Rodrigo Martino, M.D., Ph.D.

• Attending Senior Physician
• Hematology
• Hospital de la Santa Creu i Sant Pau
• Barcelona, Catalonia, Spain

Pull 16 Attachments Parts of the digestive system Tour of the digestive tract Belches and Farts Why does the stomach gurgle Vomit Poop Digestive System medicine ball chair order 150 mg norpace with mastercard. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press medications side effects prescription drugs buy generic norpace 100 mg line, neither the author nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made medications zopiclone order generic norpace online. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed medicine 2355 buy 150 mg norpace. Furthermore symptoms gastritis order 100mg norpace visa, dosage schedules are constantly being revised and new side-effects recognized medications given during labor generic norpace 150 mg line. I also wish to express my gratitude to Professors Raymond Faber, Michael R Trimble and Elden Tunks, whose kind words made this second edition possible. It is divided into three parts: Part 1 describes the diagnostic assessment of patients and details the interview, mental status examination, neurologic examination and ancillary investigations; Part 2 provides a thorough description of the various signs, symptoms and syndromes that are seen in neuropsychiatric practice; and Part 3 presents virtually all of the specific disorders seen in neuropsychiatric practice, in each instance detailing clinical features, course, etiology, differential diagnosis, and treatment. The literature devoted to neuropsychiatric disorders is vast, encompassing, as it does, much of both neurology and psychiatry, and I have attempted to cull from this tremendous reservoir those references that are of most use to the clinician. Although the preponderance of references are from the recent past, classic authors are not neglected and readers will find references to the works of such physicians as Alzheimer, Binswanger, Bleuler, Hughlings Jackson, Kraepelin, and Kinnier Wilson. In all, over 5000 references are included, thus providing readers not only with ready access to further detail on any particular subject, but also with a window on the literature as a whole. I am deeply indebted to the reviewers of the first edition, and to many other readers who have offered comments, critiques, and suggestions: they have enabled me to write a second edition, which, I believe, is far stronger than the first. Neuropsychiatry is a rapidly growing specialty, and it is my hope that this text will not only help solidify the field but also enable the reader to practice it successfully. As with the first edition, so too with this second one, I invite both newcomers and established practitioners to try using it in their own practices, as I think they may well find it as indispensable as I do. The acquisition of this skill is, for most, no easy matter, requiring, above all, practice and supervision. Certain points, however, may be made regarding the setting of the interview, establishing rapport, eliciting the chief complaint, the division of the interview itself into non-directive and directive portions, concluding the interview, and the subsequent acquisition of collateral history from family or acquaintances. Even these general points, however, allow exceptions depending on the clinical situation, and the physician must be flexible and prepared to exercise initiative. There is debate as to whether the physician should take notes during the interview: some feel it is distracting, both to the patient and the physician, whereas others recommend it in order to ensure accuracy, especially when the interview is lengthy. The idea is not to make a transcript but simply to jot down key points and dates, and to do so in a way that allows the physician to maintain his or her attention on what the patient is saying. Provided with such a forum, most patients will, with only minor help, provide the history required to generate the appropriate differential diagnosis. Setting the interview should ideally be conducted in a quiet and private setting, set apart from distractions and anything that might inhibit patients as they relate the history. Importantly, that means that family and friends should be excused during the interview, as patients may feel reluctant to reveal certain facts in their presence. Thus, once introductions are out of the way the first question put by the physician should focus on what brought the patient to the hospital. Critically, as some patients may be reluctant to reveal the actual reason for their coming to the hospital, it is necessary to weigh the chief complaint offered by the patient and ask oneself whether, in fact, it sounds like a plausible reason to seek medical attention. If not, gentle probing is in order and should generally be continued until the actual chief complaint is revealed. Importantly, the physician should never accept at face value a diagnosis offered by a patient: as Bickerstaff (1980) pointed out, `it must be made absolutely clear what the patient means by his description of his symptoms. Occasionally, it may not be possible to establish a chief complaint during the interview, as may occur with patients who are delirious, demented, psychotic, or simply hostile and uncooperative. Gentle shepherding may be required in cases when patients digress or take off at a tangent. One should not, of course, rudely pull the patient back to task, but rather tactfully suggest that refocusing on the illness that prompted admission might be more appropriate. Once the essential points have been covered, it is appropriate to summarize briefly what the patient has said in order to be sure that the history, as understood by the physician, is correct. Patients should be invited to correct any misapprehensions and once the history is complete the physician should move on to the directive portion of the interview. Here, one obtains information regarding the medications that the patient is taking, allergies, the past medical history, a review of systems, the family medical history and, finally, the mental status examination (discussed in Section 1. First, when interviewing hospitalized patients it is essential to obtain an absolutely accurate list of medicines that the patient was taking at home, prior to admission: medication changes often provide the clue to otherwise puzzling syndromes, such as delirium, which may occur during the hospital stay. Second, given the increasing importance of genetics in neuropsychiatric practice, it is essential to obtain a detailed family history regarding any neuropsychiatric illness. During the directive portion of the interview, although a question-and-answer approach is generally appropriate the physician must always be ready to adopt a non-directive approach should the patient report a symptom or illness potentially pertinent to the chief complaint. For example, if during the review of systems the patient affirms that headaches have been present it is appropriate to stop and ask the patient to elaborate on this, with an eye towards obtaining information regarding each of the essential points described earlier. Questions regarding alcohol/drug use and suicidal/ homicidal ideation must be directly pursued if not already covered in the non-directive portion of the interview. These are, of course, delicate areas, but, if approached in a straightforward and non-judgmental way, it is remarkable how forthcoming, and indeed relieved, some patients may be at being given an opportunity to speak of them. Most patients will require, however, either encouragement or some gentle shepherding at various times. If asked whether they have anything else to add, many patients will offer important information that they may have either withheld or simply not recalled earlier. Should patients remain uncooperative, it may at times be possible to infer their cognitive status indirectly; for example, during history taking, by asking the date of a recent event brought up by the patient. As noted below, abnormalities on the mental status examination typically indicate the presence of one of the major syndromes, such as dementia (Section 5. This is especially the case when patients are confused or suffer from poor memory: it is remarkable how often a collateral history will change a diagnostic impression, guide further testing or alter proposed treatments. Inquiry should also be made regarding hobbies, such as playing cards or chess, or doing crossword puzzles. In cases characterized by cognitive deficits, the loss of these abilities may serve to establish the onset of the current illness. Some have expressed concern that interviewing the family or