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Two ways which seem useful to us are either to divide the methods by how they handle data, or to divide them by the approach taken when building trees. Both these divisions can help us appreciate the differences among the various tree building techniques. Given the rapid development of methods in this field, we cannot hope to cover completely every method that has been proposed, nor would this necessarily be helpful. Note that both trees have the same topology and branch lengths, but that the parsimony tree identifies which site contributes to the length of each branch. As an example, consider the following sequences and corresponding (uncorrected) distance matrix: the trees obtained by parsimony (a discrete method) and minimum evolution (a distance method) are identical in topology and branch lengths. The parsimony analysis identifies seven substitutions and places them on the five branches of the tree. The distance tree apportions the observed distances between the sequences over the branches of the tree, and you can see that both methods arrive at the same estimates of the lengths of each branch. Under parsimony each of the seven sites requires one change, for a total of seven changes; if we sum the branch lengths on the distance tree we obtain the same value: 2 + 1 + 2 + 1 + 1 = 7. Note, however, that the parsimony tree gives us the additional information of which site contributes to the length of each branch. Furthermore, discrete methods allow us to infer the attributes of extinct ancestors, in this case extinct nucleotide sequences. These reconstructed ancestors can offer insights about molecular evolution (see Chapter 5). The tree is constructed by starting with the tree for three sequences, then adding each remaining sequence in turn until finally all sequences have been added. For example, if we have five sequences we might start with three of them (remember that there is only one possible unrooted tree for three sequences) and decide where to place the fourth sequence. Given the resulting tree for four sequences, we then decide where to add the fifth and last sequence to our tree. Clustering methods have the advantage of being easy to implement, resulting in very fast computer programs. This combination of speed and an apparently unambiguous answer is naturally very appealing, and accounts for much of the sustained popularity of clustering methods. The result obtained from simple clustering algorithms often depends on the order in which we add the sequences to the growing tree. For example, had we started with sequences b, d and e rather than a, b and c in. But the biggest limitation is that cluster methods do not allow us to evaluate competing hypotheses, they merely produce a tree. It may be that two different trees could explain our data equally, or nearly equally, well. Unless we have some way to measure the fit between tree and data, we will not be aware of this. Tree-building methods in the second class use optimality criteria to choose among the set of all possible trees. Optimality methods have the great advantage of requiring an explicit function that relates data and tree (for example, a model of how sequences evolve). These methods also allow us to evaluate the quality of any tree, hence we can compare how well competing hypotheses of evolutionary relationship fit the data. Based on this score each tree is ranked in order and typically the best tree (or trees) is used as the estimate of the phylogeny. In this example, there are three optimal trees (indicated by the ranking of first equal [= 1]). An optimality method poses two problems that must be solved: firstly, for a given data set and a given tree, what is the value of the optimality criterion for that tree? For example, what is the minimum number of evolutionary events required to explain the observed data?

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The log likelihood of obtaining the observed sequences is the sum of the log likelihoods of each individual site: where k is the number of sites. Different values of d will have different likelihoods; the value that maximises equation (6. This is equivalent to the problem just discussed, but with one important difference: in all branches at < previous page page 194 next page > < previous page page 195 next page > Page 195. Hence to compute the likelihood of a given site we need to compute the probabilities of the observed states at that site given all possible combinations of ancestral states. Obtaining the maximum likelihood estimate of branch lengths for a given tree is computationally time consuming, and in practice this has limited the application of the method to fairly small data sets. In describing likelihoods we have glossed over the model used to compute those likelihoods. Unlike parsimony, which also enables us to include variation in rates of substitution, likelihood methods provide us with a criterion for choosing the best values for the parameters, namely those values that maximise the likelihood of the data. For example, in any but the simplest of models (such as the JukesCantor model; see Chapter 5) the rate of transitions and transversions is different. If transitions in the data are much more common than transversions the observed < previous page page 195 next page > < previous page page 196 next page > Page 196. The same approach can be used to obtain maximum likelihood estimates of other parameters, such as rate variation among sites (see Chapter 5). The likelihood ratio statistic (D) is the ratio of the likelihood of the alternative hypothesis (H1) to the null hypothesis (H0). Because likelihoods are often very small it is more convenient to use log-likelihoods, so the likelihood ratio test statistic becomes where L1 is the maximum likelihood of the alternative hypothesis H1, and L0 is the maximum likelihood of the null hypothesis H0 In some cases the significance of A can be evaluated by consulting standard c2 tables. Such cases occur when H0 is a special case of H1, obtained by constraining one or more parameters in H1. For such nested hypotheses 2D is approximately distributed as c2 with the degrees of freedom (d. An example (discussed below) is the molecular clock hypothesis, which is equivalent to comparing the likelihoods of an ultrametric and an additive tree (the former is a special case of the latter). If the hypotheses are not nested then use of the c2 distribution is not warranted < previous page page 196 next page > < previous page page 197 next page > Page 197 and the distribution of D must be evaluated by other means, such as the parametric bootstrap (see section 6. Likelihood ratio tests can be used to test a range of hypotheses, such as whether a particular model of molecular evolution is valid, whether a molecular clock adequately describes the data, and whether one phylogenetic hypothesis is significantly better than another. Given the dependence of maximum