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Tzyy-Choou Wu, M.D., M.P.H., Ph.D.

  • Director, Gynecologic Pathology Division
  • Professor of Pathology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0003704/tzyy-choou-wu

The carcinoma must arise from the endometriosis and not invade it from another source 3 does cholesterol medication help weight loss buy cheap crestor 5 mg on line. The specimen must contain histological characteristics of endometriosis cholesterol ratio score crestor 10 mg on line, including stroma and glands cholesterol and food labels order 20mg crestor amex. A retrospective cohort study of >20 cholesterol medication nz generic 20 mg crestor amex,000 women with endometriosis found an overall increased cancer risk and a greater increase in risk of ovarian cancer cholesterol brain 20 mg crestor with visa. The study concluded that there is an estimate of 3 to 8-fold increase risk of ovarian tumours associated with endometriosis cholesterol readings chart uk crestor 5 mg amex. In a review by Somigliana et al,6 it was suggested that endometriotic cells may undergo malignant transformation, and the coexistence of endometriosis and ovarian cancer may be due to shared risk factors and preceding mechanisms. This theory is derived from histologic evidence of malignant transformation of the endometriosis to clear cell or endometrioid carcinoma. For instance, nulliparity, early menarche, late menopause3 and other similar risk factors. While there is a link between endometriosis and certain cancers, there is no conclusive evidence that indicates that endometriosis causes cancer. If the fmbriated end of the Fallopian tube is completely enclosed, change the point assignment to 16. However, non-pharma dometriose, o foco ainda e baseado no tratamento convencional. In light of the above, this study aimed at contributing to cao dessas terapias como recurso efetivo no controle da dor. Di the knowledge in this area and at analyzing the literature about ante do exposto, este estudo teve como objetivo contribuir com the application of such techniques to treat endometriosis pain. Foram identifcados na busca eletronica 61 artigos used massage and two cognitive behavioral therapy to relieve cientifcos e, de acordo com os criterios de inclusao e exclusao endometriosis pain. Pilates method was not applied to control pre-estabelecidos, sete foram selecionados para leitura. All studies have shown efectiveness of the empregaram acupuntura, dois massagem e dois terapia cognitiva techniques used to improve endometriosis chronic pain. Also, such Todos os estudos mostraram efcacia das tecnicas empregadas na options should be incorporated to traditional approaches ofered reducao da dor cronica nessa doenca. Descritores: Dor cronica, Endometriose, Psicologia, Terapeu tica, Tratamento nao farmacologico. Endometriosis is a chronic gynecological condition primarily characterized by chronic pain and infertility, which afects ap Submitted in June 13, 2014. Review and update articles, letters to the editor, case behavior by interrupting or avoiding sexual intercourse due to reports and experience reports were excluded. Among most common pain-related coexisting symptoms Electronic query has identifed 61 scientifc articles and seven there are back and leg pain in 75. Due to symptoms, patients have decreased productivity Results of this query are summarized in table 1. Tree studies have evaluated acupuncture to control endome Constant pain reported by endometriosis patients has nega triosis pain7-9. In the 2002 study, 67 patients with endometrio tive direct and indirect impact on their lives. A Japanese acupuncture style Endometriosis-related pain is still managed by conventional was applied to 14 young females (mean age of 17 years) with methods. Four weeks later, improvement was signifcantly higher knowledge in this area and at analyzing the literature about the for the active acupuncture group as compared to control, that application of such techniques to handle endometriosis pain. Results of Pubmed electronic query Authors Keywords # of identifed # of excluded articles/Reason # of selected articles articles for reading Xiang et al. Only two studies have used massage to control endometrio In the support group, pain levels were weekly evaluated and sis pain10,11. In one of them, massage was applied to 23 pa there has been signifcant decrease along time (from frst to tients with endometriosis and dysmenorrhea, and visual analog ninth week, p<0. Before intervention, approximately 52% of than that reported by females in the beginning of the support patients referred severe pain and six weeks after intervention group. However, there have been no specifc selection criteria 65% of them reported lack of menstrual pain10. At the end of groups, re The other study has used massage and acupuncture for leg pain ports on improvements with regard to physical and emotional relief11. From 94 patients with endometriosis, 48 (51%) have aspects associated to pain decrease were frequent. In 46% of cases, the clinician