acquaintances may violate patient confidentiality but this is simply not the case, provided that the contact knows already that the patient is in the hospital and that the physician reveals nothing about the patient while interviewing the collateral contact. This is sometimes a tedious task but, as with interviewing collateral sources, it may reveal critical information. Grooming and dress Good habits of grooming and dress may suffer in certain illnesses, sometimes with diagnostically suggestive results. Depressive patients may find that hopelessness, fatigue, and anhedonia make them give up all hope of maintaining their appearance, with the result that grooming and dress are left in a greater or lesser degree of disarray. Manic patients, overflowing with exuberance, may truly make a spectacle of themselves with decorations of make-up and garish clothing. Rarely, one may see evidence of neglect wherein dress and grooming suffer on only one side of the body (Section 2. Comments should be made on the relationship of the patient to the interviewer, noting, for example, whether the patient is cooperative or uncooperative, guarded, evasive, hostile, or belligerent. For example, as noted by Bleuler (1924), in schizophrenia, there is often a `defect in. Many of these may be determined during the non-directive portion of the interview; however, some, especially those concerning cognition. Psychomotor retardation may range from an almost total quietude and immobility to a mere slowing of speech and behavior. Mere exhaustion may slow patients down, but the response to rest is generally robust. Apathetic patients, lacking in motivation, may evidence little speech or behavior; depressed patients may appear similar but here one also sees a depressed mood. Delirium may be characterized by quietude and inactivity but is distinguished by the presence of confusion and deficits in memory and orientation. Other behavioral disturbances may occur during the interview and examination, including mannerisms, stereotypies, and echopraxia. Mannerisms represent more or less bizarre transformations of speech, gesture, or other behaviors (Section 4. Stereotypies are a kind of perseveration wherein patients repeatedly engage in the same behaviors, to no apparent purpose (Section 4. Echopraxia is said to be present when patients involuntarily mimic what others, such as the examining physician, do (Section 4. Anxious patients are beset with apprehensions, may plead for help, and may complain of tremor and palpitations. Affect has been variously defined as representing either the combination of the immediately present emotion and its accompanying expression in tone of voice, gesture, facial expression, etc. Given that, as with mood, affect may be depressed, euphoric, anxious, or irritable it may appear academic to distinguish between the two; however, disparities between mood and affect may arise. Mood is enduring, whereas affect is relatively changeable: in a sense, mood is to climate p 01. Affect, in addition to being depressed, euphoric, anxious or irritable, may also be flattened or labile. Some investigators believe flattened affect is also present in severe depression; however, in my experience there is little difficulty in distinguishing a flattened from a depressed affect. Labile affect is characterized by swift, and sometimes violent, changes in both felt and expressed emotion. Disturbances of mood are seen in a large number of conditions, as discussed in the chapters on depression, mania, and anxiety. Furthermore, it must be stressed that changes in mood, and especially affect, are also very common in dementia and delirium. This is particularly important to keep in mind, given that effective treatment of delirium typically results in a normalization of affect without the need for treatment with antidepressants or other medications. Incoherence and allied disturbances Normally the thoughts we put into words are coherent, focused, and goal-directed: abnormalities here include incoherence, circumstantiality and tangentiality, and flight of ideas. Incoherence may be found in a number of different syndromes, and it is the presence of other signs and symptoms that alerts the clinician to which syndromal diagnosis should be pursued: cognitive deficits indicate the presence of dementia or delirium; heightened mood, pressure of speech, and hyperactivity suggest mania; and bizarre behavior, hallucinations, or delusions point to a psychosis, such as schizophrenia. In general, patients with loosening of associations spoke freely and at length and, although what they said made little sense, they had no trouble in finding words. By contrast, patients with aphasia often had at least some difficulty in finding words, and their responses to questions were typically brief. Furthermore, whereas patients with loosening of associations had little or no recognition of their incoherence, the aphasic patients often seemed at least somewhat aware of their difficulty. Both of these signs are diagnostically non-specific but may be seen in the same conditions as incoherence. This differs from incoherence in that, although incomplete, the development of the subject is coherent before the patient jumps to the next. Other disturbances of thought or speech Poverty of thought is characterized by a dearth of thoughts: such patients, lacking anything to say, speak very little. Both these disturbances may be found in schizophrenia and in certain cases of aphasia. This is not a matter of simply running out of things to say, but rather an uncanny experience wherein thoughts suddenly stop appearing. To be in the presence of such patients is akin to standing in front of a dam bursting with words and thoughts. Although classically seen in mania, such a disturbance may also be seen in schizophrenia, schizoaffective disorder, and, occasionally, in dementia. Palilalia, sometimes confused with perseveration, is characterized by an involuntary repetition of the last phrase or word of a sentence, with these repetitions occurring with increasing rapidity, but diminishing distinctness (Section 4. Obsessions are distinguished from normal thoughts by the fact that they repeatedly and involuntarily come to mind despite the fact that the patient finds them unwanted and distressing. Certain auditory hallucinations are included among the Schneiderian first rank symptoms (Section 4. Although classically associated with psychosis, hallucinations are just as common in delirium and dementia. Thus, there are delusions of persecution, grandeur, erotic love, jealousy, sin, poverty, and reference. Delusions of reference are said to be present when patients believe that otherwise unconnected events in some way or other refer or pertain to them. Delusions, like hallucinations, may be seen not only in psychosis, but also in delirium or dementia. Hallucinations Patients are said to be hallucinated when they experience something in the absence of any corresponding actual object; such hallucinations may occur in the visual, auditory, tactile, olfactory, or gustatory sphere. As Bleuler (1924) pointed out, `it is of no avail to try to convince the patient by his own observation that there is no one in the next room talking to him; his ready reply is that the talkers Other disturbances of thought content Phobias are fears that patients admit are irrational. In cases when patients are disoriented, it is appropriate to subsequently, and gently, state the correct orientation. This not only ensures that they have been told the correct orientation at least once, but also opens the door to the identification of the rare syndrome of reduplicative paramnesia (Section 4. This is typically determined during the non-directive portion of the interview, when it becomes clear whether or not patients recognize that they are ill, and in a hospital for treatment, etc. This is a particularly important clinical finding given that the differential diagnosis between delirium and dementia rests, in large part, on its presence or absence. Traditionally, three aspects of memory are tested: immediate, short-term, and long-term memory. Here, the patient is given a list of random digits, slowly, one second at a time, and then immediately asked to recall them forwards, from first to last. One starts with a list of three digits, and if the patient recalls these correctly, moves to a list four digits long, proceeding to ever longer lists until the patient either errs in recall or reaches seven digits; normal individuals can recall lists of five to seven digits in length. If this is done correctly one proceeds to longer lists, again until errors are made or the patient performs within the normal range of spans of three to five digits.

