limbic system

The term ‘limbic system’ (from Latin limbus: edge) was first used by MacLean in 1952 to describe a set of structurally and functionally related structures of the brain bordering the midline, inner surface of each cerebral hemisphere. These structures were considered to be evolutionarily ancient. MacLean called them the ‘visceral brain’ and suggested they mediate behaviourally ‘primitive’ functions inherited from lower mammals, particularly emotion and motivational behaviour. Although such phylogenetic arguments (based on comparison between species) are now commonly rejected, the concept of the limbic system survives and has since grown to be highly influential yet controversial.

First, there is no consensus over exactly which structures comprise the limbic system. Most schemes, however, consider it to consist of various parts of the cerebral cortex forming a set of ‘rings’ on the inner surface of each hemisphere, linked to a central core of structures lying below the cerebral cortex. The cortical areas include the cingulate cortex, hippocampus, parahippocampal cortex, and rhinal cortex. The various subcortical areas included in the limbic system extend down through the core of the brain to the upper part of the brain stem.

Second, there is considerable debate over what the function of the limbic system is. In addition to early ideas relating the limbic system to emotion and motivation, it has also now been implicated in the processing of sensory (especially olfactory) and cognitive information, learning and memory, sexual function (as part of a reward system serving emotional reactions), and motor functions. Most intriguing is the suggestion that the limbic system is concerned with mental integration of all functions related to personal ‘experience’.

As the number of brain areas said to belong to the limbic system has grown, its proposed functions have, not surprisingly, proliferated. It has been argued that such a heterogeneous collection of structures and functions can no longer be defined by a single general criterion and that the concept of the limbic system has become incoherent, even meaningless. An alternative view is that a quantitative approach (a ‘fuzzy limbic system’), in which different brain regions are described as having a certain degree of ‘limbic-ness’, would avoid the problem of having to define precise boundaries.

Despite controversy, the popularity and universal recognition of the term cannot be denied. This may be due partly to the very vagueness of the concept, which has often been used by authors as a convenience to refer to particularly poorly understood areas of the brain

Anatomy of the Brain

The image on the left is a side view of the outside of the brain, showing the major lobes (frontal, parietal, temporal and occipital) and the brain stem structures (pons, medulla oblongata and cerebellum).

The image on the right is a side view showing the location of the limbic system inside the brain. The limbic system consists of a number of structures, including the fornix, hippocampus, cingulate gyrus, amygdala, the parahippocampal gyrus and parts of the thalamus. The hippocampus is one of the first areas affected by Alzheimer's disease. As the disease progresses, damage extends throughout the lobes.
Glossary of Terms for an Anatomy of the Brain

Amygdala – limbic structure involved in many brain functions, including emotion, learning and memory. It is part of a system that processes "reflexive" emotions like fear and anxiety.

Cerebellum – governs movement.

Cingulate gyrus – plays a role in processing conscious emotional experience.

Fornix – an arch-like structure that connects the hippocampus to other parts of the limbic system.

Frontal lobe – helps control skilled muscle movements, mood, planning for the future, setting goals and judging priorities.

Hippocampus – plays a significant role in the formation of long-term memories.

Medulla oblongata – contains centers for the control of vital processes such as heart rate, respiration, blood pressure, and swallowing.

Limbic system – a group of interconnected structures that mediate emotions, learning and memory.

Occipital lobe – helps process visual information.

Parahippocampal gyrus – an important connecting pathway of the limbic system.

Parietal lobe – receives and processes information about temperature, taste, touch, and movement coming from the rest of the body. Reading and arithmetic are also processed in this region.

Pons – contains centers for the control of vital processes, including respiration and cardiovascular functions. It also is involved in the coordination of eye movements and balance.

Temporal lobe – processes hearing, memory and language functions.

Thalamus – a major relay station between the senses and the cortex (the outer layer of the brain consisting of the parietal, occipital, frontal and temporal lobes).

Autopsy

An autopsy is a medical procedure that consists of a thorough examination performed on a body after death, to evaluate disease or injury that may be present and to determine the cause and manner of a person's death.

The decision about an autopsy occurs at a difficult time for most families since they have just lost a loved one. Counselors or spiritual advisors who specialize in bereavement services may be available to help families through the process. Family members may consider an autopsy:
When a medical condition has not been previously diagnosed.
If there are questions about an unexpected death that appears due to natural causes.
If there are genetic diseases or conditions that they also may be at risk for developing.
When the death occurs unexpectedly during medical, dental, surgical, or obstetric procedures.
When the cause of death could affect legal matters.
When the death occurs during experimental treatment.
An autopsy may be required in deaths that have medical and legal issues and that must be investigated by the medical examiner's or coroner's office, the governmental office that is responsible for investigating deaths that are important to the public's health and welfare. Deaths that must be reported to and investigated by the medical examiner's or coroner's office can vary by state and may include those that have occurred:
Suddenly or unexpectedly, including the sudden death of a child or adult, or the death of a person who was not under the care of a doctor at the time of death.
As a result of any type of injury, including a fall, motor vehicle accident (MVA), drug overdose, or poisoning.
Under suspicious circumstances, such as a suicide or murder.
Under other circumstances defined by law.

