y 2020, depression will move into second place on the list of top-ranked illnesses, just behind cardiovascular disease, according to the Global Burden of Disease Study conducted by the World Health Organization (WHO), the World Bank, and Harvard University (Murray & Lopez, 1996). There is also a link between coronary heart disease and depression. Data from the National Health and Nutrition Examination Survey (NHANES 1) identified that men and women with depression are more at risk for coronary artery disease (Ferketich, Schwartzbaum, Frid, & Moeschberger, 2000).

Depression in the first 18 months after a myocardial infarction is a significant predictor of mortality in both men and women (Frasure-Smith, Lesperance, & Talajic, 1995). The experience of depression also increases the risk of cardiac arrest due to the physiologic edge produced by imbalanced catecholamine circulation (Empana et al., 2006). Ziegelstein et al. (2000) suggest that patients with depression after a myocardial infarction are less likely to choose healthier lifestyle habits (e.g., diet, exercise, social support) or take their medications as instructed. In order to help patients maintain the highest possible level of health, it is imperative that APRNs screen patients carefully for physiologic symptoms attributable to coronary heart disease events and those diagnostic for major depression (Valentine, Byers, & Peterson, 2001).

Early in my practice, I became involved with Bristol Hospital’s Phase II Cardiopulmonary Rehabilitation program called Heart Works. The mental health segment consisted of a 12-week, psychoeducational class format that included information on stress management and cognitive behavioral techniques. Attendance was typically small, and patients complained they did not like being “in school.” After discussion with the program director we eliminated the classroom model, and we established interviews during the orientation to the program with both the Psychiatric Consultation Liaison Nurse (PCLN) and the dietician. The PCLN interview format offers both the patient and family an opportunity to share their perception of their illness/recovery experience, to identify current health promotion behaviors, and to participate in a traditional mental status exam; it also offers an opportunity to screen for depression. We encourage patients to invite any family members they wish to accompany them. Naturally, patients always have the option to refuse the interview.

Content of the Interview

No single assessment tool met my need for a holistic focus; therefore, I created a format that is systemically based, assessing multiple levels of a system and using theory to guide the questions I ask. Included are family nursing theory (Wright & Leahey, 1989), behavioral domains from the Health Promotion Lifestyle Profile (HPLP II) (Walker, Sechrist, & Pender, 1987), and stages of change theory/motivational interviewing (Miller & Rollnick, 1991). The purpose of the interview and depression screening is explained to each patient/ family member. The beginning of the discussion focuses on the beliefs that the patient/family have regarding etiology, diagnosis/prognosis, role of patient/family/providers in recovery, and the impact of the event on the family’s routines. One strategy to elicit the patient’s experience involves the use of interventive interviewing, meaning that you create a conversation inviting change.

Karl Tomm (1988) defined four categories of questions: lineal, circular, strategic, and reflexive. Lineal questions are simple and factual (”Do you have heart disease in your family?”). Circular questions help the patient think about the feedback in relationships (”Who worries the most about your recovery?”). Strategic questions help expand the options to change (”What kinds of help would you need to stay smoke free?”). Reflexive questions help the patient think differently about an issue (”If you succeeded in making your house smoke free, what other concerns might come up?”). Finally, inclusion of a genogram provides a window into the patient’s living room and explores multiple perspectives.

My assessment of current health promotion behaviors covers independent activities of daily living, including the perception of the role of spirituality in recovery. The topics were adapted from the original HPLP II tool, which addressed self-actualization, health responsibility, exercise, nutrition, interpersonal support, and stress management. I created a question about the patient’s perceptions of coping, the perception of family coping, and the expected utility of Heart Works. This is a self-report score from 1 to 10 with 10 being highest. This was added so that staff might compare results at their 6-month follow-up phone call.

The mental status exam is straightforward and includes a brief assessment of present/prior medical illness and how those experiences impact the patient’s perception of the here and now process of recovery. Substance use is also discussed during the evaluation. I have found the brief intervention strategy model, developed by Miller and Rollnick (1991), very helpful. Finally, the patient is given a self-report depression screening questionnaire to complete at home and is requested to return it to staff. There are many tools available, and we currently use the Zung Depression Scale (Zung, 1965). The Zung is a self-administered, 20-item scale that is short, simple, and quantitative. It is sensitive to severity of depression across many patient subgroups with unipolar depression. It is less specific to symptoms common to atypical depression.

PURPOSE. The Adaptive Information Processing Model (AIP), originally developed by Shapiro (2001), provides a model for understanding how trauma affects the brain and how healing occurs.

CONCLUSIONS. The effects of trauma are thought to be much broader than the diagnosis of PTSD and overlap with many other diagnostic categories. Recent physiological research supports the complexity of neurobiological responses to childhood stress and trauma.

PRACTICE IMPLICATIONS. The Treatment Hierarchy, AIP model, and evidence-based treatment framework presented here provide the context and a compass for holistic PMH-APRN practice for working with traumatized patients.

