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Introduction:

Unconscious, the bread and butter of Psychoanalysis, that has widely believed to have been started its inception in the literature by Sigmund Freud at the end of 19th century, it has been indeed coined by the German philosopher Friedrich Scheeling in 18^th century. Probing into the history, in fact, unconscious has been known in the scientific arena long ago and in the written materials, as early as 16^th century by Paracelsus, a Swiss physician. William Shakespeare has also explored the unconscious in some of his plays very well, and other philosophers such as Schopenhauer, Spinoza, Leibniz, Hegel, Kierkegaard and Nietzsche have discussed the subject.   Indeed Nietzsche in his “Thus Spake Zarathustra” who wrote between 1882 to 1885, not just describes the unconscious (soul/spirit), but the ego and the Self while making a clear distinction between them. “body am I entirely, and nothing more; and soulis only the name of some thing in the body…Ego, sayest thou, and are proud of that word. But the greater thing in which thou art unwilling to believe is thy body with its big sagacity…Instruments and playthings are sense and spirit; behind them there is still the Self. The Self seeketh with the eyes of the senses, it hearkenth also with the ears of the spirit…It ruleth, and is also the ego’s ruler. Behind the thoughts and feelings, my brother, there is a mighty lord, an uknown sage, it is called Self…” He even goes beyond what a century later Freud, the inventor of psychoanalysis discussed, and talks about self-esteem that’s a significant psychological core nowadays. “The creating Self created for itself esteeming and despising, it created for itself joy and woe”.    

 In psychology even Freud has not been the first one to address the topic, but the American psychology and philosopher, William James in his treatise, “The Principles of Psychology” examined the unconscious and subconscious. In fact Freud was influenced by the French Jean-Martin Charcot, a neurologist like Freud, who treated his hysterical patients with hypnosis and reached their unconscious minds. This influence drew Freud from neurology to hypnosis, then the world of unconscious and his following theories of compartmentalization of conscious to “ego”, and unconscious into “id” and “superego”, then “repression” of unacceptable ideas, wishes, traumatic memories and painful emotions by the conscious into unconscious. Freud used his “Interpretation of dreams” at the turn of the 20^th century and later on his technique of “Free association” by laying down the patients on his psychoanalytic couch, that became the bread and butter of the future analysts, to reach their patients’ hidden worlds so to cure them.

Freud with all his generalization to expand his theories did not go farther than discussing “neuroses” and treating neurotic and hysterical patients. But the Swiss Carl Gustav Jung, another psychiatrist, who initially had the aspiration of becoming a preacher or minister and later on study archaeology and later on mesmerized by the unconscious, brought his original interest in spirituality and mythology into his psychology. Although psychoanalysis like any other non-scientifically based ideas did not pass the test of time and is almost obsolete in our era, this paper analyzes the Jungian psychology that not for its implication in clinical psychological/psychiatric practice, as it is rarely used nowadays, but for its grandiose generalization beyond the field into culture, philosophy, arts, anthropology and so on. “Man and his Symbols” written by Jung and a few of his immediate associates just before his death that published a few years after, and contains most of his ideas is the subject of this analysis. 

Jungian Psychology: Back to the ancient mythological psychic reading

Read the Full text here:

Unconscious: Revisited

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Introduction:

Stem cells are the primordial or original cells that give rise to life and being of a living thing, from animals and humans. Zygote formed from the fusion of sperm and oocyte is the first line of stem cell that is “totipotent” meaning it gives rise to embryonic stem cells and from there to epiblast and embryonic germ stem cells, that are all “pluripotent” meaning they form all the differentiated cell types of a given tissue. These pluripotent stem cells lineage give rise to the primordial germ cells that form all the tissues from skin to bone marrow and all other body tissues. The aim of stem cell therapy over the past half a century has been to induce pluripotent stem cells (IPS) in different body tissues to repair or replace the damaged tissues and cells of specific organ or parts of the body in vitro (in lab) and in vivo (in live beings) (1-2).

