Ehab Hanna, MD, FACS

• Professor and Vice Chairman
• Director of Skull Base Surgery
• Department of Head and Neck Surgery
• Medical Director, Head and Neck Center
• University of Texas MD Anderson Cancer Center
• Houston, Texas

The national capital is Abuja in the Federal Capital Territory while Lagos remains the economic capital weight loss pills ky buy xenical 60mg with amex. The constitution grants all citizens of at least 18 years of age the right to vote weight loss images cheap xenical 120 mg on line. Women were involved in the political process since the colonial era mostly in the south weight loss in elderly discount xenical 60mg without a prescription. Their political strength is rooted in the precolonial traditions among particular ethnic groups weight loss diets for men best buy xenical, such as the Igbo weight loss natural remedies buy generic xenical 120 mg online, Edo, amongst others (Falola, Hamilton, Kirk-Greene, Udo & Ajayi et al. I am going to discuss on the objective of the thesis and skin lightening as a project and introduce the two key research questions to guide us as you read through my report. This nonetheless motivated me to take the challenge to conduct a research on the project in question. The staffs consist of nurses, social workers and psychologies while service users are mainly women of diverse background, social statues, values and religion. We also have students from the locality and public healthcare workers who frequently visit the center to exchange innovative ideas, participate in workshops and seminars on health care related themes and wellbeing. The two research questions which I am going to deliberate on to better understanding the mind-set behind skin lightening are the following; 1. Creswell (2014, 66) as noted by Schwandt in 1993 that no qualitative study begins from pure method. Theoretical framework serves as a starting point for all observation and prior conceptual structure. It further went further to state that the essence of theoretical framework is to use the knowhow acquired to better understand and exert a more informed and concrete approach to any text. The theoretical framework must demonstrate an understanding of theories and concepts that are relevant to the topic of a research paper and that relate to the broader areas of knowledge being considered. In conclusion, theoretical framework is readily found within literature, it is pertinent that a review and research studies for theories and analytic models relevant to the research problem is examined (University of Southern California Research Guides 2019). Theoretical framework will further strengthen a research work by creating explicit statement of theoretical assumptions that permits the reader to evaluate them critically. This will serve as a connecting bridge of the researcher to existing knowledge thus given a relevant basis for a hypotheses and choice of method. Cresswell (2014, 65) refers to a study by Fay in 1987 defines critical theory perspectives as concerned with empowering individuals to transcend the constraints placed on them by race, class, and gender. I hope to accomplish these measures by identifying those vices that directly or in directly prompted them to adopt their position. Ensuing into accessible opportunities conceivably attainable in a discernable manner. The theory suggests that much learning takes place through observing the behavior of others. This theory therefore suggests that, a lot of learning takes place through observation first, prior to doing it personally (Apuka 2018). The social learning proposes that for any reaction to manifest itself, there must have been a form of assimilation adopted by developing a general stance and values of the other person through development like one would do with a role model 9 Additionally, as the theory suggest, the more a person is exposed to certain behavior the more he/she tends to copy them. The advent of social media has made it easier for women to get exposed to various adverts that projects light skin female advertisers, therefore, their perception is influenced into believing that lightening of the skin has some positive significance. All characteristics of an individual to some degree reflects a given social structure. It emphasises that, it is not merely an acquisition, or receptive process, since social self affects the way a person perceives and interpret their experiences in social living (Jarvis, Holford & Griffin 2003). These writers further stress that despite the wholesomeness that it seems, it is not a one-way transaction; that human learning is self-conscious and reflexive even as socialization remains a primary function of learning. The conclusion being that, we are both products and creators of culture and that Learning is seen not as social adaptation but as social action. Since social learning theory describes human behaviour as a continuous reciprocal interaction between cognitive, behavioural and environmental determinants. Understand the stance of those who choose to lighten their skin is a socially complex subject that calls for extensive research. Most of my clients assumed that it was their fundamental human right to dictate and influence their self-direction. The felt that whatever they did to themselves was their personally affair therefore no human nor authority had the right to dictate what was good for them. Most government have banned topical products that contains mercury on the shelves of their individual countries. The ban however has not generated much effect on the attitude of those who use this merchandise. This subject had ethical implications as it was difficult for me to draw a line between what is justifiable and conflicting. This conception therefore exalts humans not as powerless objects controlled by environmental forces nor free agents meaning they can choose to be what they want. Both people and their environments are reciprocal determinants of each other (Bandura 1977 sited in Javis et al. The approaches adopted by the writer is aimed at promoting the role of criticism in the search for quality education through critical social theory. This critical form of classroom discourse is only made possible by grooming student´s ability to critique institutional as well as conceptual dilemmas, especially those that breeds domination or oppression. Critical social theory-based movement in education promotes the relationship between social systems and people, examine how the manage each other, contribute to the emancipation of both. Barbara further identified three key characteristics of critical theory namely Social engineering: through functionalist perspectives to assist in the social construction of order, control and regulation; Political mobilization: through Marxist, critical and feminist theories to establish a base for critique and emancipation; Sense making: through interpretative approaches to facilitate understanding of how sociocultural intelligibility is achieved (2000, 11). Critically thinking from the perspective of a common man and a feminist, has the authorities trespass their limit by indirectly intruding into its citizen´s private affairs. Are Nigerians not entitled to comport and adorn themselves ways that they so desires In this circumstance, It is difficult to ascertain how much influence the authority must exert in banning products that contain products that they deem harmful to it citizens. However, the complication these products may have in the long-term on consumers, there is a necessity to ethical and critically appraise and individuals own desires and rights. The pyramid dictates that the most basic levels of human needs for life, such as sufficiency needs, occupies the bottom while the most attractive need 11 are located at the top. It comprises physiological needs, safety/security, aesthetic needs and self-actualization (Maslow 1954, cited in Lee & Hanna 2015, s. Consequently, for one to emigrate to the top, the needs at the bottom must be mostly met. I wish to argue that, in this case everyone has the freedom to set their prior according to their scale of preferences; as they so desire. Most women have gone as far as forsaking food, shelter, clothing