Case Report of Secondary Narcolepsy

Case Report of Secondary Narcolepsy Title of the article: â€Å" Case Report of Secondary Narcolepsy presenting as self-inflicted genital injury † Abstract: Primary Narcolepsy is a sleep disorder with classical presentation showing tetrad of excessive daytime sleepiness, cataplexy, sleep paralysis, and Hypnogogic hallucinations. Some conditions that result in secondary narcolepsy include traumatic brain injury, tumors, and stroke. [1] A rare case of secondary narcolepsy was seen in a patient with self-inflicted genital injury. A 30 year old male was referred to Psychiatry from Surgery for a self-inflicted incised wound on hydrocoele. Since last 1 year, he had multiple episodes of — 1. Sudden falls while working 2. Sleep during daytime often at unusual places 3. Periods of unresponsiveness during which he was aware but unable to move. During hospital stay, daytime somnolence, sleep paralysis and cataplexy were noted several times, but hallucinations were not consistently reported. Based on DSM-IV-TR N arcolepsy was diagnosed. Possible reasons for genital injury were 1. To remove fluid from swelling 2. Under sleep paralysis 3. Under Hypnogogic hallucinations. Patient’s EEG was normal. MRI brain showed Gliosis at cervico-medullary junction.MRI spine was advised to examine the cervico-vertebral junction but patient was lost to follow-up. But from history and investigations, it was concluded that he had secondary narcolepsy due to traumatic brain injury. Narcolepsy typically begins in the 2nd and 3rd decades of life and negatively impacts the quality of life of affected patients. Diagnosis relies on patient history and objective data gathered from polysomnography and multiple sleep latency testing. Treatment focuses on symptom relief through medication, education, and behavioural modification. Key-words: Cataplexy; Narcolepsy; Polysomnography; Self inflicted injury, Key Messages [D1] :Secondary narcolepsy is rare and sometimes can be missed to diagnose. Such rare presentation of secondary narcolepsy helps in diagnosing other cases of self-inflicting injuries. Introduction: [D2] Narcolepsy is neither a type of epilepsy nor a psychogenic disturbance. It is an abnormality of the sleep mechanisms specifically, REM-inhibiting mechanisms and it has been studied in dogs, sheep, and humans. Narcolepsy can occur at any age, but it most frequently begins in adolescence or young adulthood, generally before the age of 30. The disorder either progresses slowly or reaches a plateau that is maintained throughout life. [2]. The prevalence of narcolepsy varies across countries and with different ethnic groups, and so the exact prevalence is not known. Prevalence estimates have been reported to be between 168 and 799 per 100,000 in most studies, although Japanese studies have indicated a higher prevalence of 1600 per 100,000. [2,3]. There are no genetic tests currently available for clinical use to make a positive diagnosis of narcolepsy. Genetic testing may correlat e best to narcolepsy when there is already clear cataplexy. [4]. Supporting the evidence for an environmental influence is the fact that the disease is not apparent at birth, but instead commonly has its onset during the second decade of life. Additionally, there are apparent precipitating factors such as head trauma, infection, and changes in sleep-waking habits that have been identified in some cases. [6] Chronic, daytime sleepiness is a major, disabling symptom for many patients with traumatic brain injury (TBI), but thus far, its aetiology is not well understood. Extensive loss of the hypothalamic neurons that produce the wake-promoting neuropeptide hypocretin (orexin) causes the severe sleepiness of narcolepsy, and partial loss of these cells may contribute to the sleepiness of Parkinson disease and other disorders. One study has found that the number of hypocretin neurons is significantly reduced in patients with severe TBI. This observation highlights the often overlooked hy pothalamic injury in TBI and provides new insights into the causes of chronic sleepiness in patients with TBI. [7] Amphetamine usage has been associated with addiction, psychosis and self-injurious behaviour . There are report s on two patients who severely and repeatedly mutilated their own genitalia while intoxicated on amphetamines and consider possible diagnostic aetiologies. [8] Genital mutilation is common in males compared to females. [9] But narcolepsy presenting as self inflicted genital injury has not been reported so far. That is why this is a rare case .

