Alzheimer's Disease

Here is another view of how massive cell loss changes the whole brain in advanced Alzheimer's disease. This slide shows a crosswise "slice" through the middle of the brain between the ears.

In the Alzheimer brain:

• The cortex shrivels up, damaging areas involved in thinking, planning and remembering.

• Shrinkage is especially severe in the hippocampus, an area of the cortex that plays a key role in formation of new memories.

• Ventricles (fluid-filled spaces within the brain) grow larger.

Introduction

Alzheimer’s disease is a brain disorder named for German physician Alois Alzheimer, who first described it in 1906. Scientists have learned a great deal about Alzheimer’s disease in the century since Dr. Alzheimer first drew attention to it. Today we know that Alzheimer’s:

• Is a progressive and fatal brain disease. As many as 5.3 million Americans are living with Alzheimer’s disease. Alzheimer's destroys brain cells, causing problems with memory, thinking and behavior severe enough to affect work, lifelong hobbies or social life. Alzheimer’s gets worse over time, and it is fatal. Today it is the sixth-leading cause of death in the United States. For more information, see Warning Signs and Stages of Alzheimer’s Disease.

The role of plaques and tangles

Two abnormal structures called plaques and tangles are prime suspects in damaging and killing nerve cells. Plaques and tangles were among the abnormalities that Dr. Alois Alzheimer saw in the brain of Auguste D., although he called them different names.

• Plaques build up between nerve cells. They contain deposits of a protein fragment called beta-amyloid (BAY-tuh AM-uh-loyd). Tangles are twisted fibers of another protein called tau (rhymes with “wow”).
  
  
• Tangles form inside dying cells. Though most people develop some plaques and tangles as they age, those with Alzheimer’s tend to develop far more. The plaques and tangles tend to form in a predictable pattern, beginning in areas important in learning and memory and then spreading to other regions.

Scientists are not absolutely sure what role plaques and tangles play in Alzheimer’s disease. Most experts believe they somehow block communication among nerve cells and disrupt activities that cells need to survive.

• Is the most common form of dementia, a general term for the loss of memory and other intellectual abilities serious enough to interfere with daily life. Alzheimer’s disease accounts for 50 to 70 percent of dementia cases. Other types of dementia include vascular dementia, mixed dementia, dementia with Lewy bodies and frontotemporal dementia. For more information about other causes of dementia, please see Related Dementias.
  
  
• Has no current cure. But treatments for symptoms, combined with the right services and support, can make life better for the millions of Americans living with Alzheimer’s. There is an accelerating worldwide effort under way to find better ways to treat the disease, delay its onset, or prevent it from developing. Learn more about recent progress in Alzheimer research funded by the Alzheimer’s Association in the Research section.

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Last Updated: Sunday, 29 April 2007, 21:10 GMT 22:10 UK

Scientists 'reverse' memory loss

The study says progress is possible even after major brain damage

Mental stimulation and drug treatment could help people with degenerative brain diseases such as Alzheimer's recover their memories, a study says.

Scientists found mice with a similar condition to Alzheimer's were able to regain memories of tasks they had previously been taught.

A team at the Massachusetts Institute of Technology found two methods - brain stimulation and drugs - both worked.

Their findings were published in British journal Nature.

The researchers used genetically engineered mice in which a protein linked to degenerative brain disease could be triggered.

Scientists had previously given the mice tests where they learnt to avoid an electric shock and how to find their way through a maze to reach food.

'Playground' test

After six weeks with the brain disease, the mice were no longer able to remember how to perform these tasks.

Some of the mice were then placed in a more stimulating environment with toys, treadmills and other mice.

Even if the brain suffered some very severe neurodegeneration... there is still the possibility to improve learning ability Li-Huei Tsai Neuroscientist

The playground mice were able to remember the shock test far better than the mice in other cages. They were also better at learning new things.

Scientists then tested a class of drugs called histone deacetylase, or HDAC, inhibitors on the mice.

These also improved memory and learning, similar to improvements made by environmental stimulation.

Neuroscientist Li-Huei Tsai of the Howard Hughes Medical Institute and the Massachusetts Institute of Technology said the results could offer hope to people with diseases like Alzheimer's.

"We show the first evidence that even if the brain suffered some very severe neurodegeneration and the individual exhibits very severe learning impairment and memory loss, there is still the possibility to improve learning ability and recover to a certain extent lost long-term memories."

She said the study suggested that in people with degenerative brain diseases, memories were not erased from the brain, but rather could not be accessed because of the disease.

She added that while most treatments for Alzheimer's targeted the disease's early stages, this research showed that even after major brain damage it was still possible to improve learning and memory.

Dr Susanne Sorensen, head of research, Alzheimer's Society, said: "These results cannot automatically be translated to people and a lot more has to be done to narrow the focus on the processes that are involved.