has scores decrease, thus contributing to improve quality of life of not suggested any treatment option for this symptom. Chronic pain is the symptom aficting the most endometrio Pilates method was not applied to endometriosis patients to sis patients, because it has negative impact on quality of life, control pain. One literature review published in 201114 has identifed The frst study has evaluated 128 Brazilian females with endo 14 studies using acupuncture to control endometriosis pain. It has also been used as satisfactory complementary on reported experiences of other chronic pain multidisciplinary therapy to treat pain in dentistry16. An interesting fnding was interventions, having as primary objective to convey informa that seven articles published in Chinese have used acupunc tion about endometriosis and to promote physical, emotional ture to treat endometriosis pain. This was because acupuncture and social well being rehabilitation of females with the disease. Menstrual pain scores according to visual analog scale in three different periods Menstrual pain intensity Before intervention Immediately after intervention Six weeks after intervention (n & %) (n & %) (n & %) 0 (no pain) 0 (0) 8 (34. However, further studies on method to decrease chronic spinal pain17 and primary dysmen this subject should be carried out, with larger samples and other orrhea18. The frst study has identifed signifcant 66% pain de conditions characterized by chronic pain, to prove the results of crease in the experimental group (20 college students aged be studies presented herein. Such options should be incorporated tween 18 and 25 years with diagnosis of non-structural scoliosis to conventional approaches ofered to endometriosis patients p=0002)17. Still, it was clear the importance of including a multi protocol of 16 ground and ball exercises for the pelvic region professional team to treat endometriosis, due to the complexity based on the Pilates method. Both results have shown that Pilates has RefeRenCeS provided pain relief with excellent results17,18. In this sense, and considering the lack of scientifc articles applying this technique 1. Quantifcation of the impact of endometriosis symptoms on health-related quality of life and work productivity. At the end burden of endometriosis: costs and quality of life of women with endometriosis and of the program (duration: eight weeks), there has been signif treated in referral centers. Ear acupuncture therapy for 37 cases cant improvement in pain intensity, incapacity and depressive of dysmenorrhea due to endometriosis. Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. Is acupuncture in addition to conventional medicine efective as pain treatment for en suggest that such intervention should be used by specialized dometriosis Eur J Obstet Gynecol Reprod pain management centers, rehabilitation centers or preventive Biol. New trends for the medical treatment of endometrio vided patients are assisted by a qualifed professional and that sis. Reducao da dor Data have shown that non-pharmacological/surgical endometri cronica associada a escoliose nao estrutural, em universitarias submetidas ao metodo osis pain treatment is still hardly explored and used in the health Pilates. In this direction, further studies should be carried out to res com dismenorreia primaria, tratadas pelo metodo Pilates. Sao Paulo, understand the real contribution of such therapies to relieve 2012;13(2):119-23. However, the few published studies have shown promising de um programa psicoeducativo no controle da dor cronica. More recently enhanced uterine contractility dyspareunia (Rock and Markham, 1992). The goals of therapy was established in close relationships with the nding of viable include relief of symptoms, resolution of existing endometriotic endometrial cells in the cul de sac and with the presence of implants, and prevention of new foci of ectopic endometrial endometriotic implants (Bulletti et al. Controlled trials on the use of medical (Reichel and Endometrial ablation (Cooper and Erickson, 2000; Sowter Schweppe, 1992; Rock et al. Yet was undertaken to evaluate differences in recurrence of ectopic despite these improvements, the disease still awaits optimal endometriotic implants between patients treated for endo therapy (Bulletti et al. Patterns of uterine contractility were extensively studied in the non-pregnant uterus with special attention to the effects of contractility in Materials and methods infertility and endometriosis (Leyendecker et al. Twenty-four months later all include relief of symptoms, resolution of existing endometriotic patients underwent a second laparoscopy to establish possible recur implants and prevention of new foci of ectopic endometrial rences of ectopic implants and to treat them. Dysmenorrhoea and endometriosis symp and/or effects of oestrogens which are well known promoters of toms were evaluated before and 3 months after the rst laparoscopy, the growth and maintenance of the eutopic and ectopic endomet and before the second laparoscopy, using