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MANAGEMENT OF THE SIDE EFFECTS OF RADIATION THERAPY IN CHILDREN: SIDE EFFECTS OF HEAD AND NECK IRRADIATION

Jul 22

Posted by admin in Cancer | Comments off

I. ACUTE EFFECTS
A. Radiation mucositis
1. Prevention
a. Remove orthodontic braces before treatment.
b. If a metal dental prosthesis or filling is in place, cover it with a substance such as chewing gum, dental rolls, dental wax, or fluoride carriers to avoid local scatter of electrons.
c. Observe scrupulous oral hygiene; brush after each meal; rinse frequently as below.
2. Treatment
a. Rinse mouth with a lukewarm solution of 1 tablespoon of salt and 1 tablespoon of baking soda in a quart of water and/or diluted hydrogen peroxide solution for several minutes, 5 or 6 times a day.
b. Consider Ulcerease.
i. Swish or gargle 5-10 mL for 15 seconds, then spit out.
ii. Use every 2 hours while awake.
iii. Use with caution for child under 6 or those unable to avoid swallowing medication.
c. Advise the patient to avoid spicy, very warm, very cold, or acidic food or drink and exposure to tobacco smoke.
d. Vigorously address patient’s nutritional status.
i. Mucositis will discourage adequate nutrition.
ii. Mucositis will resolve only when the patient is in positive nitrogen balance.
e. Use a prophylactic anti-inflammatory/antibiotic solution.
Recipes vary; this one is representative. Use tetracycline syrup 2 g, or erythromycin syrup 2 g, Nystatin oral suspension, 2 million U, and hydrocortisone 50 mg. Mix in distilled water with flavoring to make 120 mL. Take 5 mL, swish and swallow q.i.d.
f. Allow the patient to take a 3- or 4-day weekend off treatment. If mucositis is severe, a longer break until healing is well under way may be necessary.
g. Manage pain.
i. Give acetaminophen 10 mg/kg and/or codeine 1 mg/kg PO q4h.
ii. A solution of diphenhydramine (Benadryl) and Maalox in equal parts has been effective as a soothing mouthwash; small amounts can be swallowed without ill effect. Do not exceed the maximum diphenhydramine dose of 5 mg/kg/day.
iii. In an older child, who can expel the material, 296 viscous lidocaine (Xylocaine) may be used as a swish and gargle before and during meals as needed. Be aware of the increased risk of cardiac arrhythmia from lidocaine in the pediatric patient. Adding 296 lidocaine to above diphenhydramine/Maalox solution (1:1:1) is also useful.
iv. Severe mucositis may require systemic opiates.
Radiation candidiasis 1. Prevention
Scrupulous oral hygiene is needed; unfortunately, this is of limited efficacy
2. Diagnosis
Clinical evidence of candidal infection is sufficient to start treatment.
3. Treatment
a. Manage candidal infection immediately and vigorously
b. Each of the following has been used with success.
i. Fluconazole
(1) Dose
Children: loading: 10 mg/kg PO or IV, then 3-6 mg/kg PO q.i.d.
Teenagers: loading: 200 mg PO or IV, then 100 mg PO q.i.d.
(2) Available
Tablet: 50, 100, or 200 mg Injection: 2 mg/mL Suspension: 10 or 40 mg/mL
ii. Nystatin oral suspension
(1) Dose
Infants and young children: swab and swallow Older children: 1-2 mL q.i.d., swish and swallow Teenagers: 5 mL swish and swallow q.i.d.
(2) Available: suspension: 100,000 U/mL
iii. Clotrimazole troche
Dose: 10 mg (1 tablet) sublingually, 5 times daily
iv. For refractory cases: ketoconazole
(1) Dose
Children: 5 mg/kg/day PO, rounded up to the nearest 50 mg (maximum 10 m/kg/day, divided b.i.d.).
Teenagers: 200-400 mg PO q.i.d.or divided b.i.d.
(2) Available
Tablet: 200 mg
Suspension: 100 mg/mL
c. Once a candidal infection has occurred during radiation therapy, it is important to continue oral candidal treatment as prophylaxis against recurrence until the end of radiation therapy.
C. Sialadenitis
1. Painful inflammation of salivary glands in direct radiation beam occurs occasionally, at variable intervals after the start of radiation.
This condition is usually self-limiting, as it disappears when the affected glands cease to function.
Treat symptomatically with anti-inflammatory agents.
D. Loss of taste
This is most noticeable in patients with tongue in treatment field.
Some patients complain of metallic taste, others of cardboard taste of all food.
Eventually, sense of taste disappears.
Reassure the patient/parents that this is temporary; taste returns at least partially to normal.
E. Ear
1. Otitis externa
a. Etiology
i. Skin reaction
ii. Superimposed infection