"However, by demonstrating that lost memories can be accessed again these results offer hope of a better understanding of what happens to memories as dementia develops.

"It highlights the role of both an 'enriching environment' and through its focus on biochemical processes could provide important building blocks for new treatments to alleviate the symptoms of dementia."


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last updated at 23:53 GMT, Wednesday, 6 May 2009 00:53 UK

Trial drugs 'reverse' Alzheimer's

The drugs are licensed to treat certain types of cancer US scientists say they have successfully reversed the effects of Alzheimer's with experimental drugs. The drugs target and boost the function of a newly pinpointed gene involved in the brain's memory formation. In mice, the treatment helped restore long-term memory and improve learning for new tasks, Nature reports. The same drugs - HDAC inhibitors - are currently being tested to treat Huntington's disease and are on the market to treat some cancers. They reshape the DNA scaffolding that supports and controls the expression of genes in the brain. We need to do more research to investigate whether developing treatments that control this gene could benefit people with Alzheimer's Rebecca Wood of the Alzheimer's Research Trust The Alzheimer's gene the drugs act upon, histone deacetylase 2 (HDAC2), regulates the expression of a plethora of genes implicated in plasticity - the brain's ability to change in response to experience - and memory formation. This findings build on the team's 2007 breakthrough in which mice with symptoms of Alzheimer's disease regained long-term memories and the ability to learn. Lead researcher Professor Li-Huei Tsai explained: "It brings about long-lasting changes in how other genes are expressed, which is probably necessary to increase numbers of synapses and restructure neural circuits, thereby enhancing memory. "To our knowledge, HDAC inhibitors have not been used to treat Alzheimer's disease or dementia. "But now that we know that inhibiting HDAC2 has the potential to boost synaptic plasticity, synapse formation and memory formation. "In the next step, we will develop new HDAC2-selective inhibitors and test their function for human diseases associated with memory impairment to treat neurodegenerative diseases." Future hope HDAC inhibitor treatment for humans with Alzheimer's disease is still a decade or more away, she said. The chief executive of the Alzheimer's Research Trust, Rebecca Wood, said: "This is promising research which improves our understanding of memory loss in Alzheimer's. "We need to do more research to investigate whether developing treatments that control this gene could benefit people with Alzheimer's. "We desperately need to fund more research to head off a forecast doubling the UK population living with dementia." Julie Williams, an expert in the genetics of Alzheimer's for the trust, said scientists were on the brink of finding a number of candidate genes that increase the risk of developing Alzheimer's. "If we can find the triggers and causes then we can hopefully prevent them. That is the great ambition."

Remembering My Friend Muriel

Swine Flu Alert! Can We Have Another Pandemic? Yes, We Can!

This is my Great Grandfather, who died in the 1918 Flu Pandemic in 1918. He died when my Grandmother was nine years old.

So, Teach Your Children Well



Learn all the precautions,
and teach your children the precautions.
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Page last updated at 20:51 GMT, Thursday, 11 June 2009 21:51 UK

WHO declares

swine flu pandemic

Dr Chan said the pandemic would be of ''moderate severity''

The World Health Organization (WHO) has declared a global flu pandemic after holding an emergency meeting.

It means the swine flu virus is spreading in at least two regions of the world with rising cases being seen in the UK, Australia, Japan and Chile.

WHO chief Dr Margaret Chan said the move did not mean the virus was causing more severe illness or more deaths.

The swine flu (H1N1) virus first emerged in Mexico in April and has since spread to 74 countries.

We have evidence to suggest we are seeing the first pandemic of the 21st Century Dr Margaret Chan, WHO director general Send us your comments Calm urged in UK

Official reports say there have been nearly 30,000 cases globally and 141 deaths, with figures rising daily.

Hong Kong said it was closing all its nurseries and primary schools for two weeks following 12 school cases.

It is the first flu pandemic in 40 years - the last in 1968 killed about one million people.

However, the current pandemic seems to be moderate and causing mild illness in most people.

Most cases are occurring in young working age adults and a third to a half of complications are presenting in otherwise healthy people.

Dr Chan said: "We have evidence to suggest we are seeing the first pandemic of the 21st Century.

"Moving to pandemic phase six does not imply we will see increased in deaths or serious cases."

She added it was important to get the right balance between complacency and vigilance and that pandemic strategies would vary between countries depending on their specific situation.

It is global and fulfilling the requirements of a pandemic Professor John Oxford, flu expert

And the WHO does not recommend closure of borders or any restrictions on the movement of people, goods or services.

But the picture could change very quickly.

"No other pandemic has been detected so early or watched so closely," Dr Chan said.

UN Secretary General Ban Ki-moon called for calm.

"Let me stress: this is a formal statement about the geographical spread of the disease. It is not in itself a cause for alarm," he said.