a self-modied non rium. Instead, if we take into account the prevailing theories continuous ve point verbal score (Vercellini et al. Unfortunately,optimaltherapyfor surgical equipment including bipolar instruments (Storz, Germany) thisdiseasestillawaitstheidenticationoftheseidealmolecules. Endometrial ablation was the present study was conceived in accordance with the performed by hysteroscopy (Cooper and Erickson, 2000; Sowter et al. Endometrial implants were carefully identied, as well as evid ence of retrograde bleeding at the time of the rst and second laparo Sampson (Sampson and Albany, 1927). Diagnosis of endometriosis and its that endometriosis develops as a consequence of abdominal recurrence were correlated with clinical evidence of dysmenorrhoea. Endometriotic implants were by the process of menses, that can successfully attach and considered as recurrence when they were found in at least three active implant in the pelvic cavity and cause endometriosis. The abnormal contractility of this signicant reduction of the dysmenorrhoea after 3 months organ has long been suspected to cause pelvic pain including (median scores 4 versus 1, P 0. Dys Endometriosis and presence of endometrial cells in the menorrhoea symptoms increased up to 24 months but not so abdomen was recently related to specic pattern of uterine con signicantly as compared with presurgical evaluation (medians tractility (Bulletti et al. Blood and cells were found in the implantation and the subsequent biological response to hor 2677 C. Procedure of endometrial ablation (A and C) and a diagram to show the associated effects on endometrial tissues and vasculature (B, D) aimed at removing the cyclical endometrial cells. Deep endometrial ablation was effective in avoiding the subsequent cyclical bleeding. Zoladex (Goserelin acetate implant) in the treatment of endometriosis: a randomized comparison with Danazol. An attempt was made to set guidelines for the early diagnosis and effective treatment of patients with endometriosis presenting with pain and/or infertility. To promote early diagnosis and initiation of medical therapy through education of health care workers and the public; 2. To set criteria where referral to centres of excellence needs to be considered; 4. Poor knowledge of the disease amongst health care workers contributing to late diagnosis; 2. No guidelines available regarding medical treatment in primary health care facilities; 3. No referral system in place for patients failing to respond to first line therapy; 4. Poor education of young adolescent women in educational institutions and clinics regarding pelvic pain; 5. Lack of dedicated outpatient clinics for adolescent women and women of reproductive age for management of pelvic pain and /or infertility at secondary and tertiary level; 6. Lack of surgeons trained in advanced laparoscopic surgery for management of endometriosis in both public and private sector; 7. Poor communication between health care practitioners and patients regarding severity of disease and future follow up; 9. Severe shortages of dedicated centers in management of endometriosis especially in rural areas where multidisciplinary treatment can be offered; 10. Suggested Guideline for effective care of women with endometriosis the Guideline addresses the following topics regarding management: 1. Accurate diagnosis of endometriosis Early detection of disease Clinicians should consider the diagnosis of endometriosis in all women of reproductive age with symptoms of pelvic pain, dysmenorrhoea, dyspareunia, infertility, fatigue and non gynaecological cyclical symptoms. Should operative laparoscopy be needed, this should be performed by an experienced surgeon. Adolescent patient and Endometriosis Adequate counselling and information should be given regarding the disease and future follow up. Department of Health: Education of Primary care givers regarding the management of adolescent and young reproductive age women presenting with pain and/or infertility. Executive summary of recommendations What are the risk factors for endometrial hyperplasia

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Second cholesterol xrd discount crestor 5 mg on-line, the products of vaporization are dependent on the quality and composition of the underlying herbal material cholesterol medication being recalled buy 5 mg crestor visa. If that material is not highly standardized cholesterol medication and muscle pain effective crestor 5mg, the composition of the vapor will be uncertain cholesterol zvyseny crestor 10 mg with visa. Unless the vaporizer device has a lockout mechanism cholesterol per egg 20 mg crestor sale, variability in intra and interpatient inhalation patterns may make it unlikely that a known and reproducible dose will be delivered remnant cholesterol definition buy crestor 20mg with amex. Third, vaporization does not improve the side effect profile exhibited by smoked cannabis, including its psychoactive effects. In fact, patients with such persistent pain are often placed on extended