<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Baby colic and can you explain it in depth? [/INST] Baby colic, also known as infantile colic, is defined as episodes of crying for more than three hours a day, for more than three days a week, for three weeks in an otherwise healthy child. Often crying occurs in the evening. It typically does not result in long-term problems. The crying can result in frustration of the parents, depression following delivery, excess visits to the doctor, and child abuse.The cause of colic is unknown. Some believe it is due to gastrointestinal discomfort like intestinal cramping. Diagnosis requires ruling out other possible causes. Concerning findings include a fever, poor activity, or a swollen abdomen. Fewer than 5% of infants with excess crying have an underlying organic disease.Treatment is generally conservative, with little to no role for either medications or alternative therapies. Extra support for the parents may be useful. Tentative evidence supports certain probiotics for the baby and a low-allergen diet by the mother in those who are breastfed. Hydrolyzed formula may be useful in those who are bottlefed.Colic affects 10–40% of babies.  Equally common in bottle and breast-fed infants, it begins during the second week of life, peaks at 6 weeks, and resolves between 12 and 16 weeks. It rarely lasts up to one year of age. It occurs at the same rate in boys and in girls. The first detailed medical description of the problem was published in 1954.

Signs and symptoms
Colic is defined as episodes of crying for more than three hours a day, for more than three days a week for at least a three-week duration in an otherwise healthy child. It is most common around six weeks of age and gets better by six months of age. By contrast, infants normally cry an average of just over two hours a day, with the duration peaking at six weeks. With colic, periods of crying most commonly happen in the evening and for no obvious reason. Associated symptoms may include legs pulled up to the stomach, a flushed face, clenched hands, and a wrinkled brow. The cry is often high pitched (piercing).

Effect on the family
An infant with colic may affect family stability and be a cause of short-term anxiety or depression in the father and mother. It may also contribute to exhaustion and stress in the parents.Persistent infant crying has been associated with severe marital discord, postpartum depression, early termination of breastfeeding, frequent visits to doctors, and a quadrupling of excessive laboratory tests and prescription of medication for acid reflux. Babies with colic may be exposed to abuse, especially shaken baby syndrome.In 2019 Cochrane conducted a systematic review on parent training programs for managing infantile colic.  Seven studies with over 1100 participants met inclusion criteria.  Limited evidence was found for the effectiveness of such programs, one meta-analysis showed some reduction in crying time.

Causes
The cause of colic is generally unknown. Fewer than 5% of infants who cry excessively turn out to have an underlying organic disease, such as constipation, gastroesophageal reflux disease, lactose intolerance, anal fissures, subdural hematomas, or infantile migraine. Babies fed cows milk have been shown to develop antibody responses to the bovine protein, causing colic. Studies performed showed conflicting evidence about the role of cows milk allergy. While previously believed to be related to gas pains, this does not appear to be the case. Another theory holds that colic is related to hyperperistalsis of the digestive tube (increased level of activity of contraction and relaxation). The evidence that the use of anticholinergic agents improve colic symptoms supports this hypothesis.Psychological and social factors have been proposed as a cause, but there is no evidence. Studies performed do not support the theory that maternal (or paternal) personality or anxiety causes colic, nor that it is a consequence of a difficult temperament of the baby, but families with colicky children may eventually develop anxiety, fatigue and problems with family functioning as a result. There is some evidence that cigarette smoke may increase the risk. It seems unrelated to breast or bottle feeding with rates similar in both groups. Reflux does not appear to be related to colic.

Diagnosis
Colic is diagnosed after other potential causes of crying are excluded. This can typically be done via a history and physical exam, and in most cases tests such as X-rays or blood tests are not needed. Babies who cry may simply be hungry, uncomfortable, or ill. Less than 10% of babies who would meet the definition of colic based on the amount they cry have an identifiable underlying disease.Cause for concern include: an elevated temperature, a history of breathing problems or a child who is not appropriately gaining weight.Indications that further investigations may be needed include:
Vomiting (vomit that is green or yellow, bloody or occurring more than five times a day)
Change in stool (constipation or diarrhea, especially with blood or mucous)
Abnormal temperature (a rectal temperature less than 97.0 °F (36.1 °C) or over 100.4 °F (38.0 °C)
Irritability (crying all day with few calm periods in between)
Lethargy (excess sleepiness, lack of smiles or interested gaze, weak sucking lasting over six hours)
Poor weight gain (gaining less than  15 grams a day)Problems to consider when the above are present include:
Infections (e.g. ear infection, urine infection, meningitis, appendicitis)
Intestinal pain (e.g. food allergy, acid reflux, constipation, intestinal blockage)
Trouble breathing (e.g. from a cold, excessive dust, congenital nasal blockage, oversized tongue)
Increased brain pressure (e.g. hematoma, hydrocephalus)
Skin pain  (e.g. a loose diaper pin, irritated rash, a hair wrapped around a toe)
Mouth pain (e.g. yeast infection)
Kidney pain  (e.g. blockage of the urinary system)
Eye pain (e.g. scratched cornea, glaucoma)
Overdose  (e.g. excessive Vitamin D, excessive sodium)
Others (e.g. migraine headache, heart failure, hyperthyroidism)Persistently fussy babies with poor weight gain, vomiting more than five times a day, or other significant feeding problems should be evaluated for other illnesses (e.g. urinary infection, intestinal obstruction, acid reflux).

Treatment
Management of colic is generally conservative and involves the reassurance of parents. Calming measures may be used and include soothing motions, limiting stimulation, pacifier use, and carrying the baby around in a carrier, although it is not entirely clear if these actions have any effect beyond placebo. Swaddling does not appear to help.

Medication
No medications have been found to be both safe and effective. Simethicone is safe but does not work, while dicyclomine works but is not safe. Evidence does not support the use of cimetropium bromide, and there is little evidence for alternative medications or techniques. While medications to treat reflux are common, there is no evidence that they are useful.

Diet
Dietary changes by infants are generally not needed. In mothers who are breastfeeding, a hypoallergenic diet by the mother—not eating milk and dairy products, eggs, wheat, and nuts—may improve matters, while elimination of only cows milk does not seem to produce any improvement. In formula-fed infants, switching to a soy-based or hydrolyzed protein formula may help. Evidence of benefit is greater for hydrolyzed protein formula with the benefit from soy based formula being disputed. Both these formulas have greater cost and are not as palatable. Supplementation with fiber has not been shown to have any benefit.  A 2018 Cochrane review of 15 randomized controlled trials involving 1,121 infants was unable to recommend any dietary interventions.  A 2019 review determined that probiotics were no more effective than placebo although a reduction in crying time was measured.

Complimentary and alternative medicine
No clear beneficial effect from spinal manipulation or massage has been shown </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Cleft lip and cleft palate and can you explain it in depth? [/INST] A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The term orofacial cleft refers to either condition or to both occurring together. These disorders can result in feeding problems, speech problems, hearing problems, and frequent ear infections. Less than half the time the condition is associated with other disorders.Cleft lip and palate are the result of tissues of the face not joining properly during development. As such, they are a type of birth defect. The cause is unknown in most cases. Risk factors include smoking during pregnancy, diabetes, obesity, an older mother, and certain medications (such as some used to treat seizures). Cleft lip and cleft palate can often be diagnosed during pregnancy with an ultrasound exam.A cleft lip or palate can be successfully treated with surgery. This is often done in the first few months of life for cleft lip and before eighteen months for cleft palate. Speech therapy and dental care may also be needed. With appropriate treatment, outcomes are good.Cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world. Cleft lip is about twice as common in males as females, while cleft palate without cleft lip is more common in females. In 2017, it resulted in about 3,800 deaths globally, down from 14,600 deaths in 1990. The condition was formerly known as a "hare-lip" because of its resemblance to a hare or rabbit, but that term is now generally considered to be offensive.

Signs and symptoms
Cleft lip
If the cleft does not affect the palate structure of the mouth, it is referred to as cleft lip.  Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft), or it continues into the nose (complete cleft). Lip cleft can occur as a one-sided (unilateral) or two-sided (bilateral) condition. It is due to the failure of fusion of the maxillary prominence and medial nasal processes (formation of the primary palate).

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.

