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For him who has conquered the mind, the mind is the best of friends; but for one who has failed to do so, his mind will remain the greatest enemy.

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By X. Folleck. Emmaus Bible College.

Emotional and nonemotional facial behavior in patients with unilateral brain damage discount flagyl 250 mg. Journal of Neurology flagyl 200mg, Neurosurgery and Psychiatry 1988; 51: 826-832 Hopf HC generic 500mg flagyl fast delivery, Muller-Forell W, Hopf NJ. Neurology 1992; 42: 1918-1923 Jacob A, Cherian PJ, Radhakrishnan K, Sankara SP. Emotional facial paresis in temporal lobe epilepsy: its prevalence and lateralizing value. Seizure 2003; 12: 60-64 Cross References Abulia; Ageusia; Bell’s palsy; Bell’s phenomenon, Bell’s sign; Bouche de tapir; Cerebellopontine angle syndrome; Corneal reflex; Eight-and- a-half syndrome; Epiphora; Fisher’s sign; Hitselberg sign; Hyperacusis; Lagophthalmos; Locked-in syndrome; Lower motor neurone (LMN) syndrome; Pseudobulbar palsy; Upper motor neurone (UMN) syndrome Facilitation Facilitation is an increase in muscle strength following repeated con- traction. Clinically, facilitation may be demonstrated by the appear- ance of tendon-reflexes after prolonged (ca. This phenomenon of post-tetanic potentiation is most commonly seen in the Lambert-Eaton myasthenic syndrome (LEMS), a disorder of neuromuscular junction transmission associated with the presence of autoantibodies directed against presynaptic voltage-gated calcium ion (Ca2+) channels (VGCC). The mechanism is thought to be related to an increased build up of Ca2+ ions within the presynaptic terminal with the repetitive firing of axonal action potentials, partially over- coming the VGCC antibody-mediated ion channel blockade, and leading to release of increasing quanta of acetylcholine. Cross References Fatigue; Lambert’s sign “False-Localizing Signs” Neurological signs may be described as “false-localizing” when their appearance reflects pathology distant from the expected anatomical locus. The classic example, and probably the most frequently observed, is abducens nerve palsy (unilateral or bilateral) in the context of raised intracranial pressure, presumed to result from stretching of the nerve over the ridge of the petrous temporal bone. Many false-localizing signs occur in the clinical context of raised intracranial pressure, either idiopathic (idiopathic intracranial hypertension [IIH]) or symptomatic (secondary to tumor, hematoma, abscess). Journal of Neurology, Neurosurgery and Psychiatry 2003; 74: 415-418 Larner AJ. Advances in Clinical Neuroscience & Rehabilitation 2005; 5(1): 20-21 Cross References Abducens (vi) Nerve palsy; Divisional palsy; Girdle sensation; Kernohan’s notch syndrome; Oculomotor (III) nerve palsy; Proptosis; Urinary retention Fan Sign (Signe de l’éventail) - see BABINSKI’S SIGN (1) Fasciculation Fasciculations are rapid, flickering, twitching, involuntary movements within a muscle belly resulting from spontaneous activation of a bundle, or fasciculus, of muscle fibers (i. Fasciculations may also be induced by lightly tap- ping over a partially denervated muscle belly. The term was formerly used synonymously with fibrillation, but the latter term is now reserved for contraction of a single muscle fibre, or a group of fibers smaller than a motor unit. Persistent fasciculations most usually reflect a pathological process involving the lower motor neurones in the anterior (ventral) horn of the spinal cord and/or in brainstem motor nuclei, typically motor neurone disease (in which cramps are an early associated symptom). Facial and perioral fasciculations are highly characteristic of Kennedy’s disease (X-linked bulbospinal neu- ronopathy). However, fasciculations are not pathognomonic of lower motor neurone pathology since they can on rare occasions be seen with upper motor neurone pathology. The pathophysiological mechanism of fasciculations is thought to be spontaneous discharge from motor nerves, but the site of origin of this discharge is uncertain. Although ectopic neural discharge from any- where along the lower motor neurone from cell body to nerve terminal could produce fasciculation, the commonly encountered assumption that it originates in the anterior horn cell body is not supported by the available evidence, which points to a more distal origin in the intramus- cular nerve terminals. In addition, denervation of muscle fibers may lead to nerve fibre sprouting (axonal and collateral) and enlargement of motor units which makes fasciculations more obvious clinically. Fasciculations may be seen in: Motor neurone disease with lower motor neurone involvement (i. Fasciculations may need to be distinguish from myokymia or neuromyotonia. Journal of the Neurological Sciences 1997; 152 (suppl1): S43-S48 Layzer RB. Muscle Nerve 1994; 17: 1243-1249 - 120 - Fatigue F Cross References Calf hypertrophy; Cramp; Fibrillation; Lower motor neurone (LMN) syndrome; Myokymia; Neuromyotonia Fast Micrographia In “fast” micrographia, written letters are microscopic from the outset, sometimes approximating to a straight line, though produced at nor- mal speed without fatigue. This pattern has been observed in progres- sive supranuclear palsy and with globus pallidus lesions, and contrasts with the “slow” micrographia, writing becoming progressively slower and smaller, seen in idiopathic Parkinson’s disease. Journal of Neurology, Neurosurgery and Psychiatry 2002; 72: 135 (abstract) Cross References Micrographia Fatigue The term fatigue may be used in different contexts to refer to both a sign and a symptom. The sign of fatigue, also known as peripheral fatigue, consists of a reduction in muscle strength with repeated muscular contraction.

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As soon as I get on the bike in the morning generic 400mg flagyl mastercard, hey buy flagyl 500mg fast delivery, all the stiffness is gone purchase 500 mg flagyl mastercard. Certainly, chiropractic has long received professional recognition, but other alternative therapies still remain outside the Western medical mainstream, including herbal thera- pies, acupuncture, homeopathy, megavitamins, energy healing, prayer, massage, and faith healing. Roughly 40 percent of Americans say they use some type of alternative therapy, with numbers of visits exceeding en- counters with primary care physicians (Eisenberg et al. People with physical disabilities are much more likely than others to report using alternative therapies, especially to treat pain, depression, anxiety, insom- nia, and headache (Krauss et al. I asked every person whether they use or have used alternative or com- plementary therapies, such as acupuncture, chiropractic, herbal medicine, or massage. I’ve often wondered about acupuncture, but when I think of needles, I freeze up, and I don’t know many people who’ve used it. Walter Masterson has tried various alternative therapies: I’m getting massage now. A couple of years ago, the thought of seeing an acupuncturist would have been ludicrous to me. But at the end of the session, there was a sense of internal cleanness in my legs which impressed me. But when there’s no cure, it’s really impossible to say that something has no impact. I stopped going when it became apparent to me that it wasn’t going to make this go away. They tasted terrible, but I stuck with it for a couple of months just to see what impact it would have. Monkey arm, quite literally—probably about an inch and a half of monkey arm chopped up into five or six pieces. Lillian Lowell, in her late seventies, has a thick thatch of white hair and alert, inquisitive eyes. Her tiny house is neat as a pin, the living room filled with glass animals—cats, dogs, penguins. I started acupuncture shortly after I started hurting, and that worked beautifully for a year. It was very relaxing, very fun, and that kept me going for at least a year before I really thought of an op- eration. He told me it was os- teoarthritis and the cartilage was degenerating, the bones rubbing against each other—he described it fairly callously. My internist said, ‘Anything that’s good therapy for you is good therapy. She tried sev- Physical and Occupational Therapy / 179 eral practitioners, but “I wasn’t getting the same results from the acupunc- ture—the nice relaxed feeling. At that point, I realized I was starting to take over my own medical care. I was feeling guilty about going to see a chiropractor because it was an alternative medicine. So I didn’t even tell my primary care doctor”—the physician who had referred me to this woman. Some people try techniques, such as massage or prayer, they do not nec- essarily see as formal interventions. Lester Goodall is “still exploring the school where it’s mind over matter. I put my hands like this here,” Lester held both hands out straight in front of him, “and I try to communicate with my immune system. They now say the immune system,” which might affect MS, “is controlled by the brain.

