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By I. Sebastian. Alverno College.

Korsakoff syndrome is a loss of short-term memory and disinhibition generic propecia 1mg fast delivery, leading to con- Management fabulation. Aetiology Usually seen in alcoholics, but may also be seen in star- Prognosis vation, malnutrition, parenteral feeding without vita- Recovery is prompt in most cases, occurring within min supplements and chronic vomiting, e. Thiamine is present in fortified wheat chronic cases when the diagnosis is delayed. Definition r Absent cough and gag reflexes on pharyngeal, laryn- This is defined as ‘irreversible loss of the capacity for geal or tracheal stimulation. Any intracranial cause or a systemic cause Apnoea testing such as severe, prolonged hypoxia or hypotension can The patient is pre-ventilated with 100% oxygen and con- lead to brainstem death. Although If all the above criteria are fulfilled, the patient is diag- patients who fulfil these criteria can be kept alive by ven- nosed as brainstem dead, and ventilation may be with- tilation, eventually they will die from other causes. Patients with some evidence of brainstem activity may Clinical features still have a very poor prognosis. Death may occur due to In order to diagnose brainstem death several criteria cardiovascular collapse, e. However, ifthepatientremainsstable,butwithverylittle Priortobrainstemtesting,thefollowingpreconditions brain function, it may be appropriate to withdraw life must be fulfilled: r prolonging treatment, but this may require application There must be a diagnosis for the cause of the irre- to the courts. Parkinson’s disease and other r There must be no possibility of drug intoxication, movement disorders including any recent use of anaesthetic agents or paralysing agents. Parkinson’s disease r Hypothermia should be excluded and body tempera- ture must be >35◦C. Definition r There must be no significant metabolic, endocrine or Acommon degenerative disease of dopaminergic neu- electrolyte disturbance causing or contributing to the rones characterised by tremor, bradykinesia, rigidity and coma. This should be carried out by two experienced clinicians (one a consultant, another an experienced registrar or consultant) on two separate occasions 12 hours apart. Age These tests are designed to show that all brainstem re- Prevalence increases sharply with age. M slightly > F Chapter 7: Parkinson’s disease and other movement disorders 319 Geography r Other features include facial masking, dribbling of Common worldwide saliva, dysphagia, dysphonia and dysarthria – quiet monotonous speech with a tendency to peter out with continued effort. There is little known about the aetiology r Nicotine: Some epidemiological evidence suggests a decreased risk in smokers, but that may be due to Macroscopy/microscopy younger death in this group. Loss of pigment from the substantia nigra due to the r Therearesomefamilialforms,particularlyearly-onset death of melanin-containing dopaminergic neurones. Surviving cells contain spherical inclusions called Lewy bodies – hyaline centres with a pale halo. Pathophysiology Investigations The substantia nigra is one of the nuclei of the basal Clinical diagnosis, but other parkinsonian syndromes ganglia. Biochemically This includes a multidisciplinary approach for this there is a loss of dopamine and melanin in the striatum chronic disease, including education, support, physio- which correlates with the degree of akinesia. The basal r Levodopa, a dopamine precursor, is the most im- ganglia project via a dopaminergic pathway to the thala- portant agent used. It is given with an peripheral mus and then to the cerebral cortex, where it integrates dopa-decarboxylase inhibitor (such as carbidopa or withthepyramidalpathwaytocontrolmovement. Hence benserazide) to prevent the conversion of l-dopa to it is sometimes called the extrapyramidal system. Lev- Clinical features odopa exerts most effect on bradykinesia and rigidity The features are asymmetrical. It is in- ‘on’ periods when they have a good response to the creased by emotion and decreased on action. Increased tone alone may cause lead-pipe movements called dyskinesias, or painful dystonias rigidity. These appear to be due to the progressive (slowness of movement) and hypokinesia (reduced degeneration of the neuronal terminals, such that size of movement). When walking there may be a reduced arm ii ‘On/off’ phenomenon may be treated by increas- swing and increased pill-rolling tremor. There is a loss of postural tral metabolism of l-dopa and dopamine, so giving reflexes. These may be considered first-line treat- prompt the search for another cause of the symp- ment in young patients. They have a neuroprotective toms, as other causes of parkinsonism do not usually effect in vitro. This can be redressed by anticholinergic drugs such as ben- Other causes of Parkinsonism ztropine and procyclidine. They tend only to be used in mild tremor, and they do not help with akinesia or Definition gait.

