1. The document discusses chronic suicidal thoughts from the perspective of implicit and explicit memory systems. Implicit memory is encoded in early life experiences and involves emotions, actions and interactions that feel factual but cannot be consciously recalled.
2. Chronic suicidal thoughts may originate from implicit memories of emotional pain from early life that was inescapable, endless, and unable to be relieved by others. This gets encoded implicitly as a belief that future pain cannot be managed.
3. Treating chronic suicidal thoughts requires acknowledging the "suicidal self", understanding what implicit memories are being triggered, and expanding other identities. It also involves managing therapeutic anxiety and repairing any "disjunctions" that activate implicit memories of caregiver failure. Restruct
Presentation by Lucas Opitz at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015)
http://motherandchild.org.ua/eng/SimConf-2015
Presentation by Lucas Opitz at the International conference on Simulation-based training in medicine (Kyiv, Ukraine, March 19-20, 2015)
http://motherandchild.org.ua/eng/SimConf-2015
Holistic mindbody approach to trauma resolution. Trauma can be conscious or unconscious and can cause everything from depression to chronic pain via the autonomic nervous system stress response. Here I look at ways to overcome these 'unresolved emotional memories', usually laid down in childhood and exacerbated by adult events.
How Your Brain Is Taking You Hostage…(And What You can Do About It!)
Kim Long, MC, CCC, R. Psych (Alberta)
Director, Dochas Psychological Services, Inc.
Spruce Grove, Alberta
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Holistic mindbody approach to trauma resolution. Trauma can be conscious or unconscious and can cause everything from depression to chronic pain via the autonomic nervous system stress response. Here I look at ways to overcome these 'unresolved emotional memories', usually laid down in childhood and exacerbated by adult events.
How Your Brain Is Taking You Hostage…(And What You can Do About It!)
Kim Long, MC, CCC, R. Psych (Alberta)
Director, Dochas Psychological Services, Inc.
Spruce Grove, Alberta
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
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In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
2. Overview
• Memory systems and their developmental
trajectory
• Management of emotional pain
• Suicidal thoughts and memory
• Anxiety and the therapeutic space
• Managing chronic suicidal thoughts
• Changing implicit memory
3. Review of memory systems
Two systems
1/ Implicit
2/ Explicit (or declarative, or
autobiographical)
• Semantic
• Episodic
4. Neuroanatomy
• Explicit: hippocampus, parahippocampus,
fronto-basal areas, rhinal and perirhinal
• Implicit: not fully worked out, but amygdala
seems to be involved in the emotional
organization of implicit memory. Basal ganglia
also involved, and the cerebellum plays a role in
the experience of fear. Indirect evidence
suggests posterior temporal-occipital-parietal
area of right hemisphere
• Reference: Mancia 2006
5. Implicit Memory: Procedural
• Fully activated at birth (prob last trimester)
• Sensory: Remembers basic arousal,
satiety, safety in first two months
• Movement: Body in space, intentional
location, fine and gross motor actions
• Interactional (both emotions and actions):
how others are with you, and how you
relate to others
6. Implicit continued
• Acquired slowly, with practice
• Precise and inflexible (specific to specific
situations)
• Cannot be recalled, but always
experienced
• Later on it becomes reality (right parietal
stroke, with neglect syndrome)
• Most robust: “never forget how to ride a
bicycle”, Alzheimer’s
7. Implicit continued
• Imprints action and feeling (no language or
meaning)
• Reading: mother ignores child’s affection : page
846, para 3-4, The Foundational Level of
Psychodynamic Meaning, Boston Change
Process Study Group, 2007
• Expressed through action and sound initially, but
later with language through emotion, syntax,
pauses, and the way that the story is told (the
rhythm and feeling of the language, the “music”,
rather than the content)
8. Semantic memory (Explicit)
• Starts in second year of life, fully activated
around 18 months, elaborated with language
• Coincides with language acquisition
• Also “reality”, what you know about things stored
as facts
• Capital of France
• No memory of when or how these facts are
acquired, but “fact” is available to consciousness
9. Episodic memory
• Starts around 3-4 years old
• Memory of events/episodes (one trial learning)
• When it happened, who with, and how it felt, as
well as some details of the story, are
remembered = story (first plane trip)
• Less robust (more easily updated, forgotten, re-
created, lost): dementia
• False memories (playground experiment)
• Based on action, feeling, language, and
meaning (implicit memory is interwoven)
10. Memory systems and emotional
distress
• When upset, who responded, in what way, how
much
• Located in implicit and semantic memory
• Experienced as “fact” or reality
• No memory of when the experiences happened,
why, or who it involved
• Cannot bring rational thought to modify
• Difficult to describe in language, as mostly done
through action throughout the lifespan, but can
be trained to in therapy (discussed later how)
11. Managing Emotional Pain
4 ways:
• Try and stop it
• Try and manage it (work with it,
accommodate it etc.)
• Hope that it will go with time: wait
• Get help from someone else
12. Origin of Chronic Suicidal thoughts
• Why want to die?