release opioid medications once their individual daily dose is established through shortterm release medications. Finally, when cannabis joints or vaporizers are shared, dangerous pathogens can be spread amongst seriously ill patients (Zanocco V, 2005). Those agency recommendations require that highly standardized cannabis herbal material (Botanical Raw Material) be developed into a Botanical Drug Substance and ultimately into a Botanical Drug Product. Improvements in vaporization technology would need to occur in order fully to eliminate all toxic combustion products and ensure a standardized and predictable dose. Therefore, the obvious question arises: why, as a policy matter, should herbal cannabis be exempted from the modern medication model Many new promising medications are under investigation, and suffering patients understandably seek to obtain access to them as early as possible. Cosmetic Act (Abigail Alliance, 2008) or the Controlled Substances Act (United States v. These synthetic cannabinoids have been developed over the past 30 years for research purposes to investigate the endocannabinoid receptor system in non human studies. Products containing these synthetic cannabinoids are marketed as "legal" alternatives to cannabis and are being sold over the internet and in tobacco and smoke shops, drug paraphernalia shops, and convenience stores. This action will make possessing and selling these chemicals or the products that contain them illegal in the U. Rescheduling of cannabis would also not allow pharmacists to compound cannabis products for large numbers of patients. Rescheduling cannabis would not automatically reduce or otherwise affect federal criminal penalties for possession or trafficking. These statutes provide specific penalties for marijuana or for possessing a controlled substance without a 45 lawful prescription. Such statutes would require separate amendment in order for existing penalties to be modified, and this amendment process would involve different policy factors and considerations. Cannabis rescheduling would also not necessarily allow the establishment of additional cannabis cultivation facilities to produce cannabis for research purposes. If a researcher wishes to conduct a different study on the same Schedule I substance, he/she must obtain a separate registration. Pharmaceutical companies are responsible for the harms caused by contaminated or otherwise dangerous products and tobacco companies can be held accountable for harms caused by cigarettes, yet, dispensaries distribute cannabis products about which very little are known, including their source. Second, one must consider the drug approval process in the context of public health, not just for medical marijuana but also for all medicines and especially for controlled substances. When physicians recommend use of scheduled substances, they must exercise great care. If any components of marijuana are ever shown to be beneficial to treat any illness then physicians should prescribe those components by nontoxic routes of administration in controlled doses just all other medicines are in the U. In order for physicians to fulfill their professional obligations to patients, and in order for patients to be offered the high standard of medical care that we have come to expect in the United States, cannabisbased medications must meet the same exacting standards that we apply to other prescription medicines. Members of the American Society of Addiction Medicine are physicians with expertise in addiction medicine with knowledge specific to the risks associated with the use of substances with high abuse potential. Comments were submitted by interested members and incorporated into this final version September 2010. This further defines how to view and evaluate the actions of the physician who holds her/himself out as an expert in cannabis medical care who has no connection to the primary physician of the patient for whom crude cannabis is recommended. References Abigail Alliance for Better Access to Developmental Drugs and Washington Legal Foundation v. Psychopathological and cognitive effects of therapeutic cannabinoids in multiple sclerosis: A doubleblind, placebo controlled, crossover study. Efficacy of two cannabis based medicinal extracts for relief of central neuropathic pain from brachial plexus avulsion: results of a randomized controlled trial. Preliminary assessment of the efficacy, tolerability and safety of a cannabisbased medicine (Sativex) in the treatment of pain caused by rheumatoid arthritis. Lack of analgesic efficacy of oral delta9tetrahydrocannabinol in postoperative pain. California Attorney General, Guidelines for the Security and Nondiversion of Marijuana Grown for Medical Use. Enhancing cannabinoid neurotransmission augments the extinction of conditioned fear. Randomized controlled trial of cannabisbased medicine in spasticity caused by multiple sclerosis. Isolation and structure of a brain constituent that binds to the cannabinoid receptor. The Potential Medical Liability for Physicians