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Given that balance between severity of the dys- phagia and the child’s compensatory mechanisms determines the impact of the dys- function purchase nexium 20 mg with mastercard, the primary goals of dysphagia interventions are to correct or control treatable etiologies nexium 20mg online, and avoid or minimize the consequences of the swallowing Dysphagia 221 Figure 1 Feeding=swallowing problems or clinical presentations suggestive of dysphagia generic 20 mg nexium visa. Medical or surgical management may be appropriate for some inflammatory conditions (e purchase nexium 20mg line. For some children buy nexium 20 mg free shipping, management approaches may lessen the impact of the swallowing dysfunction by focussing on nutrition, GER, behavioral, or oral-motor and swallowing therapies. Interventions may include modifications in feed- ing routine or diet, and the introduction or adjustment of medications (e. Early initiation of nutritional support is critical and results in the greatest reversal of nutritional deficits in children with central nervous system insults and poor growth. Oral-motor and swallowing therapies may include changes in texture, utensils, position, posture, or pacing of feeding, and the introduction of activities that strengthen swallowing musculature or support developmentally appropriate move- ment patterns for feeding and swallowing. Older children may benefit from direct therapies and the use of compensatory techniques to increase the safety and effi- ciency of swallowing. Adjustments in therapeutic goals and interventions need to parallel improvement or regression in the underlying condition. Although some children are unable to feed orally because it is unsafe or too difficult, current evidence indicates swallowing is the best exercise for swallowing. Consequently, regardless of whether children are oral or nonoral feeders, oral-motor and swallowing therapies may facilitate the production of swallows, which in turn may promote handling of secretions. Additionally, since oral=dental disease appears to contribute to lung infections in older individuals with dysphagia, it is reasonable 222 Lefton-Greif to incorporate oral hygiene into intervention programs for all children with feeding and swallowing problems. The progression or anticipated course of the underlying etiology will influence decisions for nutritional management. For example, neurogenic dysphagia second- ary to an acute condition with anticipated recovery (e. Whereas a nasogastric tube may be appropriate for short-term nutritional and aspiration concerns, a gastrostomy tube (GT) (or percutaneous gas- trostomy [PEG]) may be more appropriate for long-term issues. Objective markers to distinguish between short- and long-term supplemental nutritional needs are not available; however, three or more months of anticipated supplemental feeding needs may constitute an appropriate time interval for making recommendations for GT placement in children without medical contraindications. When clinicians counsel caregivers about placement of long-term feeding tubes, families frequently want to know how long GTs will be needed. Families need to be told that feeding tubes will be removed when underlying conditions have been corrected or resolved, or when children are able to compensate for swallowing dysfunction without com- promising their general health and overall well being. Clinical experience indicates that many infants and young children with acute or static conditions improve with prompt initiation of appropriate interventions and time, and thereby, lessen or elim- inate the need for tube feedings. Caregivers should be reassured that although many families struggle with initial decisions about whether to place GTs, following GT placement, 90% of caregivers report that tube feedings have improved the quality of life for their children and the family. SUMMARY Oropharyngeal dysphagia is common in children with neurologic diseases. The underlying condition determines the nature and extent of the swallowing dysfunc- tion, and governs the prognosis for recovery. Early detection of the problem and prompt initiation of appropriate interventions are necessary for improving outcomes for these children and their caregivers. Swallowing disorders in severe brain injury: risk factors affecting return to oral intake. Sanders KD, Cox K, Cannon R, Blanchard D, Pitcher J, Papathakis P, Varella L, Maughan R. Diagnosis and treat- ment of feeding disorders in children with developmental disabilities. Living with cerebral palsy and tube feeding: a popula- tion-based follow-up study. Migraine is a common childhood disorder characterized by recurrent headaches. Most children with migraine are symptom free between episodic headache attacks. Headache frequency and severity increase over time for a subset of pediatric migra- neurs. Chronic migraine headache, transformed migraine, chronic nonprogressive headache, and chronic daily headache probably represent a spectrum of migraine headache syndromes.

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If you are consistently going over time discount nexium 40mg on line, you need to identify ways of speeding up: 190 WRITING SKILLS IN PRACTICE ° Can you be more concise in the way that you express yourself? Work towards analysing the title discount nexium 40 mg online, drafting a plan and writing an answer within the set time period buy cheap nexium 40 mg online. In the exam Read the paper Take time to read through the questions on your paper at the start of the exam discount 20 mg nexium free shipping. Failure to comply with these directions is likely to lead to a reduced grade or a fail buy generic nexium 40 mg on-line. For example, a fellow student failed an exam when he an­ swered all five questions from the paper. He had less time to answer each question and lost the chance to choose the best ones for him. An examiner in this situation will only mark the first three questions on the student’s paper. Write a plan Always make a rough plan on how you will answer the question. In fact a good plan will save you time and will make sure that you: ° understand what the question is asking ° plan your time effectively ° remember to include all the key points ° have a clear structure ° save on thinking time later, allowing you to just write your answer. Demonstrate your knowledge Writing coursework will have helped prepare you for answering essay questions in an exam. You will still be expected to demonstrate to the examiner the extent of your reading about the subject matter. This will partly be apparent from the range of views and theories you are able to discuss. It will also be demonstrated by your reference to other sources in your answer. You are not usually expected to give a reference list at the end of your answer. Write clearly Exams are handwritten and as students are under pressure to complete the answers as quickly as possible, legibility often suffers. Although you should not slow yourself down by trying to write as neatly as possible, it is still important that the marker can decipher your scribbles. Someone marking around 200 papers will not want to spend ten minutes trying to work out individ­ ual letters and words. Illegible work is likely to be unmarked, meaning you will lose precious points. Astute editing will also help improve the quality and accuracy of your work. Emergency solutions Sometimes plans go astray and you will need to take emergency action: ° Running out of time – jot down, in note form, the points that would have completed your essay. Indicate you know that the information is from another source by using a general reference like ‘researchers have found’. For example, if you have forgotten the side effects of a drug, describe how you would find them out. Summary Points ° Summative assessments are set at the end of a study unit, term or academic year. It is distinguished from other essays submitted as coursework by its length and detailed treatment of its subject. Each student will make their own choice of topic, unlike set essays where all the students answer the same question. The content of the dissertation will represent the student’s independent study of the subject matter, and will extend beyond the theory and practical applications for­ merly taught on the course. Writing a dissertation provides the student with an opportunity to: ° study in depth one particular aspect of a subject ° learn the process of academic enquiry ° develop his or her thinking about a specific subject ° deal with a large amount of information ° be able to express ideas coherently ° sustain a discourse throughout a lengthy composition. Choosing a title Unlike set essays, where the question is chosen by the examiner, the stu­ dent decides on the title for his or her dissertation. Although this is often the most challenging part of the task, it is important to get it right as it will shape both the structure and content of the essay. For instance, some courses con­ tain advanced study units that involve the completion of a dissertation – so if you are studying ethics, your dissertation will be about some aspect of this.