Search terms: Adaptive information processing, disorders of extreme stress (DESNOS), healing trauma, posttraumatic stress disorder (PTSD)

Trauma is an inescapable part of the human experience and affects all dimensions of the person. Psychological trauma has been posited to underlay or contribute to a wide range of psychiatric disorders and medical problems (Hennessey, Ford, Mahoney, Ko, & Siegfried, 2004; Morrison, Frame, & Larkin, 2003; Scaer, 2005; Teicher, Polcari, Andersen, Anderson, & Navalta, 2003). Trauma disconnects the person physiologically, emotionally, spiritually, cognitively, interpersonally, and socially. The National Comorbidity Study found that 60.7% of men and 51.2% of women interviewed reported having experienced at least one major traumatic event in their lifetime (Kessler et al., 1999), and of those exposed to trauma, the prevalence rate for posttraumatic stress disorder (PTSD) is approximately 25% overall in the United States (Foa, Keane, & Friedman, 2000).

Findings (Amsel & Marshall, 2003) from the World Trade Center disaster indicate that many people did have significant symptomatology afterward, such as insomnia, irritability, general anxiety, vigilance, and impaired concentration. However, those problems that people sought help for did not fit into the diagnostic categories of the DSM-IV-TR. Van der KoIk (2003) says that single incident traumas account for those diagnosed with PTSD but that most adults who seek psychotherapy have had numerous traumatic events and suffer from a variety of psychological problems, most of which do not fall within this diagnostic category. Broadly speaking, these fall into problems in aggression, self-hatred, dissociation, somatization, depression, distrust, shame, relationship problems, and affect regulation.

The Effects of Trauma Beyond PTSD

The effects of trauma are thought to be much broader than the diagnosis of PTSD and overlap with many other diagnostic categories. This is true for adults as well as children. One study (Teicher et al., 2003) found that almost two thirds of children with documented abuse do not suffer from PTSD but from a variety of other psychiatric disorders, such as dissociative disorders, borderline personality, bipolar and unipolar depression, substance abuse, eating disorders, oppositional defiant disorder, and attention deficit disorder.

An individual’s vulnerability to trauma depends on the developmental stage, genetic vulnerability, gender, past experiences, preexisting neural physiology, cognitive deficits, emotional maturity, coping skills, hardiness, relationships with others, socioculturel factors, and a host of other factors (Antai-Otong, 2002). If the trauma is particularly prolonged and/or severe and/or the person is vulnerable, pervasive personality problems develop. The person may then develop complex PTSD or disorders of extreme stress not otherwise specified (DESNOS) (Herman, 1992). Although not a DSM-IV diagnosis yet, six deficit areas for DESNOS have been delineated, which include: dysregulation of affect and impulses, disorders of attention and consciousness, disorders of self-perception, distorted interpersonal relationships, distortions of systems of meaning, and somatization of external stress manifesting in the body as disease or physical disorders (Dworkin, 2005). These individuals, referred to as the chronically disempowered by Chu (1998), are often survivors of childhood abuse and require long-term treatment extending over several years.

Shapiro (2001) expanded the concept of trauma from what we traditionally consider Big T events, such as natural disasters, terrorist activities, war, incest, physical abuse, car accidents, and other major lifethreatening events, to include small t traumas. Small t traumas are those that occur often and to most people, such as emotional neglect or indifference, humiliation, and family issues and do not rise to the level of a Big T trauma, yet may create problems and long-term sequelae, both physically and emotionally. For example, childhood experiences such as caregiver depression, chronic mother-infant misattunement, being bullied, chronic loneliness, separation from parents, feeling stupid and humiliated in the classroom setting, significant physical illness, relationship and/or personality problems between parents, economic hardships, family instability, frequent moving and/or change of school, taking care of an alcoholic parent, and many other life events impact the developing child’s brain.

With the recent outbreaks of avian influenza A (H5N1), the risk for the next influenza pandemic has increased. For effective countermeasures against the next pandemic, investigation of past pandemics is necessary. We selected cases diagnosed as influenza from medical records and hospitalization registries of Japanese army hospitals during 1918-1920, the Spanish influenza era, and investigated clinical features and circumstances of outbreaks. Admission lists showed a sudden increase in the number of inpatients with influenza in November 1918 and showed the effect of the first wave of this pandemic in Tokyo. The death rate was high (6%-8%) even though patients were otherwise healthy male adults.

Because of the emergence of avian influenza A (H5N1) virus in Southeast Asia, potential evolution of a novel type of influenza in the near future is of great concern (1,2). If an outbreak of a novel form of influenza occurs, a major worldwide pandemic is predicted because humans would not have immunity against this virus. To take effective countermeasures against new pandemics, investigation of past pandemics is essential.

Four pandemics occurred in the 20th century: Spanish flu in 1918, Asian flu in 1957, Hong Kong flu in 1968, and Russian flu in 1977 (3.4). Spanish influenza was the largest pandemic, and Japan was seriously affected. Despite abundant public records related to Spanish influenza, few primary documents, such as medical records, remain in Japan. Recently, medical records from the early 20th century were found in the depository of the International Medical Center of Japan (IMCJ) Hospital, Tokyo. We used these records to investigate the clinical characteristics of Spanish influenza. To help prepare countermeasures, we investigated the outbreak situation, clinical findings, and outcomes of Spanish influenza in the Japanese military during 1918-1920.

