Iris Publishers-Open access journal of Complementary & Alternative Medicine | Case Study of Obsessive-Compulsive Disorder (OCD)

Authored by Muhammad Zafar Iqbal

Background: This document pertains of idiographic research; the case study of Obsessive-compulsive disorder (OCD). The objective of this case study was to reaffirm the efficacy of Fear-Stimuli Identification Therapy (FSIT). FSIT was used to eliminate the symptoms of OCD in a client, a successful treatment for disorders in different cases [1-8].
Method: Initially seven sessions of semi-structured interviews were conducted with client to dig out the reasons/causes of the disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) was consulted for diagnosis [9]. Fear Stimuli Identification Therapy (FSIT) was used as therapeutic tool.
Results: After diagnosis, five sessions per week, a total of eighty-three sessions were conducted of FSIT. Positive behavioral change observed in client which proved the efficacy of FSIT.
Conclusion: Clinical observations during treatment indicated a gradual positive change in client’s personality. The client and her husband reported positive behavioral changes in different domains of life. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT.
Keywords: Obsessive compulsive disorder; Symptoms; Assessment; Case study; Idiographic

Introduction

The subject of the disorder was Mrs. S.H. (Initials of real name), age 38 years, a Housewife. The client was referred to therapist clinic by a fellow psychologist from a metropolitan southern city. She had been under treatment of various psychiatrists and psychologists in her city, but the client did not improve. She contacted therapist online. Client reported about her compulsively repeating some acts in her daily life as obsession. She supposed that her mind was persistently occupied by some specific thoughts and her act of repeating some actions is a result of these thoughts. Therapist contacted her husband for more details about the behavior of client. Aggressive behavior, Sleeplessness, weeping without any apparent reason, Breath shortness, Uncontrollable thoughts, Repetition of some of her daily life acts Symptoms are reported by Client and her husband.

Method

• Participants
Mrs. S.H, Client, Client’s Husband and Therapist.
• Instrument
No instrument/ Material used in this case study.

Procedure

As already mentioned, in the first seven sessions, semistructured interviews were conducted with Mrs. S.H. and her husband. In the subsequent eighty-three sessions Mrs. S.H. was asked to write about specific topics suggested by therapist. Crossquestioning was carried out over the ideas mentioned in the writings by client. After diagnosis of OCD, treatment was started in the light of FSIT method. Five sessions per week were conducted and total of eighty-three sessions were conducted. It may be noted that all these sessions were carried out online [4].

Assessment

Following facts were explored through initial interviews which were ‘Semi-structured’. These interviews revealed that at the age of 11 years, one day she (client) returned back from school in the company of her close friend N.S. After reaching home she and her parents received the shocking news of death of N.S. They were told that N.S. had eaten something poisonous and had died instantly. S.H., the client was shocked deeply. The incident of her friend’s death became a stimulant for fear instinct.
At the day of her funeral, she feared to see the face of her deceased friend and couldn’t enter the room where the dead body was laid. After the death of her friend another death happened that provoke more fear about the death. Her grandmother died six months later after her friend’s death. She, for the first time watched her grandmother’s dead body wrapped in white clothes which leaves bad marks on her memory that she stopped wearing white cloth especially white scarf or shawl for rest of her life.
Another incident happened after one year of marriage. Her father-in-law died in ambulance due to sudden attack. The ambulance became a stimulus for her fear. After developing death phobia, each death intensified the sense of fear in her unconscious mind. In the course of time she became a religious orator orator of a specific type as she used to narrate rhetorically upon the miseries and sorrows which had emerged from the unfortunate events of wars of Islamic history. By performing so, she felt some sort of relief as this became a source of catharsis for her. She was strongly obsessed by the idea of death that her mind often used to get stuck at the thought of her friend’s death. While doing random stuff she often found herself motionless due to the flashback of her friend’s death and to get rid from this obsession she used to force her mind to think of other things. Similarly, she taps her mobile phone with her fingers frequently while obsessing about her brother’s death. During one of Skype sessions she informed the therapist that after marriage she finds it more difficult to cope with the obsessive ideas.

Therapist and treatment

It is single case experimental study which is handled by only one therapist and after taking history, it was diagnosed that client was suffering from OCD and the treatment was carried out accordingly: As per procedure of SFW (specific free writing; one of procedures of FSIT), in very first session of treatment, client was asked to pen down her ideas freely on the topic “death”. She was asked to put a cross mark for each time whenever she feels stuck or blank-minded during writing process. The piece of writing was received by E-mail. She told that during the process of writing she felt burden at the occipital region of head and pain and burden on her shoulders. In the view of writing, client was cross-questioned over the ideas mentioned in the writing. After fifteen minutes, client went through a deep spell of drowsiness. The session was ended at this point. This drowsiness continued in the next five sessions during questioning over her writing. The extreme hate for and fear of her own death which had previously gripped her unconscious level of mind was identified and brought out clearly as it had been suppressed by patient’s unconscious for a very long time in past. Next topics given to write about were: “White shawl” (considered as coffin), “Bathing place” for a dead person at holy shrine, the “couch” upon which dead body is laid down after bath, “Ambulance”, “Funeral Bus” and “Thoughts about dead persons”. During writing practice, same mental and physical response was reported each time as it was observed first time that was a result of unconscious resistance to express fears. The thoughts of “white shawl”, “coffin” and ambulance etc caused the fear of her own death and ultimately became reason for OCD. In last sessions of treatment, the mentioned above things were rooted out and recovered from OCD.