likelihood on an explicit model of sequence evolution, it is clearly desirable to be able to say when we would reject the chosen model. One way to evaluate the model is to measure how well it fits the observed data by comparing the likelihood a tree and model confers on the data, Ltree, with the theoretical best value for the likelihood, Lmax, using a likelihood ratio test. The observed value of log Lmax log Ltree falls outside the expected distribution generated by parametric bootstrapping (see section 6. However, estimates of branch lengths can be greatly affected by the choice of model, hence for questions involving rates of evolutionary change having a good model is very important. If sequences are evolving different rates then an ultrametric tree would be a poor representation of the relationships among those sequencesan additive tree would be more appropriate. However, given a constant rate of evolution an ultrametric tree would not be significantly worse than an additive tree (see. We can test the hypothesis of a molecular clock using the likelihood ratio test which is distributed as c2 with (n2) degrees of freedom where n is the number of sequences. The degrees of freedom in this case correspond to the difference in the number of branch lengths we have to estimate in an additive and an ultrametric tree (see. Note also that in the tree inferred without the clock assumption the five hominoid sequences roughly line up, which visually confirms what the likelihood ratio test tells usthe data is consistent with a molecular clock. Comparing Phylogenetic Hypotheses As well as testing specific hypotheses about models of molecular evolution we. Using the likelihood ratio test the molecular clock hypothesis is not rejected, hence the data are consistent with a single rate of evolution for these sequences. Given two different trees for the same data, we can ask whether one tree is significantly more likely to have given rise to the observed data than the other tree. Kishino and Hasegawa (1989) proposed a test to compare the likelihoods of different trees that resembles the likelihood ratio test. If the two trees are not significantly different then the sum of these likelihood differences: will not be significantly different from zero. In this instance the test statistic is the sum of the differences in the number of steps each site requires on the two trees.

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Each time he says those words, Cannon pauses, his body visibly shakes and he cries. The last time I saw Cannon was in the summer of 2016 at a press conference for the opening of the Chicago Torture Justice Center. The center is located on the south side of the city, in the Englewood Neighborhood Health Clinic. I watched with a small crowd gathered behind the photographers, video camera operators, and reporters, who waited to ask questions after everyone had spoken. Ralph Torture without Torturers S93 Christine Haley, the executive director of the center, began the press conference by informing everyone that this building had materialized as a result of the Reparations Ordinance. We will link residents to additional community supports such as primary care, job placement, and education services. No one should have to go through hell in order to bring about a measure of justice," he said, wiping away tears. In order for us to improve the health within our communities, we really have to address this trauma. On Chicago Tonight, Cannon went into even more detail about the long-term impact of his torture, explaining that he lost "everybody" that was close to him while he was incarcerated. His mother, father, and son all passed away, Cannon said, before describing the roots of his anger once again: "I get mad. Haley imagines the center to be a space where people are free to talk about anything. Once torture survivors feel comfortable, she and her staff hope to do "trauma-focus work," she says, including narrative therapy and cognitive behavioral therapy. The opening of a center for police torture survivors demonstrates how the disproportionate exposure to state-sanctioned violence produces traumas that the center seeks to manage and heal. Its location within an existing health clinic in the lowincome African American neighborhood of Englewood is significant. The city is thus targeting members of a population that they imagine are likely to be the current and future victims of police torture, while recognizing that these residents 10. Although a neighborhood health clinic already exists to address the medical needs of this constituency, as Christine Haley notes, this particular center will address the problem of police violence, and it is only able to do so because of the reparations judgment. By positioning the center within a health clinic, a medical framework literally subsumes the problem of police torture, thereby transforming the category of "torture survivor" from someone whose constitutional rights have been violated to someone who must learn to manage the traumatic effects of disabling violence. This is not to say that the center only proposes medical solutions to the myriad social problems that torture survivors face. Still, one cannot overlook the fact that the largest funder of the center is the Chicago Public Health Department. Julie Morita, the Public Health Commissioner, not only correlates police torture with trauma but she also links this kind of trauma to disease and poor health outcomes. She draws upon her professional identity as a "neutral" and "apolitical" medical authority even though she is speaking in the context of politicized violence (cf. Notice that torture was successfully introduced as a specifically political category through the interventions of international organizations, yet this political claim is muted through and by individual clinical practice that seeks to relocate the event of torture within the treatment program of each subject (Fassin and Rechtman 2009:84). In so doing, the main practitioners at the center, its leadership, and its funders characterize police torture as a public health issue, not merely as a matter of injustice. In his Chicago Tonight interview, Cannon himself says that he had not received any counseling regarding his torture until a few weeks before the center opened. Whereas he had come to understand his torture as a violation of his constitutional and human rights, now it was also something that a trained health professional could identify and diagnose. He is also now a professional "outreach specialist," presumably learning the necessary techniques to help others cope with the medical consequences of their disability. In this process, the medicalization of torture is produced through the social context of state governance. Thus far I have discussed how marginalized groups are disproportionately subject to disabling violence; indeed, theories of governance can help us to comprehend how legal and medical categories come into being.

