IS INTEGRATIVE SENSORY TRAINING THE SAME THING AS BIOFEEDBACK?Q: Is integrative sensory training the same thing as biofeedback?A: No. “Sensory integration” is a phrase first coined by occupational therapist Dr. Jean Ayres to explain the brain’s ability to organize stimuli based on information derived from all five senses.Dr. Ayres theorizes that many of the symptoms of ADHD are the result of the brain’s inability to integrate this flood of information. The result is an information or stimulus “over load” that can cause problems with attention, learning, speech, behavior, and coordination.This concept is difficult to dismiss. ADHD children often exhibit many of the problems Dr. Ayres mentions, including clumsiness, inattention, and learning disabilities. Many ADHD children also complain of tactile overstimulation, or extreme skin sensitivity. This could explain why many ADHD children hate to wear tight-fitting clothes and shoes or dislike the sensation of water on their faces while swimming or bathing.The answer, according to Dr. Ayres and others, is what’s known as integrative sensory training, in which the nerve-cell connections are stimulated through various techniques to help the brain organize itself. It is an intriguing concept, but there have not been enough clinical studies to prove whether the technique has any lasting benefits. I suspect it is too simplistic.*75\173\2*

HOW TO SUCCESSFULLY TREAT BDD WITH MEDICATION: WHAT GETS BETTER WITH AN SRI? CONCERN WITH MORE NOTICEABLE APPEARANCE PROBLEMS Sometimes the SRIs decrease an obsessional preoccupation with a noticeable aspect of appearance, such as obesity. Some people whose appearance problem wouldn’t qualify for BDD (because the defect is obvious) may become less preoccupied with and less upset by these problems when treated with an SRI. For example, some people who are quite overweight become less consumed by their weight obsessions—they’re still not happy with their weight, but they’re no longer obsessed with it. Both their BDD-related concern and their concern with a more noticeable appearance problem diminish.*Insight was assessed with the Brown Assessment of Beliefs Scale (BABS), a scale developed by Dr. Jane Eisen of Brown Medical School, myself, and Drs. Doug Beer, Katherine Atala, Steven Rasmussen, and Lee Baer. This scale has been shown to be a reliable and valid measure of insight (degree of delusionality).In a way, this observation makes sense. The medication can’t distinguish between a slight appearance problem (i.e., BDD) and one that’s more noticeable. The medication doesn’t have eyes! The SRIs probably work by decreasing excessive, obsessional thinking, regardless of what someone actually looks like. This issue requires more research and goes beyond BDD. It raises the question of whether accident victims or people with congenital deformities who are overly preoccupied with and distressed by very noticeable defects might benefit from SRI treatment. Might they become less consumed by their concern—less preoccupied, less distressed, and better able to function? It’s possible.*253\204\8*

DEALING WITH UNPREDICTABLE PERIODS: COULD JOGGING AFFECT MY MENSTRUAL PERIOD?Ever since I graduated from college and started working, I’ve been sitting behind a desk. At twenty-five years old, I felt myself getting out of shape. I started jogging a year ago and now I run five miles on weekdays and eight or nine miles on weekends. At first, my periods were lighter, and I liked that, but for the past two months they have disappeared completely. I also seem to have a vaginal discharge which comes and goes, and I’m beginning to wonder what’s going on. Jogging is supposed to make me healthy but it seems to be making me sick.—S.C.Washington, D.C.Some exercise can enhance the menstrual cycle by alleviating stress and cramps and reducing the flow. However, excessive physical activity, such as jogging, cycling, strenuous dance, can result in complete amenorrhea. Women athletes and professional ballet dancers are known to consider amenorrhea an occupational hazard. Periods probably stop because the constant exercise results in weight loss and a change in hormonal balance, which blocks the release of the brain hormones LH and FSH. Women who are physically active need high blood counts to carry added oxygen to their muscles, and a woman who is not menstruating usually has a blood count that is higher than average. So, nature is adjusting to bodily need. Female athletes find the change especially good for them since there is no menstrual fatigue when they are training and competing.Ms. C. has no reason to worry. Menstrual absence is common to athletes, and the return of menstruation is practically a sure thing once physical activity is slowed down or stopped. She is not ovulating right now, so there is no buildup of her uterine lining, and that does not mean she is sick. It is perfectly normal for a woman doing as much strenuous exercise as she is to stop having ovulations.Her vaginal discharge, however, may be due to a hormonal change inside her vagina. Since she is not ovulating, her estrogen level is lower, and a diminished estrogen level can dry the vagina and make it more susceptible to infection. And if she is wearing nylon jogging shorts, she is providing a hot, damp, airless climate in which germs can breed with ease.This woman might attempt to restore a healthy vaginal environment by wearing cotton underpants and cotton shorts. If a change of attire does not alleviate her condition, she should consult a physician for treatment of her vaginitis.*47\333\2*