In some of these deaths an autopsy may be required, and the coroner or medical examiner has the legal authority to order an autopsy without the consent of the deceased person's family (next of kin). If an autopsy is not required by law, it cannot be performed unless the deceased person's family provides permission.

An autopsy is generally performed by a doctor (pathologist) who has training and expertise in the examination of body tissues and fluids.

Should I have an autopsy done on my loved one?
Why It Is Done

An autopsy is done to:
Determine as precisely as possible what caused the death. This can sometimes provide family members with information about diseases or conditions that they also may be at risk for developing.
Confirm or exclude a disease diagnosis made before death (such as Alzheimer's disease). An autopsy also may be done to help understand how a given disease progresses or to determine the effectiveness of the treatment for that disease.
Document the presence of a disease that was undiagnosed before death.
Collect samples of body fluids or tissues for possible genetic testing. This is generally done only after discussion with the deceased person's family.
Collect evidence and information in criminal cases.
Help health departments or other government agencies identify and track a disease or potential public health hazard (such as a suspected contagious disease or contaminated drinking water).

What is DNA evidence?

Anything biological...
...blood, semen/sperm, hair,
...tissue, bones, organs, tooth pulp
...bodily secretions, saliva,
  ...sweat, urine, fingernails

DNA Evidence can be found virtually anywhere

- If it's biological, it's potential DNA evidence
- People constantly shed DNA
- There are 3,000,000,000,000 cells in the human body...only
about 100 are needed to obtain a DNA profile

There are two types of DNA testing used in criminal and non-criminal investigations:

Mitochondrial DNA:

1. Found in the cytoplasm of the cell
2. Runs along the maternal line  
- siblings share the same mitochondrial DNA
with their mother, grandmother, etc...
3. Can be found in hair shafts  
STR DNA

1. Found in the nucleus of the cell
2. PCR/STR DNA
3. Most commonly used in criminal
investigation casework

Uses of DNA in Criminal Investigations:

1. Identifying remains
2. Provides a Record of a particular person
being in a particular place
3. Ownership of personal items such as clothing
4. Determining Kinship

DNA collection

STR DNA technology changed the rules of evidence handling:
1. STR DNA increased sensitivity in testing
2. STR DNA increased awareness in evidence handling
  - As a result, the crime scene investigator must take great precautions to avoid
  the contamination of DNA evidence

In the past, all crime scenes needed to be protected against elements such as: Weather, Animals, 
and Traffic. With the inception of STR DNA testing, the crime scene investigator must also be 
concerned with scene contamination by crime scene personnel.

It is imperative that crime scene personnel take precautions to avoid contamination of DNA evidence:

1. Personal Protective Equipment (PPE) should be worn at all times.
- a single hair or drop of sweat from an unprotected person could leave an unknown DNA
 sample at the scene
2. When collecting DNA samples, the crime scene investigator should change gloves and forceps
after each item is collected, in order to avoid cross contamination between items of evidence
Documenting and Collecting DNA Samples:

1. Photograph stain/sample with and without a scale
2. Carefully swab the stain
  - preferably with no dilution
  - if stain is dry, use one drop of distilled water on the swab
3. Allow to air dry before packaging
4. Carefully label & seal (date, time, initials).
5. Maintain the chain of custody.
6. Provide information that you think may be important.
  - Note if items were collected from an unusual location or might  
  have possible contaminants.
7. Forward to the forensic lab ASAP

The proper collection and storage of biological evidence for DNA 
testing includes the following:

1. Biological evidence should be allowed to air dry before  
packaging.
  - ideally, it should be hung up in a clean dry room,
  away from direct sunlight
2. Biological evidence should be packaged in paper bags.
  - paper breaths, and allows the item of evidence to
  remain dry.
  - Plastic bags do not breath, and can cause moisture
  and mold to grow on the evidence, which in turn can
  have a negative affect on DNA testing
3. Biological evidence should be stored under laboratory
conditions as available resources permit - or in a
cool, dry climate, free of moisture
4. Place liquid items in collection tubes and refrigerate  

Before a DNA test can be performed, a control sample should be 
obtained from the victim, suspect, and any other persons whose DNA 
may be found on the item of evidence.

A control sample can be in the form of whole blood, a buccal swab, or 
any other known exemplar from the person in question. The easiest 
type of DNA control sample to obtain is a buccal swab. A buccal swab 
involves swabbing the inside of a person's cheek with an approved 
type of swab, for about 30 seconds, to secure the buccal cells that are 
found on the inside of the cheek. If done properly, a full DNA profile 
can be obtained from this swab.

–Before obtaining DNA control samples, consider having the person
in question sign a DNA consent form.  


DNA Collection:
RFLP (Restriction Fragment Length Polymorphism)
- this was the first type of DNA used in criminal investigations
- in order to run an RFLP test, a large biological sample was needed,
(usually at least the size of a quarter)
- this type of test usually provided a fairly discriminating result
- IE: a probability result of 1 in 1,000,000

PCR (Polymearse Chain Reaction) - first generation
- to run this type of test, a very small biological sample is needed, and that sample
can be amplified, or reproduced, to obtain a DNA profile
- the results are not as discriminating
- IE: a probability result of 1 in 25,000

STR (Short Tandem Repeat) second generation PCR
- This is the current form of DNA testing currently used in most forensic DNA labs.
STR testing provides the “best of both worlds”
- only a very small biological sample is required, (sometimes the sample is not even
visible to the naked eye.)
- STR DNA provides a very discriminating result
- IE: a probability result of 1 in 300,000,000,000

Age Determination

Although the actual age can not be determined by bones, the approximate age of the individual can be.

