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Prognosis • Overall lasix 100 mg discount, testicular torsion carries a relatively poor prognosis with regards to the in- volved side discount 40 mg lasix with visa. Within 10 h buy lasix with visa, >80% of testes are 150 Emergency Medicine lost and by 24 h the number reaches almost 100% purchase lasix uk. Reasons for delay include hesita- tion in seeking medical advice as well as misdiagnosis. It has been demonstrated that torsion of one testicle leads to decreased blood flow to the contralateral side, with relative hypoxia and apoptosis. The subsequent decrease in germ cells has been implicated in decreased fertility of these patients. Periuethral Abscess Background • Periurethral abscess is a rare but life-threatening infection of the male urethra and periurethral areas. Genitourinary Emergencies 151 • Retrograde urethrography can show the presence of urine extravasation but provides overall much less information and diagnostic data than ultrasonography of anterior urethral strictures. Management • The mainstay of treatment for periurethral abscesses consists of surgical drainage and antibiotics. Fournier’s Gangrene 6 Epidemiology • First described in 1764 by Jean-Alfred Fournier as a gangrene of the penis and scro- tum, necrotizing fasciitis of the perineum, genital or perianal area affects both sexes and is a true emergency. Pathophysiology • Although seen in children and women, Fournier’s gangrene is more common in males (10:1) and was originally described as a severe gangrenous infection of the scrotum. These organisms work synergistically, with the aerobic bacteria keeping the oxy- gen tension low enough to allow anaerobic growth. Hypocalcemia, caused by chelation of calcium by the bacte- rial lipases, has been reported as an important diagnostic clue, and hyponatremia may also be present. Treatment • Treatment of Fournier’s gangrene is aimed at stabilizing the thermodynamics of the patients and beginning antimicrobial infection as rapidly as possible. Penile Emergencies Phimosis • Condition in which the foreskin cannot be retracted behind the glans penis • By 3 yr of age, 90% of foreskins can be retracted • Fewer than 1% of males have phimosis by age 17 • Usually not painful, but may produce urinary obstruction with ballooning of foreskin • May occur as a result of recurrent balanitis • May lead to chronic inflammation and carcinoma • Treatment in boys older than 4 or 5 yr of age and in those who develop balanitis or balanoposthitis is topical corticosteroids (0. This loosens the phimotic ring in two-thirds of cases and usually allows the foreskin to be retracted manually. Genitourinary Emergencies 153 Paraphimosis • Condition in which the foreskin has been retracted and left behind the glans penis, constricting the glans and causing painful vascular engorgement and edema of the foreskin distal to the phimotic ring. Short-term ice-packing may help as an analgesic or a local anesthetic block of the penis may be indicated in marked discomfort. Reduced paraphimosis should be scheduled for a dorsal slit or circum- cision at a later date, as paraphimosis tends to recur. Balanitis 6 • Inflammation of the glans, which occurs usually as a result of poor hygiene, from failure to retract and clean under the foreskin. Balanoposthitis • Severe balanitis, in which the phimotic band is tight enough to retain inflammatory secretions, creating a preputial cavity abscess. Penile Fracture • Acute tear of the tunica albuginea, presenting with acute swelling, discoloration, and tenderness. Peyronie’s Disease • Condition that results in fibrosis of the tunica albuginea, the elastic membrane that surrounds each corpus cavernosum, producing curvature of the penis during erection. Priapism • Prolonged painful and tender erection that persists beyond or is not related to sexual activity 154 Emergency Medicine • Occurs most commonly in patients with sickle cell disease but can also occur in those with advanced malignancy or coagulation disorders, those on total parenteral nutri- tion, certain drug therapy, and after trauma or idiopathically. An evaluation of the management of periurethral phleg- mon in 272 consecutive cases at the Cook County hospital. Outcome of medical treatment of bacterial abscesses without therapy drainage: Review of case reported in the literature. Clinical and radiological findings in patients with gas forming renal abscess treated conservatively. Percutaneous drainage in the treatment of em- physematous pyelonephritis: 10-yr experience. Evaluation of urethral strictures and associated abnormalities using high-resolution and color doppler ultrasound. Acute bacterial nephritis: A clinicoradiologic corre- lation based on computed tomography. