Emsam

By W. Folleck. The College of New Jersey.

Even the defined metabolic or endocrine disorders sounded a bit obscure and even mystical generic emsam 5 mg with amex anxiety facts. Whatever the reasons buy 5 mg emsam mastercard anxiety symptoms in kindergarten, we saw many patients with the referring note, Could this be a metabolic or endocrine problem? I often saw notes that said, No Gyn problem in this patient; or, I can find no evidence for cardiac disease; or, Tere is no solid evidence for GI disease. Beyond all my attraction to the biochemical sciences of medicine, a patient was sitting there with symptoms I could not explain with my mea- surements or observations. It was relatively easy, given our increasingly accurate measure- ments, to say, No metabolic or endocrine problem found. I was not aware of it at the time, but I was about to become engaged in the mind-body dichotomy. Tis false dichotomy is still very much alive and functioning today, but at that time it was deeply entrenched in medical practice. Te unwritten but nearly absolute rule, if written, would have gone something like this: Tere are diseases of the body and there are diseases of the mind. If no dis- ease is found in the body, then there must be a disease of the mind. Te mind and the body are completely separate and there is no 38 Symptoms of Unknown Origin connection. Patients either have a disease of the mind or they have a disease of the body. Whenever I could not find a medical disease, I asked my psychiatric colleague to see the patient with me. By this time, I was doing complete medical workups on these patients as a way of be- ing thorough and in an effort to find some disease to explain the symptoms and clinical state. When I asked the psychiatrists to see the patient, I (like others) was in effect saying, I cannot find a disease in the body, so please find a disease of the mind for me. I was struck by the fact that nearly every patient had some psychiatric disease label. It might be expected that each patient would have some psychiatric label, especially given my faith in the dichotomy of mind and body. After all, they had no disease in the body; therefore, they had to have a disease of the mind. Over the years, I began to have doubts about the near universality of psychiatric disease. At the time, however, I did not question the ubiquitous presence of psychiatric disorders. What I did begin to question was the lack of any defined treat- Diagnoses Without Diseases 39 ment based on the psychiatric label. Treatment recommendations were for intensive psychotherapy or protracted group therapy. In those years from 1962 to 1968, I did not see one pa- tient with multiple symptoms in the body benefit from psychiatric interventions, however defined. Of course, patients with depres- sion were greatly helped by the antidepressive drugs then coming into clinical practice. Te other troubling problem that came from my attempted collaboration with the psychiatrists was the poorly defined nomen- clature of psychiatry. I realize now that the science of the mind was still very young and not well developed. In contrast to the emerging precision of endocrinology, psychiatry was still primi- tive. Te terms most frequently used were hysteria, conversion symptoms, hypochondriasis, and later somatoform disorder. At this point, all I knew was that psychiatry was no help with these patients with physical symptoms but no demonstrable dis- ease.

When working in the out- patient environment discount 5mg emsam with visa anxiety symptoms in 5 year old boy, where and how would you obtain data reflecting the level of quality delivered in physician office practices? These are some of the questions that challenge many healthcare leaders as they struggle to develop quality improvement and measurement programs cheap emsam 5 mg with amex anxiety pain. This chapter clarifies these issues and some myths commonly held by the industry and provides a practical framework for obtaining valid, accurate, and useful data for quality improvement work. Categories of Data: Case Example Quality measurements can be grouped into four categories, or domains: clinical quality (including both process and outcome measures), financial performance, patient satisfaction, and functional status. To report on each of these categories, several separate and distinct data sources may be required. In fact, the challenge is often to collect as many data elements from as few data sources as possible, with the objective of consistency and continuity in mind. For most large and mature quality improvement projects, teams will want to report their performance in all four domains. A clinical outcome report (COR) from Spectrum Health, a large inte- grated healthcare system in Grand Rapids, Michigan, illustrates this point. The Spectrum Health system consists of nine hospitals, a 400,000-mem- ber health