Tag: Module

Suicide – Psychiatric Inputs

SUICIDE – PSYCHIATRIC INPUTS


SUICIDE – PSYCHIATRIC INPUTS

Cause:

  • Low CSF levels of 5-hydroryindoleacetic acid (5 HIAA).
  • 5-hydroryindoleacetic acid (5 HIAA)- Serotonin metabolite associated with higher suicide risk.

Psychiatric illnesses & suicide risks:

  • Depressive disorder
  • Schizophrenia
  • Alcohol dependence & other substance dependence.
  • Personality disorders (especially borderline personality disorder & antisocial personality disorder).

Suicidal risk factors:

  • Male sex
  • Age > 45 years
  • Divorced, widowed
  • Unemployed
  • Chronic illness
  • Family history of suicide
  • Poor social support.

Exam Important

  • Lower levels of 5-hydroryindoleacetic acid (5 HIAA), a serotonin metabolite is associated with higher suicide risk.
  • Males are more prone to have suicidal risk.
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Lithium – Psychiatric Usage

LITHIUM – PSYCHIATRIC USAGE


LITHIUM – PSYCHIATRIC USAGE

Indications of lithium in psychiatric disorders:

  • Used for treatment of acute episodes (both mania & depression).
    • Effective treatment for acute mania – Effective serum concentration for acute mania treatment is 1.0-1.5 mEq/ dl.
  • Antimanic efficacy of lithium is more than its antidepressive efficacy.
  • Prophylaxis in bipolar disorder.
  • Maintenance treatment with lithium decreases frequency, severity & duration of manic & depressive episodes in patients with bipolar disorders.
    • Serum concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • In schizoaffective disorders.
  • As an adjuvant to antidepressants in major depressive disorder.

Other uses:

  • Obsessive-compulsive disorder
  • Aggression
  • Headache (cluster, migraine)
  • Gout
  • Epilepsy
  • Movement disorders
  • Neutropenia
  • Ulcerative colitis.

Exam Important

  • Lithium is used in effective treatment for acute mania & its effective serum concentration is 1.0-1.5 mEq/ dl.
  • Serum lithium concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • Lithium is also used for headache (cluster, migraine) & neutropenia.
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Extrapyramidal Side Effects

EXTRAPYRAMIDAL SIDE EFFECTS


EXTRAPYRAMIDAL SIDE EFFECTS

  • Caused by antipsychotics.
    • More common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Various movement disorders caused are collectively referred to as “extrapyramidal symptoms/extrapyramidal side effects”.

Mechanism:

  • Due to dopamine receptor blockade in nigrostriatal tract (neural pathway from substantia nigra to striatum).

TYPES OF MOVEMENT DISORDERS:

  • Acute dystonia.
  • Acute akathisia
  • Drug-induced parkinsonism
  • Tardive dyskinesia
  • Neuroleptic malignant syndrome

1. Acute dystonia:

  • Earliest side effect.
  • Occurs within minutes (more with injectable antipsychotic).

Features:

  • Characterized by sudden contraction of muscle group –
  • Symptoms like torticollis, trismus (contraction of jaw muscles), eyeballs deviation (oculogyric crisis due to extraocular muscle contraction) & laryngospasm.

Management:

  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea).
  • Prevent prophylactic use of oral anticholinergics during typical antipsychotics prescription.

2. Acute akathisia:

  • Commonest side effect of antipsychotics.

Features:

  • Characterized by an inner sense of restlessness along with objective.
  • Observable movements (fidgeting of legs, pacing around, inability to sit or stand in one place for a long time).

Management:

  • Beta-blockers (propranolol DOC)
  • Anticholinergics
  • Benzodiazepines.
  • Prevented by changing to 2nd generation or low potency 1st-generation antipsychotics (lesser incidence of akathisia).

3. Drug induced parkinsonism:

Features:

  • Characterized by triad – Rigidity, bradykinesia & resting tremors.

Management:

  • Anticholinergics.
  • Changing to 2nd gen. antipsychotics or low-potency 1st gen. antipsychotics.
  • Dose reduction can be tried.
  • Prevented by prophylactic anticholinergic use.

4. Tardive dyskinesia:

  • “Tardive” refers to features developing after prolonged exposure.
  • Tardive dyskinesia develops after long-term antipsychotics treatment.

Features:

  • Involuntary movements of tongue (e.g. twisting, protrusion), jaw (e.g. chewing), lips (e.g. smacking, puckering), trunk or extremities.
  • Rapid, jerky movements (choreiform movements) or slow, sinusoid movements (athetoid movements).

Management:

  • Change to 2nd gen. antipsychotics.

5. Neuroleptic malignant syndrome: 

  • Fatal side effect of antipsychotics.

Features: 

  • Characterized by,
    • Muscle rigidity.
    • Elevated temperature (greater than 38°C). Increased CPK (creatine phosphokinase) levels.

Other symptoms: 

  • Diaphoresis, tremors, confusion, autonomic disturbances, liver enzyme elevation & leukocytosis.

Mechanism: 

  • D2 antagonism at various levels.
  • D2 receptors blockade in corpus striatum→ Causes muscle contraction & rigidityInitiating heat generation.
  • Continuing muscle damage→ Result in myoglobinuria & renal failure.
  • D2 receptors blockade in hypothalamus interferes with heat regulation.
  • D2 receptors blockade of spinal neurons causes autonomic disturbances.
    • Increased CPK indicates muscle injury.

Management:

  • Early recognition of symptoms & prompt withdrawal is paramount importance.