 Bone marrow transplant has been the earliest stem cell therapy in the treatment of leukemia and lymphoma and has been widely clinically practiced over almost half of a century all over the world with quite success. Later on umbilical cord blood storage and use for transplants has been clinically practiced, while other forms of stem cell therapy such as the use of induced pluripotent stem cells (IPS) for a wider treatment of cancers and autoimmune disorders of different organs and tissues have been mostly experimental. Another common clinical use of bone marrow transplants has been in chemotherapy of cancers, to introduce the hematopietic stem cells within the bone marrow to replace the destroyed healthy cells by chemotherapy. The most common side-effects of bone marrow and other transplants traditionally has been graft vs. host reaction that rejects the transplant. Another stem cell therapy, “Prochymal” based on allogenic stem cells therapy using mesenchyme stem cells has been used recently in the management of such transplant rejections (3-4).

 While in the past it was thought that the stem cells are basically in bone marrow and umbilical cords and most organs and tissues unlike the epidermis of the skin do not possess the capacity of renewal, in recent years it has become apparent that some other tissues in fact contain stem cells for potential renewal (5). One main reason of the delay in the stem cells therapy has been lack of recognition of different stem cells across different tissues with different potential capacities unlike the progenitor bone marrow and umbilical cord stem cells. As explained above while many of these stem cells are pluripotent, most are multipotent or unipotent, meaning having the capacity of their own specific tissue cells regeneration (6-7). In fact and with a comprehensive perspective, cancer cells could be considered as stem cells for their capacity of turnover and proliferation. This fact has been known and discussed as early as late 80s, but only recently has received widespread attention and acceptance. The cancer stem cell concept is important for opening a new venue to the novel approaches in anti-cancer therapies that instead of killing all or partial cancer cells with the potential of regrowth, to target the cancer stem cells for final cure with no possibility of relapse (8-9).

 The advancement in stem cell research over years has led to the distraction and culture of progenitor or totipotent stem cells in vitro first from the animal models such as mouse, and now from the human’s blastocysts, with the ability of generation all the differentiated cells of a being such as human, hence “cloning” that puts the science in the jeopardy of Frankenstein as it has long been anticipated and infuriated (10-11). Other than blastocysts, the progenitor or embryonic stem cells with capacity of generating differentiated tissues of the whole being, it has been shown that epiblasts first from mouse and now humans could created such pluripotency (12-14). Moreover and morally riskier is the capability of adult stem cells to be reprogrammed to a pluripotent state, through transferring the adult nucleus into an oocyte or by fusion with a pluripotent cell. The most famous example of this cloning has the creation of “Dolly” the sheep by transferring of a somatic nucleus into an oocyte (15-18).

 From a therapeutic not creational standpoint, the ability of regenerating new cells in the damaged and destroyed tissues is the art and science of IPS (induced pluripotent stem cells). Despite knowing for long that some amphibians could naturally regenerate limbs, eye or other injured body parts, therapeutic regeneration or regrowth of damaged or destroyed tissues medically by IPS is quite recent (2, 19-20). Since the original retrovirus-mediated induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by some defined factors in 2006-2007 (21), rapid progress has been made to generate iPS cells from adult human cells (22), a range of tissues that can be reprogrammed (23), and from patients with specific diseases (24). The number of transcription factors required to generate iPS cells has also been reduced (25), and the efficiency of iPS cell generation has increased (26), and techniques have been devised without viral vectors integration (27).

 From Research to the bed side:

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Stem Cell Therapy: Does it work and for what?

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Introduction:

Natural medicine or Alternative Medicine or the field of Naturopathy with their widespread health food stores that have filled up the shelves of pharmacies as well is based on the propaganda that medications are chemicals and unsafe and their own products natural and safe. The field of naturopathy and the natural or herbal medicines that have dominated the health products market and sell more than prescription medicines, is solely based on the notion that the prescribed medications are chemicals and theirs are not. The irony is that everything is chemical, the oxygen in the air that we breath (O2), the water that we drink (H2O), and all the food that we eat, and so on.

In fact the prescribed medications that are nowadays synthesized in pharmaceutical factories have been originally made out of plants, e.g. Digoxin for heart attacks, Atropine for pupillary dilatation and else, Codeine for pain relief, L-Dopa for treatment of Parkinson’s, Aspirin, Quinidine an anti-arrhythmic, Reserpine a hypotensive, Theophylline a diuretic, and Yohimbine an aphrodisiac among so many others. Investing and profiting from the popular lack of sufficient knowledge and also the mass suggestibility, the field of alternative medicine has gone so far that simple food items such as garlic, cranberry and fish oils have nowadays been packaged in capsules, tablets and sold to consumers (1-2).