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The etiology of absence epilepsy is unclear cheap 200 mg flagyl mastercard, but may involve abnormal oscilla- tory rhythms in the GABAB and T-type calcium channels of the thalamus generic flagyl 400mg with amex. DIAGNOSIS Childhood absence seizure onset is generally between 5 and 10 years and can fre- quently occur as a staring spell purchase 500mg flagyl visa, loss of awareness, or unconsciousness interpreted by observers as daydreaming (Table 1). The most typical presentation is a blank expression or stare for up to several seconds. Absence seizures can be sometimes mis- diagnosed as attention deficit disorder syndrome since these events are frequent and usually noticed by the teacher. Some mild tonic movements such as eye blinking and automatisms (semipurposeful behaviors) with involuntary movements can be seen. Autonomic symptoms such as pupil dilatation, flushing, incontinence, and diaphoresis can occur. Ninety percent of children outgrow their absences within 2–5 years, often at puberty. Juvenile absence epilepsy presents typically at an older age (age 7–16) and generalized tonic–clonic seizures are frequently the presenting symptom, as opposed to childhood absence in which the larger convulsions are rare. Automatism components with invo- luntary movements and visual hallucinations occur similarly to childhood absence. Specific duration of treatment is vari- able; average age of cessation is 10. Other seizure types such as myoclonic, tonic, and generalized tonic–clonic are frequent. Seizures are typically much more difficult to control, and may be resistant to anticonvulsants. EVALUATION In suspected typical childhood absences, hyperventilation will help and provoke the absences in the office setting. The classic EEG pattern is generalized 3 Hz spike and slow-wave complexes (Fig. On occasions some slowing can occur, but intermittent delta with sharp activity is rare. Clinically, during a several second burst of 3 Hz spike-wave discharges, the child will typically have a brief alteration in consciousness. In juvenile absence epilepsy, the EEG will show mild background slowing with occipital intermittent rhythmic delta activity. TREATMENT Because of the recurrent seizures (of which many are not noticed by family or teachers), in the majority of children of school age, treatment is usually beneficial and outweighs risks of anticonvulsants. In juvenile absence epilepsy, the risk of generalized tonic–clonic seizures often influences strongly the decision to treat. Making the correct diagnosis early can be invaluable as several medications such as carbama- zepine, gabapentin, vigabatrin, and tiagabine can make absence epilepsy significantly worse if attempted. First-line medications for absence seizures are either ethosuximide (Zaron- TM TM tin ) or valproic acid (Depakote ), with an approximately 70% chance of either seizure freedom or a dramatic reduction. Ethosuximide is initiated in doses of 10–20 mg=kg=day but may be increased to 30 mg=kg=day as needed. Although the half-life of ethosuximide is prolonged, due to possible nausea and gastrointestinal upset, a divided dose twice per day is suggested. Other rare side effects include lupus erythematous, rash and Steven Johnson Syndrome, thyroiditis, and aplastic anemia (recurrent blood work is indicated). TM TM Valproic acid (Depakote or Depakene ) may be a better choice for juvenile absence epilepsy due to its protective effects against generalized tonic–clonic seizures (not typically seen with childhood absence). Valproic acid is started at 5–10 mg= kg=day, divided twice to three times per day, increasing weekly to 20–30 mg=kg= day. It is available as 125, 250, and 500 mg tablets (including 250 and 500 mg extended 3 release formulations), 125 mg sprinkle capsules, and 250 mg=5cm syrup. Blood levels as high as 130 mg=dL are well tolerated and may be necessary for seizure control. Dose-related side effects include rare hepatic dysfunction, thrombocytopenia pancrea- tic involvement, and bone marrow suppression. These rare side effects can be life threatening and repeated blood work is necessary. Other medication options do exist should ethosuximide and valproic acid TM prove unsuccessful.