A report card on computer-assisted diagnosis—the among high-risk specialist physicians in a volatile malpractice envi- grade: C cheap propecia 1 mg with visa. Billions for defense: the pervasive nature of defensive tics on perceptions of decision support systems. February 22, 2006 [published correction appears in The New cognitive model and empirical findings. A randomised public- potential impact of a reminder system on the reduction of diagnostic health trial on automation-assisted screening for cervical cancer in errors: a quasi-experimental study. Measuring the impact of diagnostic decision support on the quality of clinical decision mak- J Med. Learning from mistakes: factors that influence how students and J Am Med Inform Assoc. Effects of computerized physician order entry on prescribing medicine: what’s the goal? Training to improve calibration and discrimina- tion: the effects of performance and environment feedback. February 13, smears: how frequently are ”abnormal” cells detected in retrospective 2006:96–107. Overconfi- evolved to deal with 10,000 specific illnesses, all of which dence is one of the most significant of these biases. In both Effective problem solving, sound judgment, and well-cali- arenas, the first presentation of the illness is at its most brated clinical decision making are considered to be among undifferentiated. Alternately, the general this important area has been actively researched for only domain where the diagnosis probably lies is identified and about 35 years. The main epistemological issues in clinical the patient is referred for further evaluation. Much current work uncertainty progressively decreases during the evaluative in cognitive science suggests that the brain utilizes 2 sub- process. By the time the patient is in the hands of subspe- systems for thinking, knowing, and information processing: cialists, most of the uncertainty is removed. Their characteristics are listed in say that complete assurance ever prevails; in some areas 9 13 Table 1, adapted from Hammond and Stanovich. The system is fast, asso- For the purposes of the present discussion, we can make ciative, inductive, frugal, and often primed by an affective a broad division of medicine into 2 categories: one that component. Importantly, our first reactions to any situation deals with most of the uncertainty about diagnosis (e. These settings, therefore, deserve the closest scru- 13 situation (Table 2), and providing further characterization tiny. To examine this further, we need to look at the deci- of System 1 decision making. It encompasses processes of emotional regulation and implicit Statement of Author Disclosures: Please see the Author Disclosures 15 learning. Automaticity High Low The essential characteristic of this “nonanalytic” reason- Rate Fast Slow ing is that it is a process of matching the new situation to 1 Reliability Low High 18 of many exemplars in memory, which are apparently Errors Normative Few but distribution significant retrievable rapidly and effortlessly. As a consequence, it Effort Low High may require no more mental effort for a clinician to recog- Predictive power Low High nize that the current patient is having a heart attack than it Emotional valence High Low is for a child to recognize that a dog is a four-legged beast. Detail on judgment Low High process This strategy of reasoning based on similarity to a prior Scientific rigor Low High learned example has been described extensively in the lit- Context High Low 19,20 erature on exemplar models of concept formation. Adapted from Concise Encyclopedia of Information Processing in Overall, although generally adaptive and often useful for Systems and Organizations,9 and The Robot’s Rebellion: Finding Meaning 21,22 our purposes, in some clinical situations, System 1 in the Age of Darwin. Thus, it may be that under certain conditions, despite a rational judgment having been reached ● Processing takes place beyond conscious awareness ● Parallel processing: each “hard-wired” module can using System 2, the decision maker defaults to System 1. Disposed to believe rather than take the skeptic position; therefore look to confirm rather than disconfirm like the hard-wired, parallel-processing capabilities of Sys- (the analytic system, in contrast, is able to undo tem 1, System 2 is a linear processor that follows explicit acceptance) computational rules. It corresponds to the software of the ● Higher cognitive (intellectual) ability appears to be brain, i. A series of studies have shown that “pure” System 1 and System 2 thinking are error prone; a combination of the 2 is closer to optimal. A simple repeated use of analytic (System 2) outputs can allow them example suffices: the first time a student answers the ques- 13 tion “what is 16 x 16? Thus, the effortless pattern recognition that characterizes compute slowly and methodically by long multiplication. If the clinical acumen of the expert physician is made possible the question is