By E. Jared. Abraham Baldwin Agricultural College. 2018.

Tetraplegic patients with active wrist extensors should be encouraged to participate in activities to strengthen these muscles and to facilitate the use of their tenodesis grip cheap 120mg silvitra otc. This occurs in the individual with a complete spinal cord lesion at C6 who is able to use active wrist extension to produce a grip between thumb and index fingers buy discount silvitra 120mg line. Some tetraplegic patients may require a variety of splints, such as those for writing and typing, wrist support splints, feeding straps, or pushing gloves, to enable them to carry out their daily activities. Home resettlement Establishing early dialogue with the patient, the patient’s family and friends is vital to enable the occupational therapist to be in a position to offer early advice and reassurance regarding (b) living in the community. When an individual does not have a suitable home to return to alternatives are discussed, i. An assessment visit involves a team from the spinal unit, including the occupational therapist and representatives from the patient’s home area—usually the occupational therapist and social worker/care manager and the patient’s family. The visit begins the lengthy processes of planning for the patient’s discharge and providing accessible accommodation. Recommendations are made to enable weekends to be spent away from hospital. Weekends away begin when the patient and family or friends feel confident to be away from the hospital. Enabling this to occur may involve the whole team in teaching techniques, procedures and instruction in the use of equipment to both patient and family. Spending time away from the hospital may enable the patient, their family and friends to decide upon what plans they wish to make for long-term resettlement in the community. The procedures involved in making alterations to a property require careful thought and planning and may take many months before completion. As well as the availability of suitable accommodation, the organising of an appropriate care package may be necessary, which involves the whole team and may take time to organise. In the event of completion of a patient’s rehabilitation occurring before long-term accommodation is accessible or available, it may be necessary for alternative interim accommodation to be sought. Activities of daily living Once tetraplegic patients are out of bed and have started work on strengthening and balance, they begin to explore methods to relearn eating, drinking, washing, brushing their hair, cleaning their teeth, and shaving. These activities often entail the use of adapted tools or splints and straps made by the occupational therapist. The patient may need to relearn writing skills and may also explore the use of a computer, telephone, page- turner, and environmental control system. As the patient becomes more confident and the wearing of a hard collar or brace all day is discontinued, he or she is able to progress to tasks involving bed mobility, in preparation for dressing, transfers, showering, and domestic activities. This can cover the whole range of domestic living and include being able to make a cup of tea, using a microwave, washing machine, vacuum cleaner or changing a duvet cover independently. Despite the patient’s social situation they should be given the opportunity to relearn these activities. Communication For tetraplegic patients unable to use their upper limbs functionally with standard communication systems, the role of the occupational therapist is to enable the patient to access alternative systems. Individual writing splints or mouthsticks may be made to enable those with limited writing skill to make a signature, which can be important to an individual for both business and personal correspondence. Alternative methods of being able to turn the pages of books, magazines and newspapers may be pursued. Trial and selection of electrically powered equipment includes telephone, computer and assessment of environmental control systems, which can enable the individual to operate via a switch a range of functions, including television, video, intercom, computer, lights, radio, and accessing the telephone. In incomplete spinal cord lesions, where there can be use variable potential for neurological recovery, it may not be possible to • May be able to assist with transfer from wheelchair onto level predict functional outcome, which can lead to increased anxiety for the surfaces using a sliding board and an assistant patient. Complete lesion below C6: As the adult with a spinal cord lesion becomes older their ability to • Able to extend wrists maintain their level of independence may diminish and require review. As soon as is practicable liaison occurs between the spinal centre staff, the patient and the patient’s local district wheelchair service. They are able to assess and provide wheelchairs from a range, which includes self-propelling, lightweight, indoor powered, indoor/outdoor powered and Figure 10.

