This chapter addresses the importance of training on comorbidity and the principles of learning. It covers the methods and structuring of such training, the content on which it is based, and what is known in the field. It includes illness versus disease management, holistic approaches, patient and doctor roles regarding shared decision-making, adherence and self-management, polypharmacy, interprofessional and team communication, and effective consultation and communication skills. We highlight methods which are learner-centred, aiming at active engagement in a collaborative endeavour with the trainer. We emphasise the need to recognise the broader systems' factors which support or undermine integration of learning into everyday practice. Training should address cognitive (knowledge), emotional and motivational (attitudes), and behavioural (skills) elements of learning. Whilst undergraduates will need more didactic elements and proscribed activities, postgraduate training benefits from flexibility to the learners' working context. Training the trainers is an important component of an education strategy so that teachers use a learner-centred approach consistent with the patient-centred consultation model needed to manage comorbidity. (C) 2015 S. Karger AG, Basel

The 2009 National Dementia Strategy exhorted the National Health Service to raise the profile of dementia in the UK and to make the diagnosis in 75% of sufferers within a few years. While this aspiration is commendable in the sense that ideologically it is an attempt to improve things for dementia sufferers, it is likely to have other consequences which may not be so well understood or considered. Raising expectations in a vulnerable population is fine if those peoples' lives can be improved even a little by making a diagnosis. It is, however, a lot to ask services to deliver at the same time that the country is experiencing one of the worst economic crises of our generation. This paper sets out what a pathway into dementia diagnosis might look like using a psychodynamic framework, including giving a dementia diagnosis and offering aftercare. The author considers some of the thoughts and feelings in the sufferers, carers and the staff who offer the service; the challenges posed by a diverse group and how to deliver best practice. The services described are from within community psychiatric settings: those used to delivering not only dementia diagnoses, but also managing delusions, hallucinations and mood disturbances associated with dementia. Mental health services do not exclusively provide memory clinics and the author is not extending these observations to services delivered by neurologists or physicians in medicine for the elderly. Keywords: dementia; NHS; psychodynamic; older

This chapter addresses the importance of training on comorbidity and the principles of learning. It covers the methods and structuring of such training, the content on which it is based, and what is known in the field. It includes illness versus disease management, holistic approaches, patient and doctor roles regarding shared decision-making, adherence and self-management, polypharmacy, interprofessional and team communication, and effective consultation and communication skills. We highlight methods which are learner-centred, aiming at active engagement in a collaborative endeavour with the trainer. We emphasise the need to recognise the broader systems’ factors which support or undermine integration of learning into everyday practice. Training should address cognitive (knowledge), emotional and motivational (attitudes), and behavioural (skills) elements of learning. Whilst undergraduates will need more didactic elements and proscribed activities, postgraduate training benefits from flexibility to the learners’ working context. Training the trainers is an important component of an education strategy so that teachers use a learner-centred approach consistent with the patient-centred consultation model needed to manage comorbidity. © 2015 S. Karger AG, Basel Physical and mental comorbidity has not been well addressed in medical education, especially in systems-based curriculum designs. Increasing specialisation of healthcare delivery also threatens integrated managemant. Training is important for a commitment to understanding comorbidity from the start of clinical training about patient care. For clinical practice to develop, it requires active engagement, adjustments in daily working and broader support from the healthcare system [1] (fig. 1). The crowded curriculum in medicine puts each discipline in competition with one another over what is most important for the firstyear medical student, foundation trainee or intern to know. The only way to cover the material adequately and ensure an appropriate attitude towards patient care is to work cooperatively and in an interdisciplinary manner. From the outset, we need to model ways of integrating mental and physical health care knowledge so that students will see their patients in a way which allows them to feel confident in both spheres. Sartorius N, Holt RIG, Maj M (eds): Comorbidity of Mental and Physical Disorders. Key Issues Ment Health. Basel, Karger, 2015, vol 179, pp 137–147 (DOI: 10.1159/000365598) Training Physicians at Undergraduate and Postgraduate Levels about

Danielle Quinodoz, trans. by David Alcorn, London, Routledge, £14.99 (paperback), £52.50 (hardback) Many will already be familiar with Danielle Quinodoz, a distinguished Swiss psychoanalyst, and he...