b. Management
See above, Section IB under “Side Effects of Skin Irradiation.”
i. Wicks
ii. Otic antibiotics
iii. Steroid creams
2. Decreased hearing/sensation of water in ear
a. Etiology: eustachian tube swelling and obstruction
b. Treatment
i. Give diphenhydramine (Benadryl).
(1) Dose
Children: 1 mg/kg per dose PO (maximum 5 doses per day)
Teenagers: 10-50 mg per dose PO q6-8h
(2) Available
Tablet: 25 or 50 mg
Syrup: 12.5 mg/5 mL
ii. Consider inserting tympanic tubes.
II. LATE EFFECTS
A. Dry mouth 1. Etiology
a. Doses greater than approximately 2700-3000 cGy in conventional fractionation obliterate salivary function in treated glands; with chemotherapy this threshold may be lower.
b. Severity of dry mouth depends on the volume of salivary glands irradiated.
2. Prevention
Pilocarpine hydrochloride 5 mg PO q.i.d. daily during and 1 month after radiation therapy to the salivary glands has been shown to decrease the severity of dry mouth in adults. This use in pediatric patients has not been established.
3. Treatment (since prevention is not often possible)
a. Perform life-long scrupulous oral hygiene.
b. Carry water at all times for sipping.
c. Consider pilocarpine hydrochloride, as above.
i. Available: 5 mg tablet
ii. Consistently use twice a day for at least 1 month before assessing response
iii. Safety and efficacy of this drug in children not
established
d. Sugarless chewing gum helps many patients.
e. Fat may help.
A teaspoon of corn or olive oil as needed, especially at bedtime, has been reported to help.
f. Room humidifier should be used at night in winter.
B. Radiation caries
1. Etiology
Dry mouth, leading to altered oral flora, not a direct effect of radiation on the teeth
2. Prevention
Life-long scrupulous oral hygiene
C. Osteoradionecrosis
This complication is seen less commonly in pediatric patients than would be expected from experience in adults; it is so devastating when it occurs that prevention is vital.
All patients requiring radiation to the mouth or parotid glands should be seen by a dentist as soon after diagnosis as possible to start a rigorous program of dental prophylaxis.
Healthy teeth should not be removed.
Permanent teeth in poor condition, requiring removal in the foreseeable future, should be removed before treatment.
After dental extractions, delay radiotherapy approximately 2 weeks for healing.
Prophylactic antibiotics should be administered for all dental work performed after head and neck radiation therapy
Ocular
1. Cataracts
a. Etiology
i. This is a direct effect of radiation to the lens.
ii. Dose dependent: >200 cGy in single fraction or 500 cGy fractionated to the lens virtually assures the development of cataract.
iii. Busulfan and steroids can exacerbate the development of cataract.
b. Treatment
Surgical removal of lens
2. Dry eye
a. Etiology
i. This is caused by loss of lacrimal gland function.
ii. Dose dependent: >~3000 cGy in conventional fractionation may lead to permanent loss of function of the lacrimal gland.
iii. Severity of dry eye depends on the volume of gland treated; sparing minor glands can diminish the problem.
iv. Dry eye can cause corneal ulceration and severe pain.
b. Treatment
i. Use over-the-counter (OTC) eyedrops during the day. Preservative-free eyedrops are preferred, such as carboxymethylcellulose 1.0% ophthalmic solution
ii. Use OTC viscous lubricant or white petrolatum/mineral oil lubricant ophthalmic ointment at bedtime.
iii. Early ophthalmologic evaluation is vital to prevent complications of dry eye.
iv. Painful, sightless dry eye can lead to enucleation as last resort.
3. Retinitis
a. Etiology
i. Apparently vasculitis-microangiopathy
ii. Dose and fraction size dependent
iii. Latency 6 months to 3 years
iv. Can lead to neovascular glaucoma
b. Treatment
i. Methods are not well understood.
ii. Appears similar to diabetic retinopathy, so similar
management seems reasonable.
iii. Laser treatment has been used.
iv. Early referral to a retinal ophthalmologist is indicated if retina receives >5000 cGy in conventional fractionation
E. Auditory 1. Etiology
a. Radiation alone rarely damages hearing.
b. Cisplatin concomitantly or after radiation to middle ear can increase hearing loss.
c. Cisplatin before radiation is not as ototoxic.
d. Hearing loss progresses gradually, up to 6 years after radiation.
F. Neuroendocrine
See above, Section I1IB under “Side Effects of Cranial Irradiation.”
*45\168\2*