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Acute focal bacterial nephritis: Focal pyelo- nephritis that may simulate renal abscess. Medically sound, cost-effective treat- ment for pelvic inflammatory disease and tuboovarian abscess. Bilateral emphysematous pyelonephritis: A case report and review of the literature. Transvaginal catheter drainage of tuboovarian abscess using the trocar method: technique and literature review. Acute gas-producing bacterial renal infection: Correla- tion between imaging findings and clinical outcome. The protective effects of nitric oxide on the contralateral testis in prepubertal rats with unilateral testicular torsion. A retrospective review of pediatric patients with epididymitis, testicular torsion, and torsion of testicular appendages. Is the conservative management of the acute scro- tum justified on clinical grounds? Suspected testicular torsion: A survey of clinical practice in North West England. Capsaicin effectively prevents apoptosis in the contralateral testis after ipsilateral testicular torsion. Glucocorticoid hormone can suppress apoptosis of rat testicular germ cells induced by testicular ischemia. Docherty Part A: Selected Obstetric Emergencies Ectopic Pregnancy Definition • Any pregnancy occurring outside the uterine cavity Location • 95% of all ectopic pregnancies occur in the fallopian tubes with 5% being ovarian or abdominal pregnancies. Incidence • Annually 70,000 cases of ectopic pregnancy occur in the United States with a current incidence of 20 ectopics per 1000 pregnancies. Clinical Presentation • Classic triad—Seen in <50% of patients • Abdominal or pelvic pain • Missed menstrual period with associated abnormal vaginal bleeding • Pelvic examination demonstrates a tender adnexal mass • The pelvic pain when it is present is usually unilateral, severe and sudden, although there may be significant variability in quality, intensity, duration and location. Differential diagnosis of ectopic pregnancy • Appendicitis • Salpingitis • Ovarian torsion • Threatened abortion • Gastroenteritis • Urinary tract infection in early pregnancy • Urolithiasis in early pregnancy • Dysfunctional uterine bleeding • Normal intrauterine pregnancy • Corpus luteum cyst • The presence of a palpable adnexal mass or fullness with associated tenderness is present in up to two-thirds of patients however its absence does not rule out the possibility of an ectopic pregnancy. Uterine decidual tissue casts may be passed in 5-10% of patients and can be mistaken for tissue from a spontaneous abortion. In the case of ec- topic pregnancy rupture, peritoneal signs may be present on abdominal examination secondary to hemoperitoneum. In the unruptured ectopic pregnancy, the vital signs are more likely to be normal. Rupture of an Ectopic Pregnancy • Rupture of an ectopic pregnancy is associated with: • syncope • sudden onset of severe pelvic/abdominal pain • hypotension • When an ectopic pregnancy ruptures, there occurs hemorrhage into the peritoneal cavity leading to peritoneal signs. A progesterone level >25 ng/ml is consistent with a viable intrauterine pregnancy with a 97. Lower levels however do not reliably correlate with the location of the patient’s pregnancy. Initial values may be normal, however a low Hg/Hct initially or an acute drop over the first several hours is concerning when considering the possibility of ectopic pregnancy in your differential diagnosis. May be helpful for identifying other potential entities in your differential diagnosis once ectopic pregnancy has been ruled out. The possible options are laparoscopy with appropriate surgical intervention if an ectopic pregnancy is identified. Indications for methotrexate usage in ectopic pregnancy • Ectopic pregnancy unruptured and <3. The procedure is done by aspiration of the con- tents from the pouch of Douglas entered by way of the posterior fornix. The aspira- tion of nonclotting blood is considered a positive test that is suspicious for ectopic pregnancy. Vaginal Bleeding in the First Half of Pregnancy Forty percent of pregnant patients present with some degree of vaginal bleeding 7 during early pregnancy. The vast majority of these spontaneous abortions occur prior to 8 wk of gestation. At least half of all spontaneous abortions are due to genetic abnormali- ties; the rest being due to a combination of factors such as uterine abnormalities, incompetent cervix, progesterone deficiency, tobacco or alcohol use.