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They often develop in young children secondary to indolent bacterial infec- tions order silvitra 120 mg free shipping. In addition to presenting with a clinical picture of a shunt infection discount 120 mg silvitra, the patient may also complain of abdominal pain and distension. The cysts may be percutaneously aspirated, and the fluid can be cultured. Given the indolent nature of the likely infections, treatment is no different from any other shunt infection. Ascites, similarly, may be indicative of an indolent infection, or it may be secondary to CSF overproduction and=or inadequate peritoneal absorption. Hernias can also develop within 3 months of shunt insertion, and are treated like any other hernia. Perforation of intraperitoneal organs is a rare but well-recognized complication. Treatment of Posthemorrhagic Hydrocephalus (PHH) Premature infants weighing 0. First, serial lumbar punctures and=or ventricular taps are performed to normalize ICP; approximately 5–15 mL of CSF must be removed daily to adequately temporize the PHH. The infant’s ICP can be assessed by palpation of the anterior fontanelle and detection of the cranial suture splaying; and ventriculomegaly can be followed by serial cranial ultrasounds. Ventriculosubgaleal shunts can safely temporize PHH while avoiding exter- nal drainage or frequent CSF aspirations. A ventricular catheter connected to a sub- cutaneous reservoir can be accessed for daily CSF aspirations with a risk of infection of less than 5%. A ventriculoperitoneal shunt should be considered when the CSF is cleared of posthemorrhagic debris, CSF protein is <1000 mg=dL, the infant weighs >1. Treatment of Hydrocephalus Associated with Myelomeningocele Approximately 85% of infants with myelomeningoceles develop symptomatic hydro- cephalus, and approximately 50% have obvious hydrocephalus at birth. Treatment is usually with a ventriculoperitoneal shunt, although recent evidence suggests that endoscopic third ventriculostomies may have a useful role. Historically, shunt place- ment is deferred until after the myelomeningocele is repaired; however, contempor- ary evidence suggests that the risks of shunt complications are not significantly increased if the shunt is placed at the same time as the myelomeningocele closure. In many centers, the shunt is placed in neonates with ventriculomegaly at the time of the myelomeningocele closure with the hope that a shunt will prevent a CSF leak from the repaired myelomeningocele site. Treatment of Hydrocephalus Associated with a Dandy–Walker Cyst To treat hydrocephalus secondary to a Dandy–Walker cyst, a contrast study can be performed to determine if the lateral ventricles communicate with the cyst. With no communication, at least two shunts are necessary, one to decompress the cyst and Hydrocephalus 35 one to drain the ventricular system. With communication, a single shunt in either the lateral ventricle or the cyst could adequately treat the hydrocephalus, although some centers recommend simply shunting both the cyst and ventricle as the initial treat- ment. A decompressed Dandy–Walker cyst can yield dramatic radiographic results (i. PROGNOSIS The prognosis of pediatric hydrocephalus is dependent more on the underlying brain morphology as well as other factors such as IVH, ventriculitis, and perinatal ische- mia, than on the severity of the hydrocephalus and ventriculomegaly. The 5-year sur- vival rate of children with congenital hydrocephalus is approximately 90%. Normal intellect has been reported to range from 40% to 65%, but obviously varies widely with each specific etiology. Before the advent of the CT scan, several studies attempted to investigate the prognosis of shunted vs. In 1963, Foltz and Shurtleff performed a 5-year study of 113 hydrocephalic children of whom 65 were shunted early, and 48 were not operated on. They found that shunted children had a significantly better survival and a higher percentage had an IQ of at least 75. In 1973, Young and colleagues performed an outcome analysis on a series of 147 shunted hydrocephalic children. They found a correlation between the width of the child’s cerebral mantle and IQ in that the IQ distribution approached a normal pattern when a cerebral mantle width of 2. Since the introduction of CT and MR imaging, there have been several studies investigating the outcomes of hydrocephalus secondary to specific etiologies.