Acute iron intoxication is associated with depletion of reduced glutathione in hepatocytes and changes in the glutathione system enzymes. We hypothesized that treatment with N-acetylcysteine (NAC), a glutathione reducing agent and an antioxidant, would reduce mortality in acute iron intoxication. We used a rat model to test this hypothesis. Male rats were assigned to 4 groups. Group 1 received 400 mg/kg elemental iron by oral gavage, group 2 received the same dose of iron followed by NAC, group 3 received NAC only, whereas group 4 received distilled water. Iron and liver transaminases in the blood, and glutathione system enzymes in the liver and erythrocytes were measured. Mortality in group 2 was significantly higher after 2, 6, and 24 hours compared with group 1 (P < .001). No deaths were observed in groups 3 and 4. Serum iron levels were significantly higher in group 2 rats compared to group 1 rats (P < .001). Hepatic and erythrocyte glutathione system enzymes were significantly lower among rats in group 2 compared to rats in group 1. The administration of NAC probably increased the absorption of iron through the gastrointestinal tract, causing higher serum iron levels with significant hepatic damage. These results indicate that in a rat model of acute iron intoxication, orally administered NAC may increase mortality.

Counselling and psychotherapy with older people: A psychodynamic approach, by Paul Terry, Second Edition, Basingstoke, Palgrave Macmillan, 2008, 224 pp., £16.99 (paperback) ISBN: 978-0415468633 One...

We must cast ourselves forwards to a time when words must fail (Samuel Beckett, Happy days, 1961).This paper approaches dementia and its care from a psychoanalytic perspective. It recognizes both the psychoanalytic literature on dementia and a biological understanding of neuro-degenerative processes. Using neuro-psychoanalysis to synthesize the two views, meeting points are found that may take the theoretical understanding of dementia processes a small step further, introducing the death instinct as one example. The mind and the brain are distinct entities which are also intimately related. A mind/brain model was proposed by Freud in his 'project' (1895). It pre-dated his psychoanalytic work but was abandoned. None the less it runs as a rich vein throughout his work.Although other causes exist there are two main types of dementia. Alzheimer's and vascular dementia have distinct differences and similarities in their respective clinical presentations. This paper explores the complex deterioration of brain and mind in both diseases and explains these in psychoanalytic terms. Developmental models of the mind are helpful, however dementia patients are adults, and are losing their minds in a non-linear fashion. Dementia is not infant/child development in reverse order.Three broad stages of dementia are proposed and psychoanalytic models of patient experience are suggested, as well as potentially offering ameliorating interventions. The first stage of dementia is dominated by anxiety and depression; also repression and denial and behavioural problems that may be akin to hysterical states. These seem to be amenable to analysis and psychoanalytically informed therapy. In the intermediate stages reality principle versus pleasure principle issues are patent, as are shame and humiliation (particularly around sexuality). Art and music therapies informed by psychoanalysis can be helpful as they depend less on words. In the final stages of extreme dependency, projective identification may be the most common method of communication. Understanding this phenomenon can assist sufferers and help carers to cope with unbearable states of mind. Some psychoanalytic ideas are already in use in some enlightened dementia services; there is room for more.

The proposed mechanism of iron-induced hepatotoxicity is free radical formation. It was hypothesized that the glutathione system of the liver and erythrocytes will be affected by acute iron poisoning. Male Wistar rats, 6-8 weeks of age, were assigned to one of three groups. Group I received distilled water, group II received 400 mg/kg elemental iron, and group III received 750 mg/kg elemental iron. All groups were gavage fed. Iron concentration, glutathione, and glutathione system enzymes were then measured in the liver and erythrocytes. The hepatic level of reduced glutathione (GSH) was significantly lower in groups II (3.1 +/- 4.6 mu mol/mg protein) and III (4.7 +/- 4.6 mu mol/mg protein) in comparison with group I (11.5 +/- 6.2 mu mol/mg protein) (p < 0.001). Hepatic levels of glutathione S-transferase (GST) were higher and glutathione peroxidase (GPX) levels were lower in group III compared to groups II and I (p < 0.001 and p < 0.001). Compared to group I, glutathione reductase (GR) was lower in groups II and III (p < 0.001). There was no correlation between GSH, oxidized glutathione (GSSG), GST, GR, and GPX levels in the erythrocytes and in the liver (p = 0.41, p = 0.48, p = 0.49, p = 0.53, p = 01.4, and p = 0.84, respectively). In conclusion, acute iron intoxication in rats is associated with depletion of reduced glutathione in the liver.