How did Roman authors choose to portray barbarians (particularly Gauls Essay

How did Roman authors choose to portray barbarians (particularly Gauls and Germans) How realistic can we expect these portraits - Essay Example The Romans enjoyed a culture based on fine arts and literature, superior technologies and advanced training techniques for their military campaigns. As the empire extended ever further, there was increasing contact with those â€Å"other† tribes and nations and the Roman historians recorded their impressions from this rather one-sided perspective of the conqueror. This paper examines the way that two Roman authors, Julius Caesar and Tacitus, portray the barbarians and examines the very different motivations of these two writers and the consequent limitations of their respective approaches. The early account of the Germans which is given by Julius Caesar (100-44BC) in Book VI of De Bello Gallico [Gallic War] is presented as a contrast to the way that he perceives the Gauls. It is interesting that this great Roman leader comments first on religious matters and war, pointing out that the Germans do not have druids and sacrifices, like the Gauls, but instead have their own gods wh om they can see and who help them in their warlike lifestyle.1 It is quite clear that Caesar accepts the different gods of these two barbarian peoples as actors in the battles that occur, and he accepts also their direct link with the sun, sky and natural world of groves and springs that go with these gods. There is no attempt to layer Roman ideas into these practices, but there is an implicit assumption that Roman ways are better. Caesar appears impressed by their dependence on animal products, rather than agriculture, and the way that leaders ensure loyalty by organising a rotation of lands and a focus on plundering neighboring tribes, since in his view this keeps them always ready for war.2 It is striking that Caesar notes also the generosity of the Germans in offering protection hospitality and food to those who visit them, because this reveals a fair-minded appreciation of German moral standards. He does not demonize his enemies, but seeks to portray them in a sympathetic light . One reason for this may be that his experience on campaigns and in the battlefields has taught him how difficult it is to maintain fitness and commitment in his fighting troops. Roman troops were motivated by monetary rewards and the promise of a happy retirement back in the warmer climes of their homeland, while the German warriors appear less materialistic and better trained for a life of fighting. For a general this must have seemed like a far better underpinning for the provision of fighting forces. When it comes to the Gauls, Julius Caesar reflects a common classical notion that those who are located furthest from the centre of the Empire in Rome are the most valiant and the greatest of the barbarians: â€Å"For Caesar this distance, combined with the Belgae’s close proximity and daily confrontations with the Germans, both offensively and defensively, had made them the bravest of the Gauls.†3 This traditional wisdom could not fail to have influenced his percepti on of the peoples that he encountered on his exploratory travels throughout the vast regions of Gaul. There is a strong possibility that he actually seeks out evidence to support these theories, and to stress that he values the barbarians more, the further away from Rome they are, thus at the same time extolling their powerful image but minimizing any possibility

The negative economic impacts of World EXPO 2010 in Shanghai, China Essay

The negative economic impacts of World EXPO 2010 in Shanghai, China - Essay Example If the negative outcomes outweigh the benefits, it is always prudent that the country resists from hosting the event. Some of the considerations that a country considers among other things include environmental effects, economic benefits, social impacts as well as its ability to host the event successfully. It is always important that a country ensure that it has the necessary infrastructure to host large international events, failure to which, it may end up to engage in internal and external borrowing, something that may have far reaching economic impacts (Chalip, Breen & Hill 2003). This paper examines the economic impacts that were associated with the hosting of the World Expo that was held in the Shanghai city of China in 2010. This is an event that is organized under the United Nations umbrella and happens on a rotational basis in major cities of the world, after a successful bidding by the respective countries. It focuses on the effects the event had on the various macroeconomic economic of China, as well as that of other hosting cities for the same event. The World Expo 2010 was held in China, in both of the banks of Huangpu River; the event took six months, running from the start of May to October of 2010. The event was marked as one of the major World Expo in the customs of international and world fairs and Expositions. The event was the first of its kind that the city was hosting after 1992, something that influenced prior proper planning before the actual event was to take place. During the Expo, the theme that was settled at was, â€Å"Better City – Better Life;† the choice of the theme was to portray Shanghai as the next great city of the world (Abelson 2011; Crompton 2006). Indeed, many of the people that attended the Expo lived to ascertain the fact that Shanghai has been developed as the major city in the world, competing with other major cities in the world