Cleft palate
Cleft palate is a condition in which the two plates of the skull that form the hard palate (roof of the mouth) are not completely joined. The soft palate is in these cases cleft as well. In most cases, cleft lip is also present.
Palate cleft can occur as complete (soft and hard palate, possibly including a gap in the jaw) or incomplete (a hole in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs, the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, or the median palatine processes (formation of the secondary palate).
The hole in the roof of the mouth caused by a cleft connects the mouth directly to the inside of the nose.
Note: the next images show the roof of the mouth. The top shows the nose, the lips are colored pink. For clarity the images depict a toothless infant.

A result of an open connection between the mouth and inside the nose is called velopharyngeal insufficiency (VPI). Because of the gap, air leaks into the nasal cavity resulting in a hypernasal voice resonance and nasal emissions while talking. Secondary effects of VPI include speech articulation errors (e.g., distortions, substitutions, and omissions) and compensatory misarticulations and mispronunciations (e.g., glottal stops and posterior nasal fricatives). Possible treatment options include speech therapy, prosthetics, augmentation of the posterior pharyngeal wall, lengthening of the palate, and surgical procedures.Submucous cleft palate can also occur, which is a cleft of the soft palate with a split uvula, a furrow along the midline of the soft palate, and a notch in the back margin of the hard palate. The diagnosis of submucous cleft palate often occurs late in children as a result of the nature of the cleft. While the muscles of the soft palate are not joined, the mucosal membranes covering the roof of the mouth appear relatively normal and intact.

Teeth
Tooth development can be delayed with increasing severity of CLP. Some of the dental problems affect the primary teeth, but most of the problems arise after the permanent teeth erupts. Problems may include fused teeth, missing teeth, and extra teeth erupting behind normal teeth. Missing teeth or extra teeth are both normal occurrences. Typically, the lateral incisors are missing. The enamel (outermost layer of the tooth) is commonly found to be hypomineralized and hypoplastic, making the teeth more likely to decay. As CLP can make oral hygiene more difficult, there is an increased rate of cavities. In addition, abnormal positioning of individual teeth may affect occlusion, which can create an open bite or cross bite. This in turn can then affect the patients speech.

Complications
Cleft may cause problems with feeding, ear disease, speech, socialization, and cognition.
Due to lack of suction, an infant with a cleft may have trouble feeding. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the babys nose if he/she has cleft palate. Gravity feeding can be accomplished by using specialized equipment, such as the Haberman Feeder. Another equipment commonly used for gravity feeding is a customized bottle with a combination of nipples and bottle inserts. A large hole, crosscut, or slit in the nipple, a protruding nipple and rhythmically squeezing the bottle insert can result in controllable flow to the infant without the stigma caused by specialized equipment.
Individuals with cleft also face many middle ear infections which may eventually lead to hearing loss. The Eustachian tubes and external ear canals may be angled or tortuous, leading to food or other contamination of a part of the body that is normally self-cleaning. Hearing is related to learning to speak.  Babies with palatal clefts may have compromised hearing and therefore, if the baby cannot hear, it cannot try to mimic the sounds of speech. Thus, even before expressive language acquisition, the baby with the cleft palate is at risk for receptive language acquisition. Because the lips and palate are both used in pronunciation, individuals with cleft usually need the aid of a speech therapist.
Tentative evidence has found that those with clefts perform less well at language.

Psychosocial issues
There is research dedicated to the psychosocial development of individuals with cleft palate. A cleft palate/lip may impact an individuals self-esteem, social skills and behavior. Self-concept may be adversely affected by the presence of a cleft lip or cleft palate, particularly among girls. Negative outcomes can also be associated with the long durations of hospitalization. Psychological issues could extend not just to the individual with CLP but also to their families, particularly their mothers, that experience varying levels of depression and anxiety.Research has shown that during the early preschool years (ages 3–5), children with cleft lip or cleft palate tend to have a self-concept that is similar to their peers without a cleft. However, as they grow older and their social interactions increase, children with clefts tend to report more dissatisfaction with peer relationships and higher levels of social anxiety. Experts conclude that this is probably due to the associated stigma of visible deformities and possible speech impediments. Children who are judged as attractive tend to be perceived as more intelligent, exhibit more positive social behaviors, and are treated more positively than children with cleft lip or cleft palate. Children with clefts tend to report feelings of anger, sadness, fear, and alienation from their peers, but these children were similar to their peers in regard to "how well they liked themselves."
The relationship between parental attitudes and a childs self-concept is crucial during the preschool years. It has been reported that elevated stress levels in mothers correlated with reduced social skills in their children. Strong parent support networks may help to prevent the development of negative self-concept in children with cleft palate. In the later preschool and early elementary years, the development of social skills is no longer only impacted by parental attitudes but is beginning to be shaped by their peers. A cleft lip or cleft palate may affect the behavior of preschoolers. Experts suggest that parents discuss with their children ways to handle negative social situations related to their cleft lip or cleft palate. A child who is entering school should learn the proper (and age-appropriate) terms related to the cleft. The ability to confidently explain the condition to others may limit feelings of awkwardness and embarrassment and reduce negative social experiences.As children reach adolescence, the period of time between age 13 and 19, the dynamics of the parent-child relationship change as peer groups are now the focus of attention. An adolescent with cleft lip or cleft palate will deal with the typical challenges faced by most of their peers including issues related to self-esteem, dating and social acceptance. Adolescents, however, view appearance as the most important characteristic, above intelligence and humor. This being the case, adolescents are susceptible to additional problems because they cannot hide their facial differences from their peers. Adolescent boys typically deal with issues relating to withdrawal, attention, thought, and internalizing problems, and may possibly develop anxiousness-depression and aggressive behaviors. Adolescent girls are more likely to develop problems relating to self-concept and appearance. Individuals with cleft lip or cleft palate often deal with threats to their quality of life for multiple reasons including unsuccessful social relationships, deviance in social appearance, and multiple surgeries.

Cause
Most clefts are polygenic and multifactorial in origin with many genetic and environmental factors contributing. Genetic factors cause clefts in 20% to 50% of the cases and the remaining clefts are attributable to either environmental factors (such as teratogens) or gene-environment interactions. The polygenic/multifactorial inheritance model predicts that most individuals will be born without clefts; however with a number of genetic or environmental factors, it can result in cleft formation.The development of the face is coordinated by complex morphogenetic events and rapid proliferative expansion, and is thus highly susceptible to environmental and genetic factors, rationalising the high incidence of facial malformations. During the first six to eight weeks of pregnancy, the shape of the embryos head is formed.  Five primitive tissue lobes grow:

If these tissues fail to meet, a gap appears where the tissues should have joined (fused). This may happen in any single joining site, or simultaneously in several or all of them. The resulting birth defect reflects the locations and severity of individual fusion failures (e.g., from a small lip or palate fissure up to a completely malformed face).
The upper lip is formed earlier than the palate, from the first three lobes named a to c above. Formation of the palate is the last step in joining the five embryonic facial lobes, and involves the back portions of the lobes b and c. These back portions are called palatal shelves, which grow towards each other until they fuse in the middle. This process is very vulnerable to multiple toxic substances, environmental pollutants, and nutritional imbalance. The biologic mechanisms of mutual recognition of the two cabinets, and the way they are glued together, are quite complex and obscure despite intensive scientific research.Orofacial clefts may be associated with a syndrome (syndromic) or may not be associated with a syndrome (nonsyndromic). Syndromic clefts are part of syndromes that are caused by a variety of factors such as environment and genetics or an unknown cause. Nonsyndromic clefts, which are not as common as syndromic clefts, also have a genetic cause.

Genetics
Genetic factors contributing to cleft lip and cleft palate formation have been identified for some syndromic cases. Many clefts run in families, even though in some cases there does not seem to be an identifiable syndrome present. A number of genes are involved including cleft lip and palate transmembrane protein 1 and GAD1, One study found an association between mutations in the HYAL2 gene and cleft lip and cleft palate formation.