Patients and Methods

The documents were stored at the medical history depository of IMCJ Hospital, at the medical records and hospitalization registries of Tokyo First Army Hospital (a predecessor of IMCJ Hospital), and at the Fifth Japanese Army Garrison Hospital, Krasnoyarsk, Russia. Medical records in which influenza was diagnosed between January 1918 and December 1920 were selected. Because the influenza virus had not yet been discovered at that time, no serologic or virologic diagnostic methods for influenza infection were available, and no examinations such as chest radiographs were performed. Thus, the diagnosis flu (kanbo in Japanese) was defined as clinical influenza.

Three types of documents were investigated. The first type was the hospitalization registry of Tokyo First Army Hospital, in which records of 127 patients from January 1918 through November 1918 were included. Because these records were bound, it was assumed that no records were missing. The second type was the medical records of 132 patients at the Fifth Japanese Army Garrison Hospital in Russia from March 1919 through April 1920. These records were also bound, and it was again assumed that no records were missing. The third type was the medical records of419 patients at Tokyo First Army Hospital from January 1918 through May 1920. These records were not associated with time and were partially discontinuous, which indicated that some records (dates) were missing. Information on the hospitals (e.g., numbers of beds and physicians) was unclear. This research was reviewed and approved by the research review boards at IMCJ Hospital. Statistical significance of between-group differences was analyzed by using the Mann-Whitney U test. A p value <0.05 was considered statistically significant.

Results

We first investigated hospitalization registries of Tokyo First Army Hospital from January to November 1918. These registries had the names and diagnoses of patients admitted to the hospital on a monthly basis. Numbers of patients admitted for respiratory infectious disease during this period are shown in the Figure. Cases diagnosed as pneumonia, acute bronchitis, and influenza were classified as respiratory infectious diseases. Although records of patients with tuberculosis were found, we excluded them from this study. In the 10-month period from January to October, the mean ([+ or -] standard deviation) monthly numbers of patients with pneumonia, acute bronchitis, and influenza were 10.9 [+ or -] 6.5, 10.0 [+ or -] 3.6, and 1.8 [+ or -] 4.1, respectively (22.7 [+ or -] 9.6 for all 3 illnesses). Death rates from pneumonia, bronchitis, and influenza during this period were 3.4% (4/116), 0% (0/109), and 0% (0/18), respectively. The number of influenza patients suddenly increased to 109 in November, and 9 of them died (8%). Because our information about these 109 patients was found only in the hospitalization registries (the patients’ medical records were not found), we could not identify their clinical symptoms. However, it can be assumed that the hospital experienced the first wave of Spanish influenza in November 1918. Because no hospitalization registry before this period was found, comparison with outbreaks in average years was not possible.

DEBORAH ANTAI-OTONG RESPONDS: The precise relationship between diabetes and depression continues to be debated. However, most research implicates a positive correlation between depression and type II diabetes (Anderson, Freedland, Clouse, & Lustman, 2001; Nichols & Brown, 2003). Controversy about this relationship and necessity to screen patients presenting with diabetes exists as well (Brown, Sumit, Majumdar, & Johnson, 2006). Depression is widespread in patients with diabetes, but it often goes unrecognized and undertreated in primary care settings. Left untreated, depression can result in negative clinical outcomes, increased healthcare and economic burden, and a threat to overall health integrity and quality of life. Psychiatric nurses must be prepared to collaborate with primary care and other healthcare providers to screen patients with diabetes who are at risk for depression. Accurate diagnosis ensures the initiation of pharmacologic and nonpharmacologic treatments that reduce complications of both chronic diseases.

Major depression occurs in one in four patients with type I and type II diabetes mellitus (Andersen et al., 2001) and is associated with poor glycemic control, negative clinical outcomes, reduced quality of life and level of function, and diabetic-related mortality (Katon et al., 2004; Zhang et al., 2005). Several studies demonstrated that individuals with diabetes experienced up to threefold incidence of depression compared to those without diabetes (Anderson et al.; Hermanns, Kulzer, Krichbaum, Kubiak, & Haak, 2005; Nichols & Brown, 2003).

Major depression is frequently linked to diabetic-related complications, particularly micro- and macrovascular conditions (Wexler, 2006). For instance, depressed patients are twice as likely to develop diabetes compared to those who are not depressed (Knol, Twisk, Beekman, Snoek, & Pouwer, 2006). Moreover, depressed patients with diabetes are likely to experience an accelerated risk of coronary artery disease and significantly higher incidence of diabetes-related mortality (Brown, Majumdar, Newman, & Johnson, 2005; Egede, Nietert, & Zheng, 2005; Katon et al., 2005). Evaluation and treatment is a priority because of the relationship between depression and poor glycemic and metabolic management in patients with type II diabetes. The pathogenesis of this relationship is still poorly understood and necessitates further study. However, behavioral, physiologic, genetic, and environmental stressors may alter neuroendocrine and neurotransmitter functions.

It is imperative to recognize risk factors along with symptoms of co-occurring depression and their impact on chronic disease management because of negative prognostic implications associated with co-occurring diabetes and depression. Age, female gender, previous history of depression, complications from diabetes, such as peripheral neuropathic pain, impaired functional status and quality of life, and psychosocial stressors are risk factors (Hermanns et al., 2005; Legato et al., 2006). Steps to establish quality health care begin with collaboration with primary care providers, patients, and their families to develop and implement an individualized treatment plan.