which are salient needs to enable them safe money to purchase these products. A client hinted me that looking good is more important to her at that stage of her life. She believes that lightening her skin will bring her much favor and possibilities in her daily pursuit. Therefore, if skin bleaching is what will guarantee self-satisfaction, who are we to question their tenacity and judgement. Most ladies are conditioned by the power of needs to actualize their dream, hope and aspiration by resorting to aesthetics measures. Maslow´s hierarchy of needs amplifies the need for self-esteem by placing it at the second stage of the pyramid. Self-esteem, which involves confidence, feeling of accomplishment and respect suggest the importance these needs. Since the most basic levels of human needs namely sufficiency needs drop to the bottom while the most attractive ones elevate cannot be least emphasized. Most of the Nigerian women I interviewed as earlier mentioned, who bleach believe that to arrive at a self -actualization, it was important to boost their self-confidence and command respect though bleaching to meet their perceived societal craving. Since everyone has the right to personal freedom and integrity, I would suggest that those who so which to practice skin-lightening should be allowed to do so. Exception can Of course, can be directed at particularly circumstances that is suspected hazardous or fatal to lives and property. Despite everything, cautious needs to be applied by both the authorities and individuals to evert trampling on the rights and freedom of individuals. This may the case as most individuals are tempted to criticize those who desire to bleach their skin while others seem nonchalant. Most of those who whiten their skin believe that it will boost their self-esteem, enable them to secure a marriage partner, boost their career and search for a job amongst others. These basic tools are essential to better understand the perceived influence, outcome and the role of popular culture and solutions. It is on this note that I am going to elaborate on namely the data collection method, the process and analysis. A person-centered approach attempts to collect a not too in-depth analysis of an individual´s immediate surrounding; gathering an overall understanding of why the responded as such to a product obtainable. According to keegan (2009), Qualitative research explores questions such as what, why and how, rather than how many or how much; it is primarily concerned with meaning rather than emphasis on the depth of the understanding and relationships that an individual perceives towards a brand. Keegan further refer to it as cultural research since it seeks to understand how individuals and groups think and behave in relation to products or services within a given cultural context. These measures involved assuming an informal interaction-based approach unlike a formal one. I was also conscious of the need for an open-minded but dynamic tactic that supports a versatile but effective impression. I adopted numerous techniques during my research process such as interviews, diary keeping, audio recording and often filming to understand my client´s relationship with the underlying subject in question. I was as well vigilant not to warrant an overly rigid method such as adhering to my pre-prepared questionnaire at some point. As emphasized by Keegan (2009), that although qualitative outcome may be referred to as data, they are not necessarily data in the sense that it evokes thoughts, opinions and behaviors. Most women are attracted to the practice mainly due to diverse factors and the only way to gather materials for my research, I reckon was to immense myself into my target group environment by participating and acting like one of them. My service-users were individuals from diverse works of life; encompassing social status, sexual orientation, education, religion and political affiliation. To collect reliable and prompt result however, I decided to focus primarily on the female group who constitute a focal point of my study. There were altogether 35 interviewees who mostly females were constituting 25 in Nigeria in tandem with 10 women of Nigerian origin residing in Finland. The essence was to add value to my research and draw a contrast considering the distance and cultural differences that surrounds them. Both groups of women nevertheless are currently and were previously exposed to bleaching products. The interviewees were not selected based on educational nor socioeconomic statues, sexual orientation, age nor occupation for fear of risking an atmosphere flanked with segregation. Nonetheless, I personally collected personal data essential to achieving a comprehensive data from each interviewee incognito while names were replaced with invented names for ethical reasons. Confidentiality and trust were paramount considering the level of intrusion into their private lives and secret life. I started by mindfully introducing myself and the purpose of the interview while stating my desire to record their conversation but also promising to personally delete every data afterward. The overall participation of the interviewee was receptive, outspoken, warmth and a rewarding experience (Robinson 2011). The data collection method used here is qualitative research, segmented into two fragments namely interview and focus group discussion as we shall consider in this report. Seale, Gobo, Jaber, Gubrium, & Silverman (2004) describes Qualitative Research Practice as an indispensable and ultimate guide in most qualitative methods. In addition, it serves as a requisite for anyone interested in social research and improving research practice. Qualitative Research Practice further demonstrates the advantages from the perspective of real-life experience. Social research is mandated to serve not only as investigation into the 15 social, but also biographical engagement in an authoritative yet reachable manner (Jaber et al. As earlier mentioned, we shall attempt to examine two qualitative research fragments namely interview and focus group discussion. Interview is described as a social encounter where speakers collaborate in producing retrospective (and prospective) accounts or versions of their past (or future) actions, experiences, feelings and thoughts (Jaber et al. Focus group in contrast supports a qualitative approach by laying emphasis on a one-on-one interview which enables a prolonged narrative that triggers an open talk on matters pertaining to issues of status, conflict and self-presentation (Michell 1999, cited in Jaber et al. The advantage here is that it helps to moderate the pressure and guilt that emanates from an interaction between the interviewer and interviewee. Group interview generates an atmosphere that offers warmth, a willingness to contribute, counsel or respond thus facilitating the task of the researcher. The main source of data collection for this research emanates from an open-ended interview. The interview was conducted in a relaxed atmosphere at the service user´s convenience and privacy. The open-ended approach of the interview permitted the interviewee to freely express their opinion on the skin-lightening subject without constraint nor coercion from any external sources. The collected data were then recorded with an audio gadget, transcribed and coded according to emergent and recurrent characteristics grounded on the interview guideline. Qualitative analysis is an approach that incorporates diversity, complex and nuanced traits (Holloway et al. Qualitative analysis is interpretation cantered, meaning that there are no given limitations nor roles on the mode of application. As in this case, I attempted to adopt an exploratory approach, content driven and mainly based on purposive sampling and use of primary data as I have chosen to do in this research (Guest & Macqueen 2012). Thematic analysis is a qualitative analytic method that attempts to analyse qualitative data by focusing on identifying themes of meaning or identifying patterned meaning across a dataset. Thematic analysis is a method for identifying, analysing, and reporting patterns (themes) within data (Braun & Clarke 2006, 6).

