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Addition of agents to enhance specific cognitive and physical functions – In patients emerging out of coma or VS 0.25 mg dostinex otc, the recovery process may be (theoretically) hastened through the use of pharmacotherapy – Agents frequently used include: Methylphenidate Dextroamphetamine Dopamine agonists (levocarbidopa and carbidopa) Amantadine Bromocriptine Antidepressants—tricyclic antidepressants (TCA’s) & selective serotonin reuptake inhibitors (SSRIs) – The efficacy of pharmacologic therapy to enhance cognitive function has not been proven Sensory stimulation—widely used despite little evidence of efficacy as previously mentioned purchase dostinex 0.25 mg. A Decerebrate Posture: There is extension of the upper and lower extremities purchase 0.25 mg dostinex free shipping. B Decorticate Posture: There is flexion of the upper extremities and extension of the lower limbs dostinex 0.5mg without a prescription. PREDICTORS OF OUTCOME AFTER TBI WIDELY USED INDICATORS OF SEVERITY IN ACUTE TBI The best Glasgow Coma Scale (GCS) score within 24 hours of injury Length of coma Duration of posttraumatic amnesia (PTA) – Note: The initial GCS and the worst GCS (within the first 24 hours) have also been pro- posed as acute indicators of severity in TBI 56 TRAUMATIC BRAIN INJURY Glasgow Coma Scale TABLE 2–1 Glasgow Coma Scale: (Teasdate and Jennett generic dostinex 0.25 mg with mastercard, 1974) Best Motor Response Best Verbal Response Eye Opening Score 6 5 4 1 None None None 2 Decerebrate posturing Mutters unintelligible Opens eyes to pain (extension) to pain sounds 3 Decorticate posturing Says inappropriate Opens eyes to loud (flexion) to pain words voice (verbal commands) 4 Withdraws limb from Able to converse— Opens eyes painful stimulus confused spontaneously 5 Localizes pain/pushes Able to converse—alert away noxious stimulus and oriented (examiner) 6 Obeys verbal commands Total GCS score is obtained from adding the scores of all three categories. Katz and Alexander (1994)—PTA correlates with Glasgow Outcome Scale (GOS) score at 6 and 12 months— predictor of outcome PTA correlates strongly with length of coma (and with GOS—see below) in patients with DAI but poorly in patients with primarily focal brain injuries (contusions) Galveston Orientation and Amnesia Test (GOAT)—developed by Harvey Levin and colleagues, is a standard technique for assessing PTA. It is a brief, structured interview that quantifies the patient’s orientation and recall of recent events – The GOAT includes assessment of orientation to person, place, and time, recall of the cir- cumstances of the hospitalization, and the last preinjury and first postinjury memories – The GOAT score can range from 0 to 100, with a score of 75 or better defined as normal – The end of PTA can be defined as the date when the patient scores 75 or higher in the GOAT for two consecutive days. The period of PTA is defined as the number of days beginning at the end of the coma to the time the patient attains the first of two succes- sive GOAT scores ≥ 75 (Ellenberg, 1996) Categories of PTA: Duration of PTA is often used to categorize severity of injury according to the following criteria: TABLE 2–2. Posttraumatic Amnesia Duration of PTA Severity of Injury Category Less than 5 minutes Very mild 5–60 minutes Mild 1–24 hours Moderate 1–7 days Severe 1–4 weeks Very severe Greater than 4 weeks Extremely severe TABLE 2–3. Classification of Posttraumatic Amnesia Length of PTA Likely Outcome 1 day or less Expect quick and full recovery with appropriate management (a few may show persisting disability) More than 1 day, Recovery period more prolonged—now a matter of weeks or months. Many patients are left with residual problems even after the recovery process has ended, but one can be reason- ably optimistic about functional recovery with good management. There must be increasing pessimism about functional recovery when PTA reaches these lengths. More than 4 weeks Permanent deficits, indeed significant disability, now certain. It is not just a matter of recovery but of long-term retraining and management. From Brooks DN and McKinlay WW, Evidence and Quantification in Head Injury: Seminar notes. In this study, the sign of responsiveness used was evidence of the patient following commands Other Indicators of Outcome after TBI Include: Age – Children and young adults tend to have a generally more positive prognosis than older adults. However, young children (< 5 yrs) and older adults (> 65 yrs) have greater