Although the science of Medicine originated from the herbs and plants, it was not until the modern era that the real based evidence medicine as we know it developed a competitor as “alternative medicine” to promote the use of natural medicine and other forms of healings. This alternative medicine or “naturopathy” from the start by the Bavarian priest Sebastian Kneipp in late 19^th century to Benedict Lust, the founder of naturopathy in US, started their propaganda against evidence-based or real medicine and medications, including vaccinations even in children and against killing infections such as small pox or chicken pox. Although naturopathy or alternative medicine cover an extensive area and different treatment modalities, e.g. acupuncture, aromatherapy, massage therapy, Chinese medicine, homeopathy, herbology, reflexology, Reiki and chiropractic, the focus here will be on the promotion of the use of natural or herbal medicines, vitamins, minerals and supplements that have become a huge profit making business and available everywhere even on the shelves of pharmacies and grocery stores (3).

 The efficacy and safety of herbal medicines:

In argument against the core of natural or herbal medicine that they are natural and safe while prescription medicines are not, there are numerous studies across the globe demonstrating evidence to the contrary. It is well known even to the lay people that one could get poisoned by food, consuming plants or even coming in touch with them. Mushroom poisoning and contact dermatitis by poison ivy are the two very common examples that almost everyone is aware of. A total of 216 medicinal plants belonging to 77 families in North and Central America and Caribbean have been reported as toxic. These herbal medicines and alike that have been promoted and used for different illnesses such as rheumatism, wound healing, flu, headache, dysentery, gastritis, constipation, diarrhea, body pains, cancer, antiseptic, digestive, diuretic, fever, infections, menopause, dysmenorrhea, postpartum, diabetes, asthma, anemia, inflammation, muscle relaxant, hair loss, seizures, hypertension, anxiety, depression, psychosis, weight loss or simply to purify body and the blood, have been reported to cause many side-effects and toxicities (4).

The list of these untoward effects and toxicities like the claimed positive effects are numerous, e.g. nephrotoxicity (toxicity of kidneys), hepatotoxicity ((toxicity of liver), dermatitis, hypertension, nausea, vomiting, diarrhea, muscle paralysis, cardiotoxicity (toxicity of heart), gastritis, even being carcinogenic, sleepiness, muscle paralysis, respiratory failure, neurotoxicity (toxicity of nerves and central nervous system), causing abortions, hallucinations (hearing voices or seeing visions), edema (swelling), hemorrhage, blurred vision, vertigo, stupor, confusion, being narcotic and addictive among others (5-16).

Other than the above gross and obvious toxicities, the herbal medicines could caused molecular and cellular toxicities (cytotoxicity), even mutagenicity and genotoxicity (causing gene mutations and toxicities). Some herbal medicines could also cause toxicities during pregnancy and reproduction and cause abortions. These facts are only the tip of the iceberg of the possible side-effects and toxicities of the herbal medicines as most people do not report to their physicians and refer to emergency rooms of hospitals when intoxicated. Moreover there are untoward interactions of the herbal or natural medicines with the prescription medications that again many patients do not report to their physicians or pharmacies when use these products in addition to their prescribed medications (17-20).

 The case of naturopathy or homeopathy and their broad advertisements in media, specially in social media, TV, and many journals are beyond control. Nowadays to skip the drug agency controls, many of these products are offered in the common food products such as drinks, teas and even candies and other snacks. Moreover the health benefits of certain herbs, vegetables, plants and food as simple as garlic or fish oil have been exaggerated and they have been produced and released into tablets, capsules and sold in the market at a much higher prices, instead of promoting these basic food items in meals. These propagandas have been at the cost of advertising against the consumption of some food health promoting foods that nowadays are missing from many people’s diet such as dairy products, eggs, lipids, red meat and fruits (21-22).