For age determination, different parts of the skeleton are more useful at different age ranges. The different age ranges include perinatal, neonate, infants and young children, late childhood, adolescence, young adult, and older adult.

The age of perinatals, those that are not yet born, can be determined by looking at bone size. This is because outside factors such as malnutrition on the mother's part is not going to affect the fetus' growth as much. During periods of low food intake the mother's body will give nutrients to the fetus, shorting the mother of nutrients.

Neonates, babies who have not gotten their teeth yet, are very difficult to accurately determine the age of because of individual variation of development. As a group, the neonates have no teeth, many areas of the skeleton have not fused together (especially the cranium and pelvis), and they have very small bones. 

Infants and young children will usually have some of their teeth in. The formation of teeth is often used in age determination for this group. Permanent teeth start to form at birth, thus the formation of permanent teeth is a relatively good age determinant. Some ossification has begun in the bones at this age, this means that soft parts of the bones become hard. However, this is not as good a determinant.

Late childhood is when the permanent teeth begin to come in. More bones begin to ossify.

Adolescence shows increased long bone length and fusion of the ends (or cap) to the shaft. This fusion is a particularly useful age technique. Each cap, or epiphysis, fuses to the shaft, or diaphysis, at a particular age range.

Young adults and older adults have several methods of age determination: closure of the cranial sutures; morphology of rib-ends, auricular surface and pubic symphysial; microstructure of bone and teeth; wear on teeth, incremental layers of cementum; and finally the 'Complex Method'. 

Cranial sutures (non-movable joints in the head) slowly fuse together, becoming obliterated in time. Although this has been known for many years, there has only been a weak association established between age and closure.

The morphology of rib-ends changes through age. Ribs are connected to the sternum by cartilage. The rib ends that meet with the cartilage are relatively flat at first, but during the aging process the ends become ragged and the cartilage becomes pitted. The irregularity of the rib ends has been found to relate to age at death.

The Circadian Clock: Good Rhythm May Play a Role in Type 2 Diabetes

Organisms ranging from bacteria to humans all rely on circadian rhythms as their molecular clocks. This complex network of molecular feedback loops not only helps to control wake-sleep patterns, but also helps to regulate body temperature, hormone levels, and metabolism, along with other systems. Whether it is from the disruption of sleep patterns through jetlag or seasonal affective disorder from the lack of sunlight, external stimuli can cause physical disturbances that are easily observable and can have serious outcomes. Along with these, perturbations can also occur that directly affect the molecular gears that keep the system running smoothly.

Although established Mendelian disorders such as familial advanced sleep-phase syndrome have been linked to circadian genes, complex disorders have remained more elusive. Recently, 3 papers published in Nature Genetics [1-3] reported such a link: a variant found within the melatonin receptor 1B (MTNR1B) is associated with both type 2 diabetes and fasting blood glucose levels.

Last summer, the first genome-wide association studies (GWAS) for fasting blood glucose levels were published using longitudinal cohorts.[4-6] Three markers were significantly associated. All were located in genes that were not surprising. The variants existed in the genes of glucokinase, glucokinase regulatory protein, and islet-specific glucose-6-phosphatase or glucose-6-phosphatase catalytic unit 2.[4-6] These 3 genes represented the most significant findings, but several other variants were near statistical significance after multiple hypothesis corrections for hundreds of thousands of tests. To gain statistical power, all 3 groups performed typing on an additional set of samples, thereby increasing their ability to discover alleles of lower penetrance. The 3 published papers represent the results of typing more than 60,000 individuals, leading to enough power to discern an association in MTNR1B as a true variant for fasting glucose levels.

Two papers, one by Lyssenko and colleagues[1] and the other by Prokopenko and colleagues on behalf of MAGIC (the Meta-Analysis of Glucose and Insulin-related traits Consortium),[2] along with several other groups who shared region-specific data, homed in on the same single nucleic polymorphism (SNP) within the MTNR1B locus. The SNP, rs10830963, maps to an 11.5-kilobase intron (regulatory region, not a protein-coding element) and does not appear to affect any known transcription factor-binding sites or cryptic splice sites. The effect of the variant reported from MAGIC and the additional cohorts of its meta-analysis, based on data from 35,812 subjects, had a per-allele effect of 0.072 mmol/L glucose and a P value of 3.2 x 10-50.[2] The 2 other studies, although they used slightly smaller datasets, showed a similar effect size and significance.

One difference in the study by Bouatia-Naji and colleagues[3] was that their highest association came from a different SNP, rs1387153. Although the strength of the association was very similar, this is a good example why functional analysis is the critical next step for all GWAS to determine the true causal variants. For MTNR1B, the true signal for association could be from either of the SNPs because they are in moderate linkage disequilibrium. Alternatively, the association could be from a separate variant for which the markers are both tagging. It is unlikely that the SNPs represent 2 separate signals because neither is significant after conditionally correcting for each other.