He warned that in the developing world the consequences of the virus could be more serious, and that the southern hemisphere was now entering the flu season.

One factor which has prompted the move to a level six pandemic was that in the southern hemisphere, the virus seems to be crowding out normal seasonal influenza.

Pandemic 'no cause for alarm'

The move was not prompted by the situation in any one country but the reports that it had spread in several parts of the world, officials said.

The BBC's Imogen Foulkes, in Geneva, says that while the number of cases has made the declaration inevitable, the WHO will have to manage the global anxiety the declaration of a pandemic will generate.

Experts have warned that poorer nations, especially those in the southern hemisphere now heading into their winter season, face the greatest risk from the flu pandemic.

Pandemic planning

There have been more than 800 cases in the UK with some areas of Scotland being particularly hard hit.

The government has been stockpiling antivirals such as Tamiflu and has ordered vaccine, some doses of which could be available by October.

SWINE FLU - THE BASICS Symptoms usually similar to seasonal flu It is a new version of the H1N1 strain which caused the 1918 flu pandemic Current treatments do work, but as yet there is no vaccine Good personal hygiene, such as washing hands, covering nose when sneezing advised What comes next in flu fight

England's chief medical officer Sir Liam Donaldson said the WHO declaration of a pandemic would not significantly change the way the UK was dealing with swine flu at the moment.

But he added there could be some minor changes to who received antivirals.

"The declaration of a pandemic per se doesn't make a big difference to the way we are handling the outbreaks we have.

"We are going to continue to investigate every case that occurs and treat their contacts with antivirals even though they may not be ill.

"The difference is that the Health Protection Agency has learnt a lot about approaching this question of antiviral prophylaxis and they are going to be treating the closer contacts of the cases, rather than the more far-flung contacts, because they feel that that is supported by what they know so far about how the disease is transmitting.

He added: "These flu viruses can change their pattern of attack, so when we come into the flu season in the autumn and winter in this country, when we expect a big surge of cases, we need to watch very carefully to see if the character of the virus is changing."

There is concern that the virus might mutate in the southern hemisphere over its winter and become more virulent, but there's no sign of that yet Fergus Walsh BBC's medical correspondent Read Fergus's thoughts in full

Scottish health secretary Nicola Sturgeon said a move to level six means that countries need to be ready to implement pandemic plans immediately but the UK was already operating at a "heightened state of readiness".

But it could affect the speed at which the UK gets pandemic vaccine supplies but that had been factored into pandemic planning.

Flu expert Professor John Oxford said people should not panic as the outbreak was milder than others seen in the past century.

"It is global and fulfilling the requirements of a pandemic but I don't think anyone should worry because nothing drastic has happened between yesterday and today."

What You Can Do to Stay Healthy

There are everyday actions people can take to stay healthy.

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hands cleaners are also effective.
• Avoid touching your eyes, nose or mouth. Germs spread that way.

Try to avoid close contact with sick people.

• Influenza is thought to spread mainly person-to-person through coughing or sneezing of infected people.
• If you get sick, CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

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1976: Fear of a great plague

On the cold afternoon of February 5, 1976, an Army recruit told his drill instructor at Fort Dix that he felt tired and weak but not sick enough to see military medics or skip a big training hike.

Within 24 hours, 19-year-old Pvt. David Lewis of Ashley Falls, Mass., was dead, killed by an influenza not seen since the plague of 1918-19, which took 500,000 American lives and 20 million worldwide.

Two weeks after the recruit's death, health officials disclosed to America that something called "swine flu" had killed Lewis and hospitalized four of his fellow soldiers at the Army base in Burlington County...
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Book: Flu: the story of the great influenza of 1918 and the search for the virus that caused it

Author: Gina Bari Kolata
Publisher: Farrar, Straus, and Giroux, 1999, NY
Reviewer: CDR Jack Rumbaugh, MSC, USN
Diplomate and CFAAMA.
US Naval War College
Newport, RI
Book Review

In this easy to read book, author Gina Kolata has captured an important and forgotten period of the Nation’s history. There are few American’s that can recall the events of the flu of 1918 and the panic, sorrow, and death it left in its wake. A virus that infected over twenty-five percent of the U.S. population and resulted in a worldwide death toll estimated at 20 -100 million in just one year.

Flu offers a sobering opportunity to study an actual account of a biological incident within the United States. Although not launched as a biological warfare agent, much can be gained from a historical review of how the public, governmental authorities, and scientific community responded to the 1918 flu. It is a book that appeals to a broad audience, it can read for: personal interest (to study history or better understand family history); improved professional knowledge (for better understanding of this unusual flu strain); or for practical application (for those who may be called upon to plan for, or respond to, a large scale biological outbreak)....