Syndromes
The Van der Woude syndrome is caused by a specific variation in the gene IRF6 that increases the occurrence of these deformities threefold. Mutations in interferon regulatory factor 6 (IRF6) that cause cleft lip palate are also implicated in neural tube defects such as spina bifida.
Another syndrome, Siderius X-linked intellectual disability, is caused by mutations in the PHF8 gene (OMIM: 300263); in addition to cleft lip or palate, symptoms include facial dysmorphism and mild intellectual disability.In some cases, cleft palate is caused by syndromes that also cause other problems:

Stickler syndrome can cause cleft lip and palate, joint pain, and myopia.
Loeys–Dietz syndrome can cause cleft palate or bifid uvula, hypertelorism, and aortic aneurysm.
Hardikar syndrome can cause cleft lip and palate, Hydronephrosis, Intestinal obstruction and other symptoms.
Cleft lip/palate may be present in many different chromosome disorders including Patau syndrome (trisomy 13).
Malpuech facial clefting syndrome
Hearing loss with craniofacial syndromes
Popliteal pterygium syndrome
Cornelia de Lange syndrome
Treacher Collins syndrome
Pierre Robin syndrome

Specific genes
Many genes associated with syndromic cases of cleft lip/palate (see above) have been identified to contribute to the incidence of isolated cases of cleft lip/palate. This includes in particular sequence variants in the genes IRF6, PVRL1 and MSX1. The understanding of the genetic complexities involved in the morphogenesis of the midface, including molecular and cellular processes, has been greatly aided by research on animal models, including of the genes BMP4, SHH, SHOX2, FGF10 and MSX1.

Environmental factors
Environmental influences may also cause, or interact with genetics to produce, orofacial clefts. An example of the link between environmental factors and genetics comes from a research on mutations in the gene PHF8. The research found that PHF8 encodes for a histone lysine demethylase, and is involved in epigenetic regulation. The catalytic activity of PHF8 depends on molecular oxygen, a factor considered important from reports on increased incidence of cleft lip/palate in mice that have been exposed to hypoxia early during pregnancy.Cleft lip and other congenital abnormalities have also been linked to maternal hypoxia caused by maternal smoking, with the estimated attributable fraction of orofacial clefts due to smoking in early pregnancy being 6.1%. Orofacial clefts occur very early in pregnancy and so smoking cessation right after recognition of pregnancy is unlikely to reduce the exposure during the critical time period.Maternal alcohol use has also been linked to cleft lip and palate due to the effects on the cranial neural crest cells. The degree of the effect, however, is unknown and requires further research. Some forms of maternal hypertension treatment have been linked to cleft lip and palate. Other environmental factors that have been studied include seasonal causes (such as pesticide exposure); maternal diet and vitamin intake; retinoids (members of the vitamin A family); anticonvulsant drugs; nitrate compounds; organic solvents; parental exposure to lead; alcohol; cigarette use; and a number of other psychoactive drugs (e.g. cocaine, crack cocaine, heroin).
Current research continues to investigate the extent to which folic acid can reduce the incidence of clefting. Folic acid alone or in combination with vitamins and minerals prevents neural tube defects but does not have a clear effect on cleft lip palate incidence. The mechanism behind beneficial folate supplementation is due to folate playing a pivotal role in DNA synthesis and methylation and contributes to both development and gene expression.

Diagnosis
Traditionally, the diagnosis is made at the time of birth by physical examination. Recent advances in prenatal diagnosis have allowed obstetricians to diagnose facial clefts in utero with ultrasonography.Clefts can also affect other parts of the face, such as the eyes, ears, nose, cheeks, and forehead. In 1976, Paul Tessier described fifteen lines of cleft.  Most of these craniofacial clefts are even rarer and are frequently described as Tessier clefts using the numerical locator devised by Tessier.

Classification
Cleft lip and cleft palate is an "umbrella term" for a collection of orofacial clefts. It includes clefting of the upper lip, the maxillary alveolus (dental arch), and the hard or soft palate, in various combinations. Proposed anatomic combinations include:
cleft lip
cleft lip and alveolus
cleft lip, alveolus, and palate
cleft lip and palate (with an intact alveolus)
cleft palate

Prenatal diagnosis
Cleft lip with or without palate is classified as the most common congenital birth defect. It has been noted that the prevalence of orofacial clefts varies by race. The highest number of cases have been recorded among Asians and Native Americans, followed by Europeans, Hispanics and African-Americans. The critical period for cleft development ranges from the 4th to the 12th week of intrauterine life. Clefts of the primary palate develop between the 4th and 7th weeks of intrauterine life, while clefts of the secondary palate develop between the 8th and 12th embryonic weeks.
Accurate evaluation of craniofacial malformations is usually possible with the ultrasound scan performed during pregnancy. This is however not a routine procedure according to the American Institute of Ultrasound in Medicine. The accuracy of ultrasonography for prenatal diagnosis of cleft lip +/- palate is dependent on the experience of the sonologist, maternal body type, foetal position, the amount of amniotic fluid and the type of cleft.
Prenatal diagnosis enables appropriate and timely education and discussion with parents by the cleft team. This helps improve the quality of treatment received by the child and improves quality of life.
An accurate prenatal diagnosis of the CLP anomaly is critical for establishing long-term treatment planning, prediction of treatment outcome, and discussion and education of the parent. Although there is no intrauterine treatment for CLP, both mother and child benefit from early diagnosis and education. A multidisciplinary team approach is now accepted as the standard of care in dealing with CLP patients.
The time period immediately after the diagnosis and the first year after the birth is most challenging for parents. A systematically planned treatment plan and support system will help assist parents. The ultimate aim is to help educate parents and create awareness so as to improve care provided for the child.

Treatment
Cleft lip and palate is very treatable; however, the kind of treatment depends on the type and severity of the cleft.
Most children with a form of clefting are monitored by a cleft palate team or craniofacial team through young adulthood. Care can be lifelong and are looked after by craniofacial cleft teams often consist of: cleft surgeons, orthodontists, speech and language therapists, restorative dentists, psychologists, ENT surgeons and audio-logical physicians. Treatment procedures can vary between craniofacial teams. For example, some teams wait on jaw correction until the child is aged 10 to 12 (argument: growth is less influential as deciduous teeth are replaced by permanent teeth, thus saving the child from repeated corrective surgeries), while other teams correct the jaw earlier (argument: less speech therapy is needed than at a later age when speech therapy becomes harder). Within teams, treatment can differ between individual cases depending on the type and severity of the cleft.

Cleft lip
Within the first 2–3 months after birth, surgery is performed to close the cleft lip. While surgery to repair a cleft lip can be performed soon after birth, often the preferred age is at approximately 10 weeks of age, following the "rule of 10s" coined by surgeons Wilhelmmesen and Musgrave in 1969 (the child is at least 10 weeks of age; weighs at least 10 pounds, and has at least 10g hemoglobin). If the cleft is bilateral and extensive, two surgeries may be required to close the cleft, one side first, and the second side a few weeks later. The most common procedure to repair a cleft lip is the Millard procedure pioneered by Ralph Millard. Millard performed the first procedure at a Mobile Army Surgical Hospital (MASH) unit in Korea.Often an incomplete cleft lip requires the same surgery as complete cleft. This is done for two reasons. Firstly the group of muscles required to purse the lips run through the upper lip. To restore the complete group a full incision must be made. Secondly, to create a less obvious scar the surgeon tries to line up the scar with the natural lines in the upper lip (such as the edges of the philtrum) and tuck away stitches as far up the nose as possible. Incomplete cleft gives the surgeon more tissue to work with, creating a more supple and natural-looking upper lip.

Pre-surgical devices
In some cases of a severe bilateral complete cleft, the premaxillary segment will be protruded far outside the mouth.
Nasoalveolar molding prior to surgery can improve long-term nasal symmetry where there is complete unilateral cleft lip–cleft palate, compared to correction by surgery alone, according to a retrospective cohort study. In this study, significant improvements in nasal symmetry were observed in multiple areas including measurements of the projected length of the nasal ala (lateral surface of the external nose), position of the superoinferior alar groove, position of the mediolateral nasal dome, and nasal bridge deviation. "The nasal ala projection length demonstrated an average ratio of 93.0 percent in the surgery-alone group and 96.5 percent in the nasoalveolar molding group," this study concluded. A systematic review found in conclusion that nasoalveolar molding had a positive effect on the primary surgery of cleft lip/or palate treatment and aesthetics.