 Read the full text here:

Hating Chemicals: Natural Medicines and Vitamins

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Introduction:

Fibromyalgia that is diagnosed and labelled by physicians in clinical practice and even research interchangeably with Chronic Fatigue Syndrome is still a controversy by some, while a clear diagnostic entity by others. As the label of fibromyalgia denotes, it is a condition of generalized body (musculoskeletal) and joint pains. The Chronic Fatigue Syndrome label indicates the patient suffering from a general body fatigue. These two labels if they are two conditions may overlap as some patients and present with both generalized symptom clusters. That is why the two conditions are considered by some as one and inter-related. While these conditions were misdiagnosed or under-diagnosed in the past, they may be over-diagnosed in the recent years. Either way the diagnosis of these conditions often is clinical and by history and physical examinations (only if muscle and joint tenderness present) as any lab or imaging tests are often non-conclusive. Therefore the pathophysiology of these conditions is still known by many as idiopathic, without any known aetiology or pathologic pathway(s).

 More than a controversy, Fibromyalgia and Chronic Fatigue Syndrome (FCFS) are elusive and the diagnosis by many could be descriptive and clinical by symptoms counting like major depression. But there is at least one or more types of FCFS that are associated with many other medical conditions, e.g. IBS (Irritable Bowel Syndrome), non-ulcer dyspepsia, esophageal dysmotility, interstitial cystitis, chronic prostatitis, vulvodynia, vulvar vestibulitis, temporomandibular joint syndrome, sickle cell anaemia, osteoarthritis to name a few. The association with some of these comorbidities that are known as autoimmune disorders, could easily classify this type (s) of FCFS as an autoimmune condition(s) (1). The common conception behind the pathogenesis of FCFS is over-focussing on the pain symptoms that could be due to super-sensitivity or hyperalgesia of the nociceptive process in the central nervous system. But here the focus will be more on the type or types of FCFS that have some true underlying pathologies (1-2). This or these pathological condition (s) are inflammatory, systemic throughout the body and associated with one or more inflammatory or autoimmune disorders (e.g. 3-4).

In the Search of a True Pathologic Fibromyalgia & CFS:

A Chronic Pain Syndrome or A Systemic Musculoskeletal Inflammation?

The first thing to reach the truth of FCFS is to separate these two different conditions that currently are diagnosed under the generic umbrella of fibromyalgia and chronic fatigue syndrome. First of all since both a chronic pain syndrome due to hyperalgesia or super-sensitivity of the nociceptive receptors in the central nervous system, and a systemic musculoskeletal inflammation could cause chronic fatigue syndrome, this secondary or post-morbid condition in this article will be excluded and the literature on fibromyalgia is solely explored (5-8).

 Although a systemic musculoskeletal inflammatory condition could cause chronic generalized body pain, but the reason for the pain is not hyperalgesia or hyper-sensitivity of the nociceptive receptors in the central nervous system, but peripheral inflammations. This inflammatory condition is separated and searched for its underpinning pathology as the true pathological fibromyalgia, as pain even a generalized type could be subjective and not a true objective and pathological condition. Even tenderness of the muscles and joints without any proof of underlying pathology such as inflammation could be all subjective. Therefore this subjective condition or “Chronic Pain Syndrome” that could be due to a hyperalgesia or hyper-sensitivity of the nociceptive receptors of the brain or in a simpler word due to hyper-perception of pain by an individual is separated from a true fibromyalgia in this paper. This sole pain condition that is simply subjective could be perhaps associated more with other subjective conditions such as depression or being influenced by psychosocial processes (9-12).

Fibromyalgia: A Systemic Musculoskeletal Inflammatory Condition  

Unfortunately since most samples of fibromyalgia studies are mixed with chronic pain syndrome and other subjective conditions without any underlying physical pathology, the physical findings of any inflammatory biomarkers are below the real level of the pathological reality of the condition. But despite this limitation, there are studies that have been able to show the presence of an underlying inflammatory process in the true cases of fibromyalgia.

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Fibromyalgia/Chronic Fatigue Syndrome: Controversy or Truth?

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(To: My daughter Tiffany, Mohammad Ali, Rafael Nadal, Milos Raonic and all the injured athletes of the world) 

Introduction:

When my daughter, a junior tennis player, injured her wrist this summer it took her about two months to recover and get back to the game. Having had to retire from a few important tournaments, I realized more of the significance and self-destruction that sport injuries could cause to a person. We all know about the consequences of sport injuries in famous world sport leaders such as Mohammad Ali who developed Parkinson syndrome (not the disease but what’s called in medicine “Punch Drunk Syndrome” with Parkinson-like symptoms). Sport injuries are almost unavoidable in athletes, and in the tennis the fans know how many operations the current world number one, Rafael Nadal has had just on his knees, or Canadian Milos Ranoic broke his hip at age 20 by falling on the grass court in Wimbledon.