The ultimate goal of all GWAS is translation of the findings to a clinical setting, where they can have a positive impact on patients. However, this requires much more than just statistical significance. The current value of GWAS lies with the biological networks that the variant exposes as an underpinning of the phenotype. Both Lyssenko and colleagues[1] and Bouatia-Naji and colleagues[3] demonstrated direct expression of the MTNR1B gene in pancreatic beta cells. This finding, independently shown by both groups, reverses previous observations.[7] Preliminary data suggest that the G allele is linked with increased fasting blood glucose levels and may affect the MTNR1B transcription levels in the pancreatic islets of subjects older than 45 years of age.[1] 

These 3 papers provide another variant for fasting blood glucose levels, bringing the total attributable variance accounted for by the 4 known markers to around 1.5%.[2] It is of interest that while the association to fasting blood glucose levels is strong, the variant's link to type 2 diabetes is still very weak. This could be because conversion to type 2 diabetes status occurred in few patients in the longitudinal cohort during the study collection and follow-up periods. It could also be a hint that there are possible subtypes of diabetes that are manifested through different pathways, all of which lead to the same end-phenotype. Type 2 diabetes may actually represent several subtypes at the molecular, root level. Regardless, these findings strengthen prior research that our circadian rhythms can have strong influences on our metabolic system. Understanding and targeting malfunctions within our internal clock could prove a viable therapeutic strategy for type 2 diabetes

Can Insulin Be Delivered via Pneumatic Tube Systems?

insulin, like other protein pharmaceuticals, has a very well-defined structure, the integrity of which must be preserved to maintain its action. Unfortunately, conformational changes can occur due to physical, chemical, and thermal stresses causing protein denaturation and aggregation, ultimately leading to impaired activity or complete inactivity.[1] 

Shaking an insulin preparation can decrease the physical stability due to aggregation of the product, thereby lessening the potency. The actual protein structure can also be altered by denaturation. Mechanical stress such as vigorous shaking can cause visible clumping of the aggregates. However, the normal mechanical mixing ("rolling") of insulin suspensions to resuspend the product before administration should not cause instability.[2] 

In addition, use of external insulin pumps may cause unwanted insulin conformational changes and/or aggregation due to elevated temperature from body heat as well as mechanical agitation from activities of daily living.[3] 

Healthcare facilities, such as hospitals, often use pneumatic tube systems to facilitate the transportation of medications. These systems come in different shapes and sizes and use different forces for transport.[4] For these reasons, each facility is responsible for establishing its own guidelines pertaining to which medications can and cannot be sent via its pneumatic tube system, based on the system model the institution has implemented as well as the specific policies and procedures of the site.[5] Based on a review of guidelines for medication delivery via pneumatic tube system from several different hospitals, most do not send insulin or other protein-based drugs in this manner due to potential protein denaturation by mechanical stress.

A previously published statement from Eli Lilly and Company asserted that regular human insulin (Humulin®) and insulin lispro (Humalog®) products should not be delivered via the pneumatic tube system more than once and should have appropriate padding to deter breakage. No information is available on how tubing of insulin multiple times might affect the physical or chemical properties.[4] 

Based on the limited information available, it may not be advantageous to risk insulin instability in the interest of quick delivery. However, the final decision to send insulin by pneumatic tube should be based on the individual facility as well as any information that your tubing system manufacturer may be able to provide.

Finally, clinicians and patients should regularly inspect insulin products and discard any products with precipitants or changes in color or clarity.

انقلونزا الخنازير --swine flu

انفلونزا الخنازير والتي يسببها فيروس الانفلونزا " Influenza Virus " من النوع A تنتشر على شكل وباء في المناطق المصابة.. وهو من السلالة " H1N1 "..

ويتميز هذا النوع من الفيروسات بما يسمى " التحور الجيني - Antigenic Variation ".. والذي يستخدمه الفيروس
لإنتاج سلالات جديدة مختلفة الجينات.. وهذا هو محور الخطر في هذا المرض.. حيث أن هذه الخاصية تجعل من عملية احتواء الفيروس
ومكافحته وتصنيع اللقاحات الخاصة به عملية صعبة جدا..

المعرضون للإصابة بهذا الفيروس هم القريبون من الخنازير بشتى أصنافها.. كعمال مزارع الخنازير ومذابحها..
وللأسف الشديد.. فإن هذا الفيروس ينتقل من شخص لآخر أيضا عن طريق التنفس..
لذلك يعتبر هذا المرض من الأمراض الخطيرة التي يجب أن يتخذ لها الجميع الاحتياطات المناسبة لتجنب الإصابة بها..

وكما أوردت منظمة الصحة العالمية.. فإن هذا المرض لا تتم العدوى به من خلال لحوم ومنتجات الخنزير..
ولكن فقط من خلال استنشاقه أثناء التنفس.. خصوصا للقريبين من حيوانات أو أشخاص مصابين..

والقلق العالمى الحالى من المرض يتمثل فى أن أكثر الفئات العمرية إصابة به من الشباب فى حين أن الأنفلونزا العادية تصيب صغار السن أو كبار السن وتلك الفئة العمرية لم تصب حتى الآن فى المكسيك (أولى الدول في ظهور المرض ) ومعظم الإصابات بين الشباب .

وتتمثل أعراض المرض فى ارتفاع فى درجات الحرارة وكحة وألم بالجسم وصداع ورشح أو زكام وفى بعض الحالات قد يحدث قىء وإسهال، وفقدان الوعى الذى يمكن أن ينتهى بالوفاة .