Cleft palate
Often a cleft palate is temporarily covered by a palatal obturator (a prosthetic device made to fit the roof of the mouth covering the gap). This device re-positions displaced alveolar segments and helps reduce the cleft lip separation. The obturator will improve speech as theres now proper airflow and improve feeding and breathing as the gap in the hard and soft palate is closed over so cannot affect it.Cleft palate can also be corrected by surgery, usually performed between 6 and 12 months. Approximately 20–25% only require one palatal surgery to achieve a competent velopharyngeal valve capable of producing normal, non-hypernasal speech. However, combinations of surgical methods and repeated surgeries are often necessary as the child grows. One of the new innovations of cleft lip and cleft palate repair is the Latham appliance. The Latham is surgically inserted by use of pins during the childs fourth or fifth month. After it is in place, the doctor, or parents, turn a screw daily to bring the cleft together to assist with future lip or palate repair.
If the cleft extends into the maxillary alveolar ridge, the gap is usually corrected by filling the gap with bone tissue. The bone tissue can be acquired from the individuals own chin, rib or hip.
At age 1–7 years the child is regularly reviewed by the cleft team.Age 7–12 years, for the children born with alveolar clefts, they may need to have a secondary alveolar bone graft. This is where autogenous cancellous bone from a donor site (often the pelvic bone) is transplanted into the alveolar cleft region. This transplant of bone will close the osseous cleft of the alveolus, close any oro-nasal fistulae and will become integrated with the maxillary bone. It provides bone for teeth to erupt into and to allow implants to be placed as a possible future treatment option. The procedure should be carried out before the upper canine has erupted. Ideally the root of the canine should be one to two-thirds formed and that there is a space available to place the bone graft. Radio-graphs are taken to determine the quantity of missing bone in the cleft area.

Other surgeries
Orthognathic surgery – surgical cutting of bone to realign the upper jaw (osteotomy). The bone is cut then re-positioned and held together by wires or rigid fixation plates to ensure theres no anterior-posterior discrepancy, also to reduce scarring as it reduces growth. Single piece or multi-piece osteotomy exist. Single piece osteotomy is carried out where there is sufficient alveolar continuity achieved from a successful bone graft. Multi piece osteotomy is performed when there is a notable residual alveolar defect with a dental gap and oronasal fistula (communication between the oral and nasal cavities). The goal of both single and multi piece osteotomy is to displace the maxilla forward to obtain adequate occlusion as well to provide better support for upper lip and the nose and to close any fistulae.Distraction osteogenesis – bone lengthening by gradual distraction. This involves cutting bone and moving ends apart incrementally to allow new bone to form in the gap. This consists of several phases. After attachment of the distracting device and the bone cuts, there is a latency phase of 3–7 days when a callus forms. In the activation phase distraction of the callus induces bony ingrowth which can last up to 15 days depending on the required distraction. Once the required bone length is reached, the distraction device is left to remain in situ as it acts as a rigid skeletal fixation device until the new bone has matured (known as the consolidation period).

Speech
Velopharyngeal insufficiency (VPI) can occur as a result of an unrepaired or repaired cleft lip and palate. VPI is the inability of the soft palate to close tightly against the back of the throat during speech, resulting in incomplete velopharyngeal closure. In turn, this results in speech abnormalities. Velopharyngeal closure is necessary during speech because it forms a seal between the nose and mouth, allowing the production of normal speech sounds. VPI can cause hypernasality (excessive nasal resonance), hyponasality (reduced nasal resonance), or a mixed nasal resonance, which is when hypernasality and hyponasality occur simultaneously. In addition, CLP may cause abnormal positioning of individual teeth, which can in turn affect the patients ability to make certain sounds when speaking such as the "f" or "v" sound and can also result in a lisp. The changes in speech may also be a manifestation on CLPs effects on the patients occlusion.

Hearing
Children with cleft palate have a very high risk of developing a middle ear infection, specifically otitis media. This is due to the immature development of the different bones and muscles in the ear. Otitis media is caused by the obstruction of the Eustachian tube, negative middle ear pressure and fluid build-up in the normally air-filled space of the middle ear. This is associated with hearing impairment or loss. The insertion of a ventilation tube into the eardrum is a surgical treatment option commonly used to improve hearing in children with otitis media. In addition, breast milk has been proven to decrease the incidence of otitis media in infants with clefts.

Feeding
There are different options on how to feed a baby with cleft lip or cleft palate which include: breast-feeding, bottle feeding, spoon feeding and syringe feeding. Although breast-feeding is challenging, it improves weight-gain compared to spoon-feeding. Nasal regurgitation is common due to the open space between the oral cavity and the nasal cavity. Bottle feeding can help (with squeezable bottles being easier to use than rigid bottles). In addition, maxillary plates can be added to aid in feeding. Whatever feeding method is established, it is important to keep the babys weight gain and hydration monitored. Infants with cleft lip or palate may require supplemental feeds for adequate growth and nutrition. Breast feeding position as suggested by specialists can also improve success rate.

Breast-feeding
Babies with cleft lip are more likely to breastfeed successfully than those with cleft palate and cleft lip and palate. Larger clefts of the soft or hard palate may not be able to generate suction as the oral cavity cannot be separated from the nasal cavity when feeding which leads to fatigue, prolonged feeding time, impaired growth and nutrition. Changes in swallowing mechanics may result in coughing, choking, gagging and nasal regurgitation. Even after cleft repair, the problem may still persist as significant motor learning of swallowing and sucking was absent for many months before repair. These difficulties in feeding may result in secondary problems such as poor weight gain, excessive energy expenditure during feeding, lengthy feeding times, discomfort during feeding, and stressful feeding interactions between the infant and the mother. A potential source of discomfort for the baby during or after feeding is bloating or frequent "spit up" which is due to the excessive air intake through the nose and mouth in the open cleft. Babies with cleft lip and or palate should be evaluated individually taking into account the size and location of the cleft and the mothers previous experience with breastfeeding.Another option is feeding breast milk via bottle or syringe. Since babies with clip lip and cleft palate generate less section when breastfeeding, their nutrition, hydration and weight gain may be affected. This may result in the need for supplemental feeds. Modifying the position of holding the baby may increase the effectiveness and efficiency of breastfeeding.

Alternative Feeding Methods
Preoperative feeding – using a squeezable bottle instead of a rigid bottle can allow a higher volume of food intake and less effort to extract food. Using a syringe is practical, easy to perform and allows greater administered volume of food. It also means there will be weight gain and less time spent feeding.Post-operative feeding (isolated lip repair, or lip repair associated or not with palatoplasty) – post palatoplasty, some studies believe that inappropriate negative pressure on the suture line may affect results. Babies can be fed by a nasogastric tube instead. Studies suggest babies required less analgesics and shorter hospital stay with nasogastric feeding post-surgery. With bottle-feeding, there was higher feeding rejection and pain and required more frequent and prolonged feeding times.

Treatment schedule
Each persons treatment schedule is individualized. The table below shows a common sample treatment schedule. The colored squares indicate the average timeframe in which the indicated procedure occurs. In some cases, this is usually one procedure, for example lip repair. In other cases, it is an ongoing therapy, for example speech therapy. In most cases of cleft lip and palate that involve the alveolar bone, patients will need a treatment plan including the prevention of cavities, orthodontics, alveolar bone grafting, and possibly jaw surgery.

Cleft team
People with CLP present with a multiplicity of problems. Therefore, effective management of CLP involves a wide range of specialists. The current model for delivery of this care is the multidisciplinary cleft team. This is a group of individuals from different specialist backgrounds who work closely together to provide patients with comprehensive care from birth through adolescence. This system of delivery of care enables the individuals within the team to function in an interdisciplinary way, so that all aspects of care for CLP patients can be provided in the best way possible.

Outcomes assessment
Measuring the outcomes of CLP treatment has been laden with difficulty due to the complexity and longitudinal nature of cleft care, which spans birth through young adulthood. Prior attempts to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards for outcomes assessment in cleft care.The International Consortium for Health Outcome Measurement (ICHOM) has proposed the Standard Set of Outcome Measures for Cleft Lip and Palate. The ICHOM Standard Set includes measures for many of the important outcome domains in cleft care (hearing, breathing, eating/drinking, speech, oral health, appearance and psychosocial well-being). It includes clinician-reported, patient-reported, and family-reported outcome measures.