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Blepharoplasty of upper or lower eyelids for blepharochalasis or skin excess without documentation of visual impairment. Custodial Care Service means any service primarily for personal comfort or convenience that provides general maintenance, preventive, and/or protective care without clinical likelihood of improvement of the condition. Custodial Care Services also means those services which do not require the technical skills or professional training and clinical assessment ability of medical and/or nursing personnel in order to be safely and effectively performed. These services can be safely provided by trained or capable non-professional personnel, are to assist with routine medical needs. Custodial Care Service also means providing care on a continuous Inpatient or Outpatient basis without any clinical improvement by the member. The nature of a service, rather than the licensure or certification of the person(s) providing the service, determines whether the service is skilled or custodial. A day rehabilitation program is a non-residential planned rehabilitative program of speech, occupational, and/or physical therapy. Day rehabilitation is considered outpatient rehabilitative therapy and is counted against the maximum benefit for these services. Only services directly related to teeth damaged by the accident are eligible for benefits. Certain oral surgical procedures are covered, such as the removal of fully bony impacted teeth (See "Oral Surgery"). Hospitalization for non-covered dental procedures is in benefit under certain conditions specified below. Interpretation: Routine dental care: the following services are not covered: Routine dental exams, cleaning, fillings, orthodontics (braces), endodontics, prosthodontics, periodontal services, and restorative or prosthetic services that alter jaw or teeth relationships. The member may have dental coverage for routine care and should ask his/her employer about such insurance. Injury to sound natural teeth: Treatment following sudden physical trauma to sound natural teeth is covered. Repair of the injury, including the need for root canals, and the use of caps, crowns, bonding materials and other procedures to repair the structure and function of the tooth is covered. Bridges or partial dentures are covered when used to replace sound natural teeth lost in the accident. Non-removable dental appliances are considered to be sound natural teeth for purposes of this benefit. Therefore, repair or replacement of non-removable dental appliances damaged by trauma would be in benefit. Temporary restorative services should be included in the final restoration and are not a separate benefit. All the treatment mentioned above continues to be in benefit, even if the injury becomes apparent several months later. Hospitalization/Ambulatory Surgical Facility use for non-covered dental procedures: An admission (or use of an ambulatory surgical facility) for non-covered dental services is a covered benefit when one or more of the following conditions exist: A non-dental physical condition makes hospitalization or use of an ambulatory surgical facility medically necessary to safeguard the health of the member. The member requires medical management during a dental procedure because of serious systemic disease. The member needs anesthesia because of inability to cooperate with extensive dental procedures while conscious. Examples include, but are not limited to, members who are mentally or physically handicapped, or young children. The surgical procedures are complex and carry a high probability of life-threatening complications. The member is also responsible for the anesthesia charges, unless the member meets the following criteria for anesthesia coverage: 1. The member has a chronic disability that includes, but is not limited to Cerebral Palsy, Epilepsy, Autism Spectrum Disorder and/or a Developmental Disability that is the result of a mental or physical impairment, is likely to continue and that substantially limits major life activities such as self-care and expressive language 3. Diabetic instruction in nutrition, blood glucose monitoring and interpretation, exercise/activity, foot and skin care, medication and insulin treatment plans, and prevention of diabetic complications is covered. The primary care physician, a consulting physician, or a certified health care professional who has expertise in diabetes management may instruct the member. Training is limited to three medically necessary visits after a new diagnosis of diabetes. Diabetic supplies including lancets, alcohol pads and testing strips are in benefit.