Treatment:

  • Skeletal muscle relaxants (dantrolene).
  • Dopamine agonists (amantadine & bromocriptine).

Supportive measures:

  • Adequate hydration.
  • During antipsychotics treatment is restarted – 2nd gen. antipsychotics should be used.

NOTE: ALL EXTRAPYRAMIDAL SIDE EFFECTS ARE ALSO CAUSES BY ATYPICAL ANTI-PSYCHOTICS BUT WITH LESSER INCIDENCE.

Exam Important

  • Extrapyramidal side effects are caused by antipsychotics.
  • Extrapyramidal side effects by antipsychotics are due to dopamine receptor blockade in nigrostriatal tract.
  • Extrapyramidal side effects are more common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Types of movement disorders includes acute dystonia, acute akathisia, drug-induced parkinsonism, tardive dyskinesia & neuroleptic malignant syndrome.
  • Acute dystonia is the earliest side effect.
  • Acute dystonia is characterized by torticollis, trismus (contraction of jaw muscles).
  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea) is used for managing acute dystonia.
  • Acute akathisia is commonest side effect of antipsychotics.
  • Acute akathisia is characterized by observable movements (fidgeting of legs)
  • DOC for acute akathisia is beta-blockers (propranolol).
  • Tardive dyskinesia develops after long-term antipsychotics treatment.
  • Neuroleptic malignant syndrome is a fatal side effect of antipsychotics.
  • Neuroleptic malignant syndrome is characterized by muscle rigidity, elevated temperature (greater than 38°C) & increased CPK (creatine phosphokinase) levels.
  • Skeletal muscle relaxants (dantrolene) is used for management of neuroleptic malignant syndrome.
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Depression – Introduction & Symptoms

DEPRESSION – INTRODUCTION & SYMPTOMS

Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Ans. A

Explanation:

Female REF: Kaplan and sadock’s synopsis in psychiatry 10th ed p. 529

Risk factors of suicide in depression are:

  • At end( involutional) or beginning of depression
  • Mood disorders , personality disorders , psychosis , hypochondriac
  • >45yrs male, unemployed, single, divorced, chronically ill, widowed, recently bereaved
  • Family history

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Ans. A

Explanation:

A i.e. Formal thought disorder


Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Ans. B

Explanation:

B i.e. Middle age female

Quiz In Between


Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Ans. B

Explanation:

B i.e. Serotonin & Noradrenaline (Nor epinephrine)


Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Ans. C

Explanation:

C i.e. Third person hallucination


Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Ans. B

Explanation:

B i.e. Endogenous depression

Quiz In Between


Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Ans. C

Explanation:

Ans. C: Vague body aches

Multiple physical symptoms (such as heaviness of head, vague body aches) are particularly common in the elderly depressives and depressed patients from the developing countries (such as India)

Depression:

  • MC psychiatric disorder in India: Depression
  • Neurotransmitter involved: Serotonin and nor-epinephrine
  • MC cause of suicide: Depression
  • Risk features of suicide in depression:

— Endogenous type of depression

— Psychotic depression

  • MC type of post-purpueral psychosis: Depression
  • Nihilistic ideas: Seen in depression

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Ans. D

Explanation:

Ans. 32°C


Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Ans. B

Explanation:

Ans. 2 weeks

Quiz In Between


Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Ans. C

Explanation:

Ans. c. Cognitive behaviour therapy

The evidence-based psychological therapy of choice for depression is cognitive behaviour therapy.

“Cognitive Behavioral Therapy (CBT) developed by Aron Beck, is an extremely useful and evidence based non pharmacological intervention for depression. This therapy involves identification of the cognitive errors (thinking errors) in an individual and replacing the same with alternative thoughts, which are more adaptive and healthy in nature. It is most useful in patients suffering from mild to moderate depression.”- Kaplan and Sadock 10/e pe p553

Cognitive (Behaviour) Therapy

  • It was developed by Beck and Meichenbaum, for the treatment of depression°, anxiety disorder°, panic disorder°, phobias°, eating disorders°, anticipatory anxiety°, and also for teaching problem solving skills° (methods).
  • It involves:
  • Cognitive techniques (e.g. recognizing and correcting negative thoughts, teaching reattribution techniques, increasing objectivity in perceptives, identifying and testing maladaptive assumptions, and decentering) Behaviour techniques (activity scheduling, homework assignment, graded task assignment, behavioral rehearsal, role playing, and diversion technique)

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e., All of the above

  • All the given drugs are SSRI antidepressants.

Antidepressants

  • Typical

a. Tricyclic antidepressants

  1. NA + 5HT reuptake inhibitors:- Imipramine, Trimipramine, Amitriptyline, Clomipramine.
  2. Predominantly NA reuptake inhibitors:- Desipramine, Nortriptyline, Amoxapine, Reboxetine.

b. Selective serotonin reuptake inhibitors:- Fluoxetine, Paroxetine, Sertaline, Citalopram, Scitalopram.