Unilateral enlargement is found in unilateral hydronephrosis and renal cell carcinoma order lasix with amex. In Abdominal problems 218 Handbook of Critical Care Medicine women cheap lasix 100 mg without prescription, large fibroids proven 100mg lasix, uterine and ovarian malignancies maybe felt lasix 100mg free shipping. Appendicular abscess, which occurs if appendicitis is not treated surgically early, is felt in the right iliac fossa. Helpful in determining if malaena is present, if the patient has not yet had a motion. Tenderness in the vaginal fornices is present in pelvic inflammatory disease; an abscess or ectopic gestation may be felt by the experienced clinician. It is best therefore, to have a proper vaginal examination performed by a gynaecologist in patients where a pelvic pathology is strongly suspected. In addition to the above, look for signs and symptoms of developing or worsening sepsis and organ failure. Increased abdominal pressure and abdominal pain can restrict respiratory movements and predispose to respiratory infection. Intravascular fluid depletion can easily be tested by passively raising the legs - a rise in blood pressure indicates volume depletion. It is, like pulmonary embolism, the other ‘blind spot’, and is often missed until late. Condition Gross appearance Protein, Serum- Cell Count Other tests g/dl ascites albumin gradient Red blood cells, White Blood cells, g/dl >100,00/µL per µL Cirrhosis Straw-coloured or <25 (95%) >1. Adequate hydration, use of non-ionic contrast, and pre-treatment with N-acetylcysteine will prevent this to an extent. It is most commonly seen in patient with ascites; liver cirrhosis is the commonest cause; it can also occur in patients with nephrotic syndrome or chronic renal failure. Secondary peritonitis is bacterial infection of the peritoneal fluid secondary to bowel perforation, infection or abscess formation in the gastrointestinal tract or trauma. Tertiary peritonitis is where peritoneal inflammation persists due to nosocomial infection. Abdominal problems 222 Handbook of Critical Care Medicine Peritonitis is diagnosed by finding a positive ascitic fluid bacterial culture and an elevated ascitic fluid absolute polymorphonuclear leukocyte count 3 (250 cells/mm ). Protein concentration >1 g/dL, low ascitic fluid glucose concentration (<50 mg/dL) and Lactate dehydrogenase greater than the upper limit of normal for serum are also supportive. Secondary bacterial peritonitis should be treated with cefotaxime and metronidazole. Treatment should be given for at least 5 days, and reviewed based on clinical recovery and cultures. Intra-abdominal hypertension Intra-abdominal pressure is the pressure within the abdominal cavity. While assessment of tenseness of the abdominal wall can give a rough idea of intra-abdominal pressure, it is usually estimated by measuring intravesical pressure. Intra-abdominal hypertension is a sustained increase in intra-abdominal pressure above 12mmHg. It can result in gut dysfunction; increased bacterial translocation occurs across the gut wall, causing multi-organ failure and death. Treatment of intra-abdominal hypertension o Improvement of abdominal wall compliance by sedation and neuromuscular paralysis o Nasogastric aspiration o Gastric prokinetics: metoclopramide, erythromycin o Rectal tube and enemas o Colonic prokinetics: neostigmine o Endoscopic decompression of large bowel o Drainage of ascitic fluid o Reduction of capillary leak of fluid o optimise serum protein levels by giving albumin o diuretics o Surgical or percutaneous drainage of intra-abdominal abscesses If abdominal compartment syndrome occurs, laparotomic decompression of the abdomen is necessary. Bowel ischaemia Acute mesenteric ischaemia This is sudden onset of intestinal perfusion due to either arterial embolism, arterial or venous thrombosis, or vasoconstriction with low blood flow. Embolism is the commonest cause, often due to valvular heart disease, atrial fibrillation and myocardial infarction. Advanced age, atherosclerosis, low cardiac output states, intra- abdominal malignancy are risk factors. Venous thrombosis, due to acquired or inherited hypercoagulable states is an important cause in young patients. Factor V Leiden is the most common cause of hypercoagulability; other causes include protein C /S deficiency, hyperhomocysteinaemia and antiphospholipid syndrome. Fortunately, colonic ischaemia is often non-gangrenous, which resolves without sequalae. Abdominal problems 224 Handbook of Critical Care Medicine Around 15% of patients with ischaemic colon will develop gangrene and its life threatening complications. Patients classically develop rapid onset severe periumbilical pain, with relatively little physical signs. Later on, as bowel infarction occurs, the abdomen becomes grossly distended, bowel signs disappear, and features of peritonitis appear. It is vital that the diagnosis is made early, as outcome is much better if interventions are taken early; unfortunately the early features are easily missed. A high index of suspicion should be maintained in any patient with risk factors for bowel ischaemia presenting with rapid onset central abdominal pain. Dobutamine is the best choice because it is thought to have the least vasoconstrictor effect on the splanchnic circulation. Specific therapeutic options are; o Papaverine