much more quickly than the relatively mobile aortic arch. As a result, shear forces in the aorta may cause it to rupture. Similar situations can occur at the renal pedicles and at the cervicothoracic junction of the spinal cord.

The second is when intra-abdominal contents are crushed between the anterior abdominal wall and the vertebral column or posterior thoracic cage. This produces a crushing effect, to which solid viscera (eg, spleen, liver, kidneys) are especially vulnerable.

The third is external compression forces that result in a sudden and dramatic rise in intra-abdominal pressure and culminate in rupture of a hollow viscous organ (ie, in accordance with the principles of Boyle law).
Presentation

History

The initial assessment of a trauma patient begins at the scene of the injury, with information provided by the patient, family, bystanders, or paramedics. Important factors relevant to the care of a patient with blunt abdominal trauma, specifically those involving motor vehicles, include the following:
The extent of vehicular damage
Whether prolonged extrication was required
Whether the passenger space was intruded
Whether a passenger died
Whether the person was ejected from the vehicle
The role of safety devices such as seat belts and airbags
The presence of alcohol or drug use
The presence of a head or spinal cord injury
Whether psychiatric problems were evident

Priorities in resuscitation and diagnosis are established based on hemodynamic stability and the degree of injury. The goal of the primary survey, as directed by the Advanced Trauma Life Support protocol, is to identify and expediently treat life-threatening injuries. The protocol includes the following:
Airway, with cervical spine precautions
Breathing
Circulation
Disability
Exposure

Key elements of the pertinent history include the following:
Allergies
Medications
Past medical and surgical history
Time of last meal
Immunization status
Events leading to the incident
Social history, including history of substance abuse
Information from family and friends

Resuscitation is performed concomitantly and continues as the physical examination is completed. The secondary survey is the identification of all injuries via a head-to-toe examination.

It is imperative for all personnel involved in the direct care of a trauma patient to exercise universal precautions against body fluid exposure. The incidence of infectious diseases (eg, HIV, hepatitis) is significantly higher in trauma patients than in the general public, with some centers reporting rates as high as 19%. Even in medical centers with relatively low rates of communicable diseases, safely determining who is infected with such pathogens is impossible. The standard barrier precautions include a hat, eye shield, face mask, gown, gloves, and shoe covers. Unannounced trauma arrival is probably the most common situation that leads to a breach in barrier precautions. Personnel must be instructed to adhere to these guidelines at all times, even if it means a 30-second delay in patient care.
Physical examination

The evaluation of a patient with blunt abdominal trauma must be accomplished with the entire patient in mind, with all injuries prioritized accordingly. This implies that injuries involving the head, the respiratory system, or the cardiovascular system may take precedence over an abdominal injury.

The abdomen should neither be ignored nor the sole focus of the treating clinician and surgeon. In an unstable patient, the question of abdominal involvement must be expediently addressed. This is accomplished by identifying free intra-abdominal fluid using diagnostic peritoneal lavage (DPL) or the Focused Assessment with Sonography for Trauma (FAST) examination. The objective is to rapidly identify patients who need a laparotomy.

The initial clinical assessment of patients with blunt abdominal trauma is often difficult and notably inaccurate. Associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult. Lower rib fractures, pelvic fractures, and abdominal wall contusions may mimic the signs of peritonitis. In a collected series of 955 patients, Powell et al reported that clinical evaluation alone has an accuracy rate of only 65% for detecting the presence or absence of intraperitoneal blood.1 In general, accuracy increases if the patient is examined repeatedly and at frequent intervals. However, repeated examinations may not be feasible in patients who need general anesthesia and surgery for other injuries. The greatest compromise of the physical examination occurs in the setting of neurologic dysfunction, which may be caused by head injury or substance abuse.

The most reliable signs and symptoms in alert patients are pain, tenderness, gastrointestinal hemorrhage, hypovolemia, and evidence of peritoneal irritation. However, large amounts of blood can accumulate in the peritoneal and pelvic cavities without any significant or early changes in the physical examination findings.