IMMUNE POWER DIET: AMINO ACID TIPSThere are two key rules to help your amino acid supplements do the most good:Take all amino acid supplements with plenty of fluid.Don’t take them directly before or after a heavy meal; the protein you eat will block the absorption of amino acids. Amino acids should always be taken on an empty stomach one hour before meals or at bedtime.”DOUBLE A” CELL BUILDERSWe’ve seen how amino acids can smooth out your moods and regulate your energy thermostat. Now, I want to look very briefly at yet another way these amazing building blocks affect immune power.Amino acids directly strengthen your immune fighters. This research is so new, at the very edge of the scientific frontier, that most studies have only been done on animals. Still, those studies show over and over that a strong amino acid balance increases antibodies, strengthens immune tissues, and helps the body fight infection.A very promising amino acid for immune power is arginine. Preliminary studies indicate that it stimulates the immune tissues, and on-going research is seeking to define arginine’s role as a potential amino acid immune booster.We are now on the brink of understanding how and why amino acids improve our immunity. The complete story of amino acids and the immune system simply can’t be written yet—it is a story only time will finish.*63\242\2*

THE BEVERLY HILLS DIET: WEEKS ONE THROUGH THREEEvery fat person is seriously undernourished in some foods and overnourished in others. So in these first few weeks, you will burn, feed, and wash your body to bring it back to its natural nutritional balance. You will bum up your fat by using highly intensive enzymatic fruits, you will feed your body concentrated doses of vitamins and minerals to replace what former eating habits have destroyed, and through washing you will push out the extra water and, once and for all, get rid of the bloating that is an unavoidable adjunct to fat.If you’re overweight you’re getting too much of some things and not enough of others. It is the “others” you are about to experience.Some of these foods you will taste for the first time. For the first week, you will eat a lot of fruit, fresh and organic, if possible. And you can literally eat your heart out—from the time you open your eyes to the time you close mem—anytime, anywhere. There is no calorie counting, no food weighing, and unless specified, no portion control. You will not lose more if you eat less. It’s exactly the opposite!*62\251\8*

SYCOSIS, URTICARIA AND ZOSTER AS COMMON SKIN DISEASES
SycosisThis term is applied to the condition in which there is a chronic inflammation of the hair follicles. This and many other forms of a similar complaint affect the hair, the beard, and other hair growth, and are due to some form of parasitism. Sycosis affects the skins of persons who are run down and whose natural immunity has been diminished. It is often the last link in a long series of events, and a return to normal functioning is sometimes a long and difficult task. The sufferer has sometimes to be willing to accept disappointments, but with patience and care the trouble can be finally eliminated.
UrticariaSeveral names are used to denote this condition: nettle-rash, hives, and, in more recent times, the various allergies. It is an acute inflammation, characterized by intense itching and the formation of weal or large spots. There is always some immediate cause which must be looked for.   Foods, insect bites, drugs and external irritants are the usual offending substances. It goes through various forms, and may disappear in a short time or sometimes persist for an indefinite period. The nervous factor should not be overlooked, especially in the case of children, and   the presence of these irritating rashes is a good indication that the daily eating and resting habits should receive the most careful attention. The Epsom salts bath will often give relief and clear the skin of the irritating toxins.
ZosterThe more common term is shingles. It is an eruption of acute vesicles over a nerve pathway and may be found around the intercostals parts or near the eye. It is an indication that the sufferer is in a run-down condition needing rest and building up treatment. It indicates the close relationship of nerves and skin.
*33/154/5*