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Occasional cases of metamorphopsia have been reported with lesions of the optic chiasm buy silvitra 120mg free shipping, optic radiation generic silvitra 120 mg visa, and retrosplenial region. Indeed, it seems that meta- morphopsia may occur with pathology at any point along the visual pathway from retina to cortex. Differing patterns of metamorphopsia may assist with clinico-anatomical correlation: ● retinal lesions: ipsilateral monocular ● chiasmal lesions: bitemporal ● occipitoparietal lesions: contralateral homonymous Metamorphopsia may be associated with visual hallucinations. Metamorphopsia and visual hallucinations restricted to the right visual hemifield after a left putaminal hemorrhage. Journal of Neurology, Neurosurgery and Psychiatry 1996; 61: 420-421 Cross References “Alice in Wonderland” syndrome; Hallucination; Illusion; Macropsia; Micropsia; Pelopsia; Porropsia; Telopsia Micrographia Micrographia is small handwriting. It is most often recognized in asso- ciation with the extrapyramidal features of idiopathic Parkinson’s dis- ease (indeed it may be the presenting sign), but may occasionally occur with other parkinsonian syndromes (e. In Parkinson’s disease, handwriting may initially be of normal size but then become progressively smaller, slower, and more illegible as writing proceeds, an example of parkinsonian fatigue, a gradual - 195 - M Micropsia decline in the amplitude and speed of initiation of voluntary move- ments. Such “slow” micrographia may be distinguished from “fast” micrographia in which letters are small throughout although written at normal speed without fatigue, which may be seen in PSP or other pal- lidal pathologies. There is a poor correlation between micrographia and the side, severity or duration of classical parkinsonian features, and its response to levodopa preparations is very variable. These observations, along with reports of isolated micrographia with cortical lesions demon- strated by neuroimaging, suggest that the anatomical basis of micro- graphia may be at the level of the cortex (dominant parietal lobe) rather than the basal ganglia. Micrographia has also been described following large right ante- rior cerebral artery infarcts and lacunar infarcts involving the putamen and genu of the internal capsule. Journal of the Neurological Sciences 1972; 15: 141-152 Scolding NJ, Lees AJ. Micrographia associated with a parietal lobe lesion in multiple sclerosis. Journal of Neurology, Neurosurgery and Psychiatry 1994; 57: 739-741 Cross References Fast micrographia; Fatigue; Parkinsonism Micropsia Micropsia, or “Lilliput sight,” is an illusory phenomenon in which the size of a normally recognized object is underestimated. It is the most common form of metamorphopsia, and is most often associated with lesions of the right temporo-parietal cortex, although macular edema and optic chiasm lesions may also cause micropsia. Hemimicropsia, micropsia confined to one visual hemifield, has been recorded. The entirely subjective nature of the disorder may account for the relative rarity of reports. Seeing objects smaller than they are: micropsia following right temporo-parietal infarction. Selective deficit of visual size per- ception: two cases of hemimicropsia. Journal of Neurology, Neurosurgery and Psychiatry 1994; 57: 73-78 Cross References Metamorphopsia Microsomatognosia - see “ALICE IN WONDERLAND” SYNDROME - 196 - Mirror Agnosia M Milkmaid’s Grip Milkmaid’s grip is the descriptive term applied to the inability to main- tain a firm grip (e. Seen in Huntington’s disease, this may reflect a combination of chorea and motor impersistence. Cross References Chorea, Choreoathetosis; Impersistence; Trombone tongue Miosis Miosis is abnormal reduction in pupillary size, which may be unilateral or bilateral. Philadelphia: Lippincott Williams & Wilkins, 2002: 135-146 Cross References Age-related signs; Anisocoria; Argyll Robertson pupil; Horner’s syn- drome; Mydriasis Mirror Agnosia Mirror agnosia, or the “looking glass syndrome,” is a phenomenon observed in patients with left hemispatial neglect as a result of right parietal lobe lesions. There is inability to point to objects seen in a mirror, with repeated reaching “into” the mirror even when the actual location of the target is shown. In a milder form, known as “mirror ataxia,”patients reach in the direction of the object but with increased errors of reach and grasp, suggesting that visual information is not adequately transformed into a body-centered frame of reference. Mirror agnosia and mirror ataxia constitute different parietal lobe disorders. Annals of Neurology 1999; 46: 51-61 Ramachandran VS, Altschuler EL, Hillyer S. Proceedings of the Royal Society of London, Series B 1997; 264: 645-647 Cross References Agnosia; Neglect - 197 - M Mirror Ataxia Mirror Ataxia - see MIRROR AGNOSIA Mirror Hallucination - see AUTOSCOPY Mirror Movements Mirror movements are involuntary movements of one side of the body that accompany and “mirror” (reflect) intentional movements on the opposite side of the body (also known as imitation synkinesis). They are usually symmetrical and most often seen when using distal muscles of the upper limb.