Different sports are more prone to injuries and different parts of the body are more common to injuries in different sports. For example tendonitis of the wrist, elbow, shoulders and injuries to the knees, ankles and foot are more common in tennis. But head injuries are more common in boxing and hockey, while foot, legs and knees injuries are more common in soccer. Overall some sports are more prone to injuries due to the nature of the sport and the behavior of the athletes and due to more lenient rules and prohibition executed by the specific sport authorities and the referees in some specific sports such as hockey. While the physical injuries are more obvious and attended to, the mental and emotional injuries due to the stress and expectations of the athlete performance by the athlete, coaches, fans and families should not be ignored(1).

We need not to forget that sport injuries do not occur only in professional athletes that comprise a small population in sports in general, but in many healthy youngsters who engage in sports curricular in schools or extra-curricular sport activities. There are more than 30 millions injuries alone in the United States in teenagers and children. We also need to realize that some sport injuries when befall on the neck and head could lead to permanent disabilities and loss of lives that often happen to the otherwise healthy and young ones. We need not to be scared and avoid the sports for ourselves and our children, as playing sport or exercise is the best that we or they can do as a guarantee for a healthy life, but we need to know how to do it right so to prevent injuries. Although this article is focused on sport injuries in the athletes of all ages and different levels, but ordinary people who engage in harsh and in-calculated exercises could have injuries as well (2).

In this article after classifying the common sport injuries, considering different age groups, in non-professionals and professionals, and across different sports, and also among ordinary people regarding over-use and improper injuries, prevention of such injuries will be discussed.

 Soft-Tissue Injuries:

Soft-tissue injuries are the most common type of injuries that include simple cuts, lacerations and bruises, easily seen by the naked eyes. But deep soft-tissue injuries that could affect tendons, muscles, blood vessels, nerves and could cause more pains, discomfort and longer disability mostly due to deep inflammations, may be ignored. The most common of these deep soft-tissue injuries are tendonitis and neuritis or neuralgic pains that demand longer and more specific treatments.  

  Read the full text here:

https://medicinerevisited.com/sport-injuries-when-young-and-healthy-break/

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(“I went to see an old woman with asthma, a customer at La Gioconda. The poor thing was in a pitiful state, breathing the acrid smell of concentrated sweat and dirty feet that filled her room, mixed with the dust from a couple of armchairs, the only luxury items in her house. On top of her asthma, she had a heart condition. It is at times like this, when a doctor is conscious of his complete powerlessness, that he longs for change: a change to prevent injustice of a system in which only a month ago this poor woman was still earning her living as a waitress, wheezing and panting but facing life with dignity. In circumstances like this, individuals in poor families who can’t pay their way become surrounded by an atmosphere of barely disguised acrimony; they stop being father, mother, sister or brother and become a purely negative factor in the struggle for life and, consequently a source of bitterness for the healthy members of the community who resent their illness as if it were a personal insult to those who have to support them….In those dying eyes there is a submissive appeal for forgiveness and also, often a desperate plea for consolation which is lost to the void, just as their body will be soon lost in the magnitude of mystery surrounding us.”)    

Ernesto Che Guevara,

Motorcycle diaries

Introduction:

Asthma that is the narrowing of the airways of lung, causing difficulty in  breathing with sound of wheeze, is a chronic disease often starts in childhood and is an interaction between the environmental allergens or pathogens and the individual lung’s susceptibility or genetic make up. This early onset asthma that often leads to asthma attacks, frightening the person and the relatives for the fear of inability in total breathing and death, is usually due to an allergic eosinophilic reaction of the lung airways, causing their narrowing due to thickness of their smooth muscle walls and also obstruction caused by reactive sputum (1-3).

 But not all asthma is an allergic eosinophilic reaction of the lung airways and there is a heterogeneity even in the inflammatory asthma known and reported since 1922 by Huber and Koessler (4). It has been shown and reported that any problems with the lung function such as reduced its function even as early as infancy could lead to late on obstructive lung disease such as asthma (5-6). At the same time, having a history of allergy or atopic sensitization as long as not related to such sensitivity in the lung airways, it will not necessarily lead to asthma in childhood. (7) Following an epigenetic model of causation in asthma, the airway hyper-responsiveness or sensitivity or overwhelming the lung airways with too much dust mites, heavy smoking specially at an early age could prolong the childhood asthma into adulthood and also cause exacerbations and further attacks (8).