B. Atypical :- Trazodone, Mianserine, Mitrazapine, Venalafaxin, Duloxetine, Tianeptine, Amineptine, Bupropion.

C. MAO inhibitors :Tranylcypramine, Meclobemide, Clorgyline


Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Ans. C

Explanation:

Ans. is ‘c’ i.e., Nihlistic ideas

Diagnostic criteria for major depression

  • 5 or more of following symptoms should be present most of the day for at least 2 weeks: ‑
  1. Depressed mood
  2. Loss of interest or pleasure in all activities.
  3. Decrease/increase appetite or loss/gain of weight.
  4. Insomnia or hypersomnia (Increased or decreased sleep).
  5. Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  6. Fatigue or loss of energy (weakness or lethargy).
  7. Feelings of worthlessness or excessive guilt.
  8. Diminished concentration
  9. Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.
  • At least one of symptoms should be either :‑
  1. Depressed mood or 2) Loss of interest or pleasure —) These two (1 & 2) are essential criteria. Therefore 1 essential criterian and 4 other criteria (total 5) should be persent.

Quiz In Between


Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Ans. C

Explanation:

Ans. is ‘c’ i.e., Distractibility

Clinical features of depression

  • The classical triad of depression is depressed mood, psychomotor retardation, and slowed-down thinking.
  1. Mood : Mood is characteriztically low and sad. There is loss of interest and pleasure in almost all activities, which result in social withdrawal, avolition,occupational dysfunction. In severe cases there may be anhedonia (inability to experience pleasure).
  2. Thoughts (Thinking) : – Pesimistic thoughts conerning the patients past, present and future occur which results in Hopelessness, Helplessness, and worthlessness. Other thought problems may be guilt-feeling, Loss of self esteem, Suicidal ideas, Delusion of nihlism (World has come to an end, Intestines has been rotated away, No brain in head), Hypochondriacal delusions [Patient believes that he has severe (cancer) or incurable disease (eg. AIDS)]. Other delusions that may occur in elderly include paranoid or persecutory delusion, and delusional jealousy.
  3.  Psychomotor activity : – There is psychomotor retardation —> Movements are sluggish & laboured, lack of initiative & energy, Easy fatiguability. In severe form, the patient becomes stuporous (depressive stupor). In older patient there may be agitation and restlessness.
  4. Cognition : – There is poor concentration, which may lead the patient to think (mistakenly) that the memory is also impaired (However, memory is normal). In old patients depression may present similar to dementia, i.e., Pseudodementia.
  5. Somatic symptoms & biological disturbances : – Multiple physical symptoms are common in elderly patient. Symptoms include heaviness of head, generalized ache & pain, Loss of sexual drive and amenorrhea, severe disturbance in biological function is called somatic syndrome (melancholia). Somatic syndrome (melanocholia) is characterized by :-
  • Decrease in appetite or weight
  • Early morning awakening, at least 2 hours before usual time.
  • Diurnal variation, depession is worse in morning
  • Loss of interest and loss of reactivity to pleasurable stimuli, and loss of pleasure in all activities.
  • Psychomotor agitation or retardation.
  • Excessive or inappropriate guilt.

6. Psychotic symptoms (Psychotic depression) : – Occur in 15-20% of patients. Symptoms include 2″a person auditory hallucinations, delusions, grossly inappropriate behavior. These symptoms may be mood congruent (e.g., nihilistic delusions, delusions of poverty or guilt) which are understandable in the light of depressed mood or can be mood incongruent (e.g., delusion of control) which are not directly related to depressive mood. Psychotic depression usually occur later in life and is associated with severe depression.


Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Ans. A

Explanation:

Ans:A. Melancholia


Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Ans. A

Explanation:

Ans. is ‘a’ i.e. Cerebro-vascular disorder

[Ref: Oxford Textbook of Stroke and Cerebrovascular Disease p. 2461]

important causes of depression

  • General medical/neurological/endocrine disorders: – Cerebrovascular disorders, CNS infection, Parkinson’s disease, Dementia (Alzheimer’s disease), Hyperthyroidism, Hypothyroidism,Cushing’s disease or Addison’s disease, Hypopituitarism, Acromegaly, Hyperparathyroidism, Hypoparathyroidism, Postpartum period, Menses related disorders, Cancer, Tuberculosis

Quiz In Between


Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Ans. A:B:D

Explanation:

Ans. A,Self B,Future & D,World and environment 

  • Aaron Beck postulated a cognitive triad of depression.

Consists of,

  • Views about tlw self-a negative self precept.
  • About environment-a tendency to experience the world as hostile and.demanding.
  • About future – expectation of suffering and failure.

Therapy consists of modifying these distortions.

  • Cognitive triad :Beliefs about oneself, the world, and the future.

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Ans. A

Explanation:

Ans. A. Delusion of grandeur

[Ref Niraj Ahaia p. 7l-72; Keplarn and Sadsck  p. 357]

Diagnostic criteria for major depression

  • 5 or more of the following symptoms should be present most of the day for at least 2 weeks: –
  • Depressed mood
  • Loss of interest or pleasure in all activities.
  • Decrease/increase appetite or loss/gain of weight.
  • Insomnia or hypersomnia (Increased or decreased sleep).
  • Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  • Fatigue or loss of energy (weakness or lethargy).
  • Feelings of worthlessness or excessive guilt.
  • Diminished concentration
  • Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.

Quiz In Between



Depression – Introduction & Symptoms

DEPRESSION – INTRODUCTION & SYMPTOMS


DEPRESSION – INTRODUCTION & SYMPTOMS

INTRODUCTION:

  • One of commonest psychiatric disorder.
  • Responsible for maximum DALYs (disability-adjusted life years) amongst all psychiatric disorders.
  • Most common cause of suicide.
  • Characterized by major depressive episodes in absence of any manic, mixed or hypomanic episodes.

EPIDEMIOLOGY:

  • Lifetime prevalence = 17%
  • More prevalent in women (Middle-aged)
    • Mean onset age – 40 years.
  • More commonly in divorced & separated persons.