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Iris Publishers-Open access journal of Complementary & Alternative Medicine | Why We Get Sick and Old?

Authored by Vivina Siddhi

We can slow down and even reverse the effects of aging with a preventive health care that includes alternative approaches. It’s never too late to start changing ourselves. Man needs a healthy body for a healthy mind, filed worth good thoughts. Physical fitness alone is not enough. Mental health is equally important. Together with the gross physical body everybody has a subtle body. One has to take good care of this subtle body also. For this, spiritual exercises will have to be performed which will help one to realize the purity of the heart, mind and soul. We have to practice human values for healthy living, too.

Peace – Stress - Peace

The greatest disease (or absence of ease) is the absence of peace of mind. When the mind gets peace, the body also will have health. We must pay attention to the emotions, feelings and motives that animate the individual. We should have good company. Bhagavan’s Satya Sai Baba’s statement is that falsehood, injustice, indiscipline, cruelty, hates form the dirt. Truth, Righteousness, Peace, Love - these form the clean elements. If you inhale the pure air your mind will be free from evil and you will be mentally sturdy and physically strong.
Science is finding more and more that psychological stress has severe impacts on the body and mind. Stress can trigger depression and anxiety; it can trigger asthma attacks and strokes, it can set off heart-beat disturbances; it can irritate digestion and even cause ulcers; it can cause impotence in man and menstrual difficulties in women, it can trigger muscle twitches and nervous tics, and it cause the skin break out in various diseases. The modern lifestyle leads to stress, anger, depression and lack of time for spiritual work. Anger is a great cause of ill health, besides being dangerous for other reasons. We must conquer these negative emotions within us when they arise in the mind and try to think of something else than the circumstances that roused your anger, jealousy etc. Go for a long walk, do yoga, gym, ride a bike, and do activities that make you happy. Than you struggle less and win fast. Man does not take preventive measures; he allows things to worsen and then the disease is aggravated by fear, uncertainty and anxiety.
“Stress hormones – the “fight-or-flight” hormone adrenaline literally pour into our cardiovascular system when you’re under stress, especially in situations involving anger or hostility. This sends your blood pressure sky-rocketing and it’s implicated not only in heart disease but in heart attacks” [1]. It decreases in blood flow to the extremities, including the sexual organs; and a slowing of digestion. The “fight-or-flight” response also increases the level of the hormone cortisol, which reduces the activity of the immune system. Cortisol plays a useful role in the temporary reduction of inflammation. When the danger has passed, these systems return to normal in the relaxation response. However, in chronic stress, this physiological arousal persists, which can lead to a decrease in the activity of the immune system and continual anxiety.
When we dive through consciousness and we are exposed to the negative influences from other people who are meditating on us, we also get stressed out. Such kind of influences have very bad effects on our daily life. We make wrong decisions and destructions that are essential for entire life. Unfortunately, people who have opened third eye are sometimes paid to create destructions just to satisfy others wishes. They are imposing thoughts into the brains during sleep time. Instead to send another person positive affirmation for long, healthy and wealthy life they are analyzing and criticizing others, imposing dangerous illusions via thoughts and images. They are also trying to control others. This is not our natural state of mind. It is very unhealthy approach and against the natural law. Every human being has the right to have freedom to live in a healthy way.
If we can relieve stress, we can help keep our mind and body in youthful condition. When you feel better, you behave younger and you live younger. You have more optimism, more courage. By changing your lifestyle through diet, exercise and attitude – your biological age can be that of a younger person.

Breath

There are ranges of techniques for inducing the relaxation response such as: meditation, yoga, breathing exercises, muscle relaxation and hypnosis (deep relaxation state). All these methods led to decreases in oxygen consumption, respiration rate, and heart rate. In patients with high blood pressure, the blood pressure went down. “There was also decrease in the level of lactic acid in the blood, falling by around 40 percent within ten minutes of starting to meditate. Lactic acid is normally produced as a result of muscular activity, and in people prone to anxiety, it increases the likelihood of anxiety attacks” [2].
When the breath slows down and we have negative entity in the aura, this entity can create a feeling of “protection field”; however, it is causing an anxiety. It can trigger brain and causes stroke. Breathing techniques awakens Kundalini energy. Kundalini is described as a sleeping, dormant potential force in the human being. It is one of the components of an esoteric description of the subtle body, which consists of nadis (energy channels), chakras (psychic centers), prana (subtle energy), and Bindu (drops of essence). Ida, pingala and sushumna are the three major nadis or psychic energy channels responsible for the activation and rising of kundalini, known otherwise as the “serpent power”. Slow and deep breathing reduces stress. We stay young when kundalini energy is speeding up in all chakras equally and stays this way.
Any kind of activity can be transformed into active meditation. One can learn active meditation via mandala’s workshops that I teach over 30 years. We slow down; however, we do quality work without any stress.

Indigenous People

Indigenous people are very knowledgeable about power of thoughts via prayers. Unfortunately, most of them suffer and it’s very hard for them to step out of struggling circle of psychic attacks. This is one of the main reasons that indigenous people are vulnerable for alcohol and drugs.
“For the tribes’ people themselves, an essential element is the involvement of their shamans, their spiritual guides and the keepers of traditional tribal knowledge. A shaman is using a small pouch from around his neck. He shook out a fine, black powder into his palm and he uses the powerful snuff, made from tobacco, to “open up” the mind and reach the tribe’s people using his thoughts. By performing traditional rituals, including dances, he and the other tribal shamans can build a protective wall with the spirits to keep miners’ loggers and drug traffickers out of the forbidden territories. Through their spiritual work with their thoughts, they give them space, so they can live in peace”.