Implications for Psychiatric Nursing Practice

Treating depression in the diabetic patient is similar to treating other co-occurring chronic diseases. It is imperative to evaluate the patient’s physical condition by asking questions about prescribed and over-the-counter medications and adherence to treatment adherence. Ordering blood chemistries, hemoglobin A^sub 1C^ (HgbA^sub 1C^), drug screens when appropriate, and lipid profile; measuring vital signs, height, and weight; and working with the primary care provider to evaluate metabolic/ glycemic control is advisable. It is equally important to rule out coexisting psychiatric (e.g., anxiety disorder, substance-related disorders) and medical conditions, including cardiovascular disease, hypertension high low-density lipoprotein cholesterol and triglycéride, and obesity. The decision to seek psychiatric evaluation and treatment can be unsettling to the patient who may deny the distress associated with diabetes and depression. Establishing collaborative relationships with the primary care provider helps ensure their support of mental health treatment. Open communication about the patient’s medical problems and history, including adherence to treatment, quality of support systems, cultural perceptions of diabetes and depression (e.g., gender, generational), and coping styles is helpful in co-collaborating.

Rationale: Recent U.S. data suggest an increased risk of work-related asthma among health care workers, yet only a few specific determinants have been elucidated.

Objectives: To evaluate associations of asthma prevalence with occupational exposures in a cross-sectional survey of health care professionals.

Methods: A detailed questionnaire was mailed to a random sample (n = 5,600) of all Texas physicians, nurses, respiratory therapists, and occupational therapists with active licenses in 2003. Information on asthma symptoms and nonoccupational asthma risk factors obtained from the questionnaire was linked to occupational exposures derived through an industry-specific job-exposure matrix.

Measurements: There were two a priori defined outcomes: (1) physician-diagnosed asthma with onset after entry into health care (”reported asthma”) and (2) “bronchial hyperresponsiveness-related symptoms,” defined through an 8-item symptom-based predictor.

Main Results: Overall response rate was 66%. The final study population consisted of 862 physicians, 941 nurses, 968 occupational therapists, and 879 respiratory therapists (n = 3,650). Reported asthma was associated with medical instrument cleaning (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.34-3.67), general cleaning (OR, 2.02; 95% CI, 1.20-3.40), use of powdered latex gloves between 1992 and 2000 (OR, 2.17; 95% CI, 1.27-3.73), and administration of aerosolized medications (OR, 1.72; 95% CI, 1.05-2.83). The risk associated with latex glove use was not apparent after 2000. Bronchial hyperresponsiveness-related symptoms were associated with general cleaning (OR, 1.63; 95% CI, 1.21-2.19), aerosolized medication administration (OR, 1.40; 95% CI, 1.06-1.84), use of adhesives on patients (OR, 1.65; 95% CI, 1.22-2.24), and exposure to a chemical spill (OR, 2.02; 95% CI, 1.28-3.21).

Conclusions: The contribution of occupational exposures to asthma in health care professionals is not trivial, meriting both implementation of appropriate controls and further study.

Keywords: work-related asthma; health care workers

It is well established that certain occupational groups are at increased risk of developing asthma, including Western red cedar workers (1), isocyanate chemical workers (2), construction workers (3), and farmers (4). However, whereas the risk magnitude and etiologic agents are well characterized for many of these occupations, this has been less well studied in the case of health care workers (HCWs), where data largely derive from case series but relatively few population-based studies or surveillance systems.

In the 1990s, attention began focusing on respiratory hazards among HCWs, partly because of increasing concern over occupational latex allergy after passage of the 1992 Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard, which resulted in a significant increase in the use of latex-containing personal protective equipment, such as powdered latex gloves. However, potential asthmagens in health care settings go beyond latex, and may include disinfectants and sterilants (e.g., glutaraldehyde, formaldehyde), pharmaceuticals (e.g., psyllium, antibiotics), sensitizing metals (e.g., in dental alloys), methacrylates, irritant aerosolized medications (e.g., pentamidine and ribavirin), and cleaning products (5, 6).

Previous studies from various countries have reported cases of work-related asthma among specific groups of HCWs, including physicians (7), respiratory therapists (8), workers in endoscopy units and radiology departments (9), nurses (10), and general HCWs (5). Confirmation and estimation of risk, however, in population-based studies has been more problematic. In a cross-sectional analysis of the European Community Respiratory Health Study (ECRHS), significant excesses of risk among HCWs were not consistently observed (4). In the United States, using data from the National Health and Nutrition Examination Survey III, conducted between 1988 and 1994, the odds for either work-related asthma or wheezing in health-related occupations were not significantly increased (11). Data from the 2001 National Health Interview Survey did find significantly increased odds for physician-diagnosed asthma in the U.S. health care industry, but this excess was limited to white females (12). More recently, surveillance data from four U.S. states found that work-related asthma among HCWs represented 16% of total reported cases, exceeding their representation in the workforce (8%) (6). Interestingly, the U.S. National Institute for Occupational Safety and Health (NIOSH) reported that 5 of the top 11 industries and 9 of the 22 leading occupations associated with significantly increased asthma mortality were related to health care services (13).