Sometimes laceration of the junctura tendinwu can also lead to extensor tendon subluxation weight loss pills nbc xenical 60 mg buy on line. Lack of complete active digital extension at the metacarpophalangeal joint associated with a sagittal band disruption weight loss pills and cleanse 60mg xenical mastercard. These views will exclude any mechanical or bony pathology limiting extension of or predisposing the sagittal band to dislocate weight loss near me order 60 mg xenical with visa. If the injury clearly is not responding to immobilization weight loss pills perscription xenical 60 mg mastercard, surgery is recommended weight loss hair loss order xenical online. Studies have shown that 44% to 100% of patients treated conservatively will be asymptomatic at an average of 13. Although we believe that this is usually not possible more than 8 weeks after injury, Hame and Melone5 reported on 11 direct repairs at an average of 3. All patients were asymptomatic with full recovery of range of motion and retum to professional sports at an average of 5 months. Positioning · the patient is placed supine on the operating table with the affected hand outstretched onto a hand table. Preoperative Planning · With open injuries, the surgeon should determine if the cause was related to a bite. The remaining ulnar sagittal band was repaired to prevent radial subluxation of the extensor tendon (red arrowhead. Once the lumbrical muscle is separated, continue distally to identify its tendinous insertion. Wrth the extensor tendon reduced, an isometric point in the extensor tendon must be identified. Surgical exposure identifying the extensor dislocation (black arrow) with a large chronic defect in the radial sagittal band (white arro! The lumbrical muscle-tendon unit is isolated and mobilized for transfer (black arrow). This segment of tendon is then passed through a small slit in the remaining tendon at the level of the deep transverse metacarpal ligament to prevent further pro~ agation of the tendon split. A distally based slip of extensor tendon constituting no more than one-third the width of the tendon is harvested. The tendon slip is then attached to the extensor tendon (usually radially) through a weave distal to the metacarpophalangeal joint. The junctura tendinum is released from its ulnar-sided insertion into the adjacent tendon. Five were treated operativdy using a slip of extensor tendon looped around the collateral ligament. After splinting and therapy, all patients were pain-free with full extension and active flexion to 90 degrees or more. There were no recurrences of symptoms in either group and no complications in the surgical group. Each athlete demonstrated full range of motion postoperatively and all returned to professional sport at 5 months on average. Acute dislocation of the extensor digitorum communis tendon at the metacarpophalangeal joint. Posttraumatic u1nar subluxation of the extensor tendons: a reconstructive technique. Closed treatment of nonrheumatnid extensor tendon dislocations at the metacarpophalangeal joint. It secretes lubricant (synovial fluid) needed for tendon gliding and reduces friction in synovial joint motion. Flexor and extensor tenosynovitis is most commonly a se· qulae of rheumatoid arthritis. This is termed the Mannerfelt lesion and results in loss of thumb interphalangeal joint. Preoperative Planning · Consider withholding rheumatoid medications (eg, methotrexate, Etanercept. A straight longitudinal incision is made of the extensor retinaculum over the third compartment. Transverse incisions are made over the proximal and distal borders of the retinaculum, creating a radially based flap. Extend the incision proximally 4 em in a zigzag fashion when crossing the wrist crease. Protect the palmar cutaneous branch of the median nerve at the wrist flexion crease. Passive flexion of the finger should equal the flexion obtained when pulling on the tendon (simulating active flexion. Patrick Williams Tendon Transfers Used for Treatment of Rheumatoid Disorders · Rheumatoid arthritis is a progressive disease that, if wtcon· trolled, leads to joint destruction, secondary to progressive synovitis, ligament instability, joint dislocation or subluxation, and attrition of adjacent tendons either by bony erosion or direct tenosynovial infiltration. The flexor pollicis, along with the median nerve and the profundus and sublimis tendons to each digit, passes beneath the deep transverse carpal ligament and reprcsena the contena of the carpal canal. T enosynovial proliferation can exist within the carpal twtnel, arising from the undersurface of the ligament but more commonly proliferating along the tendons themselves. While the ulnar tendons are involved most commonly, it is possible for all of the tendons crossing the dorswn of the wrist to rupture, making reconstruction more difficult. The first compartment contains the tendons of the abductor pollicis longus and the extensor pollicis brevis. The former tendon often contains multiple slips, which can con· tribute to limited space in its respective compartment and secondary De Quervain tenosynovitis. The disease would occasionally "bum itself out,· however, with the radiocarpal joint subluxing in a volar and radial direction, leading to instability and loss of function. Theradial wrist extensors may also rupture; however, in part as a re· sult of the more robust nature of the tendons themselves, they tend to remain intact even with progressive disease. If left unchecked, such proliferative tenosynovitis can contribute to extensor tendon rupture at the level of the wrist. The examiner should question the patient re· garding symptoms of crs and should assess for signs of crs. These tendons are particularly vulnerable when subluxa· tion and spur formation are present at the trapeziometacarpal or scaphotrapezial joints as well as the volar radiocarpal joint. Direct pressure on the flexor pollicis longus muscle in the forearm should lead to passive flexion in the interpha· langeal jo. In a patient with Mannerfelt syndrome, attempted a~ve flexion of the thumb and fingers results in absent flexion of the interphalangeal joint of the thumb and in this situation the distal interphalangeal joint of the index finger. Clinically this is similar to anterior interosseous nerve syndrome and must be distinguished dinically and often by electromyography. Compression of both the anterior interosseous and posterior interosseous nerves can occur in rhewnatoid arthritis, usually secondary to ganglion cyst formation at the level of the elbow jo. Radiographs may reveal arthrosis and deformity in the digits themselves responsible for motion loss. Cervical disc disease or rheumatoid arthritis of the cervical spine with subluxation or instability may also be the cause for weakness of the finger or wrist extensors, and the cervical spine should also be imaged. While the functional deficit is generally greater with loss of finger extensors than loss of active flexion of the interphalangeal joint of the thwnb and distal interphalangeal