CAUSES:

Biological factors – 

  • Neurotransmitters disturbance (Decreased levels of serotonin & norepinephrine).
  • Hormonal disturbance (Elevated HPA activity (hypothalamic-pituitary-adrenal axis activity) & hypothyroidism).
  • Neuroanatomical consideration – Decreased activity in dorsolateral prefrontal cortex & increased activity in amygdala).
  • Genetic factors – Element binding protein (CREB 1)on chromosome 2.

Psychological theories –

  • Cognitive theory – 
  • Cognitive triad of depression – Negative view of self (ideas of worthlessness), negative views about environment (ideas of helplessness) & negative view about future (ideas of hopelessness).
  • Learned helplessness.

SYMPTOMS:

  • Pneumonics = SIGECAPS.

1. Sleep disturbances:

  • Insomnia & sometimes hypersomnia.
  • Characteristic sleep pattern – Early morning awakening & reduced latency of REM sleep.

2. Interest (Loss)/anhedonia:

  • Loss of interest in activities which interests patient before.

3. Guilt: 

  • Excessive guilt feelings.
  • Blaming himself for trivial matters.

4. Energy (lack): 

  • Decreased energy levels.
  • Ea
  • sy fatigability.

5. Cognition/Concentration:

  • Negative cognitions (thoughts).
  • Poor concentration.

6. Appetite:

  • Loss of appetite & weight loss (usually).
  • Sometimes weight gain also.

7. Psychomotor agitation or retardation:

  • Psychomotor – Changes in motor activity secondary to psychological causes.
  • Increased activities (restlessness) or decreased (dormant activities).

8. Suicidal thoughts.

9. Sadness of mood (depressed mood).

SPECIAL FEATURES IN DEPRESSION:

Psychotic features

  • Severe depression patients present with psychotic symptoms (delusions & hallucinations) – Referred as “psychotic depression”.
  • Psychotic symptoms are mood congruent (content of delusion) or nihilistic delusion.

Atypical features:

  • Presents reverse biological symptoms (hypersomnia, overeating & weight gain).

Melancholic features:

  • Depression with melancholic features referred to “involutional melancholia”.
  • Seen in old age.
  • Characterized by severe anhedonia, profound guilt feelings, early morning awakening, eight loss, agitation & high suicide risk.

Catatonic features:

  • Catatonic symptoms like stupor & negativism.

DIAGNOSTIC CRITERIA:

  • All symptoms must last for > 2 weeks.
  • SWAG (suicidality, weight loss, anhedonia and guilt feelings) – Suggestive of depression.

Exam Important

  • Depression is responsible for maximum DALYs (disability-adjusted life years) amongst all psychiatric disorders.
  • Depression is most common cause of suicide.
  • Depression is caused by neurotransmitters disturbance due to decreased levels of serotonin & norepinephrine.
  • Depression is caused by hormonal disturbance due to hypothyroidism.
  • Depression is caused by neuroanatomical disturbance due to decreased activity in dorsolateral prefrontal cortex.
  • Cognitive theory includes cognitive triad of depression which includes negative view of self (ideas of worthlessness), negative views about environment (ideas of helplessness) & negative view about future (ideas of hopelessness).
  • Symptoms of depression include insomnia, loss of interests, lack of energy, gulit feeling, poor concentration, loss of appetite & weight, suicidal thoughts, psychomotor agitation or retardation.
  • Characteristic sleep pattern in depression is early morning awakening & reduced latency of REM sleep.
  • Severe depression patients presents with psychotic symptoms (delusions & hallucinations) collectively referred as “psychotic depression”.
  • Psychotic symptoms in depression are mood congruent (content of delusion) or nihilistic delusion.
  • Melancholic features are seen in old age.
  • Depression is diagnosed only after all symptoms must last for > 2 weeks.
Don’t Forget to Solve all the previous Year Question asked on DEPRESSION – INTRODUCTION & SYMPTOMS

Module Below Start Quiz

Depression – Treatment

DEPRESSION – TREATMENT


DEPRESSION – TREATMENT

Treatment modalities:

  • Pharmacotherapy.
  • Psychotherapy.
  • Other somatic treatments.

1. Pharmacotherapy:

Considerations:  

  • All available antidepressants takes 3-4 weeks to exert significant therapeutic effect.
  • Usage of specific pharmacotherapy doubles chances for recover within 1 month.
  • All available antidepressants have similar profile except adverse effects.
    • Choice of drug also depends on their adverse effects.

Duration of therapy:

  • Antidepressant treatrnent should be maintained for atleast 6 months or equal to duration of previous episode, whichever is greater.
  • Prophylactic antidepressant treatment is effective in reducing number & severity of episodes.
    • Should be given to patients who have had 3 or more prior depressive episodes or in chronic major depressive disorder (> 2 years duration).

Drugs used – 

Tricyclic and tetracyclic antidepressants (TCAs):

  • 1st class of antidepressants used.

MOA: 

  • Primary action – Acts by blocking serotonin & norepinephrine transporters —> Increases neurotransmitters levels in synapses.
  • Secondary action– Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage. 
  • Responsible for their side effect.

Drugs included: 

  • lmipramine, desipramine, trimipramine, amitriptyline, nortriptyline, protriptyline, amoxapine, doxepin, maprotiline & clomipramine.
  • Clomipramine – Most serotinin selective drug.
  • Desipramine – Most norepinephrine selective drug.