plan, and more than 130 service locations throughout western Michigan. This example provides a complete picture of the care delivered to several distinct patient populations by one of the inpatient hospitalist groups, Michigan Medical, a multispecialty group practice with more than 170 healthcare providers in 30 locations across West Michigan. To produce this COR, a variety of data sources was required, including extracts from 117 118 The Healthcare Quality Book the finance and medical record systems. The data were then processed by a third-party vendor who applied a series of rigorous data cleanup algo- rithms and added severity adjustment and industry benchmarks. The result- ing report, or dashboard, contains information for patients with congestive heart failure, ischemic stroke, community-acquired pneumonia, and gas- trointestinal bleeding. The report contains measures of the clinical processes (use of angiotension converting enzyme [ACE] inhibitors, beta-blockers, digoxin, coumadin, natrecor, and echocardiograms), financial performance (length of stay, total patient charges, pharmacy charges, lab charges, X-ray charges, and IV therapy charges), and clinical outcomes (acute renal failure, mor- tality rate, and readmission within 31 days). The measures were selected by the hospitalist team from more than 200 indicators available in the data- base as the most important in assessing the quality and cost of care deliv- ered. The measures also include some of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) Core Measures. The results can be reported by nursing unit, are updated quarterly, and can be trended over the last six to eight quarters. In the future, the team hopes to have patient satisfaction information by physician or physician group, such as the Michigan Medical hospitalists group. Many hospital procedures are intended to improve the functional status of the patient. A patient who undergoes a total knee replacement, for example, should experience less knee pain when he or she walks, have a good range of motion of the joint, and be able to perform the activities of daily living that most of us take for granted. In summary, it is important to maintain a balanced perspective of the process of care when designing data collection efforts by collecting data in all four categories: clinical quality, financial performance, patient satis- faction, and functional status. Quality improvement teams who fail to main- tain this balance may experience some surprising results of their improvement efforts. For instance, a health system in the Southwest initially reported on a series of very successful quality improvement projects—clinical care had Data Collection 119 improved, patient satisfaction was at an all-time high, and patient outcomes were at national benchmark status. However, subsequent review of the projects identified that some of the interventions had an untoward effect on the financial outcomes of the process under improvement. Several inter- ventions significantly decreased revenue, and others increased the cost of care unnecessarily. If financial measures had been included in the data col- lection and reporting process, the negative financial effect could have been minimized and the same outstanding quality improvements would have resulted. In the end, the projects were considered only marginally successful because of the lack of a balanced approach to process improvement and measurement. Considerations in Data Collection The Time and Cost of Data Collection All data collection efforts take time and money.

Work backwards: what headlines would you hope your research to attract (provided all goes well)? Use these thoughts to inform your message cheap emsam 5mg without prescription anxiety 411, and make sure that your message is clearly given when you write your application buy emsam 5mg visa anxiety symptoms zenkers diverticulum. Was it sent to the wrong organization, in which case how do you find out the right one? Did it fail to inspire the panel, in which case was it because you failed to make clear the amazing implications – or was it a run-of-the-mill idea that will not advance anything very much and therefore will prove difficult to fund? Good for glittering careers, but hardly reader-friendly (see putting on the posh overcoat). Green ink brigade There is a prejudice among many editors that those who write in green ink are mad. Until someone does the definitive study, however, if you write a letter to an editor, hide your ink preference by using a word processor. Although the system is not scientific, it is as good as any other system of selection – perhaps better. Hard copy Text that appears on paper rather than being elec- tronically stored and presented. Headlines There is a useful distinction to make between titles and headlines. Titles (as appearing on the top of scientific papers) are labels