Recommending Marijuana as Medicine. A pilot clinical study of 9tetrahydrocannabinol in patients with recurrent glioblastoma multiforme. A multicenter doseescalation study of the analgesic and adverse effects of an oral cannabis extract (Cannador) for postoperative pain management. The Future of Cannabinoids as Analgesic Agents: A Pharmacologic, Pharmacokinetic, and Pharmacodynamic Overview American Journal of Therapeutics 2007; 14(5); 475483,476. A total synthesis of d, 1delta1tetrahydrocannabinol, the active constituent in hashish. Efficacy of dronabinol alone and in combination with ondansetron versus ondansetron alone for delayed chemotherapyinduced nausea and vomiting. A Phase I evaluation of pulmonary dronabinol administered via a pressurized metered dose inhaler in healthy volunteers. Sativex successfully treats neuropathic pain characterized by allodynia: A randomized, doubleblind, placebocontrolled clinical trial. Long term marijuana users seeking medical cannabis in California (20012007): demographics, social characteristics, patterns of cannabis and other drug use of 4117 applicants. On the preparation of the Indian hemp or gunjah (Cannabis indica): the effects on the animal system in health and their utility in the treatment of tetanus and other convulsive diseases. Randomized controlled trial of cannabis based medicine in central neuropathic pain due to multiple sclerosis. A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. There is an exception for stocks held by manufacturers of pharmaceutical preparations. Inhibition of fattyacid amide hydrolase accelerates acquisition and extinction rates in a spatial memory task. Longterm use of a cannabisbased medicine in the treatment of spasticity and other symptoms in multiple sclerosis. Dosedependent effects of smoked cannabis on capsaicininduced pain and hyperalgesia in healthy volunteers. A randomized, placebocontrolled, crossover trial of cannabis cigarettes in neuropathic pain. Low dose treatment with the synthetic cannabinoid Nabilone significantly reduces spasticityrelated pain. The Article Processing Charge was paid by the Guthy-Jackson Charitable Foundation. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4. Relevant full-text articles were inde pendently rated to identify those used for data extraction. Table e-2 contains characteristics meant to enhance diagnostic specificity a glossary of terms to guide interpretation of individual must also be present. Exclusion of alternative diagnosesa sentation,e54 the natural history of asymptomatic Core clinical characteristics 1. Area postrema syndrome: episode of otherwise unexplained hiccups or nausea and vomiting 4. Area postrema syndrome: requires associated dorsal medulla/area postrema lesions (figure 2) 4. Acute brainstem syndrome: requires associated periependymal brainstem lesions (figure 2) the main clinical red flags concern the temporal course of the syndrome rather than the actual manifestations. None of these modalities were included in the Longitudinally extensive cord atrophy (sharply demarcated atrophy extending over $3 revised diagnostic criteria because of concerns regard complete, contiguous vertebral segments and caudal to a particular segment of the spinal cord), withor without focal or diffuseT2 signal change involvingthe atrophic segment(figure1, ing lack of evidence, specificity, or reliability. Cell-based assay has the best medulla/area postrema (figure 2)22,33,40,e36,e73,e78 current sensitivity and specificity and samples may and periependymal regions in the brainstem need to be referred to a specialized laboratory. There neuromyelitis optica spectrum disorder may be technical explanations in some cases but anti body levels also increase with clinical relapses and decrease with immunosuppressive therapy in some patients. Figure 3 Diencephalic and cerebral lesions in neuromyelitis optica spectrum disorder A variety of brain lesion patterns are associated with neuromyelitis optica spectrum disorder. The occurrence of a second clin ical attack, which defines a relapsing disorder, was often considered sufficient to revise the diagnosis to Pathology. It is unclear whether the occurrence of bilateral optic neuritis and myelitis at findings supportive of astrocytopathy such as truncated initial presentation are helpful or essential to distin astrocyte processes or cell loss may be detected by immunostaining for glial fibrillary acidic protein. Although early risk of relapse is infiltration with neutrophils and eosinophils are supportive characteristics,e102 butmaynotbepresent. An interval attacks with no brain involvement, although some longer than 4 weeks between index attacks indicates investigators allow occurrence of certain brainstem syndromes. These include have not experienced clinical involvement of either but are not limited to studies that (1) systematically optic nerves or spinal cord. These criteria are appropriate for adults ria commensurate with the next era of scientific and, with minor caveats, children. Bennett participated in the acquisition