infusion given intra-arterially following cannulation of the mesenteric artery. This relieves secondary vasospasm o Thrombolysis o Angioplasty and stenting o Embolism is usually treated with surgical embolectomy o If bowel infarction has developed, laparotomy and surgical resection is required Long term anticoagulation with warfarin is usually required. Abdominal problems 225 Handbook of Critical Care Medicine Intestinal obstruction This is often due to mechanical obstruction. Common causes are: o Small intestinal obstruction o adhesions from previous surgeries o hernias o intussusception o malignancy o Crohn’s disease o Colonic obstruction o Colonic carcinoma o Sigmoid volvulus o Diverticular disease Clinical features are of colicky abdominal pain, vomiting and absolute constipation (no passage of stools or flatus). Vomiting is more profuse in small bowel obstruction, and may even be absent in large bowel obstruction. Examine the hernial orifices for possible obstruction, and do a rectal examination. Investigations: plain abdominal radiograph may show distended bowel with multiple fluid levels in small bowel obstruction. Air-insufflation during barium enema (to obtain a double contrast barium enema) is risky and must be performed only with care. Prophylactic antibiotics are usually given; cephalosporins with metronidazole provide reasonable cover. Sigmoid volvulus can sometimes be treated by passage of a flexible sigmoidoscope to un-kink the bowel. If the patient is deteriorating and developing signs of severe sepsis with increasing pain, exploratory laparotomy is indicated. In the case of strangulation or intussusception, the gangrenous Abdominal problems 226 Handbook of Critical Care Medicine bowel is resected and anastomosis peformed. Most large bowel obstruction is due to colon cancer, and resection of the affected bowel is necessary; if possible primary anastomosis is performed. In severely ill patients, a defunctioning colostomy is performed, with secondary anastomosis later, once the patient has recovered. If bowel sounds are normal, and there are no signs of obstruction, this may not be of any serious consequence. Opiate analgesics cause constipation, and calcium channel antagonists such as verapamil are also a cause. Most of the time, simple laxatives such as lactulose, liquid paraffin, or enemas are adequate treatment. Paralytic ileus is common after abdominal surgery, and usually resolves spontaneously. If paralytic ileus persists for longer than 5 days, a plain x-ray abdomen should be performed to exclude mechanical obstruction. Acute colonic pseudo-obstruction or Ogilvie syndrome mimics acute large bowel obstruction, except that there is no mechanical obstruction. Symptoms and signs are similar to mechanical obstruction, and massive dilatation of the large bowel can occur, with perforation. Severe sepsis, electrolye imbalance, abdominal surgery, and steroid use are causes. Surgical decompression maybe required if the colonic diameter exceeds 10cm on plain abdominal radiograph. Toxin-induced gastroenteritis is usually self limiting and rehydration is adequate.

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The therapeutic benefits that methods and therapies described as follow may variously involve reduction of ischemia buy generic lasix online, as well as release of local endorphins lasix 40 mg low cost, and possibly naturopathic physical medicine in a safe discount lasix 40mg without prescription, enkephalins (Baldry 1993 order cheap lasix, Kiser et al 1983), and also a healthful and clinically integrated manner degree of mechanoreceptor stimulation affecting pain consistent with naturopathic principles and transmission (Melzack & Wall 1994). Naturopathic manipulative treatment as a therefore follows in response to simple applications of traditional, integral and essential part of focused compression or repetitive shear loading. Naturopathic medical educational programs model in most schools of manual medicine educate and train naturopathic physicians to (DiGiovanna & Schiowitz 1991, Greenman 1989). Other proposed educate and train naturopathic physicians to models for effective management of musculoskeletal safely and effectively utilize physiotherapeutic dysfunction incorporate somatic as well as behavioral medical devices, modalities, procedures and features. Langevin & Sherman (2006) have described injection therapies a pathophysiological model in which a broader – and 5. Reproduced with permission from Langevin & Sherman (2006) integration, functional training and therapeutic Whether applying pressure to help deactivate a trigger exercise programs point, or to take out slack prior to application of a high 6. Naturopathic physical medicine continues to velocity thrust technique, or in mobilizing and articu- evolve and integrate new therapeutic methods lating joints, or in use