THE PROCESS PARADIGM IN PSYCHIATRY: INTRODUCTION TO THE SOCIAL WORK PROJECT – ‘TRICKS AND TRAPS’ OF THE CLIENTS

Jul 12

Posted by admin in Anti-Psychotics | Comments off

The problems involved in working with severely disturbed people were a combination of what the team experienced as ‘tricks and traps’ of the clients, pressure from the client’s environment to make him more adapted, internal stress between the team members, internal difficulties of each individual on the team, and a lack of training in signal awareness. A quasi-medical approach to the patient of viewing him as if he had a brain disease often clouded accurate perceptions. Furthermore, difficulties arose which were outside the scope of the video taping, difficulties involving interactions with the client’s neighbors, police and court. In addition, I realize now in retrospect, after having spent hundreds of hours studying and transcribing the case material, that I, too, learned a lot about where I needed to learn more. There were times I wasted energy conflicting with instead of following the client. Frequently things happened so quickly that I was not able to understand the process structure until after having studied the tapes.
*29\227\8*

THE PROCESS PARADIGM IN PSYCHIATRY: INTRODUCTION TO THE SOCIAL WORK PROJECT – ‘TRICKS AND TRAPS’ OF THE CLIENTS The problems involved in working with severely disturbed people were a combination of what the team experienced as ‘tricks and traps’ of the clients, pressure from the client’s environment to make him more adapted, internal stress between the team members, internal difficulties of each individual on the team, and a lack of training in signal awareness. A quasi-medical approach to the patient of viewing him as if he had a brain disease often clouded accurate perceptions. Furthermore, difficulties arose which were outside the scope of the video taping, difficulties involving interactions with the client’s neighbors, police and court. In addition, I realize now in retrospect, after having spent hundreds of hours studying and transcribing the case material, that I, too, learned a lot about where I needed to learn more. There were times I wasted energy conflicting with instead of following the client. Frequently things happened so quickly that I was not able to understand the process structure until after having studied the tapes.*29\227\8*