والوقاية من انفلونزا الخنازير تبدأ بغسل الايدى بالماء والصابون عدة مرات بعد التعرض للحيوانات ، بالاضافة إلى الحذر الشديد أثناء التعامل مع الحيوانات المصابة والإبلاغ الفورى عند ظهور أية أعراض تشابه أعراض انفلونزا الخنازير خاصة اذا كان المبلغ مخالطا للخنازير ، وسحب عينات من انف وحلق المصاب للتأكد من إصابته بالفيروس .

كذلك ينبغي القيام بعادات النظافة العامة.. مثل غسيل اليدين بصفة متكررة، وتجنب الاتصال بالمرضى والابتعاد بقدر الإمكان عن الأماكن المزدحمة والغير نظيفة.. مع الراحة الجيدة والتغذية السليمة
 
لا أحد يعلم متى سوف تنتهي أزمة أنفلونزا الطيور التي حلت على معظم أنحاء الكرة الأرضية، فكل العلامات تشير إلي مواصلة انتشار هذا الفيروس حتى انتقل إلي الخنازير، ففي الوقت التي تحاول فيه الدول مواجهة هذا الفيروس، أعلنت منظمة الصحة العالمية عن انتشار حالات بشرية من أنفلونزا الخنازير التي تضرب المكسيك والولايات المتحدة، الأمر الذي يجعله قد يتحول إلى وباء عالمي ليصبح مصدر قلق يهدد العالم بأسره.

وتسبب ظهور فيروس أنفلونزا الخنازير في حالة من الذعر في الأمريكتين‏,‏ تحسبا للانتشار السريع لوباء جديد وفتاك‏,‏ ينتقل من الحيوانات الأكثر رواجا هناك إلي البشر‏.
وقد أعلن وزير الصحة المكسيكي جوزيه إنجيل، أن عدد ضحايا أنفلونزا الخنازير في البلاد ارتفع إلى 81 شخصاً خلال شهر أبريل الجاري.

وأكدت مارجريت تشان مدير عام منظمة الصحة العالمية، أن أنفلونزا الخنازير تنطوي على سلالة من فيروس "H1N1" الذي يمكن أن يتحول إلى وباء متفشٍ، مشيرة إلى أنه من المبكر التنبؤ بما إذا كانت أنفلونزا الخنازير ستنتشر في كافة أنحاء العالم أم لا.
وأكدت تشان أن المعلومات المتوافرة عن مرض أنفلونزا الخنازير لا تزال غير كافية، كما أن طبيعة المرض لا تزال تتضح يوماً بعد يوم.

ودعت المنظمة دول العالم إلى توخي الحيطة والحذر من تفشي فيروسات مشابهة بعد اكتشاف سلالات مرتبطة بالمرض في كل من المكسيك والولايات المتحدة.

وقد اتخذت السلطات الصحية في المكسيك إجراءات وقائية عاجلة، وأضافت المنظمة أن المرض الذي ينتقل من شخص إلى آخر أصبح يشكل "وضعاً خطيراً" يجب مراقبته جيداً.

ويعني إعلان المنظمة أنه يتعين على دول العالم كافة تصعيد إجراءات الرقابة والإبلاغ عن حالات انتشار المرض وخصوصا في أوساط الشباب البالغين.

وكانت منظمة الصحة العالمية قد أعلنت اعتزامها اتخاذ إجراءات طارئة من جانبها للسيطرة على الفيروس، إذ نصحت كل أعضائها بضرورة الاحتراس من انتشار أنفلونزا موسمية غير معتادة، وخاصة بين البالغين الأصحاء.

وكانت السلطات الصحية الأمريكية قد حذرت في وقت سابق من انتشار الفيروس، معلنة عن ظهور حالات جديدة، وبلغ عدد حالات الإصابة بالمرض المعلن عنها في الولايات المتحدة 8 حالات، كان آخرها طفل يعيش في ولاية كاليفورنيا، كما وصلت العدوى إلى ولاية تكساس أيضاً، وقد تعافى كل المصابين من المرض عدا واحد فقط لا يزال خاضعاً للعلاج.
وحذَّر الخبراء من ضرورة اتخاذ الاحتياطات اللازمة لمنع انتشار المرض، وكان بعض العلماء قد حذروا منذ سنوات من احتمال ظهور أوبئة ناجمة عن فيروسات تحمل عناصر جينية من كل من البشر والحيوانات.

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

Near Drowning

Near drowning is severe oxygen deprivation (suffocation) caused by submersion in water but not resulting in death; when death occurs, the event is called drowning.

When a person is submerged under water, water enters the lungs. The vocal cords may go into severe spasm, temporarily preventing water from reaching the lungs. When filled with water, the lungs cannot efficiently transfer oxygen to the blood. The decrease in the level of oxygen in the blood that results may lead to brain damage and death. Water in the lungs, particularly water that is contaminated by bacteria, algae, sand, dirt, chemicals, or a person's vomit, can cause lung injury.