Most studies have focused on the short-term impact of interventions medicine in french norpace 100mg on line, and have studied only emotional symptom improvements medications 8 rights generic norpace 100 mg online. This study evaluated the effectiveness of a twophase mindfulness intervention (8-week initial treatment plus 10-month maintenance phase) in reducing work stress-related emotional and physical symptoms (burnout holistic medicine purchase norpace uk, heart rate and blood pressure) in physicians symptoms jaw bone cancer buy genuine norpace online. Description: this was a randomized-control study of 42 physicians in Spain who were randomized to the intervention (n=21) or to a waitlist control (n=21) medications you cannot crush discount norpace 100 mg online. Blood pressure and heart rate were checked before and after each session for the intervention group throughout the 10-month period treatment leukemia purchase norpace online. The effects on depersonalization and personal accomplishment were non-significant. Over the 10-month maintenance period, the improvements were maintained in the intervention group especially for mindfulness and systolic blood pressure. Acceptance was high, as indicated by low attrition rate and high compliance with program activities. Contribution: this study substantiates prior evidence that mindfulness-like interventions can decrease emotional exhaustion and increase mindfulness in physicians. The findings add to evidence that this type of intervention can also positively impact heart rate and blood pressure. Additionally, this study showed sustained positive effects during a maintenance phase that extended the intervention to 12 months total. Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. Sixtyeight primary health care professionals (physicians, nurses, social workers and clinical psychologists) were randomized into intervention (n=43) and control (n=25). The magnitude of change was large in total mood disturbance and mindfulness and moderate in burnout and empathy scales. Contribution: this randomized controlled trial was able to show the effectiveness of a mindfulness-based stress reduction program for primary health care professionals in Spain. The authors demonstrated a decrease in burnout and mood disturbance over the course of the 8-week program, as well as an increase in compassion and mindfulness. Helping the helpers: mindfulness training for burnout in pediatric oncology-a pilot program. Impetus: the prevalence of burnout among pediatric oncology staff is documented between 40% and 60%. Despite the urgent need for modifying interventions, there is little research on successful interventions to prevent or reduce burnout symptoms among pediatric oncology providers. The intervention was a structured skillstraining program with weekly meetings consisting of an introductory 6-hour session, six weekly 1-hour follow-up sessions, and a final 3-hour wrap-up session, for a total of 15 contact hours, significantly fewer hours than other courses that entail an investment of 30 to 60 hours. Qualitative review of journals from the intervention arm suggested that participants were experiencing expected benefits of mindfulness training. The authors suggest that the severity of the stress and burnout within the pediatric oncology specialty may in part explain the lack of improvement in objective measures. At baseline, the sample in this study was significantly more stressed and burned out compared to samples from other similarly-designed studies that have shown benefit with other groups of healthcare professionals. The authors suggest that future interventions for this population may need to be more robust or may benefit from additional stress reduction or relaxation techniques. Contribution: this research suggests that mindfulness-based training does offer some apparent subjective benefits for pediatric oncology clinical staff, but has not demonstrated significant objective improvements in measures of stress, burnout, and depression. The abbreviated nature of the intervention may also have limited its effectiveness. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: A pilot study. Impetus: Burnout, attrition and poor work satisfaction are pervasive issues among primary care physicians that can negatively influence patient care. However, interventions for improving work-life balance are limited in scope and evaluation. This study aimed to understand the potential impact of an abbreviated mindfulness course for 30 primary care physicians at University of Wisconsin-Madison. Retention in the intervention was high (29/30); 28 (93%) of the participants gave responses for survey 2, and 23 (77%) gave responses for surveys 3 and 4. Impressively, at the 9-month post-intervention time-point, participants showed sustained significant improvements in emotional exhaustion, depersonalization, personal accomplishment, depression, anxiety, stress, and perceived stress. Additionally, this study evaluated physicians in three different primary care specialties and added a website portion, which allowed physicians to directly apply their mindfulness lessons to their clinical practice. Most impressively, improvements in burnout, stress and work satisfaction were sustained at nine months post-intervention, without any maintenance phase. A mindfulness course decreases burnout and improves wellbeing among healthcare providers. Impetus: this study aimed to understand the potential impact of a continuing education course in mindfulness for a broad range of multidisciplinary healthcare providers near Charlottesville, Virginia. The course was taught 11 times between 2004-2010, with a total of 93 participants (51 physicians, 42 non-physician providers) for a tuition cost of $400 for all enrollees and a $200 discount for residents/fellows. Common themes emerging throughout the years include perfectionism, self-criticism, guilt, feelings of not doing enough, feeling powerless to help, and frustration with patients who are unable or unwilling to make lifestyle changes. Impetus: this qualitative study sought to understand the impact of a mindful communication program on patient-centered care and physician wellbeing. Description: this paper reports the qualitative themes obtained on exit interviews of 20 primary care physicians after participation in a mindful communication program. The program consisted of eight weekly sessions, a silent retreat, and 10 monthly sessions, totaling 52 hours. The course focused on mindfulness meditation, self-awareness exercises, narratives of clinical experiences, didactic material, and discussion. The authors randomly selected 20 physicians from those who had completed at least four weekly and four monthly sessions. Contribution: the study identified important themes in understanding the impact of a mindfulness program on primary care physicians. Impetus: Stress and burnout symptoms are endemic among health care professionals and have been shown to have a negative influence on providers, patients and the health care system. Description: Mindfulness-based stress reduction is an 8-week psycho-educational program that consists of seven weekly 2. Participants are encouraged to make a significant time commitment to home practice of techniques during and after completion of the program. This approach was developed by Kabat-Zinn and colleagues at the University of Massachusetts Medical Center and has demonstrated efficacy among a variety of clinical populations. However, the authors identify some significant conceptual and methodological limitations in the existing literature. However, the existing body of research has some significant conceptual and methodological limitations. The authors call for further research to better understand the application of mindfulness training and provide evidence-based recommendations for optimizing outcomes. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Impetus: this study was designed to evaluate the effectiveness of an intensive educational program focused on mindful communication. Description: this intervention consisted of eight weekly sessions, a silent retreat, and 10 monthly maintenance sessions, totaling 52 hours. These surveys were distributed at a total of five time points: (1) at the time of registration (a mean of 37 days before the start of the program); (2) at the beginning of the first session; (3) at the conclusion of the eighth weekly session; (4) at the conclusion of the last monthly session; and (5) three months after the program ended. There were improvements in all the validated outcome measures; mindfulness scores had the largest effect sizes. The Maslach Burnout Inventory had a medium-sized improvements across all three subscales. The Profile of Mood States showed moderate effect sizes in the total score and the depression, anger and fatigue subscales, with a smaller effect size for vigor. Personality traits of conscientiousness and emotional stability showed small to moderate improvements. Contribution: the authors of this study found that participation in an intensive mindful communication program was beneficial for primary care physicians. This study showed improvements in all of the tested outcome measures, and the benefits of this program were shown to be sustained over time. While the intervention was shown to be effective, the uncontrolled nature of the study limits its methodological strength. Passage meditation reduces perceived stress in health professionals: A randomized, controlled trial. Impetus: Meditation interventions have increasingly been associated with stress reduction and improved health outcomes in clinical populations in scientific literature. However, critics have argued that much of this research suffers from methodological shortcomings. This randomized controlled trial aimed to understand the potential impact of passage meditation training on perceived stress reduction for health professionals. Participants were recruited via in-service talks, flyers, and word-of-mouth communication, and subsequently randomized to the intervention arm (n=27) or the wait list control arm (n=31). The intervention group included physicians, nurses, chaplains, and other health professionals who met for two-hour weekly sessions. Results showed beneficial effects on mental health and a large decrease in perceived stress that was sustained through the 19-week follow-up. Interestingly, findings indicate that the stress reduction and mental health benefits were greater for participants who identified as only moderately or less spiritual relative to those who identified as highly spiritual. Future research should evaluate generalizability and sustainability, and include qualitative analysis to study potential moderating variables. Mind-body skills training to improve distress tolerance in medical students: a pilot study. Impetus: Throughout medical education, stressful work environments can result in high rates of psychological distress for learners. However, distress tolerance, defined as the ability to withstand emotional distress, is considered to be protective against psychological distress and can be improved through mind-body training. Description: the intervention was an 11-week skills training workshop that focused on mind-body skills such as biofeedback, guided imagery, relaxation, meditation, breathing exercises, and autogenic training. The study recruited 52 first and second year medical students who were enrolled in either the mind-body intervention or a control group. The authors found that the students in the mind-body group showed a modest improvement in all distress tolerance subscales over time; the control group showed no change. In addition, they demonstrated that improvements in distress tolerance was also associated with improvements in psychological symptoms. Contribution: the authors demonstrated that the 11-week mind-body training improved distress tolerance and was correlated with a decrease in psychological distress. They postulate that this is a novel way to improve the wellbeing of medical students and reduce the impact of psychological distress. Impetus: Medical students are known to experience high rates of stress during their education, with consequent decline in empathy, negative impact on patient relationships, and symptoms of burnout. Mind-body practices, including meditative breathing and relaxation, have been shown to enhance self-efficacy and self-regulation. Description: the intervention was an 11-week elective course, Embodied Health, that combined sessions in yoga, meditation, and neuroscience didactics about mind-body practices for 27 first and second year medical students at Boston University School of Medicine. Students completed pre- and post-course surveys that evaluated four areas: empathy (Jefferson Scale of Physician Empathy), perceived stress (Perceived Stress Scale), self-regulation and goal achievement (Self-Regulation Questionnaire), and selfcompassion (Self-Compassion Scale). Statistically significant changes were seen in self-regulation and self-compassion; a positive but non-significant trend was seen in empathy and perceived stress scores. Contribution: this novel course incorporates experiential and didactic teaching of mind-body medicine, but is limited by a small and self-selected sample size, lack of control group, a high empathy baseline rating in students, and no long-term post-course data on student wellbeing. This study suggests a small favorable short-term effect of mind-body medicine on medical student wellbeing. This article explores a wellness curriculum at a medical school aimed at reducing burnout and increasing emotional intelligence through mindfulness-based self-care. The assessment strategies are also integrated into the overall medical school assessments in order to avoid marginalizing the wellness curriculum. This study aimed to create and evaluate the results of a web-based tool for medical students that would encourage self-reflection, promote positive lifestyle habits, and educate on the foundations of health. Students who completed the module were provided with a summary of their self-written health plan and were then asked to complete a questionnaire to assess the effectiveness of the tool. Contribution: this study contributes significantly to the literature on self-care and wellbeing of medical students and trainees. The results show that having medical students develop their own health plans can be an effective method towards encouraging self-care and understanding foundational concepts of health and wellbeing. Impetus: Stress and burnout are common throughout medicine for practicing doctors, residents and students. Stress reduction programs in medical training have been found to reduce stress in medical students; however, previous studies had no control groups and lacked longer term follow-up. This study aimed to assess the effectiveness of a stress reduction elective on second year medical students, and to determine if improvements would be sustainable. Description: In 2004, an elective entitled "Mind-Body Medicine: an Experiential Elective" was offered at the University of Washington School of Medicine. The study compared 30 second-year medical students who self-selected to enroll in a 10-week mind body elective to 46 student volunteers who did not enroll in the elective. At the end of the elective and three months later, there were no differences in scores between the elective and control students in any of the instruments. Contribution: this study contributes significantly to research surrounding stress-reduction programs in medical training.

