Low-income urban working mothers face many challenges in their domestic, environmental, and working conditions that may affect their mental health. In India, a high prevalence of mental health disorders has been recorded in young women, but there has been little research to examine the factors that affect their mental health at home and work.Through a primarily qualitative approach, we studied the relationship between work, caring for family, spousal support, stress relief strategies and mental health amongst forty eight low-income working mothers residing in urban slums across Bangalore, India. Participants were construction workers, domestic workers, factory workers and fruit and vegetable street vendors. Qualitative data analysis themes included state of mental health, factors that affected mental health positively or negatively, manifestations and consequences of stress and depression, and stress mitigators.Even in our small sample of women, we found evidence of extreme depression, including suicidal ideation and attempted suicide. Women who have an alcoholic and/or abusive husband, experience intimate partner violence, are raising children with special needs, and lack adequate support for child care appear to be more susceptible to severe and prolonged periods of depression and suicide attempts. Factors that pointed towards reduced anxiety and depression were social support from family, friends and colleagues and fulfilment from work.This qualitative study raises concerns that low-income working mothers in urban areas in India are at high risk for depression, and identifies common factors that create and mitigate stress in this population group. We discuss implications of the findings for supporting the mental health of urban working women in the Indian context. The development of the national mental health policy in India and its subsequent implementation should draw on existing research documenting factors associated with negative mental health amongst specific population groups in order to ensure greater impact. Mental health disorders contribute significantly to the global burden of non-communicable chronic disease: the World Health Organization has estimated that mental and behavioural disorders account for 12% of the global burden of disease . While iLow-income urban working mothers face a range of challenges in their domestic, environmental, and working conditions that may affect their mental health. In India, the second most populous country in the world, approximately 31% of the total population lives in urban areas  and almoA few small-scale initiatives to provide community-based mental health services in India have been successful ,17, but While a number of studies have considered factors associated with mental health in rural and urban settings in India, this is the first qualitative study that analyses the specific needs of low-income working mothers in urban areas in India. In this paper, we examine life stressors as well as stress mitigating factors amongst low-income working mothers in Bangalore, the fifth most populous city in India , in ordeData for this analysis is drawn from a project aimed at understanding how low-income urban working mothers balance child care and work obligations within the context of family and community support, working conditions, children’s health and education, and their own health needs. Therefore, women of reproductive age were recruited for the study. This paper reports specifically on how the interplay of these factors affects mental health, assessed both qualitatively through descriptions of well-being and sadness, as well as quantitatively through the Kessler-10 scale.Mothers of children between the ages of 0-8 years old who were currently working (and had been working for a minimum of a year) as construction workers, domestic workers, garment factory workers, or fruit/vegetable/flower street vendors were eligible to participate in the study. The four occupation groups were selected on the basis of being the most common low-income occupations amongst mothers of young children living in slums in Bangalore, and were initially identified through discussions with key informants . These occupations also represented a range of working conditions, such as variable work hours and multiple employers for domestic workers; daily wage labour for construction workers and some street vendors; self-employment and flexible working hours for some street vendors; and, unionization and industrial labour regulation for garment factory workers. The appropriateness of the selected occupations was validated through rapid mapping of women’s occupations and incomes on visits to 5 small/medium slums in the city. Other common women’s occupation groups that were encountered during these visits were street sweepers and incense makers. Street sweepers were not included as part of the study because the majority of street sweepers were older and did not have children between 0-8 years. Incense rollers were not included as part of the study because they worked short and flexible hours at home, and consequently did not face the same challenges balancing work and home responsibilities as other working mothers. Amongst the selected occupation groups, monthly income for a full day’s work ranged from INR4,000-INR8,000 (USD75-150).A qualitative researcher visited multiple worksites  and low-income residential areas  to recruit study participants who would represent a range of working and living conditions. Forty-eight women (12 from each occupation group) who met the inclusion criteria were recruited.The study protocol received ethical approval from the institutional review board of the St. John’s Medical College, Bangalore, India. The purpose and procedures of the study were verbally explained to participants, and they were advised that they could choose not to answer any of the questions or withdraw from the interview at any time. Information sheets were available to literate participants, and all participants signed or initialled an informed consent form. A small cash honorarium of a hundred Indian rupees (USD1.60) was provided to participants, as compensation for their time.Interviews were conducted by a qualitative researcher in the local language, Kannada, at a time and place of the participant’s choice. To maintain confidentiality, a private location was sought for the interview; however, some participants selected locations where they could continue to do their work, even if others could hear the conversation. The data was collected in 2 phases between August-November 2011 (24) and December 2011-January 2012 (24). All participants (n = 48) were administered a short closed-ended questionnaire. The closed-ended questionnaire was developed for this study to include basic indicators to assess the demographic and economic profile of the household. It included questions on participant age, marital status, participant and spouse highest education level, years of experience in current occupation, house ownership, number and age of children, monthly household income, household assets , and workplace benefits . The participants were then interviewed with in-depth open ended questions for about an hour about their working conditions, child care and spousal support, child and maternal health and wellbeing, and family, community and other types of support available to them. Following a preliminary analysis of the first phase of interviews, more detailed questions were added in the second phase on mental health status, the relationships between work, caring for family, spousal support and mental health, the availability of emotional support, and stress mitigators. The Kessler psychological distress questionnaire was also administered to the second phase participants. This 10-item scale, validated for use in India, yields a global measure of distress based on questions about anxiety and depressive symptoms that a person has experienced in the past four weeks ,22. PartAfter completion of data collection, all participants were assigned aliases to maintain anonymity in the reporting of results. Interviews were simultaneously translated and transcribed in English by bi-lingual research assistants. The transcripts were reviewed by the interviewer, who listened to the audio recording while reading through the transcripts to check for accurate and consistent translation. Transcripts were subsequently language edited to ensure contextual translation. The transcripts were then analysed thematically, using NVivo 9.2 qualitative data analysis software . TranscrThe socio-economic and Kessler scale data were entered and analysed in Statistical Package for the Social Sciences v.18 . A variaStudy participants were aged between 19 to 40 years, and had between 1 and 5 children. Socio-demographic and economic characteristic of the participants are detailed in Table Out of the 24 respondents who were administered the Kessler 10 test, nearly half (11) were diagnosed as likely to have a moderate to severe mental disorder. One third (8) were likely to have a mild mental disorder, and only a fifth (5) were diagnosed as likely to be well. In the qualitative interviews with all 48 participants, about two thirds of women (32) mentioned that their mental health was not good. Less than one fifth of the participants (9) mentioned that they felt peaceful or happy with the current situation in their life. Amongst Phase 2 participants, 17 of the 21 women who spoke about their mental health concerns in interviews were found likely to have a mild to severe mental disorder as per the Kessler scale. This indicates a correspondence of over 80% between qualitative assessment and the Kessler assessment.Some women had experienced sustained states of depression and hopelessness, while others spoke about experiencing a poor state of mental health which had passed when circumstances changed. The mothers in this study described a range of symptoms commonly associated with manifestations of poor mental health  in the study reported that their husbands drank alcohol regularly and heavily. Most of the women whose husbands drank regularly also reported experiencing intimate partner violence (22), which profoundly affected their mental health. Most of the respondents (5 of 7) who spoke about attempted suicide or suicidal ideation were victims of intimate partner violence. In some families, children were also victims of abuse by an alcoholic father. None of the women mentioned seeking help in dealing with an alcoholic spouse or intimate partner violence.Bhavya related how constant verbal and physical abuse from her alcoholic husband had pushed her to attempt suicide, and continued to be a source of domestic strife:“My daughter was very small at that time. One night [my husband] came and beat me a lot and told me to leave the house. I went to the railway station and tried to commit suicide on the railway track. One of my relatives saw me there and took me back [home], telling me: ‘a drunkard’s words are not serious, in the morning it will be alright.’ Another time I took off my mangalsuthra (necklace symbolising marriage in Hinduism) and gave it to him, saying ‘I don’t want you,’ and went to my sister’s place. I stayed there for one week, he came to me after a week and asked for forgiveness and took me back [home]. Even last night he was drunk and fought with me till midnight. When he comes home drunk, he tells me to leave the house, sometimes he asks me to go out alone, sometimes he asks me to take my children also”. Bhavya, Construction WorkerManjulla spoke about wishing she could die when her husband abused her, but recognized the need to live to take care of her children:“I feel ‘why should I be abused by him, let me die,’ but seeing my children’s faces, I think: ‘I am alive, if I die my mother-in-law might take care for some days, [what] after that? My husband will get married again, he will not take care of my children.’’ Manjulla, Domestic WorkerSruti, a 19 year old mother of a six month old infant, has suffered significant mental distress as a result of spousal abuse, but had experienced relief upon separating from her husband:“I am at peace now, that’s what I feel because when my husband was around he used to fight everyday and I had no peace of mind. But for the past one month (after separating), now I am at peace”. Sruti, Street VendorMahima, a 28 year old mother of 3 children spoke about the physical and verbal abuse that her children endured due to their father’s alcoholism. To protect them, she sent her children away to boarding school. She worries that her children are not receiving adequate care and nutrition at school, but feels that she cannot keep them at home because of her abusive spouse:“My husband is an alcoholic, when he drinks and comes home he uses bad words in front of the children and that has an effect on the children…. Besides that, my husband hits the children a lot or sometimes when he hits me my children start crying and they come to stop the father, but my husband does not bother and he hits the children also. I feel bad to see them getting beatings…so I sent them away to a hostel”. Mahima, Domestic WorkerMothers with special needs children are particularly susceptible to chronic stress and depression. Most respondents also reported that they faced barriers in providing adequate care when their children fall sick, including not having enough money for treatment and not having time to care for the sick child due to work commitments. These ill-health episodes could cause significant mental anguish, leading to short-term anxiety and even depression. When Lalitha, a mother of two children, had to care for her 4 year old daughter who fell sick, she had to take out loans to pay for her daughter’s health care, and did not have money to pay for transportation to bring her daughter home from the hospital, despite working hard to earn an income to support her family; this contributed to her feelings of hopelessness:“When my elder daughter was not feeling well, I didn’t eat for 2-3 days, I was crying the whole day and sitting on the road, while she had to come back from hospital at 3 pm. Somebody helped me by giving me a ride in their vehicle at night…..I didn’t have money, I had pledged my mother’s jewellery and taken her to the hospital, I felt very bad that time, I didn’t have money and my daughter was very serious, at that time, I felt, why should we be living?” Lalitha, Domestic WorkerFinancial difficulties, lack of support, and devaluation of the lives of children with special needs affected both the mothers and their children. Sameena, a 31 year old mother of four girls, found it difficult to cope with caring for her 8 year old daughter who was born with a heart defect, given her financial constraints and the lack of support from her alcoholic husband. She took six months off from work to get the child treated, which worsened her economic situation, and increased her feelings of frustration and extreme despair:“The third child had a heart problem. She was very weak, that’s why she had a problem in her growth. I really had a tough time in caring for that child. I really suffered a lot with my alcoholic husband. And, seeing my financial problems, many [people] used to suggest that I kill this baby”. (Crying). Sameena, Factory workerRoona, mother of two daughters and two mentally retarded sons, spoke about how she struggled with the responsibilities of caring for two special needs children, given her tenuous financial situation and her unhelpful and sometimes abusive husband:“I feel bad about my condition. I have a lot of financial problems, health problems. God has given me two mentally retarded children. At least I should have had one normal boy child; that really makes me feel low, especially when I fall sick and my husband gives no support in looking after children. Instead of cleaning (the mess the children make), he calls me. So often, I feel that I have problems with my children and even with my husband. So I get angry with the children and hit them. Today morning, too, I cried thinking of my situation”.Roona shared these circumstances that she felt had made her chronically depressed and described her two suicide attempts: she was rescued once by her neighbours and once by her 12 year old daughter.“I was really depressed. It was 4 years ago. I was 3 months pregnant and I tried to commit suicide. I had closed the door so that no one would be able to see me hanging. Usually I don’t close the main door in the evening so my neighbours got suspicious and they came in looking of me and they broke the door. I was hanging and struggling so they came and rescued me for the second time, and my husband ran away from the city and came back after 4 months”. Roona, Domestic WorkerAmongst working mothers, routine child care concerns could also be a cause of anxiety and stress. Respondents expressed a number of concerns about their children’s well-being, including abusive childcare, children’s safety in the absence of supervised child care, financial and time constraints to providing adequate nutrition and supervision for children, and lack of physical and emotional support to care for their children.Anjali, a factory worker who had placed an infant daughter in her workplace day care centre had worried daily that the day care providers were giving the child medications to make her sleep. Similarly, Radhika, a domestic worker and mother of two girls and two boys, who had sent her pre-school age children to a free government child care centre, was concerned about abusive care providers:“If we leave them with someone else, they hit and scold when they feed the children. So when I see all that, I don’t feel like leaving them there. Only a few people might take care well, not everyone. I feel bad…(about it)…being a mother”. Radhika, Domestic WorkerAandal, a construction worker with an 11 year old son and a 6 year old daughter, leaves her children at home while she is at work because of lack of alternative childcare, and experiences constant fear about her younger child’s safety:“I worry a lot, I’m always thinking about what she (my daughter) is doing, vehicles are moving on the street…whether she is safe, I have fear”. Aandal, Construction Worker“pan” betel leaf to cope with stress:Eeswari, a 25 year old mother of 5 children, was forced to carry her children to her workplace and feels extremely physically and mentally stressed due to the strenuous work at construction sites and unsympathetic contractors who wouldn’t let her care for her children at the work site. She has to work even when she is injured at work or sick so that she doesn’t miss her daily wage. She spoke about hitting her children when she is stressed; she also admits eating “Sometimes when I get really irritated I just hit the children and they cry for some time. Most of the time if I get tense, I take it out on my children”. Eeswari, Construction WorkerRajeswari a 23 year old mother expressed her frustration about the lack of financial, emotional and physical support for raising her two daughters:“Sometimes I sit alone and cry. I don’t want children or my husband…no one, I feel like running away somewhere. My husband is a big problem, if he works properly I will not have any problem. From where shall I bring money, children are growing, thinking all this I am not able to eat properly. Both are daughters. How to bring them up, I don’t have support from any one, so I worry a lot. Nobody comes and supports us. So I feel very disappointed about it”. Rajeswari, Construction WorkerMeena, a 36 year old mother of 5 children, was one of several respondents who expressed helplessness and distress due to not being able to provide her children with appropriate nutrition:“I feel shame…because I go to work and wouldn’t know how [my children] eat, there is no time, every mother ensures that their children are eating at school, but we do not have that fortune, we go to work, we have left it up to them, but I feel, that they don’t eat properly, they eat as they want…I have just left it upon God’s mercy, what to do we have difficulty. We have to work to take care of them”. Meena, Domestic WorkerThe women in our study expressed how negative working conditions also affect their mental health. Domestic workers had no formal leave from work. This was a source of anxiety when women had to take long leaves because of their own or children’s health problems, and they worried about losing their job as a consequence.Selvi was denied leave when she was having a high fever and feeling too weak to stand, she narrated an instance when she had an injury at work and her employer refused to give her leave:“I had gone to the doctor and he gave me an injection. The next day I didn’t go to work. “For this small wound you didn’t come to work? I thought you were not feeling well. If your son is not feeling well we need to give you leave, if you daughter is not feeling well we need to give leave?” They (employers) scold”. Selvi, Domestic WorkerSome factory workers spoke about how they were affected by the reprimands of their supervisors if they did not achieve production targets:“They (supervisors) have scolded us. They have scolded us many times. I do make mistakes, we might have missed something and sent [the garment]. Because of that they scold us many times. We have felt bad many times, we have cried, sometimes at night we don’t get sleep. We feel so bad”. Bhanu, Factory WorkerConstruction workers reported instances of abuse from drunken male co-workers and contractors, and contractors threatening them if they lodged any complaints about the physical strain of the work.“If I complain anything about work [the contractors] beat us..... They don’t even feel bad (about beating us)…. So we don’t tell anyone that they beat us like that.…If they get to know that I am speaking against them they will kill me. That’s why I just go, do my work and come back. We borrow money from them, so they call us whenever there is work and they take money from us. Many times we have health problems, so we take a loan”. Aleyamma, Construction Worker“If we tell [the contractor] ‘I can’t do this work,’ [the contractors] say ‘If you cannot work, why have you come here, stay at home.’ If I am at home, how can we live our life? We have to do the work that they tell us to do”. Nisha, Construction WorkerHaving a supportive spouse who contributes to household expenses, participates in childcare and helps in household tasks was a significant mitigator of life stressors. A few respondents (8) mentioned that their husband helped them with household chores when they were unwell. Many respondents (31) also mentioned that their husband contributed money to meet the household expenses, although in most cases, insufficiently or irregularly. Some of the respondents (12) mentioned that that their husband helped to take care of the children on a routine basis, which reduced their concerns about child care. This was described by a street vendor:“In the afternoon my husband comes for lunch so he takes [our daughter] out and spends time with her so if my husband is there I need not worry at all about her”. Alaka, Street VendorWhile a few women spoke about work as being a stressor, empathetic employers and friendly colleagues were commonly mentioned as factors that helped to relieve stress caused by problems at home. More than a quarter of the respondents (14) mentioned that work had a positive impact on their mental health. These women discussed problems related to children, spouse, work or their general state of mind with their employers or colleagues, and found the sharing to be very effective in relieving stress and alleviating depression. The respondents who reported that work had a positive impact on their mental health all spoke about experiences of sharing their feelings, especially when they are facing difficult times at home. A few examples are cited below:“Just this morning, I cried thinking about my situation. For the coming festival, all children will wear good clothes but I have no money to spend for my children. I can’t give them clothes. I felt I should die and I should not live when I can’t fulfil my children’s desires. When I went for work, my employer felt bad about my situation and she gave me 700 Rupees to get new clothes for my children. She listens to my problem and acts accordingly, so I feel a little relaxed. She is more than a mother to me, whenever I am very depressed I don’t even share with my mother but I share with my employer”. Mahima, Domestic Worker“If I come to work, everyone here talks nicely to me and I can share my feelings with them and people crack jokes and spend time in a very jolly manner so I get a feeling that if I come to work I can forget a few bad things which have happened in my life and be happy for sometime at least. If I am alone I start thinking about so many things and I get disturbed mentally, so I feel that it is good for me if I can come to work since I forget the tensions I have and involve completely with work that gives me peace of mind”. Devi, Street Vendor“Only if I go to work I feel peaceful, if I don’t go to work I don’t feel peaceful”. Rajeshwari, Construction Worker“If I have too many problems and I am in tension, [my colleagues] ask me ‘What is wrong with you, why you are sitting like this? Only if you share, you will feel better.’ They try to console me”. Khadija, Factory Worker“I share with my colleagues what is happening in my family and they tell me not to worry about such things in life and console me. I keep saying that I want to die and all, so they tell me ‘you have two children, so you should not think like that.” Anjali, Factory WorkerThis qualitative study raises concerns that low-income working mothers in urban areas in India are at a high risk for depression. Women who have an alcoholic and/or abusive husband, face intimate partner violence or are raising children with special needs appear to be more susceptible to severe and prolonged periods of depression and suicide attempts. At the same time, when a range of more temporal life stressors  strike at the same time, this could push women into spells of severe depression. Even within our small study sample, extreme consequences of depression were evident: several women spoke of instances of attempted suicide and suicidal ideation. None of the women in the study, including those who attempted suicide, mentioned seeking professional support for anxiety or depression. There were a number of mitigating factors that could help women to battle anxiety and depression, such as social and financial support from family, friends and colleagues and the distraction or fulfilment of work. Given the need to address mental health issues amongst women in India, these findings suggest potential directions for mental health interventions among low-income working mothers in urban India.Firstly, intimate partner violence, usually associated with spouses’ alcohol consumption, was reported as one of the most frequent causes of poor mental health by this study population. The relationship between intimate partner violence and depression is widely documented at a global level. Most of the women in our study who spoke about suicidal ideation or suicidal attempts have been victims of intimate partner violence. A WHO multi-country study in other low- and middle-income countries (study did not include India) showed that intimate partner violence has a strong association with suicidal attempts in women . AnotherSecondly, while routine child care concerns were a source of anxiety for mothers of healthy young children, the emotional and physical demands of caring for special needs children appeared to be associated with long-term depression and worse mental health, especially amongst mothers who received little help from their spouses. This finding is consistent with research conducted amongst low-income parents of special needs children in the United States. In industrialized countries, employer education and labour legislation have been recommended as strategies to address these issues . HoweverThirdly, with declining access to extended family support, working mothers of pre-school aged children face challenges in accessing adequate child care, particularly when spouses were unsupportive. Concerns about child abuse, nutrition and safety were a source of significant anxiety for these mothers. Government policies and strategies to improve the quantity and quality of safe and affordable childcare could play a large role in supporting better health outcomes for mothers and children alike.Lastly, our study examined the role of supportive work environment particularly in relation to psychological benefits of emotional support offered by colleagues. In India, data on the effects of work on the mental health of mothers is virtually non-existent. In our study, many of the mothers who had school-aged children spoke about the psychological benefits of their work: these included support when their employers were sympathetic and helpful, the chance not be exposed to and focus on the problems at home for some hours of the day, and, most of all, the emotional support and encouragement they received from their colleagues when they spoke about their problems, including depression and suicidal ideation. These findings suggest that, apart from economic benefits, working outside the home can promote the mental health of mothers with children who are school-age, and pre-school age when care is available.A strength of our study is that we examined women’s perspectives on factors that have impacted their mental health across their family and work roles. Previous research in India has not detailed the role of work in women’s mental health and how this interplays with women’s family responsibilities. Our study thus provides new and potentially more holistic insights into a combination of life stressors and triggers that can challenge the psycho-social resilience of low-income working mothers in urban India, as well as coping strategies to alleviate these. Our study findings should be interpreted in light of the following limitations: the study sample was small, limited to one city, and focused on four occupations groups, which limits the generalizability of the findings. Furthermore, the cross-sectional nature of data collected limits causal inference about the factors that triggered depression in this population. Keeping these limitations in mind, the findings nevertheless suggest important areas for further investigation through quantitative surveys and longitudinal intervention studies, while also highlighting areas for programme and policy action.India was one of the first of the low-income countries to recognize the need to address mental health with its National Mental Health Programme (NMHP) which was launched in 1982. Unfortunately, its goals remain largely unattained . One of The authors declare that they have no competing interests.ST conducted the data analysis, wrote the first draft, and finalized the manuscript. DR conceptualized the study, supervised the data collection, provided guidance on data analysis, and co-wrote the final manuscript. JH conceptualized the study, provided guidance on data collection and analysis, and co-wrote the final manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/22/prepub


The number of his books is not certainly clear, but it is signified that he has written a couple of great books concerning medicine for Persians and too many treatises in such fields as philosophy, theology, medical ethics, human anatomy, chemistry, pharmacy and other sciences. His most famous and important book is “Zakhireh Khwarazmshahi” or “The Treasure of King Khwarazm”, which is really a complete and valuable medical encyclopedia in Persian language.Seyyed Esmaeil Jorjani is one of the most prominent pioneers and scientists of Islamic and Iranian traditional medicine in the 11In the present study, authors have attempted to state the life and time of Jorjani and his views by studying the history, old medical sources, and other provided recent medical literature in these fields.The biography of Hakim Jorjani has been well reviewed and described precisely.Based on our findings, it is clear that Jorjani described and explained the symptoms, signs and treatments of several diseases, introduced the activities of various medicinal plants, and compound formulations. He achieved all of this during his continuous visits to prestigious medical centers and famous people of his time. There is a limited knowledge about the history of science and medicine in old Iran, unlike its deep 10000 years of history and historical evidences. Persian civilization is one of the oldest living civilizations . PersianAll of these gimmicks represent the fame pinnacle of this physician from centuries ago up to the present time.Seyyed Zeynoddin (Sharafoddin) Abu Ebrahim Esmaeil Ibn Hassan Ibn Mohammad Ibn Ahmad Al-Hosseini Al-Jorjani (Gorgani) was born in 434, A.H.  in Jorjan . A.H. stands for “After Hijrat”, referring to the Muslim calendar, and A.D. stands for “Anno Domini” that its Latin meaning is “In the Year of Our Lord” and referring to the Gregorian calendar system. It is said that Jorjani was from the Sadat Hosseini of Isfahan in such a way that he was also named Sepahani-e Jorjani . HoweverSeyyed Esmaeil Jorjani in addition to being proficient in medical and pharmaceutical sciences, like most of his great predecessors and forerunners such as Abubakr Mohammad Ibn Zakaryya Razi (Rhazes) and Ibn Sina, he was also a capable practiced in theological, philosophical and ethical sciences. Thus, it can be said that Jorjani probably has begun to learn medicine and Hekmat from his tutors in Jorjan , 3, 7.Later, he travelled from Jorjan to Neishaboor and then went to different parts of Fars, Isfahan, Ghom, Khorassan and Khouzestan provinces. He benefited from the physicians over there too. At that time, Neishaboor was the great center of science and there were great colleges and sanatoriums . Cities This great and eminent scientist completed his studies under the guidance of “The Second Hippocrates”, or Abu Al-Ghasem Abdul Al-Rahman Ibn Ali Ibn Abi Sadegh Al-Neishaboori, who was one of the academic and serious scholars of Ibn Sina. Ibn Abi Sadegh played an incomparable role in his education, where according to Ghotbeddin Lahiji and Ibn Abu Assibia statements, he had a brilliant intellect and was capable in philosophy, morality, ethics and medicine. Ibn Abi Sadegh has been considered as one of the greatest hakims concerning human anatomy sciences too , 6, 10. According to Yaghut Al-Hamavi Al-Rumi’s statement in this regard, who was an Islamic biographer and geographer, Jorjani acquired the Hadith sciences from Abu Al-Ghasem Ghoshairi, the famous scientist of Neishaboor. Most probably, Jorjani prior to his trip to Khwarazm, he remained in Marv for a long time where he composed the book entitled “Zakhireh Khwarazmshahi” and most of his other writings and compilations while he was at the service of Ghotbeddin Mohammad. After sultan’s death, Jorjani spent the last years of his life in kindness of Alaoddowleh atsœz, the sultan’s son, who greatly admired Jorjani , 9, 13. Jorjani’s outstanding contribution to the improvement of knowledge in medicine, pharmacy and medical laboratory sciences is honoured in Tehran University of Medical Sciences, Iran by prizing sponsorship and research grants to the university academics with “Hakim Jorjani” Prize and medals in an annually scientific festival . In IranThe exact number of the books and writings of Hakim Jorjani has not been mentioned in the bibliography of the history of medicine. During Jorjani’s time, medicine and pharmacy in Iran switched to the Persian language and encouraged the learning and teaching of this science. He compiled a couple of books concerning medicine in Persian language and an innumerable amount of others in fields such as philosophy, medical ethics, theology, human anatomy, chemistry, pharmacology, pharmacy and other natural sciences , 17, 18.His two important books are:1. Zakhireh Khwarazmshahi: “Zakhireh Khwarazmshahi” is Jorjani’s most important book that has been written in Persian language with nearly 750000 words. It might be considered as the oldest and long-established Persian medical encyclopedia. He dedicated this book to Ghotbeddin Khwarazmshah. At the age of 70 with an ample and broad knowledge of medicine and other natural sciences, Jorjani wrote this masterpiece from his own experiences, thoughts and the writings of several previous physicians. It has been standing along with Ibn Sina’s “Canon of Medicine”. Arrangement of “Zakhireh Khwarazmshahi” volumes is very similar to the “Canon of Medicine”. His treatise was the most popular medical atlas in the Safavid dynasty of the 17th century, more than 600 years after its compiling , 25, 26.In fact, this distinguished treasure is a supreme encyclopaedia of medical sciences, which consists of eleven books. He compiled it in nine treatises but as referred at the end of the book he changed his judgment, in the last volume entitled “Gharabazin”, he added two more volumes dealing with the anatomy of the human body, especially neuroanatomy, and helpful introductions to the various parts of animals’ organs , 8.Several archives of “Zakhireh Khwarazmshahi” exist in the world, Iran and couple of volumes of this book have been published in Iran by Iranian Academy of Medical Sciences and other publishers. It was translated to various languages like Turkish, Arabic, Urdu and Hebrew , 14, 26.2- Khoffi-e Alaei: This book is a brief and compact form of the “Zakhireh Khwarazmshahi” that included a short review of the science of medicine. Jorjani wrote this medical manual at the request of Amir Isfahar Arsalan, the grantee prince of Abu Al-Muzaffar atsœz Khwarazamshahi. In the first chapter of the book, Jorjani composed “I prepared “Khoffi-e Alaei” as a summary and pocket book form “Zakhireh Khwarazmshahi” which can be easily read and skim at almost all times even travelling, wars and battles” , 18.The exact date of the composition of “Khoffi-e Alaei” has not been recorded. Jorjani mentioned it clear that it was written after the year 504, A.H.  that is after the precise composition of “Zakhireh Khwarazmshahi” , 18. OneConclusions: Jorjani was a great hakim, scientist, physician and pharmacist in Iran whose life and works were introduced by several authors. He is one of the pioneers of Islamic and Iranian Traditional Medicine. His contribution to the different fields of sciences gives back his great personality in the history of science in Islam and Iran. He gave a shape to the different systems of medicine and redefined several concepts based on his clinical experiences. Although a millennium has been passed from his birth date , his great role in the revival of Islamic and Iranian traditional medicine is incontestable yet. He belongs to all people of the earth, “Worldwide Jorjani.”