The abdominal examination must be systematic. The abdomen is inspected for abrasions or ecchymosis. The seat belt sign, ie, a contusion or abrasion across the lower abdomen, is highly correlated with intraperitoneal pathology. Visual inspection for abdominal distention, which may be due to pneumoperitoneum, gastric dilatation, or ileus produced by peritoneal irritation, is important. Ecchymosis involving the flanks (Grey Turner sign) or the umbilicus (Cullen sign) indicates retroperitoneal hemorrhage, but this is usually delayed for several hours to days. Rib fractures involving the lower chest may be associated with splenic or liver injuries. Auscultation of bowel sounds in the thorax may indicate the presence of a diaphragmatic injury. Palpation may reveal local or generalized tenderness, guarding, rigidity, or rebound tenderness, which suggests peritoneal injury.

A rectal examination should be performed to search for evidence of bony penetration resulting from a pelvic fracture, and the stool should be evaluated for gross or occult blood. The evaluation of rectal tone is important for determining the patient's neurologic status, and palpation of a high-riding prostate suggests urethral injury.

A nasogastric tube should be placed routinely (in the absence of contraindications, eg, basilar skull fracture) to decompress the stomach and to assess for the presence of blood. If the patient has evidence of a maxillofacial injury, an orogastric tube is preferred.

As the assessment continues, a Foley catheter is placed and a sample of urine is sent for analysis for microscopic hematuria. If injury to the urethra or bladder is suggested because of an associated pelvic fracture, then a retrograde urethrogram is performed before catheterization.

Because of the wide spectrum of injuries, frequent reevaluation is an essential component in the management of patients with blunt abdominal trauma.

Pediatric patients are assessed and treated at least initially as adults with respect to the primary and secondary surveys. However, obvious anatomical and clinical differences exist and these must be kept in mind: the child's physiologic response to injury is different; communication is not always possible; physical examination findings become more important; the pediatric patient's blood volume is less, predisposing them to rapid exsanguination; technical procedures tend to be more time consuming and challenging; and a child's relatively large body surface area contributes to rapid heat loss. Perhaps, the most significant difference between pediatric and adult blunt trauma is that, for the most part, pediatric patients can be resuscitated and treated nonoperatively. Some pediatric surgeons often transfuse up to 40 mL/kg of blood products in an effort to stabilize a pediatric patient. Obviously, if this fails and the child continues to be unstable, laparotomy is indicated.

Tertiary examination

This concept was first introduced by Enderson et al to assist in the diagnosis of any injuries that may have been missed during the primary and secondary surveys.2 The tertiary survey involves a repetition of the primary and secondary surveys and a revision of all laboratory and radiographic studies. In one study, a tertiary trauma survey detected 56% of injuries missed during the initial assessment within 24 hours of admission.
Indications

Aggressive radiographic and surgical investigation is indicated in patients with persistent hyperamylasemia or hyperlipasemia, conditions that suggest significant intra-abdominal injury.

Stable patients with inconclusive physical examination findings should undergo radiographic studies of the abdomen.

DPL is indicated in blunt trauma as follows:
Patients with a spinal cord injury
Those with multiple injuries and unexplained shock
Obtunded patients with a possible abdominal injury
Intoxicated patients in whom abdominal injury is suggested
Patients with potential intra-abdominal injury who will undergo prolonged anesthesia for another procedure

An indication for immediate blood transfusion is hemodynamic instability despite the administration of 2 L of fluid to adult patients; this instability indicates ongoing blood loss.

Indications for laparotomy in a patient with blunt abdominal injury include the following:
Signs of peritonitis
Uncontrolled shock or hemorrhage
Clinical deterioration during observation
Hemoperitoneum findings after FAST or DPL examinations

Finally, surgical intervention is indicated in patients with evidence of peritonitis based on physical examination findings.
Relevant Anatomy

The abdomen can be arbitrarily divided into 4 areas.

The first is the intrathoracic abdomen, which is the portion of the upper abdomen that lies beneath the rib cage. Its contents include the diaphragm, liver, spleen, and stomach. The rib cage makes this area inaccessible for palpation and complete examination.