of basic massage methods, load consistent with naturopathic principles and is a feature – indeed, these treatment methods are philosophy. Examples of manipulative treatment where benefit Load is also a key word (see Chapter 2) used to has resulted in treatment of pathological conditions describe stressors (of all sorts, not just biomechanical (see separate list of beneficial massage influences later ones). All forms of load create adaptive demands, and In Chapter 10 a number of the conditions listed in when prolonged or repetitive this becomes a feature Box 7. These thoughts highlight the observation that all Therapy as a form of stress forms of therapy, manual or otherwise – involving The use of the word ‘load’ has been prominent in anything from the insertion of an acupuncture needle, these descriptions of manual methods of treatment. Placebo interventions Structural abnormalities Fear, Distress or injury Movement Pain Scoliosis Spondylolisthesis Acute ‘back sprain’ Psychosocial factors Disc herniation Pathogenic Pain behavior mechanism Job dissatisfaction Connective Neuroplasticity Genetic tissue plasticity predisposition to connective Genetic differences tissue injury in sensory proccesing Direct tissue mechanical stimulus Acupuncture Massage Yoga Manipulation B Figure 7. Based on physical examination criteria in the tion of subgroups of patients with low back pain who peer-reviewed literature, patients in the respond favorably to particular therapeutic interven- Classification group were placed into one of tions has been (and continues to be) an important four categories requiring: objective of clinical research (Borkan et al 1998). Of the many classification • stabilization approaches that have been developed, those reported • traction. The model reported by Delitto et al (1995) has been shown to be a clinically useful tool. The symmetry and standing and primary goal of treatment during this stage is seated flexion tests suggested to be pain modulation. Lumbar pattern Unilateral symptoms without • Stage 2 patients can accomplish basic signs of nerve root functions, but are limited in their activities of compression; lumbar side- daily living. The objective of treatment hypomobility at this stage is considered to be to modulate pain Adapted from Fritz et al (2003). A negative Gaenslen sign (pain provocation test 4-week mark, demonstrating a statistically significant with the patient supine, one hip taken into full difference (p = 0. The test is positive if pain is reported in Clinical prediction the sacroiliac joint (and/or thigh) on the side of the hyperextended leg. For many of these the answer may lie • Symptoms not distal to the knee in a quite different form of categorization, based on • At least one hip with internal rotation greater the answer to a simple question: Do the symptoms than 35° change for the better based on positioning? Centralization/peripheralization It is suggested that the more of these feature that are present, the greater the chance of success with manip- categorization ulation (Box 7. McKenzie (1981) has identified three major groups of Flynn et al suggest that, of these features, the most back pain patients. To understand the differences we significant is ‘duration of symptoms less than 16 need to look at the processes of centralization and days’. These are: extending the low back, or flexing it) that result in distal symptoms reducing in that limb, i. Longer than 3 weeks’ duration of symptoms becoming more proximal, even temporarily, 2. No hypomobility on spinous process springing The importance clinically is that anything that 4. Reduced discrepancy in left-to-right hip exercise, change of position or manual treatment – is medial rotation contraindicated as it will slow down recovery, and may significantly increase symptoms. In such individuals it is considered that posteroanterior spring test (hypomobility + pain) normal tissue is being strained by prolonged inappropriate posture. The recommendation is that exercise, repetitive Biopsychosocial factors: a broader movement (even if briefly uncomfortable) and classification approach manual treatment should aim to reduce O’Sullivan (2005) has produced a much wider model fibrosis and increase elasticity. This helps to illustrate commonly restricted in one or more directions, why taking a generic rather than a cookbook approach with local pain being felt at the end of range. Exercise, factor containing a number of elements and variables, repetitive movement and treatment should aim all of which interact (Fig. In this last Tight/loose indicators category, if there are no positions, movements or treatments that encourage centralization, the When evaluating the status of joints and soft tissues prognosis is poor, with poor responses likely to there should be a sense of the degrees of tension and almost all therapeutic