Epidemiology
Cleft lip and palate occurs in about 1 to 2 per 1000 births in the developed world.Rates for cleft lip with or without cleft palate and cleft palate alone varies within different ethnic groups.
According to CDC, the prevalence of cleft palate in the United States is 6.35/10000 births and the prevalence of cleft lip with or without cleft palate is 10.63/10000 births. The highest prevalence rates for cleft lip, either with or without cleft palate are reported for Native Americans and Asians. Africans have the lowest prevalence rates.
Native Americans: 3.74/1000
Japanese: 0.82/1000 to 3.36/1000
Chinese: 1.45/1000 to 4.04/1000
Caucasians: 1.43/1000 to 1.86/1000
Latin Americans: 1.04/1000
Africans: 0.18/1000 to 1.67/1000Cleft lip and cleft palate caused about 3,800 deaths globally in 2017, down from 14,600 deaths in 1990.Prevalence of "cleft uvula" has varied from 0.02% to 18.8% with the highest numbers found among Chippewa and Navajo and the lowest generally in Africans.

Society and culture
Abortion controversy
In some countries, cleft lip or palate deformities are considered reasons (either generally tolerated or officially sanctioned) to perform an abortion beyond the legal fetal age limit, even though the fetus is not in jeopardy of life or limb. Some human rights activists contend that this practice of what they refer to as "cosmetic murder" amounts to eugenics.

Works of fiction
The eponymous hero of J.M. Coetzees 1983 novel Life & Times of Michael K has a cleft lip that is never corrected. In the 1920 novel Growth of the Soil, by Norwegian writer Knut Hamsun, Inger (wife of the main character) has an uncorrected cleft lip which puts heavy limitations on her life, even causing her to kill her own child, who is also born with a cleft lip. The protagonist of the 1924 novel Precious Bane, by English writer Mary Webb, is a young woman living in 19th-century rural Shropshire who eventually comes to feel that her deformity is the source of her spiritual strength. The book was later adapted for television by both the BBC and ORTF in France. Similarly, the main character in Graham Greenes 1936 crime noir novel A Gun for Sale, Raven, has a cleft lip which he is sensitive about, and is described as "an ugly man dedicated to ugly deeds". In the 1976 Patricia A. McKillip novel The Night Gift, one of the high-school aged protagonists is shy because she has a cleft lip, but learns to have more confidence in herself.
In the first edition of Harry Potter and the Chamber of Secrets, one of the people Gilderoy Lockhart stole credit from was a witch with a harelip who banished the Bandon Banshee. In later editions, this was changed to a witch with a hairy chin.In chapter 26 of Mark Twains The Adventures of Huckleberry Finn, Huck Finn meets the three Wilks sisters, Mary Jane, Susan, and Joanna. Joanna is described as, "the one who gives herself to good works and has a hare-lip." As a form of offensive synecdoche, Huck Finn refers to Joanna as "the hare-lip" rather than by her name.
In Inheritance, the final title of Christopher Paolinis Inheritance Cycle, the main character Eragon heals a newborn girl with this condition in a display of complicated healing magic. It is stated that those within Eragons society born with this condition are often not allowed to live as they face a very hard life.Cleft lip and cleft palate are often portrayed negatively in popular culture. Examples include Oddjob, the secondary villain of the James Bond novel Goldfinger by Ian Fleming (the film adaptation does not mention this but leaves it implied) and serial killer Francis Dolarhyde in the novel Red Dragon and its screen adaptations, Manhunter, Red Dragon, and Hannibal. The portrayal of enemy characters with cleft lips and cleft palates, dubbed mutants, in the 2019 video game Rage 2 left Chris Plante of Polygon wondering if the condition would ever be portrayed positively.

Notable cases
Other animals
Cleft lips and palates are occasionally seen in cattle and dogs, and rarely in goats, sheep, cats, horses, pandas and ferrets. Most commonly, the defect involves the lip, rhinarium, and premaxilla. Clefts of the hard and soft palate are sometimes seen with a cleft lip. The cause is usually hereditary.  Brachycephalic dogs such as Boxers and Boston Terriers are most commonly affected. An inherited disorder with incomplete penetrance has also been suggested in Shih tzus, Swiss Sheepdogs, Bulldogs, and Pointers. In horses, it is a rare condition usually involving the caudal soft palate. In Charolais cattle, clefts are seen in combination with arthrogryposis, which is inherited as an autosomal recessive trait.  It is also inherited as an autosomal recessive trait in Texel sheep.  Other contributing factors may include maternal nutritional deficiencies, exposure in utero to viral infections, trauma, drugs, or chemicals, or ingestion of toxins by the mother, such as certain lupines by cattle during the second or third month of gestation. The use of corticosteroids during pregnancy in dogs and the ingestion of Veratrum californicum by pregnant sheep have also been associated with cleft formation.Difficulty with nursing is the most common problem associated with clefts, but aspiration pneumonia, regurgitation, and malnutrition are often seen with cleft palate and is a common cause of death.  Providing nutrition through a feeding tube is often necessary, but corrective surgery in dogs can be done by the age of twelve weeks. For cleft palate, there is a high rate of surgical failure resulting in repeated surgeries. Surgical techniques for cleft palate in dogs include prosthesis, mucosal flaps, and microvascular free flaps. Affected animals should not be bred due to the hereditary nature of this condition.

See also
Smile Pinki
Palatal obturator
Vomer flap surgery
Cleft lip and palate organisations
Face and neck development of the embryo

References
Notes

Further reading

FIGURE 1 | Development of the lip and palate and FIGURE 2 | Types of cleft in Dixon MJ, Marazita ML, Beaty TH, Murray JC (March 2011) </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Cocaine dependence and can you explain it in depth? [/INST] Cocaine dependence is a neurological disorder that is characterized by withdrawal symptoms upon cessation from cocaine use. It also often coincides with cocaine addiction which is a biopsychosocial disorder characterized by persistent use of cocaine and/or crack despite substantial harm and adverse consequences. The Diagnostic and Statistical Manual of Mental Disorders (5th ed., abbreviated DSM-5), classifies problematic cocaine use as a "Stimulant use disorder". The International Classification of Diseases (11th rev., abbreviated ICD-11), includes "Cocaine dependence" as a classification (diagnosis) under "Disorders due to use of cocaine”.The use of cocaine creates euphoria and high amounts of energy. If taken in large doses, it is possible to cause mood swings, paranoia, insomnia, psychosis, high blood pressure, a fast heart rate, panic attacks, cognitive impairments and drastic changes in personality. Cocaine overdose may result in cardiovascular and brain damage, such as: constricting blood vessels in the brain, causing strokes and constricting arteries in the heart; causing heart attacks.The symptoms of cocaine withdrawal range from moderate to severe: dysphoria, depression, anxiety, decreased libido, psychological and physical weakness, pain, and compulsive cravings.

Signs and symptoms
Cocaine is a powerful stimulant known to make users feel energetic, cheerful, talkative, etc. In time, negative side effects include increased body temperature, irregular or rapid heart rate, high blood pressure, increased risk of heart attacks, strokes and even sudden death from cardiac arrest. Many people who habitually use cocaine develop a transient, manic-like condition similar to amphetamine psychosis and schizophrenia, whose symptoms include aggression, severe paranoia, restlessness, confusion and tactile hallucinations; which can include the feeling of something crawling under the skin (formication), also known as "coke bugs", during binges.  Different ingestion techniques have their own symptoms that accompany them. Snorting it can cause a loss of sense of smell, nose bleeds, problems swallowing and an inflamed, runny nose. Smoking it causes lung damage and injecting it puts users at risk of contracting infectious diseases like HIV and hepatitis C. Heavy users of cocaine have also reported having thoughts of suicide, unusual weight loss, trouble maintaining relationships, and an unhealthy, pale appearance.

Withdrawal symptoms
When used habitually, cocaine, because of its highly addictive nature, can change brain structure and function. Circuits within the brain structure, that play a part in stress signals become more sensitive. When cocaine is not being used this increases an individuals displeasure and negative moods. In 1986, Gawin and Kleber led an important study on the withdrawal symptoms of cocaine users. In this study, three distinct phases were reported. These phases are the crash, withdrawal and extinction. The crash phase or phase 1 occurs directly after cocaine is not being used anymore. Withdrawal symptoms for this phase are exhaustion, hypersomnia, no cravings to use, dysthymia, increased appetite, restlessness, and irritability. The second phase, or withdrawal phase occurs 1–10 weeks after cocaine users quit, symptoms include: lethargy, anxiety, erratic sleep, strong craving, emotional lability, irritability, depression, poor concentration, and bowel issues. Finally the last phase or the extinction phase occurs up to 28 weeks after discontinued use, symptoms include: episodic cravings and some dysphoria.