Contribution: this articles reviews the pathobiology of sleep and fatigue in neurology residents medicine used to treat chlamydia purchase generic norpace from india, discussed the negative consequences of sleep deprivation and offers practical solutions that can be used to alleviate this problem through focused interventions to improve alertness medicine vocabulary norpace 100 mg overnight delivery, increase sleep duration treatment herniated disc order norpace with a visa, safety measures symptoms quitting tobacco buy cheap norpace online, circadian alignment and maximizing educational opportunities symptoms neuropathy buy 150mg norpace with amex. Management strategies for shift work disorder are discussed in the review and include approaches to promote sleep medicine youth lyrics norpace 150 mg with amex, wakefulness and adaptation of the circadian clock to the imposed work schedule. Contribution: the existing body of literature on shift work disorder is summarized, and may prove relevant to medical residents and staff physicians. Impetus: this systematic review of literature published from 1989 through 2010 summarizes the impact of shift length, protected sleep time and night float on patient care, resident health and educational outcomes among residents. Most studies used single-institution, observational designs and many were felt to be methodologically weak, with a high risk for bias. However, 73% of the studies that examined shift length showed that shorter shifts were associated with decreased medical errors, motor vehicle crashes, and percutaneous injuries. While heterogeneous, this body of evidence appears to support reducing shift length; however, optimal shift duration was not adequately addressed. Other recommendations about protected sleep time and night float were limited by the quality of the methodology used in the original studies and unclear generalizability for most outcomes. Contribution: Because of limitations in study quality, the outcomes of broad-based changes in residency training, including decreased shift length, protected sleep time and night float systems, are uncertain and warrant further investigation. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy and burnout among interns. Description: this study evaluated a cohort of internal medicine interns (n=47) at a large academic medical center. Results confirmed previous findings showing that the prevalence of chronic sleep deprivation, depression, burnout and empathy increased from baseline to year end. This review examines literature on physician nutrition and hydration and suggests potential multifactorial interventions to improve these measures. Description: this review illustrates the influence that a balanced diet, meal timing, hydration, caffeine, nutrient deficiencies, and work hours have on physician fatigue, cognitive performance, and wellbeing. Contribution: the findings highlight the need to incorporate physician wellbeing and nutrition in the workplace, and it indicates barriers that prevent physicians and physicians-in-training from receiving adequate nutrition including time, lack of healthy food options, and limited access to meals during night shifts. The authors suggest individual (taking nutrition and hydration breaks), professional (promoting a culture of physician self-care and nutrition), and organizational (implementing break schedules, increasing access to healthy food, and extending hours for food services near clinics operating overnight) interventions for physician wellbeing. Physician nutrition and cognition during work hours: effect of a nutrition-based intervention. Impetus: Hectic scheduling often prevents physicians from receiving adequate hydration and nutrition. Description: A pre/post-test design was used to examine the impact of scheduled nutrition breaks on 20 physicians from surgical, medical, and primary care specialties in a large, urban hospital. Participants selected two similar work days to undergo baseline and intervention testing. For baseline testing, physicians followed their typical hydration and nutrition habits. For intervention testing, physicians were provided nutritious food and drink by the research staff at scheduled intervals. The impact of the intervention was evaluated using simple and complex reaction tests, blood glucose levels, activity level, body mass, heart rate and reported hypoglycemic symptoms. On intervention day, physicians reported significantly increased caloric intake, better hydration status, lower mean glucose levels, less variable mean glucose levels, improved cognitive functioning, and fewer hypoglycemic symptoms (although this was not statistically significant). Participants felt that the wellness initiative they participated in increased their awareness of the importance and impact of workplace nutrition, and helped encourage intent to change nutrition habits. Future studies could evaluate alternate delivery methods to impact of increased physician access to food and drink. Cost: Unknown, but resources for personalized delivery and healthy options would be necessary. Food for thought: an exploratory study of how physicians experience poor workplace nutrition. This study explored physician views on their nutrition in the workplace, including impact on personal wellness and professional performance. Description: this qualitative study involved 20 physicians (10 from medical specialties, eight from surgical specialties, and two from primary care) from an urban teaching hospital who had agreed to participate in a nutrition-based wellness study participated in semi-structured interviews before and after the intervention. The two lead co-investigators independently reviewed the transcripts using an inductive strategy to derive predominant themes. Study participants identified several ways inadequate nutrition could negatively impact their emotional and physical health, cognitive and professional abilities and interpersonal interactions with colleagues, care providers, and patients. Barriers to good nutrition were identified, and included lack of time, stringent work ethic, poor access, limited choice, and cost. Contribution: the study was helpful in elucidating some of the issues and impacts of inadequate nutrition for physicians in the workplace. The study findings could be used to design a larger study to better define and quantify the issues delineated around impact and barriers of workplace nutrition. Activity monitor intervention to promote physical activity of physicians-in-training: randomized controlled trial. Impetus: Research suggests that resident physicians exercise less than medical students and attendings. Description: the study was carried out over two 6-week phases with 104 residents at a large academic medical center in Boston. During the study, residents were granted free access to: an on-site fitness center; a weekly, one-hour personal training session; and two sessions with a nutritionist. Phase 1 was a randomized controlled trial in which 52 residents received an activity tracker with visible step data and 52 received an activity tracker with blinded step data. Phase 2 was a non-randomized team step competition, and all participants had visible step data. Contribution: the study contributes to the literature as the first randomized trial to use activity trackers to promote physical health among resident physicians. Future studies should collect baseline step activity and consider the impact of free fitness center access. Physical Activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. This study evaluated the effect of a voluntary, incentivized exercise program on resident and fellow physical activity, quality