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In the acute form massive activation of coagulation does not allow time for compensatory increase in production of coagulant and anticoagulant factors. Patients present with bleeding manifestation, extensive organ dysfunction, shock, renal corticle ischemia, coma, delirium and focal neurological symptoms. Clinical feature for adult thrombocytopenia appears to be more common in young women than in young men but amoung older patients, the sex incidence may be equal. Most adult patient presents with a long history of purpura, menorrhagia, epistaxis and gingival haemorrhage. Discoloration, venous distention and prominence of superficial veins and cyanosis. Treatment of Venous Thromboembolism Long term anticoagulation is required to prevent a frequency of symptomatic extension of thrombosis and/or recurrent venous thromboembolic events. Warfarin is started with initial heparin or clexane therapy and then overlapped for 4-5days. Record the respiratory rate (normal 10-20/min adults; 30-60/min children) Assess for chest asymmetry, abnormal movements or chest in-drawing Locate the trachea centrality Ensure air entry into both lungs by auscultation Intervention Position him/her in semiquater prone. Blunt injuries to the chest, abdomen or the dorsal spine may indicate the life threatening ailment underneath. We will exclude maxillo-facial injuries and eye injuries from this discussion (Ref this to eye section). Mortality is increased if hypotension or airway/breathing problem is not adequately solved. Exclude fractures by performing appropriate X-rays Note Referral must not be delayed by waiting for a diagnosis if treatment is logistically impossible Closed injuries and fractures of long bones may be serious and damage blood vessels Contamination with dirt and soil complicates the outcome of treatment I. Maximum of 4 doses per 24 hours Plus S: Cloxacillin 500mg 6 hourly for 7 days Plus B: Tetanus prophylaxis: 0. In children less than 6 months calculate dose by weight Perform X-ray to rule out dislocations or sublaxations Referral If Severe progressive pain. Progressive swelling Extensive bruising Deformity Joint tenderness on bone No response to treatment Severe limitation of movement 2 258 P a g e 3. Hemorrhagic shock may ensue in situations involving multiple fractures or pelvic ring fractures. Paralysis may be associated, often been brought by improper transfer of the patient to the hospital. Thus lion, tiger, leopard, hyena, bear, elephant, hippopotamus, buffalo, wolf and wild pig are examples of the wild animals that have bitten man. Clinical features of these bites arise from the pathology inflicted by teeth, tusks, claws and horns. Severe facial and eye innuries are common and pneumothorax, hemothorax, bowel perofration and compound fractures have occurred. Treatment Emergency surgery is often needed Replace any blood lost Treat complications of injury. Symptoms:Most bites and stings result in pain, swelling, redness, and itching to the affected area Treatment and Management Treatment depends on the type of reaction Cleanse the area with soap and water to remove contaminated particlesleft behind by some insects Refrain from scratching because this may cause the skin to break down and an infection to form Treat itching at the site of the bite with antihistamine Give appropriate analgesics Where there is an anaphylactic reaction treat according to guideline. If area burnt is larger than 10% of body surface then this is extensive because of fluid loss, catabolism, anaemia and risk of secondary infection. Table 5: Rule of Nine for calculatin % of Body surface burned Body Areas Entire head Upper limb Anterior or posterior surface of trunk Lower limb Perineum Adult (%) 9 9 18 18 1 Child % 18 18 18 14 1 Treatment Ensure that there is an adequate airway, adequate breathing and adequate circulation Immerse burnt area in cold water for 10 minutes Clean with Normal saline or Chlorhexidine ­ cetrimide solution Apply Gentian Violet solution Do not cover Calculate fluid requirement per 24 hours: weight x % of surface burnt x 2 = quantity of fluid Give 75% of fluid requirement as sodium lactate compound solution and 25% as 6% Dextran 70 as blood/plasma expanders. In such cases refer to secondary or tertiary level health care centre Children give A: Paracetamol 10 mg/kg every 8 hours Plus C: Procaine Penicillin 0. Foreign bodies introduced through the mouth (or nose) may be arrested in the larynx, bronchial tree, oesophagus or stomach. Foreign bodies in the stomach rarely produce symptoms and active treatment is usaullynot required. Decision of treatment for carcinoma of the cervix is best done in hospital under specialist care. Primary prevention (screening) and early detection: Vaccination is now available Avoid early sex.