jo. When extensor tendon rupture leads to loss of extension in only one digit, such as the small finger, end-~ide transfer of the distal ruptured tendon to the more proximal, adjacent extensor digitorum communis tendon of the ring finger can be performed. If the ruptured end is distal to the mid-metacarpal region, this transfer may lead to abduction of the small finger metacarpal, and under these circumstances, tendon transfer of the extensor indicis proprius to the distal stump of the extensor digiti quinti is undertaken (depicted here as an end-to-end transfer. Extensor indicis proprius to extensor digiti quinti, depicted here as a Pulvertaft weave between the distal tendon and the proximal transferred extensor indicis proprius. Tendon re<:onstruction is therefore not complete unless it involves removal of the dorsal osteophyte by a modified Darrach procedure and coverage of the distal ulna with a flap of extensor retinaculum. When the distal ulna is unstable, the pronator quadratus may be brought dorsal to stabilize the bone. The proximal muscle will usually begin to atrophy and become nonfunctional by 6 months after the injury. Preoperative Planning · All patientll with rheumatoid arthritis require a thorough general physical examination a. If the findi~ on electromyography are negative and the surgeon is certain that tendon rupture is responsible for the lack of active finger motion, plans should be made to transfer expendable existing tendons to those that have ruptured. The hemostat then grasps the transferred ten· don, weaving it through the recipient tendon. Positioning · Most tendon transfers are done with the patient in the supine position on the operating table. Make a second 2- to 3-cm incision over the mid-dorsal wrist (unles& a dorsal wrist incision has already been made for another procedure). The distal incision in the palm is used to isolate the sublimis tendon as far distal as possible by flexing the finger so that the chiasm of camper is visible in the wound. Immobilize the hand and wrist with the wrist in 40 degrees of extension and the fingers flexed until tension is noted at the suture line (. Finger flexion at the metacarpophalangeal joint is ideal to prevent scarring of the collateral ligaments and secondary loss of finger flexion. Confirm the tendon rupture by direct exposure of the slightly more distal and radial tendon of the flexor pollicis longus. The transfer is secured at each weave with one or two nonabsorbable braided nylon sutures. The thumb is splinted or casted for 4 weeks and a protective splint is worn for strenuous activities for 6 to 8 weeks. Tendon transfer of the extensor pollicis longus proximally to the site of insertion of the extensor pollicis brevis, allowing the hyperextended interphalangeal joint to drop into a more flexed position and allowing active extension at the level of the metacarpophalangeal joint. Extensor pollicis longus is anchored through drill holes to the base of the proximal phalanx. While some experts recommend repair, others feel confident that the defect can be left with no risk of extensor lag. If this occurs, the suture is weakened or possibly cut in two by the needle, and the graft or transfer is predisposed to rupture. More may be desirable in ~ertain instances, but too mud extension ~ould damage already fragile joints. Inunobilization is ~ontinued for 6 weeks, at whid time a gentle a~tive range-of-motion program is begun without resistan~. At 12 weeks resistive exercises are added and the patient is permitted to gradually resume normal activity. Attrition ruptures of &xor rendons in rheumatoid arthritis caused by bony spurs in the carpal tunnel: a clinical and radiological study. Rupture of exrensor rendons by attrition at the inferior radio-ulnar joint: report of two cases. Leversedge Operative Reconstruction of Boutonniere and Swan-Neck Deformities · Rhewnatoid arthritis is a poorly understood systemic disease aff~ting the synovium of joints and tendon sheaths. These conjoined lateral bands coalesce to form the terminal tendon (77), which inserts at the dorsal base of the distal phalanx to extend the distal interphalangeal joint. The triangular ligament (n stabilizes the conjoined lateral bands from volar subluxation. The two conjoined lateral bands combine to form the terminal tendon (77), which inserts into the dorsal base of the distal phalanx. The lateral slips continue distally to insert into the base of the middle phalanx. Thumb · Type I boutonniere deformity is the most common rheuma· toid deformity of the thumb. Attenuation of the transverse retinacular ligaments may occur from synovitis, thereby resulting in a loss of the nor· mal restraints to dorsal translocation of the lateral bands. Thumb · Type m rheumatoid thumb deformity is the second most common thwnb deformity after boutonniere deformity. Lateral radiograph of the thumb demonstrating a swan-neck deformity involving carpometacarpal joint subluxation, metacarpal adduction contracture, hyperextension of the metacarpophalangeal joint. Boutonniere Defonnity · Deformity may not be evident immediately after injury but may develop over 2 to 3 weeks. This test assists the examiner in determining the relative contribution of intrinsic tightness to the deformity. Rheumatoid Deformity · the rate of progressive rheumatoid arthritis-related upper extremity deformity appears to be slowing due to improved medical management of this systemic disease process. The carpus typically collapses into supination, with concomitant volar translation and ulnar translocation. Wrist stabilization with total wrist arthrodesis and concomitant distal ulnar resection may include soft tissue reconstruction such as tendon repair or tenodesis; such reconstruction should occur before digital reconstructions due to its influence on the outcomes of swan-neck or boutonnil! Reconstruction of the metacarpophalangeal joints should occur before or simultaneously with digital swan-neck or boutonnil! Skin in~ity is asseS&ed for attenuation and for its contribution to joint contracture. Swelling, palpable crepitus along the digital flexor sheath, and a discrepancy between active and passive digital motion are hallmarks of flexor tenosynovitis of the digit. Flexor tendon rupture may be present, often secondary to attenuation at the volar carpus,l! Lateral radiograph of the finger demonstrating a central slip avulsion injury involving an avulsion fracture from the dorsal base of the middle phalanx. Swan-Neck De omtity · Once the deformity has developed, nonoperative treatment is rarely effective. It is most appropriate in those with dosed injuries who present within 8 to 12 weeks of injury. If the release is followed by an intensive exercise and splinting program, the sewnd stage may be avoided. Rheumatoid Deformity · Principles of surgical ~orre~tion of rheumatoid deformities in the hand should be guided by the relief of pain and the improvement of fun~tion. A 1-~ segment of lateral band with atta~hed sagittal band fibers is excised as de~ibed by Nalebuf£.