Thus, results are inconsistent, and few studies have been conducted in HCW populations allowing a more detailed characterization of potential associations between asthma and various workplace exposures. Studies that address these remaining issues are particularly important considering that HCWs comprise approximately 8% of the U.S. workforce, and constitute one of the fastest growing sectors of the workforce (14). Using representative samples of selected HCW groups in Texas, the purpose of this study was to evaluate associations of asthma prevalence with occupational exposures in health care professionals, and to estimate their magnitude.

Three simple decision-making charts can help teachers assess when intervention is appropriate and legally required.

Did you ever suspect that a student in your classroom had been the victim of child abuse or neglect? When that happened, did you know what to do about it? Did you decide just to “let it go” because you were not sure whether you had a real case? Did you decide to “wait and see” because you were afraid of a lawsuit from the parents? If you reported the case to your school administrator, was the administrator hesitant to take action? In these days of lawsuits falling on school districts like snowflakes, we all hesitate.

We fear the consequences of making a false accusation. If the abuse of a child were at the hands of a schoolyard bully or lurking pedophile, parents most likely would applaud intervention. However, precisely because most cases involve an abusive parent, intervention is almost automatically deemed a dicey proposition. The law, however, now requires teachers to report cases of suspected child abuse or neglect. Failure to report raises issues of criminal and civil liability.

An estimated 896,000 children across the country were victims of abuse or neglect in 2002 (U.S. Department of Health and Human Services 2004). That is almost 1 in every 100 Americans, with an obviously higher classroom incidence when reduced to the K-12 age group. The math implies that you already have several abused students in your school, and maybe they were, are, or will be in your classroom. You or a coworker should know when and how to intervene. This article offers three simple decision graphics that clarify when a teacher’s intervention is appropriate and necessary.

Dimensions of the Problem

Research shows that the child abuse and neglect problem in this country not only has physical, emotional, and psychological dimensions, but also serious educational impacts. Some of the research findings are enlightening:

* Cases of child abuse and neglect have been increasing nationwide (Howe 2005; Pass 1986).

* The trauma of abuse or neglect of a child often lingers with that victim into adulthood and even can influence the raising of that victim’s own children (Anda et al. 2005).

* Abused children can become child abusers themselves (Anda et al. 2005).

* Chronic malnutrition and abusive child behavior adversely affect the child’s social and emotional functioning in school, starting in preschool (Barrett, Radke-Yarrow, and Kline 1982; Anda et al. 2005).

* Most often, the abuser or neglector is someone known by the child (i.e., a relative or neighbor), and the problem usually happens in the child’s home or child-care center (Administration for Children and Families 2004).

* To prevent child abuse from happening, many suggest that the first line of defense should be the school teacher (Haeseler 2006).

* Unfortunately, because of the reluctance of educators (Pass 1986) to report possible cases, deaths have been increasing at an alarming rate (Child Welfare Information Gateway 2004).

* In 2003, the total costs of child abuse and neglect were estimated at more than $94 million. These costs included demands on the health care, mental health care, law enforcement, child welfare, and judicial systems. Additionally, indirect costs included special education, juvenile delinquency programs, and adult criminality (Goldman et al. 2003).

Knowing these facts, schools are concerned with creating protocols to enable educators to address issues of abuse and neglect more efficiently (Crosson-Tower 2002).

Educators on the Front Line

In 1974, Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), which sets some minimum standards pertinent to the reporting of child abuse and neglect. CAPTA was amended and reauthorized several times, most recently in 2003. To qualify for funding under the Act, all 50 states enacted laws to promote the prevention of child abuse. Under many of these laws, the failure of a teacher to report a suspected incident could lead to the teacher’s dismissal and revocation of his or her teaching license. Generally, however, the laws protect teachers and administrators when they report in good faith (Smith 2006).

While overwhelming similarity exists in the statutes from state to state, there are still many differences. Some of these are small, but substantial; others are more nuanced, but potentially significant (Crosson-Tower 2002). For example:

* One state may require “school officials” to report, but not specify teachers, as might be the case in the law of another state. A number of states identify no particular person or category of persons as a “mandated reporter,” but require “any person” to report.

* “Some statutes call for reporting upon a mere ‘reasonable cause to believe’ or a ‘reasonable suspicion.’ Other statutes require the reporter to ‘know or suspect,’ which is a higher degree of knowledge” (Smith 2006, 1).

* Liability may be civil, criminal, or both, depending on the state.

Most healthcare attorneys will advise a client that “it is far better, in theory, to be faced with defending a civil action for reporting suspected abuse rather than the bleak alternative of defending a civil action . . . if a child is injured or killed as a result of failing to make a report of suspected child abuse” (Cox and Osowiecki 1998). To prevent unnecessary reporting of child abuse, social service, medical, and educational agencies provide teachers and administrators with information about identifying and reporting abuse. Reports and guidelines to help teachers, however, often are written in narrative form and are not easily accessible to busy educators.

Background: It is widely recommended that children younger than five years who have persistent asthma be treated with low-dose inhaled corticosteroids delivered via metered-dose inhaler with a spacer device and face mask. Fluticasone (Flovent) is commonly used in this population, although few data are available on the safety or effectiveness of its use with hydrofluoroalkane (HFA), which recently replaced chlorofluorocarbon as the propellant in metered-dose inhalers. Many physicians prescribe fluticasone with HFA to control asthma symptoms in preschool-age children, although in the United States it is currently approved only for children four years and older. Qaqundah and colleagues evaluated the effectiveness of fluticasone with HFA in children younger than four years.