The second is the pelvic abdomen, which is defined by the bony pelvis. Its contents include the urinary bladder, urethra, rectum, small intestine, and, in females, the ovaries, fallopian tubes, and uterus. Injury to these structures may be extraperitoneal in nature and therefore difficult to diagnose.

The third is the retroperitoneal abdomen, which contains the kidneys, ureters, pancreas, aorta, and vena cava. Injuries to these structures are very difficult to diagnose based on physical examination findings. Evaluation of the structures in this region may require a CT scan, angiography, and an intravenous pyelogram.

The fourth is the true abdomen, which contains the small and large intestines, the uterus (if gravid), and the bladder (when distended). Perforation of these organs is associated with significant physical findings and usually manifests with pain and tenderness from peritonitis. Plain x-ray films are helpful if free air is present. Additionally, DPL is a useful adjunct.
Contraindications

While not a contraindication to surgical repair, the evaluation of a patient with blunt abdominal trauma must be prioritized based on the most urgent problems. This implies that injuries involving the head, the respiratory system, or the cardiovascular system may take precedence over an abdominal injury.

Although a nasogastric tube is routine in order to decompress the stomach and assess for the presence of blood, it is contraindicated in patients with basilar skull fracture. An orogastric tube is preferred if the patient has evidence of a maxillofacial injury.

Operative treatment is not indicated in every patient with positive FAST scan results. Hemodynamically stable patients with positive FAST findings may require a CT scan to better define the nature and extent of their injuries. Operating on every patient with positive FAST scan findings may result in an unacceptably high laparotomy rate.

The only absolute contraindication to DPL is the obvious need for laparotomy. Relative contraindications include morbid obesity, a history of multiple abdominal surgeries, and pregnancy.

Resuscitative thoracotomy is not recommended in patients with blunt thoracoabdominal trauma who have pulseless electrical activity upon arrival in the emergency department. The survival rate in this situation is virtually 0%. These patients may be allowed a thoracotomy in the emergency department only if they have signs of life upon arrival to the emergency department.
source :emedicine

Principles of Drug Addiction Treatment

Drug addiction is a complex disorder that can involve virtually every aspect of an individual's functioningÑin the family, at work, and in the community. Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use. Others, like employment training, focus on restoring the addicted individual to productive membership in the family and society (see Components of Comprehensive Drug Abuse Treatment diagram).

Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with drug use disorders.

Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of drug addiction and its medical consequences.

Drug abuse and addiction are treated in specialized treatment facilities and mental health clinics by a variety of providers, including certified drug abuse counselors, physicians, psychologists, nurses, and social workers. Treatment is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting.

General Categories of Treatment Programs

Research studies on drug addiction treatment have typically classified treatment programs into several general types or modalities, which are described in the following text. Treatment approaches and individual programs continue to evolve, and many programs in existence today do not fit neatly into traditional drug addiction treatment classifications. Examples of specific research-based treatment components are described in the Approaches to Treatment Section

Working With Drug Addicts

Recent survey of more than 1100 personnel administrators concluded that drug and alcohol abuse are more likely to cost a person their job than incompetence. Drug abuse has affected every area of society; the music business is no exception.

Some believe that drug addiction is more pervasive in show business, while others counter that this perception exists only because of the high-profile nature of the industry. The fact that drug addiction crops up everywhere suggests that it is an illness particular to human nature, not a specific industry.

There is little solace in this however, when a musician you know becomes difficult to get along with, unreliable or untrustworthy, incapable of performing, or even violent due to their worsening drug or alcohol problem. It would be wonderful if we lived in a world free of drugs and drug addiction, but until that day arrives musicians may find themselves inadvertently working with others who have become victims of this very serious illness. What follows is some helpful perspective and advice for those who are struggling with this situation, or those who simply wish to know more about it.

There are a myriad of attitudes concerning drug addiction, and drug addicts. (From here on we will refer to persons addicted to drugs and/or alcohol as one group: drug addicts.) Unfortunately, there are still those who believe this condition to be the result of poor judgement, or perhaps a flawed character. The consensus among modern health care professionals, including the American Medical Association (AMA), is that drug addiction is a disease. Theories concerning its origins embody the classic "nature vs. nurture" arguments: Does one become an addict because of genetics, environment and upbringing, or a combination thereof? It may be safely concluded that the origins of drug addiction are many, and complex.