In premarital weight loss pills used by miranda lambert buy xenical 120 mg with amex, committed relationships weight loss pills 60mg xenical purchase visa, boyfriends or girlfriends may be excluded and shut out from contact by protective family members who "circle the wagons" against someone not perceived as being part of the family; this can have poisonous effects for years weight loss pills in pakistan 120 mg xenical fast delivery. In traditional families in which the husband was the "family executive weight loss pills target xenical 120mg otc," the wife may be thrust into managing and decision-making roles for which she is not prepared weight loss pills phen purchase cheap xenical. Persons with brain injury may have decreased capacity for intimacy and either heightened or lowered sexual drive and may be impaired in their ability to perform sexually (for physiological or psychological reasons). Wives in particular may be pressed to meet the sexual demands of the injured spouse, with little satisfaction for themselves. It is not uncommon for sexual relationships to stop entirely; when the spouse chooses to stay in the marriage, he or she may seek out (with much guilt and need for support) sexual relationships outside the marriage. With social sympathy and concern flowing mainly toward the injured partner, the caretaking spouse often feels his or her needs go totally neglected, and this can lead to bitterness, despair, or burnout. Especially in more severe injuries, spouses may feel married to a different person, one he or she no longer loves or feels attracted to . Spouses face an enormous conflict between commitment and guilt if they consider leaving the relationship. This is particularly the case when the couple is young and have either no children or young children. The spouse often realistically faces the choice of sacrificing his or her life to the injured partner or leaving the relationship to develop a new family. These are difficult moral and personal choices, and the professional is best advised to help the spouse sort out the options rather than imposing his or her own value system. In less tragic cases, enough of the personality and competence of the injured person remain on which to build a mutually satisfying commitment. The situation in which the uninjured partner is considering divorce poses ethical and treatment dilemmas for the clinician. When the identified "patient" is the family, however, it is appropriate for the clinician to work with the whole system-or the parental subsystem-to help the family face these issues. These feelings can arise in either direction: the therapist may unconsciously encourage the partner perceived as trapped to find a way out or unconsciously discourage a desperate spouse from abandoning the injured partner. Awareness of his or her personal feelings is crucial for the therapist, and transfer of the case is appropriate if the decisions of the uninjured partner make it impossible for the clinician to be fully supportive. Sorting out these countertransference issues, from realistically helping the partner to think through the consequences of his or her choices to knowing when to turn the case over to a colleague, is a crucial but tricky process, requiring self-searching by the therapist and, often, consultation with a colleague. Impact on Parents When a child is injured, special burdens and pressures exist for the parents. When a young child living at home is injured, the mother usually takes on the role of primary nurturer and caregiver. This may create tension within the marital relationship, and underlying cracks or strains in the relationship may become manifest. When couples are composed of persons with complementary coping styles, the stress of caring for a severely injured child may drive them to opposite extremes of reaction and threaten the relationship; for example, the father may bury himself in his work while the mother drops everything (including any attention to her husband) and devotes all her energy to the injured child. Parents may also find it difficult to apportion their time and energy to other children or to elderly parents whom they may care for. Even when they work well together around the crisis, parents may find their lives dominated by the needs of the injured child and may be in jeopardy of neglecting their own marital relationship. When the injured child is an adult who had been living independently, parents often are thrown back into an earlier developmental phase of caring for a dependent child, with the complication that the grown child resents and resists the dependency. This is an extremely difficult position for both parents and child, especially when the child is male, recently past adolescence, and striving for autonomy. Driving, independent living, dating, and establishing friends and intimate relationships become volatile family issues. Parents often have great difficulty accepting the permanent changes in their children and in fact may complicate the rehabilitation process by refusing to give up unrealistic expectations ("My son will become a lawyer! Conflicts may develop between the parents over what is reasonable to expect of their adult child with brain injury. When adult children move back in with their parents for a period after a brain injury, it is not uncommon for old psychological terrain of the struggle for independence to be traversed again. How this was negotiated the first time around in adolescence is often predictive of how things will go the second time around. Sensitive clinicians can be extremely helpful to families during this period by normalizing the conflicts around independence and individuation and helping negotiate a series of compromises that respect both the needs of the parents to be protective and the needs of the adult child to start regaining independence. The Family System Special issues attend the parent-school relationship for younger children through adolescents. Younger children may suddenly find that they have lost the nurturance and guidance of a formerly loving and competent parent. Older children at home usually have increased responsibilities, less attention from the other parent, and an awkward home situation into which they are uncomfortable bringing their peers. Depending on the preexisting relationship, the child may be drawn emotionally closer to or driven farther away from and resent the injured parent. Older children may have more capacity to understand what has happened but also more freedom to create distance. It is not uncommon for school or behavioral problems to surface in children who are depressed, angry, or guilty about their new family situation. When an older parent incurs a brain injury, adult children who are out of the house are inevitably faced with the issue of taking on increased responsibility. Because of their own adult responsibilities, children are often limited in how much assistance they can actually contribute, with inevitable feelings of guilt. Adult children are often torn between the needs of their partners and children and those of their parents. Conflicts often develop between the caregiving adult child and his or her spouse, with resulting imbalance and conflict within the family. Conflicts can also erupt among siblings with an injured parent over perceptions of uneven participation in caregiving. Therapists need to be realistic, however, in assessing how much any one child is willing and able to give and help other siblings deal emotionally with perceived inequalities. Older siblings who are not living at home experience stresses similar to those of adult children of injured parents. The demands of their own lives, perhaps including a spouse and children, compete against the need and desire to help their injured sibling. Typically, one adult sibling is designated as the primary caregiver, especially if the injured sibling is unmarried and the parents are distant or too old to take on a primary caregiving role. The reality is that, especially in a mobile, urban society, kinship bonds often are more tenuous than they used to be, and aunts, uncles, and cousins seldom play a significant role in the primary care of any person with brain injury. Nuclear families that are able to tap into the support systems of extended families, even once or twice a year for respite, have a great advantage. Families often are unable to elicit the active support of relatives, however, because extended family members who do