and analysis of data and writing and critical review als who would have been diagnosed with idiopathic of the manuscript for important intellectual content. The criteria should participated in the acquisition and analysis of data and writing and critical review of the manuscript for important intellectual content. Early-stage diagnostic specificity participated in the acquisition and analysis of data and writing and critical 186 Neurology 85 July 14, 2015 2015 American Academy of Neurology. Jarius Research from the Ministry of Education, Science and Technology of Japan participated in the acquisition and analysis of data and writing and and as the secondary investigator by the Grants-in-Aid for Scientific Research critical review of the manuscript for important intellectual content. Levy participated in the acquisition and analysis of data and support from the Guthy Jackson Charitable Foundation. Simon participated in the acquisition and analysis of data Chugai, Alexion, and Biogen. Jarius has been supported by a research and writing and critical review of the manuscript for important intellec grant from the European Committee for Treatment and Research in Mul tual content. Traboulsee participated in the acquisition and and by a travel grant from the Guthy-Jackson Charitable Foundation.

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Following the primary injury cholesterol medication necessary buy 5mg crestor overnight delivery, sec ondary effects cholesterol levels diet buy cheap crestor on line, such as hypoxia keep cholesterol levels low cheap crestor 5 mg otc, hemorrhages can cholesterol medication make you tired order 5 mg crestor mastercard, seizures cholesterol scientific definition buy generic crestor 10mg on line, and edema may also occur cholesterol in butter purchase discount crestor. Edema, the rapid diffuse cerebral swelling that is due to increased fluid secondary to trauma, and/or intracranial hemorrhages can exacerbate the damage to brain function related to the primary injury, but can also lead to additional damage to brain paren chyma and further compromise recovery. The brain, cerebrospinal fluid, cerebral blood and extracellular fluid, are all within the skull, and an increase in any one of these areas. Brain damage, related to neuronal apoptosis and/ or degeneration of synapses and/or axons and/or associated neuronal glia result from a complex neurochemical process. In the weeks post-injury, a number of physical symptoms may occur, including fatigue, headache, drowsiness, irritability, labile mood, dizziness, and nausea and emesis. However, there is some agreement that there is a group, both children and adults, who continue to experience such symptoms, and go on to develop psychological and cognitive problems including anxiety, irritability and depression, reduced speed of information processing and executive control, and difficulties with memory and attention (Asanow et al. Brain imaging will often identify abnormalities associated with damage to the brain. Consciousness, and the ability to respond appropriately to the environment, depend on the functioning of the centers in the ascending reticular formation and on the level of communication between these centers and the cerebral cortex. Early assessment of the level of consciousness is essential, as it gives an indication of 768 C. After the recovery of consciousness, there may follow a period of time during which recent events are not recalled reliably or accurately. Advances to the understanding for the gradations in brain injury and distinctions between different forms of diffuse brain damage have increasingly become evident with advances in neuroimaging (Wilson et al. Like adults, residual physical, cognitive, and psychological/ psychiatric problems can occur in children/adolescents. Anderson educational/vocational and social areas have been reported (Engberg and Teesdale 2004; Hoffien et al. It has been argued that the developing brain is particularly vulnerable to brain trauma (Anderson et al. Injuries sustained during childhood are more likely to result in generalized brain pathology, therefore derailing normal developmental processes. While intra or inter-hemispheric functional neuroanatomical reorganization has shown to account for recovery of previously attained (and/or develop new) cognitive functions following more focal neurological injuries. Like adults, recovery of cognitive functions or skills requires increased recruitment of brain areas, and may result in reduced efficiency. This gives qualitative information that is difficult to obtain elsewhere and often gives the clini cian an insight into the dynamics of the family situation. At this time, the child is also able to become acquainted with the clinician, and therefore more comfortable, Once the assessment is underway, it is important to ensure the child is comfort able in the testing situation and is able to work to the best of their ability. Children should be aware that it is not expected they be able to answer every question