Epidemiology and prevalence rates
In the United States, past year cocaine users in 2019 was 5.5 million for people aged 12 or older. When broken into age groups, ages 12–17 had 97,000 users; ages 18–25 had 1.8 million users and ages 26 or older had 3.6 million users.Past year cocaine users with a cocaine use disorder in 2019 was 1 million for people aged 12 or older. When broken into age groups, ages 12–17 had 5,000 people with a cocaine use disorder; ages 18–25 had 250,000 people with a cocaine use disorder and ages 26 or older had 756,000 people with a cocaine use disorderIn the United States, cocaine use overdose deaths have been on the rise and in 2019, the CDC reported over 16,000 deaths from cocaine overdose.

Risk
A study consisting of 1,081 U.S. residents who had first used cocaine within the previous 24 months was conducted. It was found that the risk of becoming dependent on cocaine within two years of first use was 5–6%. The risk of becoming dependent within 10 years of first use increased to 15–16%. These were the aggregate rates for all types of use considered, such as smoking, snorting, and injecting. Among recent-onset users individual rates of dependency were higher for smoking (3.4 times) and much higher for injecting. Women were 3.3 times more likely to become dependent, compared with men. Users who started at ages 12 or 13 were four times as likely to become dependent compared to those who started between ages 18 and 20.However, a study of non-deviant users in Amsterdam found a "relative absence of destructive and compulsive use patterns over a ten year period" and concluded that cocaine users can and do exercise control. "Our respondents applied two basic types of controls to themselves: 1) restricting use to certain situations and to emotional states in which cocaines effects would be most positive, and 2) limiting mode of ingestion to snorting of modest amounts of cocaine, staying below 2.5 grams a week for some, and below 0.5 grams a week for most. Nevertheless, those whose use level exceeded 2.5 grams a week all returned to lower levels".

Treatment
Therapy
Twelve-step programs such as Cocaine Anonymous (modeled on Alcoholics Anonymous) have been widely used to help those with cocaine addiction. Cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), rational emotive behavior therapy (REBT), and motivational interviewing (MI) can be especially powerful approaches to treating cocaine addiction. Cognitive behavioral therapy (CBT) combined with motivational therapy (MT) have proven to be more helpful than 12 step programs in treating cocaine dependency. However, both these approaches have a fairly low success rate as research suggests that the withdrawal symptoms can last for several weeks. For instance, one of the main predictors of a successful recovery is dependent on the number of continuous days a user is able to stay off of the substance. Alternative holistic treatments such as physical exercise and Meditation has been proven effective in reducing cocaine cravings. Other non-pharmacological treatments such as acupuncture and hypnosis have been explored, but without conclusive results.

Medications
Numerous medications have been investigated for use in cocaine dependence, but as of 2015, none of them were considered to be effective.  Anticonvulsants, such as carbamazepine, gabapentin, lamotrigine, and topiramate, do not appear to be effective as treatment. Limited evidence suggests that antipsychotics are also ineffective for treatment of cocaine dependence </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Elder abuse and can you explain it in depth? [/INST] Elder abuse (also called "elder mistreatment", "senior abuse", "abuse in later life", "abuse of older adults", "abuse of older women", and "abuse of older men") is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person." This definition has been adopted by of the World Health Organization (WHO) from a definition put forward by Hourglass (formerly Action on Elder Abuse) in the UK. Laws protecting the elderly from abuse are similar to and related to laws protecting dependent adults from abuse.
It includes harms by people, the older person knows, or has a relationship with, such as a spouse, partner, or family member; a friend or neighbor; or people that the older person relies on for services. Many forms of elder abuse are recognized as types of domestic violence or family violence since they are committed by family members. Paid caregivers have also been known to prey on their elderly patients.
While a variety of circumstances are considered elder abuse, it does not include general criminal activities against older persons, such as home break-ins, "muggings" in the street, or "distraction burglary," where a stranger distracts an older person at the doorstep while another person enters the property to steal.
The abuse of elders by caregivers is a worldwide issue. In 2002, WHO brought international attention to the issue of elder abuse. Over the years, government agencies and community professional groups, worldwide, have specified elder abuse as a social problem. In 2006, the International Network for Prevention of Elder Abuse (INPEA) designated June 15 as World Elder Abuse Awareness Day (WEAAD), and an increasing number of events are held across the globe on this day to raise awareness of elder abuse and highlight ways to challenge such abuse.

Types
Although there are common themes of elder abuse across nations, there are also unique manifestations based upon history, culture, economic strength, and societal perceptions of older people within nations themselves. The fundamental common denominator is the use of power and control by one individual to affect the well-being and status of another older individual.
There are several types of abuse of older people that are generally recognized as being elder abuse, including:
Physical: e.g. hitting, punching, slapping, burning, pushing, kicking, restraining, false imprisonment/confinement, or giving excessive or improper medication as well as withholding treatment and medication.
Psychological/Emotional: e.g. humiliating a person. A common theme is a perpetrator who identifies something that matters to an older person and then uses it to coerce an older person into a particular action. It may take verbal forms such as yelling,  name-calling, ridiculing, constantly criticizing, accusations, blaming, or nonverbal forms such as ignoring, silence, shunning or withdrawing affection.
Elder financial abuse: also known as financial exploitation, involving misappropriation of financial resources by family members, caregivers, or strangers, or the use of financial means to control the person or facilitate other types of abuse. Also, failure to pay financial support to impoverished elders in jurisdictions which have filial responsibility laws, such as France, Germany, and most of the United States.
Sexual: e.g. forcing a person to take part in any sexual activity without his or her consent, including forcing them to participate in conversations of a sexual nature against their will; which may also include situations where the person is no longer able to give consent (dementia).
Neglect: e.g. depriving a person of proper medical treatment, food, heat, clothing, comfort, essential medication, or depriving a person of needed services to force certain kinds of actions, financial and otherwise. Neglect can include leaving an at-risk (i.e. fall risk) elder person unattended. The deprivation may be intentional (active neglect) or happen out of lack of knowledge or resources (passive neglect).In addition, some U.S. state laws also recognize the following as elder abuse:

Abandonment: deserting a dependent person with the intent to abandon them or leave them unattended at a place for such a time period that may be likely to endanger their health or welfare.
Rights abuse: denying the civil and constitutional rights of a person who is old, but not declared by court to be mentally incapacitated. This is an aspect of elder abuse that is increasingly being recognized and adopted by nations.
Self-neglect: any persons neglecting themselves by not caring about their own health, well-being or safety. Self-neglect (harm by self) is treated as conceptually different than abuse (harm by others). Elder self-neglect can lead to illness, injury, or even death. Common needs that older adults may deny themselves or ignore include the following: sustenance (food or water); cleanliness (bathing and personal hygiene); adequate clothing for climate protection; proper shelter; adequate safety; clean and healthy surroundings; medical attention for serious illness; and essential medications. Self-neglect is often created by an individuals declining mental awareness or capability. Some older adults may choose to deny themselves some health or safety benefits, which may not be self-neglect. This may simply be their personal choice. Caregivers and other responsible individuals must honor these choices if the older adult is sound of mind. In other instances, the older adult may lack the needed resources, as a result of poverty, or other social condition. This is also not considered "self-neglect."
Institutional abuse refers to physical or psychological harm, as well as rights violations in settings where care and assistance is provided to dependent older adults or others, such as nursing homes. Recent studies of approximately 2,000 nursing home facility residents in the United States reported a growing abuse rate of 44% and neglect up to 95%, making elder abuse in nursing homes a growing danger. Exact statistics are rare due to elder abuse in general and specifically in nursing homes being a silent condition.

Warning signs
The key to prevention and intervention of elder abuse is the ability to recognize the warning signs of its occurrence. Signs of elder abuse differ depending on the type of abuse the victim is suffering. Each type of abuse has distinct signs associated with it.