CANCER: THE PRACTICAL GUIDE TO ENJOYING SUNSHINEThe advice that we have given here about avoiding malignant melanoma has to be set firmly within a reasonable perspective. Melanoma is a risk that can be eliminated by simple changes in lifestyle for ourselves and our children. Our advice should not be interpreted as meaning that the outdoor life, recreation, sport and summer holidays are necessarily harmful. Simple measures to avoid sunburn will mean that all of these can be enjoyed to the full without incurring risk. There are good reasons for wishing for this, and not only because of the great pleasure enjoyed by millions in outdoor recreations and pastimes – it is recognized that fit and happy people are less likely to get all sorts of diseases, not least cancer. We will discuss briefly the topic of exercise and work patterns in relation to cancer. It is sufficient to say here that retaining an outdoor lifestyle and having a good time is quite compatible with a low risk of melanoma.*77\194\4*

LIVING WITH EPILEPSY: MARRIAGE AND PARENTHOOD”Can I get married?”Of course! If you are competent to be a spouse, however that competence is defined, there is no reason why a person with epilepsy should not get married.”Can I have children?”Yes. Most women with epilepsy can bear children.”Can a person with epilepsy be a competent parent?”The answer is clearly, “Yes!” Most people who have epilepsy are extremely competent parents, just as are most people without. Some are incompetent parents, just as are some without epilepsy. Individuals with epilepsy have personal strengths and weaknesses just as others do. You will have to ask yourself and your partner whether you as individuals have the ability, maturity, and judgment to be good parents. That is for you to decide, but a “no” decision should not be based simply on the fact that you have epilepsy.”Can someone who still has seizures be a good parent?”Absolutely, although the problems of being a parent with ongoing seizures may be more difficult. If your seizures are frequent and result in sudden loss of consciousness, you might drop or injure your child during a seizure. You may have to make arrangements for special help in the home or special arrangements for child care outside the home. But even so, you can be a good parent.*265\208\8*

PERICARDIAL DISEASE: PERICARDIAL CONSTRICTION (STIFFNESS)One of the aftereffects of some cases of pericarditis is the development of a very stiff pericardium. It is similar to the result of soaking your leather shoes in the rain—the leather becomes stiff. The stiff pericardium decreases the ability of the heart muscle to expand between contractions and fill with blood. It occurs in all age groups, but it is more common after age 30.Causes of Pericardial Constriction.Pericarditis that was originally caused by infectious agents such as tuberculosis, by radiation exposure during treatment of cancers in the chest, or by inflammatory conditions is most likely to lead to pericardial constriction.Symptoms of Pericardial Constriction. Pericardial constriction involves both ventricles, but the most prominent symptoms are usually those of right-sided heart failure such as swelling of the abdomen and legs. Shortness of breath and fatigue are also common and usually precede the swelling.How Serious Is Pericardial Constriction? In cases of heart failure, the pericardium may need to be removed surgically. If this happens, you do not need to worry. You can get along fine without your pericardium, just as you can get along without your appendix or gallbladder.*219\252\8*