Non-severe nocturnal hypoglycemic events (NSNHEs) are hypoglycemic events that occur during sleep but do not require medical assistance from another individual. This study was conducted to better understand the NSNHEs as patients actually experience them in their daily life, and how they impacted functioning and well-being.Nine focus groups were held in four countries with diabetics (Type 1 and Type 2) who had experienced an NSNHE within the previous month: France (2 groups); Germany (2 groups); United Kingdom (2 groups); and United States (3 groups). These groups were audio-taped, translated to English where applicable, and analyzed thematically.Seventy-eight people with diabetes participated in the focus groups: 41 (53 %) were female and 37 (47 %) were male; 24 (31 %) had Type 1 diabetes, and 54 (69 %) had Type 2 diabetes. Participant reports were grouped into several major themes: next day effects, symptoms, sleep impacts, social impacts, corrective action, practical management, feelings about NSNHEs, and work impacts.People with both Type 1 and Type 2 diabetes experience NSNHEs. The range of impact on these patients is wide, from very mild to severe with a majority of participants experiencing strong impacts that limit their daily functioning. This finding suggests that NSNHEs are more impactful than previously believed. Hypoglycemia in general, including non-severe nocturnal hypoglycemic events (NSNHEs), is a frequent complication of anti-diabetic medication. NSNHEs are rarely studied for their impacts on patient function or well-being and may be misunderstood and underreported by healthcare practitioners . NSNHEs Research on NSNHEs is limited. A review of the literature reveals that the majority of research that has been conducted has focused on either severe hypoglycemic events during sleep, or laboratory-induced NSNHEs. The conclusions drawn from these investigations are not generalizable to the everyday life of patients with diabetes. There is a lack of data specific to how NSNHEs are experienced by patients, and their impacts or consequences. There is evidence of sleep-related hypoglycemia-associated autonomic failure among those with Type 1 diabetes that result in a failure of the patient to awaken during hypoglycemia . These rFurthermore, research on the impacts on non-severe hypoglycemic events generally (day or night) concludes that non-severe hypoglycemia is associated with substantial negative economic consequences for both patients and their employers, resulting from lost productivity and missed work time. Productivity loss was highest for NSNHEs that occurred during sleep . Additiopatient functioning, which refers to the patient’s day-to-day ability to accomplish their tasks; (2) well-being, which refers to their psychological state; and (3) patient perspective, which refers to how the patient views their experience (of NSNHEs).Only a small number of studies have evaluated the impact of NSNHEs on diabetes management, sleep quality, daily functioning, productivity, well-being, and/or quality of life in adults with diabetes –7. In orUsing focus group interviews conducted in North America and Europe, the primary objective was to qualitatively characterize and describe the experience of NSNHEs and their impacts on patient functioning and well-being.A qualitative design was chosen to meet the study objectives, with semistructured focus group interviews conducted in four countries  to gather data on patient experience of NSNHEs. Focus group interviews are suited to this investigation because they help to identify a “range of experiences and perspectives” as well as provide a forum for both agreement and disagreement between participants, which facilitates insight into the variability of experience and the collection of disconfirming evidence –10. AddiTo be eligible for the study, participants were required to be over the age of 18, read and speak the native language of the country in which they reside, have a diagnosis of Type 1 or Type 2 diabetes, currently be using insulin, oral medications and/or Byetta (GLP-1) to treat their diabetes, and have experienced an NSNHE within the past 3 months. For the purposes of this study, an NSNHE was defined as having typical hypo symptoms  that may or may not have been confirmed by monitoring blood sugar, not having any of the hypo symptoms but monitoring blood sugar showed that it was too low (≤70 mg/dl), or having symptoms but not having low blood sugar. Participants were excluded from this study if they were using an insulin pump.All focus groups were moderated by professional focus group leaders, and in the first language of the participants. The focus groups were audio-taped, translated into English where appropriate, and transcribed. The first author, who has extensive professional experience in moderating focus groups with patients, moderated the English-language focus groups in the US and UK. Professional facilitators moderated the focus group interviews in France and Germany. The first author coached these moderators and observed these groups with the aid of simultaneous translation to insure quality of discussion. The focus group interviews were semistructured, and the interview guide was designed to elicit participant experience with NSNHEs, their corrective action strategies, and the social and practical impacts of these events on their lives.The transcripts were analyzed thematically using qualitative analysis software ATLAS.ti, which was chosen for its ability to handle and organize large data sets, provide documentation of the coding process, and assist in organizing disconfirming evidence within the data set . DescripNine focus groups were conducted in the four countries , totaling 78 participants Table . Forty-oThe average duration of diabetes for the sample was 12 years (range: 1–44 years). Over half of the sample considered their diabetes to be controlled well or very well (51.3 %), and 34 participants (43.6 %) considered their diabetes to be controlled moderately well. Both Type 1 and Type 2 diabetics reported that they experienced NSNHEs: Type 1 diabetics reported an average of 4.4 NSNHEs per month (range: 1–22.5 per month) and Type 2 diabetics reported an average of 3.8 NSNHEs per month (range: 1–12.5). The average incident rate of NSNHEs for both groups combined was 4.0 per month (range: 1–22.5).Ethnically and racially, nearly three quarters of the participants in this study self-identified as White/Caucasian (57 or 73.1 %). A majority of participants in this study worked fulltime (62.8 %), and income was distributed across all income categories.Samantha: What I wake up to is my hair is really, really sweaty. My hands are dripping and my night clothes are absolutely drenched and as soon as you get up you have that chill. (London #1)Participants noted anxiety or panic, shaking, and confusion or disorientation. Here are three examples of impacts on emotional states described by patients as typical symptoms during an NSNHE:Anxiety or panicFlorence: I think it’s also kind of like… for me, anyway, it’s sort of like… it’s a shock and like yourself, I kind of get the panic attack as well and then I’ve got to calm myself down from that. (London #2)ShakingMale Speaker: I don’t have any palpitations, I am very weak and shaking and I feel anxiety; I feel oppressed because it is a situation that is outside your control; each time we hope it’s going to be ok by taking some sugary things, and each time is a surprise. (Paris #2)Confusion and disorientationDevon: But the hardest part I find is that when I do get up I’m so confused and I struggle with my speech at times and all sorts, just to get thoughts together and it leaves me drained for a day or two and then it’s very hard to get back to normal life after an incident. (London #1) Additional symptoms included feeling hot or cold, dizziness, heart pounding or palpitations, restlessness, trouble with walking or balance, bad or weird dreams, vision disturbances, headache, weakness, muscle tension, neuropathy, anger, and nausea. The wide range of symptoms reported suggests that the experience of nocturnal hypoglycemia is individualized.Both Type 1 and Type 2 diabetics experience NSNHEs. Participants noted wide ranges of symptoms and severity of NSNHEs. NSNHEs involved a constellation of symptoms along a continuum ranging from unpleasant to traumatic, with the most common symptom as sweating:When participants experienced NSNHEs, their corrective action did not significantly differ from typical corrective action taken for daytime hypoglycemic events. Most participants reported eating or drinking something sweet to raise their blood sugars. Although many participants noted that they check their blood sugar to confirm hypoglycemia, some do not and respond instead to their symptoms alone. Many participants reported that they kept treatment food and drink on their bedside table so that it was nearby in the event of an NSNHE.Male Speaker: It’s an interruption during the night, it’s a decrease in the level, it’s a fear, a fear of something that I don’t understand and cannot control. (Paris #1)Additional emotional consequences of NSNHEs included frustration, anger, helplessness, and feelings of sadness.Generally, participants reported having strong feelings as a consequence of NSNHEs, and they emphasized fear and worry the most:Participants often compared and reported that the experience of nocturnal hypoglycemia was different from daytime hypoglycemia. They offered varied responses to the differences between daytime and nighttime events; however, the sentiment that NSNHEs are in some way more difficult than daytime events was more common.Although a few participants suspected that they do not always awaken during an NSNHE, most participants stated that nocturnal hypoglycemia caused them to wake up and take corrective action.Stephanie: I feel that way every night. Well, not that I’m scared every night, but if I feel uncomfortable and can’t fall asleep, then I’m worrying about it. (Atlanta)Some people remained awake for the remainder of the night. Of those individuals who reported an estimate of the time they spent awake, the range was 5 min to 5 h. Individuals also varied greatly in their tolerance to sleep disruption.The sleep impact data revealed a wide range of experiences. Some individuals reported that it was easy for them to get back to sleep. However, others reported that it is very difficult to get back to sleep. Participants reported that sleep was very generally disrupted:Generally, participants reported that NSNHEs disrupt sleep, which amplifies the next day effects of the event. There was a range of experience with regard to the severity of the sleep disruption, from mild to severe.Carol: Yes, I feel low, very tired. Very tired. And when I’m at work, I’m just counting down the hours to go home. (London #2)Khalid: Yes. It’s pretty much like having a really bad hangover. It’s like you’ve gone out for a real session for a drink one night, the next day you feel like tired… that’s just how you feel, it’s like a really bad hangover. (London #2)Participants reported a wide range of consequences that included feeling irritable, needing naps the next day, and an inability to focus or concentrate the next day:IrritationDjamila: Irritation because that’s another night that is broken up into 2 or 3 bits. I won’t feel very fresh in the morning to go to work, so the