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These combinations commonly occur in chronic myositis or in rapidly progressing motor neuron disease. The quantitative distribution becomes broad rather than shifting to long Normal 500 V ­ + 0. Spikes and turns reflect the number of fibers; duration is determined by fiber size and synchrony. Doublets (Multiplets) Motor units under voluntary control normally discharge as single potentials in a semirhythmic fashion. In some disorders or occasionally in otherwise normal individuals, they fire two or more times at short intervals of 10­30 ms (Table 26­13). The bursts of two or more potentials recur in a semirhythmic pattern under voluntary control. Tremor Tremor is the most common pattern of motor unit firing that is caused by disorders of the central nervous system. While the electrical discharge in tremor is often associated with a clinical tremor, this is not always the case. They are recognized by their rhythmic (often regular) pattern and changing appearance. Only through knowledge of these combinations can reliable interpretations be made. The result should then be interpreted on the basis of known pathophysiologic mechanisms or by common association with known disorders. Each pattern of abnormality changes with the severity and duration of the disease. The findings then can be interpreted most reliably by listing the disorders that may be seen with the pattern of abnormality found (Table 26­14). The sensitivity is usually greater than clinical measures; specificity in identifying the cause of the disease often requires muscle biopsy or other clinical measures. It was the first of the electrophysiologic techniques to be applied in this way, and it has remained a mainstay of electrodiagnosis. It is heavily dependent on controlling technical factors, mastering the skills of data collection, and understanding the changes that occur with the many disorders that may affect peripheral nerves, neuromuscular junctions, and muscle. The extent and distribution of these abnormalities allow conclusions to be drawn about the type and severity of 1. Turn and phase counts of individual motor unit potentials: Correlation and reliability. Iatrogenic complications and risks of nerve conduction studies and needle electromyography. Survey of electrodiagnostic laboratories regarding hemorrhagic complications from needle electromyography. Complications of needle electromyography: Hematoma risk and correlation with anticoagulation and antiplatelet therapy. Is there an age-dependent continuous increase in the duration of the motor unit action potential? Normal needle electromyographic insertional activity morphology: A clinical and simulation study. Configuration of normal and abnormal non-volitional single muscle fiber discharges. Fibrillation potential amplitude and muscle atrophy following peripheral nerve injury. Severity, type, and distribution of myotonic discharges are different in type 1 and type 2 myotonic dystrophy. Pain and calf hypertrophy associated with spontaneous repetitive discharges treated with botulinum toxin. Comparison of clinical methods for fasciculation detection in amyotrophic lateral sclerosis. Fasciculation potentials: A study of amyotrophic lateral sclerosis and other neurogenic disorders. Acquired neuromyotonia: A new autoantibody-mediated neuronal potassium channelopathy.

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Notification is a communication received from a provider informing Priority Partners of the intent to render covered medical services to a member. For services that are emergent or urgent, notification should be provided within 24 hours or by the next business day. Prospective means the coverage request occurred prior to the service being provided. Preauthorization Determination Time Frames For services that require preauthorization, Priority Partners will make a determination in a timely manner so as not to adversely affect the health of the member. The determination will be made within two business days of receipt of necessary clinical information, but no later than seven calendar days from the date of the initial request. Preauthorizations for high tech radiology and cardiology imaging services will be provided through the vendor eviCore healthcare. Utilization Management ­ Inpatient Services Inpatient Admission Preauthorization Notification/preauthorization requirements are as follows: · Except for an emergency admission, the admitting physician is responsible for contacting Priority Partners to obtain preauthorization for a hospital admission. Inpatient Admission Notification Time Frames · All elective admissions must receive prior approval through Provider Services at least 72 hours prior to the admission or scheduled procedure. Priority Partners will not pay for any costs associated with admissions on the day before surgery unless specific medical justification is provided and approved. Inpatient Admission Review · All medical inpatient hospital admissions, including those that are urgent and emergent, will be reviewed for medical necessity within one business day of the facility notification to Priority Partners. Inpatient Concurrent Review Each network hospital will have an assigned concurrent review clinician. The concurrent review clinician will conduct a review of the medical records electronically or by telephone to determine the authorization of coverage for a continued stay. Additional information may be requested in order to make a determination, and must be provided within 24 hours of the request. If the information is not received within the 24 hours, an administrative adverse determination. Exceptions to one-day-at-a-time authorizations may be made for confinements when the severity of the illness and subsequent course of treatment is likely to be several days. The request for this review must be made within two (2) business days of the verbal notification of intent to deny, and the review must take place within four (4) business days of verbal notification of denial. To initiate this request the physician may contact Priority Partners at 800-261-2421 from 8:30 a. If a delay in service, treatment, procedure, or discharge is identified during the process of utilization review for an inpatient stay, and the delay will result in, or is anticipated to result in an overall extended length of stay, the hospital days resulting from the delay in service, treatment, procedure, or discharge will be