Adverse effects: 

  • Anticholinergic side effects (constipation, urinary retention), cardiac arrhythmias, hypotension & seizures (Sodium channel bloack in heart & brain), & sedation.

Contraindications: 

  • Glaucoma, prostate hypertrophy, 

Selective serotonin reuptake inhibitors (SSRIs):

  • Most commonly prescribed antidepressants.
  • Lesser adverse effects.
  • DOC for depression, obsessive compulsivel disorder, post-traumatic stress disorder, panic disorder, generalized anxiety disorder & phobia.
  • MOA: Acts by blocking serotonin reuptake.
  • Drugs included: Fluoxetine, fluvoxamine, citalopram, escitalopram, sertraline, paroxetine, vortioxetine, & vilazodone.
  • Adverse effects: Nausea (most common) –> anxiety & diarrhoea.

Vortioxetine: 

  • Recent antidepressant.
  • MOA: Serotonin reuptake inhibitor. agonism at 5-HT1A receptor, partial agonism at 5-HT1B receptor & antagonism at 5-HT3. 5-HT1D & 5-HT7 receptors.

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors):

  • MOA: Blockade of neuronal serotonin & norepinephrine uptake transporters.
    • Hence,“dual reuptake inhibitors”.
  • Drugs included:Venlafaxine, desvenlafaxine, duloxetine, milnacipran, levomilnacipran.

Monoamine oxidase inhibitors:

  • MOA: Inhibits monoamines enzyme (MAO-A & MAO-B) metabolism.
  • Drugs included: Non-selective MAO inhibitors – Tranylcypromine, phenelzine & isocarboxazid.

Atypical antidepressants:

Drugs included: 

  • SARI (serotonin antagonist & reuptake inhibitors): Trazodone & nefazodone.
  • NSSA (nor adrenergic and specific serotonergic antidepressant): Mirtazapin.
  • NDRI (norepinephrine-dopamine reuptake inhibitors): BupropionInhibition of norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer: Tianeptine & amineptine – Acts by enhancing serotonin reuptake.
  • Antipsychotics: In patient with depression & psychotic symptoms.

2. Psychotherapy:

Techniques used:

  • Cognitive behavioral therapy:
    • Aims at correcting cognitive distortions (faulty ways of thinking) & faulty behaviors.
    • Most effective psychotherapeutic technique for depression.
  • Interpersonal therapy.
  • Other therapies: 
    • Behavior therapy, family therapy & psychoanalytically oriented therapy.

3.  Other somatic treatments

Electroconvulsive therapy (ECT): 

Indications: 

  • Severe depression with suicide risk.
  • Severe depression with stupor.
  • Depression with psychotic symptoms
  • Refractoriness to other treatment modalities.

Transcranial magnetic stimulation:

  • Newer modality using magnetic energy.
  • Nonconvulsive.
  • Not requires anesthesia.
  • Lesser side effects.
  • Vagal nerve stimulation.

Deep brain stimulation – 

  • Used for chronic & intractable depression.

Exam Important

  • Choice of antidepresseant drug depends on their adverse effects.
  • Antagonism of muscarinic, histaminic H1, α1 & , α2 adrenergic receptors & cardiac sodium channels bloackage by TCA’s is responsible for their side effect.
  • NDRI (norepinephrine-dopamine reuptake inhibitors) like Bupropion inhibits both norepinephrine & dopamine reuptake.
  • Serotonin reuptake enhancer like tianeptine & amineptine acts by enhancing serotonin reuptake.
  • Cognitive behavioral therapy is most effective psychotherapeutic technique for depression.
  • Electroconvulsive therapy (ECT) is therapy of choice for patient with severe depression with suicide risk & with stupor.
  • Somatic treatments methods used for treating depression includes transcranial magnetic stimulation, vagal nerve stimulation & deep brain stimulation.
  • Antidepressant drug used in nocturnal eneuresis is Imipramine.
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Benzodiazepine

BENZODIAZEPINE


CLASSIFICATION:

  • Long Acting
    • Flurazepam 50-100 t1/2(hrs)
    • Diazepam 30-60 t1/2(hrs)
    • Nitrazepam 30 t1/2(hrs)
    • Flunitrazepam 15-25 t1/2(hrs)
  •  Short-Acting 
    • Temazepam with t1/2 8-12 hrs
      • Benzodiazepine without anticonvulsant property.
    •  Triazolam with t1/2 2-3 hrs
    •  Midazolam 2 t1/2(hrs)
    • Alprazolam 

MOA:

PHARMACOKINETICS:

  • Short-acting BZDs:
  • Eg: Midazolam – IV or IM as an induction agent.
    • Rapid onset of action.
    • Quick drug clearance.
    • Causes anterograde amnesia, tachyphylaxis during high dose infusions.
    • Decreased cardiovascular effects as compared to propofol 
  • Temazepam or oxazepam – Revives insomnia. 
    • At lower doses, relieves acute symptoms of anxiety, such as panic attacks & phobias.
  • Long-acting BZDs: 
    • Slower onset of action following oral administration → Hence prolonged pharmacological action.
    • Sedation.
    • Prevents increased muscle tone of tetanus infection. 
  • Metabolized in liver by dealkylation and hydroxylation.
  • Excreted in urine as glucuronide conjugates.