HOW TO DIAGNOSE BDD IN CHILDREN AND ADOLESCENTS: RESEARCH AND TREATMENT

Jul 5

Posted by admin in Anti Depressants-Sleeping Aid | Comments off

While a lot more research is needed on how to effectively treat BDD in children and adolescents, in my experience they respond to SRIs similarly to adults. It appears that about half to two thirds of adolescents will respond to a particular SRI, and if one SRI doesn’t work, another one may. Like adults, adolescents appear to often need fairly high SRI doses (e.g., an average of 50-60 mg/day of fluoxetine or 150-200 mg/day of sertraline), which they usually tolerate well. Like adults, they may need to take an SRI for as long as 3 months before they begin to feel better.
CBT has also been used to treat adolescents with BDD, although no published research has been done in this age group. It’s reasonable to expect that CBT approaches that work for adults would also work for adolescents. However, the treatment needs to be modified somewhat to make it suitable for adolescents and so parents can participate. Non-CBT psychotherapy, added to an SRI and/or CBT, may also be helpful for some adolescents, to help them with other problems or issues they may have. For example, family therapy may help both the adolescent and family members cope better with BDD. Or an adolescent who responds well to an SRI after being out of school and housebound for several years will probably benefit from therapy aimed at helping him or her re-enter school and establish friendships.
It’s important to find a psychiatrist, other physician, or qualified therapist who is familiar with BDD and knowledgeable about its treatment. This requires first recognizing BDD and taking it seriously. Early and successful treatment has the potential to minimize or even eliminate BDD symptoms and prevent the longer-term disability that the disorder so often causes. It enables an adolescent to get back on track, resume normal functioning, and live an enjoyable and healthy life.
*162\204\8*

LIMITATIONS AFTER A HEART ATTACK: WHEN CAN I TAKE PART IN GAMES ? WHAT SORT OF EXERCISE IS IDEAL FOR ME ?

Jun 30

Posted by admin in Cardio & Blood-Сholesterol | Comments off

Q.   When can I take part in games ?
A.   While exercise is good for the heart, excessive exercise can be dangerous. Games, therefore, should be played strictly with the idea of deriving fun and exercise. All s competitive games are prohibited after a heart attack. Your physician can advise you, after checking your exercise tolerance, when precisely you should start playing games, lighter ones first, and more strenuous ones later.
Q.   What sort of exercise is ideal for me ?
A.   This aspect has been discussed in detail in the previous chapter.
Q.   I want to go on a pilgrimage to Vaishnodevi, which is located in the hills near Jammu. When can I go?
A. You must reach that state of physical fitness in which you can tolerate the rail and bus travel as well as travel by pony and on foot, and also be able to wait in a queue for an almost indefinite amount of time. It will take some months, or may be a year, before such a state can be attained provided the damage to your heart muscle has not been extensive and there have been no complications. Your physician will evaluate your fitness for such a venture by examing your exercise tolerance.
Similarly, going on Haj will entail travel by air or ship to Mecca, local travel by taxi and on foot. The same remarks as above apply to the pilgrimage for Haj.
*95\328\8*

EFFECTIVE TREATMENTS OF CANCER

Jun 17

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Although cancer treatments have changed dramatically over the past 20 years, surgery, in which the tumor and surrounding tissue are removed, is still common. Today’s surgeons tend to remove less surrounding tissue than previously and to combine surgery with either radiotherapy (the use of radiation) or chemotherapy (the use of drugs) to kill cancerous cells.
Radiation works by destroying malignant cells or stopping cell growth. It is most effective in treating localized cancer masses. Unfortunately, in the process of destroying malignant cells, radiotherapy also destroys some healthy cells. In addition, in recent years, many scientists have come to suspect that radiotherapy may increase the risks for other types of cancers. Despite these qualifications, radiation continues to be one of the most common and effective forms of treatment.
When cancer has spread throughout the body, it is necessary to use some form of chemotherapy. Currently, over 50 different anticancer drugs are in use, some of which have excellent records of success. A chemotherapeutic regimen including four anticancer drugs in combination with radiation therapy has resulted in remarkable survival rates for some cancers, including Hodgkin’s disease. Ongoing research into new drug development will result in compounds that are less toxic to normal cells and more potent against tumor cells. Current research indicates that some tumors may actually be resistant to certain forms of chemotherapy and that the treatment drugs do not reach the core of the tumor. Scientists are currently working to circumvent resistance to chemotherapeutic drugs and to make tumor cells more vulnerable throughout treatment.
Whether used alone or in combination, radiotherapy and chemotherapy have possible side effects, including extreme nausea, nutritional deficiencies, hair loss, and general fatigue. Long-term damage to the cardiovascular system and many other systems of the body can be significant. It is important to discuss these matters fully with doctors when making treatment plans.
Substances found in nature, such as taxol (originally found in Pacific Yew trees), are being synthesized in laboratories and tested on a variety of cancers. Other compounds, including those derived from sea urchins, are rich in resources for anticancer drugs.
*31/277/5*