• Because: overwhelming emotional pain
- no escape (can’t do anything to stop it)
- Unbearable (cant manage it with usual
strategies)
- Never-ending (timeless)
- Others can’t help
13. Suicidal thoughts and implicit
memory
• No studies
• Speculation: what phase of life is pain:
- Inescapable
- Forever
- Unmanageable
?
14. Very early experience!
Babies are unable to escape pain
• Cannot use mental strategies to diminish
or contextualize pain
• Here and now is only experience, no past
or future (painful experience is never-
ending)
• Totally dependent on caregiver to relieve
pain
15. Caregiver regularly unable to
relieve pain?
• Then, implicit memory stores pain as:
- Unbearable
- Endless
- Nobody there to help
- Therefore: any experience that mimics the
original experience will activate implicit
memory, but is felt as current and real
16. Function of chronic suicidal
thoughts
Function: (Ultimate) escape from the pain
that is
1. Overwhelming
2. Never-ending
3. No one can help
17. Problem with the chronically
suicidal patient (BPD)
• Experience traumatic memory system in suicidal
thoughts
• No awareness of memory
• Fundamental belief that nobody can help (“you
cant help”), and that suffering will go on forever
• Create bi-directional field of despair and anxiety
• Therapist struggles to hold reflective space
(collapsed by own anxiety)
18. Problem with suicidal patient
continued
• Extra anxiety from
- patient’s family or friends
- Our colleagues
- Hospitals, mental health teams etc.
- Medicolegal
- Supervision (internalised and real)
19. Enactments vs anxiety
Shut down reflective space =
1. Suicidal threat: all anxious
2. enactment: mutually interacting trauma
system (me: overwhelming pain, failure)
• Combination of both
20. What doesn’t work
• Explaining, cognitive understanding,
reassuring, “you have so much to live for”,
“what would happen to your children” etc.
• Above appropriate for later memory
systems (bad experiences for older
children/adults)
• Ineffective for implicitly coded experiences
that lead to chronic suicidal thoughts
21. General management of chronic
suicidal thoughts
• Recognise value of suicidal thoughts
• Acknowledge, explore and understand
“suicidal self” (feelings, thoughts and
actions) – hard to do, counterintuitive
• Later, look for, explore and expand “other
selves” – initially stunted or hidden
• Beware of patient’s actions to shut down
therapeutic conversation (deliberate self
harm, not turning up etc.)
22. Our Anxiety
• Acknowledge: must feel it
• Watch for tempting action/solutions that
reduce therapeutic space: “slow response”
- Taking over control
- Suicide contracts
- Hospitalization
- Medication
23. Triggering implicit memory and
suicidal thoughts in session
• “disjunction” = therapist is experienced as
emotionally unavailable)
• Implicit memory of original caregiver failure is
triggered
• Not aware of memory, experience is with
therapist, but with the power of implicit memory
• Patient feels despair and hopelessness, with
suicide the only solution, and therapist “not
there”
24. Repair of disjunction
• If suicidal thoughts come up in session,
look for disjunction
• Together, acknowledge that something has
gone wrong
• Try and “re-find” patients experience that
was missed
• Later on, possibility of understanding what
was triggered, and how
25. Access Implicit Memory?
Disjunction (suicidal thoughts), but also:
• Unusual, incongruous feelings
• Enactments
• Extreme behaviours between sessions
• Unusual behaviour in session – theirs and
ours = frame changes
26. Importance of the frame
• “Frame” = Behavioural rules that make
therapy run smoothly, effectively and
safely
• Some verbalised, many assumed
• Many patient (and therapist) actions arise
out of implicit memory systems
• Therefore, discuss any frame changes =
avenue to implicit memory understanding
• Example, open window
27. Restructuring implicit memory
• Long-term therapy?
• Many times learning new implicit memory
• Because of the function of suicidal
thoughts as “the only escape”, hard to shift
• Therapist fear and despair should not be
underestimated – supervision
• Crucial: forged in rel, changed in rel
28. How does implicit change occur?
• Who Knows?
• Something different is experienced in
therapeutic rel. Mediated by:
Words
Syntax
Non verbal communication
Affective sharing
Cross modal communication (another talk)
29. But I Prefer….
My (hoped for) way of doing
psychotherapy
• Listening deeply
• Giving value to all pt experience (esp
suicidal)
• Allowing not knowing (take time to puzzle
together)
• Understanding together
• Being moved profoundly
30. References
• Meares: The Metaphor Of Play (3rd Ed)
• Nelson (2005):Evolution and Development
and Human Memory Systems
• Liotti, Cortina (2007): New Approaches to
Understanding Unconscious Processes….
• Gabbard and Westen (2003): Rethinking
Therapeutic Action
31. References continued
• Levine (2004) Autobiographical Memory
And the Self in Time…
• Stern, BCPSG (2006) The Foundational
Level of Psychodynamic Meaning….
• Mancia (2006) Implicit memory and early
unrepressed unconscious
• Tulving (1972): Episodic and Semantic
Memory