Cultivating an awareness of this issue begins with the realization that drug addicts are not necessarily bad people, but rather victims of their illness. Some people have what is known as an addictive personality - a predisposition to become dependent on a certain lifestyle, or substance. Examples are compulsive eaters or gamblers, those who accumulate excessive debt, and drug addicts, who become addicted to substances. For the drug addict, a simple "just say no" is insufficient. The nature of their illness is such that they have not naturally developed the kind of rational self-control that allows most people to remain free of addiction. Addicts become mired in their habit without realizing that a problem is developing, and they practice denial in order to maintain their increasingly fragile world.
The drug addict will go to great lengths to deny that their use of drugs is the reason for a deteriorating situation. They tend to blame their problems on those around them, including friends, co-workers, and loved ones. Being in a band with such a person is very, very difficult if that person is hostile and blaming, when it's obvious that the drug habit is the real problem. Most groups will tolerate this situation for a while, hoping the problem "solves itself" by merely disappearing, or that the addict will respond to suggestions, or even ultimatums that they "clean up their act." Ultimatums may be temporarily effective, but unless the addict seeks true rehabilitation, problems will invariably recur. Sadly, many addicts lose their jobs and are left alone, denying responsibility, blaming the band member(s) responsible for his or her firing.

When a musician loses his or her job, it's because the other band members have been forced to make a choice. A band is a unique environment: one third team, one third business, one third family. It's very difficult to discharge a member of this "family" when the person is in such obvious trouble and pain. And yet, that person is most likely not contributing fully to the team effort, and may actually be severely damaging to the business effort. A band may have to cancel engagements, or whole tours if a crucial member is unable to perform, and the situation becomes more critical when the other members' livelihoods, including the ability to feed a family, or pay rent or a mortgage are threatened. Every drug addict is an individual, and the demands of every band's situation vary, but there are limits to the number of times band members are able to give the addict the benefit of the doubt, and to the number of broken promises a band is able to endure.

The past decade has seen increased awareness of and concern for drug addicts, and increased ability to effectively treat their illness. There are full-time self-help groups such as Alcoholics Anonymous (AA), and its first cousin Narcotics Anonymous (NA) dedicated to providing drug addicts with help and support. There are many other public and private organizations with similar goals, including those oriented towards helping "concerned persons" - the family, friends, and co-workers of addicts. One of these groups is an excellent place for band members to go for help with bringing one of their own to rehabilitation. While AA and NA offer free support, private rehabilitation facilities can be very costly. The costs and types of rehabilitation programs vary however, and the addition of substance abuse to the list of illnesses recognized by the AMA has made treatment for drug addiction eligible for coverage under many health insurance policies.
In the health care industry, it's believed that in order for rehabilitation to succeed, an addict must sincerely want to be helped. There is a natural tendency, in observing a person's debilitating addiction, to try to help the addict with a heart-to-heart talk, to try to "bring them to their senses." As well-intentioned as this may be, most addicts feel they don't want help, instead believing they have no problem, or that those outside their situation don't understand. It's also possible for a talk of this nature to backfire, leaving the addict alienated and angry with his or her friends. It may be more helpful to have a recovering (rehabilitated) addict talk to the addict, someone who does understand, someone who has been there and made it back. If you don't know such a person, a call to a local chapter of either AA or NA may prove helpful, as these groups are in touch with successfully rehabilitated addicts who are willing to help with these situations. Frequently however, merely talking to an addict won't inspire any significant change, regardless of who's doing the talking. In order for many addicts to abandon their denial, and want to renounce drugs, they must first hit bottom.

"Hitting bottom" is fairly self explanatory: the person's life must reach a profound level of unhappiness, the previously unlimited reservoir of denial finally gone dry. A person may hit bottom due to a combination of undeniable circumstances, such as failing health, divorce, or arrest for drunken driving or drugs. The fact that these events are referred to as "sobering" is no coincidence. If an addict/musician you know does hit bottom, and asks for help getting straight, it behooves you to give that addict all the help and support you can. It may be difficult to completely forgive and forget all the transgressions that person may have committed as a result of his or her addiction, but remember: they were incapacitated by a very serious illness. Their previously irrational behavior was most likely irrelevant to their true personality, the one finally asking for, and deserving of your help.

