By B. Rasarus. Northern State University. 2018.

Increased awareness among the public of the possibility of successful resuscitation from cardiopulmonary arrest has added to the need to determine the best ways of teaching life-saving skills buy discount inderal 80mg on-line, both to healthcare professionals and to the general public cheap inderal 80 mg fast delivery. In the United Kingdom the Resuscitation Council (UK) has more than 10 years experience of running nationally accredited courses and these have established the benchmarks for best practice buy generic inderal 40 mg on-line. This chapter examines the principles of adult education and their application to the teaching of the knowledge and skills required to undertake resuscitation order inderal 80mg mastercard. Levels of training Medical students practising resuscitation Resuscitation training may be categorised conveniently into four separate levels of attainment: ● Basic life support (BLS) ● BLS with airway adjuncts ● BLS with airway adjuncts plus defibrillation ● Advanced life support (ALS) inderal 80mg discount. BLS This comprises assessment of the patient, maintenance of the airway, provision of expired air ventilation, and support of the circulation by chest compression. It is essential that all healthcare staff who are in contact with patients are trained in BLS and receive regular updates with manikin practice. BLS with airway adjuncts The use of simple mechanical airways and devices that do not pass the oropharnyx is often included within the term BLS. The use of facemasks and shields should be taught to all healthcare workers. Increasingly, first-aiders and the general public also request training in the use of these aids. BLS with airway adjuncts plus defibrillation The use of defibrillators (whether automated or manual) should be taught to all hospital medical staff, especially trained nursing staff working in units in which cardiac arrest occurs often—for example, coronary care units, accident and emergency departments, and intensive therapy units—and to all emergency ambulance crews. Training should also be available to general practitioners, who should be encouraged to own defibrillators. ALS ALS techniques should be taught to all medical and nursing staff who may be required to provide definitive treatment for cardiac arrest patients. They may be members of the hospital Medical students practising BLS resuscitation team or work in areas like the accident and and emergency department or cardiac care unit, where cardiac defibrillation 90 Teaching resuscitation arrests occur most often. The techniques are taught to ambulance paramedics and to general practitioners who wish to acquire these skills. Adults as learners Most resuscitation training courses are designed for adults, and the educational process is very different to that used when teaching children. Adult candidates come to resuscitation courses from widely varying backgrounds and at different stages of their career development. Each individual has their own knowledge, strengths, anxieties, and hopes. Flexibility in the teaching of resuscitation will enable candidates to maximise their learning potential. The previous knowledge and skills of an adult learner greatly influence their potential to acquire new knowledge and skills. Adults attending resuscitation courses have high intrinsic motivation because they recognise the potential application of what they are learning and how they can apply it to the everyday context. The importance of being able to recognise the uniqueness Group learning of each candidate, and to create learning environments that help each individual, remains of the highest importance when teaching resuscitation techniques. This approach is largely accepted as an established principle in higher education and has had a substantial impact on how European resuscitation courses have developed. The question of how medical personnel and others are trained to respond to cardiopulmonary arrest patients is a key issue, but high quality research into the best approach to teaching is lacking. Principles of adult education Although there seems to be a general acceptance that ● Adult learners are likely to be highly current training approaches are well developed and produce a motivated ● They bring a wealth of experience to build high level of learner interaction, satisfaction, and professional upon development, little formal evaluation of courses has been ● Knowledge presented as relevant to their reported to date. These studies are useful in providing ● Instructors should be aware of the needs information about the syllabus and conduct of training but fail and expectations of the adult learner to indicate the strengths and weaknesses of training classes, and it proves difficult to compare one approach with another. Two important questions about the educational process are: ● How does it enable the acquisition of knowledge and skills and help their retention? Teaching adults ● Treat them as adults The process of learning is largely dependent on the individual ● The “self” should not be under threat and the preferred personal approach of that individual towards ● Ensure active participation and self learning. In order to teach adults in an optimal fashion it is evaluation as part of the process important to ensure that this individuality and preferred learning ● Previous experience should be recognised style is considered and provided for, wherever possible. Yet many courses concentrate on only two of these areas, with the emphasis on knowledge and skills. Failing to acknowledge fully attitude and the building of relationships can have a detrimental effect on the outcome of this style of education. Key areas of the resuscitation curriculum ● Knowledge Retention of resuscitation skills ● Skill ● Attitude This subject is one of the most studied areas of healthcare ● Interpersonal relationships provision and several general principles have been established.