of life, and burnout. Description: the voluntary, team-based, incentivized exercise program lasted 12-weeks, and all medical fellows and residents (n = 1060) at Mayo Clinic in Rochester, Minnesota were invited to participate in the exercise program, submit baseline data, and complete the exit survey. Both participants and non-participants had access to the same institutional exercise facilities. The impact of the intervention was measured on self-reported gym attendance and aerobic activity; participation in baseline and exit surveys; participation in a wellness exam; body fat percentage; and leg press strength. Residents and fellows who participated in the intervention showed significantly increased physical activity (with almost half meeting the daily recommendation) and had a significantly higher median quality of life. There was a small trend towards decreased burnout, but this finding was not statistically significant. Contribution: this study supports the finding that physical activity is linked with higher quality of life in physicians. The study also shows that an incentivized exercise program can increase physical activity among medical residents and fellows. Impetus: Workplace health promotion programs have been shown to increase productivity. This study evaluated the impact of a workplace health promotion program on presenteeism among orthopedic and general surgery residents. All residents were granted free, 24 hour, onsite access to a health promotion facility equipped with strength and cardiovascular equipment. Residents using the facility were asked to document their use of the equipment by signing into a logbook upon entering and exiting the room. Response rates were similar at baseline and end of the year: 78-79% of residents filled out the surveys. The data show a non-statistically significant improvement in residents mean presenteeism score post intervention. Contribution: this study supports the finding that a workplace health promotion program has potential to improve presenteeism. A physician fitness program: enhancing the physician as an "exercise" role model for patients. Impetus: Research shows that only 30% of physicians report regular physical activity. This study examined the effectiveness of a fitness program on resident cardiovascular fitness, body mass index, physical activity, and patient exercise counseling. Description: this study was a non-randomized intervention with outcomes measured at baseline, three months (at the end of the intervention), and six months (three months post intervention). Forty-two internal medicine resident physicians completed testing at baseline and first follow-up. The effectiveness of the physician fitness program was measured by (1) participant attendance at intervention activities. Contribution: this study was the first to evaluate a fitness program in resident physicians. However, study attrition at the 3- and 6month time points limited the scope of the results. The impact of a required longitudinal stress management and resilience training course for first-year medical students. Impetus: Prior studies using mindfulness-based stress reduction in trainees and practicing physicians have shown reductions in burnout. Content was delivered through small groups led by inter-disciplinary with content and small-group facilitation expertise, and included a check in, reflection activity, group discussion, and skills training. Students completed a preand post- survey with the Maslach Burnout Inventory, Medical Outcomes Study Short Form, Perceived Stress Scale, Connor-Davidson Resilience Scale, and Happiness and Gratitude Scale. Compared to baseline at the start of the year, stress significantly increased and happiness and quality of life significantly declined. Empathy also declined, although the decline was only significant in the 2014 cohort. Burnout increased, although the increase was not statistically significant, and resilience did not change significantly. Students appreciated efforts to incorporate wellness into the curriculum but felt that it took time away from other efforts. Although direct comparison to prior classes was not possible, the changes in wellbeing were not improved compared to a pre-intervention cohort. Overall, this required curriculum did not improve resilience or clearly mitigate the impact of the rigors of medical school on wellbeing. Given the discrepancy between this finding and prior studies of volunteers, the authors suggest that the benefits that have been seen in opt-in interventions may not translate into improvements in wellbeing when participation is required. They highlight the need to offer a variety of options that students can select, in addition to programmatic interventions that improve the learning environment. Cost: the authors note that funding and resources to support the curriculum were included in the student affairs budget but do not specify the amount. Impetus: Prior to this publication, past studies have shown that teaching mindfulness in medical school reduces distress, and has the potential to decrease burnout and increase quality of life. Description: this article summarizes 14 medical school programs that teach mindfulness to medical and dental students and residents. Programs were identified and program or course directors were contacted for more information. A wide range of formats were used to teach mindfulness including simple lectures, daylong workshops, and 8-10-week programs in mindfulness-based stress reduction. Contribution: this publication describes the multiple different ways mindfulness was being taught in medical schools and provides ideas for integrating mindfulness-based stress reduction programs and training into medical education. The article also provides links to various programs as well as faculty contact information. The variability of the delivery of mindfulness interventions highlights the heterogeneity of this body of literature; the authors suggest more rigorous studies are needed to further evaluate how this intervention can best be incorporated into medical school curricula. A randomized controlled trial of the effects of mindfulness practice on medical student stress levels. Impetus: Mindfulness interventions have been shown to reduce stress in medical students and physicians. However, these interventions are often time consuming and require determination and commitment. Description: this study was a multicenter, randomized controlled trial with intention-to-treat analysis in three medical schools attached to the University of Tasmania in Hobart, Tasmania. Sixty-six students were randomized to either usual care or the intervention group. Contribution: this study contributed significantly to literature on mindfulness and stress among medical students. First, the study confirmed that medical students experience higher rates of stress than their agematched peers. This intervention requires less time and fewer resources than traditional mindfulness-based stress reduction, and is self-guided by students, making it more accessible for their schedules. Mindfulness-based stress reduction lowers psychological distress in medical students. Description: this study was conducted at Jefferson Medical College from 1996-2000. The control group students (n=162) participated in a didactic course on complementary and alternative medicine. Contribution: this study contributes to literature on mindfulness-based stress reduction for medical students. Impetus: Given the growing prevalence and impact of physician burnout in the modern health care system, targeted interventions designed to reduce burnout and promote wellbeing are necessary in medical training and practice.