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Automated marking may be difficult for such assessments order silvitra 120mg overnight delivery, and the teacher is likely to have to do a substantial Advantages and disadvantages of web based learning amount of work before he can add his or her comments to the Advantages student’s record purchase 120 mg silvitra otc. Further guidance on how to design web based x Ability to link resources in many different formats assessments for online courses can be found at www. Appropriate technology and reasonable computer x Learners find it frustrating if they cannot access graphics, images, skills are needed to get the best out of web based or online and video clips because of poor equipment learning. Programmes and web pages can be designed to x The necessary infrastructure must be available and affordable x Information can vary in quality and accuracy, so guidance and accommodate different technical specifications and versions of signposting is needed software. It is frustrating for learners, however, if they are trying x Students can feel isolated to work on the internet with slow access or cannot download images and videos they need. On the other hand, web based programmes may, for example, encourage more independent and active learning and are often an efficient means of delivering course materials. Effective web teaching and learning Course designers need to remember that younger students are more likely to be familiar with using the internet than older learners, who may feel less comfortable with a web based course. To get the best out of their learning experience, learners need basic computer skills, support, and guidance. Teachers must design their courses to encourage effective web based learning rather than aimless “surfing. This change means that doctors are becoming more adept at using computers and online resources to support their daily work and continuing professional development. Electronic media can facilitate access to evidence based 44 Web based learning resources such as the Cochrane Library. These web based Further reading clinical support sites are excellent resources for postgraduate “on the job” learning. The online learning handbook:developing awareness of good practice, and standards should be set in and using web based learning. The role of teachers is to ensure that the learning environment provided takes account of learners’ needs and ensures that they are effectively prepared and supported. Online learning has advantages, but web based learning should not always be viewed as the method of choice because barriers (such as inadequate equipment) can easily detract from student learning. The technology must therefore be applied appropriately and not used simply because it is available and new or because students and teachers have particular expectations of this means of course delivery. Teaching materials can often distract learners rather than help them to learn. Common avoidable problems include overcrowded or illegible slides, irrelevant or badly prepared handouts, and incompatible multimedia equipment. It is important therefore to know how to create effective teaching materials. Ground rules Five basic principles apply to preparing teaching materials, irrespective of the type of material you choose: links, intelligibility, general style, highlighting, and targeting (LIGHT). You may sometimes decide to ignore one or more of these principles, but if you do, think carefully about what you are trying to achieve. Links Your teaching materials should have obvious and direct links to your talk, discussion, or presentation. Handouts are the main offenders in this category, and it is not unusual for handouts to have little in common with the talk. It is quite acceptable for the Preparing overhead transparencies teaching materials to give some additional information, but this Do should not be excessive. How this is achieved will depend on the medium used x Limit each transparency to one idea or concept and the venue of the talk or presentation. Diagrams can help x Use small print x Use overhead transparencies packed with tables and figures to clarify a complex message. If you are using slides or overhead x Use light colours transparencies, the size of the print needs to be large enough to be read from the back of the auditorium. General style You should aim to use a consistent style throughout your Uniformity in the teaching materials will teaching materials, particularly if you are giving a series of talks. Highlighting It is easy to overdo highlighting by emphasising virtually every point that Highlighted information helps to emphasise important issues or pivotal points in a developing argument. This reduces the usefulness of the technique and hides the highlighting include changing the colour of text or underlining words or phrases. This also applies to videotapes and really pivotal shifts in a morass of highlighted text.

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