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In introducing such a ● Fetal maceration proposal flagyl 400 mg on line, it is essential to ensure that death is not erroneously In these groups purchase flagyl 250 mg without prescription, death can be recognised by the clinical diagnosed and a potential survivor is denied resuscitation purchase 200 mg flagyl visa. In addition, (CPR), for more than 20 minutes in a normothermic patient a further group of patients with terminal illness should not be ● Patients who have received no resuscitation for at least 15 resuscitated when the wishes of the patient and doctor have minutes after collapse and who have no pulse or respiratory effort on arrival of the ambulance personnel been made clear. Timings must be accurate No instances have been recorded of patients surviving with In all these cases, the ECG record must be free from artefact the conditions listed in group A, nor of adults who have been and show asystole. There must be no positive history of sedative, submersed for over three hours. Authorities are agreed that it is hypnotic, anxiolytic, opiate, or anaesthetic drugs in the totally inappropriate to commence resuscitation in these preceding 24 hours circumstances. The futility of CPR in patients with mortal Group C—Terminal illness trauma has been highlighted in several publications. Cases of terminal illness when the doctor has given clear The concept of a “Do Not Resuscitate” policy has received instructions that the patient is not for resuscitation international support for patients with terminal illness whose condition has been recently reviewed by the family doctor, in consultation with the relatives and patient where appropriate. Issues in training A study of 1461 patients found that when persistent ventricular fibrillation was excluded, all survivors had a return of Use of the recently dead for practical skills training spontaneous circulation within 20 minutes. No patient survived Opportunities for hands-on training in the practical skills required for resuscitation are limited. In another group of intubation cannot be taught to everyone attending a cardiac 1068 patients who experienced out-of-hospital cardiac arrest, arrest. Although the laryngeal mask may offer an alternative only three survived among those who were transported to option for airway management in the short term, the hospital with ongoing CPR. Those three survivors were introduction of that device on a widespread scale into discharged from hospital with moderate to severe cerebral anaesthetic practice has, in itself, reduced the opportunities for disability. These findings support the proposal that death may training in the anaesthetic room. Manikin training offers an alternative, but most would agree that training on patients is be recognised in normothermic patients who have had a period required to amplify manikin experience. Informed collapse to the arrival of ambulance personnel exceeds consent is difficult to obtain at the sensitive and emotional time 15 minutes, provided that no attempt at CPR has been made in of bereavement, and approaches to relatives may be construed as coercion. Proceeding without consent may be considered as that time interval and the ECG has shown an unshockable assault. This recommendation is supported by a review of 414 The dilemma does not stop with tracheal intubation, and other patients who had not received any CPR in the 15 or more techniques, such as fibre optic intubation, central venous access, minutes to ambulance arrival. No patient survived who had a surgical cut-down venous access, chest drain insertion, and non-shockable rhythm when the first ECG was recorded. This resulted in an algorithm for ambulance personnel 105 ABC of Resuscitation encountering death in these conditions, which has been The involvement of relatives and close friends accepted by the Professional Advisory Group of the Scottish Ambulance Service and the Central Legal Office to the Bystanders should be encouraged to undertake immediate basic life support in the event of cardiorespiratory arrest. Traditionally, The validity of the proposed guidelines depends on the relatives have been escorted away from the victim when the accurate diagnosis being cardiac arrest within the first 15 or so healthcare professionals arrive. The Resuscitation unsupported arrest could be less—perhaps much less—than Council (UK) has confirmed the need to identify and respect 15 minutes. In these circumstances, resuscitation could possibly relatives’ wishes to remain with the victim. Clearly, care and consideration of the relative in these stressful situations become still be successful. When the 15 minute asystole guideline has of increasing concern as the invasive nature of the resuscitation been used in the United States, however, this concern has attempt escalates from basic life support, to defibrillation and proved to be unfounded. These must be disseminated throughout the service and to all other concerned groups. Legal aspects Doctors, nurses, and paramedical staff functioning in their official capacity have an obligation to perform CPR when medically indicated and in the absence of a “Do Not Further reading Resuscitate” decision. The emergency services must avoid such 1 complications in unconscious patients by being aware of the 2 3 possibility of spinal cord injury from the nature of the accident, 4 and in conscious patients by suspecting the diagnosis from the 5 6 history and basic examination.