not live with the injured person often do not understand, are less sympathetic toward the family stresses, or are simply more wary of becoming involved. It is extremely useful for professionals working with families to include extended families in family meetings, especially early on, to establish a basis for a wider support network. Successful clinical intervention with families requires the professional to be aware of where in this process of adjustment the family is; this determines what the family is able to hear and what kind of support is needed. There are a number of useful ways to conceptualize the continuum of changes that families pass through. These are expressed as various stages, although it is clear that there is no objectively and universally true sequence. When the siblings are young and living at home with the injured child, the parents characteristically reorient all of their attention and energy toward the child with the brain injury. This acting out may take the form of failing grades or getting into trouble at school. Parents need support in finding a balance in allocating limited resources among their children. Older children at home may, like children of injured parents, have more domestic responsibilities and perhaps also a socially awkward situation into which they are embarrassed to bring friends. Siblings of different personality styles and relationships with the injured child may also respond in different ways; one sibling may become closer to the injured child while another moves away in anger. Olshansky (1962), for example, introduced the notion of "chronic sorrow" to describe the continued experience of sadness and ongoing adjustment that parents of children with mental retardation feel. Wikler (1981), working within the same framework, recognized that such chronic sorrow is punctuated by periods of more intense grieving at critical developmental junctures. Unique to having a family member who has a serious mental illness is that the loss and grief experience of the family is cyclical in nature: the periodic "reappearance of the former self" creates a prolonged period of grieving. The principal element of this sense of grief involves a sense of loss of a person who is "there but not there. The authors found that there was an ongoing process of making sense and adjusting to loss and that the adaptation experience was cyclical in nature, marked by noticing changes in the person, making sense of these changes as a couple, and gradually accepting what was happening and its relation to their expectations and experiences as a couple. They also described the movement of adjustment as a process of oscillation between acknowledging losses and developing coping strategies. The authors described the insidious nature of dementia in that there is a continued presence of the person. These concrete reminders of "how it used to be" are also integral to the experience of families of individuals with brain injury. Kiser and Black (2005) pointed out that adaptation to stress or crisis typically relies on the stage model to conceptualize and describe the phenomenon. The acute stage follows the transitional stage, and the third stage is entry into more stable family patterns or longer-term adaptation. Unlike more traditional crisis models, these individuals and their families had to cope with their "initial crisis" on a long-term basis, perhaps lifelong because adjustment meant fundamentally redefining identities. The crisis is not time limited; it is never ending, varying in intensity over time yet never absent. And it leaves the families with a "precarious homeostasis" whereby the critical moment may recede until the next imbalance occurs. The deficits caused by the brain injury leave the individual with the brain injury Rape et al. They proposed integrating a family systems perspective into stage theories to solve some of these problems, and they advocated longitudinal research. Lezak emphasized that many families are unable to move beyond chronic depression and despair. First, the fact that the mourned person still lives and is present interferes with the normal grieving process in and of itself. The reality is that early denial-especially continuing to believe in the possibility of significant recovery-is an effective buffer against depression (Ridley 1989), may be necessary for the family to regroup, and should be respected by professionals. Third, the notion of a steady final stage of acceptance-in the sense of an emotionally peaceful embracing of the way things are-is neither realistic nor, perhaps, desirable to expect. Most important, harm has been done to families in turmoil years after an injury by professionals who expect that because families are not demonstrating "acceptance" after so much time, a psychopathological process must be occurring. The reality is that living with an adult with brain injury brings cycles of adjustment, disequilibrium, and reestablishment of a new balance on a periodic basis, and this recycling never ends. The Family System with fewer resources to cope with and surmount the particular problems. There is, therefore, a greater need for intervention from supporting family members. The authors deemed this perpetual crisis as more akin to a "transcrisis" state in which the injury and crisis experiences are chronic and long term. Professional intervention should not be reserved for severe management problems or dysfunctional families. Family intervention should be proactive, flexible, health and prevention oriented, and responsive to the needs of families within the context of a progressive reestablishment of family equilibrium after brain injury. The quality of family functioning has direct impact on the process of rehabilitation. However, much of what professionals perceive as dysfunctional in families is the result of families being uninformed, underinvolved, and not having basic needs met, all of which may be preventable with appropriate interventions. We propose a three-dimensional model of intervention (Table 31­1): where the intervention is aimed (concentric circles of intervention), what the intervention is (levels of intervention), and when it occurs (stages of intervention). The clinician should evaluate individual family members in terms of their personality structure, their expectations for the injured person and the family, the individual strengths and weaknesses they bring to the family, and how they respond both to the person with the injury and to the current family situation. Individual family members may have particular attitudes, limitations, or strengths that become crucial in the rehabilitation process. At times, the most effective family intervention is a targeted intervention with an individual family member. The family system must be considered as a unit above and beyond its individual members. Each of these systems must be assessed independently, and different interventions can be made at each level depending on what stage the family is in. What are the patterns of relationship and communication, and how are problems solved How cohesive is the family unit, and what is the degree of enmeshment or disengagement What specific cultural norms does the family hold that may differ from those of members of the rehabilitation team, and will those color expectations of what is important to achieve Assessing the family system is crucial, and often strategic interventions within the family structure are critical to enabling a family to move on and cope more effectively. The community is both the professional community of services that needs to be accessed and the psychosocial community of friends, recreation, and extended family. In the early stages, intervention at this level almost always involves negotiating a good working relationship between the family (often as represented by one or two key members) and the rehabilitation team. In later stages, families must learn to deal with the world of multiple, often bureaucratic, community services, and if they are to overcome the natural tendency toward isolation, they must reestablish functional social and recreational opportunities. For families with injured children, the educational world is the major community relationship. Special issues exist for recent immigrant families, often in large urban centers, who are locked into enclaves of culturally homogeneous families. Mainstream services often do not extend into such communities or are unknown or rejected.