irritation is more for the next day because it won’t be very good. (Paris #2)Needing napsRichard: I’m fine once I’ve had my jam sandwich and tea. The way I get round the tiredness bit is I have catnaps. On the way to work, on the train, I might doze off for about 10 min. On the way back home I might doze off. (London #1)Inability to focus or concentrateWildi: But sometimes I simply cannot comprehend it, that I can’t concentrate, I think to myself, “It cannot be that I’m not able to pull myself together for 5 min.” (Frankfurt #2)The overall experience of the NSNHE was two-pronged, leading to many discomforts the day following the event. These discomforts the next day were the most frequent major theme noted by participants. These effects were caused by: (1) sleep disruption (and resulting sleep deprivation for some), in confluence with (2) physiological effects of fluctuating blood sugars, in the night and throughout the next day. Participants identified these impacts and consequences as disruptive and often upsetting:There were only a very few participants who stated that they did not feel particularly tired the following day, and these participants also reported that they were not awake for very long during an NSNHE. Likewise, there were a few incidences of participant reports that they felt fine the next day, experiencing little impact from the event. This demonstrates (again) the individuality and range of the experience of NSNHEs.However, despite this disconfirming evidence, nearly all commentary about next day effects of NSNHEs was negative. Other effects reported include lowered energy, headaches, the need to sleep in late, awakening to high blood sugars, moodiness, feeling down, nausea, anxiety, and dizziness. In summary, NSNHEs cause a wide range of negative consequences the day following the event that include physiological symptoms, temporary cognitive impacts, and emotional reactions.Neil: But if it seems like more of a minor one but I’m tossing and turning-waking up, even though sometimes I feel like she’s sleeping through it, she’ll say she’s up and she’ll say she’s more tired than me. And she’ll give me a guilt trip over it. “You could’ve been quieter when you got up.” So she does care, but at the same time, she’ll act like she’s more tired than even me. It’s almost a guilt trip thing. (Los Angeles)Participants also reported that they make an effort to avoid waking bed partners. Here is an example:Farma: He panics. So I tend to try not to wake him up or let him know what’s going on actually. He hates that but that’s from over the years seeing how he reacts. (New York)Participants reported that they receive social support from others who are knowledgeable about nocturnal hypoglycemia, especially partners. Support in this context refers to understanding, kindness, and general accommodation for their NSNHE difficulties: social support. However, they also reported that the day after an NSNHE, they have reduced social interaction due to their fatigue levels and general feelings of illness, and described their own social withdrawal due to the event. More specifically, participants stated that they cancel social events due to how they feel after an NSNHE:when I don’t feel well, so I prefer to go a longer way. And normally I’m very spontaneous and if I get asked to go out after work, then no, I can’t. […] it’s not because I don’t want to see the person, I just don’t want to have company. (Frankfurt #2)Respondent: I just wanted to say, when I’m not feeling well I’m taking a different way home then I go usually, I don’t like going through a particular street, don’t ask me why, I don’t know it, but I don’t like to go into a crowd of people Participants noted that their families were negatively impacted by worry for the participant. Participants’ fatigue also affected their interactions. Participants also noted that sometimes they worried about their family:Barbara: Because usually you spend time with your kids, the homework, whatever we do, it’s a routine. Sometimes I’m just too tired to even ask them how their day was. I just come in and go straight to bed. (New York)Some participants regularly received assistance from others in their households, even though they did not require this assistance:Victoria: I normally… I’m normally aware and I just take myself, get myself a drink, but sometimes I’ll have to because I panic from it. And I’ll wake him, he’s great, he’ll go and get me a drink instead. (London #2)In summary, the strongest social impacts included waking others up during an NSNHE and disrupting their sleep, enlisting other’s support and assistance during the event, and the experience of reduced social interaction the following day by withdrawing or canceling events.The most important consequence reported by participants in all focus groups was that the NSNHE disturbed the sleep of their bed partners, resulting in fatigue for them the following day. All of these reports were of waking bed partners during the night and as a result of an NSNHE:Impacts of NSNHEs on work mirror concerns reported on next day effects of NSNHEs. Broadly, the tiredness and fatigue from sleep disruption and the physiological effects of fluctuating blood sugars contribute to many difficulties at work. The most frequent impacts reported were problems with focus or concentration for work tasks, and reduced productivity while at work. Additionally, participants reported that they call in sick, take extra breaks or leave early, or go to work late in the morning. In summary, NSNHEs have negative work impacts and lead to lost work time.Based on these findings from the qualitative data, a preliminary theoretical model of the impact of NSNHEs was developed, as shown in Fig. NSNHEs were found to be disruptive and cause considerable distress to the majority of both Type 1 and Type 2 participants in this study. Among Type 2 diabetics, NSNHEs are not limited to those who are insulin-dependent. These data also suggest that the range of individual experience of NSNHEs is very wide. However, for the majority of participants, the continuum of experience ranges from unpleasant to traumatic. The impacts on the individual’s life and daily routine are equally wide-ranging, from moderate to extreme. This is an important finding as primary care clinicians attending to patients with Type 2 diabetes may not appreciate the severity of the impacts and potential consequences that NSNHEs have on their patient’s functioning and well-being [NSNHEs produce symptoms that awaken and frighten people who experience them and sleep is often disrupted. The day after the event is often a difficult day due to the physiological effects of fluctuating blood sugars (during the event and the following day) and sleep disruption or deprivation. Next day effects are so uncomfortable that they may be more disturbing to individuals than the hypoglycemic event itself. NSNHEs are often thought to be more difficult to predict, understand, or manage as compared to daytime hypoglycemia, and patients are often afraid or worry about their occurrence. Given the challenges of the symptoms and the emotionally laden experience of NSNHEs, participants wanted to avoid them if possible. Some participants stated that they run their sugars high before bedtime as a strategy for avoiding NSNHEs. It is unclear whether this is on advice from their physicians or diabetes educators. Potentially, keeping blood sugar high can lead to other complications of diabetes over time.Although not a major theme in this data set, a few participants reported that they were prone to falling during their event due to dizziness and disorientation during making this an interesting topic for further inquiry. Furthermore, NSNHEs also have not inconsequential work impacts of reduced productivity and lost work time for both the person with diabetes as well as for some of their bed partners. This echoes the conclusions drawn in a prior study of the impacts of non-severe hypoglycemia, which noted that productivity loss was highest for NSNHEs .It is not surprising that participants recruited for their experiences with NSNHEs would report that NSNHEs are problematic for them, and findings of this study must be placed within this context. However, previous research has found that approximately 16 % of all persons with diabetes experience at least one of these events in the previous month. For this not insignificant percent of persons with diabetes, this study does demonstrate that there are serious negative impacts and consequences that are generally unacknowledged in the literature. Further research is needed in this area in order to evaluate the level of concern this poses for people with diabetes in general. Additionally, the study found that NSNHEs are not only problematic for those using insulin or only those with Type 1 diabetes.As participants with Type 1 or Type 2 diabetes and insulin and non-insulin users participated in the focus group interviews together, it was not possible to differentiate the experiences of NSNHEs between these two forms of diabetes or treatments conclusively. It is possible that the frequency, severity, and personal reactions may differ between Type 1 and Type 2 diabetics or treatments. In these focus group interviews, there suggestion that participants who had Type 1 diabetes and, therefore, typically had a longer tenure with insulin use and its titration were slightly less bothered by NSNHEs due to familiarity with them. For these individuals, the NSNHE experience entailed similar impacts and consequences physically, but it is possible they were less worried or fearful of them. Future research in this area may illuminate diabetes type-specific moderators for the overall impacts of NSNHEs.Study limitations include translation and transcription problems for those focus group interviews held in a language other than English as it was difficult for the translators to relate nuances and the full intent of the focus group discussion. This resulted in less description than would occur within the first language. Despite these discrepancies, the data yielded insights that were quite rich in understanding the impact of NSNHEs on these participants.Additional qualitative and quantitative research is needed to understand the phenomenon of NSNHEs from a physiological, emotional, and social perspective. These data indicate that NSNHEs are not always experienced in the same way as hypoglycemia occurring during the day. Research that explicitly investigates NSNHEs may alter diabetes management strategies overall and lead to new recommendations for the practical and daily management of hypoglycemia.Finally, this study did not explore the experiences of patients with their healthcare providers about NSNHEs in depth. However, a few participants suggested that physicians may not appreciate the impacts of NSNHEs on patients. In contrast, some participants reported discussing NSNHEs with their doctor and receiving helpful advice. Given the role of physicians and other clinicians in directing diabetes management, it is important to know what influence they may be having on the management and treatment of NSNHEs. Given the substantial negative impacts reported in this study, it would be of concern if health care providers as well as patients do not fully understand these NSNHE impacts. The study findings warrant further research on physicians’ views on NSNHE impacts.


