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By: B. Asaru, M.B. B.CH., M.B.B.Ch., Ph.D.
Associate Professor, CUNY School of Medicine
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Overall, individu cal changes that occur in the brain during the recovery pro als with brain injury were found to experience signicant cess and the severity of injury have been postulated to be levels of fatigue. Insomnia, dened as difculty in initiating or tients with brain injury fatigued more easily than control maintaining sleep associated with daytime fatigue or subjects and correlated positively with the subjective rat impaired functioning, is common in patients with acute ing scales. In the study by LaChapelle and Finlayson (1998), mented the relationship between the two. There jury admitted to an outpatient rehabilitation center an av was no signicant difference between the patient and erage of 3 months after injury. More studies are necessary to estab complains of excessive daytime sleepiness should be eval lish this association, although clinical evidence reveals uated for sleep apnea and narcolepsy. Sleep apnea is clas that pain is closely associated with insomnia in the general sied as obstructive (cessation of breathing with contin population (Peres et al. Latency Test), has been reported in individuals after brain In a study of 10 adult subjects with a history of chronic injury (Castriotta and Lai 2001; Masel et al. In a mild to severe closed head injury and complaints of exces study of 184 patients referred to a sleep clinic approxi sive sleepiness, all were found to have a sleep disorder. Upper airway resistance syndrome (hypersomnia Approximately 82% of the patients were found to have secondary to sleep disturbance due to increased effort of hypersomnia with a multiple sleep latency score of less breathing through a narrow airway without measurable than 10, and 32% were found to have sleep-disordered apnea or hypopnea) was found in one subject, and narco breathing problems. Prolonged coma of longer than 24 lepsy was diagnosed in two subjects (Castriotta and Lai hours, neurosurgical intervention, pain, and skull fracture 2001). Sleep apnea has also been described in the post were commonly associated with hypersomnia. Sleep-related breathing and nontraumatic) referred to a rehabilitation facility, hy episodes were also found to be primarily more central persomnia (dened as a mean sleep latency score of less than obstructive, which is in contrast to those seen in the than 10) was observed in 47% (Masel et al. This also suggests that trauma to the this group, 17% had abnormal respiratory indices and pe brain may be partly responsible for this phenomenon riodic leg movements as detected by polysomnography. We recommend that clinical diagnosis of narcolepsy should always be accompanied by formal sleep studies and Sleep-wake cycle disturbances. There are several varieties of sleep-wake cycle prevalence, varieties, associated psychiatric disturbances, disturbances, including the delayed, advanced, and disor and effect on rehabilitation and physical, cognitive, and ganized types. The pathogenesis remains unclear, social level of functioning are yet to be identied. Such although dysfunction of the suprachiasmatic nucleus has Fatigue and Sleep Problems 377 been postulated (Okawa et al. Evaluation of fatigue and sleep associated with this disorder in the general population disturbances in traumatic brain injury include shift work and travel through different time zones (Patten and Lauderdale 1992). None had past history of neurological Alcohol and substance abuse history illness, psychiatric history, or sleep apnea syndrome. More Medical history, including chronic pain, dizziness than one-half of the patients were diagnosed with delayed phase type and the rest disorganized-type sleep-wake cy Current medications and dosages cle disturbance.
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If severe, there is virtual tact visual tracking is essential for the diagnosis; its pres absence of goal-related thought content: no interests, ence excludes more extensive damage involving the brain no intentions, no plans. Meaningful responses occur in akinetic mutism, but and, of course, akinetic mutism. Diminished emotional responses to goal-related events sim tiation of behavior and cognition as well as preservation ply means that when something of importance hap of visual tracking are the essential features of akinetic pens, emotional responses are decreased: they are mutism (American Congress of Rehabilitation Medicine brief, shallow, or restricted in range. The term is used in recent litera To summarize, we can say that diminished motivation ture (Fisher 1983; Mega and Cohenour 1997) for symp is present if a patient with intact level of consciousness, at toms less severe than but qualitatively identical to akinetic tention, language, and sensorimotor capacity presents mutism: poverty of behavior and speech output, lack of ini with simultaneous decrease in the overt behavioral, cog tiative, loss of emotional responses, psychomotor slowing, nitive, and emotional concomitants of goal-directed be and prolonged speech latency. This is an operational denition of diminished mutism when it worsens and into apathy when it improves. Diminished motivation is riparesis) (American Congress of Rehabilitation Medi not a feature of aprosodia, however (Marin 1996a). Executive cognitive impairments may be seen in affect personality and executive cognitive dysfunction. Waxy exibility, if present, points to catatonia Clinicians should proceed with differential diagnosis (Fink and Taylor 2001). Underdiagnosis psychomotor retardation should not be viewed as a leads to premature attempts at physical rehabilitation or pathognomonic feature of depression or any other diag other interventions whose success depends on strong mo nosis (Benson 1990; Widlocher 1983). Antidepressant treatment may also fail, not be order of movement rather than motivation. How tients have poverty of speech because they have poverty of ever, motivational symptoms are commonplace in de recall. Demoralization, like de and preoccupation, which also may bring apathy and abu pression, is a dysphoric state. Psychotic thought content may lead to autistic or self-absorbed presentation of self. Thought blocking, circumstantiality, and impaired Mechanism coherence of thought may appear as reduced goal-direct A model for the mechanism of motivation aids in the edness or drive. It also provides a In light of these factors, the two groups of disorders to framework for dening research questions and integrat distinguish in differential diagnosis are those in which the ing new knowledge.