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In vitro and in vivo inhibition of Helicobacter pylori by Lactobacillus casei strain Shirota my medicine order norpace 150mg on line. Beneficial lactobacilli in food and feed: longterm use symptoms ear infection order generic norpace on line, biodiversity and proposals for specific and realistic safety assessments symptoms flu purchase cheap norpace on line. Probiotic administration attenuates myocardial hypertrophy and heart failure after myocardial infarction in the rat medicine under tongue order norpace 150mg visa. Antihypertensive effects of probiotics Lactobacillus strains in spontaneously hypertensive rats symptoms 8 days after ovulation purchase discount norpace online. Effect of administration of fermented milk containing whey protein concentrate to rats and healthy men on serum lipids and blood pressure symptoms herpes buy norpace overnight delivery. Intake of Lactobacillus reuteri improves incretin and insulin secretion in glucosetolerant humans: a proof of concept. Effects of intraduodenal injection of Lactobacillus johnsonii La1 on renal sym pathetic nerve activity and blood pressure in urethaneanesthetized rats. Yamashiro K, Tanaka R, Urabe T, Ueno Y, Yamashiro Y, Nomoto K, Takahashi T, Tsuji H, Asahara T, Hattori N. Gut dysbiosis is associated with metabolism and systemic inflammation in patients with ischemic stroke. Qualitative and quantitative analyses of the bifidobacterial micro biota in the colonic mucosa of patients with colorectal cancer, diverticulitis and inflammatory bowel disease. Lower Bifidobacteria counts in both duodenal mucosaassociated and fecal microbiota in irritable bowel syndrome patients. Molecular characterization of rectal mucosaassociated bacterial flora in inflammatory bowel disease. Synbiotic therapy (Bifidobacterium longum/Synergy 1) initiates resolution of inflammation in patients with active ulcerative colitis: a randomised controlled pilot trial. BullOtterson L, Feng W, Kirpich I, Wang Y, Qin X, Liu Y, Gobejishvili L, JoshiBarve S, Ayvaz T, Petrosino J, et al. A global network of coexisting microbes from environmental and wholegenome sequence data. Karczewska E, Wojtas I, Sito E, Trojanowska D, Budak A, Zwolinska Wcislo M, Wilk A. Assessment of coexistence of Helicobacter pylori and Candida fungi in diseases of the upper gastrointestinal tract. This year we address one of the "hottest" topics in medicine and medical science: gut microbes. Rapid developments in technology have permitted the detailed description of the bugs that normally inhabit our gastrointestinal tracts and are beginning to reveal their many functions in heath and disease. With such progress have come new challenges: in comprehending new terminology, in distinguishing hype from science, in attempting to understand claims for new diagnostic or therapeutic advances based on the assessment or modulation of the microbial populations of our guts. To that end Professor Francisco Guarner and his team have assembled some of the most renowned scientists and clinicians in the field to provide an overview of the most important aspects of science and clinical practice related to gut microbes. Supporter Partners the "Gut Microbiota for Health Experts Exchange" is a community where experts can share news, innovation and information on the topics of gut microbiota. The content of "The Gut Microbiota For Health Experts Exchange" offers a selection of current topics of conversation organized around the cross-cutting themes of: digestive health, immune function, metabolic conditions, gut brain axis, research tools, trends and discoveries, nutrition, and probiotics. Each topic is enriched by a selection of articles from scientific literature, traditional media, social media and the best contributions of users. A media room is also included in the platform to help identify key scientific events, important press releases and more. The new content is sent to the members through our Gut Microbiota for Health newsletter twice a month. The Community encourages contributions from readers, interactions within the website, and beyond. Further sharing and discussions are possible through the Gut Microbiota for Health digital presence on social media. Fossils and associated geochemical markers of biologic activity indicate that microbial organisms inhabited the oceans in Archean times (2. Cyanobacteria are still vastly abundant in modern days, and can be found as planktonic cells in oceans and fresh water. They do not require organic nutrients and can grow on entirely inorganic materials. Cyanobacteria obtain their energy through photosynthesis, and convert solar energy into biomass-stored chemical energy. Like plants, the cyanobacteria release oxygen gas and contribute to carbon fixation by forming carbohydrates from carbon dioxide gas. Some cyanobacteria cell types are able to fix nitrogen gas into ammonia, nitrites or nitrates, which can be absorbed by plants and converted to protein and nucleic acids (nitrogen gas is not bioavailable to plants). Microbial communities are ubiquitous and truly essential for maintaining life conditions on Earth. As summarized in a report from a colloquium convened by the American Academy of Microbiology, microbial communities can be found in every corner of the globe, from the permafrost soils of the Arctic Circle to termite guts in sub-Saharan Africa, and on every scale, from microscopic biofilms to massive marine planktonic communities. Because of their enormous global size, microbial communities have a massive impact across the globe. Their diverse contributions affect many aspects of life, not only in relation to human or animal infections, but, more importantly, through their role in cycling the critical elements for maintaining life on Earth. Genome size and the number of coding genes are much smaller in prokaryotes than in eukaryotes. Genome size is a gross estimate of biological resources linked to a given species and correlates with a range of features at the cell and organism levels, including cell size, body size, organ complexity, and extinction risk. Thus, single microbial species may not have enough genetic resources by their own for adequate fitness and survival. Single species are likely to have obligate dependencies on other species, including other microbes or animals or plant hosts. Therefore, multispecies communities with complex nutritional and social interdependencies are the natural lifestyle for survival for most prokaryotic microorganisms. Natural microbial communities are diverse but behave like a single multicellular organism. One fascinating attribute of microbial communities is the ability for adaptation to environmental changes. Microbial communities are capable of recovering from, and adapting to , radical habitat alterations by altering community physiology and species composition. In this way, they are able to maintain stability in structure and function over time. These attributes facilitate community survival by ensuring that they can evolve, adapt and respond to environmental stressors. The stomach and duodenum harbor very low numbers of microorganisms, typically less than a thousand bacterial cells per gram of contents, mainly lactobacilli and streptococci. Acid, bile, and pancreatic secretions suppress most ingested microbes, and phasic propulsive motor activity impedes stable colonization of the lumen. The numbers of bacteria progressively increase along the jejunum and ileum, from approximately ten thousand cells in the jejunum to ten million cells per gram of contents in the distal ileum. In the upper gut, transit is rapid and bacterial density is low, but the impact on immune function is thought to be important because of the presence of a large number of organized lymphoid structures in the small intestinal mucosa. These structures have a specialized epithelium for uptake and sampling of antigens and contain lymphoid