Children younger than 4 years are at greatest risk of near drowning because their energy and curiosity can easily lead them to fall into water, including bathtubs and large buckets, from which they cannot escape. In teenagers and adults, near drowning is common in those who are intoxicated, who have taken sedatives, who have had a seizure, or who are physically impaired because of a medical condition. Spinal injuries and paralysis caused by diving accidents, which are likely to occur when diving into shallow water, increase the chances of near drowning. People who intentionally hold their breath under water for extended periods may pass out and be unable to surface, thus increasing the risk of near drowning as well.

Submersion in cold water has both good and bad effects. Cooling of the muscles makes swimming difficult, and dangerously low body temperature (hypothermia) can impair judgment. Cold, however, protects tissues from the ill effects of oxygen deprivation. In addition, cold water may stimulate the mammalian diving reflex, which may prolong survival in cold water. The diving reflex slows the heartbeat and redirects the flow of blood from the hands, feet, and intestine to the heart and brain, thus helping to preserve these vital organs. The diving reflex is more pronounced in children than in adults; thus children have a greater chance of surviving prolonged submersion in cold water than adults.

Symptoms and Diagnosis

People who are drowning and struggling to breathe are usually unable to call for help. Children who are unable to swim may become submerged in less than 1 minute compared with adults, who may struggle longer.

People who are rescued may have symptoms ranging from anxiety to near death. They may be alert, drowsy, or comatose. Some may not be breathing. People who are breathing may gasp for breath or vomit, cough, or wheeze. The skin may appear blue (cyanosis), indicating insufficient oxygen in the blood. In some cases, respiratory problems may not become evident for several hours after near drowning.

A doctor diagnoses near drowning based on the events and the person's symptoms. Measurement of the level of oxygen in the blood and chest x-rays help reveal the extent of lung damage.

Prevention

Swimming pools should be adequately fenced, because they are one of the most common sites of near-drowning accidents. In addition, all doors and gates leading to the pool area should be locked. Children in or near any body of water, including pools and bathtubs, need constant supervision, regardless of whether flotation devices are used. Because a child can drown in only a few inches of water, even water-filled containers, such as buckets or ice chests, can be hazardous.

A person should not engage in swimming or boating when under the influence of alcohol or sedatives. Swimming should be curtailed if a person feels or looks very cold. People who have seizures that are well controlled need not avoid swimming but should be careful near water, whether boating, showering, or bathing.

To decrease the risk of drowning, a person should not swim alone and should swim only in areas patrolled by lifeguards. Ocean swimmers should learn to escape rip currents (strong currents that pull away from the shore) by swimming parallel to the beach rather than by swimming toward the beach. Wearing life jackets when in boats is encouraged for everyone and is required for nonswimmers and for small children, who should also wear a life jacket when playing near bodies of water. Spinal injuries can be prevented by not diving into shallow water.

Treatment

Immediate on-site resuscitation is the key to increasing the chance of survival without brain damage. Attempts should be made to revive the person even when the time under water is prolonged. Artificial respiration and CPR should be provided as necessary (see First Aid: First-Aid Treatment). The neck should be moved as little as possible if there is a chance of spinal injury. Anyone who nearly drowns must be transported to a hospital, by ambulance if possible.

In the hospital, most people need supplemental oxygen, in some cases given with the help of a ventilator. A ventilator can deliver oxygen using high pressures to reinflate collapsed sections of the lungs. If wheezing develops, bronchodilator drugs can help. In some cases, treatment with oxygen in a high-pressure (hyperbaric) chamber may be tried.

If the water was cold, the person may have a dangerously low body temperature (hypothermia) and may need warming (see Cold Injuries: Hypothermia). Spinal injury requires special treatment (see Spinal Cord Disorders: Treatment).

If a person who was submerged has only mild symptoms, discharge home may be possible, but only after several hours of observation in the emergency department. If symptoms persist for a few hours, or if the level of oxygen in the blood is low, the person needs to be admitted to the hospital.

Prognosis

The factors that most influence the chances of survival without permanent brain and lung damage are the duration of submersion, the water temperature (cold water accidents can have a better outcome), the person's age (children are more likely to have a better outcome), and how soon resuscitation begins. People who have consumed alcoholic beverages before submersion are especially likely to die or develop brain or lung damage. Survival is possible after submersion for as long as 40 minutes. Almost all people who are alert and conscious upon their arrival at the hospital recover fully. Many people who need CPR can also recover fully.

Munchausen syndrome by proxy and sudden infant death

Everyone can empathise with the grief of parents who have lost a baby and even more so with the nightmare scenario of being wrongly held responsible for the child's death. It is therefore not surprising that the media showed intense interest in three recent cases in which mothers were accused of murdering their babies.¹ Nothing in this article should be construed as personal opinion on any individual case, but we are concerned that everything we have learnt over the past 40 years about sudden infant death syndrome and the spectrum of child abuse seems to have been forgotten.

Attacks on paediatricians who give evidence in child protection cases^w1 and journalists' use of phrases like "Meadow's discredited theory of Munchausen syndrome by proxy" have left the public and the health professions anxious and bewildered. In this paper we outline the evolving understanding of the relation between unexplained death in infancy and child abuse, draw lessons from recent events, and offer proposals for the future.

History

Caffey described what was undoubtedly child abuse in 1946^w2 but was reluctant to draw the obvious conclusions. Another 16 years passed before Kempe and colleagues published their seminal paper on the battered child syndrome in 1962.^w3 At about the same time, the problem of "cot death" began to attract interest. The phenomenon of unexplained death in previously well babies had been known for centuries and was blamed on overlying, "status thymolymphaticus," witchcraft, and many other causes, including infanticide.