Insertion of Suprapubic Catheter

The video is a British video but the process is the same in the United States. Above is a picture of my suprapubic catheter. That is a 20 French silicone foley catheter. After my surgeries I had a rubber foley. My skin is very sensitive. The rubber made my skin very red. A resident who took care of my surgeries, and who is a doctor now, recommended a silicone foley. That is much more agreeable with my skin. Do you see the red spot where the catheter is coming out? It is a fleshy growth. My surgeon has burned it off at least three times with nitrate. The nitrate was on a long Q-tip, which my surgeon used to touch the growth to burn it off. The procedure was only a minute long but it is very painful. I have not asked him to burn it off anymore!


The bigger the Foley, the faster the urine drains out. The different types are 12 Fr, 14 Fr, 18 Fr, and 20 Fr. At the end of the Foley there is a balloon. My balloon is filled with 10 cc (10 ml) sterile water. I require my Foley catheter to be changed every 2.5-3 months. The process only takes less than 10 minutes. First, my urology nurse prepares my site. She puts a disposable pad under my pants so any blood or medicine she uses will not get on my pants. She numbs the area around my site with lidocaine by inserting it into my site with a syringe. She uses a small syringe to deflate the balloon by drawing out the sterile water. She fills another syringe with 40-60 cc sterile water. She then inserts the syringe into my catheter and injects the sterile water into my bladder. She then slides the catheter out and puts a new one in.

Most of you who look at my blog know that I am 60 years old with a primary diagnosis of spastic quadriplegic cerebral palsy. To give you a little more information, on June 16, 2004 I had two surgeries: my colostomy and my supra pubic catheter insertion.


My colostomy and my supra pubic insertion were my decision and my decision only! George Klauber, MD (Pediatric Urologist) was my consultant on my surgeries. I am grateful to George for coordinating my surgeries in one day. In the 1980s, I worked with George at the Floating Hospital for Children at New England Medical Hospital doing research on Myelodysplasia. We stayed in touch and that is the reason I asked George if it would be possible to have both surgeries in one day.


At the time, I was 55 years old and I knew my recuperative period would be longer than it would have been if I were younger. Before my surgeries, I net with the two surgeons and asked them numerous questions. They were very honest with me and they told me the benefits and deficits of having these surgeries. I was prepared for both the benefits and the deficits to my increasing severity of weight bearing. As some of you know, weight bearing is standing up. The only transferring I did for myself was getting on and off the toilet. The other transfer was a stand-pivot with the assistance of my caregivers. I contacted George when I began to fall more often in the bathroom as a result of arthritis in my hip.



Dissection at the base of the bladder to reach the anterior vaginal wall and uterine cervix creates edema, interrupts the small nerve pathways, and thereby sets up the physiologic changes that produce urinary bladder atony. Therefore, catheter drainage of the urinary bladder is an essential feature of many pelvic surgical procedures. Fortunately, in most cases, these conditions reverse themselves in 3-5 days, and catheter drainage is no longer needed.

Suprapubic bladder catheterization is superior to transurethral bladder catheterization because it is cleaner. It also leaves the urethra open for voiding when urinary function has returned. The use of an ordinary Foley catheter (No. 16 French with 5-mL bag) is preferable to the commercially available suprapubic catheter kits because a Foley catheter, when inserted as described in this section, is usually not dislodged from the bladder during sleep or activity. In addition, the Foley catheter is less costly and is available in all surgical clinics. The instrument used for insertion of the Foley catheter is an ordinary Randall stone forceps. The fulcrum of this instrument is toward the rear, which keeps the overall diameter of the axis virtually unchanged except at the jaws and gives it an advantage over a Kelly clamp.

The operation provides drainage of the urinary bladder through a clean surgical incision and ensures that the catheter does not slip out of the patient or become dislodged within the abdominal wall.

Physiologic Changes.
The procedure reduces edema at the base of the bladder, allowing the return of normal vesical function.

Points of Caution.
After grasping the catheter with the jaws of the Randall forceps (Fig. 4) and before inflating the Foley balloon, the catheter should be drawn through the bladder until the tip can be seen in the urethral meatus. This ensures that the catheter tip and balloon are in the bladder and not in the subcutaneous or subfascial space.



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Technique












This procedure can be performed in the inpatient treatment rooms of a hospital, clinic, or doctor's office. Local anesthesia is adequate for most patients. The bladder does not have to be empty. The patient is placed in the dorsal lithotomy position. The periurethral area and suprapubic area are surgically prepped and draped. A routine pelvic examination is performed prior to placement of the suprapubic catheter. If local anesthesia is to be used, a 4 x 4 cm area around the insertion site is infiltrated with 1% lidocaine. Infiltration should include the fascia and, if at all possible, a small area of the bladder wall.

A Randall stone forceps is inserted through the urethral meatus and used to elevate the dome of the bladder from the inside, pushing the suprapubic abdominal wall upward to the palpating finger.