As many of the medications used have not been thoroughly studied in childhood order inderal 80mg visa, clinicians should listen carefully to parental=caregiver concerns about any changes in their children after medication initiation purchase inderal 40mg on line. Parents=caregivers will continue to administer medications if they see positive benefits order inderal 80 mg line, which should be an important determinant in clinician decision making with regard to use and dosing order 80 mg inderal with visa. A helpful additional aid is to keep community therapists masked as to onset and dosing of medications inderal 40mg amex, utilizing their opinions as to changes in motor function with medication use=adjustments. ASSOCIATED PROBLEMS While this chapter is primarily directed toward medical management, it is important to recognize that affected children and their families may have a wide range of med- ical, financial, psychosocial, educational, and vocational needs, which may change over time. The identification of a person who can coordinate various aspects of care is of great benefit in overall management. Furthermore, housing accessibility is critical for those children with more severe forms of cerebral palsy, both to optimize independence of the affected child, as well as to limit other impairments such as herniated disks from repeated lifting by caregivers. A practical recommendation is to find a dwelling on one floor, such as a ranch-style home. COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) Families may use complementary alternative medicine, including acupuncture, cra- niosacral therapy, myofascial release, therapeutic taping, diet and herbal remedies, 22 Puscavage and Hoon electrical stimulation, constraint-induced training, chiropractic treatments, massage and hyperbaric oxygen. While there are individual reports of improvements with various alternative therapies, some carry substantial risks. Furthermore, rigorous studies have not been conducted to assess efficacy. Prior to utilizing these therapies, cost, efficacy, and potential side effects should be carefully considered. CONCLUSIONS Despite the wide range of available interventions with demonstrated benefits in individual children, there is currently no clear consensus regarding the nature of optimal therapy(ies), as well as timing and duration of specific interventions (8–11). Further advances in treatment will require controlled trials, matched on etio- logical antecedents and using reliable, valid quantitative measurement systems to assess effectiveness. Singer and Kossoff, the authors acknowledge the thoughtful comments of numerous Kennedy Krieger Institute physicians, clinicians, and thera- pists, including Drs. Michael Johnston, Charles Silberstein, Frank Pidcock, Bruce Shapiro, Eric Levey, and Elaine Stashinko; Ms. This WE MOVE web site offers informa- tion and support for healthcare professionals and others whose lives are affected by pediatric movement disorders. United cerebral palsy (UCP) is the leading source of information on cerebral palsy and is a pivotal advocate for the rights of persons with any disability. As one of the largest health charities in America, UCP’s mission is to advance the independence, productivity, and full citizenship of people with cerebral palsy and other disabilities. The Children’s Hemiplegia and Stroke Association, a non profit organization, offering support and information to families of infants, children, and young adults who have hemiplegia, hemiparesis, hemiple- gic cerebral palsy, childhood stroke, infant stroke, or in utero stroke. This web site is provided for the parents, sib- lings, physicians, and therapists of children born with lissencephaly (smooth brain), and other neuronal migration disorders. Exception Parent magazine’s on-line resource, pro- viding information, support, ideas, encouragement, and outreach for parents and families of children with disabilities, and the professionals who work with them. Neurosurgical treatment of spasticity and other pediatric movement disor- ders. Evidence of the effects of intrathecal baclofen for spastic and dys- tonic cerebral palsy. Diseases of the Nervous System: Clinical Neuroscience and Therapeutic Principles. Hoon AH, Freese PO, Reinhardt EM, Wilson MA, Lawrie WT, Harryman SE, Pidcock FS, Johnston MV. Age dependent beneficial effects of trihexyphenidyl in children with extrapyramidal cerebral palsy. Spasticity associated with cerebral palsy in children: guidelines for the use of botulinum A toxin. Therapeutic choices in the locomotor management of the child with cerebral palsy—more luck than judgement? Qualitative analysis of therapeutic motor interven- tion programmes for children with cerebral palsy: an update. Avellino Division of Pediatric Neurosurgery, Children’s Hospital and Regional Medical Center, University of Washington School of Medicine, Seattle, Washington, U. INTRODUCTION Hydrocephalus is the abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles and subarachnoid spaces.