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Uncufed tubes are still prompting a rapid drop in oxygen saturation during intubation routinely used in many institutions. Monitor urine output as an indirect measurements to assess An even lower dose of induction agent should be used if adequate organ perfusion and keep the patient warm in the the patient is in shock not responding to fuid. If the child perioperative period with the means which you have available has been sick for some time, the blood pressure may drop to you in your hospital setting. Never perform an inhalation induction in these The use of inhalation agents, ketamine, opioids or any patients. You will need to control the ventilation, the intraoperative and postoperative course. If the patient is acidotic (determined Maintenance concerns clinically or by measurement of the venous or arterial blood After induction of anaesthesia and intubation with gas), they will not tolerate spontaneous ventilation with low succinylcholine, monitor the haemodynamic status closely. If this happens, give a fuid bolus of normal depolarising muscle relaxant to assist the surgeon and expedite saline or blood in 10ml. Place a three-way stop-cock in line so that due to hypovolaemia, myocardial depression, or associated blood or normal saline can be pushed with a 20-60ml syringe. Blood should be given based upon blood loss, with the goal of At the end of surgery, consider the options for extubation improving oxygen delivery dictated by cardiac output, oxygen carefully. In severe this fgure may need to be higher due to the weak medical cases of obstruction and sepsis, primary anastomosis would infrastructure and support systems. In either case, the child needs to be fully awake, breathing well Inotropes will need to be started if blood pressure remains low and adequately reversed, indicated clinically by fexion of the despite fuid administration. In addition, movement of The two most important factors for safe postoperative care are bacteria from the obstructed, and possibly necrotic intestines the location in the hospital and the nurse: patient ratio. The to the blood stream may release mediators and hydrogen ideal location should have oxygen, suction, good lighting, be ions (producing acidosis), resulting in more cardiovascular close to the nursing station; the room should be warm, the instability during surgical manipulation and repair of the head of the bed elevated, and there should be, one paediatric damaged intestines. In many hospitals the nurse: may be useful whilst an infusion of adrenaline is prepared patient ratio is 1:15, with very ill children, and this will not (dilute 1 mg adrenaline in 1000ml saline to give a solution of be safe for this child for the 72 hour period when the risk 1mcg. Many of these patients will have an oxygen requirement reFerenceS for a few days while the sepsis and any pneumonia resolves. Profle of pediatric The respiratory status, respiratory rate, should be monitored abdominal surgical emergencies in a developing carefully, particularly if opioids are given to a child receiving countries. A fall in saturation is a late fnding and narcotics should only be used in the setting of a 1:2 nurse:patient ratio. Mayo Clin Proc 2003; 29: 605-606, Emergency surgery for bowel obstruction in children presents vii.
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What is the role of psychological therapies in the treatment of bipolar disorders A randomized trial on the efficacy of group education in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. Family-focused treatment of bipolar disorder: One-year effects of a psychoeducation program in conjunction with pharmacotherapy. Adjunctive psychotherapy for bipolar disorder: Effects of changing treatment modality. Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial. Cognitive behavior therapy: Applying empirically supported techniques in your practice. Treating cocaine-using methadone patients: Predictors of outcomes in a psychosocial clinical trial. Superior efficacy of cognitive-behavioral therapy for urban crack cocaine abusers: Main and matching effects. Effects of brief cognitive-behavioral interventions on confidence to resist the urges to use heroin and methamphetamine in relapse-related situations. Achieving abstinence by treating depression in the presence of substance-use disorders. Cognitive-behavioural therapy and motivational intervention for schizophrenia and substance misuse: 18-month outcomes of a randomized controlled trial. Cognitive-behavioral treatment of bipolar disorder and substance abuse: A preliminary randomized study. A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: Findings from a pilot study. Two group therapy models for clients with a dual diagnosis of substance abuse and personality disorder. Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics. Cognitive-behavioral coping skills and psychoeducation therapies for adolescent substance abuse. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. Couples relapse prevention sessions after behavioral marital therapy for male alcoholics: Outcomes during the three years after starting treatment. Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: Results of a placebo-controlled trial. Outpatient cognitive behavioural therapy programme for alcohol dependence impact of naltrexone use on outcome. Cognitive behavioural therapy combined with the relapse-prevention medication acamprosate: Are short-term treatment outcomes for alcohol dependence improved
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