Upward pressure is maintained on the forceps, and a small incision is made in the suprapubic skin and fascia until the forceps can be felt with the blade of the knife.

A sudden upward thrust of the forceps pierces the bladder wall and pushes the forceps through the incision. The jaws of the forceps are opened and used to grasp the tip of the Foley catheter.

The Foley catheter is pulled through the bladder, and the forceps is withdrawn from the urethra until the tip of the Foley catheter can be seen in the urethral meatus.

Traction is placed on the Foley catheter from above while the balloon is simultaneously inflated. This draws the catheter back into the body of the bladder.

When 5 mL of sterile saline solution have completely filled the Foley balloon, the catheter is firmly retracted upward.

It is not necessary to suture the catheter to the abdominal skin. A sterile dressing is applied, and the Foley catheter is connected to straight drainage.

What is a Neurogenic Bladder?

Brainstem

The brainstem is located at the base of the skull. Within the brainstem is a specialized area known as the pons, a major relay center between the brain and the bladder. The pons is responsible for coordinating the activities of the urinary sphincters and the bladder so that they work in synergy. The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC). The PMC coordinates the urethral sphincter relaxation and detrusor contraction to facilitate urination.




The pons is a major relay center between the brain and the bladder. The mechanical process of urination is coordinated by the pons in the area known as the pontine micturition center (PMC)



Complications of a Neurogenic Bladder:
The following problems are often associated with a neurogenic bladder:

* Urine leakage
Urine leakage often occurs when the muscles holding urine in do not get the right message.
* urine retention
Urine retention often happens if the muscles holding urine in do not get the message that it is time to let go.
* damage to the tiny blood vessels in the kidney
Damage to the tiny blood vessels in the kidney often happens if the bladder becomes too full and urine backs up into the kidneys, causing extra pressure.
* infection of the bladder or ureters
Infection of the bladder or ureters often results from urine that is held too long before being eliminated.

Neurogenic bladder is bladder dysfunction (flaccid or spastic) caused by neurologic damage. The primary symptom is overflow incontinence. Risk of serious complications (eg, recurrent infection, vesicoureteral reflux, autonomic dysreflexia) is high. Diagnosis involves imaging and cystoscopy or urodynamic testing. Treatment involves catheterization or measures to trigger urination.

Any condition that impairs bladder and bladder outlet afferent and efferent signaling can cause neurogenic bladder. Causes may involve the CNS (eg, stroke, spinal injury, meningomyelocele, amyotrophic lateral sclerosis), peripheral nerves (eg, diabetic, alcoholic, or vitamin B₁₂ deficiency neuropathies; herniated disks; damage due to pelvic surgery), or both (eg, Parkinson's disease, multiple sclerosis, syphilis). Bladder outlet obstruction often coexists and may exacerbate symptoms.

In flaccid (hypotonic) neurogenic bladder, volume is large, pressure is low, and contractions are absent. It may result from peripheral nerve damage or spinal cord damage at the S2 to S4 level. After acute cord damage, initial flaccidity may be followed by long-term flaccidity or spasticity, or bladder function may improve after days, weeks, or months.

In spastic bladder, volume is normal or small, and involuntary contractions occur. It usually results from brain damage or spinal cord damage above T12. Precise symptoms vary by site and severity of the lesion. Bladder contraction and external urinary sphincter relaxation are typically uncoordinated (detrusor-sphincter dyssynergia).

Mixed patterns (flaccid and spastic bladder) may be caused by many disorders, including syphilis, diabetes mellitus, brain or spinal cord tumors, stroke, ruptured intervertebral disk, and demyelinating or degenerative disorders (eg, multiple sclerosis, amyotrophic lateral sclerosis).

Symptoms and Signs

Overflow incontinence is the primary symptom in patients with a flaccid or spastic bladder. Patients retain urine and have constant overflow dribbling. Men typically also have erectile dysfunction. Patients with spastic bladder may have frequency, nocturia, and urgency or spastic paralysis with sensory deficits.

Common complications include recurrent UTIs and urinary calculi. Hydronephrosis with vesicoureteral reflux may occur because the large urine volume puts pressure on the vesicoureteral junction, causing dysfunction with reflux and, in severe cases, nephropathy. Patients with high thoracic or cervical spinal cord lesions are at risk of autonomic dysreflexia (a life-threatening syndrome of malignant hypertension, bradycardia or tachycardia, headache, piloerection, and sweating due to unregulated sympathetic hyperactivity). This disorder may be triggered by acute bladder distention (due to urinary retention) or bowel distention (due to constipation or fecal impaction).