correctly, however, the clinician should encourage the child to perform at his/her best on all items administered. Thus, we advocate the clinician plan the assessment to have breaks (time when no paper and pencil testing is administered, although assessment of gait, coordination, jumping, strength, etc. For some young children, a break of up to 30 minutes is adequate, and they will often have a drink or something to eat. Alternatively, some children with various neurological, psychiatric, and/or systematic medical diseases may fatigue more quickly or become very anxious, and more frequent breaks of longer duration may be required. For children with severe impairment, it may be impossible to rely on formal, standardized assessment methods. In such instances, other techniques such as contextual observation (clinic, home, school) and parent and teacher ratings can be used. This can involve the clinician observing the child at home and/or school, and observing how the child interacts and/or behaves in certain settings. Furthermore, regular review is important up to 12 months post-injury, and then at key transi tional periods, such as school entry or completing primary school and entering secondary school. Assessment completed acutely (within days to weeks of the injury) will not, in all likelihood, reflect static (fixed) level of deficits (if any), and change over time, particularly in the first several months from the time of injury, should be expected. Depending upon the severity of the injury, neuropsychological assessment during the acute phase should be tailored to the referral questions and the individual child. Such an assessment is not likely to be lengthy, and may initially be limited to acute bedside assessment. The neuropsychologist should incorporate recom mendations above to not test when the child is unable to participate in the assessment. Neuropsychological assessment using psycho metric instruments may be postponed if the neuropsychologist believes reliable data could not be obtained. If a child becomes distressed during the assessment, we advocate the assessment should stop, and to take a break (stop administering psychometric-based tests). As mentioned above, a break of up to 30 minutes is preferable, but at times a longer break may be required. In our experience, most children like to re-unite with their parents during the break, and some may go for a short walk and/or have something to eat or drink. It is important to try and determine the cause of the distress and attempt to make the child comfortable again. Once the child is ready to continue with the assessment, then the session may continue. On rare occasions, if the child is still distressed/anxious after a break, the assessment may be rescheduled for another day. Indeed, it is not uncommon to have more than one office visit initially scheduled for the neuropsychological evaluation to reduce testing demands on the child on any 1 day. Referral may be from various sources including a neurologist, a neurosurgeon, a general practitioner, a teacher or the parents. Such evaluations are useful in guiding interventions in academic and behavioral management treat ments. It is not uncommon for the referral question(s) of a physician to differ from questions of a parent, but often it is possible to address questions of both parties with careful consideration of the assessment procedures. When planning the assessment, it is essential the referral question has been addressed. We generally encourage the clinical assessment to incorporate a measure of general cognitive functioning. Finally, qualitative information can provide essential information to guide the implementation of treatment programs across a variety of settings. Research A neuropsychological assessment protocol for research purposes will be determined by the hypothesis(es) of the study. An example of a research protocol investigating executive functions among adolescents/young adults whom had sustained a head injury between the ages of 7 and 12 years is presented in Table 25. When conduct ing research in our laboratory, feedback is provided to the family and child, and this is often in the form of a neuropsychological report. When required, and with consent from the family, a child may be referred to other clinicians for further assessment or intervention. Sequelae of Haemophilus Influenzae meningitis: Implications for the study of brain disease and development. Measuring psychosocial recovery after traumatic brain injury: Psychometric properties of a new scale. Deficits have been reported at one time point, or longitudinally, in many areas including attentional capacity (Catroppa and Anderson 2005; Catroppa et al. A combination of severe injury and social disadvantage have been found to be particularly detrimental to recovery following early brain insult (Breslau 1990; Taylor et al. Psychiatric problems may increase post-injury for children where such problems were present pre-injury (Brown et al. Thus, damage or disruption may have implications for future skill acquisition, within