denied. These services can often be delivered in a nonhospital facility such as: · Hospice facility · Skilled nursing facility · Home health care program. Utilization Management ­ Outpatient Services Outpatient Preauthorization Preauthorization is required and must be requested at a minimum of 72 hours before the service/procedure/ etc. For preauthorization requirements for behavioral health services, please refer to the Beacon Health Options website at maryland. The request for this review must be made within three (3) business days of the fax notification of intent to deny, and the review must take place within five (5) business days of fax notification of denial. Ambulatory Surgery Preauthorization Priority Partners is committed to providing quality, accessible health care in the most efficient manner. In most cases, certain outpatient services can be safely performed in a freestanding facility rather than a hospital outpatient setting. Therefore, certain types of outpatient surgery/services will require site-of-service preauthorization if hospital outpatient service is requested. Services that cannot be safely and effectively provided at a freestanding site will be precertified at hospitals in these areas. These ambulatory surgical procedures must receive coverage approval through the Medical Management department at least 72 hours prior to the scheduled procedure. Site of Service Requirements One way to control costs is to reduce the number of services performed in regulated space that would be just as effective in lower-cost facilities such as ambulatory surgery centers. We are collaborating with leaders in Johns Hopkins Medicine to develop mutual solutions: enabling patients to have necessary procedures while ensuring that care is as cost-effective as possible for our members and our organization alike. Services and codes required under the site of service initiative will be added quarterly.

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Interruption of blood flow to the visual cortex causes sudden graying of vision, occasionally with flashing lights or other symptoms that mimic migraine. Pts should be questioned about the precise pattern and duration of visual loss and other neurologic symptoms such as diplopia, vertigo, numbness, or weakness. In central or branch retinal vein occlusion, the fundus exam reveals engorged, phlebitic veins with extensive retinal hemorrhages. In age-related macular degeneration, characterized by extensive drusen and scarring of the pigment epithelium, leakage of blood or fluid from subretinal neovascular membranes can produce sudden central visual loss. Transient visual obscurations are common, but visual acuity is not affected unless the papilledema is severe, long-standing, or accompanied by macular exudates or hemorrhage. Most pts are young, female, and obese; some are found to have occult cerebral venous sinus thrombosis. Optic neuritis is a common cause of monocular optic disc swelling and visual loss. Glucocorticoids, consisting of intravenous methylprednisolone (1 g daily for 3 days) followed by oral prednisone (1 mg/kg daily for 11 days), may hasten recovery in severely affected patients but makes no difference in final acuity (measured 6 months after the attack). Optic neuritis involving both eyes simultaneously or sequentially suggests neuromyelitis optica. The latter is caused by giant cell (temporal) arteritis and requires immediate glucocorticoid therapy to prevent blindness. If pt has diplopia while being examined, motility testing will usually reveal an abnormality in ocular excursions. However, if the degree of angular separation between the double images is small, the limitation of eye movements may be subtle and difficult to detect. With genuine diplopia, this test should reveal ocular malalignment, especially if the head is turned or tilted in the position that gives rise to the worst symptoms. A dilated pupil suggests direct compression of the third nerve; if present, the possibility of an aneurysm of the posterior communicating artery must be considered urgently. The apparent occurrence of multiple ocular motor nerve palsies, or diffuse ophthalmoplegia, raises the possibility of myasthenia gravis. Paralysis indicates weakness that is so severe that the muscle cannot be contracted at all, whereas paresis refers to weakness that is mild or moderate. The prefix "hemi-" refers to one half of the body, "para-" to both legs, and "quadri-" to all four limbs. Increased fatigability or limitation in function due to pain or articular stiffness is often confused with weakness by pts. Increased time is sometimes required for full power to be exerted, and this bradykinesia may be misinterpreted as weakness. Finally, apraxia, a disorder of planning and initiating a skilled or learned movement, is sometimes mistaken for weakness. The history should focus on the tempo of development of weakness, presence of sensory and other neurologic symptoms, medication history, predisposing medical conditions, and family history. Weakness or paralysis is typically accompanied by other neurologic abnormalities that help to indicate the site of the responsible lesion (Table 42-1). Table 42-3 summarizes patterns with lesions of different parts of the nervous system. Bradykinesia Inability to initiate changes in activity or perform ordinary volitional movements rapidly and easily. There is a slowness of movement and a paucity of automatic motions such as eye blinking and arm swinging while walking. Tremor Rhythmic oscillation of a part of the body due to intermittent muscle contractions, usually involving the distal limbs and less commonly the head, tongue, or jaw. A fine postural tremor of 8­10 beats/s may be an exaggeration of normal physiologic tremor or indicate familial essential tremor. Approximately 50% of cases have a positive family history with an autosomal dominant pattern of inheritance. When activities of daily living such as eating and writing are impaired, therapy with primidone (25­100 mg/d) or propranolol (20­80 mg/d) leads to benefit in 50% of patients. Therapy for focal dystonias usually involves botulinum toxin injections into the affected musculature. Choreoathetosis A combination of chorea (rapid, jerky movements) and athetosis (slow writhing movements). Hemiballismus is a violent form of chorea that comprises wild, flinging movements on one side of the body; the most common cause is a lesion (often infarct or hemorrhage) of the subthalamic nucleus.