The Study: This placebo-controlled, randomized, double-blind trial included children one to three years of age with a history of symptomatic asthma. Participants experienced at least two asthma exacerbations requiring medical treatment within the previous year and needed short-acting beta agonists at least three times a week during the four weeks before the study. Exclusion criteria were receiving low-dose inhaled corticosteroids within the previous two weeks, moderate- or high-dose inhaled corticosteroids within the previous eight weeks, or systemic corticosteroids within the previous 10 weeks. Those with unresolved respiratory tract infections also were excluded.

The 359 participants were randomly selected to receive fluticasone or placebo. The fluticasone group received 88 mcg of fluticasone with HFA propellant twice a day, and the placebo group only received the HFA propellant. Both treatments were delivered via metered-dose inhaler attached to a spacer device with a face mask. Participants were standardized to receive nebulized albuterol (Proventil) as their short-acting beta agonist but were allowed to continue other previously prescribed noninhaled corticosteroid asthma medications (e.g., cromolyn [Intal], leukotriene modifiers, long-acting beta agonists).

Parents recorded the severity of their child’s asthma symptoms and the use of albuterol and the study medication. Urine cortisol levels were measured at the beginning and end of the study. Patient progress was assessed during office visits at weeks 2, 4, 8, and 12. The main outcome was improvement in asthma symptom scores from baseline.

Results: Children in the treatment group had a 10 percent greater improvement in 24-hour asthma symptom scores than the placebo group, a significant difference. Nighttime symptom scores were significantly improved in the treatment group. A nonsignificant trend toward decreased albuterol use and daytime symptom scores was also noted in the treatment group. Although the number of symptom-free days was equal in both groups, 12 percent of the placebo group discontinued the study because of asthma exacerbation, compared with 5 percent of the treatment group. The number of adverse events was similar between the two groups. Although the overnight urine cortisol levels in the treatment group decreased by a mean of 0.5 mcg, no clinically significant systemic effects were noted.

Background & objectives: Outbreaks of an acute encephalopathy syndrome affecting children, with high case-fatality, have been reported in western Uttar Pradesh, India for the last many years. We investigated these cases in Bijnor district and present our findings.

Methods: Fifty five children aged 2-10 yr hospitalized from 2003 to 2005 in Bijnor, Uttar Pradesh, with features of acute encephalopathy were selected by defined clinical criteria. Various laboratory investigations were performed.

Results: The disease had peak incidence in early winter months. Previously healthy, 2-4 yr old rural children (mean age-3.78 yr) of very low socio-economic background were most vulnerable. Almost all had vomiting preceding unconsciousness and a majority had mild fever and abnormal behaviour/agitation. Abnormal posture of trunk and limbs were distinctive features. Fluctuation of blood pressure was seen in three-quarter cases. Serum aminotransferases, creatine phosphokinase and lactic dehydrogenase levels were found markedly raised virtually in all cases in whom the tests were performed. Serum glucose was found low (

Interpretation & conclusion: Our findings showed that the outbreaks were due to a multi-system disease with toxic injury to liver, muscles and brain (hepato-myo-encephalopathy) and not due to viral encephalitis as believed so far. The cause remains unknown but several features suggest the possibility of phytotoxin-induced pathology.

In many parts of India, children are prone to Japanese encephalitis (JE), endemically or in outbreaks1·2. Outbreaks of other acute encephalitislike syndromes also occur, mostly in northern and central India3″8. Such outbreaks are often conflated with encephalitis9″12. In some reports, encephalitis was defined simply as acute brain disease in febrile children, thus losing diagnostic specificity8·10′12. Many outbreaks were not investigated satisfactorily11. These have been reported as “mystery disease” in the absence of specific diagnosis9·13″15. The strikingly common features included sharp seasonality, absence of prodrome, rapid progression to unconsciousness, cerebrospinal fluid (CSF) without pleocytosis and very high mortality. Either the child died or fully recovered in a matter of 2-4 days. Among various proposed diagnoses, the common ones were viral encephalitis due to measles or Chandipura viruses8·12·16 or Reye’s syndrome, especially when brain oedema was present5·6-9·17 or acute vascular ischaemic attack18. The clinical features did not concur with viral encephalitis and in two instances, the very same outbreak6·8 was reported twice with mutually incompatible diagnoses16·18. No putative diagnosis or causative agent was consistently confirmed in subsequent outbreaks. During investigations the urgency was to identify aetiology8-12·16, but as the weakest component was epidemiology, distinguishing the nature of one outbreak from another has been difficult or impossible9·11·18.

Outbreaks of encephalopathy occur annually in many western districts of the State of Uttar Pradesh in In0 dia7·13″15′17′19·20. We have observed it in Bijnor district over several years7·14. The Indian Council of Medical Research investigated it in the neighbouring Saharanpur district in 2003 and reported: “Common clinical symptoms included mild to moderate fever for short duration, vomiting, irritability, altered sensorium followed by coma and death within 24 h after hospitalization. Abnormal movements, inability to suckle (suck) and teeth grinding were observed in a few patients. Marked irritability was also observed which remained even after heavy sedation…. however, no neck rigidity was observed. The age range was 1-10 yr with no significant difference in male to female ratio…. Patients appeared malnourished and from poor socio-economic background with poor hygiene”20. Of the 59 specimens (CSF, serum, throat swab, urine) collected from 34 patients (among whom 28 died) admitted to the Government District Hospital, Saharanpur, none was positive for virus or diagnostic antibody against JE, dengue, West Nile and Chandipura viruses20.