 Other than the common allergic or eosinophilic asthma with an early onset in life and running a chronic course, microbial invasions of the lungs and respiratory airways, also contribute to asthma. There have been reports on neutrophilic and lymphocytic infiltrations of the lung airways among others causing the narrowing of the airways, hence asthma (9-10). Such infiltrations of other white blood cells even in the airways or sputum of allergic or eosinophilic asthma that for long thought to be due to T helper type 2 disease and as an allergic reaction, has more recently been shown to have an underlying immunologic susceptibility. This is the beginning of a new understanding of asthma and its genetic susceptibility as an immune or perhaps an early autoimmune disease (11-12).

Che Guevara: An Iconic Asthma Sufferer

Ernesto Guevara was an Argentine physician, who later on by his Cuban comrades was popularized as “Che”, meaning comrade or friend, and since then he has been known as Che Guevara. Before joining the Cuban revolution along with Fidel and Raul Castro and other guerillas, since he suffered from a severe asthma with frequent attacks from his childhood, causing him staying home sick often, he spent all his sick time reading a lot of everything from literature, poetry, philosophy, politics and else. He was also in love of photography and travelling, that his trip across South America, that he called one nation, on a motorcycle with his friend Alberto Granado, under the title of “The Motorcycle Diaries”, before his graduation from medical school and becoming a revolutionary, has been a popular book and film. Despite his severe asthma in his continental trip, he swam at night across Amazon river, a considerable distance of 4 kilometers (2.5 miles) when visiting and helping the lepers in a leper colony in Peru. He unlike the doctors and nurses in the colony, did not wear gloves to shake hands and touch the lepers, but bravely did so with his bare hands.

Read the full text here:

https://medicinerevisited.com/general-medicine/asthma-tribute-ernesto-che-guevara/

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Introduction:

As adults we spend or should if we don’t one third of our time in sleep and as children up to half of their time. We all sleep when tired and when have a good sleep, we would feel rested. We therefore know that the sleep function is for restoration of physical tiredness or fatigue. But sleep is not just for restoration of physical fatigue, but for the restoration of the mental or brain fatigue as well. We may think that during the sleep, the body is totally shout down and in rest. But surprisingly the body is quite active in sleep and like a factory, does self-restoration or repair during the hours of sleep. In deep sleep, if we can get any, the physical restoration or repair is done and in REM (Rapid Eye Movement) or dream stage of sleep, the mental or brain restoration or repair is done. More importantly, many hormones such as growth hormone in children are secreted in sleep and mostly in deep sleep.

 In this paper, the architecture or different stages of sleep will be explored. Then the sleep-wake cycle that is a major component of our circadian rhythm and our body homeostasis and health balance will be exposed. Then the importance of sleep hygiene and lack of it and the disorders of sleep will be discussed. The treatment for sleep disorders and the most common one, insomnia or sleeping pills will not be discussed, as majority are of Benzodiazepine class of drugs, addictive and more habit forming and perpetuating the insomnia. The purpose of this article among the others on this site is more to understand the pathophysiologic process of every disease, so hopefully soon move towards the prevention. Finally what is a very dilemma and question for many, the world of dream and its interpretations will be explained.    

Stages of sleep:

During a night sleep of about 8 hours that is normal for adults, the body or brain goes through about 5 cycles, starting with the stage 1 that is the drowsiness or falling asleep stage lasting only a few minutes. Then the second stage that comprises about %45-50 of a normal adult sleep, that is still light and the person could be aroused by sounds and noises and it is the usual toss and turn stage of sleep. The second stage lasts about 40-45 minutes in each cycle that lasts normally 90 minutes. Then the deep sleep kicks in that is comprised of stages 3 & 4 and most adults do not get it much nowadays, while they need to have it at least %20 of their sleep. These stages of 3 & 4 or deep sleep is for the restoration of physical fatigue and if the person does not get it enough, he or she would not feel rested in the morning.