that identify what the writing covers, but (with the exception of declarative titles) they do not give away, or try to sell, the message. The job of subeditors on newspapers and magazines is to write these headlines. They often have to do this to tight deadlines, and on copy where the message is not always clear. They also have to write to very tight design specifications – such as (in the first story above) four lines of no more than 10 characters each. These design considerations mean that, when you submit an article, the title you choose is unlikely to make it through to publi- cation. Yet it will be on the headline that your peers will focus their critical powers (see false feedback loop). Heartsink writer Some writers always know better than their editors, never accept no for an answer, keep arguing and generally behave like the worst kind of patient. Homophones When it comes to words, there are many confusing pairs; homophones are those that sound the same, such as: • born and borne: (1) arriving in this world, and (2) carried, • complementary and complimentary: (1) something that adds, and (2) something that is free or giving praise, • discreet and discrete: (1) not likely to gossip, and (2) each separate piece, • principal and principle: (1) main (person), and (2) a rule, • stationary and stationery: (1) at a standstill, and (2) envelopes and writing paper. Which sentence brings us to another question: should we be ending sentences with prepositions? Humiliation Some see this as an essential part of commenting on what another person has written (see balanced feedback; politics of writing). Hyphens These give rise to two main problems: • whether to put them in at all. As a general guide, put them in to help the reader group words correctly, or to avoid ambiguity (last-minute changes or last minute changes? When narrow columns are being used, many of the words become split over two lines, and therefore hyphenated. This can turn the right-hand margin into a succession of small horizontal lines. In the old days, when type was set by hand, typesetters could take time and care to avoid this by subtle manipulation of letters and spaces. Now the computers seem to be in control: there seems to be little we can do to change this. Icarus fallacy In Greek mythology, Icarus was the one who soared nearer and nearer to the sun. Unfortunately, while the notion of building wings was ingenious and the construction of them skilful, the theory was based on a major miscalculation: his wings were made of feathers and wax, and when he flew near to the sun the wax melted and he fell back to earth.

Speculation about their function is based on Relaxation of antagonistic muscles the assumption that buy emsam 5 mg cheap anxiety symptoms tingling, in movements generic emsam 5 mg line anxiety 120 bpm, an adequate Co-ordinated synergies also imply relaxation of contribution of Ia afferent activity to motor output antagonistic muscles, whether by inhibition or depends not only on the fusimotor drive but also the disfacilitation. Discharge of remote motoneurones direct depolarisation by the central command of the through heteronymous Ia excitation presupposes relevant motoneurones (Hultborn & Illert, 1991). The relaxation of the antag- Lower limb onists at different joints during multi-joint move- Contractions of lower-limb muscles are usually ments may therefore be due to activation by the weight-bearing and often eccentric. These are cir- descending drive of the same spinal pathways as cumstances when the co-activated drive can rep- those ensuring the inhibition of the antagonists dur- resent a powerful input to muscle spindle endings ing single hinge (pp. Activation of various synergies 529 Flexible synergies role of the fusimotor system is now known to be sup- portive (Matthews, 1972). At times, an invariant diffuse pattern of monosynap- tic Ia connections in the human lower limb could be functionally inconvenient, because the activation of Ia afferents from a contracting muscle might then Cervical propriospinal system result in the automatic activation of unwanted mus- cle(s) linked in Ia synergism. In the cat, propriospinal neurones have also beenshowntoprojecttoIainhibitoryinterneurones, Activation of excitatory group II pathways. This creates a network ade- quate for translation of descending commands for The hypothesis regarding the role of group II path- multi-joint movements into the appropriate coordi- ways in supporting isometric contractions, pre- nated muscle synergies which underlie those move- sented above for one muscle (see p. The corticospinal projections onto specific and smaller FRA hypothesis suggests that a diffuse feedback sys- sets of motoneurones. The extensive convergence tem with a multisensory input, including group II ofdescendingexcitation,feedforwardinhibitionand afferents, could be used for the selective