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Syndromes

• Chronic inflammatory disease
• Severe fatigue
• Smoking
• Extreme social isolation
• Chromosome 18q deletion syndrome
• Headache
• Tumor of the skin or muscles
• Dislocation of the artificial joint

Mood stabilizers and atypical antipsychotics appear to be well tolerated in elderly dementia patients weight loss workouts quality 60 mg xenical, though with appropriate decreases in dosage and rate of titration weight loss pills vegan xenical 60 mg without prescription. Increased sensitivity to side effects of sedation weight loss after menopause order xenical on line, tremor weight loss pills under 10 purchase xenical in india, and ataxia are common in older patients with any neurological disease weight loss pills 375 xenical 60mg discount. Atypical antipsychotic medications may reduce irritability and aggression in elderly patients with dementia. Care must be taken to provide the optimum degree of therapeutic benefit with a minimum of side effects. The atypical antipsychotic medications have been well studied in treatment of dementia-related agitation and psychosis. The modest overall efficacy of these drugs must be weighed against the small but statistically significant risk of increased mortality and cerebrovascular adverse events (Schneider et al. Educating families and caregivers regarding the practical implications of these changes may reduce caregiver distress. Caregivers and patients must be helped in the process of grieving lost functioning. As in the dementias, behavioral disturbances are a major cause of caregiver distress and an obstacle to successful community functioning. Likewise, such disturbances may accelerate the need for institutional placement, primarily mediated through the impact of behavioral problems on caregiver distress (Yaffe et al. Therefore, providing caregivers with psychoeducational and supportive interventions may enable them to better cope with their new roles and challenges. Cognition Acetylcholine has been recognized as a principal neurochemical mediator of learning and memory (Thiel 2003). However, dopaminergic functioning has also been identified as an important component to the neurochemistry of cognition (Nieoullon and Coquerel 2003). Amphetamine has been found to enhance functional recovery in a chart review study (Hornstein et al. In older patients who demonstrate reduced initiative and attention, these medications may be useful adjuncts to environmental stimulation. Management of Neuropsychiatric Syndromes Depression Depression is an independent risk factor for mortality in advanced age and accounts for substantial functional impairment (Reynolds et al. Greater dependence on others for cognitive and, at times, physical tasks may engender feelings of loss and helplessness. Dosing and titration should be adjusted based on the timehonored philosophy of "start low, go slow" in recognition of heightened sensitivity to medication side effects and potential drug-drug interactions with other nonpsychotropic medications. Moreover, older patients are at high risk for less favorable outcomes and secondary complications. The thoughtful application of principles of geriatric medicine will improve the assessment and management of this complex patient group. Nevertheless, timely and appropriate rehabilitative and neuropsychiatric interventions may provide older patients with substantial functional and cognitive benefits. Recommended Readings Ballestros J, Guemes, I, Ibarra, N, et al: the effectiveness of donepezil for cognitive rehabilitation after traumatic brain injury: a systematic review. J Am Geriatr Soc 54:1590­1595, 2006 References Aharon-Peretz J, Kliot D, Amyel-Zvi E, et al: Neurobehavioral consequences of closed head injury in the elderly. Neurobiol Aging 18:431­435, 1997 Friedman G, Froom P, Sazbon L, et al: Apolipoprotein E-epsilon4 genotype predicts a poor outcome in survivors of traumatic brain injury. J Neural Transm Gen Sect 84:103­117, 1991 Haug H, Eggers R: Morphometry of the human cortex cerebri and corpus striatum during aging. Neurobiol Aging 12:336­338, 1991 Hefti F, Hartikka J, Knusel B: Function of neurotrophic factors in the adult and aging brain and their possible use in the treatment of neurodegenerative disease. Neurobiol Aging 10:515­ 533, 1989 Elderly Hornstein A, Lennihan L, Seliger G, et al: Amphetamine in recovery from brain injury. Nat Med 1:135­137, 1995 Nieoullon A, Coquerel A: Dopamine: a key regulator to adapt action, emotion, motivation and cognition. Brain Inj 15:857­864, 2001 Rapoport M, Wolf U, Herrmann N: Traumatic brain injury, apolipoprotein E-epsilon4, and cognition in older adults: a twoyear longitudinal study. Bureau of the Census: Population projections of the United States by age, sex, race, and Hispanic origin, 1995­2050, in Current Population Reports (P25­1130). Ann Neurol 44:143­147, 1998 Whyte J, Hart T, Vaccaro M, et al: Effects of methylphenidate on attention deficits after traumatic brain injury: a multidimensional, randomized, controlled trial. Am J Phys Med Rehabil 83:401­420, 2004 Yaffe K, Fox P, Newcomer R, et al: Patient and caregiver characteristics and nursing home placement in patients with dementia. Acceptance of both categories of disorders as independent and interactive enhances the total treatment of the patient (Kreutzer et al. If only one condition is the focus of the treatment, incomplete treatment and poor prognosis are likely to result for either condition. Treatment protocols can be implemented from the time of first contact during the acute intervention through chronic maintenance. Although a specialist may be employed for either category of disorder, he or she must know the ramifications of both disorders. The two specialists, then, must work to coordinate the treatment of both disorders (Substance Abuse Task Force 1988). Moreover, 58% of all surgical admissions and 72% of all hospital contacts, defined as visits to the hospital or emergency department, involve this same patient population. The role of drugs other than alcohol is not well documented because often specific testing and history taking for drugs are not part of either routine clinical practice or research studies. Many hospital records do not mention the implications of drug histories when clear evidence exists. The reasons for poor documentation are complex and include poor skills in assessing the importance of drugs and alcohol as well as ignorance that effective treatment 461 462 Textbook of Traumatic Brain Injury trol and Prevention 2009). Fifty percent of all fatal accidents in the United States are motor vehicle accidents. Of these fatal motor vehicle accidents, 50% are associated with alcohol and drugs. Most long-term survivors are young adult men (Sparadeo and Gill 1989; Sparadeo et al. Studies of prognosis and outcome after brain injury frequently exclude individuals who are addicted to drugs, alcohol, or both before accidents, even though this practice produces significant and relevant distortions of data (Sparadeo and Gill 1989; Substance Abuse Task Force 1988). Research protocols do not often include measurement of urine or blood for illicit or prescription medications. Many individuals are brought to the hospital by police after slight bodily injury. The long-term diagnosis of alcoholism can be made in 29% of men and 7% of women in the United States. The mean age at onset of alcoholism is 22 years in men and 25 in women, according to the Epidemiologic Catchment Area study (Miller 1991b). The reported prevalence rate for drug addiction in the general population ranges from 9% to 20%. The majority of drugaddicted individuals are addicted to alcohol, and substantial numbers of alcoholic individuals are addicted to at least one other drug, namely, cannabis, cocaine, benzodiazepines, opiates, and/or hallucinogens, in decreasing order of frequency (Miller 1991b; Schuckit 1990). In one evaluation of primary care physicians (Miller 2002), 94% were unable to identify a substance disorder as one of five diagnostic possibilities in case studies of patients with the early signs of an alcohol disorder. When case studies described early