Family therapy has long been the traditional psychological model with which to treat problems in later life; particularly depression and dementia, but also some physical illnesses. In more recent years however, a growing interest in couple therapy has been seen, and this has been linked to some extent with a burgeoning enthusiasm for psychodynamic psychotherapeutic principles as applied to older people. A number of psychoanalytic models are quite helpful when addressing the problems of ageing and loss in old age. Theories about Narcissism and those that address Object Relations particularly, can be used to view the changing dynamics within an elderly couple. These and other theoretical frameworks are elucidated and ‘illustrated’ with composite clinical material. This paper also examines some of the non-medical model understanding of late life depression within the context of intimate partnerships. Treatment models involving the couple are discussed, including the use of a Couples' group. Same sex partnerships in old age are also discussed.

AIM:To investigate glutathione and antioxidant status changes in erythrocytes from febrile children receiving repeated supratherapeutic paracetamol doses.METHODS:Fifty-one children aged 2 months to 10 years participated in the study. Three groups were studied: group 1 (n = 24) included afebrile children who did not receive paracetamol; and groups 2 (n = 13) and 3 (n = 14) included children who had fever above 38.5 degrees C for more than 72 h. Patients in group 2 received paracetamol at a dose of 50 +/- 15 (30-75) mg kg(-1) day(-1) and those in group 3 received paracetamol above the recommended therapeutic dose, ie 107 28 (80-180) mg kg(-1) day(-1). A blood sample was taken for the measurement of liver transaminases, gammaglutamil transferase (GGT), reduced glutathione (GSH), glutathione reductase (GR), glutathione peroxidase (GPX), glutathione S-transferase (GST), superoxide dismutase (SOD) and antioxidant status.RESULTS:Aspartate aminotransferase activity in group 3 was higher than in the other groups (P = 0.027). GSH, SOD and antioxidant status were significantly lower in group 3 compared with groups 1 and 2 (mean differences: for GSH 3.41 micromol gHb(-1), 95% confidence interval (CI) 2.10-4.72, and 2.15 micromol gHb(-1), 95% CI 0.65-3.65, respectively; for SOD 856 U min(-1) gHb(-1), 95% CI 397-1316, and 556 U min(-1) gHb(-1), 95% CI 30-1082, respectively; and for antioxidant status 0.83 mmol l(-1) plasma, 95% CI 0.30-1.36, and 0.63 mmol l(-1) plasma, 95% CI 0.02-1.24, respectively). GR activity was significantly lower in groups 3 and 2 in comparison with group 1 (mean differences 3.44 U min(-1) gHb(-1), 95% CI 0.63-6.25, and 5.64 U min(-1) gHb(-1), 95% CI 2.90-8.38, respectively). Using multiple regression analysis, paracetamol dose was found to be the only independent variable affecting GR, GST and SOD activities (P = 0.007, 0.003 and 0.008, respectively).CONCLUSIONS:In febrile children, treatment with repeated supratherapeutic doses of paracetamol is associated with reduced antioxidant status and erythrocyte glutathione concentrations. These significant changes may indicate an increased risk for hepatotoxicity and liver damage.

Monoselenation of the chiral bisphosphine (S)-(+)-1-[(R)-2-(diphenylphosphino)ferrocenyl]ethyldi-t-butylphosphine gives the first enantiomerically pure chiral bisphosphine monoselenide prepared from a commercially available chiral bisphosphine. This bisphosphine monoselenide ligand is an effective chelating ligand that utilizes a [P,Se] donor set when forming chelates with half-sandwich complexes of ruthenium(II), rhodium(III) and iridium(III). These complexes have been characterised spectroscopically and, in some cases, crystallographically. The chirality of the ligand influences and controls the metal-centred chirality yielding one of two possible chelate complexes with high diastereoselectivity.