interventions (Aina et al relaxation (the shorthand words for these two states 2004). The tissues provide the palpat- ing hands or fingers with a sense of these states which can be interpreted to reflect the tissue’s current degree Using directional preference in of activity, comfort or distress. If form closure is a feature, there should also be A useful example of ‘tight/loose’ features can be every effort to restore normal balance to the soft observed in sacroiliac dysfunction. These factors closure tests should be conducted (supine and prone) might actually be offering the body an effective means in which these features are evaluated (Lee 1997). If problems involving Treatment of these features (tight hamstrings form closure are confirmed as a major feature, then an housing active trigger points) would be unlikely to Chapter 7 • Modalities, Methods and Techniques 209 Latissimus dorsi Longissimus lumborum Iliocostalis lumborum Lumbar intermuscular aponeurosis Iliocostalis Erector spinae Multifidus Gluteus Lumbodorsal thoracis maximus aponeurosis fascia Sacrotuberous Biceps femoris Sacrotuberous Biceps femoris A Figure 7. B Enlarged view of the lumbar spine area showing the link between biceps femoris, the lumbar intermuscular aponeurosis, longissimus lumborum, iliocostalis lumborum and multifidus. Reproduced with permission from Vleeming et al (1997) have a beneficial effect until the actual stability issues variations of hydrotherapeutic and/or electrothera- of the joint are addressed – and indeed stretching the peutic attention. And apart from possible pathological changes (disc Making choices herniation, arthritis, inflammation as examples), there Depending on which elements from this selection of may also be hyper- and hypomobility conditions, staging, categorizations, identified imbalances (tight/ fibrotic changes, active myofascial trigger points, loose) and biopsychosocial factors are operating, as (core) muscular weakness, modified motor control, well as the degree of chronicity and other features, altered muscular recruitment patterns, breathing therapeutic choices might include application to local pattern and postural disorders. Level of normal Along with the classification models outlined above, resistance each of these variables can offer clues as to which of the range of potential treatment and/or rehabilitation Alarm Stage of approaches might be the most likely to enhance func- response exhaustion tionality, without undue side-effects. This defines what Selye termed the stage of To simplify decision-making it is useful to be reminded exhaustion, or collapse, where frank disease and death of the message (see Chapter 1) from which clinical follow in an inexorable progression as self-regulating decision-making in care of all health problems can mechanisms fail (see Fig. However, where Examples include the following: degenerative processes have advanced to a certain stage, recovery may be impossible, although stabiliza- • As we have seen in the discussion above, using tion and modulation of symptoms may remain a the concepts of categorization it is possible, in possibility. Treatment should offer support to the Pointers to clinical choices are not always as clear as processes involved, although recovery without these two examples, in which circumstances the gath- any therapeutic input is probable. Since naturopathic medicine embraces self-regulation Self-regulation needs help to remove obstacles as the key element in recovery or health improve- to recovery and to enhance functionality. There may be This is therefore a fundamentally naturopathic means value in a more deliberate consideration of such of treatment. Evaluation of the various modalities Selye’s general adaptation syndrome (see Chapters 1 and 2) describes a process, following the initial alarm The naturopathic dimension stage of adaptation, that continues until adaptation For clarity in making therapeutic choices we should potential is exhausted. One of the limiting factors in refer back to the summary towards the end of Chapter Chapter 7 • Modalities, Methods and Techniques 211 Box 7. To enhance functionality (better posture, enhanced there is evidence of risk, this is highlighted – and the breathing function, greater mobility, etc. To ease symptoms without adding to the patient’s cervical area (Haldeman et al 2002a, Hurwitz et al adaptive burden (how sensitive and vulnerable, and 2005) are discussed in detail in Box 7. To support self-repair, self-regeneration, self-healing Validation of efficacy processes (see items 1, 2 and 3 above). To take account of the whole person, the context, Living as we do in an age of evidence-based medicine, and not just the symptoms (see item 6 below). To identify where the individual is in the spectrum that show efficacy (or lack of it) for the methods and of adaptation – judging as best