mor- tality – Katz and Alexander (1994): Age ≥ 40 correlates with worse functional outcome when compared with patients < 40 Rate of early recovery reflected in serial disability rating scales (DRS): found to be predic- tive of final outcome Pupillary reaction to light: – 50% of patients with reactive pupils after TBI achieve moderate disability to good recovery (in DRS scale) vs 4% with nonreactive pupils Time – Most recovery usually occurs within the first 6 months postinjury Postcoma use of phenytoin: – Long-term use of phenytoin has been reported to have adverse cognitive effects (neu- robehavioral effects in severe TBI patients compared to placebo group) HEAD INJURY PREDICTOR SCALES AND TESTING Prognosis in Severe Head Injury TABLE 2–4 Predicative Indicator Poorer Better Glasgow Coma Scale score < 7 > 7 CT scan Large blood clot; massive Normal bihemispheric swelling Age Old age Youth Pupillary light reflex Pupils remain dilated Pupil contracts Doll’s eye sign Impaired Intact Caloric testing with ice water Eyes do not deviate Eyes deviate to irrigated side Motor response to noxious Decerebrate rigidity Localizes defensive gestures stimuli Somatosensory evoked potentials Deficient Normal Posttraumatic amnesia length > 2 wks < 2 wks (Reprinted with permission from Braddom, RL. Absent awareness of self and environment; patient may open eyes; absence of cortical function as judged behaviorally; characterized by the presence of sleep-wake cycles 3 Severe disability Patient unable to be independent for any 24-hour period by reason of residual mental and/or physical disability 4 Moderate disability Patient with residual deficits that do not prevent independent daily life; patient can travel by public transport and work in a sheltered environment 5 Good recovery Return to normal life; there may be minor or no residual deficits Widely used scale; documented correlation between acute predictors of outcome and GOS score at 6 months and 12 months Cons: – In the GOS, categories are broad; scale not sensitive enough – Not real indicator of functional abilities (Continued) 60 TRAUMATIC BRAIN INJURY Disability Rating Scale (DRS) TABLE 2–6 1. Motor Response 0 Spontaneous 0 Oriented 0 Obeying 1 To Speech 1 Confused 1 Localizing 2 To Pain 2 Inappropriate 2 Withdrawing 3 None 3 Incomprehensible 3 Flexing 4 None 4 Extending 5 None 4. Employability *Note: measuring cognitive skills only in these categories. The change as a percentage of total score was greater for the CRS than for the GCS or DRS (Horn and Zasler 1996) Neuropsychological Testing Prior to the development of the CT Scan, neuropsychological assessment was targeted at determining whether a brain lesion was or was not present, and, if present, discerning its location and type This diagnostic approach supported the development of the Halstead-Reitan Neuropsychological Battery (HRNB). This battery was initially designed to assess frontal-lobe disorders by W. Halstead (1947) and subsequently used by Reitan (1970 1974), who added some tests and recommended its use as a diagnostic test for all kinds of brain damage. Most examiners administer this battery in conjunction with the WAIS-R (Wechsler Adult Intelligence Scale—Revised) and WMS (Wechsler Memory Scale) or the Minnesota Multiphasic Personality Inventory (MMPI) Wechsler Adult Intelligence Scale—Revised (WAIS-R): eleven subtests (6 determine verbal IQ and 5 determine performance IQ), WAIS-R is the most frequently used measure of general intellectual ability. It is the most widely and thoroughly researched objective measure of personality. MEDICAL COMPLICATIONS AFTER TBI Posttraumatic Hydrocephalus (PTH) Ventriculomegaly (ventricular dilation) is common after TBI , reported in 40%–72% of patients after severe TBI. It should remain > 60 mmHg to ensure cerebral blood flow CPP = MAP—ICP Fever, hyperglycemia, hyponatremia, and seizures can worsen cerebral edema by ↑ ICP Indications for Continuous Monitoring of Intracranial Pressure and for Artificial Ventilation 1. Patient in coma (GCS < 8) and with CT findings of ↑ ICP (absence of third ventricle and CSF cisterns) 2. Severe chest and facial injuries and moderate/severe head injury (GCS < 12) 4. After evacuation of IC hemorrhage if patient is in coma (GCS < 8) beforehand Factors that May Increase ICP Turning head, especially to left side if patient is completely horizontal or head down Loud noise Vigorous physical therapy Chest PT Suctioning Elevated blood pressure Methods Used to Monitor ICP Papilledema: papilledema is rare in the acute stage after brain injury, despite the fact that ↑ ICP is frequent – Usually occurs bilaterally – May indicate presence of intracranial mass lesion – Develops within 12 to 24 hours in cases of brain trauma and hemorrhage, but, if pro- nounced, it usually signifies brain tumor or abscess, i.