posed again soon after, the student recog- by accretion of a vast experience (the repetitive use of a nizes the solution and volunteers the answer quickly and System 2 analytic approach) that eventually allows the pro- accurately (assuming it was done correctly the first time) 16,17 cess to devolve to an automatic level. Therefore, it is important for S26 The American Journal of Medicine, Vol 121 (5A), May 2008 decision makers to be aware of which system they are using tions and conclusions they have reached, rather than take a and its overall appropriateness to the situation. This is referred to as con- use this mode, for example, to put a man on the moon; only 36 firmation bias, which is one of the most powerful of the System 2 would have worked.

The benefts of cally active throughout their teens purchase 1 mg propecia mastercard, as an undergraduate sustained, moderate-intensity aerobic activity are protean and medical student, the resident realizes that over the and go well beyond improving cardiovascular health. Regular four years of the postgraduate program they have become physical activity can be a time for recreation—in the fullest increasingly sedentary. Thirty minutes spent walking, biking, jogging, swim- to spend time with their partner and young daughter seem ming or skating can permit an escape from pagers, telephones to have eliminated the cherished private time when they and the pressures of practice and provide an opportunity for would jog to and from the hospital as a student and frst- retreat and refection. The so-called “talk test” (exercising at Evidence of the health benefts of physical activity is long- an intensity that permits simple conversation with an exercis- standing, incontrovertible and ever-increasing. Regular par- ing partner or friend) is a remarkably accurate indicator of a ticipation in physical activity greatly decreases the likelihood level of activity that optimizes cardio-respiratory function and of chronic disease and premature mortality. How does the busy practitioner despite this knowledge, physicians appear to be no more active protect suffcient time for physical exercise? And, sadly, although medical integrate physical activity into one’s personal and professional students are typically active on a regular basis, it is too often the lifestyle? How do we normalize such activity within the profes- case that as they embark upon their careers they give less time sional community? Activities that are te- likelihood that regular physical activity will be part of a physi- dious, uncomfortable or intimidating are not likely to form the cian’s lifestyle. At the same time, many medical practitioners basis of a lifetime of healthy physical activity. Find something bring to exercise the same achievement-oriented, goal-driven you enjoy and look forward to the release it offers from the approach that is in part responsible for their success as stu- pressures of a busy professional life. However, while an athletic model of physical activity may be motivating and rewarding for some, it Feasible. It is reassuring to know that the health ized facilities or signifcant travel are diffcult to integrate into benefts of physical activity accrue with as little as thirty min- daily life. A lunchtime walk, an evening jog, or a regular swim utes of moderate-intensity exercise most days of the week. Biking to work and taking the stairs whenever pos- important, health-enhancing properties of an active lifestyle. Physical activity that frequently involves family and friends has a further motivation built in. Encouraging Case resolution the whole family to engage in regular physical activity can allow Deciding to make one’s personal health a priority is an you to pass on your exercise “values” to your children, opti- important step in making time for physical activity. Skiing, biking, sledding, will always be rounds to attend and journals to read, and hiking—he choices are limitless. Establishing time, recognizing the realities of an on-call schedule, favourite physical activities early in a career helps to ensure and discussing these issues with resident colleagues, this that enjoyable, anticipated and active periods will be integrated resident is able to incorporate regular physical activity into into weekly rhythms for the long term. The resident no longer takes elevators unless of exercise intensity will help prevent injury and increase the absolutely necessary (there’s a “Stairway to Health” pro- likelihood of enjoyable physical recreation over a lifetime. As benefts to physical health, physical activity allows private, chief resident, they also encourage younger colleagues to personal time for refection and recreation. Family vacations for physicians to integrate physical activity into their personal are now chosen with physical activities in mind: camping lifestyles in ways that are both practical and, most importantly, and canoeing in the summer. By demonstrating to friends and colleagues