The close similarity of the clinical and demographic features described above, and those of the cases investigated by us over the three consecutive years in Bijnor, is described in this paper. We present here a previously unrecognized disease entity in India.

Material & Methods

Outbreaks occurred in 2003 through 2005, in a secondary care private sector paediatric hospital at Bijnor, the headquarters town of Bijnor district, U.P. (altitude 1342 ft. above sea-level; between 29′ 2 and 29′ 58 degree north latitude and 78′ O and 78′ 57 degree east longitude), were investigated.

Hospitalized children with the following criteria were included: acute onset and rapid progression of unconsciousness in a previously well child; CSF without pleocytosis; no malarial parasite on blood smear; no plausible clinical diagnosis to explain the disease. Detailed clinical and demographic information was entered in a pre-designed form.

You can overcome generalized tiredness, disabling fatigue or outright exhaustion and restore high-level wellness to the body and mind. One’s ability to conquer symptoms and signs of Chronic Fatigue Syndrome (CFS) is proven by a newly completed, randomized, placebo-controlled, double-blind study undertaken in the Commonwealth of Puerto Rico, USA. The naturopathic medical study was conducted by a consortium of MDs and NMDs working together in the Clinical Research Division of the Apostolic School of Natural Medicine, Peoples University of the Americas, in Ponce City, PR.

Author of this impressive study model and protocol for the treatment of CFS and other health problems is the school’s medical director and its Chief of Clinical Research, Peter R. Rothschild, MD, PhD. Dr. Rothschild was ably assisted by the investigation’s managing director, Jesus Garcia, MD. With colleague input, the two medical scientists ran a 120-day test to observe therapeutic responses to RM-10 [TM] for the reduction of symptoms in chronic fatigue syndrome.

Dr. Rothschild states, “We had highly significant results with the multi-mushroom formula, brandnamed RM-10 [TM]. For affected patients, there was a remarkable percentage of remissions and a quite noticeable improvement in symptomology overall.

“I am so impressed with the preventive value of the food supplement that I had tested, I now take it myself every day,” says Dr. Rothschild. “At age 73, I am in perfect health, and RM-10 [TM] along with other Garden of Life formulas, are the only supplemental nutrients I use routinely to keep me that way. My supplementation includes a combination of RM-10 [TM], six caplets daily in divided doses before meals; FYI [TM], one caplet taken three times daily to prevent rheumatoid arthritis and fibromyalgia; Clear Energy [TM], ingested three daily for periodic energy boosts; Primal Defense [TM], dosed at three per day to insure proper intestinal function; and the Male Vitality Formula of Revivall [TM], a dose of six caplets per day. I take nothing else as add-ons to my food supply. The clinical studies I have conducted prove that these supplements are the best nutritional preventatives for me to maintain my good health.”

The Clinical Study Criteria Followed by Dr, Rothschild

People suffering from clinically confirmed CFS, who have been shown to be resistant to any conventional forms of therapy were selected to receive the RM-10 [TM] formula. Such components include the ten medicinal mushrooms: Ganoderma lucidum (Reishi), Cordyceps sinensis, Coriolus versicolor, Lentinula endodes (Shiitake), Agaricus blazei, Grifola Frondosa (Maitake), Hericium erinaceus, Poria cocos, Tremella fuciformus, and Polyporus umbellatus. Adjunctive to the mushrooms are certain herbs: Aloe vera and Uncaria tomentosa (Cat’s Claw). These ingredients are processed and potentiated by Poten-Zyme[TM], a natural fermentation using beneficial microorganisms and their enzymes to release the active ingredients in herbs and inactive nutrient inhibitors.

The individuals chosen for participation in the study were between 25 and 60 years old, suffering from chronic exhaustion of more than six months’ duration, showing an imbalanced immune system, and feeling recurrent random muscle soreness. These sick people must not have been treated previously with tranquilizers, antidepressants, steroids, and/or chemotherapeutic drugs for at least three months before the study’s beginning. And they should not have received any prescription medicines for at least three months.

No persons were accepted as participants if they were declared in critical condition by a licensed health practioner or were afflicted with any acute infectious disease, diabetes, cardiovascular illness, renal condition, or some other immediately life-threatening pathology. They were excluded if they responded allergically to any component of RM-10[TM] or were alcoholics or drug addicts. Convalescents of any trauma more recent than three months were not taken into the study.

Over a period of four months (from January 17, 2002 to May 19, 2002), this test was undertaken of RM-10[TM] under the research direction of Dr. Peter Rothschild and with the daily management of Dr. Jesus Garcia. They carried forward a standard, ambulatory, randomized, mono-therapeutic, double-blinded regime on 35 CFS patients with an equivalent control group. Using caplets of RM-10[TM], the test preparation being marketed since June, 2001 by Garden of Life, Inc. of Jupiter, Florida USA, furnished striking therapeutic results for patients.