Diagnosis

• Postvoid residual volume
• Renal ultrasonography
• Serum creatinine
• Usually cystography, cystoscopy, and cystometrography with urodynamic testing

Diagnosis is suspected clinically. Usually, postvoid residual volume is measured, renal ultrasonography is done to detect hydronephrosis, and serum creatinine is measured to assess renal function. Further studies are often not obtained in patients who are not able to self-catheterize or ask to go to the bathroom (eg, severely debilitated elderly or post-stroke patients). In patients with hydronephrosis or nephropathy who are not severely debilitated, cystography, cystoscopy, and cystometrography with urodynamic testing are usually recommended and may guide further therapy. Cystography is used to evaluate bladder capacity and detect reflux. Cystoscopy is used to evaluate duration and severity of retention (by detecting bladder trabeculations) and to check for bladder outlet obstruction. Cystometrography can determine whether bladder volume and pressure are high or low; if done during the recovery phase of flaccid bladder after spinal cord injury, it can help evaluate detrusor functional capacity and predict rehabilitation prospects (see Voiding Disorders: Testing). Urodynamic testing of voiding flow rates with sphincter electromyography can show whether bladder contraction and sphincter relaxation are coordinated (see Voiding Disorders: Testing).

Treatment

• Catheterization
• Increased fluid intake
• Surgery as last resort

Prognosis is good if the disorder is diagnosed and treated before kidneys are damaged.

Specific treatment involves catheterization or measures to trigger urination. General treatment includes renal function monitoring, control of UTIs, high fluid intake to decrease risk of UTIs and urinary calculi (although this measure may exacerbate incontinence), early ambulation, frequent changes of position, and dietary Ca restriction to inhibit calculus formation.

For flaccid bladder, especially if the cause is an acute spinal cord injury, immediate continuous or intermittent catheterization is needed. Intermittent self-catheterization is preferable to indwelling urethral catheterization, which has a high risk of recurrent UTIs and, in men, a high risk of urethritis, periurethritis, prostatic abscesses, and urethral fistulas. Suprapubic catheterization may be used if patients cannot self-catheterize.

For spastic bladder, treatment depends on the patient's ability to retain urine. Patients who can retain normal volumes can use techniques to trigger voiding (eg, applying suprapubic pressure, scratching the thighs); anticholinergics may be effective. For patients who cannot retain normal volumes, treatment is the same as that of urge incontinence (see Voiding Disorders: Treatment), including drugs (see Table 3: Voiding Disorders: Drugs Used to Treat Incontinence ) and sacral nerve stimulation.

Surgery is a last resort. It is usually indicated if patients have had or are at risk of severe acute or chronic sequelae or if social circumstances, spasticity, or quadriplegia prevents use of continuous or intermittent bladder drainage. Sphincterotomy (for men) converts the bladder into an open draining conduit. Sacral (S3 and S4) rhizotomy converts a spastic into a flaccid bladder. Urinary diversion may involve an ileal conduit or ureterostomy.

An artificial, mechanically controlled urinary sphincter, surgically inserted, is an option for patients who have adequate bladder capacity, good bladder emptying, and upper extremity motor skills and who can comply with instructions for use of the device; if patients do not comply, life-threatening situations (eg, renal failure, urosepsis) can result.

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The Urinary System is made up of five major parts:

The Kidneys
The two kidneys filter waste and excess water from the blood and produce urine. Urine is being produced every minute of the day.

The Ureters
Each kidney has a thin, hollow tube that connects to the bladder. Urine flows down the ureters from the kidneys and empties into the bladder. The ureters have one-way valves in them, so even if you were to stand on your head, urine could not flow back to the kidneys from the bladder.

The Bladder
The bladder is a collapsible sac lying in the pelvis. It is able to stretch to hold urine until you are ready to urinate. The bladder walls are made up of muscles known collectively as the detrusor muscles. When you are ready to urinate, the detrusor muscles contract (squeeze) to help push the urine from the bladder. The lower portion of the bladder, which funnels urine into the urethra, is called the bladder neck or bladder outlet.

The Urethra

The urethra is a small tube that allows urine to flow from the bladder to outside the body. The male urethra is 8-10 inches long and the female urethra is 1-2 inches long. The external urethral opening from the body is called the meatus for both men and women.

The Sphincter Muscles

The internal and external sphincter muscles form a ring around the urethra to keep urine in the bladder. When you are ready to urinate, these muscles relax to allow urine to flow out of the bladder.

Voiding (Urination)

Normally, when the bladder become full (about 1-2 cups for most people), nerve endings in the bladder wall send a message to the brain via the spinal cord. The brain sends a message back to the bladder to contract the detrusor muscles and relax the sphincter muscles so you can void. If you can't get to a toilet, the brain delays the messages until you are ready to void.

The bladder, along with the rest of the body, undergoes dramatic changes. Since messages between the bladder and the brain cannot travel up and down the spinal cord, the voiding pattern described above is not possible. Depending on your type of spinal cord injury, your bladder may become either "floppy" (flaccid) or "hyperactive" (spastic or reflex).