ACTIONS:

  • Antianxiety
  • Sedation: 
    • Increasing dosage produce sleep & hence considerable as hypnotic
    • I.V administration used extensively to produce conscious sedation during unpleasant procedures. 
    • Eg: Diazepam & midazolam.
    • Cardiovascular stability – IV diazepam 
    • Midazolam potentiates propofol in co-induction technique.
  • Anticonvulsants: 
    • Clonazepam & diazepam – Effective in status epilepticus.
  • Muscle relaxation: 
    • Reduce muscle tone.
  •  Amnesia: 
    • IV benzodiazepines produces antegrade amnesia. 
    • Midazolam – Very intense for 20-30 minutes
    • Lorazepam – Longer amnesia – 6 hr.

DRUGS:

  • Inverse agonist of benzodiazepine receptor – Beta carboline.
  • Benzodiazepine antagonist – Flumazenil

USES:

  • As hypnotic –
    • Daytime sedation (Alprazolam)
  • As anxiolytic.
  • Antidepressant  (Alprazolam)
  • As anticonvulsants, especially emergency control of status epilepticus  
    • To avoid future recurrence of seizure attacks Oral Diazepam 6 hourly is given.
  • As centrally acting muscle relaxant.
  • For anesthetic medication and IV anesthesia 
  • Alcohol withdrawal in dependent subjects 
  • Mostly given along with analgesics (NSAIDs|). 
  • DOC in elderly & with liver disease.
    • Lorazepam, OxazepamTemazepam
  • Spasmolytics.
  • Anti-ulcer.

ADVERSE EFFECT:

  • Dizziness, lassitude, vertigo, disorientation, amnesia, increased reaction time with motor incoordination, impairment of mental coordination occur. 
  • Weakness, blurring of vision, dry mouth and urinary incontinence.
  • BZD poisoning:
    • Benzodiazepine antagonist -Flumazenil
    • Eg: Diazepam poisoning.
  • Paradoxical stimulation, irritability, and sweating may occur with flurazepam.
  • Increase in nightmares and behavioral alterations 
  • Increased psychological effects with usage of short-acting benzodiazepines in insomnia. 
  • Disturbed REM sleep patterns.

Exam Important

  • Diazepam poisoning is treated by Flumazenil
  • Benzodiazepine antagonist  Flumazenil
  • Benzodiazepines of choice in elderly and those with liver disease Lorazepam, Orazepam & Temazepam
  • Shortest acting benzodiazepine is Triazolam
  • Benzodiazepine without anticonvulsant property is Temazepam
  • To avoid future recurrence of seizure attacks Oral Diazepam 6 hourly is given
  • Alprazolam is an anxiolytic benzodiazepine with  antidepressant  action
  • IV diazepam  shows Coronary dilatation
  • Inverse agonist of benzodiazepine receptor is Beta carboline
  • Midazolam causes  Anterograde amnesia, tachyphylaxis during high dose infusions & Decreased cardiovascular effects as compared to propofol
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Pelvis Musculature

PELVIS MUSCULATURE


 PELVIC MUSCULATURE:

The pelvic muscles of importance in gynaecology are those of the pelvic floor grouped into three layers:

LAYER MUSCLE
Pelvic Diaphragm 2 levator ani muscles

  • Pubococcygeus
  • Iliococcygeus
  • Ischiococcygeus
Obturator internus
Puborectalis
Urogenital Diaphragm Sphincter urethra

Deep transverse Perineal

Compressor urethra

Superficial Layer Superficial transverse Perineal

Ischiocavernous

bulbospongiosus

The external
sphincter muscle of the anus

Muscle Origin Insertion
Pubococcygeus Post. Pubic bone Anococcygeal raphe and coccyx
Iliococcygeus white line of the pelvic fascia coccyx.
Ischiococcygeus ischial spine coccyx
Obturator internus Pelvic aspect of ischium & ilium

Obturator membrane

 Greater trochantor of femur
Puborectalis  Posterior surface of pubis   Midline sling posterior to rectum
Sphincter urethra   Circular anatomical sphincter  Fuses with deep transverse perinei
Compressor urethra  ischiopubic ramus Blends with its partner on the other side

anterior to urethra

below external urethral sphincter

Superficial transverse Perineal  Ischial tuberosity   Perineal body
Ischiocavernous   Ischial tuberosity  Clitoris
bulbospongiosus  Central point of  perineum  symphysis pubis
Deep transverse Perineal  Ramus of ischium  Perineal body
The external
sphincter muscle of the anus
Central point of the perineum Surrounds the anus

ACTION OF MUSCLES:

The roles of the pelvic floor muscles are:

  • Support of abdominopelvic viscera (bladder, intestines, uterus etc.) through their tonic contraction.
  • Resistance to increases in intra-pelvic/abdominal pressure during activities such as coughing or lifting heavy objects.
  • Urinary and fecal continence.The muscle fibers have a sphincter action on the rectum and urethra. They relax to allow urination and defecation.Puborectalis is essential to maintain continence

Exam Important

  • Muscles that can cause external rotation of the hip include Obturator internus
  • Pubovaginalis, External urethral sphincter & Bulbospongiosus are sphincters of lower genito urinary tract of female 
  • Pelvic diaphragm is formed by Pubococcygeus,Iliococcygeus & Pubovaginalis
  • Urogenital Diaphragm is made up of Sphincter urethrae , Perineal membrane & Deep transverse Perineal muscle
  • Superficial perineal muscles include Bulbospongiosus
  • Lateral border of ischeorectal fossa is formed by Obturator internus
  • Puborectalis is essential to maintain continence
  • Sphincter urethrae is Voluntary, Arises from ischiopubic ramus and are Supplied by pudendal nerve
  • Pubococcygeus supports prostate
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TUBERCULOSIS OF SPINE (Pott’s disease)

TUBERCULOSIS OF SPINE (Pott’s disease)


TUBERCULOSIS OF THE SPINE  (Pott’s disease)

  • The spine is the commonest site of bone and joint tuberculosis.
  • Dorso-lumbar region affected most frequently.