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The long period of holding allows time for the client to address internal thoughts as they arise buy dostinex 0.25mg fast delivery. The spasm of the muscles is often painful and this condition may be caused by a birth injury to the sternocleidomastoid muscle generic 0.5mg dostinex with mastercard. The method of treatment requires a second person who per- forms muscle testing cheap dostinex 0.25 mg with visa. Touch Research Institute: A facility at Miami University in Florida dedicated to studying the effects of touch therapy cheap dostinex 0.5mg with mastercard. Trager: An approach to bodywork developed in the 1920s by American medical practitioner Dr order dostinex 0.5mg with amex. It makes extensive use of touch-contact and encourages the client to experience the freeing-up of different parts of the body. A procedure in which electrodes are placed on the surface of the skin over specific nerves and electrical stimula- tion is done in a manner that is thought to improve CNS function, reduce spasticity, and control pain. TIAs have many symptoms, such as dizziness, weakness, numbness, or paralysis of a limb or half of the body. TIA may last only a few minutes or up to 24 hours, but does not have any persistent neurologic deficits. A transudate, in contrast to an exudate, is characterized by high fluidity and a low content of protein, cells, or solid materials derived from cells. An insult to the brain caused by an exter- nal physical force, that may produce a diminished or altered state of consciousness, which results in impair- ment of cognitive abilities or physical functioning. Application of or involvement in activities/ stimulation to effect improvement in abilities for self- directed activities, self-care, or maintenance of the home. If sufficiently hypersensitive the trigger point causes referred pain and sensitivity. Type A behavior: A cluster of personality traits that includes high achievement motivation, drive, and a fast-paced lifestyle. Type B behavior: A cluster of personality traits that include low achievement motivation, laziness, and a laid-back sort of lifestyle. Associated with inactivity, lack of exercise, and sedentary-related diseases, such U ulcer: An open sore on the skin or some mucous mem- brane characterized by the disintegration of tissue and, often, the discharge of serous drainage. Pulsed ultrasound: The application of therapeutic ultrasound using predetermined interrupted frequencies. Universal Calibration Matrix (UCL): The UCL forms part of the energy anatomy of a human being. The practitioner uses their hand and finger sensitivity to react to the changes created by their presence thus hav- ing a lasting effect on even the deepest tissues. V valgus: A limb deformity in which the extremity is moved away (laterally) from the midline. Massage therapy is contraindicated over varicose veins due to the possibility of breaking loose a blood clot. An agent that stim- ulates the contraction of the muscular tissue of the cap- illaries and arteries. Mechanical ventilation is the use of equip- ment to circulate oxygen to the respiratory system. The muscles include the diaphragm; the intercostal, scalene, and sternocleidomastoid muscles; accessory muscles of ventilation; and the abdominal, triangular, and quadratus lumborum muscles. Interpreting stimuli regarding head position and movement based on the shift of fluid and inner ear receptors. Sixteen basic techniques that align, loosen, and connect the body restoring the body to the liquid process appropriate to it. Interpreting stimuli through the eyes, including peripheral vision and acuity. Distinct from deficits in functional visual skills and tested separately. Maturity is reached when occupational activities are aligned with what is expected of the corresponding age group. The phalangeal joint should be slightly flexed, thus enabling this type of splint con- struction to prevent stiffening of the phalangeal joints in extension. Volkmann’s contracture: Permanent contracture of a muscle due to replacement of destroyed muscle cells with fibrous tissue that lacks the ability to stretch. Destruction of muscle cells may occur from interference with circulation caused by a tight bandage, splint, or cast.