Physical abuse can be detected by visible signs on the body including bruises, scratches, scars, sprains, or broken bones. More subtle indications of physical abuse include signs of restraint such as rope marks on the  wrist or broken eyeglasses.
Emotional abuse often accompanies the other types of abuse and can usually be detected by changes in the persons personality or behavior. The elder may also exhibit behavior mimicking dementia, such as rocking or mumbling. Emotional abuse is the most under reported abuse of elder abuse. Elder abuse occurs when a person fails to treat an elder with respect and includes verbal abuse. The elder experiences social isolation or lack of acknowledgement in this type of abuse. Some indicators of the emotional effects of elder abuse is the elder adult being unresponsive or uncommunicative. Also they can be unreasonably suspicious or fearful, more isolated, and not wanting to be as social as they may have been before. Emotional abuse is under reported but can have the most damaging effects because it leads to more physical and mental health problems.
Financial exploitation is a more subtle form of abuse, in comparison to other types, and may be more challenging to notice. Signs of financial exploitation include significant withdrawals from accounts, belongings or money missing from the home, unpaid bills, and unnecessary goods or services.
Sexual abuse, like physical abuse, can be detected by visible signs on the body, especially around the breasts or genital area. Other signs include inexplicable infections, bleeding, and torn underclothing.
Neglect is a type of abuse in that it can be inflicted either by the caregiver or oneself. Signs of neglect include malnutrition and dehydration, poor hygiene, noncompliance to a prescription medication, and unsafe living conditions.In addition to observing signs in the elderly individual,  abuse can also be detected by monitoring changes in the caregivers behavior. For example, the caregiver may not allow them to speak to or receive visitors, exhibit indifference or a lack of affection towards the elder, or refer to the elder as "a burden." Caregivers who have a history of substance abuse or mental illness are more likely to commit elder abuse than other individuals.Abuse can sometimes be subtle and therefore difficult to detect. Regardless, awareness organizations and research advise to take any suspicion seriously and to address concerns adequately and immediately.

Signs of elder abuse
Lacks medical aids such as glasses, walker, hearing aids
Displays signs of emotional trauma
Broken eyeglasses/frames, or physical signs of punishment or being restrained
Displays signs of insufficient care or unpaid bills despite adequate financial resources
Broken bones or fractures
Poor physical appearance
Changes in mental status
Frequent infections
Bruising, scratches, welts, or cuts
Unexplained weight loss
Refusal to speak
Signs of dehydration
Lack of cleanliness

Health consequences
The health consequences of elder abuse are serious. Elder abuse can destroy an elderly persons quality of life in the forms of:
Declining functional abilities
Increased dependency, sense of helplessness, and stress
Worsening psychological decline
Premature mortality and morbidity
Depression and dementia
Malnutrition
Bedsores
DeathThe risk of death for elder abuse victims are three times higher than for non-victims.

Common abusers
An abuser can be a caregiver, spouse, partner, relative, friend, neighbor, volunteer worker, paid worker, practitioner, solicitor, or any other individual with the intent to deprive a vulnerable person of their resources. Relatives include adult children and their spouses or partners, their offspring, and other extended family members. Children and living relatives who have a history of substance abuse or have had other life troubles are of particular concern. For example, Hybrid Financial Exploitation (HFE) abusive individuals are more likely to be a relative, chronically unemployed, and dependent on the elderly person. Additionally, past studies have estimated that between 16% and 38% of all elder abusers have a history of mental illness. Elder abuse perpetrated by individuals with mental illnesses can be decreased by lessening the level of dependency that persons with serious mental illness have on family members. This can be done by funneling more resources into housing assistance programs, intensive care management services, and better welfare benefits for individuals with serious mental illness. People with substance abuse and mental health disorders typically have very small social networks, and this confinement contributes to the overall occurrence of elder abuse.Perpetrators of elder abuse can include anyone in a position of trust, control or authority over the individual. Family relationships, neighbors and friends, are all socially considered relationships of trust, whether or not the older adult actually thinks of the people as "trustworthy." Some perpetrators may "groom" an older person (befriend or build a relationship with them) in order to establish a relationship of trust. Older people living alone who have no adult children living nearby are particularly vulnerable to "grooming" by neighbors and friends who would hope to gain control of their estates.
The majority of abusers are relatives, typically the older adults spouse/partner or sons and daughters, although the type of abuse differs according to the relationship. In some situations the abuse is "domestic violence grown old," a situation in which the abusive behavior of a spouse or partner continues into old age. In some situations, an older couple may be attempting to care and support each other and failing, in the absence of external support. In the case of sons and daughters, it tends to be that of financial abuse, justified by a belief that it is nothing more than the "advance inheritance" of property, valuables, and money.
Though corporate abusers, such as brokerage firms and bank trust companies have been considered too regulated to be able to abuse the elderly, cases of such abuse have been reported. Such corporate abuse might escape notice both because they have more aptitude at methods of abuse that can go undetected and because they are protected by attorneys and the government in ways that individuals are not.
Within paid care environments, abuse can occur for a variety of reasons. Some abuse is the willful act of cruelty inflicted by a single individual upon an older person. In fact, a case study in Canada suggests that the high elder abuse statistics are from repeat offenders who, like in other forms of abuse, practice elder abuse for the schadenfreude associated with the act. More commonly, institutional abuses or neglect may reflect lack of knowledge, lack of training, lack of support, or insufficient resourcing. Institutional abuse may be the consequence of common practices or processes that are part of running of a care institution or service. Sometimes this type of abuse is referred to as "poor practice," although this term reflects the motive of the perpetrator (the causation) rather than the impact upon the older person.
With the aging of todays population, there is the potential that elder abuse will increase unless it is more comprehensively recognized and addressed.
Elder abuse is not a direct parallel to child maltreatment, as perpetrators of elder abuse do not have the same legal protection of rights as parents of children do. For example, a court order is needed to remove a child from their home but not to remove a victim of elder abuse from theirs.

Risk factors for elder abuse
Various risk factors increase the likelihood that an elderly person will become a victim of elder abuse, including an elderly person who:
Has memory problems (such as dementia)
Has a mental illness, either long-standing or recent
Has physical disabilities
Has depression, loneliness, or lack of social support
Abuses alcohol or other substances
Takes prescribed medications that impair judgment
Is verbally or physically combative with the caregiver
Has a shared living situation
Has a criminal historySeveral other risk factors increase the likelihood that a caregiver will participate in elder abuse, including a caregiver who:
Feels overwhelmed or resentful
Has a history of substance abuse or a history of abusing others
Is dependent on the older person for housing, finances, or other needs
Has mental health problems
Is unemployed
Has a criminal history
Has a shared living situationIn addition:

Lower income or poverty has been found to be associated with elder abuse. Low economic resources have been conceptualized as a contextual or situational stressor contributing to elder abuse.
Living with a large number of household members other than a spouse is associated with an increased risk of abuse, especially financial abuse.Risk factors can also be categorized into individual, relationship, community, and sociocultural levels. At the individual level, elders who have poor physical and mental health are at higher risk. At the relationship level, a shared living situation is a huge risk factor for the elderly, and living in the same area as the abuser is more likely to result in abuse. At the community level, caregivers may knowingly or inadvertently cause social isolation of the elderly. At the sociocultural level, a representation of an older person as weak and dependent, lack of funds to pay for care, elderly people who need assistance but live alone, and destruction of bonds between the generation of a family are possible factors in elder abuse.