The following case study describes a 22-year-old woman with depression and symptoms of psychosis who developed neuroleptic malignant syndrome after using Risperidone, thus requiring life support equipment and Bromocriptine, later recovering after seven days. From a psychiatric and neurological point of view, however, the persistence of catatonic syndrome and Cotard syndrome delusions was observed, based on assertions such as “I do not have a heart,” “my heart is not beating,” “I can not breathe,” “I am breaking apart,” “I have no head” (ideas of negation) and statements about the patient being responsible for the “death of the whole world” (ideas of enormity). Brain NMR revealed leukoencephalopathy, interpreted as scar lesions caused by perinatal neurological damage, after discarding other pathologies. The patient responded well to electroconvulsive therapy after 11 sessions. Organic vulnerability to these syndromes, as well as their coexistence and clinical differentiation is discussed in the light of the data observed. Catatonia is a neuropsychiatric disorder that was initially described by Kahlbaum in 1874 and is characterized by motor disturbance in which patients are unable to move normally despite full physical capacity in the limbs and trunk, also it is associated with behavioral and affective disorders . CurrentCotard syndrome (CS), on the other hand, was first described by Jules Cotard in 1880  as a negThis study reports on the case of a young woman who, while struggling with psychotic depression, developed NMS and persistence of catatonic syndrome as well as delusions compatible to what has been described for CS in the same episode.FM is a 22-year-old woman with a background of depressive episodes, which had been successfully treated with 20 mg of Citalopram a day for 2 months at the age of 19. She requested a consultation because she had been feeling tired, sad, and anxious for 2 months, which was diagnosed as a depressive episode and was treated with Sertraline and Clonazepam. After 2 weeks of no improvement, the patient began to have trouble sleeping and paying attention, felt restless and started to have delusions, thus making statements such as “I killed my mother and grandmother,” “I killed the world,” and “I saw God and must now save the world.” In this condition the patient was sent to the emergency unit of a psychiatric hospital, where she was diagnosed with psychotic syndrome and received intravenous 5 mg of Haloperidol and 4 mg of Lorazepam for once and 3 mg of Risperidone, 50 mg of Chlorpromazine, and 10 mg of Zolpidem a day, orally. She evolved with dullness, slowing down, muteness, rigidity, and progressive psychomotor inhibition, associated with having difficulty to swallow, being less aware, and disconnected from her surroundings, until she reached a state of stupor after 4 days.3), and an increase in total CK that was up to 4,839 U/L. She was diagnosed with neuroleptic malignant syndrome, thus requiring life support in the ICU as well as Bromocriptine. She stabilized after 9 days, based on normal laboratory parameters and the absence of fever and autonomic instability. Nonetheless, from a psychiatric and neurological perspective, the catatonic symptoms  persisted and did not cease when receiving Lorazepam. Consequently, she was transferred to the psychiatric unit, where electroconvulsive therapy was initiated before 48 hours of being admitted. Due to her catatonic state, she required special medical and nurse care, and, because of her immovability and difficulty to swallow, she needed nasogastric intubation and assisted mobilization to avoid thromboembolisms. Delusional ideas compatible with CS were detected during subsequent mental examinations, relating to ideas of negation and hypochondriasis, such as “I do not have a heart,” “my heart does not beat,” “I cannot breathe,” “I'm breaking apart,” “I have no head.” Ideas of enormity were also observed through statements such as “I am responsible for the death of the whole world.” Brain NMR revealed leukoencephalopathy, interpreted as scar lesions caused by perinatal neurological damage, after discarding other pathologies. The patient responded well to electroconvulsive therapy (3 times a week), with partial response observed at the 8th session and then at the 11th session, where she showed hypomanic symptoms. The patient received maintenance ECT for 2 months, associated with the use of 20 mg of Olanzapine and up to 200 mg of Lamotrigine. Olanzapine was suspended after 4 months, and she has been euthymic to date, with important improvements in autonomy and functionality, thus having been able to maintain a stable job, a relationship, and constant psychiatric followups and partial psychotherapy sessions.Considering such condition, she was admitted to the emergency unit of a general hospital. Her exams confirmed universal rigidity, fever, autonomic instability, leukocytosis , which would explain the overlapping of symptoms and treatment responses. What varies is their neuromodulation. In this sense, catatonia could be characterized as a cortical psychomotor syndrome, while NMS may be considered to be a subcortical motor syndrome . RegardiFurthermore, this case study contributes to the literature that has identified a trend of CS in the adolescent and young adult population as well as its greater frequency in women with bipolar disorders. The patient's positive response to electroconvulsive therapy and her mood change toward a hypomanic or manic state during treatment are also in line with what has been previously described.The search for organic vulnerabilities is important in patients who present catatonic syndromes as well as high vulnerability to collateral effects of antipsychotics , 20. AltThe pattern of signs and symptoms that characterizes catatonic syndrome is not specific to its cause. In this sense, the case described here supports what Fink et al.  claims iWith regards to Cotard syndrome, most studies that have included electroconvulsive treatment or brain resonance  have obsFrom a therapeutic point of view, electroconvulsive treatment led to positive results in terms of managing acute catatonia , 23 and


The oral hormonal agent anastrozole improves clinical outcomes for women with breast cancer, but women have difficulty taking it for the five-year course. The unique medication-taking experiences related to self-management of anastrozole therapy for women with early stage breast cancer are not known. Our purpose was to describe the medication-taking experiences for postmenopausal women with early stage breast cancer who were prescribed a course of anastrozole therapy. Twelve women aged 58 to 67 years, midway through therapy, participated in audio-recorded interviews. Women's medication-taking experiences involved a belief in their importance and an imperative to take anastrozole. We found that women's side effect experiences, particularly menopausal symptoms, were significant, but only one woman stopped anastrozole due to side effects. Medication-taking included routinization interconnected with remembering/forgetting and a storage strategy. Some women noted a mutual medication-taking experience with their spouse, but most felt taking anastrozole was something they had to do alone. Our results provide insight into the way some women with early stage breast cancer manage their hormonal therapy at approximately the midpoint of treatment. Next steps should include examinations of patient-provider communication, potential medication-taking differences between pre- and postmenopausal women, and the effects of medication-taking on clinical outcomes. Treatment of cancer has shifted to greater use of oral cancer agents , transfeSelf-management has been defined as one's ability to manage symptoms, treatment, physical and psychosocial consequences, and lifestyle changes that are fundamental to living with a chronic condition such as cancer . Self-mahow women with early stage breast cancer managed their anastrozole therapy daily . But, there was this short period of time where I'd take my water, drink it down and say, “Okay, do your thing, Arimidex®, get in there, kill any cells that you see...”When discussing their beliefs and motivation to take anastrozole, most women used imagery rather than the term “cancer recurrence”: “I'm taking it to keep the boogie man away.” Another took it to keep “loose cells [from] travelling where they shouldn't.” Another woman said, “That's very important, that pill... I want to live... I want to stay healthy.” One participant with 100% adherence described a heightened consciousness about the role of anastrozole:So I think if you're taking Arimidex® over years, they're [adrenal glands] not going to all of a sudden, if you miss one, they're not going to all of a sudden get back going again when they've been put to sleep as... for as long as they have been... I mean if you skipped a whole month... or even a whole week... that might be a different story...' cause then they'd start getting their act back together.Conversely to the above description, two women indicated that it was “no big deal” to take or to miss a dose of anastrozole, presumably meaning that missing one dose would not harm her overall outcome.To me, the benefit of not getting cancer, whether it's breast or some other site, is certainly more advantageous than putting up with a little bit of wrinkles or some other problem... but on the other hand, you wonder.Although all women were motivated to take anastrozole and recognized its value, some interviews suggested tension between the desire to prevent cancer recurrence and uncertainty about taking anastrozole. This woman's comments further revealed ambiguity regarding the value of the medication in preventing cancer recurrence: Women further indicated that there was a necessity or obligation to take anastrozole that went beyond their belief in its importance. This treatment imperative included her commitment to the program and “wanting to get to the finish line.” The imperative was self-motivated, “I would never dream of quitting” “I truthfully want to do the five years. I want to complete the program as is,” or externally motivated from a relative, a friend, or a health care provider, “My mom... would push me to take it and say ‘you need to continue on this.” Several women mentioned an imperative to take anastrozole based “on doctor's orders.” “He told me that I'd have to take it, and so I took it.” Women were told by their health care provider (HCP) to take anastrozole daily, but they were they given no other instructions. The women expressed willingness to discuss their side effects with their oncologist or HCP; however, they were rarely asked about their experiences. In some cases, they received conflicting advice from HCPs. For example, when discussing her foot pain, one woman indicated, “Foot doctor says no [unrelated to anastrozole].” Everyone else says “Ah, yeah.” Furthermore, when some women desired specific information about anastrozole, such as what time of day to take the medication, they asked their pharmacist (or chemist).Overall it feels like a torch... the chest area and face and forehead; my forehead's like soaking wet now... they come on real fast and last about a minute or two... during the night I might wake up it seems every two hours... like at midnight, two o'clock, four o'clock, six o'clock, and you know it wakes me up and sometimes I can't go back to sleep so that is an additional problem.For all women, the opening question (“Tell me about your experience taking anastrozole”) led without prompting to a description of the side effects of anastrozole. All women immediately described challenges with hot flashes and associated sleep disturbances, arthralgias, fatigue, “female things”, weight gain or loss, and struggles with forgetfulness or memory loss, regardless of their MEMS cap adherence level. The women described the timing of when side effects occurred in relation to starting anastrozole , the time of day the side effects occurred, and the duration of the side effects . They described how the side effects affected their daily life or altered their lifestyle, characterization , frequency , and their attribution that the side effect was due to anastrozole, another therapy, or a process such as aging. One woman experiencing menopausal-like symptoms stated that anastrozole “threw me back into menopause.” Another woman characterized her hot flashes:The only thing I do have a problem with, and I have noticed it, is my memory. Now I'm remembering a lot of things... today, talking to you, but if somebody said, “Well, I told you that yesterday,” or “Don't you remember I...” “I