reinforce- feedback inhibition onto C3–C4 propriospinal neu- ment and prolongation of the descending command rones allows the cortical command to be updated at (see p. Because of the prewired limb, heteronymous group II excitatory projections connections of each subset of propriospinal neu- are widespread and strong (Chapter 7,Table 7. Available Reaching: an example of hierarchical control experimental data provide more evidence for an important role of group II pathways in posture and It is likely that, as in the cat, the human cervical pro- gait (see pp. Georgopoulos&Grillner(1989)have porting the contraction, not driving it, much as the proposed that, much as in locomotion, a significant 530 Spinal pathways in different motor tasks part of such movements may be accomplished (see pp. Thus,specificationofthedirectionand Motor learning probably speed of the movement would be elabo- rated by supraspinal motor structures, especially the The motor performance of deafferented patients motor cortex (the higher level). This contribution of showsthatreflexsupportisnotindispensabletoper- themotorcortextotheinitiationofreachingispartly forming or grading a contraction, at least in labo- channelled through the spinal propriospinal system ratory tasks. The required co-ordinated motions afferent feedback and the resulting activity in spinal of the shoulder, elbow and wrist are then assisted by circuitry are important in refining the motor output the divergent projections of propriospinal neurones (see pp. Whenlearningamotortask,movementsareslowand often involve co-contraction of antagonists to brace thejoint. Suchcontractionswouldbeassociatedwith State-dependent modulation of an effective increase in drive to the contracting sensory feedback muscles(seebelow). Thefeedbackfromspindleend- ings would be important, not only for smoothing The spinal cord contains the substrate for many the movement trajectory but also for providing the complex motor actions (e. This holds for both homonymous and rones involved in generating these complex move- heteronymous -driven spindle discharges. This internalisation of learnt programmes, and perfec- requires a dynamic regrouping of interneurones to tion of the movement depends on trial and error. As would learning progresses, a motor programme is shaped beexpectedfromthisconceptualframework,experi- which is subsequently available to command the mentsonreflexcontrolofmuscleactivityduringvar- movement (see Windhorst et al. Co-activation of information regarding the different spinal pathways antagonistic finger and wrist muscles is used in the (see Lundberg, Malmgren & Schomburg, 1987). Co-contractions information is essential for calling up the coor- of antagonists also occur in many voluntary tasks, dinated synergies that characterise the movement such as when unpredictable perturbations may be when the motor programming has been learnt. Smith, 1981; Akazawa, Milner & Stein, 1983; Llewellyn, Yang & Prochazka, 1990). Efference copy C3–C4 propriospinal neurones in the cat have ascending collaterals to the lateral reticular nucleus Control of spinal pathways during (LRN). Via these ascending collaterals, the LRN, co-contraction of antagonists which projects to the cerebellum, receives mirror information of the action that reaches motoneu- Hinge joints rones via the propriospinal neurones, and this con- stitutes a perfect efference copy. This may allow the AcomprehensivereviewoftheextensiveworkbyJens cerebellum to take corrective measures with a mini- Nielsenonco-contractionattheanklejointhasbeen mal delay, for which purpose it has at its disposal the published in a thesis (1998). Internal feedback of this type may regu- late a forthcoming movement at its onset. Feed- Reciprocal Ia inhibition between antagonistic ankle back inhibitory interneurones also have ascend- muscles is almost completely suppressed when dor- ing projections to the LRN, indicating that correc- siflexors and plantar flexors are voluntarily activated tion of the movement takes into account the out- simultaneously (see pp.

Inhibition of withdrawal reflexes from the the early responses occurring with latencies com- supporting area would prevent them from conflict- patible with a spinal pathway fall within the field of ing with the support role discount 5mg emsam free shipping anxiety treatment without medication, as discussed below cheap emsam 5mg mastercard anxiety symptoms - urgency and frequent urination. However, there must be some discussion of long-latency transcorti- Postural tasks cal responses, in part because some have long been considered spinal reflexes. Reflex responses evoked in tibialis anterior by a nox- ious stimulus applied to the medial anterior part of the sole have been explored while the subjects RII reflex at rest maintained different postures during upright stance RII reflex (Rossi & Decchi, 1994). Standing