PEDIATRIC ONCOLOGY: THERAPEUTIC MEASURESA. Device-related septicemiaInfection remains a significant cause of morbidity for patients with long-term venous access devices. The incidence of device-related infections reportedly ranges from 2% to >60%. Externally tunneled silastic catheters have a much higher rate of infection than totally implanted ports. The most common organism involved in a device-related bacteremia is Staphylococcus epidermidis. External catheters are also at higher risk for infections caused by gram-negative enteric organisms.Device-related infections may be treated by administering an antibiotic through the infected device or removing the device and administering an antibiotic through a peripheral site. Consider removing the device if it is no longer required, if the patient is septic with signs of clinical instability, or if there is persistent device-related bacteremia unresponsive to appropriate antibiotic therapy in 24-48 hours.a. Neutropenic patienti. For suspected device-related septicemia, broad-spectrum gram-positive and gram-negative antibiotic coverage is indicated until the source of the infection is identified. The patient should be givenvancomycin (40 mg/kg/day in patients with normalrenal function), tobramycin (6-7.5 mg/kg/dayin patients with normal renal function), andceftazidime (100-150 mg/kg/day).ii. It is essential to treat through the lumen(s) of thedevice rather than through a peripheral intra-venous line.iii. Consider thrombolytic therapy with urokinase(5000 U/mL). The medication comes prepared in1 mL vials. For most pediatric internal catheters, mL will be an adequate amount. For most ports,vials (2 mL) should be injected. The entire volume may be injected into the device at one time and allowed to dwell undisturbed for 30-60 minutes. It should then be aspirated rather than flushed through, to avoid an additional bacteremia. The device should then be properly flushed. iv. If cultures are positive, continue specific antibioticcoverage for 7-14 days after cultures are negative. Obtain surveillance cultures at intervals during the course of therapy, v. If cultures remain positive after 48 hours of appropriate therapy or if clinical signs of deterioration develop and no other source of infection is clearly present, remove the device, b. Non-neutropenic patienti. For suspected device-related septicemia in the non-neutropenic patient, use vancomycin (40 mg/kg/dayfor patients with normal renal function) due to thehigh incidence of coagulase-negative staphylococcal infections. Monitor serum concentrations. Inaddition, an aminoglycoside (6-7.5 mg/kg/day forpatients with normal renal function) or anadvanced-generation cephalosporin such as ceftazidime (100-150 mg/kg/day) may be added untilculture results are known. Some clinicians woulduse the cephalosporin alone until cultures indicatethe need for vancomycin.ii. Consider administering urokinase (5000 U/mL) asdescribed above.iii. If cultures are positive, continue specific antibioticcoverage for 7-14 days after cultures are negative.Obtain surveillance cultures at intervals during thecourse of therapy.iv. If cultures remain positive after 48 hours of appropriate therapy or if clinical signs of deteriorationdevelop and no other source of infection is clearlypresent, remove the device.Despite the high salvage rate (>75%) of infected devices and the importance of preserving access when limited sites are available, avoid prolonged efforts at salvaging the device in the ill, immune-compromised child.A number of clinical studies have demonstrated a relationship between thrombus formation and device infection. Thrombolytic therapy, most often with urokinase, has been reported as a successful adjuvant in the therapy of infected catheters.If fungal sepsis is present, a device can be infrequently salvaged (<10%). However, if access is limited, treatment may be initiated through an existing device. If subsequent cultures remain positive or if the patient shows clinical signs of deterioration, remove the device. 6. If a device is removed because of sepsis, the insertion of a new device should await the completion of antibiotic therapy if possible. Additionally, in the neutropenic patient, neutrophil counts should be allowed to normalize as well. If peripheral access is impossible during this time period, a temporary central venous catheter or PICC line can be used. If necessary, a new device may be inserted during the course of antibiotic treatment if the patient has no signs of sepsis, surveillance blood cultures are negative, and the neutrophil count is acceptable.
B. Local device-related infections1. Infection of the catheter exit-site and/or tunnela. Exit site infections may be very difficult to control andoften lead to the removal of the catheter if the cathetercuff is infected. However, local wound care of the exitsite may prove beneficial in the treatment of an earlysite infection. Avoid transparent, occlusive plasticdressings, since these have been found to increase therisk of catheter colonization. Topical antibiotics(polymyxin, Neosporin, bacitracin, etc.) are also effective in minimizing catheter colonization, whereas povidone-iodine ointment is ineffective.b. Use systemic antibiotic therapy for the neutropenicpatient and the patient who does not respond rapidlyto local therapy. Obtain blood cultures and exit site cultures. Start therapy with dicloxacillin 25 mg/kg/day bymouth (PO) or nafcillin 150 mg/kg/day intravenous(IV). If there is progression in the exit site infectionafter 48 hours or if a tunnel infection develops, changeto broad-spectrum antibiotics and remove thecatheter.c. Tunnel infections of either an external catheter or animplanted port usually require the removal of thedevice, since systemic antibiotic therapy with broad-spectrum gram-positive coverage is seldom effective incontrolling the infection.2. Infection of the reservoir or pocketAn infection of the reservoir or