can't remember.” I have to really think, and that scares me. I mean I had a bad memory before (laughs)... but it, it is worse. It is, it is worse.One woman who took anastrozole in combination with chemotherapy described how she felt about her experiences with memory problems:I think once you have cancer you start to think, “Is this mets to the bone, or is this mets somewhere else... or is it a side effect from the medication”…when I take medication, I try not to read the side effects unless I'm having problems and then I go to the side effects and say, “Ah, yeah, maybe this is it.” But when I started... in my hips, and it was at night and I was having trouble sleeping, I just decided that... this [anastrozole] wasn't for me.The woman who discontinued AI therapy due to hip pain described the related uncertainty of the underlying cause of her pain:n = 10) reported five or more side effects. The two women classified as “low-adherers” reported the same type and number of side effects as the two 100% adherers. The woman who discontinued AI therapy due to side effect severity was classified as a “good” adherer and reported the same five side effects as the other women. Women expressed varying levels of depressive symptoms and anxiety when completing the BDI-II and POMS surveys; however, only one woman expressed these symptoms during her interview, and her scores did not indicate depression or anxiety. This mixed data analysis revealed no patterns between symptom number, type, and severity and adherence category.To further explore the problem of the women's side effects and side effect severity, we constructed profiles of side effects for each participant by combining those side effects reported in interviews with information from the BDI-II, POMS, and BCPT . ParticiI've worked with lots of women, and we all say (laughter) estrogen, the menopausal breakdown. But, I have days when I just... can't remember things like names or specific words for thoughts... And I'm usually really good. I love words, and I'm usually pretty good with them. But, I just have days when I can't, and I'm not as articulate... I just finished helping with the summer camp and we had about 18 college counselors... I remembered all their names, and once in a while I'd completely blank... but I had a notebook, I had my cheat sheet.Generally, women used pharmaceuticals , physical therapy, or other daily management or compensation strategies to alleviate the side effects they experienced. For example, one woman avoided or limited her activities, while another wrote down tasks or names to remember them. The woman with “summertime blues” described her frustration with word-finding problems and how she compensated:... My husband had to get them out... Arimidex® people ought to know that that is not acceptable. (Laughter) Maybe they found that out... but I'll tell you that was the only time that I considered stopping. Because I have arthritis in my hands... and they're old hands... it was very, very difficult. I couldn't put it through, you know, so I tried to use a penknife, I tried to flip up the little foil thing... and sometimes I'd try to slice off the bubbles like this. (Gestures). It's just hard. I couldn't do it.All women described in detail the actual hand-to-hand, tangible characteristics of taking anastrozole. Many women mentioned that the pill was tiny and easy to swallow. However, when anastrozole was packaged in blister packs for a short time , the women expressed extreme difficulty and irritation with opening the blister pack. One woman who received two three-month supplies of anastrozole packaged in blister packs described how the packaging affected her daily medication-taking of anastrozole:n = 11) were already taking other prescription medications, vitamins, or supplements and incorporated anastrozole within their established routine. Central to self-management of anastrozole for all of the women was the routinization or integration of anastrozole into their everyday lives as anastrozole-taking became a consistent, accepted, or habitual medication self-management practice. They described timing anastrozole administration with meals or other medications, associating it with a visual cue , a central location , or a storage strategy . Women stated that participation in The AIM Study helped to routinize their medication-taking practice. Most  put it on the little machine to see that I had missed it a few times. Now last night I went to bed and I remembered about 1:00 [AM] and I came down the steps and took it.Associated with routinization was remembering/forgetting to take anastrozole and their realization, reaction, and strategies for taking anastrozole after forgetting a dose:When I started it, that's when I put into my day [pill minder]... I've had no trouble remembering to take it, and that seems to be a good time [after supper] since its after my work day, except when I have a meeting, I don't forget.Frequently, remembering was linked to a certain time of day or a storage strategy, such as a weekly pill container. For example, one woman stated she did not forget to take her anastrozole “Cause I take it with my morning vitamin, my calcium, and fish oil.” Another woman described:Sometimes I might play the 12 hour shuffle if I know I didn't take it the night before... maybe I'll take it in the morning, and then at bedtime, so it's probably putting two in one day, but trying to spread them apart, so it's not quite the same.Although women felt they remembered to take anastrozole, over half stated they occasionally missed a dose, only realizing it when noticing the pill was still in the container or her pocket, or when the MEMS cap was downloaded. Both low adhering women discussed the management of their missed doses in a similar manner. Some women described medication-taking as a social or a “mutual medication-taking” experience, referring to taking anastrozole at the same time a spouse or other family member took their own medications. Several women mentioned that they had friends or relatives who were prescribed anastrozole and were no longer taking it, but they denied that this deterred them from taking their own anastrozole. Most women described a “solitary” experience in which no one can or needs to help with taking anastrozole. A woman who lived alone stated, “I just have to do it.” Another stated, “... I don't think he [husband] thinks about me taking my medication at all.” Our purpose was to describe the medication-taking experiences of postmenopausal women with early stage breast cancer who were receiving anastrozole therapy. The women's engagement in the self-management of anastrozole involved a predominant belief in the importance of anastrozole, as well as an imperative to take it. We found that though their side effect experiences were significant, the women remained motivated to take anastrozole; only one woman stopped taking anastrozole due to side effects. All medication-taking practices were facilitated by routinization that was interconnected with remember/forgetting to take anastrozole and a storage strategy . Some women noted a mutual medication-taking experience with their spouse, but most felt that taking anastrozole was something they had to manage alone.Little research has addressed motivation to take oral AI therapy for women with breast cancer. For example, The ATAC Trialists' Group  found thThe side effects the women reported were consistent with reports of menopausal symptoms induced by breast cancer treatment , 27, as Given these findings, we would have expected women in the current study to describe switching or discontinuing AI therapy more often, but 11 of 12 women indicated that side effects did not deter them from taking anastrozole. The fact that the women who were lower-adherers reported the same type and number of side effects as women who were 100% adherers is interesting and suggests that side effects related to AI therapy are significant to women midway through treatment. The impact of side effects on the medication-taking process with AI therapy for breast cancer prevention requires further examination. It is possible that completion of the BCPT, POMS, and BDI II surveys may have primed the women to describe the side effects that they felt were the most important, most persistent, and/or most present.  The manner in which women logistically and socially managed anastrozole therapy was consistent with research examining medication-taking for patients with chronic conditions , 32, 33;The most significant limitation in the current study is the potential influence of participation in The AIM Study. The women who participated in the interviews were neither naïve to research nor to anastrozole adherence, which may have affected their responses. We interviewed all women who responded to the mailings, but most of the women were already successful in self-management of anastrozole. Women may have had difficulty recalling their early experiences taking anastrozole, or they may have been primed to discuss side effects due to the recent completion of The AIM Study surveys. All women in the current study were white and well educated. Although the women we interviewed were representative of the women who took anastrozole in The AIM Study, they may not represent postmenopausal women with early stage breast cancer in the general population. Racial/ethnic disparities in treatment may affect self-management of medication and should be investigated.Qualitative description allows one to fully describe a particular phenomenon; however, our sampling strategy did not allow us to obtain a complete picture of the women's process of taking anastrozole. In the current study, the women were approximately midway through their five-year course of therapy; therefore, they may have been more established in their medication-taking routines and less likely to discontinue anastrozole therapy. Interviewing women at earlier points in their treatment may help elicit the full scope of how side effects of hormonal therapies affect medication-taking. The women in the current study were mostly 100%- or good-adherers. While we reached information redundancy in our sample, we did not saturate with regard to those who were low-adherers or who had stopped AI therapy. We were able to interview one participant who had discontinued anastrozole due to hip pain; however, we may have missed women at the beginning of their treatment who discontinued or were switched to other AIs. Nonetheless, our results provide a snapshot of the way some women at approximately the midpoint of their hormonal therapy manage their medications, and thus may inform interventions that would aid them in completing the full five years of anastrozole therapy.The women's experiences suggest several implications for clinical practice concerning medication self-management. Given that women were offered minimal information about taking anastrozole therapy, provision of information about anastrozole, its side effects, and how and when to take it may be beneficial, beginning with the first clinic visit with ongoing reassessment at subsequent clinic visits. Second, while most women indicated they experienced similar side effects, the trajectory of those side effects differed among the women. This suggests that ongoing side effect assessment by the health care team is needed even after therapy is well established. Finally, questions focusing on the patient's medication-taking experiences as a whole, rather than an overall verbal assessment of adherence, may prompt further discussion, including why they do or do not take their medication.Our study offers a unique perspective into the medication-taking experiences of some postmenopausal women with early stage breast cancer who were midway through a course of anastrozole who were successful at self-management of anastrozole therapy. While reports examining the end result of self-management of medication (adherence) have been published, reports of research explaining how women view their experiences taking oral hormonal therapy are lacking. Our results help explain why some women, regardless of their measured adherence level, take anastrozole therapy without question and continue despite the side effects of anastrozole. Next steps should include investigations of medication-taking about: (a) women who are low-adherers to AI therapy; (b) socioeconomically and ethnically diverse patient samples; (c) potential differences between pre- and postmenopausal women, particularly side effect severity and medication-taking; (d) effects of medication-taking on clinical outcomes; and, (e) women with breast cancer taking oral targeted therapies.