Objective of the investigators was to determine the palliation or attenuation of chronic fatigue syndrome in both sexes among 35 affected people between ages 25 and 60 years of age. Taken with eight ounces of pure drinking water, three caplets were taken 3 times daily before meals. Each test subject’s total daily dosage amounted to 9900 mg of RM-10[TM].

Dr. Julian Kenyon Defines Chronic Fatigue Syndrome

In the November 2001 issue of the Townsend Letter for Doctors & Patients, the renowned clinician, Julian Kenyon, MD, MB, ChB, Medical Director of The Dove Clinic for Integrated Medicine located in Hants, England, defined chronic fatigue syndrome as “…a debilitating disease of increasing social and economic importance” with its prevalence in the United States averaging 50 cases per 100,000 population.

This material was presented at the International Institute for Advanced Studies in Systems Research and cybernetics at their meeting in Baden Baden, Germany on August 2-7, 2000 where Dr. Schuldt was one of the panelists.

Standard medicine in most developed countries is highly regulated and expensive whether this relates to individual complaints on price or to governments’ trouble in financing national health programs. Bio-energetic medicine offers enormous cost savings by its non-invasive, fast, reliable diagnosis as well as selection of treatment and, especially, a better recovery for those afflicted. This system, as an informative method in diagnosis and therapy, has reached sufficient maturity to be incorporated into standard medical practice.

In Dr. Voll’s practice of electro-acupuncture he would tell the patient the nature of his/her disease after completion of the testing procedure on various points, as prescribed by the art, without prior examination of the patient’s history. This manner of establishing the patient’s history is most dramatic and convincing to anyone applying for treatment in electro-acupuncture. There is one drawback in that it is quite time-consuming.

In the operation of a busy medical clinic, time is an important factor. It is imperative that diagnosis be achieved not only accurately but with efficiency. Therefore, I found it necessary in bio-energetic medicine to reverse the process of establishing the diagnosis in that communication with the patient is given first priority. That is to say, diagnostic tests with the instrument are conducted according to the patient’s own description of his health or complaints or observations to confirm or discard the statements obtained. On the basis of this, therapy is planned. Following this regimen a multitude of symptoms disclosed by patients can be transformed into proper homeopathic prescriptions. This is very precise and, by re-affirmation, fully complies with the requirements of holistic medical practice.

The term bio-energetic medicine was used years ago by various practitioners of medical treatment outside the mainstream, such as physiotherapists and psychologists. In such fields the term seems a little displaced since it applies only indirectly. When using electrical current as a means of intervention with the body’s own energy, the term bio-energetic is justified and most appropriate. I adopted this term, therefore, in teaching and publications in spite of its being in use elsewhere, as it cannot be described any better; in short, to assign it to the virtual mode of action.

This modality has developed steadily over the past 40 years. Bio-energetic medicine, which refers to the body’s energy and its intervention from outside, developed from electro-acupuncture in a stepwise manner as my work proceeded. While electro acupuncture concentrated chiefly on the anatomical location of a symptom or disease, bio-energetic medicine is based on physiology and patho-physiology. By measuring the body’s micro energy the skilled diagnostician can determine the precise nature of a disease as well as select the most appropriate therapy. With the measuring device, a portable instrument, the presence of pathology can be determined even before the onset of overt symptoms, thus, to The patient’s observation, preventing disease. Also, followup care during recovery can be adapted quickly and inexpensively to the individual’s needs. Many diseases termed cured by standard diagnostic procedures are found to leave residual pathology amenable to removal by this technique, resulting in a healthier patient

Electro-Acupuncture

When I introduced electro-acupuncture worldwide in company with Reinhold Voll, MD who along with others founded the discipline commonly called EAV, the acceptance by a significant portion of the medical profession was cordial and encouraging. At that time I did not foresee the forces that would develop to ban this modality from standard medicine, even without examining the evidence as should be expected of reliable scientists. On the other hand, the medical profession without dispute accepts diagnoses obtained electrically with the electroencephalogram and electrocardiogram to verify conditions of the brain and heart, but refuses to study the possibility that similar micro current can be very useful for evaluations of the entire body. Bio-energetic medicine is of great informative value. It yields data that can be most difficult, if not impossible, to obtain by standard medical methods. Its multitude of information is of great importance for cybernetic evaluation in its pragmatic or intentional aspects. Syste mic series of information could be run by cybernetic derivation in order to determine scope, intensity, duration, frequency, interrelations of outcome besides establishing criteria to confirm those already in use. The process of aging may also be researched this way. When added to standard medical procedures, or used in conjunction with such procedures, bio-energetic medicine yields quick uncomplicated resolution of health problems as well as easy management of differentiated and complex pathology without invasive or damaging procedures. Treatment can be adapted to the specific needs of each patient rather than the prescription of one medication for all patients afflicted with a disease of the same title, or one medication for many different diseases. Pre- and after-care can be individually selected according to the actual condition and requirements of each patient rather than one mass treatment regimen based on statistics from many people, many of which do not conform to a specific individual’s need. From su ch data it is no longer a matter of far-fetched conclusions to give precise recommendations for lifestyle and guidance tailored to each individual’s need, such as nutrition. Bio-energetic medicine has a secure base, repeated and evaluated by many physicians from worldwide sources and institutions.