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Treatment is symptomatic, with intermittent use of hypnotics and resolution of the underlying stress. Inadequate sleep hygiene is characterized by a behavior pattern prior to sleep and/or a bedroom environment that is not conducive to sleep. In preference to hypnotic medications, the pt should attempt to avoid stressful activities before bed, reserve the bedroom environment for sleeping, and maintain regular rising times. Psychophysiologic Insomnia these pts are preoccupied with a perceived inability to sleep adequately at night. Rigorous attention should be paid to sleep hygiene and correction of counterproductive, arousing behaviors before bedtime. Drugs and Medications Caffeine is probably the most common pharmacologic cause of insomnia. Alcohol and nicotine can also interfere with sleep, despite the fact that many pts use these agents to relax and promote sleep. A number of prescribed medications, including antidepressants, sympathomimetics, and glucocorticoids, can produce insomnia. In addition, severe rebound insomnia can result from the acute withdrawal of hypnotics, especially following use of high doses of benzodiazepines with a short half-life. For this reason, doses of hypnotics should be low to moderate and prolonged drug tapering is encouraged. Movement Disorders Pts with restless legs syndrome complain of creeping dysesthesias deep within the calves or feet associated with an irresistible urge to move the affected limbs; symptoms are typically worse at night. Other Neurologic Disorders A variety of neurologic disorders produce sleep disruption through both indirect, nonspecific mechanisms. Psychiatric Disorders Approximately 80% of pts with mental disorders complain of impaired sleep. The underlying diagnosis may be depression, mania, an anxiety disorder, or schizophrenia. Medical Disorders In asthma, daily variation in airway resistance results in marked increases in asthmatic symptoms at night, especially during sleep. Inhaled glucocorticoids that do not disrupt sleep may provide a useful alternative to oral drugs. Cardiac ischemia is also associated with sleep disruption; the ischemia itself may result from increases in sympathetic tone as a result of sleep apnea. Chronic obstructive pulmonary disease, cystic fibrosis, hyperthyroidism, menopause, gastroesophageal reflux, chronic renal failure, and liver failure are other causes. Insomnia Insomnia without Identifiable Cause Primary insomnia is a diagnosis of exclusion. Treatment is directed toward behavior therapies for anxiety and negative conditioning; pharmacotherapy and/ or psychotherapy for mood/anxiety disorders; an emphasis on good sleep hygiene; and intermittent hypnotics for exacerbations of insomnia. Cognitive therapy emphasizes understanding the nature of normal sleep, the circadian rhythm, the use of light therapy, and visual imagery to block unwanted thought intrusions. Judicious use of benzodiazepine receptor agonists with short half-lives can be effective; options include zaleplon (5­20 mg), zolpidem (5­10 mg), or triazolam (0. Limit use to 2­4 weeks maximum for acute insomnia or intermittent use for chronic. Sleep Apnea Syndromes Respiratory dysfunction during sleep is a common cause of excessive daytime sleepiness and/or disturbed nocturnal sleep, affecting an estimated 2­5 million individuals in the United States. Episodes may be due to occlusion of the airway (obstructive sleep apnea), absence of respiratory effort (central sleep apnea), or a combination of these factors (mixed sleep apnea). Obstruction is exacerbated by obesity, supine posture, sedatives (especially alcohol), nasal obstruction, and hypothyroidism. Sleep apnea is particularly prevalent in overweight men and in the elderly and is undiagnosed in 80­90% of affected individuals. Treatment consists of correction of the above factors, positive airway pressure devices, oral appliances, and sometimes surgery (Chap. Cataplexy, the abrupt loss of muscle tone in arms, legs, or face, is precipitated by emotional stimuli such as laughter or sadness. Symptoms of narcolepsy (Table 45-2) typically begin in the second decade, although the onset ranges from ages 5­50. Hypersomnias Somnolence is treated with modafinil, a novel wake-promoting agent; the usual dose is 200­400 mg/d given as a single dose. Older stimulants such as methylphenidate (10 mg twice a day to 20 mg four times a day) or dextroamphetamine are alternatives, particularly in refractory pts.