Psychic Attacks

We often hear people saying, “I am feeling low”, I feel some kind of negativity”, “this place is negative”, psychic interventions, cursing, jealousy etc. All these thoughts, words, feelings and emotions point towards a negative presence or a negative entity. They impact our lives physically, mentally, emotionally, and spiritually around the body. “These entities can become enmeshed in the aura, the energy field around the body. The emotional or physical trauma endured by a person can render the energy centers vulnerable. They are open like doors to allow entry and attachment by entity” said Dr. William J. Baldwin.
Holes in our aura can be created during surgeries, traumas, etc. When our aura is not whole, its ability to fight the negativity drastically reduces. With a prolonged period of suffering, long bouts of anger and extended periods of stress, all of this can create holes in the aura leading to easy invasion. Black magic and sorcery exist in every culture and proofs of the same exist widely. People who are unhappy with themselves on the first place and with others can send negative energy to bring misery to the victim. They will try to invade your space, time and stay with you, until is cleansed or to the end of one’s life span.
Spirit possession or control by non-physical entity goes against our most basic human and spiritual rights. Unfortunately, they are coming from unhappy people who are lost in illusions and they are triggering our weak spots. These human beings can be very lovely and at the same time evil, too. It is a possibility both terrifying and preposterous.

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Iris Publishers- Open access Journal of Nursing & Care | Providing a Peaceful Passage through Care, Comfort, and Compassion

Authored by Karin L Ciance

Advocating for hospice care for your loved one sooner than later can help provide a peaceful passage. When faced with the need to address end of life patients, families and loved ones this will require a multidisciplinary approach of care and support. Nurses, particularly novice nurses and newer graduates are not comfortable addressing the need to discuss or explore planning for end of life care options. In today’s high-tech society, from my observations the basic needs of nursing care are somewhat lacking. Therefore, the development of the 3 C’s which include: caring, comfort and compassion should be utilized in all patient care situations but particularly in end-of-life hospice care. My theory is that the nurse who embraces the 3 C’s who provides direct care and coordinates the members of the interdisciplinary team to augment part or all of the 3 C’s will thus assist the individual and family to both a peaceful and meaningful death.

As a nurse educator for prelicensure nursing students, I have expanded this care approach to end-of-life hospice care during the Community Health Nursing course using case studies. These case studies have been used in pre and post clinical conference discussions and during class to augment theory presentation to prepare the nursing student for the hospice experience. One common theme that continues to surface in my practice is that often clients referred to hospice services stated they do not regret it, but rather wish they had started sooner. Hospice provides care, comfort, and compassion to everyone; thus supporting a peaceful passage and death with dignity.

Providing a Peaceful Passage through Care, Comfort and Compassion

Advocating for hospice care for your loved one sooner rather than later can help provide a peaceful passage. As nurses, we need to educate the patient and family members during their illness, when the treatment is no longer working, or when the treatment has completed, and the person’s health and longevity cannot be extended with further interventions. Quality of life versus quantity of life needs to be addressed with the loved one before they are days away from death. Engaging the hospice care team will provide beneficial care, comfort and compassion to the entire family.
Who can benefit from hospice care? According to Bernazzani [1]. Individuals who have been diagnosed with a terminal illness and are medically certified as having a life expectancy of six months or less can receive this type of care. For hospice care to be covered, a patient must decline curative treatments and elect symptom management and comfort care instead (para. 5).
Other life events, for example the birth of a baby, families actively engage in making plans for this significant life event. There is a lot of time and attention devoted to planning for and celebrating the birth of a new life. Certain choices are made, supported and respected by the new mother and families involved. There is not this level of preparation or view held towards end of life care and needs. When faced with the need to address end of life patients, families and loved ones will require a multidisciplinary approach of care and support. Mutual decision making to not prolong life and seek comfort care is important and can be difficult. Advanced directives will guide the decision-making process. Serving as an advocate, team leader, provider of hands-on-care, the nurse has a crucial role in ensuring the patient receives necessary care during this challenging stage of life.
Preparation for this role begins in a nurse’s foundational education for practice. However, although this is an essential component of nursing education curriculums, it can become an underappreciated concept in the high-tech/low-touch health care environment. Nurses, particularly novice nurses and newer graduates are not comfortable addressing the need to discuss or explore planning for end of life care options. Nursing education and nursing has lost a valuable practice concept as defined by Virginia Henderson. Henderson’s (1966) definition of nursing practice states: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to this in such a way as to help him gain independence as rapidly as possible as cited in Ahtisham & Jacoline [2].

Virginia Henderson focused on individual care. She described the nursing role as assisting individual’s with essential activities to maintain health, to recover, or to achieve peaceful death [2].
As a new graduate nurse over 3 decades ago from a diploma program, I found myself and my family being faced with the decision to make my mother a do not resuscitate (DNR). My mother, diagnosed with lung cancer at 48, received 30 radiation treatments and several chemotherapy courses, even though there was no cure. I recall the doctor stating, “This is treatable but not curable”. Nine months later at the age of 49 she passed away while being intubated and on a ventilator in the intensive care unit.