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By the time she applied buy generic inderal 40mg line, her MS had progressed significantly; with her doctor’s prescription discount inderal 80mg online, the scooter approval process went smoothly inderal 40mg sale. Jones believes that her training as a social worker helped: “It’s being edu- cated in how things work inderal 80 mg mastercard. I always have worked with people who are cowed by the system before they’d even try it inderal 80 mg discount. My partner called them time after time after time because I’d get so angry. In either case, only the educated, sophisticated consumer is likely to succeed. Others will prob- ably be worn down by the process, and many will simply give up. The cyn- ical among us would argue that this is the purpose of the process” (1999, 182). The medical director of a large western health insurer finds that only certain people appeal denials: “Educated people clearly have more technical knowledge and are more assertive than the nontechnical folks. They usually have others state their case— not necessarily a lawyer, but that’s often who it is. Johnny Baker was Erna Dodd’s primary care physician and dreads the time consumed by applying for equipment and appealing denials. Baker, who works in an academic practice with social workers readily available. Winnie Dowd, a physical therapist, finds that sometimes physicians provide inadequate help. She re- called a recent patient: This person had a stroke and really has no use of her right side. She has a manual wheelchair, but she’s getting overuse injuries in her left arm now. She would definitely benefit from an electric wheel- chair, but she has Medicare managed care. This person doesn’t have $10,000 to shell out for an electric wheelchair. Odds are she won’t get it unless her physician and myself and everyone go to bat as hard as we can. The vendor isn’t going to do anything unless they know they’ll get paid. Medicare may say this woman’s in a gray area where she doesn’t need the electric wheelchair for just household distances. Sometimes insurers seem motivated by good intentions, although their decisions run contrary to requests. One midwestern medical director said that he generally refuses scooters and authorizes only four-wheeled power What Will Be Paid For? If you’re going to deal through the insurance company, you don’t do it that way. But I’m going to buy another motorized chair—I’ve got an estimate from the vendor. For this one, I’m going to the insurance com- pany and say I’ve got to have this. The vendor told me that, at the most, my insurance will only cover $1,200 a year for equipment. Jody Farr’s health insurance bought her scooter, charging a 20 percent copayment. Health insurance rarely pays for home renovations and other environ- mental changes, large and small, meant to improve mobility and enhance safety. Medicare, for example, views many mobility-related aids as “per- sonal comfort items” and therefore not reimbursable. It refuses payment for grab bars, seeing them as a “self-help device, not primarily medical in nature,” and for raised toilet seats, labeled a “convenience item; hygienic equipment, not primarily medical in nature” (Pope and Tarlov 1991, 228). According to a 1990 federal survey, people themselves pay for almost 78 percent of home accessibility improvements (LaPlante, Hendershot, and Moss 1992, 9). Treat- ing people who fall will cost insurers much more than grab bars, shower chairs, and raised toilet seats.

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His father buy inderal 80 mg low price, however order inderal 40 mg with amex, insisted that discount inderal 40mg amex, occurred on November 19 40mg inderal, 1939 buy inderal 40 mg on line, after a long, dis- in the family tradition, Guillaume become a 89 Who’s Who in Orthopedics surgeon. As a first step in his training, he was These two were passed over because of their close enrolled in the medical-surgical courses in relationship with Napoleon, and Guillaume Limoges, but after a few months, Dupuytren set Dupuytren became Chirurgien en chef at the out for Paris, where he remained for the rest of Hôtel Dieu at just under 38 years of age. This period corresponds with Terror was over, there was money to be made in the restoration of the monarchy in France after the manufacture and commerce, glory to be grasped Revolution, and the Empire, with the return of in the battlefields. This was also a period of dis- the brother of Louis XVI, King Louis XVIII. He became Chef des Travaux 1824 and was succeeded by his younger brother, Anatomiques (Director of Anatomical Studies) in Charles X; thus Dupuytren immediately became the Medical School in 1801 and the Council of chief surgeon of