The first major conference on cot death was held in Seattle in 1963, and the possibility that some such deaths might be due to foul play was raised but not pursued.² A second conference in 1969 adopted the term sudden infant death syndrome. The hypothesis that episodes of prolonged apnoeic pauses, possibly of genetic origin, might be the basis for sudden infant death syndrome was investigated by Steinschneider^w4 and many others. This resulted in the widespread adoption of apnoea alarms across the United States and subsequently in the United Kingdom.

Over the next decade doubts emerged about the apnoea hypothesis.² At the Baltimore conference in 1982 Southall et al reported, firstly, that after monitoring almost 10 000 babies they were unable to show any relation between apnoeic pauses and sudden infant death^w5-7 and, secondly, that they had found no case of a second cot death in the same family after following the siblings of over 200 babies who had died from sudden infant death syndrome.^w8

It is now known that sudden infant deaths do not follow a random pattern.^{w9 w10} Substantial relations exist between unexplained death and social background, social chaos, poverty, parental mental illness, prematurity, parental smoking and substance misuse, and pre-existing symptoms of illness in the baby.^w11 The relation with prone sleeping position is still not fully explained, but the United Kingdom's Back to Sleep campaign was associated with a large reduction in incidence.³ However, a completely satisfactory explanation is still elusive in many infant deaths.

Link between child abuse and sudden infant death

The evolving interest in unexplained death and child abuse converged when several families who had apparently lost several babies from sudden infant death syndrome were subsequently found to have murdered their children.^{2 w12} In 1982, Taylor and Emery introduced the concept of gentle battering to describe cases in which suffocation by an object or a hand led to the infant's death.^w13 Several strands of evidence support this. Some parents of babies thought to have died from sudden infant death syndrome have subsequently admitted suffocating their infant. Other unequivocal evidence of physical abuse is sometimes found. The siblings of suspected cases (sometimes including genetically unrelated adopted siblings) are more likely to have died than would occur by chance.

Such scenes have left many paediatricians reluctant to take on child protection cases Credit: CHRIS YOUNG/AP

Southall et al used covert video surveillance to investigate apparent life threatening events and showed that parents do indeed cause suffocation by deliberate airway obstruction. They emphasised that the aim of covert video surveillance was to protect the child rather than to secure convictions.^{4 w14} Covert video surveillance is now an accepted procedure when there is no other way of confirming a diagnosis of suffocation.

Meanwhile, other more subtle forms of abuse were identified.⁵ In 1976, Money and Werlwas described a case of dwarfism caused by starvation in which the parents presented misleading accounts of the child's illness, suggesting an analogy with Munchausen's syndrome.^{w15 w16} The term Munchausen syndrome by proxy received wider publicity when in 1977 Meadow reported a case with deliberate fabrication of bizarre symptoms.⁶ Many manifestations of Munchausen syndrome by proxy are now recognised—for example, intentional poisoning by salt or medicines and fictitious accounts of seizures.⁷

It gradually became clear that parentally induced apnoeic attacks^w17 and cases of deliberate suffocation should be regarded as a form of Munchausen syndrome by proxy. Contrary to the impression created by the recently announced review of 5000 child protection cases, non-accidental suffocation is not a common paediatric diagnosis. A UK-wide survey of Munchausen syndrome by proxy in 1992-4 identified just 128 cases in two years, of which only 32 were related to suffocation.⁸ However, a growing number of case reports suggest that many manifestations of Munchausen syndrome by proxy are underidentified because of lack of professional expertise and public awareness.

The most recent estimate is that around 10% of all otherwise unexplained sudden infant deaths may be caused by deliberate suffocation, though this probably varies over time and between populations.^9-11 Bleeding from the nose and mouth suggests deliberate suffocation,¹¹ and the presence of haemosiderin laden macrophages in the lungs might signify previous episodes of suffocation.^{w18 w19} However, in a single case neither the autopsy findings nor other background information are likely to provide unequivocal evidence.¹²

Recurrent sudden infant death syndrome

Since the Back to Sleep campaign, sudden infant death syndrome has become less common in the United Kingdom and the social class gradient has become steeper. In low risk families, sudden infant death affects just over 1 in 8500 babies. The probability of any two randomly selected low risk babies dying of sudden infant death syndrome is that number squared (about 1 in 73 million), but this does not apply in an individual family that has already had one baby die from sudden infant death syndrome. Chance has no memory, so a low risk family would have a 1 in 8500 risk of a second death.

There is little evidence of familial clustering of sudden infant death syndrome, and more than one unexplained infant death in the same family suggests two other possibilities^w20: homicide or inherited conditions such as metabolic disorders (for example, medium chain acyl coenzyme A dehydrogenase deficiency), cardiac arrhythmias (including prolonged QT syndrome), immune deficits predisposing to infection, and abnormalities of ventilatory control.² These conditions probably account for a small fraction of cases,^w21-23 but their existence and the possibility that some may remain to be discovered add a dimension of uncertainty in any death where autopsy findings are negative or equivocal.

Is Munchausen's the best label?