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Iris Publishers- Open access Journal of Current trends in Clinical & Medical sciences | Uranium in the History of Medicine

Authored by Fathi Habashi

Joachimsthal in Saxony was an important silver mining district since the Middle Ages when around the 1770s production started to decrease and the mining town was about to become a ghost town. It was at that time that Martin Heinrich Klaproth (1743-1817) a pharmacist in Berlin who became later professor of chemistry at the Royal Mining Academy, discovered that the black mineral in the ore can be used to give glass a brilliant yellow color with green fluorescence when added to the molten batch. He was also convinced that this mineral must have contained a new metal. This discovery coincided with the discovery in 1781 of a new planet in the solar system by his compatriot William Herschel who had immigrated to England in 1757 and called the planet Uranus. Hence Klaproth named the new metal “uranium” to honor his compatriot. In 1789 he was able to isolate a black heavy solid from the ore which he thought it to be the new metal. Since that time uranium started to play a dominant role in the history of medicine.  The history of uranium is closely connected with the silver mining town Joachimsthal1 in the Erzgebirge on the border between Saxony and Bohemia (Figure 1). The town was founded in 1516 when few years earlier silver was discovered. Further settlings in the neighborhood, Freiberg (1168) and Schneeberg (1446) are also known by their silver discoveries. It was there in Joachimsthal that uranium was discovered but uranium industry went through many stages of prosperity and depression with different industrial products other than uranium till finally uranium became the most sought-after metal during World War II that started in Europe in 1939. Within few years of mining in the district, it became known that the miners in the town suffered from a mysterious sickness. It was also too often that the miners came across a heavy black mineral which was for them a bad luck because it did not contain silver (Figure 2). For this reason they called it “Pechblende” which is German for “the bad luck mineral”. Because it was black, it became known in English as “pitchblend”. Soon, the miners’ sickness was attributed to this black mineral.The town recognized remarkable prosperity, the population increased gradually, becoming the second largest town in Bohemia after Prague. However, during the religious war of 1546-1547 and the lack of pumps needed to remove water from the deep mines made it difficult to compete with silver from the new Spanish American colonies, which was arriving in increasing quantities on the European market. As a result, the town knew its depression and the population decreased drastically. With decreased silver production, Joachimsthal was about to become a ghost town when Martin Klaproth (1743-1817) (Figure 3) a pharmacist in Berlin who became later professor of chemistry at the Royal Mining Academy in Berlin, discovered that the black mineral from Joachimsthal can be used to give glass a brilliant yellow color with green fluorescence when added to the molten batch.
Klaproth was also convinced that this mineral must have contained a new metal. This discovery coincided with the discovery in 1781 of new planet in the solar system by his compatriot William Herschel and called the planet Uranus [2]. Hence Klaproth named the new metal “uranium” to honor his compatriot. In 1789 he was able to isolate a black heavy solid from the ore which he thought it to be the new metal.

Uranium in the Glass Industry

In 1851 the Austrian chemist, Adolf Patera (1819-1894) (Figure 4) at the Imperial Geological Institution in Vienna investigated the possibility of the commercial application of Klaproth’s discovery. He devised a procedure for preparing “uranium yellow” known at that time as “Uranoxyd-natron”. Consequently, a plant was built in 1854 next to the silver smelting operations to process this black uranium mineral for pigment manufacture which was kept a guarded secret and a monopoly of Bohemian glass manufacturers. In 1873, Joachimsthal suffered greatly from a fire and since the silver operation was becoming unprofitable the government of the then Austrian Empire decided to close all the mines.

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Iris Publishers- Open Access Journal of Neurology & Neuroscience| Diagnostic Coding: A Novel Approach to Quality Assurance in Private Practice

Authored by Roy G Beran

Abstract

Quality Assurance (QA) measures in private practice require the collaborative effort of practitioners and their administrative staff and are designed to monitor and improve the efficiency and quality of clinical practices and patient care. The private research company ‘Strategic Health Evaluators’ (SHE) in Sydney, Australia, has developed a unique QA system based on diagnostic coding to monitor follow-up treatment for patients, report incidents and assess the appropriateness of current patient treatment. Concurrently, the system is also useful in creating a pool of potential subjects for clinical trials as patients are categorised within a database by their diagnosis. This paper reports the benefits of the application of diagnostic coding in the private practice environment and evaluates the extent to which the system has achieved its goal of quality assurance.

Introduction

Quality Assurance (QA) procedures are critical in clinical practice to ensure the highest standard of patient-oriented care [1]. To guarantee that QA measures are being conducted and adhered to by healthcare practitioners, efficient operation systems must be in place to ensure that a patient’s health, wellbeing and care are monitored, long after the patient has left the waiting room [1]. These systems aim to provide the highest quality of patient care through incident reporting and care monitoring [2,3], to reduce the risk and recurrence of errors, such as patient loss to medication errors [4], follow up, and patient non-compliance with treatment [2]. Methods of providing such QA are usually only practiced in large institutions and are usually not adopted by single practitioner clinics [5]. In large institutions, where much QA is in place, there is usually a department within the hospital which assures responsibility for monitoring and is answerable to the hospital administration rather than the clinicians who deliver patient care [6].

Strategic Health Evaluators (SHE) in Sydney, Australia, is a private research company operating in conjunction with, and as an integral component of, a single clinician community-based neurological outpatient service. Due to the limited resources available, as a result of being a small, privately owned practice, the clinic has developed a unique system of diagnostic coding to assess patient specific parameters to help monitor with patient care that is directly comparable to that of the measures offered in larger institutions. This diagnostic coding system examines patient files and identifies patients by their diagnosis, allowing for the neurologist and all staff to monitor patient treatment, compliance, communications, content of medical records and results and serves as a safeguard to prevent against medication errors and other anomalies.