Not every drug addict is completely incapacitated by their addiction. In fact, the greatest numbers of addicts in society today are called "functional" drug addicts. They can regulate when they ingest their substance(s) of choice, which enables them to function in an apparently normal fashion. The functional addict can hold a job, make payments on a car or house, even maintain a family life. Amazingly, it's even possible for the addict to keep his or her addiction a secret from a spouse! If you are in a band with such a person, you will notice their regular abuse of the substance, their devotion to it, and a tendency to promote its usage. Functional alcoholics are capable of drinking large quantities without appearing drunk, because of their increased tolerance for alcohol. Ironically, the ability to drink large amounts is viewed by some as a sign of strength, while it is in fact a warning signal of alcoholism - a long-term degenerative illness.

Coexistence with the functional drug addict is somewhat more feasible than with the chronic addict, but there are definite dangers. While the functional drug addict is not completely out of control, he or she is still dependent on their drug, and that dependence is more likely to show itself at times of stress or pressure. In the music business, this can manifest itself at the worst possible times, such as when a group is given an important break, and pressure is at peak level. Remember that the addict's behavior, even the functional addict, is not necessarily based on rational thought. Thus, any working relationship with even a functional addict involves some element of risk. Again, a matter of choice: How much risk is acceptable in order to continue to work with a functional drug addict?

An important part of an addict's denial is the ability to excuse and rationalize his or her behavior. When a band is on the road, an addict will stubbornly maintain that "what I do on my own time is my business." The rationale is that as long as they are not at the gig, they are free to do as they please. This is a flawed, dangerous argument. The road is a twenty-four hour/day work environment; the musician on the road is responsible to the band all of the time. Most top organizations subscribe to this policy, and will not tolerate any drugs at any time while on the road. The reasoning is obvious when one considers the illegal nature of many abused drugs, and that a musician's offstage drug habits can very well affect what happens onstage. It is unlikely that a musician up all night the previous night "partying" will perform up to standards. No top organization can afford to have any member perform below par at any time.

The freelance musician works in a different context than the band player. Rather than being part of a full-time "family," the freelance works with a variety of faces from gig to gig. The dynamics are quite different than those of a band. Band members depend on one another, and the consequences of any member being in trouble with drugs are deeply felt by all. But the independent musician may not consider an addict on the gig a threat to his or her own career. The freelance may view the addict's dependency on drugs as "someone else's problem," and take comfort in knowing that he or she was not responsible for a bad performance. In a world where individual survival is difficult enough, such an attitude may suffice. More likely the freelance, like the band member, will feel the stress imposed upon the work environment by the drug addict. Attempting to make music with an intoxicated musician is a difficult, sometimes embarrassing experience. It brings a sense of disappointment - even though the freelance can look forward to a different lineup on the next gig, he or she will feel cheated out of the joy derived from playing music. The experience also leaves one feeling sad. The community of professional musicians is a tight-knit group, and one need not work in the family environment of a band in order to feel concern for a friend and fellow musician.

Thankfully, many millions of drug addicts have sought rehabilitation. Upon asking for help, an addict must learn to accept the knowledge that even if they give up drugs forever, they will still be addicted to them, forever. It becomes their goal to live life "one day at a time" by not doing any drugs that day, rather than dwelling on staying clean for their entire lifetime, which may seem an overwhelming task. This is a proven philosophy, and has helped millions of addicts enjoy healthy lifestyles and productive careers. The addict/musician who seeks help is faced with some special challenges, however. A large number of the opportunities to play occur in places where alcohol is not only served, but encouraged. The recovering addict will be regularly surrounded by people consuming alcohol, which can be very unnerving, especially in the first year of rehabilitation. Those helping the addict may recommend that they eliminate their exposure to drugs and alcohol entirely, which poses a very difficult situation for the musician who makes a living playing in nightclubs. There is no single solution to this dilemma; every addict is an individual. Some addicts must severely modify their lifestyle to stay clean, some are able to continue on the club circuit. If an addict must forgo the nightclub scene however, they need not completely retire from playing. There are opportunities to perform in a drug-and-alcohol-free environment, such as the recording studio, rehearsal band, orchestra pit, and of course, the concert stage.