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We believe it is important for children and parents to participate in a network of other families in order to better understand the problems and solutions that may arise buy generic nexium 40 mg. THE FUTURE Improvement in care for patients with RS lies along many avenues discount 40mg nexium. Certainly generic nexium 20mg on line, a bet- ter understanding of the pathogenesis will lead to better therapies buy nexium 20 mg with amex. This may include novel strategies such as immunoablation with high-dose cyclophosphamide discount 20 mg nexium mastercard, in which 124 Vining one attempts to eliminate the entire host population of ‘‘sensitized’’ T cells, or the use of other immunosuppressive agents such as tacrolimus. Improved neuroimaging may provide us with additional strategies to assess the impact of therapy. Surgical strategies need constant refining, in order to eliminate the 10–20% of children who appear to be left with residual tissue or ‘‘nondisconnected’’ tissue. Finally, rehabilita- tion must improve with better strategies to improve gait; programs that might involve computer-assisted devices to improve hand and finger function; and finally improved understanding of the cognitive, language, and behavioral problems these children face so that they can function as productive, capable, and happy adults. Bien CG, Bauer J, Deckwerth TL, Wiendl H, Deckert M, Wiestler OD, et al. Destruction of neurons by cytotoxic T cells: a new pathogenic mechanism in Rasmussen’s encephalitis. Improvement in adult-onset Rasmussen’s encephalitis with long-term immunomodulatory therapy. Hemispherectomy for the treatment of epilepsy due to chronic encephalitis. Vining EPG, Freeman JM, Pillas DJ, Uematsu S, Carson BS, Brandt J, et al. The outcome of 58 children after hemispherectomy––The Johns Hopkins Experience 1968–1996. Singer Departments of Neurology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, U. OVERVIEW The Gilles de la Tourette syndrome (TS) is a chronic, inherited neuropsychiatric dis- order characterized by the presence of involuntary motor and phonic tics that wax and wane. Although once considered a rare disorder, the prevalence of TS may be as high as 3. In addition to tics, individuals with TS often have a variety of concomitant psychopathologies including obsessive compulsive dis- order (OCD), attention deficit hyperactivity disorder (ADHD), learning difficulties, and sleep abnormalities. Although the presence of neurobehavioral problems is not required for the diagnosis of TS, their clinical impact on the patient may be more significant than the tics themselves. Tourette syndrome is an inherited disorder (spe- cific gene and mode of inheritance remain unclear), but nongenetic environmental factors can influence tic frequency and severity. Pathophysiologically, tics arise within cortico-striatal-thalamo-cortical pathways and likely represent a dysfunction of synaptic neurotransmission. Diagnosis Formal diagnostic criteria include: (a) onset of symptoms before age 21; (b) the pre- sence of multiple motor and at least one vocal tic (not necessarily concurrently); (c) a waxing and waning course, with tics evolving in a progressive manner; (d) the presence of tic symptoms for at least 1 year; (e) the absence of a precipitating illnesses (e. Tics, the essential component of the syndrome, are manifest in a variety of forms, with different durations and degrees of complexity. Common characteristics of tics include: brief voluntary suppression; exacerbation by anxiety, excitement, anger, or fatigue; reduction during absorbing activities or sleep; and fluctuation over time. Premonitory urges or sensations, such as a tickle, itch, discomfort, or ‘‘feeling,’’ are reported in some TS patients before they make a tic movement or vocalization. Investigators used a mathematical model to assess the time course of tic severity over the first two decades, which suggested that maximum tic severity occurs between the ages of 8 and 12 years and is then followed by a steady decline in symptoms. In a study of 58 teenager=young adults, tics virtually disappeared in 26%, diminished considerably in 46%, remained stable in 14%, and increased in 14%. Early tic severity is not a good predictor of later tic severity, but some authors have suggested that the presence of only mild tics through adolescence was a good indicator of mild tics in adulthood. Nevertheless, even cases with severe tics in childhood had the potential for a good outcome. EVALUATION AND EDUCATION Although approaches to the assessment and treatment of individuals with TS may vary, there are several important steps (Table 1). All patients with tics should be evaluated to assure the proper diagnosis and to eliminate the possibility that tics are secondary to another medical condition. Personal interview of the patient and parent and the use of standardized parent=teacher questionnaires are helpful in iden- tifying the presence of comorbid psychopathology and academic problems.

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