The clinic, which is the subject of this review, has instigated a number of QA measures, such as writing to the referring practitioners, should a patient fail to keep an appointment without notifying the clinic. As the clinician sees approximately 100 patients per week, it is important to both maintain QA as well as undertake clinic audits to ensure that the additional demands, imposed by QA procedures, are valid and productive. Diagnostic coding requires significant time investment, work delegation and collaboration of practice staff with the objective of verifying that treatment regimens were adhered to; that the risk of medication errors was minimised; that necessary tests have been performed; patient compliance was maintained with proper follow up ensured; and that correspondence between specialists, general practitioners and carers was complete.

Being a research company, the diagnostic coding system not only serves to provide a means for effective QA but also aids in the clinical trial recruitment process by identifying a possible source of trial candidates, found to have specific diagnoses. The purpose of this paper is to determine if the time, collaborative effort and resources, necessary to conduct diagnostic coding and QA, was of sufficient benefit to the practice and its patients to justify continuing the process, and, if so, to what extent has it satisfied the goal of QA.

Methods

At SHE, patients who attend the practice are assigned a medical reference number (MRN), numerical in sequential order, similar to the procedure adopted in much larger institutions. All medical documents related to a patient are filed into that patient’s medical record using their MRN as an identifier, as patient records are filed by number rather than alphabetically. During diagnostic coding, 50 recent patient files are selected and offered for review for every 50- 60 new patients that are seen at the clinic. The files are selected based on MRN, in sequential lots of 50, leaving a gap of 100-150 files (MRN numbers) between the newest patient to the practice (who will have the highest MRN), and the first MRN in that set of diagnostic coding files. For example, if the newest patient’s MRN is 2000, the diagnostic coding process will begin with MRN 1850 and end in MRN 1900, and after seeing 50 new patients (namely, the last seen will have MRN 2050), the next diagnostic coding set of 550 will begin with MRN 1900 and the last MRN will be 1950). The purpose of leaving this gap, between the latest patient and the start of the diagnostic coding set, is to allow for follow up material (such as letters and results) to be received by the practice and to allow for sufficient time to establish a better working diagnosis or for necessary tests to be performed. It also overcomes some logistic problems that may delay certain tests to be performed, such as in-patient polysomnography, as the clinician is also an accredited sleep physician.

Should a follow up letter be required, consequent to review of the patient’s record, the neurologist will dictate such a letter, which will be sent to the relevant recipient- which may be a general practitioner, an authority such as the driver licensing authority, a caregiver or another referring doctor and, where appropriate, copied to the patient. Patients with particular medical conditions or diseases will have these diagnoses coded and the files noted by said diagnosis, for future reference. This confirms that the file has been reviewed and allows for ease of access, should research focus on that medical condition. If a patient’s file needs to be accessed by the neurologist or a staff member, dependent on their diagnoses, the diagnosis is entered into the system and the MRN’s of all patients with that diagnosis will appear.

Diagnostic coding requires specific time allocation - the neurologist will require 1.5 hours on average to review 50 files and complete any necessary dictations, or institute follow up procedures, whilst concurrently recording the diagnosis. The medical typist will require 2-3 hours to produce appropriate correspondence as required and to document diagnostically coded patients by their MRN with diagnostic categories. Responses from patients, healthcare specialists, caregivers and authorities are monitored by the neurologist and the office staff to ensure that all recommended follow up procedures are performed. The process requires a significant amount of invested time by all concerned.

If, at the time of coding, a patient’s file is unavailable, due to the patient having an appointment and their file allocated for a consultation, diagnostic coding will need to occur following that consultation. This may necessitate extra time per patient depending on the complexity of the tasks involved, such as making a diagnosis, entering new codes electronically and preparing a follow up letter (if needed).

If action is required by the patient, as a consequence of the diagnostic coding having identified a deficiency, such as having a test performed before resuming driving, this is notified to the referring doctor, and with the correspondence copied to the patient. Office staff maintains a separate record of such correspondence to ensure compliance and, should there be no response, then follow up action, such as notifying driving authorities, ensues.

Results

Between the 1st of May 2013 and the 13th of April 2016, patient files 19951-21450 inclusive, and file 13842 were reviewed for diagnostic coding. Of the 1501 patient files reviewed, 1263 (84.1%) required no further action after coding, whilst the remaining 238 patients (15.9%) required a follow up letter. During our review, no medical errors or other anomalies were noted and no medication revisions were required. Thirty two of the 238 letters sent were regarding fitness to drive assessments; more than half (20/32) required further correspondence to the Roads and Maritime Services attesting a lack of fitness to drive, eight required no further action due to appropriate follow-up having taken place, and four patients were lost to follow up regarding driving fitness.

Thirty of the 238 letters regarded follow up of results, reminders or cancellations of Magnetic Resonance Imaging, Electroencephalograms, polysomnographs, and/or CPAP titrations, including 14 patients who did not attend their appointments, cancelled their appointments or failed to follow through with clinical advice. Correspondence was returned by the GP of one patient to inform the practice that the patient had since died. Ten letters indicated that the patient was under the care of another specialist and did not need to return to the practice. Other patients had failed to keep follow up appointments at the practice, failed to have necessary tests performed, had been ordered therapy with no indication of success (or otherwise) and left doubt that proper care had been provided. Many letters simply sought feedback to ensure that the patient was receiving appropriate care.