both cognitive and behavioral domains. From a func tional perspective, young children possess few established skills, and so the younger the age at injury, the fewer mature skills available to the child, with the possibility that future skill acquisition may be compromised (Dennis 1989). However, professionals report only small numbers of injured children having access to rehabilitation resources (Cronin 2000; Di Scala and Savage 1997). Outpatient therapy Intervention to assist re-entry into home/school/ community: Direct approach Behavioral compensation Environmental modifications and supports Behavioral interventions Psycho-educational approaches Psychological treatments Family-based interventions advantaged families (Rivara et al. Rehabilitation can be divided according to the goal of the intervention, reflecting either (1) Restitution/Restorative or (2) Substitution/Adaptation. Restitution/restor ative rehabilitation focuses on restoring function via re-establishment of impaired functions and/or regaining lost skills (Cicerone and Tupper 1990; Sohlberg and Mateer 1989). Prior to school return, a number of issues must be considered (Anderson and Catroppa 2006) including the physical incorporation of adaptive equipment, environmental aspects, and instructional adaptations or accommodations that may be necessary. Physical incorporation of adaptive equip ment involves consideration of including wheelchairs, special desks, computers, and/or communication devices. Environmental aspects for return to school includes the provision of extra time for assignments, instruction, and/or taking exams, pro viding a quiet, well-structured classroom, and/or opportunity for the child to receive increased repetition of material and/or opportunities practice skills and revi sion of assignments, class work, etc. Instructional aspects to consider in returning to school include inclusion of specific educational programming, individual tuition, and social skills retraining. These modifications should be negotiated prior to school return to allow the transition to be as smooth as possible. This pro cess may be supported by: (1) providing training for the individual to prepare cur riculum vitae/resume; (2) furnishing training to perform adequately in interviews. We believe there are several benefits of the program: (1) including the family in the intervention process; (2) teaching the family strategies to deal with behavioral issues, and so empowering family members; (3) increasing coping strategies and self-esteem of the family; (4) enhancing a more-so cohesive and adaptive family environment; and (5) improving child behaviors and child well-being. Intervention, particularly at times of transition, whether with the child, the family, or including external sources. Anderson there is a need for the development, implementation and evaluation of intervention programs for this population (Catroppa and Anderson 2010). While much is now known regarding outcomes in this population, there is much research required in the intervention area, in order to help these children and their families to achieve a better quality of life. Advances in post-acute rehabilitation after childhood acquired brain injury: A focus on cognitive, behavioural and social domains. Age at injury as a predictor following pediatric head injury: A longitudinal perspective. Predictors of acute child and family outcome following traumatic brain injury in children. Understanding predic tors of functional recovery and outcome five years following early childhood head injury. Behavior problems and adaptive functioning in children with mild and severe closed head injury. Head injury in children and adolescents, Clinical Psychology Publishing Company, Inc. Recovery and predictors of intellectual ability two years following pediatric traumatic brain injury. Recovery and predictors of language skills two years following pediatric traumatic brain injury. A prospective study of the recovery of attention from acute to 2 years post pediatric traumatic brain injury. Functional performance of young children after traumatic brain injury: A 6-month follow-up study. The epidemiology of paediatric head injuries: Data from a referral centre in Victoria, Australia. Appraising and managing knowledge: Metacognitive skills after childhood head injury. Psychosocial outcome following traumatic brain injury in adults: A long-term population-based follow-up. Early brain injury in children: Development and reorganization of cognitive function. Behavioural supports for parents of children with an intellectual disability and problem behaviours: An overview of the literature. Epidemiology of pediatric closed head injury: Incidence, clinical characteristics and risk factors. Evaluation of an intervention system for parents of children with intellectual disability and challenging behaviour.

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Source: http://www.rxlist.com/script/main/art.asp?articlekey=96819

References

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