possible the techniques under discussion. Develop a focused question based on the client 1 in order to evaluate how and where modalities, context, the specific intervention and the techniques and methods relate to the principles expected outcome of the intervention. Critically analyze the validity, reliability and The modalities, techniques and methods described generalizability of the research. Integrate the evidence with clinical experience from the perspective of their place within this frame- and client needs, to develop an intervention work of naturopathic objectives. A naturopathic filter needs to be incorporated into • Does the method/technique/modality this process in order to ensure that ‘results’ do not significantly add to the individual’s adaptive conflict with basic principles. There are, for example, a • If symptom relief is the objective, is this likely wide range of different methods of stretching soft to be achieved at the cost of self-regulation? In tissues, and these are compared in relation to their other words, is the method suppressing or known and purported value in different therapeutic retarding the normal healing processes?

Co-morbidity with other psychiatric illness- - High levels of anxiety are often found in elderly patients in the early stages of dementia order generic lasix pills. Recent studies revealed that different genes showed evidence for association with specific types of anxiety disorders purchase lasix overnight delivery, such as panic disorder cheap lasix 40 mg with amex, social phobias or generalised anxiety disorder (Academy of Finland discount lasix express, 2008). Specific anxiety disorders and their clinical features Phobic disorder Phobia occurs commonly in the elderly with increasing frailty and prevalence ranges from 0. These disorders provoke clinically significant levels of distress and disability due to high levels of anxiety. They are usually heralded by a traumatic event usually of a physical nature and may have had a public manifestation. However, in spite of the complete resolution of the physical event, the psychological impairment persists. There are 3 main types of phobia: Agoraphobia- prevalence in the elderly is estimated to range from 1. These individuals may be rendered housebound because many are terrified by the thought of collapsing and being left helpless in public. It can occur with or without panic attacks but always causes anxiety symptoms during the situation. This fear may spiral out of control if there is no obvious escape route and embarrassment is perceived. Consequently the individual learns to avoid these situations and this avoidance in turn reinforces the fear. Fear can also occur merely in anticipation of the anxiety-provoking situation and symptoms are not better explained by another mental or physical disorder. Specific phobias- fear is experienced only in the presence of a particular object or situation. Onset is usually in childhood and prevalence in the elderly is estimated to range from 3. Anxiety is restricted to the presence of the specific phobic object or situation, all other diagnostic criteria are similar to those of social phobia. Panic disorder Panic attacks and panic disorder are rare and symptomatically less severe in the elderly, estimates of prevalence ranges from 0. However, the prominent physical symptoms of panic disorder may result in patients being referred instead to cardiologists, neurologists and gastroenterologists. In one study of cardiology patients with chest pain and no coronary disease, one third of those aged 65 and over met the criteria for panic disorder. Several attacks occur within a period of one month and symptoms are not better explained by another psychiatric or physical disorder. Panic attacks are often co-morbid with other psychiatric disorders, particularly depression, and it may be severe enough to mask depressive features. In addition the condition should not meet the criteria for other anxiety disorders, psychiatric or physical disorders. Onset in old age is rare, the majority starting before the age of 25 and usually running a chronic fluctuating course into old age especially if left untreated. Obsessional symptoms may appear at any age following head injury or cerebral tumour. The individual recognizes them as originating from his own mind but is unable to resist them despite repeated attempts at doing so. Compulsion is the irresistible urge to perform an act repeatedly despite the futility of that action. Insight is usually fully intact and the patients usually regard these symptoms as unreasonable and are distressed by them so much so that their functioning is impaired to a greater or lesser degree. Obsessions and or compulsions should last at least two weeks and not arise as a result of another mental disorder. The experience of the event is sometimes regarded as “near