Three potential trial candidates were able to be identified by the trial coordinator using the diagnostic coding categories and were subsequently screened for inclusion into the suitable trials.

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Iris Publishers- Open access Journal of Neurology & Neuroscience| Telomerase and the Brain: A Special Relationship

Authored by Gabriele Saretzki

Abstract

While telomerase is best studied in its canonical function on telomere maintenance during cell division, various non-canonical functions beyond any telomere involvement and nuclear localisation of the protein part TERT (Telomerase Reverse Transcriptase) have been discovered in recent years. It currently emerges that the TERT protein seems to have a particular important function in the brain and neurons. While in most human somatic tissues the TERT component is downregulated while the RNA component TR/ TERC persists, in human brain it seems to be the opposite: the RNA component is downregulated early during development and TERT persists even in neurons from old brain. This mini-review gives a brief overview of the special relationship of telomerase in the brain which might be exploited in future therapies of neurodegenerative diseases.

Telomerase in Mammalian Cells

Telomerase is a reverse transcriptase that maintains telomeres in cells where it is active. For that function, 2 minimal components are required and sufficient in vitro [1]: the catalytic subunit TERT (Telomerase Reverse Transcriptase) and the RNA component TR/TERC which also contains the 11 nucleotide template region for the addition of TTAGGG hexanucleotides onto the 3’ G-rich telomeric overhang. This catalytic function of telomerase has been initially described by E. Blackburn and colleagues in unicellular protozoans [2]. However, it quickly emerged that most eukaryotic organisms use this ancient enzyme which, due to its composition, is a ribonucleoprotein, for maintaining linear chromosomal ends. Telomeres shorten during cell division predominantly due to the inability of the semiconservative DNA replication process which leaves an RNA primer at the very end which cannot be replaced by DNA [3]. This is also known as the “End Replication Problem” (ERP) [4]. In addition, oxidative stress can contribute to telomere shortening as well as telomeric DNA damage [5-7].

The catalytic function of telomerase has been well studied and described and plays a major role in dividing cells. However, telomere shortening, due to induction of cellular senescence or apoptosis, also acts as a tumour suppressor mechanism [8]. While most mouse tissues have telomerase activity present during adulthood in the majority of tissues and organs, most human somatic cells downregulate telomerase activity early during development [9- 11]. In contrast, germline cells, embryonic stem cells and most cancer cells have high, constitutive activity of telomerase which is a prerequisite for their immortality [12-14]. The majority of human somatic cells does not have telomerase activity. Exceptions are endothelial cells and lymphocytes such as T- and B-cells as well as adult stem cells that are both able to upregulate telomerase activity upon stimulation [15-17]. During differentiation of human embryonic stem cells in vitro telomerase activity and the expression of hTERT are downregulated quickly, while the hTR component is still detectable after differentiation [18]. This scenario most likely also occurs in vivo during development.

In general, it is thought, that the presence of the catalytic subunit TERT is the limiting factor for the presence of telomerase activity in cells, including human cells. This is the reason, why human somatic cells can be transfected by hTERT in order to generate telomerase activity and extend the lifespan of mortal cells and avoid senescence and apoptosis due to continuous telomere maintenance [19,20]. This is due to the fact that the RNA component is present in most human somatic cells and it had been speculated that it might fulfil other roles in there. In addition to its canonical function in telomere maintenance, over the past years it emerged that the catalytic subunit TERT has various non-canonical functions. This includes it’s shuttling to mitochondria where it protects cells from oxidative stress, DNA damage in mitochondrial and nuclear DNA as well as apoptosis [20-22]. TERT has a mitochondrial localisation signal and is exported from the nucleus upon phosphorylation in a Src-kinase dependent manner [23,24]. Moreover, TERT is able to complex with mitochondrial RNA’s in order to generate a reverse transcriptase function within the organelle [25], although it’s biological significance is not entirely clear. In addition, the non-canonical role of TERT has been shown to promote various properties of tumour cells such as migration, epithelial-mesenchymal transition (EMT), invasion and more [26].

Telomerase in Mouse and Human Brain Cells

Over the last years various groups have demonstrated a particular role of the TERT protein in brain and specifically in neurons [27-29]. Mouse and human microglia due to their macrophage-related origin display some telomerase activity and TERT protein [30,28]. However, contradicting data exists for rodent astrocytes, with some studies demonstrating initial but over time subsiding telomerase activity during in vitro culture [30] while other studies found a decrease of telomerase activity and TERT expression during in vitro differentiation of mouse neural stem cells into astrocytes [31]. Our group did not detect TERT protein in astrocytes of the human hippocampus and cultured mouse astrocytes [28]. However, we found TERT protein present even in brain neurons from old AD patients, while no telomerase activity is detectable in embryonic brains after post-conception week 10 when measured with a conventional TRAP assay at 30 cycles [32]. Our study demonstrated that instead of TERT, in human brain it seems to be rather the RNA subunit hTR that is downregulated. This could be the mechanism how telomerase activity is downregulated in the human brain in contrast to most other human tissues. Our results suggest a different mechanism of down-regulation of telomerase activity in human neurons compared to other human tissues (Figure 1).