Life on the road may conflict with the recovering addict's attempt to maintain a sense of stability in their new life. One of the ways musician/addicts are able to maintain their sobriety while on the road is by seeking the help and support of other recovering addicts. Alcoholics Anonymous and Narcotics Anonymous hold free meetings on a regular basis at their thousands of local branches. The recovering addict can find strength and support at these meetings, enough to make it through the gig and on to the next town. This is a very viable option for the travelling musician.

It is important to note that it's possible for the recovering addict to suffer a relapse, especially if that person was not truly ready to renounce drugs. A relapse is a very traumatic experience for all concerned persons, and can lead to feelings of hopelessness, and questions of the entire rehabilitation process. During this difficult time, try to remember that drug addiction is an illness, and like many other illnesses, relapse is an unfortunate fact of life. Of the millions of successful recovering addicts in our society, many have had to battle their addiction more than once. Never abandon hope for such a person.

The preceding paragraphs pose a number of very difficult questions about making choices and taking risks. There are no easy answers to these questions; they are left to the individual. Working in a band, or freelance situation with one or more drug addicts can be a frustrating, confusing, even heartbreaking experience. But regardless of how difficult a situation becomes, and how debilitating an addict's illness grows to be, there is always hope. Anyone who has witnessed a drug addict's hitting bottom, and subsequent rehabilitation, will also witness the elation and rejuvenation of that person. Recovering addicts have enormous energy, as well as renewed feelings of clearheadedness and self-worth. It is a great joy to regain a friendship that had been disabled since the person's addiction took over, and to witness the return of artistic prowess that had been buried for so long. In an imperfect world, full of imperfect people, this is the one silver lining found within the cloud of drug addiction.

Drug addiction

You may be hooked emotionally and psychologically. You may have a physical dependence, too. If you have a drug addiction, you have intense cravings for the drug. You want to use it again and again. When you stop taking it, you may have unpleasant physical reactions.

While not everyone who uses drugs becomes addicted, many people do. Drug addiction involves compulsively seeking to use a substance, regardless of the potentially negative social, psychological and physical consequences. Certain drugs are more likely to cause physical dependence than are others.

Breaking a drug addiction is difficult, but not impossible. Support from your doctor, family, friends and others who have a drug addiction, as well as inpatient or outpatient drug addiction treatment, may help you beat your drug dependence.

مقالة مختارةSpectacular spectrum reveals Sun's chemistry

This is what visible light from the sun looks like if you split it into its constituent colours. But playing with a prism at home will not give you this high-resolution masterpiece, which was created using a sophisticated spectrometer fixed to the world's largest solar telescope at the Kitt Peak National Observatory in Tucson, Arizona. The spectrometer splits light from the sun into two beams and sends them towards two mirrors, which bounce the light back to a detector where the beams recombine. Via a complex mathematical technique, the resulting interference pattern appears as a spectacular solar spectrum, covering the entire range of visible light.

What are the dark blobs in the image? These are known as Fraunhofer lines after German physicist Joseph von Fraunhofer, who first studied them in detail in 1814. They are caused by specific elements in the outer layers of the sun absorbing a characteristic wavelength of light - the missing wavelength showing up as a dark line. This barcode-like image tells us about the elements present in the sun. For instance, the broad dark patch in the red part of the spectrum (upper right) indicates the presence of hydrogen and the two prominent lines in the yellow part are sodium.

As well as helping us to study the chemical composition of stars, such spectra can also tell us about the atmosphere of planets orbiting other stars. Astronomers first collect the spectrum when the planet is behind its host star, then when the planet passes in front. Subtract the first from the second, and you get the spectrum of the planet. If we find other Earth-like planets in a star's habitable zone, astronomers can study their spectra to look for water vapour, oxygen or methane in the planet's atmosphere - all tantalising hints of life elsewhere.
source:newscientist