Types of vertebral tuberculosis:

1. Paradiscal: commonest type

2. Central:

  • Single vertebra is affected.
  • This leads to early collapse of the weakened vertebra.
  • The nearby disc may be normal.
  • The collapse may be a ‘wedging’ or ‘concertina’ collapse 

 3. Anterior:

  • infection is localised to the anterior part of the vertebral body.

 4. Posterior:

  • the posterior complex of the vertebra i.e., the pedicle, lamina, spinous process and transverse process are affected.

CLINICAL FEATURES

  • Pain (back pain)
  • Stiffness
  • Cold abscess
  • Paraplegia
  • Deformity: increasing prominence of the spine – gibbus.
  • Constitutional symptoms: Symptoms like fever, weight loss etc.

RADIOLOGICAL INVESTIGATIONS

X-ray examination:

  • Reduction of disc space: earliest sign  
  • Destruction of the vertebral body 

Evidence of cold abscess:

1). Para-vertebral abscess-

  1. fusiform para-vertebral abscess (bird nest abscess – an abscess whose length is greater than its width (Fig-23.7a);
  2. globular or tense abscess – an abscess whose width is greater than the length

2). Widened mediastinum-

3). Retro-pharyngeal abscess

4). Psoas abscess

  • Rarefaction: diffuse rarefaction of the vertebrae above and below the lesion.
  • Unusual signs: erosion of the posterior elements of pedicle, lamina etc.
  • Signs of healing

CT scan:

  • very useful investigation in cases presenting as ‘spinal tumour syndrome’.

MRI:

  • Investigation of choice to evaluate the type and extent of compression of the cord.

Other investigations:

  • ESR, Mantoux test, ELISA test for detecting anti- tubercular antibodies, chest X-ray, etc.,

COMPLICATIONS

  1. Cold abscess:  commonest complication of TB of the spine.
  2. Neurological compression: At times the patient presents as a case of spinal tumour syndrome.
  • First clinical symptom being a neurological deficit.

Exam Important

  • Tuberculosis in Pott’s disease involves Spine.
  • Pott’s spine is commonest at Thoracolumbar spine.
  • Tuberculosis of spine is common at Thoracolumbar.
  • Most common cause of cold abscess of chest wall is Pott’s spine.
  • Commonest presenting symptom of Pott’s spine is Back pain.
  • The paradiscal type is M/C type of vertebral tuberculosis.
  • Wedging or Concertina collapse: in central type.
  • Pott’s disease: M/C cause for kyphosis & cold abscess.
  • Earliest radiological sign of spine tuberculosis is reduction of intervertebral disc space.
  • M/C complication of spine tuberculosis cold abscess.
  • Investigation of choice- MRI.
  • M/c performed surgery- Antero lateral decompression.
  • TB of spine à bony ankylosis, other bones & joints a fibrous ankylosis.
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Cesarean Section

Cesarean Section


DEFINITION:

  • It is an operative procedure whereby the fetuses after the end of 28th weeks are delivered through an incision on the abdominal and uterine walls.

FACTORS FOR RISING CESARIAN SECTION RATE:

  • Rising incidence of primary cesarean delivery
  • Identfication of at risk fetuses before term (FGR)
  • Identfication  of high-risk pregnancy
  • Wider use of repeat CS
  • Rising rates of induction of labor and failure of induction
  • Decline in operative vaginal delivery & vaginal breech delivery
  • Increased number of women with age >30 years
  • Wider use of electronic fetal monitoring and increased  diagnosis of fetal distress
  • Fear of litigation

INDICATIONS:

Absolute Indications:

  • Vaginal delivery is not possible
  • Central placenta previa
  • Contracted pelvis or cephalopelvic disproportion
  • Pelvic mass
  • Advanced carcinoma cervix
  • Vaginal obstruction

Relative Indications:

  • Previous cesarean delivery
  • Fetal distress
  • Dystocia
  • Antepartum hemorrhage
    • Placenta previa
    • Abruptio placenta
  • Malpresentation
  • Failed surgical induction
  • Recurrent fetal loss
  • Hypertensive disorders
  • Medical-gynecological disorders
    • Diabetes
    • Coarctation of aorta
    • MS, AR, AS
    • Marfan’s syndrome
    • Mechanical obstruction

TYPES OF OPERATIONS:

  • Lower segment CS.
  • Upper segment (classical) CS.
  • Modified classical (de-lee) CS.

Lower segment cesarean section (LSCS):

PATIENT PREPARATION

  • Counseling.
  • Written informed consent.
  • Pre-operative evaluation.
  • Preparation of incision area
  • Bladder catheterization
  • Blood arrangements
  • Antibiotics
  • Heparin therapy.

PATIENT PREPARATION IN OPERATION THEATRE

  • Left lateral tilt at least 15 degree
  • Oxygen inhalation
  • Pediatrician should be available
  • Auscultation of fetal hearts before starting.

ANESTHESIA

  • General anesthesia
  • Spinal anesthesia
  • Epidural anesthesia
  • Local infiltration.