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Iris Publishers- Open access Journal of Current Trends in Clinical & Medical Sciences | Pain Physical and Emotional

Authored by Andrew Hague
 
Abstract
The only way to be released from pain is to cure the cause of the pain.
Four options:
1. Mask the pain by switching off the brain.
2. Death.
3. Learning to live with it.
4. Cure the cause of the pain.

Introduction

Only the fourth option is acceptable, and this paper will show that it can be done. Unfortunately, the other three options are too common. There are three components in the body that are always found together. If one does not work, the other two cannot work. They are the nerves, veins and arteries. Repairs must suit all three components. Veins and arteries carry blood. If there is no blood at a place in the body, that place cannot be healed. Blood is the life support liquid. In humans even maintaining its temperature is essential.
Nerves carry signals to the brain which is the body’s control centre.
Every cell in the body is connected to the brain. The language of the nerve network is pain. From a finger pulling back from a hot surface to the workman stopping to eat, messages flow to the brain and action is taken to keep the body operating. If a message is unable to reach the brain, harm will continue with consequences that can be disastrous. If pain continues and the brain is unable to make a repair, the person suffers. The body’s operating system depends on the requests for help being answered and, like an unanswered telephone, will continue ringing until it gets help. It is that perpetual pain that is the subject of the essay.

Masking the Pain

Drugs can switch off the brain either drastically or slightly. They are never a remedy. Ethanol, a popular poison known as alcohol, has been used by humans since fermentation was discovered by early farmers. Interestingly, reports of animals being allowed to drink alcohol show that the animals also like to be inebriated [1]. If alcohol was originally reserved for celebrations, it eventually became a crutch to carry people through their daily life. Compounding this inadequate answer to a problem is the fact that dependency on the escape or mask becomes addictive.
Worse, whatever the trouble the person wanted to avoid becomes more difficult and they enter a downward spiral (Figure 1). [2] Archaeologists investigating the Neolithic ages, 7,000 years ago, found poppy seeds used medicinally. Before the poppy is ripe, the seed pod can be cut to allow a latex to ooze out and be collected. Observe babies, they put everything in their mouth. Little imagination is required to accept that humans discovered the use of the poppy as an anaesthetic. Poppies are the raw material for opium from which heroin, methane, codeine and thebaine are derived and the synthetic forms of oxycodone, hydrocodone, hydromorphone, and other semisynthetic opiates.

The Opioid Crisis

In the American Civil War, the Union Army used 175,000lb (80,000kg) of opium tincture and powder and about 500,000 opium pills [1]. During this time of popularity, users called opium “God’s Own Medicine”. Opium’s anaesthetic and addictive powers were well known by the 20th century. Britain had used it to profit from China by forcefully cultivating poppies in India and militarily pushing them on the Chinese [3]. By 1840 there were 10 million Chinese opium addicts; largely due to illegal British imports. Sales were sustained by the users’ addiction.
In the late 1990s, around 100 million people or a third of the U.S. population were estimated to be affected by chronic pain [4]. Lower back pain, arthritis, post-surgery pain and cancer were the usual causes of pain and without a cure the patient wanted escape. Pharmaceutical derivatives of opium were the low cost, highly profitable answer to demand. When the pain relievers were launched, they were claimed to be non-addictive. That was soon found to be untrue. “An investigation by the US Senate Committee on Homeland Security and Governmental Affairs detailed the financial ties that exist between opioid manufacturers, advocacy groups, and medical professional societies.
The report exposed patient advocacy groups and professional societies spending millions of dollars to promote messages and policies favoring the interests of the pharmaceutical industry [5].” The patients were addicted to the drugs [6]. Every day, more than 130 people in the United States die after overdosing on opioids. The Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.

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Iris Publishers- Open access Journal of Current Trends in Clinical & Medical Sciences | Can Emergency Medicine Become Redundant?

Authored by Andrew Hague

So long as there are emergencies, we shall need emergency doctors. Is it unrealistic to believe that we can plan our lives so that emergencies never happen? Utopia is dreamland, it is said, but nevertheless, without such visions we have no sense of direction. If the unexpected can be anticipated and avoided then pain, suffering and disruption is minimised.

Introduction

Injury and illness

Injury and illness are the two medical problems. Injury can be sudden and requires emergency treatment. Illness is incremental and treated progressively.

Doctors are role models

Much work is done to prevent illness. We see this in better hygiene, personal and social; washing hands and sanitation. Lifestyle affects health and people are advised on diet and exercise. The equivalent advice from doctors about emergencies and injuries is missing. In all societies, doctors are role models. We all grew up thankful for the attention of a doctor at some stage. They brought us into this life and will see us out. Seldom do they pronounce on politics and although they have a good income are never seen as having more than their fair share of wealth. People respect doctors and this status should be used by doctors to influence behaviour. Doctors, whether they like it or not, are role models. What they say, is influential.

Causes of injury

There are four classes of causes of injury:
1. Carelessness.
2. Recklessness.
3. Aggression.
4. Misfortune
From the first of carelessness to the last of misfortune, the chance of avoiding disaster gets less which means that a doctor has less influence. Nevertheless, statements by doctors will be heeded and when it is understood that the doctor invites redundancy this advice will be respected. We wish for the same from the police and fire brigades. Indeed, the fire service devotes a lot of effort to inspecting buildings for fire safety. Do the police invest time preventing crime or is that left to the deterrent effect of sentencing and punishment? In many cases, it is hoped that people will be careful to avoid injury but still they turn up at the A&E in pain and talking about accidents. Investigators admit that the truth is there are no accidents, only mistakes that were avoidable.