the new king. For Lisfranc, Dupuytren The Revolution had released a flood of energy and was “the brigand of the Hôtel Dieu”; for Percy in this brilliant era of French medicine, the rising “the greatest of surgeons and the least of men. The Hôtel Dieu was the most Dupuytren at the head of European surgery” important hospital in Paris. Phillippe Joseph Pelletan, with whom Dupuytren Dupuytren’s powers of diagnosis were leg- had unceasing conflicts, which reduced his surgi- endary and the list of his innovations is too long cal activity. For example, in the field of animal experimentation at the school of veteri- orthopedics, he described in 1822 the congenital nary medicine at Maisons-Alfort (which still dislocation of the hip, which he distinguished exists). Dupuytren proved description of fractures of the lower end of the that the spleen could safely be removed and he fibula, for which he devised a splint. He described published, with Dupuy, reports on the nervous, a distortion of the wrist, now called Madelung’s cardiac, circulatory, and cerebral systems and on deformity. He was also the first to perform a the role of the nerves in respiration. In 1812 he resection of the lower jaw, and the first to excise was Professor of Operative Medicine at the the neck of the uterus for cancer. In his thesis on “lithotomy” In 1815, Pelletan was 68 years old and wanted (1812) he gave an anatomical description of the to “organize” his succession at the Hôtel Dieu. He perineal region, layer by layer, which is still a put forward his son Gabriel, who was a surgeon classic. He reported a considerable number of in the Imperial Guard, for the appointment as self-mutilations of the genitalia and took account clinical assistant, but with the passing of the of their determining factors: “self-punishment, Napoleonic era, Pelletan’s position was weak- guilt, jealousy, remorse, expiation, any of these ened. He even noticed the presence of Dupuytren’s name was third on the list, after ulceration of the gastrointestinal tract in severely Boyer and Dubois, his elders by some 20 years. For Garrison (in have of his operations, no error escaped the 1966), his most enduring title to modern fame is record. One failure, said Cruveilhier (1841), in the field of surgical pathology and perhaps afflicted Dupuytren more than 20 successes above all for his diagnosis and treatment of con- delighted him. All those who worked with him and all who visited his clinics agreed For twenty years, day in, day out, the Dupuytren that he showed toward these humble outpatients program was all but unvaried. When Marjolin became the same attentiveness and care he showed to the Dupuytren’s adjunct surgeon, Dupuytren told him he rich and famous who came to him for private was expected to act as substitute when the chief was consultations. Even Christmas found him at his with operations on private patients, medical post. His arrival would be signaled by the clinical research, and private consultations. Ward round began promptly and Dupuytren’s professional day was not yet over might take as long as three hours. This lecture was reported verbatim from Paris, from France, from the world beyond. Dupuytren began his clinical lectures in a low voice, in the Journal Universel et Hebdomadaire de which would force his auditors to pay close attention, Médecine et de Chirurgie Pratique by his assis- “His voice was soft and smooth, with not only a clarity tants, Paillard and Marx (Dupuytren, 1831). The lecture notes, religiously recorded by his assistants, Other well-documented biographies of Brière de Boismont, Paillard and Marx, were pub- Dupuytren have been written by Cruveilhier lished in the Leçons Orales de Clinique Chirurgz- (1841) and Mondor (1945). They began in 1832 and by his associates and promptly translated abroad filled five volumes. Dupuytren died in November attest to the method, content, and style of these 1835. Surgery was an exten- Later, Dupuytren’s assistants and Dupuytren sion, a demonstration of clinical lectures. In 1818, himself discovered that this condition had already 2,363 patients were admitted to Dupuytren’s been mentioned by Astley Cooper, and the service and 764 major operations performed, “Leçon sur la Rétraction Permanente des Doigts” ranging from strangulated hernias, skull fractures, was relegated to article XI of volume 4 of the mastectomies, amputations of the upper and second edition, which appeared in 1839, after lower jaw, artificial anus and malignant tumors, Dupuytren’s death. He devised oped pleurisy and died in a few days, while an apparatus for leg lengthening, an operation for Cruveilhier, Bouillaud and Broussais were debat- correction of internal rotation of the hip in spastic ing whether to drain his empyema.