UPPER RESPIRATORY TRACT INFECTIONS: VIRAL PHARYNGITIS

Jun 4

Posted by admin in Anti-Infectives | Comments off

Most community-acquired cases of acute pharyngitis are viral. In general, viral pharyngitis is a self-limited illness isolated to the upper respiratory tract. Treatment is generally supportive with antipyretics, analgesics, and adequate oral intake. Some viral causes of pharyngitis have more systemic consequences.
Infectious Mononucleosis
Infectious mononucleosis is a clinical syndrome consisting of fever, lymphadenopathy, and pharyngitis, caused the Ebstein-Barr virus. Lymphadenopathy may be present in the anterior cervical and posterior cervical regions, but axillary and inguinal nodes may also be involved. There may be a prodome consisting of fever; malaise that precedes this classic triad. In addition to these features, splenomegaly is common, and hepatitis can occur. Pharyngitis and fatigue may persist for longer than is usually suspected with other forms of pharyngitis. Clues to the diagnosis include lymphocytosis, often with more than 10% lymphs. Testing for heterophil antibodies can confirm the diagnosis. Treatment is generally supportive. Patients should be instructed not to participate in sports or other vigorous activities because of the risk of splenic rupture. Corticosteroids may be needed for patients with severe thrombocytopenia, hemolytic anemia, or upper airway edema that threatens airway obstruction.
Acute Human Immunodeficiency Virus Infection
Acute HIV infection may cause a syndrome of fatigue, weight loss, fevers, rash, and pharyngitis. It should be considered in any young adult with these symptoms. Patients should be questioned for risk factors for HIV. Lymphadenopathy, splenomegaly, and transaminitis are also often present. Laboratory testing may show lymphopenia.
Influenza
Influenza may also manifest with pharyngitis but tends to manifest with more severe constitutional symptoms than most viral upper respiratory tract infection. The presence of an epidemic in the community may provide a clue to the diagnosis.
*38/348/5*