that physi- Key references cal activity is important to one’s well-being, the resident Frank E, Breyan J, Elon L. Physician disclosure of ensures understanding and support as they optimize time healthy personal behaviors improves credibility and ability to for personal health. Physical inactiv- portive advice on the importance of personal health and ity among physicians. The resident’s bicycle helmet serves as a reminder to colleagues, hospital and attending staff that personal health and physical activity are important, central components of a contemporary practitioner’s lifestyle. The resident’s example and leadership result in the hospital providing bike racks and shower facilities for staff. And it is a • introduce a model of considering the role of spirituality in practice that requires ongoing self-refection and attention. We tend to forget to care Case for ourselves when we are single-mindedly committed to the A frst-year resident is feeling disillusioned with medicine. Compassion that does not include The resident entered medicine because their father died oneself is incomplete. Now feeling frustrated by the inevitable deaths of too many of Burnout is distressingly common in medicine, as in other their patients the resident is thinking of taking a year off occupations where time is spent supporting others. The what might be regarded as a spiritual illness: if engagement wisdom and compassion that this engenders does not make us with one’s life is a sign of spiritual health, burnout is the oppo- more expert; it makes us more human. Physicians who were once wholeheartedly committed to to do; spirituality, how to be. As physicians, we can beneft from medicine begin to avoid work, become less interested in their practising both. Courses on spirituality have begun to appear in medical school Not surprisingly, burnout can lead to depression, addiction and curricula. Spirituality is primar- ideals, long hours, tensions between personal and work obliga- ily an inner, subjective matter, whereas Western medicine is tions, and historical insensitivity of the medical profession to based on objective, empirical science. Whether or not spiritual the health of its members all contribute to the psychological matters belong in our medical curricula, surveys suggest that and emotional vulnerability of physicians.

Heroin While these are crude assessments order propecia 1 mg with amex, they clearly Cocaine show that the categories of seriousness ascribed to various substances in international treaties need to be Barbiturates reviewed in the light of current scientifc knowledge. The current system of measuring success in the drug policy feld is fundamentally fawed. We simply criminals (that take years to plan and implement) have cannot treat them all as criminals. Similarly, To some extent, policymakers’ reluctance to eradication of opium, cannabis or coca crops merely acknowledge this complexity is rooted in their displaces illicit cultivation to other areas. Many ordinary citizens do have genuine fears about the A new set of indicators is needed to truly show the negative impacts of illegal drug markets, or the behavior outcomes of drug policies, according to their harms or of people dependent on, or under the infuence of, benefts for individuals and communities – for example, illicit drugs. These fears are grounded in some general the number of victims of drug market-related violence assumptions about people who use drugs and drug and intimidation; the level of corruption generated markets, that government and civil society experts need by drug markets; the level of petty crime committed to address by increasing awareness of some established by dependent users; levels of social and economic (but largely unrecognized) facts. For example: development in communities where drug production, selling or consumption are concentrated; the level of • The majority of people who use drugs do not ft the drug dependence in communities; the level of overdose stereotype of the ‘amoral and pitiful addict’. Policymakers can and should Nations estimates that less than 10 percent can be articulate and measure the outcome of these objectives. In the current opportunities are better investments than destroying circumstances in most countries, this would mean their only available means of survival. Profting from weak governance, endemic poverty, A more mature and balanced political and media discourse instability and ill-equipped police and judicial institutions, can help to increase public awareness and understanding. Corruption and money use and dependence can help to counter myths and laundering, driven by the drug trade, pervert local politics misunderstandings. Countries that continue to invest mostly in a law A dangerous scenario is emerging as narco-traffc threatens enforcement approach (despite the evidence) should to metastasize into broader political and security challenges. New evidence44 suggests that criminal networks are expanding