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In this way buy 0.25 mg dostinex, the junior researcher receives the credit deserved 0.25mg dostinex for sale, and this buy dostinex 0.25 mg amex, in turn dostinex 0.25mg with visa, can help to ease them gently into the system and to foster their reputation order dostinex 0.25 mg without prescription. As a reviewer, you can contact the editor at any time to request information about the progress of a paper. Once a decision has been made about publication, many journals send a copy of the reply to the authors and copies of all reviewers’ comments to each reviewer. Some journals may ask you to write an editorial, leading paper, or comment for the same edition in which the paper will appear. This brings a bonus of an immediate and ensured publication on a current hot topic. Writing review comments As an editor, David [David Sharp, former editor of Lancet] worked on all sections of the Lancet. He believed in plain language … As a teacher, he had exacting standards. Many an overconfident doctor arrived at the Lancet sure that aptitude with a scalpel 140 Review and editorial processes rendered the pen a trivial challenge, only to be shown the true meaning of humility. Richard Horton21 Being a good reviewer is something that experts, or experts in training, are automatically expected to know how to do. Once you have established your research reputation, you will be asked to review papers that fall within your own area of expertise. The journal editor may give you some ideas of what to be on the look out for, will ask you to rank the quality of the paper in various ways, or may even send you a checklist. You may be asked to rank your feedback under general comments, or under comments that recommend major or minor revisions. You must ensure that your comments are listed on the comment summary sheets and your ratings on the rating summary sheets. Writing comments on the pages of the paper is not useful since most editors will not want to inspect every page of every copy that they send out for review22 and they do not send marked-up copies back to the authors. As a reviewer, you can make general comments about style but do not need to address specific problems with punctuation, grammar, spelling, etc. These problems will be addressed by the editor in deciding whether to accept the paper and by the copy editors when typesetting the paper. It is important that external reviewers treat these issues sensitively especially for authors who are from a non-English speaking background. Nevertheless, you will need to take a general overview of the presentation, the spelling, and the grammar, since this will give you some insight as to whether the writer has paid attention to detail and whether the paper can be made interesting and readable if the writing is improved. Lack of attention to detail is not a good quality in scientific research. Most of your review comments should deal with the more substantive issues of content, science, and interpretation. If you are unsure whether the statistics are sound, you can ask 141 Scientific Writing the editor to call a biostatistician into the process. Although your review will be anonymous, you should write as though you were being made known to the authors. Remember also that most editors maintain databases of the style, reliability, and judgements of their reviewers. If you want a respected position on the database, you will need to write critical responses that are polite, considered, and helpful to both the editor and the authors. Some examples of the types of comments made by reviewers are shown in Box 5. In all review comments, it helps to state the problem as you perceive it and a possible solution. It also helps to number your comments so that the authors can make it clear how they have responded to each of them. Finally, you may have the option of giving a short opinion to the editors that is not passed on to the authors. This is the place where you can make cryptic comments about the quality of the paper that would be too blunt to send to the authors.

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