SKIN IN ADOLESCENCE: COSMETICS AS AN AGGRAVATING FACTOR OF ACNE

May 29

Posted by admin in Skin Care | Comments off

Although acne is due to a combination of genetic and hormonal factors, certain influences can exacerbate it and so should be avoided.
It can be hard for acne sufferers to withstand the pressures of advertising, enticing them to use a lot of inappropriate cosmetics. Because they may lack self-esteem, acne sufferers tend to be vulnerable and are likely to be misleading by cosmetic sales staff, whose main interest is to sell something, irrespective of its effect. On the other hand, people with acne may benefit psychologically from using an appropriate make-up which helps to camouflage blemishes without adversely affecting the skin.
Skin care products, particularly moisturizers and creamy cleansers, tend to aggravate acne by blocking the oil glands which in turn leads to more blackheads, whiteheads and pimples. Moisturizers do not prevent ageing or wrinkles and are only useful for people with dry skin. Because acne is caused by excessive oil production, people with acne have predominantly oily skin and therefore will not benefit from using moisturizers. Only if the skin becomes excessively dry is a moisturizer necessary. A light, oil-free preparation should be used, for example, Neutrogena moisturizer, Nivea Visage, Nutrasorb or Almay lotion for oily skin. There products will not aggravate pimples, while heavier moisturizing creams will only exacerbate acne. Vitamin E cream, which is often falsely promoted to help heal scarring, is of no real value for acne scars and may even worsen the acne by clogging the pores. Non-creamy cleansers should be used, for example mild soaps such as Almay oil control soap, Clinique soap bar or Neutrogena for oily skin, or liquid cleansers such as Cetaphil Lotion, Almay foaming cleanser or Yardley foaming cleanser.
Many people with acne are discouraged from using foundation make-ups. The majority of foundations is oil-based and so is unsuitable. But there are ranges of ‘oil-free’ make-up which can be safely used. Examples here are Maquicontrole (Lancome), Demi-matte (Estee Lauder), Revlon New Complexion oil-free make-up, Clinique Oil Free foundation, Max Factor Pan-cake or oil-free foundation, Shiseido ‘Pureness’, and Almay oil-free foundation. True water-based foundations such as Clinique Pore Minimizer and other ‘shake’ lotions are too dry and spread poorly on the skin, giving uneven coverage and an overall unsatisfactory cosmetic result. All powders (dusting and compressed powders) are very suitable for acne skin and in fact absorb oil. Contrary to popular belief, they do not clog the pores.
Medicated ‘cover sticks’ may also be used directly on acne spots. They often contain an active anti-acne ingredient plus pigment to disguise the blemishes. Examples include Clearasil, Eskamel, Oxycover and Clinique medicated cover sticks. On the other hand, ordinary non-medicated cover sticks contain oil and aggravate acne.
Use of an appropriate foundation and powder should be encouraged if this will improve an individual’s self-confidence, while other skin care products should be avoided or kept to a basic minimum. Despite this counseling, many young women are so brainwashed by cosmetic advertising that they feel moisturizers are essential for their skin’s wellbeing. They complain that their face feels tight after washing, that it must need a cream to soften it. The truth is that ‘tight’ skin is less likely to sag and wrinkle, and so should be seen as an advantage.
*16/150/5*