Dysesthetic sensations may be helped by agents effective 80mg inderal, such as carbamazepine buy inderal 80 mg overnight delivery, amitriptyline 80 mg inderal sale, gabapentin and prega- balin cheap 40mg inderal with amex. Cross References Allodynia; Hyperalgesia; Hyperpathia; Paresthesia Dysexecutive Syndrome The term executive function encompasses a range of cognitive processes including sustained attention buy inderal 40 mg without a prescription, fluency and flexibility of thought, problem solving skills, planning and regulation of adaptive and goal-directed behavior. Some authors prefer to use these individ- ual terms, rather than “lump” them together as executive function. Deficits in these various functions, the dysexecutive syndrome, are typ- ically seen with lateral prefrontal cortex lesions. Cambridge: MIT Press, 2003: 259-279 Cross References Attention; Frontal lobe syndromes - 101 - D Dysgeusia Dysgeusia Dysgeusia is a complaint of distorted taste perception. It may occur along with anosmia as a feature of upper respiratory tract infections, and has also been described with various drug therapies, in psychiatric diseases, and as a feature of zinc deficiency. Cerebellar dysfunction, mental changes, anorexia and taste and smell dysfunction. Archives of Neurology 1975; 32: 745-751 Cross References Ageusia; Anosmia Dysgraphesthesia - see AGRAPHOGNOSIA; GRAPHESTHESIA Dysgraphia - see AGRAPHIA Dyskinesia Dyskinesia may be used as a general term for excessive involuntary movements, encompassing tremor, myoclonus, chorea, athetosis, tics, stereotypies, and hyperekplexia. The term may be qualified to describe a number of other syndromes of excessive movement, e. In MPTP-induced parkinsonism, dyskinesias tend to occur early, hence it may be the depth of dopamine deficiency rather than chronicity of treatment which is the key determinant; reduction in over- all levodopa use (increased frequency of smaller doses, con- trolled-release preparations, addition of dopamine agonists) may reduce these effects; amantadine is sometimes helpful. Boston: Butterworth-Heinemann, 1998: 215-231 Cross References Athetosis; Chorea, Choreoathetosis; Dystonia; Hyperekplexia; Myoclonus; Parkinsonism; Stereotypy; Tic; Yo-yo-ing Dyslexia Dyslexia is difficulty or impairment in reading, usually applied to developmental abnormalities of reading ability. A loss of previously acquired reading ability is probably better termed alexia. Cross References Alexia Dysmentia The term dysmentia has been suggested as an alternative to dementia, to emphasize the possibility of treating and preventing cognitive decline. International Journal of Geriatric Psychiatry 1994; 9: 1-4 Cross References Dementia Dysmetria Dysmetria, or past-pointing, is a disturbance in the control of range of movement in voluntary muscular action, and is one feature of the impaired checking response seen in cerebellar lesions (especially hemi- sphere lesions). Dysmetria may also be evident in saccadic eye movements: hypometria (undershoot) is common in parkinsonism; hypermetria (overshoot) is more typical of cerebellar disease (lesions of dorsal ver- mis and fastigial nuclei). In cerebellar disorders, dysmetria reflects the asynergia of coordi- nated muscular contraction. Saccadic dysmetria and “intact” smooth pursuit eye movements after bilateral deep cerebellar nuclei lesions. Journal of Neurology, Neurosurgery and Psychiatry 1994; 57: 832-834 Cross References Asynergia; Cerebellar syndromes; Dysdiadochokinesia; Parkinsonism; Rebound phenomenon; Saccades - 103 - D Dysmorphopsia Dysmorphopsia The term dysmorphopsia has been proposed for impaired vision for shapes, a visual recognition defect in which visual acuity, color vision, tactile recognition and visually-guided reaching movements are intact. These phenomena have been associated with bilateral lateral occipital cortical damage (e. Whether this condition is an agnosia for shape or visual form, or a per- ceptual problem (“pseudoagnosia”), remains a subject of debate and the term dysmorphopsia has been suggested as a compromise between the different strands of thought. This may have local mechanical causes which are usually gastroenterological in origin (tumor; peptic ulceration/stricture, in which case there may be additional pain on swallowing -odynophagia) but sometimes vascular (aberrant right sub- clavian artery – dysphagia lusoria). Dysphagia of neurological origin may be due to pathology occurring anywhere from cerebral cortex to muscle. Neurological control of swallowing is bilaterally represented and so unilateral upper motor neurone lesions may cause only tran- sient problems. Poststroke dysphagia is common, but there is evidence of cortical reorganization (neuroplasticity) underpinning recovery. Dysphagia of neurological origin may be accompanied by dysphonia, palatal droop, and depressed or exaggerated gag reflex. Recognized neurological causes of dysphagia include: Upper motor neurone pathology: pseudobulbar palsy, e. Difficulty swallowing may on occasion be functional in origin (globus hystericus). If swallowing is compromised with a risk of aspiration, feeding may need to be undertaken via nasogastric tube, percutaneous gastrostomy or jejunostomy placed endoscopically (PEG or PEJ), or even parenterally. The cortical topography of human swallowing musculature in health and disease. Philadelphia: Lippincott Williams & Wilkins, 2002: 227-235 Cross References Bulbar palsy; Dysphonia; Gag reflex; Jugular foramen syndrome; Pseudobulbar palsy Dysphasia - see APHASIA Dysphonia Dysphonia is a disorder of the volume, pitch or quality of the voice resulting from dysfunction of the larynx, i. Hence this is a motor speech disorder and could be considered as a dysarthria if of neurological origin.

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