pocket of an implanted port is difficult to clear without removal of the entire device. When this is suspected, do not access the device. Initiate systemic antibiotic therapy with broad-spectrum gram-positive coverage through a peripheral site if salvage of the device is to be attempted.C. Device-related occlusion1. Fibrinolytic therapyMost cases of total or partial occlusion of the device can be successfully treated with urokinase. In the case of a total occlusion, obtain a radiograph to rule out the possibility of mechanical complication such as catheter dislodgement or migration.a. Urokinase is available in premeasured 1 mL vials at aconcentration of 5000 U/mL. Draw up enough urokinase into a syringe to fill the device. For most pediatricBroviac catheters, 1 mL will be an adequate amount,while most ports have a fill volume closer to 2 mL. Forthe larger devices, do not dilute the medication; morethan one vial of the medication may be required.b. Inject the urokinase into the device and lock in place.If resistance during the injection becomes too high, initially inject one-third to one-half of the volume and lockin place. Inject the remaining volume 30 minutes later.c. Wait 60 minutes and then aspirate. If unable to with-draw, repeat with a second administration of urokinase.d. After successful treatment of the occlusion, immediately flush the device with saline and then heparinizedsaline as per institutional protocol to prevent rethrombosis.e. For persistent occlusive problems minimally responsive to bolus therapy, a continuous infusion of urokinase at 200 U/kg/h for 24 hours can be attempted. Thisapproach does not require intensive monitoring of thepatient or assessment of coagulation parameters.2. Precipitate occlusionThe device that has been occluded by precipitation from total parenteral nutrition (TPN) or medication incompatibility may be treated by attempting to solubilize the precipitate by altering its pH through the administration of HC1 or NaHC03. Such a condition is to be suspected when precipitate is visible in the clear intravenous tubing line connected to the device.a. For TPN-associated occlusions, which usually involveCaP04 precipitation, do the following.i. Mix 1 mL of sterile 0.1 N HC1 with 9 mL standardheparin lock (Hep-Lock) saline (10 U/mL) for a finalconcentration of 0.01 N HC1.ii. Inject 0.5 mL of the solution into the device and lockin place.iii. Wait 30 minutes and then aspirate. If unable to with-draw, repeat the administration of 0.5 mL of thesolution every 5 minutes until 30 minutes haveelapsed or device patency is restored.iv. After successful treatment of the occlusion, immediately flush the device with saline and thenheparinized saline as per institutional protocol toprevent rethrombosis.b. For medication incompatibilities resulting in an occluding precipitation, a similar protocol may be attemptedusing sodium bicarbonate at a concentration of1 mEq/mL.Mechanical problems1. Reservoir extravasation from implanted portsExtravasation of injected fluids may occur as a result of inappropriate needle placement for port access before the infusion, needle dislodgement during the infusion, or malfunction of the device. Causes of device malfunction include the separation of the catheter from the reservoir, a fracture or break in the reservoir structure, and a fracture or break in the tunneled catheter portion of the port.a. When inappropriate needle placement or dislodgement is suspected do the following.i. Attempt to reaccess the reservoir properly.ii. Flush the device with heparinized saline to preventocclusion if the device is not to be used.iii. Use local therapy with warm compresses to helpeliminate the surrounding swelling.iv. See Chapter 14 for treatment recommendations if adrug extravasation has occurred.b. If proper needle position has been confirmed and anextravasation due to a structural problem with theport is suspected, a contrast injection study of thedevice will help pinpoint the defect. Therapy usuallyrequires complete removal of the port, although salvage of the site can be attempted if there is no associated infection.2. Extravasation within a tunnel of an external cathetera. A contrast injection study of the device will help pin-point the defect.b. Therapy usually requires complete removal of thecatheter, although salvage of the site can be attemptedif there is no associated infection by insertion of aguidewire before its removal.Dislodgement or malposition of the catheter Dislodgement or malposition of the intravascular catheter portion of the device generally requires replacement of the device. Occasionally, manipulating the guidewire under sterile conditions may be successful.Fracture of the devicea. External catheteri. Cracks or breaks of the external catheter can berepaired with kits available for the specific size andbrand of the catheter. Carefully follow the instructions accompanying the kit.ii. Use sterile technique, including mask, gloves, andsurgical preparation, to avoid contamination.iii. Temporary repair of an external catheter can beaccomplished by the insertion of an appropriate-sized plastic IV catheter into the lumen of thecatheter at the break point under sterile technique.iv. The catheter should then be flushed withheparinized saline solution to prevent occlusion.Permanent repair should be accomplished as soonas a kit is available.b. Internal catheteri. Fracture of the tunneled or intravascular portion ofthe catheter of either an external catheter or animplanted port may lead to intravascular embolization of that portion of the catheter.ii. The most common site of the catheter for this tooccur is the point where the catheter passesbetween the clavicle and the first rib.iii. The embolized portion of the catheter usually travels to the right ventricle or to the pulmonary arteryoutflow tract.iv. Retrieval of the embolized catheter can usually be accomplished in the cardiac catheterization laboratory.*77\168\2*