THE CARBOHYDRATE ADDICT’S DIET: LOW-CARBOHYDRATE MEAL FOODS

May 16

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Your Low-Carbohydrate Meals may include any of the foods in the following list. Remember that your portions should be of average size. In preparing the Low-Carbohydrate Meals, you may broil, boil, saut?, bake, poach, or roast. Eggs may be fried in a pat or two of butter or margarine. Low-Carbohydrate Snacks contain the same low-carbohydrate foods but are about half the quantity.
Meat and Poultry
* Up to four to six ounces of any of the following meats, poultry, or meat substitutes at each of your two Low-Carbohydrate Meals:
Bacon (or breakfast meat substitutes that contain fewer than four grams of carbohydrate per serving)
Beef
Cheeseburgers (with regular or with low-fat cheese)
Chicken
• Chicken roll (without filler or added sugar)
• Chicken wings
Corned beef
Dried beef
Duck
Frankfurters (beef, chicken, or other all-meat varieties only; none with sugar or fillers are allowed)
Ham or smoked turkey
Hamburgers
Lamb
Liver (chicken only)
Luncheon meats, including salami and bologna (all-meat varieties only; none with sugar or fillers are allowed). You may want to choose low-fat, low-salt varieties of luncheon meats.
Pastrami
Pork
Sausages (all-meat varieties only; none with sugar or fillers are allowed)
Turkey or turkey loaf (no sugar or fillers)
Turkey wings
Veal
Fish and Shellfish
* Approximately four to six ounces of any of the following fish or seafood at each of your two Low-Carbohydrate Meals. In tuna, salmon, and other seafood salads, be sure to avoid any filler, bread crumbs, or relish.
Bass
Bluefish
Clams
Cod or scrod
Crabmeat
Flounder
Haddock
Halibut
Lobster
Mackerel
Oysters
Perch
Salmon (cooked, canned, or fresh)
Sardines (in oil or tomato sauce)
Scallops
Shrimp
Smelt
Sole
Sturgeon
Swordfish
Trout
Tuna
Fats, Oils, and Dressings
* Two to three tablespoons of any of the following fats, oils, and dressings at each of your Low-Carbohydrate Meals, less if you are following low-fat dietary guidelines.
Butter or margarine
Corn oil
Mayonnaise (regular, substitute, or light)
Olive oil
Peanut oil
Safflower oil
Sesame oil
Sunflower oil
Soybean oil
Vegetable oil
Commercially available prepared salad dressings (note that low-cal varieties are higher in carbohydrates)
Eggs and Dairy Products
* Up to two ounces daily of milk, cream, or half-and-half in one cup of coffee
* Two eggs (or equivalent egg substitutes); two to three ounces of any cheese; or one-half cup of cottage or farmer cheese.
* You may also combine two eggs with one ounce of cheese in preparing an omelet.
Low-carbohydrate dairy foods include:
Sour cream or low-cholesterol substitute
Eggs or low-cholesterol equivalents
Regular or low-fat varieties of these cheeses: (Watch out for added sugar or wine.)
American
Blue (Stilton, Gorgonzola, Roquefort, or varieties)
Brick
Brie
Camembert
Cheddar
Colby
Cottage, regular or low-fat*
Cream cheese or cream-cheese substitute
Edam
Feta
Gouda
Gruyere
Havarti
Hot pepper cheese
Jarlsberg
Monterey Jack
Mozzarella
Muenster
Parmesan
Pasteurized processed: American, Swiss, cheese food or spread
Provolone
Ricotta (regular, not skim-milk variety)
Romano
String
Vegetables and Salads
One and one-half to two cups of any of the following vegetables or salad fixings at each of your Low-Carbohydrate Meals. Vegetables may be eaten raw or boiled or saut?ed.
Alfalfa sprouts
Arugula
Asparagus
Bamboo shoots
Beans (snap, green, or wax)
Bean sprouts
Cabbage, all kinds
Capers
Cauliflower
Celery
Chicory
Collard greens
Cucumbers
Cabbage
Dill pickles
Eggplant
Endive
Fennel
Kale
Kohlrabi
Lettuce
Mushrooms
Mustard greens
Okra
Onions (up to two tablespoons)
Parsley
Peppers
Radishes
Scallions
Spinach
Squash (summer varieties only)
Tomatoes (raw; one-half only per meal)*
Turnip greens
Turnips
Watercress
Zucchini
Desserts
You may have a low-carbohydrate gelatin dessert with homemade whipped cream or a low-fat, low-carbohydrate (no sugar added) whipped cream substitute at any of your Low-Carbohydrate Meals.
At Low-Carbohydrate Meals, you should not have the usual sweets or desserts sold in stores, markets, or restaurants. Even though many of these desserts are labeled “low-calorie,” they may be high enough in carbohydrates to produce an insulin rebound.
Do not consume fruit as a dessert at a Low-Carbohydrate Meal. This is a common mistake—don’t make it yours.
Save your regular desserts for the Reward Meal. Or, try the low-carbohydrate dessert recipes
*32\236\2*