The next stage of sleep in the cycle is REM (Rapid Eye Movement) sleep that is the dream stage of sleep when the individual enters the world of his or her dreams. This stage that comprises about 20-25% of a night sleep is very active not just for the eyes that moves fast as its term suggests, but the whole body physiology such as heart beat, respiration and else are active even more than in the waking state.  After the first cycle of sleep and REM, the brain may not start over from stage 1, unless someone’s sleep is very light and broken and keeps waking up in the middle of the night, or after a nightmare. So in a normal restful sleep, after the first cycle and REM, in the second cycle and thereafter, the brain starts from stage 2 and the rest. If the individual’s sleep is light, he or she may not go much or at all through the deep sleep of stages 3 &4 that is very common in the modern era of sleepless nights. Therefore everybody gets mostly stage 2 and REM sleep even if one does not remember having any dreams. REM sleep due to its high brain and physiological activity, has the vital role of restoration of brain fatigue. That’s why people with many mind preoccupation or worries may have lots of dreams and even nightmares. The following figure shows how the body enters the different stages of sleep from a waking state and the repeated sleep cycles throughout a night sleep:

 Now in the following each stage of sleep will be discussed in more detail:

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https://medicinerevisited.com/psychiatry/1883-2/by

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Physicians or medical doctors who are in charge of our health and well-being world wide, are the products of different medical training standards around the world. The medical schools training could last from 5 to 8 years to graduate a general practitioner or GP. Many medical schools around the world accept the high school graduates after an entry exam into the medical schools that mostly last about 6 years. This could be true in many developed countries such as in Europe. But in US, Canada and UK that hold higher standards in medical training, the entry into medical school is much more sophisticated, longer and more competitive. The applicants in these countries, mostly need a bachelor degree principally in biological science or alike, passing a medical entry test, MCAT (Medical Colleges Admission Test), voluntary works, references, etc. to be accepted to medical schools that is highly competitive. In these countries, then the medical schools training is four years, all focused on medical sciences, from the basic to the clinical and specialties, concluding general practitioners. But there are no jobs or positions for GPs per se in these countries without any specialties, and the shortest training for these would be family practice that lasts two years that is equivalent of GPs in other countries, only after 6 years of post-graduate studies past high school. Therefore one could easily appreciate the difference in the quality of medical training across the globe that could be translated to the quality of medical care. (1-3)

 In many places in the world after graduation from medical schools, there might not be any final general exams of all the pre-clinical and clinical subjects for licensing to practice general medicine. But in US, Canada and UK there are several step exams during the medical school years and after graduation for licensing to practice medicine. In US there are three step of such exams, step 1, testing basic medical sciences in one-day of 8-hours session, step 2 consisted of two sub-steps of clinical knowledge (one-day of 9-hour test) and clinical skills (one-day of practical clinical skills assessment with mock patients). The final step licensing exam, or step 3 of USMLE (United States Medical Licensing Examination) assesses the capability of the application of basic medical and clinical sciences in a two-day exams, 7-hours the first day and 9-hours the second day including clinical skills assessment of 13 simulation cases across major medical disciplines. (4-5)

In Canada there is a similar licensing exams or MCCQE (Medical Council of Canada Qualifying Examination). The first part of MCCQE in 3.5 hours assesses the general medical knowledge, followed by 4-hours of clinical decision making scenarios assessment. The part 2 of MCCQE consists of an objective structured clinical examination in total simulated clinical sessions with patients, that could be taken after one year past the clinical training graduation.

 In England, unlike US and Canada but like many other parts of the world, entry into medical schools are right after graduation from high schools, though the competition is quite high and the rate of acceptance is not more than 10%. Other than traditional or multiple mini-interview, depending on the university, there is the United Kingdom Clinical Aptitude Test (UKCAT) required by most universities and Biomedical Admission Test (BMAT) required by five universities. The medical courses in English medical schools are “problem-based learning” and “lecture-based learning”, and consist of 2-3 years in pre-clinical and 3 years in clinical. The graduates after these 5-6 years of medical training are recognized as Foundation House officer (FHO) and are only permitted to work in supervised clinics and hospitals for one year before being granted independent license to practice as GP and fully register in the General Medical Council. (6-7)

Which system is better?