signs of a drug disorder in teenagers, 41% of pediatricians failed to provide substance disorder as one of five diagnostic possibilities. Also, nearly three-fourths of patients seeking treatment for a drug disorder did not receive guidance from their primary care physician. These results highlight the importance of physicians knowledgeable in addiction medicine to perform clinical examinations and assessments on drug use and history. The average age for men in treatment is 30­35 years, and the average age for women is 25­30 years. Motor vehicle accidents are the leading cause of death for teens in the United States, accounting for more than one-third of the deaths in this age group. Precautions should be taken to address the medical and psychiatric sequelae of acute and chronic drug and alcohol use. Frequent complications include drug­drug interactions, drug overdose, increased sensitivity to medication effects, and seizures either from drug intoxication or from drug and alcohol withdrawal. Other possible complications include behavioral dyscontrol, hallucinations, delusions, anxiety, depression induced by intoxication and withdrawal from drugs and alcohol, and drug seeking because of the presence of an addictive disorder (Miller 1991b; Schuckit 1983) (Table 30­1). The second clinical caveat is that behaviors such as lethargy, agitation, confusion, disorientation, and respiratory depression after acute intoxication and overdose are similar to those following brain injury. Importantly, some intoxicated patients are discharged from the emergency department when in fact they have undiagnosed brain injuries. In a study of 167 patients (Gallagher and Browder 1968), alcohol obscured changes in consciousness, leading to misdiagnosis or delayed diagnosis of complications of brain trauma. Criteria for substance dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12month period: (1) tolerance, as defined by either of the following: (a) (b) (2) a need for markedly increased amounts of the substance to achieve intoxication or desired effect markedly diminished effect with continued use of the same amount of the substance the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms withdrawal, as manifested by either of the following: (a) diagnosed only at postmortem (Galbraith 1976), and others have reported similar results (Rumbaugh and Fang 1980). Three of the seven criteria for the dependence syndrome reflect the behaviors of addiction: 1) preoccupation with acquiring alcohol or drugs, 2) compulsive use of drugs despite adverse consequences, and 3) a pattern of relapse or inability to cut down on use despite adverse consequences. Two of the seven criteria reflect development of tolerance and dependence on alcohol and drugs. Any three of the seven criteria are required to make the diagnosis of alcohol or drug dependence, or both. The manifest loss of control often is reflected by the circumstances surrounding and including the actual trauma that culminates in the brain injury. It has been well documented that the most effective clinical approach to both diagnosis and treatment of an alcohol or drug disorder involves the acknowledgment of substance dependence as a disease state rather than as a moral or character problem. Twin and adoption studies provide adequate support for the powerful role of inheritance in alcohol or substance disorders (Pickens and Svikis 1991). A parallel may be drawn between substance disorders and other inherited diseases such as hypertension, in which a person has little control over the development of the disorder but is solely responsible for treatment of the disorder. By using this approach in a clinical setting, patients often are able to overcome the common feelings of shame and blame associated with alcohol or drug depen- (6) (7) Specify if: With physiological dependence: evidence of tolerance or withdrawal. Reprinted from Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, pp. The use of medications for the treatment of withdrawal from alcohol or drugs and to assist patients with achieving abstinence may aid in the belief that alcohol or drug dependence is, in fact, a disease (Miller 2001). The partnership of these assessment tools has been effective in a study by Cherner et al. Identification of the neural basis of pathological craving for alcohol and drugs may also serve as a vital tool for diagnosing patients with a substance dependency (Dackis and Miller 2003). Neuroimaging studies have identified limbic system pathways that are responsible for both normal and pathological cravings in human and animal studies. Changes in limbic system pathways have been identified in studies in which human and animal subjects have had chronic exposure to alcohol or drugs. A new set point, or alleostasis, may be responsible for intense cravings that occur long after "liking" a drug. Structural neuroimaging studies have also revealed alcohol-induced brain atrophy, occurring in both limbic and frontal lobe structures. After a period of abstinence, the degree of atrophy in these regions tends to diminish, especially when abstinence occurs at a younger age. Further research on these issues may someday equip clinicians with an essential tool for the diagnosis and treatment of substance dependency (Netrakom et al. As independent disorders, each has a characteristic course and predictable consequences. Although patients with alcoholism and those with drug addictions report drinking and using drugs because of anxiety and depression, objective and controlled studies fail to confirm the hypothesis that alcohol and drugs are used to improve mood and thinking. The conclusions from many studies are that continued alcohol and drug use results in the appearance and worsening of psychiatric symptoms in proportion to the amount and duration of alcohol and drug use (Mayfield and Allen 1967; Schuckit et al. Family history is the best predictor for the onset of alcoholism and drug addiction in a given individual. Screening tests are available for alcohol disorders that can be modified for drugs by inserting drug for the word alcohol. During this initial abstinence, the influence of alcohol and drugs on mood, cognition, and behavior, as well as the degree of drug-seeking behavior, can be assessed. A differential diagnosis for coexisting psychiatric disorders can also be assessed longitudinally apart from the effects of alcohol and drug intoxication and dependence (Blankfield 1986; Miller and Mahler 1991). The identification of alcohol and drug intoxication and withdrawal follows the general principles of pharmacological dependence. The use of blood and urine toxicology is important to identify presence and levels of alcohol and drugs for assessment of intoxication and anticipation of withdrawal. The use of vital signs, particularly blood pressure, pulse, and temperature, is critical in determining the presence and severity of the withdrawal state (Miller 1991b). If this is used as a self-administered written instrument, the scoring system should not be shown on the form. However, the doses should be reduced to allow for the increased sensitivity of brain-injured patients to medication and drug effects. The optimal level of medications for withdrawal can be assessed in an individual on an as-needed basis according to the clinical status of the patient. For instance, for detoxification from alcohol, a dose of benzodiazepines can be given for systolic blood pressure greater than 150 mm Hg, diastolic pressure greater than 100 mm Hg, or both. For detoxification from benzodiazepines, a standing schedule can be designed for 2­3 weeks on the basis of estimates of doses taken during chronic use preceding withdrawal. In general, benzodiazepines are used to treat alcohol withdrawal (Table 30­3) and phenobarbital or benzodiazepines are used to treat sedative-hypnotic withdrawal (see Table 30­3), including withdrawal from benzodiazepines (Table 30­4). For cocaine, other stimulants, and cannabis withdrawal, medications usually are not required. For opiates, either clonidine or methadone can be used in 2-week or 4-week tapering schedules.

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