operations and strengthening their positions The resources of law enforcement agencies can be much through new alliances, notably with armed groups. Current more effectively targeted at battling the organized crime responses need to be urgently scaled up and coordinated groups that have expanded their power and reach on the under West African leadership, with international fnancial back of drug market profts. Responses should integrate the violence, intimidation and corruption perpetrated law enforcement and judicial approaches with social, by these groups is a signifcant threat to individual and development and confict prevention policies – and they national security and to democratic institutions, so efforts should involve governments and civil society alike. There is a plausible theory put forward by MacCoun and Reuter43 that suggests that supply reduction efforts are most effective in a new and undeveloped market, where the sources of supply are controlled by a small number of traffcking organizations. Where these conditions exist, appropriately designed and targeted law enforcement operations have the potential to stife the emergence of new markets. On the other hand, where drug markets are diverse and well-established, preventing drug use by stopping supply is not a realistic objective. Similarly, the demand for drugs from those increased law enforcement on drug market violence, dependent on some substances (for example, heroin) 91 percent concluded that increased law enforcement can be met through medical prescription programs that actually increased drug market violence. Instead, the existing evidence suggests that practices can actually increase the level of violence, drug-related violence and high homicide rates are likely intimidation and corruption associated with drug a natural consequence of drug prohibition and that markets. Law enforcement agencies and drug traffcking increasingly sophisticated and well-resourced methods of organizations can become embroiled in a kind of ‘arms disrupting drug distribution networks may unintentionally race’, in which greater enforcement efforts lead to a similar increase violence. Promote alternative sentences for small-scale and rates of drug use through mass prevention campaigns frst-time drug dealers. While the presentation of good (and credible) information on While the idea of decriminalization has mainly been the risks of drug use is worthwhile, the experience of discussed in terms of its application to people who use universal prevention (such as media campaigns, or drugs or who are struggling with drug dependence, school-based drug prevention programs) has been we propose that the same approach be considered mixed. Simplistic ‘just say no’ messages do not seem for those at the bottom of the drug selling chain. There have been some carefully planned and targeted They are young people who are exploited to do the prevention programs, however, that focus on social skills risky work of street selling, dependent drug users trying and peer infuences that have had a positive impact on to raise money for their own supply, or couriers coerced the age of initiation or the harms associated with drug or intimidated into taking drugs across borders. The energy, creativity and expertise of civil society people are generally prosecuted under the same legal and community groups are of particular importance provisions as the violent and organized criminals who in the design and delivery of these programs. Young control the market, resulting in the indiscriminate people are less likely to trust prevention messages application of severe penalties. Around the world, the vast majority of arrests are of Successful models of prevention have tended to target these nonviolent and low-ranking ‘little fsh’ in the drug particular groups at risk – gang members, children in market. They are most visible and easy to catch, and do care, or in trouble at school or with the police – with not have the means to pay their way out of trouble. Implemented to a and with no impact on the scale or proftability of suffcient scale, these programs have the potential the market. Offer a wide and easily accessible range of options fghting the drug war, many countries implement laws for treatment and care for drug dependence, and punishments that are out of proportion to the including substitution and heroin-assisted treatment, seriousness of the crime, and that still do not have a with special attention to those most at risk, including signifcant deterrent effect. Invest more resources in evidence-based prevention, a tragic loss of potential for the individual involved, with a special focus on youth. Clearly, the most valuable investment would be in activities that stop young people from using drugs in Preventing and treating drug dependence is therefore the frst place, and that prevent experimental users a key responsibility of governments – and a valuable from becoming problematic or dependent users.