DELIRIUM: DIFFERENTIAL DIAGNOSIS-DEMENTIA

May 5

Posted by admin in Anti-Psychotics | Comments off

Dementia and delirium share two important characteristics: (1) a global impairment of cognition, and (2) a greater prevalence among elderly persons. Despite these similarities, the syndromes can be readily distinguished.
Demented individuals are usually alert and attentive. It is easy to “make contact” with them and to sustain a conversation, even when their problems with memory and reasoning are obvious. Delirium is characterized by a disturbance of consciousness; dementia is not.
Other important differences between delirium and dementia are found in their typical onset and course. In delirium, cognitive impairment develops over hours or days; in most cases of dementia, over months or years. Although hallucinations and delusions can occur in both syndromes, they are usually seen early in delirium and late in dementia.
Because demented individuals are especially vulnerable to delirium, an acute cognitive deterioration may be superimposed on a chronic one. When that occurs, the diagnosis of delirium can be made in the usual way, though the EEG needs careful interpretation. In dementia due to Alzheimer disease, for example, there is a clinicopathological correlation between worsening cognitive impairment and progressive slowing of the EEG. When dementia is severe, the EEG changes associated with delirium may not be evident in a tracing that is already slow and disorganized. In the early stages of Alzheimer disease, however, the EEG is often normal. Thus, when a mildly demented patient has a rapid decline in cognitive function accompanied by moderate or severe slowing of the EEG, delirium is likely, especially if these changes occur in the context of a medical or surgical illness. Whatever the stage of dementia, as delirium abates, the EEG returns to the patient’s baseline.
Although delirium may be responsible for the rapid onset of agitation and increased cognitive impairment in a demented patient, consideration should also be given to the possibility of a catastrophic reaction. Here, the setting of the patient’s distress will help to identify its cause. Catastrophic reactions are precipitated by unpleasant interactions or unfamiliar
surroundings — circumstances that overwhelm the patient’s capacity to cope. When such predicaments are appropriately dealt with, the patient will be reassured and can regain his composure. This link between a stressful situation and an emotional response is often lacking in agitation caused by delirium. In these cases, the patient’s distress appears to develop spontaneously (e.g., on awakening in the middle of the night) or to parallel the course of hallucinations or delusions. Although an agitated, delirious patient needs reassurance, it may be insufficient to calm him or to prevent his distress from recurring.
*26\172\2*

BACH FLOWER REMEDIES: THE NEGATIVE SWEET CHESTNUT STATE

Apr 30

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Deepest mental anguish and hopeless despair mark the necessity for Sweet Chestnut which is connected with the principle of release.
In the positive Sweet Chestnut state, the person does not feel overwhelmed or incapacitated in circumstances where no earthly solution seems possible to alleviate the mental anguish and hopeless despair. He stands on his ground, keeps his wits about him and seeks his release from the torturous position by beckoning the assistance of supernatural powers through faith and prayers to God, and sure enough the miracles do happen for “more things are wrought by prayers than this world dreams of.
However, in the negative Sweet Chestnut state the person feels knocked out by the mental anguish and despair which certain situations present.
Dr. Krishnamoorthy in his lectures gave some samples of such situations:-
(a) A Chest virgin forcibly raped by gangsters.
(b) A newly wedded wife turned widow before even seeing the face of her spouse in a family where re-marriage is not permitted.
(c) A tempest in which all the assets and all members of his family have been washed away.
(d) A man whose total salary went to the pickpocket, leaving him nothing to live on for the next month, when he has no friend or acquaintance, and no assets on which to draw on.
(e) A person in a foreign land who has lost everything, including his passport and identity card, and cannot communicate with his people back home and knows nobody in the foreign land, where he can get some help. Surely in situations as given above, it is very very difficult to keep one’s poise and balance of mind. One sees no hope, no chance of rescue.   He feels like standing on a precipice alone with deep sea before and great abyss behind and wild animals all around. Even in such intolerable situations, the Sweet Chestnut character, does not think of suicide because he is brave and has a strong character unlike, the Cherry Plum type who would rather end his life than live with this sustained mental torture.
The hopelessness of Sweet Chestnut is far more oppressive than that of GORSE. Gorse hopelessness has evolved steadily from incidents covering some length of time, such as a long treatment of some chronic ailment which has not given any relief, or a civil suit in an Indian court which never terminates. This hopele sness does not have any element of shock about it. But th-^ hopeless despair of Sweet Chestnut comes from sudden ani unexpected accident of which the sufferer has had no warning, ^nd the damage is final and irritrievable.
When the sufferer finds hims^it completely on his own, alone with back to the wall, all avenues of help closed, feeling utterly helpless and unprotected after his valiant fight against odds, Sweet Chestnut Remedy comes to his help.
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