Consequences

A child has no concept of consequences. Over time, by trial and error coupled to imitation, the process of conditioning adds to the memory bank and the child becomes an adult aware of the consequences of their actions. People who have not acquired this knowledge should be recognized by doctors for their ignorance which will become evident in frequent visits to the clinic. Their teachers will have already identified these people at school as slow learners. It is in these encounters that doctors have a role to play. Interestingly, the accident prone are not always those scoring low in education. There are many explanations for mistakes. The person who does nothing may stay safe but achieve nothing and the ambitious may push the boundaries of sense to explore beyond. This is the consequence of having the brain we acquired when we mutated into homo sapiens.

Carelessness

There is an assumption that tidiness is safer than a mess. Do more accidents happen in a messy or tidy workplace? I do not know but from my own experience and this includes owning a factory for many years, a mess is not the cause of mistakes and tripping over wires. Where there are obvious dangers, people are alert and avoid them. When there is deceptive safety, one’s attention can wander letting the day dreamer trip or walk into a half open door. Our brains are not born to cope with neatness. The cave and the jungle floor are always a tangle and walking depend on watching where to put your feet for every step. Only since manufacturing required orderliness has a clear path become essential. This allows carelessness.
There is the often-quoted story of two mountaineers trying to find their way to the Royal Geographical Society through the back streets of London. These men had climbed the world’s mountains and then one of them tripped over the kerb when crossing the road in London and broke his leg. As a doctor, what can you advise to prevent such mishaps? Obviously, the fellow was safer on Mount Everest than the paved streets of London.

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Iris Publishers-Open access Journal of Oceanography & Marine Biology | Characterization of Short-Finned Pilot Whales (Globicephala Macrorhynchus) Population along the Caribbean Coast of Martinique

Authored by De Montgolfier B

The Caribbean coast of Martinique has a great wealth of marine mammals, with almost twenty species observed, including the short-finned pilot whale Globicephala Macrorhynchus. Little is known about this specie in Martinique. Boat surveys between “le rocher du Diamant” and “l’îlet la Perle” allow gathering data and pictures. Statistical analysis, SIG and photo identification provide first information on the pilot-whale population. Results indicate there is a rather small but healthy population of G. macrorhynchus in Martinique. It is composed of both resident and migrant groups and no seasonality was observed. Correlation between the percentage of teenagers and the number of boats might imply an effect of whale-watching on individuals.
Martinique Island, located in the Lesser Antilles, is surrounded to the east by the Atlantic Ocean and to the west by the Caribbean Sea. It is located in the middle of Agoa sanctuary, an MPA established in October 2010 by the French Government, that includes all Exclusive Economic Zones (EEZs) of French Antilles (143 256 km² [1]. This sanctuary, currently managed by the “Agence des aires marines protégées”, implements measures for the protection of cetaceans. Over the last few years, coastal regions of Martinique were exposed to demographic growth and tourism [2,3]. Whalewatching is booming on the Caribbean coast of Martinique [4]. Tourism can bring some advantages such as revenue for local communities or an improvement of people’s attitude toward the environment [5]. However, anthropogenic activities can impact marine mammals through environmental pollution, prey depletion or physical disturbances, especially in coastal areas [6].
In Martinique, whale-watching has been rapidly increasing over the past decade due to a stronger demand. Almost twenty species of marine mammals have been recorded in the Caribbean Sea [1]. For example, humpbacks whales (Megaptera novaeangliae), Bryde’s whales (Balaenoptera bryde), toothed whales such as sperm whales (Physeter macrocephalus) and various species of dolphins (Stenella attenuata, Lagenodelphis hosei, Tursiops truncatus) are observed. Many of them, like the pantropical spotted dolphin (Lange et al., in prep) or the sperm whale [7], are increasingly studied.
Amongst all cetaceans of the Caribbean French Antilles, the short-finned pilot whale (Globicephala Macrorhynchus, Gray 1846) is one of the less studied. This specie is found in all oceans and primarily distributed in warm waters [8-11], such as the Caribbean coast of Martinique. It is a highly gregarious species, travelling in socially cohesive groups from 10 to 50 individuals, but also encountered in large herds of several hundred [12,13]. Based on several studies, Globicephala sp. appear to live in relatively stable pods and not in fluid groups [10,14]. Pods generally contain individuals with close matrilineal associations [15,16]. Despite this, information on G. macrorhynchus is scarce in literature and its population trend is not well known [17].
Even if its northern Japan population is considered at risk, there is not enough data to evaluate its status elsewhere [11]. Due to this lack of data, the IUCN Red List of Threatened Species categorized the conservation status of this species as “data deficient” (IUCN). Moreover, this specie was principally studied in Japan [6,18,19], in the archipelago of Madeira [17,20], in the east coast of United States [21,22], in Canary Islands [9,23,24] and in Faroe Islands [12,13] but has never been studied in Martinique nor in the Caribbean.
Agoa sanctuary is committed to the sustainable management of cetacean populations of this area [1], because they play an important role in marine ecosystem as top predators and affect the entire food-chain through trophic linkages [19]. Detailed knowledge on marine mammals’ population, especially their movements, their survival rate or the pressures they are subjected to [6,25], are crucial to effectively manage and preserve the entire marine ecosystem. Since G. macrorhynchus is more observed and often exposed, as demonstrated by Bordes [26], this study focuses on this specie for the first time in Martinique. Our aim is to characterize its population to enhance our knowledge about it.

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