OBJECTIVES:Pseudohypoaldosteronism type 1 (PHA1) is a rare inherited disorder characterized by salt-wasting due to target organ unresponsiveness to mineralocorticoids. PHA1 comprises two clinically and genetically distinct entities; isolated renal and systemic forms. DESIGN:The aim of this study was to investigate red blood cell (RBC) Na+,K+-ATPase activity and nasal potential difference (PD) in two pairs of unrelated dyzygous twins; one with the systemic form of the disease (PHA1-S) and the second with the isolated renal form (PHA1-R). Total and ouabain-sensitive ATPase activities were measured spectrophotometrically by a method that couples ATP hydrolysis with NADH oxidation. Maximal PD and response to amiloride perfusion were evaluated by a standard technique. RESULTS:In the twins with PHA1-S, persistently low activity of RBC Na+,K+-ATPase was found during a 6-year follow-up. Normalization of plasma renin activity (PRA) and plasma aldosterone was observed at the end of the first year of life. Maximal nasal PD was low and there was no significant response to amiloride. In the twins with PHA1-R, RBC Na+,K+-ATPase activity was very low at the time of diagnosis and normalized at the age of 6-8 months. PRA reverted gradually to normal values, whereas aldosterone levels remained high during the 6 years of follow-up. Maximal nasal PD and response to amiloride were normal. CONCLUSIONS:The observed differences in RBC Na+,K+-ATPase activity and nasal PD response to amiloride between the two pairs of twins support the contention of different basic pathogenic mechanisms in the two forms of PHA1.

Objectives: To evaluate the effect of hyperthyroidism on bone in relation to the menopausal state. Methods: Fifty-nine hyperthyroid (HYPER), 40 hypothyroid (HYPO), and 51 control euthyroid (EUTH) women were studied. Bone mineral density (BMD) was assessed by dual X-rays absorptiometry (DXA) at the lumbar spine, and at the femoral neck. A multi-site QUS device evaluated speed of sound (SOS) at the radius (RAD), tibia (TIB), metatarsus (MTR), and phalanx (PLX). Bone markers used were serum bone specific alkaline phosphatase (BSAP) and urinary deoxypyridinoline (DPD). Results: At all sites, SOS was lower in HYPER than in EUTH (RAD P<0.05, TIB P<0.01, MTR P<0.05, PLX P=0.01). The low SOS was only noted at the early postmenopausal period. BMD at the femoral neck but not at the lumbar spine was lower in HYPER as compared to EUTH (P<0.05). Both femoral neck and tibia were the sites with the highest odds ratio for being hyperthyroid (2.3 and 2.04, respectively). There was no correlation between BMD or SOS and FT4, TT3 or duration of hyperthyroidism. BSAP and DPD positively correlated with FT4 and TT3 (P<0.05). Conclusions: This study suggests that hyperthyroidism affects bone mineralization especially during the early postmenopausal period, and the effect is mainly at the cortical bone.

Attention-deficit hyperactivity disorder (ADHD) is the most common behavior disorder among children; methylphenidate is a drug frequently prescribed for the control of its symptoms. One of the potential side effects of methylphenidate that concerns parents is its impact on the growth of children, since the mechanism by which methylphenidate might influence growth is not known. As linear growth is associated with an increase in bone mineral density and turnover, this study was undertaken to evaluate bone mineral density by dual photon absorptiometry and bone turnover by measuring serum bone-specific alkaline phosphatase and the urinary deoxypyridinoline excretion rate in children treated with methylphenidate for 1 to 2 years as compared to a control group. There were no significant differences in bone mineral density at either the lumbar spine or femoral neck in the study group (0.662 ± 0.04 and 0.735 ± 0.07 g/cm2, respectively) as compared to the controls (0.675 ± 0.05 g/cm2 and 0.734 ± 0.07 g/cm2, respectively). Furthermore, there were no significant differences in serum bone-specific alkaline phosphatase in the study group (58 ± 22 U/L) as compared to the control children (71 ± 34 U/L) or in urinary deoxypyridinoline in the study group (34 ± 38 nM/mM), as compared to the control group (27 ± 12 nM/mM). In conclusion, our data do not support a significant effect of methylphenidate on bone mineral density turnover in children when used for 1 to 2 years. (J Child Neurol 2000;15:436-439).