Yorifuji Okuno syndrome

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Examine shoes for evidence of scuffing and wear at the toe; · observe for pronator drift (see b p. Falls and unsteadiness due to phenomena other than ataxia Dyspraxia · Also known as developmental coordination disorder. Consider whether ataxia is acute or chronic, progressive or non-progressive, or episodic. A parainfective subacute onset ataxia is particularly characteristic 7­14 days post-Varicella. Slowly progressive ataxias (over months to years) with initial symptom-free period · Nearly all genetically determined progressive ataxias of older childhood are both extremely rare and dominantly inherited with high penetrance so that a family history will be informative (see b p. Congenital, non- or slowly progressive ataxias with no initial symptom-free period · If imaging suggests unilateral or very asymmetric cerebellar involvement, the cause is probably acquired. Suggested approach to initial investigation of chronic non-progressive or slowly progressive cerebellar disorders (see b p. In developing countries, around 50% of children die within a few years of the onset of blindness. Key points on examination from anterior to posterior · External inspection: microphthalmia, dysmorphism? Central retinal artery occlusion (causing sudden painless and unilateral blindness)? Clues from examination · External eye: microphthalmia, aniridia, albinism, buphthalmos, dysmorphism, colobomata. Cataracts in childhood Less than half are idiopathic; all warrant a vigorous search for aetiology · Congenital infections (rubella). Progressive visual loss is usually noticed by a teacher or parent, rather than by the child. It is therefore best to consider both acute and progressive causes in every child (Tables 3. In addition, the causes of progressive loss overlap with the causes of congenital blindness. A visual field deficit (or indeed any visual sign or symptom) that is truly confined to one eye. Toxic, nutritional · Usually present with decreased acuity and colour vision, especially if there are central scotomata. Most other metabolic disorders do not usually present with visual disturbance, although eye features are common (see Table 1. These children have in common: · Focal or multifocal patterns of injury leading to idiosyncratic and unusual combinations of impairments. Demonstrating low levels of awareness requires careful and skilled multidisciplinary assessment-identifying movements (typically eye blinks, eye pointing or limb movements) that are under some voluntary control, but may follow many seconds after requests. Unexplained distress on movement in children recovering from traumatic injury should prompt a careful evaluation for bony injury. It follows that late outcome is generally better for functions that were nearly fully established at the time of injury. In crude terms, motor development completes before language development, which completes before cognitive development: hence the particular concern about late cognitive outcomes, and children injured at a young age. Time Interdiscipinary working and goal setting the distinguishing feature of rehabilitation is a process of working together. Multidisciplinary working can become problem based, and focused on impairments, with each professional seeing one part of the picture (dysphasia, contractures, seizures) and addressing it in isolation. In contrast, rehabilitation is characterized by a cross-disciplinary, forward-looking setting of specific, relevant and measurable goals, ideally involving child and family. The cognitive effects of injury (which are ultimately the main determinants of outcome) tend to compound over the period of development remaining, and deficits tend to become more apparent with time. Typical areas of difficulty include new learning (what the child knew at the time of injury is retained but learning efficiency for new material is reduced requiring more repetition) and frontal lobe functions including attention, impulse control and executive skills (see b p. This period ends with the restoration of orientation (awareness of time, place and person) and the ability to form new memories (`who came to visit you this morning? Causes Trauma · Falls and road-traffic accidents with no, or poorly adjusted, seat belts (particularly cervical trauma in young children). Inflammatory · Post-infectious processes (transverse myelitis, acute disseminated encephalomyelitis, see b p. Vascular · the anterior spinal artery supplies the ventral two-thirds of the cord.


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