Only a minority of parents who deliberately harm their children have exhibited features of Munchausen's syndrome themselves,^{13 14} and little is known about the psychopathology underlying the fabrication of illness in older children. It probably differs from that described in parents who induce illness in infants by suffocation or other means. Some parents who induce illness in infants have a personality disorder^w24 or (rarely) a psychotic illness.¹¹ In the postnatal period women have reported a variety of fantasies, obsessions, and anxieties regarding their babies,^{w25 w26} including concerns about their ability to care for the child and worries that they might cause them harm.^w27 An association seems to exist between postnatal depression and sudden infant death.^w28-30

As there is no single psychological profile in Munchausen syndrome by proxy,^{10 w31-34} and the label makes unwarranted assumptions about the parent's mental state and motivation, many UK paediatricians feel that the term should be abandoned. The preferred term is now fabricated and induced illness.¹⁵ Fabricated and induced illness is seen as part of a spectrum of child abuse, and death caused by suffocation is at the severe end of that spectrum. The term keeps the focus on the presenting features of the child who needs to be protected, rather than on the supposed psychopathology of the parent.

Learning the lessons

Recent events have prompted some soul searching about the ways professionals respond to the unexpected death of an infant. We agree with Meadow's comment in his first paper on Munchausen syndrome by proxy: "doctors, although (occasionally) deceived, will rightly continue to believe what most parents say, most of the time."⁶ Stanton and Simpson reported a tragic case in which a mother who clearly loved her baby nevertheless smothered her. They commented on the "difficult cognitive processes involved for a paediatrician to shift from being the parent's ally in attempting to alleviate a child's suffering, to suspecting the parent of being the agent responsible for the child's suffering."^w26 This may explain why some professionals offer conflicting and sometimes improbable explanations for injuries to children, leading to difficulties for the judiciary and increased risks for children.

We need to rethink our approach to cases of unexplained infant death, particularly with families who have had more than one such tragedy. We stress the importance of being alert to inconsistencies in the history, scene of death inquiries,¹⁶ collection of background data,^w35 and an autopsy by a paediatric or forensic pathologist with appropriate training, working to a standard protocol. In future this may sometimes need to include a search for genes that might be associated with conditions predisposing to sudden death. Parents have a right to expect that their baby's tragic unexplained death will be investigated as thoroughly as would be the case for any other citizen.

There are important lessons for the judiciary as well. In a criminal trial the standard of proof is "beyond reasonable doubt." In the United States, a Court of Appeals judgment stated that there might be insufficient evidence in any one child death to prove murder or infanticide, but evidence of repeated incidents was admissible as evidence of non-accidental deaths.^w12 We agree, but at the same time feel that securing a conviction for murder is rarely the priority in cases where evidence rests on epidemiological data, probabilities, and clinical findings whose interpretation is subject to several opinions.^{17 18 w36}

What is the alternative?

We believe that complex child deaths and child protection cases should normally be handled by civil proceedings, following the procedures introduced by the Wolff reforms. There should be a non-adversarial meeting of experts from each of the key agencies and disciplines to share and review all the evidence. More than one opinion should be obtained on difficult issues. The emphasis must be first on assessing and minimising the risk to any other children cared for by the parents and secondly on management of the parents' needs.^{7 14} Although the reasons why parents kill their babies are poorly understood, perhaps many deserve sympathy and treatment rather than imprisonment.

Some cases will nevertheless result in criminal proceedings. Professionals who offer expert evidence must not promote ideas that are unsupported by research but should present the facts as they currently see them. In an adversarial legal system, it is for the lawyers and the judge to make sure that experts explain to them, and to the jury, the limits of knowledge and the extent of uncertainty.

Expert evidence

Professionals expect to be accountable for, and challenged about, the reliability of their research, evidence, and interpretation. Nevertheless, they must be able to undertake their duties without fear of ill informed attacks on their competence and integrity by the media or parental organisations. Orchestrated campaigns intended to discredit expert opinion¹⁹ have made professionals increasingly reluctant to participate in child protection cases. A recent survey undertaken by the Royal College of Paediatrics and Child Health found that 14% of paediatricians have had an official complaint made against them in respect of child protection issues arising in general paediatric practice. The often vexatious and malicious nature of these complaints is illustrated by the fact that although many resulted in unpleasant local or national publicity, only a tiny proportion were upheld.²⁰ Of 87 paediatricians referred to the General Medical Council whose cases have been completed, none was found guilty of serious professional misconduct.

Summary points Recent court cases regarding unexplained infant deaths have raised questions about the diagnosis of Munchausen syndrome by proxy and professional judgment Many paediatricians are now reluctant to take part in child protection cases A non-adversarial approach needs to be introduced to deal with sudden infant deaths The public needs to be better informed of research on sudden infant death and child abuse

Conclusions

We must restore the faith of the public and the professions in the child protection systems that are vital for a civilised society. Munchausen syndrome by proxy has captured the public imagination, but there is still much that we do not know about other aspects of child abuse. For example, questions remain unanswered about subdural bleeding and the interpretation of physical signs in child sexual abuse. We need urgently to review procedures and to fund more research into the causes, mechanisms, and diagnosis of child abuse. And we call on journalists, lawyers, and the judiciary to ensure that they are well informed about the mass of evidence and data gathered over the past 40 years in child protection.
Source: B M J