Neurologic complications are a recognized but unusual manifestation of celiac disease (CD) in adults and children. The use of antigliadin and antiendomysial antibodies in screening has revealed the frequency of CD among symptom-free individuals to be high. Recently, a high frequency (57%) of antigliadin antibodies was demonstrated in adult patients with neurologic dysfunctions of unknown cause. We investigated the yield of screening for CD in children with common neurologic disorders. One hundred sixty-seven children, 1-16 years of age, were included in the study: 41 with migraine headaches, 39 with attention-deficit disorder with or without hyperactivity, 36 with epileptic disorders, and 51 with hypotonia and motor abnormalities. Positive IgG antigliadin antibodies were evident in 22 children (13%) in the study group compared with three children (9%) in the control group. However, in all children, negative IgA and endomysial antibodies were observed; thus duodenal biopsies were not performed. Contrary to studies performed in adults, these results did not demonstrate any relationship between common neurologic disorders without a specific diagnosis during childhood and CD. Thus screening for CD does not need to be routinely included in the diagnostic evaluation of children with these disorders.

Drug assays may yield false-positive results caused by cross-reacting compounds. After finding a serum salicylate concentration of 81 microg/mL by using Trinder's colorimetric method, in a comatose child admitted to the authors' pediatric intensive care unit, in the absence of reported salicylate intake, the authors aimed to compare this situation with the phenomenon involving endogenous digoxin-like substances, which cross-react with the routine assay of digoxin. None of the participants in the study had been exposed to salicylate. Salicylate concentration was measured in all patients using Trinder's colorimetric method and in the second stage of the study also by AxSYM salicylate assay. Salicylate concentration using Trinder's method was 18 +/- 25 (4-81) microg/mL among nine seriously ill children in the pediatric intensive care unit, of whom two children with extensive burns had salicylate levels of 30 and 81 microg/mL, respectively. Salicylate concentrations were 107 +/- 24 (45-143) microg/mL and 60 +/- 25 (28-92) microg/mL, among 18 premature newborns and 18 term newborns, with hyperbilirubinemia, respectively. In the second stage, which involved 22 jaundiced term newborns and cord blood from 21 pregnant women, Trinder's method yielded elevated salicylate blood levels among the hyperbilirubinemic infants: 82 +/- 5 (73-89) microg/mL; however, the AxSYM assay yielded significantly lower blood levels: 2.5 +/- 3.4 (0-10.9) microg/mL (P < 0.0001). Among the pregnant women, salicylate cord blood levels were found to be low-within the limit error of the assay with both assay methods. In conclusion, when salicylate intoxication is suspected, particularly during the neonatal period, it is advisable to measure salicylate levels by immunoassay technology.

AIM:To investigate sodium (NA(+)) potassium (K(+)) adenosine triphosphatase (ATPase) activity in newborn infants at different gestational ages, to elucidate the mechanism underlying poor renal sodium conservation in preterm infants.METHODS:Fifty three healthy newborn infants, gestational age 30-42 weeks, were studied. Umbilical cord red blood cell Na(+) K(+)ATPase activity, plasma renin activity, and plasma aldosterone activities were measured in all of them. Red blood cell Na(+) K(+)ATPase activity was re-examined in eight preterm infants, one and two weeks after birth. Total and ouabain sensitive ATPase activity was measured spectrophotometrically using a method that couples ATP hydrolysis with NADH oxidation.RESULTS:Red blood cell Na(+) K(+)ATPase activity was significantly lower (p<0.01) in preterm babies with a gestational age below 35 weeks, compared with those with aged 35 weeks and above: 2.3 (0.8) and 6.7 (1.3) nmol NADH/minute/mg protein, respectively. There was no correlation between gestational age, Na(+) K(+)ATPase, plasma renin activity and aldosterone values either in the preterm or term babies. Two weeks after birth, irrespective of gestational age, the enzyme activity of the preterm babies increased to values similar to those observed in the term neonates at birth.CONCLUSION:The differences in sodium homeostasis between term and preterm babies are modulated via changes in Na(+) K(+)ATPase activity.