death” for the individual and might actually have involved the death of another person. Symptoms begin within six months of the event and should be present for more than a month, are severe enough to cause distress and impair functioning. Heightened emotional arousal in the form of exaggerated startle response, hypervigilance, emotional numbness, insomnia, irritability and poor concentration that were not there prior to the incident. Older persons who are frail have a greater tendency to feel threatened than their younger counterparts. Acute stress reaction This happens when symptoms of anxiety occur in response to extreme physical or psychological trauma. The risk of developing this disorder is increased if physical exhaustion or organic factors are also present as in the elderly. It is usually of brief duration, onset is within a few hours and it lasts only hours or days. Patient is initially ‘dazed’ with associated reduction in attention and consciousness, inability to comprehend stimuli and disorientation. This is followed by either withdrawal from the situation or agitation and severe distress, depression, anger and despair. The preceding event is a life changing one that is associated with significant subjective distress and emotional disturbance. The major difference is that the anxiety that follows lasts longer and emanates from difficulty in adjusting to the prevailing situation. Onset of symptoms is within one month of the event and duration is usually less than six months. Brief (< one month) or prolonged mild depressive reaction might accompany the anxiety symptoms. Symptoms may impair functioning but do not meet the criteria for another psychiatric diagnosis. Community prevalence is about 5% and in the elderly, an adjustment disorder often follows physical illness or disability, moving into a residential or nursing home and bereavement. Supportive psychotherapy, social and occupational support are the mainstay of treatment. Psychological therapy is more effective than pharmacological therapy and should be used as first line where possible. Pharmacological therapy is also effective but should be used as second line for most anxiety disorders. High doses of medication are often required and there may be delay in onset of action of up to 12 weeks. Sensorium remains intact but deficits in cognitive function may manifest over time. The individual loses their sense of uniqueness and individuality with a persistent feeling that their innermost thoughts and ideas are being infiltrated upon and hijacked by others, with their actions and impulses under bizarre external influences and belief in the validity of these experiences may grow to become unwavering. There may be perceptual disturbances in terms of delusions and hallucinatory experiences most especially in the auditory modality. Sensory impairment (mainly deafness) Genetic predisposition and neurodevelopmental factors have lesser impact than in earlier onset psychosis. Clinical features Schizophrenia The symptoms of schizophrenia are divided into positive (symptoms that are typical only to schizophrenia, they include the group listed 1 to 5 below) and negative (symptoms that are 968 not typically found only in schizophrenia but may be found in other disorders, they are the symptoms listed on number 6 below). Auditory hallucinations- running commentary, 2 (includes command hallucinations) and rd 3 person or other hallucinatory voices coming from some part of the body. Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions or sensations; delusional perception. Thought disorder- breaks in the train of thought resulting in incoherent or irrelevant speech or neologisms. Negative symptoms such as flat or blunted affect (apathy), poverty of thought and speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form relationships (asociality), lack of motivation (amotivation). Persistent hallucinations in other modality (olfactory and gustatory hallucinations) when accompanied by delusions without clear affective component, persistent overvalued ideas, occurrence every day for months on end. Catatonia (stupor, excitement, waxy flexibility, negativism, mutism and posturing). The diagnosis of schizophrenia should not be made if depressive or manic symptoms are prominent and extensive unless it is clear that psychotic symptoms predate the affective disturbance. If both psychotic and affective symptoms develop at the same time, then a diagnosis of schizoaffective disorder should be made. If affective symptoms predate the psychotic symptoms, then a diagnosis of either mania with psychotic symptoms or depression with psychotic symptoms should be made. Other associated symptoms are depression, agitation, cognitive impairment and soft neurological signs. New positive symptoms rarely develop in old age, but old hallucinations and delusions may persist.