on one leg resulted in a significant decrease in the withdrawal reflex The RII reflex elicited at rest in the short head of the of the ipsilateral tibialis anterior, whereas a signif- biceps femoris by low-intensity stimuli to the sural icant facilitation was observed when the subject was nerve at the ankle (Fig. A tent example of a cutaneomuscular reflex record- progressive depression of the withdrawal response able at rest (see Hugon, 1973;p. A RII-like response may loaded the ipsilateral leg, the smaller the response be occasionally recorded in other muscles (cf. Thus, the withdrawal responses of several drawbacks tibialis anterior are suppressed when the support- ing function of the leg increases. Organisation, connections and Cutaneomuscular reflexes during physiological implications of voluntary contraction cutaneomuscular reflexes evoked Modulation of the on-going EMG by non-noxious stimuli The technique of modulating the on-going EMG The different responses activity by tactile cutaneous volleys was introduced by Gassel & Ott (1970) for triceps surae and by Reflexresponsesevokedbylow-thresholdcutaneous Caccia et al. This tech- afferents can be documented by different methods nique has since been used extensively to investi- (cf. Apriori,only gate human pathways mediating effects produced Non-noxious cutaneomuscular reflexes 415 by low-threshold cutaneous afferents. They have been documented in facilitation have also been found in tibialis anterior many limb muscles. The technique is simple and the after stimulation of the superficial peroneal nerve at cutaneomuscular reflexes so produced are consis- the ankle (Nielsen, Petersen & Fedirchuk, 1997). This further difficulty arises because the cutaneous input isillustratedin9. Similar responses have and there are important task-related changes in the been recorded in many hand and forearm muscles: modulation of the on-going EMG (cf. E1 response habituates Lower limb rapidly (Harrison, Norton, & Stephens, 2000), and this could explain why it is not always seen in nor- The dominant effect of sural nerve stimulation using malsubjects(Chen&Ashby,1993;Hallettetal. Single shocks at There are, however, more modest preceding effects, 2 × PT to the digital nerves of toe 2 produce a which are considered on p. Sural nerve stimula- (FCR) H reflex, with weak short-latency inhibition tion using five shocks at 300 Hz and 2×PT evokes appearing at 2 ×PT, followed some 3–4 ms later quite variable short-latency responses at ∼50 ms or by a potent facilitation appearing just above 1 ×PT less in the different muscles: excitation in the per- (Cavallari & Lalli, 1998). Qualitatively similar results oneus longus and the gastrocnemii, and inhibition were obtained whether the stimulus was applied to in both the soleus and tibialis anterior (Fig. The same early inhibition and sub- responses are followed by a long-latency excitation sequent potent facilitation have now been observed 416 Cutaneomuscular and withdrawal reflexes (a) (c) (d ) (e) (f ) (b) (g) Fig. Cutaneomuscular reflexes evoked by low-threshold cutaneous afferents in the lower limb. Cutaneous afferents excite peroneus longus (PL) and gastrocnemius medialis (GM), and inhibit soleus (Sol) and tibialis anterior (TA) motoneurones (MN) through spinal interneurones (INs), and excite TA MNs through a transcortical pathway. Responses are in PL ((c), 500 sweeps), TA ((d ), 500 sweeps), Sol ((e), 250 sweeps), GM ((f ), 250 sweeps), and gastrocnemius lateralis (GL, (g), 250 sweeps). The vertical thick dotted line and thin dashed line in (c)–(g) indicate the onset of the stimulus train, and the limit below which the responses may be considered as spinal, respectively. Modified from Jenner & Stephens (1982)(b), and Aniss, Gandevia & Burke (1992)((c)–(g)), with permission. This inhibition differs from trical stimulation of the skin of the palmar side of the disfacilitation that occurs with inhibition of the index finger (Fig. The brief rones in a number of respects: (i) brief latency; (ii) latency and short duration of the inhibition exclude the target muscle (FCR instead of ECR); (iii) the apresynapticinhibitorymechanism. Sincethereflex subsequent potent facilitation; and (iv) that it can be inhibition occurs at rest,itpresumably results from elicited from both sides of the hand. Spinal reflex effects evoked by low-threshold cutaneous afferents in the upper limb. Cutaneous afferents through spinal interneurones (INs) excite flexor digitorum superficialis (FDS) and first dorsal interosseus (FDI) motoneurones (MNs), both excite and inhibit flexor carpi radialis (FCR) MNs, and both excite and inhibit FDI MNs through a transcortical pathway. The arrow at 11 ms indicates the arrival of the cutaneous volley at motoneuronal level. The zero on the abscissa corresponds to the expected time of arrival of the cutaneous volley at motoneuronal level.