Research and statistics
There has been a general lack of reliable data in this area and it is often argued that the absence of data is a reflection of the low priority given to work associated with older people. However, over the past decade there has been a growing amount of research into the nature and extent of elder abuse. The research still varies considerably in the definitions being used, who is being asked, and what is being asked. As a result, the statistics used in this area vary considerably.
One study suggests that around 25% of vulnerable older adults will report abuse in the previous month, totaling up to 6% of the general elderly population. However, some consistent themes are beginning to emerge from interactions with abused elders, and through limited and small scale research projects. Work undertaken in Canada suggests that approximately 70% of elder abuse is perpetrated against women and this is supported by evidence from the Hourglass helpline in the UK, which identifies women as victims in 67% of calls. Also domestic violence in later life may be a continuation of long term partner abuse and in some cases, abuse may begin with retirement or the onset of a health condition. Certainly, abuse increases with age, with 78% of victims being over 70 years of age.The higher proportion of spousal homicides supports the suggestion that abuse of older women is often a continuation of long term spousal abuse against women. In contrast, the risk of homicide for older men was far greater outside the family than within. This is an important point because the domestic violence of older people is often not recognized and consequently strategies, which have proved effective within the domestic violence arena, have not been routinely transferred into circumstances involving the family abuse of older people.
According to the Hourglass helpline in the UK, abuse occurs primarily in the family home (64%), followed by residential care (23%), and then hospitals (5%), although a helpline does not necessarily provide a true reflection of such situations as it is based upon the physical and mental ability of people to utilize such a resource.Research conducted in New Zealand broadly supports the above findings, with some variations. Of 1288 cases in 2002–2004, 1201 individuals, 42 couples, and 45 groups were found to have been abused. Of these, 70 percent were female. Psychological abuse (59%), followed by material/financial (42%), and physical abuse (12%) were the most frequently identified types of abuse. Sexual abuse occurred in 2% of reported cases.Age Concern New Zealand found that most abusers are family members (70%), most commonly sons or daughters (40%). Older abusers (those over 65 years) are more likely to be husbands.In 2007, 4766 cases of suspected abuse, neglect, or financial exploitation involving older adults were reported, an increase of 9 percent over 2006. 19 incidents were related to a death, and a total of 303 incidents were considered life-threatening. About one in 11 incidents involved a life-threatening or fatal situation.In 2012, the study called Pure Financial Exploitation vs. Hybrid Exploitation Co-Occurring With Physical Abuse and/or Neglect of Elderly Persons by Shelly L. Jackson and Thomas L. Hafemeister brought attention to the hybrid abuse that elderly persons can experience. This study revealed that victims of hybrid financial exploitation or HFE lost an average of $185,574, a range of $20–$750,000.

Barriers to obtaining statistics
Several conditions make it hard for researchers to obtain accurate statistics on elder abuse. Researchers may have difficulty obtaining accurate elder abuse statistics for the following reasons:

Elder abuse is largely a hidden problem and tends to be committed in the privacy of the elderly persons home, mostly by his or her family members.
Elder abuse victims are often unwilling to report their abuse for fear of others disbelief, fear of loss of independence, fear of being institutionalized, fear of losing their only social support (especially if the perpetrator is a relative), and fear of being subject to future retaliation by the perpetrator(s).
Elder abuse victims cognitive decline and ill health may prevent them from reporting their abuse.
Lack of proper training of service providers, such as social workers, law enforcement, nurses, etc., about elder abuse, therefore the number of cases reported tend to be low.
The subjective nature of elder abuse, which largely depends on ones interpretation.
Another reason why there is a lack of accurate statistics is the debate of whether to include self-neglect or not. Many are unsure if it should be included since it does not involve another person as an abuser. Those opposed to the inclusion of self-neglect make the claim that it is a different form of abuse and thus, should not be included in the statistics. Due to this discrepancy and the others mentioned above, it is difficult to get accurate data concerning the abuse of the elderly.

Prevention
Doctors, nurses, and other medical personnel can play a vital role in assisting elder abuse victims. Studies have shown that elderly individuals, on average, make 13.9 visits per year to a physician. Although there has been an increase in awareness of elder abuse over the years, physicians tend to only report 2% of elder abuse cases </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Factitious disorder and can you explain it in depth? [/INST] A factitious disorder is a condition in which a person, without a malingering motive, acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms, purely to attain (for themselves or for another) a patients role. People with a factitious disorder may produce symptoms by contaminating urine samples, taking hallucinogens, injecting fecal material to produce abscesses, and similar behaviour.
Factitious disorder imposed on self (also called Munchausen syndrome) was for some time the umbrella term for all such disorders. Factitious disorder imposed on another (also called Munchausen syndrome by proxy, Munchausen by proxy, or factitious disorder by proxy) is a condition in which a person deliberately produces, feigns, or exaggerates the symptoms of someone in their care. In either case, the perpetrators motive is to perpetrate factitious disorders, either as a patient or by proxy as a caregiver, in order to attain (for themselves or for another) a patients role. Malingering differs fundamentally from factitious disorders in that the malingerer simulates illness intending to obtain a material benefit or avoid an obligation or responsibility. Somatic symptom disorders, though also diagnoses of exclusion, are characterized by physical complaints that are not produced intentionally.

Causes
The causes are mostly unknown. One possible cause is trauma but the rest is still going through a testing process. It is also been suspected that it might be hereditary, like depression. There are still many possible causes for this disorder which havent been defined yet.These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. In some cases, individuals with factitious disorder are accustomed to actually being sick, and thus return to their previous state to recapture what they once considered the "norm". Another cause is a history of close contact with someone (a friend or family member) who had a severe or chronic condition. The patients found themselves subconsciously envious of the attention said relation received, and felt that they themselves faded into the background. Thus medical attention makes them feel glamorous and special.

Diagnosis
Criteria for diagnosis include intentionally fabricating to produce physical or psychological signs or symptoms and the absence of any other mental disorder. Motivation for their behavior must be to assume the "sick" role, and they do not act sick for personal gain as in the case of malingering sentiments. When the individual applies this pretended sickness to a dependent, for example, a child, it is often referred to as "factitious disorder by proxy".The DSM-5 differentiates among two types:

Factitious disorder imposed on self (Munchausen syndrome)
Factitious disorder imposed on another (Munchausen syndrome by proxy), defined as: When an individual falsifies illness in another, whether that be a child, pet, or older adult.

Factitious disorder imposed on self
Factitious disorder imposed on self, previously called Munchausen syndrome, or factitious disorder with predominantly physical signs and symptoms, has specified symptoms. Factitious disorder symptoms may seem exaggerated; individuals undergo major surgery repeatedly, and they "hospital jump" or migrate to avoid detection.

Factitious disorder imposed on another
Factitious disorder imposed on another, previously Munchausen syndrome by proxy, is the involuntary use of another individual to play the patient role. For example, false symptoms are produced in children by the caregivers or parents, to produce the appearance of illness, or they may give misleading medical histories about their children. The parent may falsify the childs medical history or tamper with laboratory tests to make the child appear sick. Occasionally, in Munchausen by proxy, the caregiver actually injures the child or makes them sick to ensure that the child is treated. For instance, a father whose son has celiac disease might knowingly introduce gluten into the diet. Such parents may be validated by the attention that they receive from having a sick child.

Ganser syndrome
Ganser syndrome was once considered a separate factitious disorder, but is now considered a dissociative disorder. It is a disorder of extreme stress or an organic condition. The patient experiences approximation or giving absurd answers to simple questions. The syndrome is sometimes diagnosed as merely malingering—however, it is more often defined as a factitious disorder. This has been seen in prisoners following solitary confinement, and the symptoms are consistent in different prisons, though the patients do not know one another.Symptoms include a clouding of consciousness, somatic conversion symptoms, confusion, stress, loss of personal identity, echolalia, and echopraxia. Individuals also give approximate answers to simple questions such as, "How many legs on a cat?" "Three"; "Whats the day after Wednesday?" "Friday"; and so on. The disorder is extraordinarily rare with fewer than 100 recorded cases. While individuals of all backgrounds have been reported with the disorder, there is a higher inclination towards males (75% or more). The average age of those with Ganser syndrome is 32, though it stretches from ages 15–62 years old.

Differential diagnosis
Factitious disorder should be distinguished from somatic symptom disorder (formerly called somatization disorder), in which the patient is truly experiencing the symptoms and has no intention to deceive.
In conversion disorder (previously called hysteria), a neurological deficit appears with no organic cause. The patient, again, is truly experiencing the symptoms and signs and has no intention to deceive.
The differential also includes body dysmorphic disorder and pain disorder.

Treatment
No true psychiatric medications are prescribed for factitious disorder. However, selective serotonin reuptake inhibitors (SSRIs) can help manage underlying problems. Medicines such as SSRIs that are used to treat mood disorders can be used to treat factitious disorder, as a mood disorder may be the underlying cause of factitious disorder. Some authors (such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family therapy can also help. In such therapy, families are helped to better understand patients (the individual in the family with factitious disorder) and that persons need for attention.
In this therapeutic setting, the family is urged not to condone or reward the factitious disorder individuals behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrists establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of factitious disorder. Monitoring is also a form that may be indicated for the factitious disorder patients own good; factitious disorder (especially proxy) can be detrimental to an individuals health—if they are, in fact, causing true physiological illnesses </s>