Despite the advent of and exciting advances in novel endovascular therapies, t-PA remains the only proven treatment for acute ischemic stroke to date. Although a variety of reasons likely underlie why past trials of endovascular strategies have been unsuccessful, we address in this perspective piece one critical unknown for which a solution is undoubtedly necessary if future ones are to meet with success: determination and selection of patients that are “just right” for endovascular treatments, or the Goldilocks dilemma. Key clinical criteria highlighted in past trials may help provide a solution to this critical problem. However, for them to do so, we propose that they must be applied in service of a model that accounts for the nuanced, dynamic nature of acute ischemic stroke better than the prevailing “time is brain” model. We provide and examine three clinical cases to illustrate this proposal towards solving the Goldilocks dilemma and advancing treatment in acute ischemic stroke. Further, we address our field’s ongoing challenge and mission in the meantime to best care for the “not-so-right” patients, by far the majority of the affected stroke population. The introduction of intravenous tissue plasminogen activator (t-PA) heralded a sea change in the management of acute ischemic stroke (AIS). For the first time ever, a medical therapy for acute stroke was proven effective in reducing long-term impairment . Since tUnfortunately, as of yet, no endovascular method has demonstrated itself more clinically effective than t-PA either in head-to-head comparison or in combination with it –7. Why iThe recent disappointing outcomes in related trials are a reflection not necessarily of flawed endovascular therapies, but, rather, of flawed selection of candidates likely to benefit from them. We also propose that improvement of the theoretical framework of ischemic stroke on which the criteria for determination of “just right” trial-eligibility is based may allow future trials to finally achieve success. Finally, we emphasize that, although our Goldilocks search for the “just right” acute stroke patient is necessary for future improvement in care, we must not be distracted and neglect our primary mission to care for all stroke patients including those “not-so-right” – by far, the vast majority for whom we neurointensivists and neurohospitalists currently provide acute stroke care.Despite disappointing outcomes, multiple studies within the acute stroke trial literature have nevertheless proven informative. For one, they have identified and highlighted three clinical parameters that repeatedly and reliably impact stroke outcome regardless of intervention: patient age, symptom severity (NIHSS score), and event duration (time). As a result of their clinically predictive value, the stroke community has heavily weighted its determination of endovascular eligibility on these criteria. Strokes of higher severity (NIHSS score >10 and/or consistent with a large-vessel occlusion), shorter duration  <4.5 h), and in younger patients  <80 years) have been preferred for trial selection. On the other hand, those of lower severity and longer duration especially in older patients have been considered less preferred for enrollment. At first glance, this inclusion/exclusion “just right” criterion appears reasonable especially in consideration of its reflection of and adherence to our field’s current prevailing theoretical framework of ischemia: that is, ischemic burden is a direct, absolute function of time, and hence, “time is brain.” However, if this set of criteria and model of ischemia that it reflects really do offer a best determination of “just right” endovascular candidacy, then why have our trials not proven this so? The answer certainly cannot entirely lay in device or operator limitation or inadequacy. Completed trials have demonstrated that a variety of endovascular therapies and their operators have consistently yielded revascularization success rates higher than those of t-PA alone particularly for large-vessel occlusions . As a result, this patient’s active disease state is not only severe, but also poorly amenable to preserving penumbral tissue and, therefore, salvaging endovascular therapies which target it.The second theoretical candidate is a younger patient with a severe stroke of shorter duration: within the prevailing “time is brain” paradigm of acute stroke treatment, an excellent candidate who appears “just right” for endovascular therapy. However, in consideration of the related pathophysiology driving his clinical status, we argue that this patient is not only a poor candidate, but, perhaps, even a worse one than the first case. In similar fashion to the first example, this patient’s current clinical state signifies a significant load of active disease. However, more importantly, it has been sustained in an even shorter period of time. This active disease state therefore indicates a profoundly more diminished capacity to tolerate and withstand acute ischemia, and likely is the result of a more pronounced presence of chronic co-morbidities and/or absence of disease-mitigating factors. Consequently, this patient’s active disease state is, in actuality, even more severe; even less favorable to penumbral preservation; and, therefore, even less amenable to salvaging therapies than the first candidate’s.The final theoretical case is an older patient with a stroke of mild severity and longer duration: by currently applied eligibility guidelines, another relatively poor candidate for endovascular therapy. But, in consideration of the state of active disease that has resulted in this patient’s clinical status, we argue that one should consider him not only a good candidate, but, in fact, as the true “just right” candidate of the three considered. In contrast to the first two examples of large-vessel occlusive stroke, this patient’s current clinical state reflects a minimal load of ischemia but a large area of penumbra preserved despite, strikingly, a longer duration of acute illness. This active disease state consequently indicates an inherently better capacity to tolerate and withstand acute ischemia, and likely is the result of a notable absence of chronic co-morbidities and/or presence of disease-mitigating factors. Consequently, this patient’s active disease status is not only fundamentally different than those of the former cases; but, as a result, also more amenable to endovascular rescue therapies.These theoretical case examples that fall along a continuum of age, stroke severity, and duration illustrate our contention that these strong predictors of acute stroke clinical outcome do in fact have potential utility in determining which patients are “just right” for endovascular treatments. However, we propose that our field’s currently favored model of ischemia, “time is brain,” is an inadequate oversimplification of the complex, dynamic pathophysiology in acute stroke. As a consequence, its promotion has led unintentionally to a misinterpretation of these three clinical parameters; subsequent selection bias toward “not-so-right” trial candidates; and ultimately continued stasis in the progress of acute stroke therapy. Therefore, we argue for its replacement with a theoretical framework that better encapsulates and accounts for the dynamic, nuanced complexity of the active ischemic disease state. In support, we provide as a basis for these clinical predictors a framework of ischemia that accounts for the global state of pathophysiology during acute stroke: one that incorporates stroke severity and duration not as independent factors, but as interactive and compounding contributors along a spectrum of active disease states. Indeed, we must be mindful that although severity and duration undoubtedly influence clinical outcomes, so too do a host of other exacerbating and mitigating factors that fall under the umbrella of the active disease state and influence tissue ischemia and viability.Accordingly, we should give pause to consider whether there may be multiple or, unfortunately, no patients that are “just right” for endovascular therapies. Both possibilities suggest that such a Goldilocks search may be unjustified and not worthwhile. Indeed, the vast majority of stroke patients that require our acute care in the hospital are overwhelmingly “not-so-right” precisely because they represent a broad continuum of active disease states across the myriad of interactive acute and chronic illnesses that can clinically declare themselves as acute cerebrovascular pathology. If we desire to advance the field of acute stroke and its treatments, it is imperative that we not lose sight of this fact. It begs us to remain humble, open-minded, and open-hearted to the notion that our current understanding of acute stroke is still relatively superficial. And with that acceptance comes a hope that, with continued improvement in our understanding, we be able to call fewer and fewer patients “not-so-right” in the future. To this end, we propose that a more nuanced framework of acute ischemia replace our field’s current one to allow for improved interpretation of valid clinical criteria and determination of eligibility for endovascular treatments in acute stroke trials. Such a step gives promise that our Goldilocks search will continue and ultimately, hopefully, identify the ideal acute stroke patient: one whose acute stroke may be small in severity or even long in duration, but whose active disease state, regardless, is just right.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.