The Flaccid Bladder

A floppy bladder loses detrusor muscle tone (strength) and does not contract for emptying. This type of bladder can be easily overstretched with too much urine, which can damage the bladder wall and increase the risk of infection. Emptying the flaccid bladder can be done with techniques such as Crede, Valsalva, or intermittent catheterization. It is very important that you do not let your bladder get overfull, even if it means waking up at night to catheterize yourself more frequently.

The Reflex Bladder

The detrusor muscles in a hyperactive bladder may have increased tone, and may contract automatically, causing incontinence (accidental voiding). Sometimes the bladder sphincters do not coordinate properly with the detrusor muscles, and medication or surgery may be helpful.

Foley or Suprapubic Catheter

A tube is inserted through the urethra or abdomen and into the bladder, where a balloon on the end holds it in place. It remains in the bladder and drains constantly, so the bladder is never full.

External Catheterization

• Condom Catheters
  These collection devices are worn by men for incontinence problems. They are made of latex rubber or silicone that covers the penis and attaches to a tube that drains into a collection bag.

• External Continence Device (ECD)
  An ECD is a method of continence management that attaches only to the tip of the penis using hydrocolloid, a hypoallergenic adhesive commonly used in wound and ostomy care. Urine is directed into a collection bag and does not come in contact with skin.

Intermittent Catheterization

You drain your bladder several times a day by inserting a small rubber or plastic tube. The tube does not stay in the bladder between catheterizations.

Spontaneous Voiding

The bladder muscles contract to start the bladder-emptying process. This may be under your control (voluntary) or not (involuntary):

• Normal Voiding
  This is done under your control. When the bladder gets full, messages are sent to the sacral level of the spinal cord and carried to the brain. The brain sends messages back to the bladder to contract, and to the sphincter muscle to open, so you can void.
• Spincterotomy
  This surgical process weakens the bladder neck and sphincter muscle to allow urine to flow out more easily. After this surgery, you will urinate involuntarily, and must wear a collection device.
• Condom Catheter
  These collection devices are worn by men for incontinence problems or after sphincterotomy (see above). They are made of latex rubber or silicone that covers the penis and attaches to a tube that drains into a collection bag.

Stimulated Voiding

Voiding is encouraged in one of several ways, such as:

• Anal or Rectal Stretch
  This method for relaxing the urinary sphincter is usually used along with an abdominal corset and valsalva (see below).
• Crede
  This method involves manually pressing down on the bladder.
• Tapping
  The area over the bladder is tapped with the fingertips or the side of the hand, lightly and repeatedly, to stimulate detrusor muscle contractions and voiding.
• Valsalva
  This method involves increasing pressure inside the abdomen by bearing down as if you were going to have a bowel movement.

Surgical Alternatives

• Mitrofanoff
  A passageway is constructed using the appendix so that catheterization can be done through the abdomen to the bladder.
• Bladder Augmentation
  Surgical enlargement of the bladder.

A Family Tragerdy Did Not Stop John Walsh From Saving Other Children

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In the summer of 1981, Walsh was a partner in a hotel management company in Hollywood, Florida. He and his wife, Revé, had a six-year-old son, Adam. On July 27, 1981, Adam was abducted from a Sears department store at the Hollywood Mall, across from the Hollywood Police station. Revé had dropped Adam off in the Sears toy department while she looked for a lamp. When she returned, Adam was missing. Police records in Adam's case released in 1996 show that a 17-year-old security guard asked four boys to leave the department store. Adam is believed to have been one of them. Sixteen days after the abduction, his severed head was found in a drainage canal more than 100 miles away from home. His body was never recovered. The prime suspect in Adam's abduction and murder, Ottis Toole, was never charged in the Adam Walsh case. He died in prison in September 1996 while serving a life sentence for other crimes. In January 2007, however, deceased serial killer Jeffrey Dahmer fell under suspicion for the murder of Adam. This speculation was discounted by Walsh in an America's Most Wanted statement on February 6, 2007. The Walsh family soon began a campaign to help missing and exploited children. Despite bureaucratic and legislative problems, John and Revé's efforts eventually led to the creation of the Missing Children Act of 1982 and the Missing Children's Assistance Act of 1984. Subsequently, they founded the Adam Walsh Child Resource Center, a non-profit organization dedicated to legislative reform. The centers, originally located in West Palm Beach, Florida; Columbia, South Carolina; Orange County, California; and Rochester, New York; recently merged with the National Center for Missing and Exploited Children (NCMEC), where John Walsh serves on the Board of Directors. Today, Walsh continues to testify before Congress and state legislatures on crime, missing children and victims' rights issues. His latest efforts include lobbying for a Constitutional amendment for victims' rights. The Adam Walsh Child Protection and Safety Act (Pub.L. 109-248) was signed into law by U.S. President George W. Bush on July 27, 2006 following a two-year journey through the United States Congress and was intensely lobbied for by Walsh and the National Center for Missing and Exploited Children. Primarily, it focuses on a national sex offender registry, tough penalties for not registering as a sex offender following release into society, and access by citizens to state websites that track sex offenders.