SKIN INCISIONS :

  • Pfannenstiel incision
  • Joel-Cohen incision.
  • Midline incision
  • Para-median incision

Uterine incision:

  1. Peritoneal incision: Transverse cut  across lower segment with convexity downwards
  2. Muscle incision:  Low transverse(90%):Slightly below peritoneal incision
  • Ease of operation
  • Less bladder dissection
  • Less blood loss
  • Easy to repair
  • Complete reperitonization
  • Less adhesion
  • Less risk of scar rupture

Other:

  • Lower vertical
  • Classical incision (upper segment).
  • “J” incision
  • Inverted “T” incision

PROCEDURE:

  • Two index fingers are then inserted through the incision down to the membranes and the muscles of the lower segment are split transversely.

Delivery of the head:

  • Membranes are ruptured
  • Suction of blood mixed amniotic fluid
  • Hooking the head with fingers by elevation and flexion using the palm
  • If the head is jammed push up the head by fingers introduced into the vagina
  • Wrigley’s or Barton’s forceps  also be used
  • Mucus from the mouth, pharynx and nostrils is sucked

Delivery of the trunk

  • After delivery of shoulders IV oxytocin 20 units or methergine 0.2 mg is to be administered
  • Head tilted down for gravitational drainage
  • Cord is cut between two clamps
  • The Doyen’s retractor is reintroduced.
  • The optimum interval between uterine incision and delivery should be less than 90 seconds.

Removal of the placenta and membranes:

  • Traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen using left hand

Suture of the uterine wound:

  • Allis tissue forceps or Green Armytage hemostatic clamps are used to pick margins of the wound

The uterine incision is sutured in three layers:

First layer:

  • Suture material is No “0” chromic catgut or vicryl
  • Continuous running suture taking deeper muscles excluding or including the decidua

Second layer:

  • Continuous suture placed taking superficial muscles and adjacent fascia overlapping first layer of suture.
  • Uterine muscles may be closed  taking full thickness muscle and decidua
  • The peritoneal flaps may be apposed by continuous inverting suture
  • Concluding part: The mops placed inside are removed and the number verified.
  • Peritoneal toileting is done and the blood clots are removed meticulously
  • After being satisfied that the uterus is well contracted, the abdomen is closed in layers.

CLASSICAL CESAREAN SECTION:

  • Abdominal incision is always longitudinal (paramedian)12.5 cm (5″) starting from below the fundus
  • Delivery commonly as breech extraction.
  • The uterus is eventrated.
  • The placenta is extracted by traction on the cord or removed manually
Lower Segment Classical
Techniques Difficult Easy
Blood loss is less More
Wall is thin and as such apposition is perfect Wall is thick and apposition of the margins is imperfect
Perfect peritonization  possible Not possible
Technical Difficulty in placenta previa or transverse Comparatively safer
Post-operative Less Hemorrhage and shock More
Peritonitis is less More
Convalescence is better Relatively delayed
Morbidity and mortality are much lower Morbidity and mortality are high
Less Peritoneal adhesions and intestinal obstructions More
Wound healing Perfect muscle apposition Imperfect
Minimal wound hematoma More
Wound  Quiescent during healing process Wound in state of tension
Chance of gutter formation is unlikely More
During future
pregnancy
Scar rupture(0.5–1.5%) More risk of scar rupture(4–9%)

COMPLICATIONS:

Maternal:

INTRAOPERATIVE::

  • Extension of uterine incision
  • Uterine lacerations
  • Bladder injury
  • Ureteral injury
  • Gastrointestinal tract injury
  • Hemorrhage
  • Morbid adherent placenta (placenta accreta)

POSTOPERATIVE COMPLICATIONS:

IMMEDIATE:

  • Postpartum hemorrhage
  • Shock
  • Anesthetic hazards:Mendelson’s syndrome
  • Infections
  • Intestinal obstruction
  • Deep vein thrombosis and thromboembolic disorders

Wound complications:

  • Sanguineous or frank pus
  • Hematoma
  • Dehiscence
  • Burst abdomen
  • Necrotizing fasciitis
  • Secondary postpartum hemorrhage

REMOTE:

  • Gynecological: Menstrual excess or irregularities, chronic pelvic pain or backache.
  • General surgical: Incisional hernia, intestinal obstruction due to adhesions and bands.
  • Future pregnancy: There is risk of scar rupture

FETAL:

  • Iatrogenic prematurity
  • RDS
  • MATERNAL AND PERINATAL MORTALITY

Exam Important

  • Indications for caesarean section in pregnancy are Aortic stenosis, M.R. & Aortic regurgitaion
  • Lower Segment Caesarean section (LSCS) can be carried out under  
    • General anaesthesia 
    • Spinal anaesthesia 
    • Combined Spinal Epidural anaesthesia
  • Absolute indication for caesarean section in pregnancy are
    •  Advanced Carcinoma Cervix 
    • Central Placenta Praevia 
    • Contracted Pelvis
  • History of previous classical CS  is the contraindication for trial of normal labour after caesarean section
  • Cephalopelvic disproportion is an absolute indication for Caesarean section.
  • In classical caesarean section more chances of rupture of uterus is in Upper uterine segment
  • Best management in Mento-posterior presentation Caesarean section
  • Absolute indication for caesarean section is Type IV placenta previa
  • Ideal management of a 37 weeks pregnant elderly primigravida with placenta praevia and active bleeding is Caesarean section
  • Placenat accrete complicates third stage of labour and is associated with a past history of caesarean section
  • Incidence of scar rupture in previous lower segment caesarean section 1%
  • Risk of rupture of uterus with previous classical caesarean section is 4-8%
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