Is the straight entry from high school to medical school better or an entry after a four years under-grad university education? While entry into medical school in most parts of the world is probably the hardest among any other university courses, when entered most students graduate and there is not much scrutiny and not much failure. A major difference between the two systems is the age and maturity of the applicant. In the straight from high school entry with 6 years course, the applicant is younger and less mature, but in the other system entry after a bachelor degree, the applicant is four years older and more mature. At the same time in the first system of straight six years medical studies, two years basic medical sciences and four years of clinical, the students acquire more knowledge due to studying medicine two years longer. But in the four years course after a bachelor degree, unless those students who have studied four years of basic medical sciences, the rest have only four years to study medicine, including basic and clinical sciences. That is why in countries with this latter system such as US and Canada, there is no GP or licensure to practice after graduation from medical school, unless finishing a specialty training that equivalent to general practice is family practice in these countries that require an additional two years of training. At the end both system in regard with training, education and knowledge could be equivalent, but the only difference will remain age and maturity that the latter system could provide more better health care service due to age and maturity.(8-9)

 Are the licensing examinations well justified?

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(In the memory of my father, a common man, but a poet)

Introduction:

Heart attack that medically known as Myocardial Infarction (MI) is the leading cause of death in the developed countries and the second in the developing world with over 12% of the cause of the death worldwide. The prevalence of such deaths due to heart failure after acute myocardial infarction from the 10% within 30 days and 20% in 5 years in the 70’s, have skyrocketed to 23% and 34%, respectively, in the 90’s. MI usually is a result of Coronary Artery Disease (CAD) of the blood supplies to the heart muscles, that is caused by the occlusion of these arteries by atherosclerotic or lipid plaques that finally rupture and leading to the necrosis or infarction of the cardiac muscles, impeding its pumping function, finally failure and death.

The accumulation of the atherosclerotic plaques which is a long or chronic process, after years warns the individual with symptoms of Angina, e.g. chest pain that my feel like heartburn, radiating to left arm, shoulder and other associated symptoms such as nausea and vomiting, shortness of breath, numbness on the left side, faint feeling and cold sweat, etc. While the precipitating process is long, the end result could be sudden and acute, causing sudden death in minutes even at times without warning or chest pain, so called silent MI or heart attack. In certain situations, MI could happen without a precipitating long process, by coronary arteries spasm due to the use of some illicit drugs such as cocaine and extreme cold among others. (1-2)

Why a beating heart stops?

A beating heart does not stop incessantly, as it looks in the heart attack or myocardial infarction to be sudden and acute. Underlying a stopping heart or attack that is seemingly acute and sudden, there are chronic or long-standing processes that lead to its standstill. There are more than one factor in the process that ends in the heart attack and understanding of these factors could help to prevent sudden death from heart attacks. Although there are many modern treatment modalities from angioplasty to coronary bypass, saving an infarcted or a partially or more complicated dead heart muscle, hence saving lives, the ultimate goal in this arena needs to be prevention of such fatal accidents, as there are many unfortunate instances such as my father’s that any treatment even advanced ones could be already too late!

While to many people, including the patients themselves and their clinicians, heart attack or myocardial infarction is interpreted as coronary arteries (blood supplies to heart itself) occlusion, there is a big and long-standing secret behind it. Moreover the great majority of myocardial infarctions are not fatal, whether treated or untreated, and understanding, prevention and treatment of the precipitating factors are crucial as subsequent attacks may kill the person if not the first one, like in the case of my father. Among many of these factors, there are comorbidities or other illnesses such as diabetes mellitus or hypertension, plus the size and location of the infarct that influence the clinical course, treatment and prevention. The exact anatomic territory infarcted and whether it includes the sinus node or AV node or important neuro-receptors; whether many small arteries are occluded (especially downstream of narrowed main coronary branches) are all important. Also whether the heart is hypertrophied, dilated, infected, or infiltrated; and whether there may be intra-cardiac, extra-cardiac, or intracranial neuro-pathological conditions that could destabilize cardiac electrical activity are needed to be identified. (3)

Moreover it is known that apoptosis plays a major role in myocardial infarction or ischemia, but it also occurs within the heart completely and independently of infarction. There is also the vexing dilemma that an effective coronary collateral circulation, which is determined primarily by trans-anastomotic pressure gradient, is made less effective by exactly those treatments that reestablish flow in an occluded coronary artery. Since thrombolysis and angioplasty are automatically considered urgent treatment for an occluded coronary artery, it is prudent to remember the complex causes that determine whether the patient lives or dies. (3)

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https://medicinerevisited.com/general-medicine/heart-attack-killer/by