The Killing of Adam Walsh, The Son of John Walsh

fetc ng d Adam's mother, Revé, let him watch a small group of older boys play video games at a Sears store in Hollywood, Florida, while she walked a few aisles away to shop for a lamp. When Revé returned to the video game section, she was frightened to find that Adam was not there. She then told a Sears associate, who announced over the intercom for Adam to meet his mother at one of the information desks. Revé later said that she had no confidence that Adam would be able to locate the desks. Adam and his mother were never reunited. There are claims that a female security guard threw the children out of the store for bickering over the video game, and perhaps Adam was confused and thought he had to leave too. Investigators think Adam had been mistakenly associated with a group of older children who were causing trouble and told to leave the shopping mall. It is suspected that Adam was abducted near the front exterior of the store after the other boys went on their way. Adam's severed head was found in a Vero Beach, Florida, canal on August 10, 1981; the rest of his remains have never been recovered

To Be, Or Not To Be, a CNA

The couse takes place over 3 weeks. The program is given at our nursing
home. There is a final exam before being issued a certificate to prove
an individual successfully completed the program.


JoAnn Cameron
Human Resources Director

-----Original Message-----
From: dobiemax1948@aol.com [mailto:dobiemax1948@aol.com]
Sent: Friday, April 17, 2009 5:37 PM
To: JoAnn Cameron
Subject: RE: Certification in Nursing Assistant Training

Hello JoAnn,

I am actually asking for research purposes so I would appreciate it if
you could still answer my questions.

Sincerely,

Carolyn V. Wojcik

-----Original Message-----
From: JoAnn Cameron 
To: dobiemax1948@aol.com
Sent: Fri, 17 Apr 2009 4:45 pm
Subject: RE: Certification in Nursing Assistant Training

Sorry, but we are not offering the training program at this time.


JoAnn Cameron
Human Resources Director

-----Original Message-----
From: dobiemax1948@aol.com [mailto:dobiemax1948@aol.com]
Sent: Friday, April 17, 2009 2:50 PM
To: JoAnn Cameron
Subject: Certification in Nursing Assistant Training

Hello,

I am interested in learning about your CNA training program. How long
does the program last? I would also like to know if you offer part of
the training at a hospital or if all of the training occurs at Marian
Manor. If there is training at a hospital, how long does that part of
the training last? Is there a licensing exam at the end of the program?

Sincerely,

Carolyn V. Wojcik

-------

Bunker Hill Community College: Patient care assistant certificate program:

This program teaches students the skills they will need to give basic patient care as Certified Nursing Assistants (CNAs) in Massachusetts. The CNA certification program requires 26 credit hours of class study in the form of lectures, laboratory practice and clinical experience. Required course titles include principles of clinical practice, patient care skills and CNA practicum. After graduating, nursing students are eligible to take the Massachusetts State Certification Examination. Those who pass this exam can work as CNAs throughout the state.

Largest Massachusetts School Offering a CNA Certification Program: Bunker Hill Community College in Boston, MA

Bunker Hill Community College is a community college with two campuses and six satellites in Massachusetts. In addition to CNA certification, it offers an associate's degree program in nursing.

Colon - Colostomy - Ostomy

Colostomy Facts

A colostomy indicates that the opening is from the colon. A colostomy is created when a portion of the colon or the rectum is removed and the remaining colon is brought to the abdominal wall. It may further be defined by the portion of the colon involved and/or its permanence. When the colostomy is in the left colon, only a pad may be needed to cover the opening. When the opening is in the right side of the colon, some type of appliance or bag is required. There are various types of colostomies. The physician and surgeon recommend the appropriate one for each patient.


Temporary Colostomy

Allows the lower portion of the colon to rest or heal. It may have one or two openings (if two, one will discharge only mucus).

Permanent Colostomy

Usually involves the loss of part of the colon, most commonly the rectum. The end of the remaining portion of the colon is brought out to the abdominal wall to form the stoma.





Sigmoid or Descending Colostomy
The most common type of Colostomy surgery, in which the end of the descending or sigmoid colon is brought to the surface of the abdomen. It is usually located on the lower left side of the abdomen.








Transverse Colostomy

The surgical opening created in the transverse colon resulting in one or two openings. It is located in the upper abdomen, middle or right side.










Ascending Colostomy
A relatively rare opening in the ascending portion of the colon. It is located on the right side of the abdomen.