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She could walk down the stairs to catch her subway discount flagyl 400mg mastercard, but what about someone using a wheelchair? Although the 10 percent of adults reporting mobility difficulties re- mains a minority 200mg flagyl with mastercard, it is a large minority—a group anyone can join at any time and which many will in the future discount flagyl 250mg with visa. The good news is that ways to re- store mobility exist, even in a mechanized form. The bad news is that the Final Thoughts / 271 elevators at subway stations often don’t work—the quintessential symbol of needless societal barriers. For many, health and other policies, public and private, still impede their way. In the future, I hope that members of my rolling focus group won’t have to ask my advice—that they’ll already know how to get what they need. His boss had already jokingly sug- gested he affix a cowcatcher to the front of his scooter to scoop up wayward pedestrians. Exhaustion had enveloped Gerald at our first encounter: now he was a man transformed. Yet I cite some people much more than others, and they become familiar voices, recurring across chapters. Here, I intersperse additional descriptions of several key interviewees with shorter sketches of others I frequently quote, listing them alphabetically but changing small details about their lives to pro- tect their anonymity. Arnis Balodis Early sixties; white; never married; high-school education; retired from diverse jobs, including security guard; low income; amputations below the knees of both legs because of diabetes-related gangrene; walked with one or two canes. Several years after our interview, Arnis died suddenly from a heart problem, shortly after his mother’s death. Bernadine is in his late fifties and white, with a graduate degree in busi- ness. He had worked as the manager of a law practice before being fired from his job in the early 1990s after being diagnosed with MS. His wife works and their income is good; they live in a comfortable Boston suburb. After losing his job, he taught part-time at a local university, where I went for both of our inter- views. He is deeply religious and feels that his MS has been, in many ways, a blessing. His MS is pro- gressing, and he now needs a brace for both legs (previously, he used only one brace). Bernadine can no longer operate his car with foot ped- als, so he has installed hand controls—also something to learn. He still loves 273 274 / Appendix 1 his bright red scooter, which had become encrusted with tree pollen from his springtime walks. Bernadine was planning to hire a neighbor- hood boy to give his scooter a wash and a shine. Mike Campbell Mid sixties; white; married to Betty, with several grown children and grand- children; high-school education; retired from building maintenance; low in- come; arthritis from degenerative joint disease, had each knee replaced; used cane when in pain. Long-standing dia- betes mellitus had made her almost blind and forced amputation of all five toes on one foot and three on the other; and she had had bilateral congenital hip dis- placements requiring surgical repair. When I went to find her, she was sitting in a chair in the lobby, her manual wheelchair by her side, its seat loaded with parcels. Carter walked slowly pushing her wheelchair, refusing our offer to push her. During the in- terview, Lonnie didn’t want to sit in her wheelchair—no surprise! One of Lonnie’s eyes bore the opalescent blue of blindness behind thick glasses, but we main- tained eye contact during the entire interview, she fixing me somewhat skepti- cally with her remaining eye. Most of her teeth were missing, and her hair had receded like a man’s, the remainder a grizzled gray. She wore round-toed, clay- colored orthopedic shoes, her legs encased in gray support hose. She also worked part-time in various jobs, including as an advocate for minorities with disabilities.

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