germinal centers for induction of adaptive immune responses. In the colon, however, transit time is slow and microorganisms have the opportunity to proliferate by fermenting available substrates derived from either the diet or endogenous secretions. The large intestine is heavily populated by anaerobes with billions of cells per gram of luminal contents. By far, the colon harbors the largest population of human microbial symbionts, which contribute to 60% of solid colonic contents. Several hundred grams of bacteria living within the gut lumen certainly affect host physiology and pathology in different ways, which are currently the focus of extensive research in order to fully understand their impact in medicine. The Gut Microbiota Human beings are associated with a large and diverse population of microorganisms that live on body surfaces and in cavities connected with the external environment. The prevalence of symbiosis has long been recognized on the basis of observations from microscopy, but most aspects of symbiont origins and functions have remained unexplored before the age of molecular techniques because of the difficulties involved in culturing and isolating a large majority of these microbial species. The skin, mouth, vagina, upper respiratory tract, and gastrointestinal tract of humans are inhabited by site-specific microbial communities with specialized structures and functions. Microbial communities in the gut include native species that colonize the intestine permanently, and a variable set of living microorganisms that transit temporarily through the gastrointestinal tract. The gastrointestinal mucosa exhibits a very large surface (estimated at up to 4,000 square feet when laid out flat), and contains References 1. The large intestine is the most densely populated habitat due to the slow transit time and the availability of fermentable substrates. Organ weights (heart, lung, and liver), cardiac output, intestinal wall thickness, gastrointestinal motility, serum gamma-globulin levels, lymph nodes, among other characteristics, are all reduced or atrophic in germ-free animals. Germ free mice display greater locomotor activity and reduced anxiety when compared with mice with a normal gut microbiota. Evidence obtained through such animal models suggests that the main functions of the microbiota are ascribed into three categories, i. The normal interaction between gut microbes and their host is a symbiotic relationship, defined as mutually beneficial for both partners. Evidence accumulated over past decades incriminates some gut bacteria in toxin formation and pathogenicity when they become dominant. Some other resident species are potential pathogens when the integrity of the mucosal barrier is functionally breached. However, knowledge on gut microbes with proven benefits for human health is very rudimentary. There is currently little consensus regarding definition or characterization of potentially healthy bacteria in the human gut. Thus, our current concepts on host-microbe symbiosis in the gut are mainly supported by observations using germ-free animal models. Comparison of animals bred under germ-free conditions with their conventionally raised counterparts (conventional microbiota) has revealed a series of anatomic characteristics and physiological functions that are associated with the presence of the microbiota. Germ-free animals have extraordinary nutritional requirements in order to sustain body weight, and are highly susceptible to infec- Metabolic functions the enteric microbiota has a collective metabolic activity equal to a virtual organ within the gastrointestinal lumen. For mammalians, the genes encoding enzymes for biosynthesis of many required organic compounds were lost early in evolution. Bacterial or fungal symbionts have, through evolution, adapted to provide the required organic compounds (essential amino acids and vitamins) and the ability to obtain energy from different sources. The guts of ruminants are well-studied examples of a host-microbe metabolic partnership. Symbiont communities carry out the task of breaking down complex polysaccharides of ingested plants, and provide nutrients and energy for both microbiota and host. The amino acid supply of ruminants eating poorly digestible low protein diets largely depends on the microbial activities in their fore-stomachs. In the human being, the distal intestine represents an anaerobic bioreactor programmed with an enormous population of microbes. Due to the slow transit time of colonic contents, resident microorganisms have ample opportunity to degrade available substrates, which consist of non-digestible dietary residue and endogenous secretions. Colonic microbial communities provide genetic and metabolic attributes to harvest otherwise inaccessible nutrients. Short chain fatty acids acidify the luminal pH, which suppresses the growth of pathogens, and favor the absorption of ions (Ca, Mg, Fe) in the cecum. They also influence intestinal motility and contribute towards energy requirements of the host. Butyrate is largely metabolized by the colonic epithelium where it serves as the major energy substrate as well as a regulator of cell growth and differentiation. The human proximal colon is a saccharolytic environment with the majority of the carbohydrate entering the colon being fermented in this region. When compared to conventionally colonized animals, germ-free animals have increased nutritional requirements in order to sustain body weight, are highly susceptible to infections and show structural and functional deficiencies. Trophic functions these functions include the control of epithelial cell proliferation and differentiation, modulation of certain neuro-endocrine pathways, and the homeostatic regulation of the immune system. Epithelial cell differentiation is influenced by interactions with resident micro-organisms, as shown by the expression of a variety of genes in germ-free animals mono-associated with specific bacteria strains, and in humans fed with probiotic lactobacilli. For instance, the microbiota suppresses intestinal epithelial cell expression of a circulating lipoprotein-lipase inhibitor, fastinginduced adipose factor (Fiaf), thereby, promoting the storage of triglycerides in adipocytes. The ability of the gut microbiota to communicate with the brain and thus influence behavior is emerging as an exciting concept. Recent reports suggest that colonization by the enteric microbiota impacts mammalian brain development and subsequent adult behavior. In mice, the presence or absence of conventional enteric microbiota influences behavior, and is accompanied by neurochemical changes in the brain. Germ-free mice have increased locomotor activity and reduced anxiety, and this behavioral phenotype is associated with altered expression of critical genes in brain regions implicated in motor control and anxiety-like behavior. When germ-free mice are reconstituted with a microbiota early in life, they display similar brain characteristics as conventional mice. Gut microbes also play an essential role in the development of a healthy immune system. Animals bred in a germ-free environment show low densities of lymphoid cells in the gut mucosa and low levels of serum immunoglobulins. Exposure to commensal microbes rapidly expands the number of mucosal lymphocytes and increases the size of germinal centers in lymphoid follicles. Immunoglobulin producing cells appear in the lamina propria, and there is a significant increase in serum immunoglobulin quantities. Most interestingly, commensals play a major role in the induction of regulatory T cells in gut lymphoid follicles. Control pathways mediated by regulatory T cells are essential homeostatic mechanisms by which the host can tolerate the massive burden of innocuous antigens within the gut or on other body surfaces without resulting in inflammation.

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