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The risk for CP in a child of triplets is up to 18 Hemiplegia—Paralysis of one side of the body purchase 500 mg tinidazole amex. Furthermore cheap 1000 mg tinidazole overnight delivery, recent evidence suggests that Hypotonia—Reduced or diminished muscle tone cheap 300mg tinidazole overnight delivery. Serial casting—A series of casts designed to grad- Demographics ually move a limb into a more functional position 500 mg tinidazole. Spastic—A condition in which the muscles are Approximately 500 purchase 500mg tinidazole mastercard,000 children and adults in the rigid, posture may be abnormal, and fine motor United States have CP, and it is newly diagnosed in about control is impaired. Spasticity—Increased muscle tone, or stiffness, Ironically, advances in medicine have decreased the inci- which leads to uncontrolled, awkward move- dence from some causes, Rh disease for example, but ments. However, people of disadvan- Tenotomy—A surgical procedure that cuts the ten- taged background are at higher risk due to poorer access don of a contracted muscle to allow lengthening. Signs and symptoms review, CP is categorized first by the type of move- By definition, the defect in cerebral function causing ment/postural disturbance(s) present, then by a descrip- CP is nonprogressive. However, the symptoms of CP tion of which limbs are affected, and finally by the often change over time. For example, spastic diple- relate in some way to the aberrant control of muscles. To gia refers to continuously tight muscles that have no vol- GALE ENCYCLOPEDIA OF GENETIC DISORDERS 215 untary control in both legs, while athetoid quadraparesis Diagnosis describes uncontrolled writhing movements and muscle The signs of CP are not usually noticeable at birth. These three-part descriptions Children normally progress through a predictable set of are helpful in providing a general picture, but cannot give developmental milestones through the first 18 months of a complete description of any one person with CP. Children with CP, however, tend to develop these addition, the various “forms” of CP do not occur with skills more slowly because of their motor impairments, equal frequency—spastic diplegia is seen in more indi- and delays in reaching milestones are usually the first viduals than is athetoid quadraparesis. Babies with more severe cases of CP loosely categorized as mild, moderate, or severe, but are normally diagnosed earlier than others. Selected developmental milestones, and the ages for A muscle that is tensed and contracted is hypertonic, normally acquiring them, are given below. Spastic, not acquire the skill by the age shown in parentheses, hypertonic muscles can cause serious orthopedic prob- there is some cause for concern. A contracture is shortening of a • Babbles—6 months (8 months) muscle, aided sometimes by a weak-opposing force from a neighboring muscle. Contractures may become perma- • Crawls—9 months (12 months) nent, or “fixed,” without some sort of intervention. Fixed • Finger feeds, holds bottle—9 months (12 months) contractures may cause postural abnormalities in the • Walks alone—12 months (15–18 months) affected limbs. Clenched fists and contracted feet (equi- nus or equinovarus) are common in people with CP. This CP” refers not only to the number of symptoms present, same preference for one side of the body may show up as but also to the level of involvement of any particular class asymmetric crawling or, later on, favoring one leg while of symptoms. Mechanisms that can cause CP are not always It must be remembered that children normally restricted to motor-control areas of the brain. Other neu- progress at somewhat different rates, and slow beginning rologically–based symptoms may include: accomplishment is often followed by normal develop- ment. Other causes for developmental delay—some • mental retardation/learning disabilities benign, some serious—should be excluded before con- • behavioral disorders sidering CP as the answer. CP is nonprogressive, so con- • seizure disorders tinued loss of previously acquired milestones indicates • visual impairment that CP is not the cause of the problem. Babies that have low • abnormal sensation and perception Apgar scores are at increased risk for CP. About one-third of individuals with CP have mod- associated with CP include scarring, cysts, expansion of erate-to-severe mental retardation, one-third have mild the cerebral ventricles (hydrocephalus), periventricular mental retardation, and one-third have normal intelli- leukomalacia (an abnormality of the area surrounding the gence. Blood and urine biochemical tests, as well as genetic tests, may be used to rule out other possible causes, including muscle and peripheral nerve diseases, mitochondrial and meta- bolic diseases, and other inherited disorders. Evaluations by a pediatric developmental specialist and a geneticist may be of benefit. Cerebral palsy cannot be cured, but many of the dis- abilities it causes can be managed through planning and timely care. Treatment for a child with CP depends on the severity, nature, and location of the primary muscular symptoms, as well as any associated problems that might be present. Optimal care of a child with mild CP may involve regular interaction with only a physical therapist and occupational therapist, whereas care for a more severely affected child may include visits to multiple medical specialists throughout life. With proper treat- ment and an effective plan, most people with CP can lead productive, happy lives. Therapy Spasticity, muscle weakness, coordination, ataxia, and scoliosis are all significant impairments that affect the posture and mobility of a person with CP.

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It gives a politically correct standards by which experience can be view of stages of historical ordered and valued buy 500 mg tinidazole free shipping, and may involve development order 500mg tinidazole with mastercard, in respect of reflection tinidazole 1000mg discount. Influences occur from Existential or individuals/groups to be knowledge that derives from the knowledge that affect our polity cognitive influenced by knowledge cognitive organization (the set of determined order 500 mg tinidazole free shipping, in part discount 500mg tinidazole visa, by how we (unconscious) that relate to our social beliefs, attitudes, values) of other think about the constraints on domain environment. It ultimately determines group and individual freedoms, Worldviews consequence for our how we interact and influences our and in connection with this to Knowledge social structures and understanding of formative organize and behave. This appears to be consistent with the notion of Luhmann (1995), who considers information to be a set of coded events. It can also be defined as, that which enables a viewer to perceive greater variety differentiation in a complex situation • All knowledge is worldview local, and belief related. It can be defined as patterns of meaning that can promote a theoretical or practical understanding that enables the recognition of variety in complexity. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Connection between data, information and knowledge through the relationship between understanding and context, based on Bellinger (1996) Independence of context Context defining Wisdom Context forming Knowledge Context bound Information Context free Data Understanding relations patterns principles through a coalescing of information. If information is seen as a set of coded events, then consistency with Nonaka and Takeuchi occurs when they say that explicit knowledge is codified. The second part of the definition for information derives from Information Theory. It supports the idea that if the entropy of a situation is increased, structures become less differentiated. In a well-ordered situation there is a high probability of finding differen- tiation. If this is expressed in terms of distinct microstructures (that is, microscopically distinct structures), then they are differentiated through the boundaries or frames of reference that distinguish them. If a viewer is to be able to recognize that these boundaries or frames of reference are differentiable, then that viewer must be able to adopt concepts (that is, characteristics of knowledge) that enable differentiation. A view about the relationship between knowledge and information is based on Bellinger (1996), that provides an interconnection between data, information, data and wisdom derived through the relationship between contexts and understanding (Figure 2). According to this construction, data, as an unattached symbol or mark, are context free, and with no reference to time any point in space and time. Meaning is attributed to data by associating it with other things, that is, defining a context. Bellinger refers to wisdom as an understanding of the foundational principles responsible for the patterns representing knowledge being what they are, and it creates its own context totally. These foundational principles are completely context independent, and have been referred to here as context determining because the context is bound into the wisdom. A traditional view in finding information is to seek data, and this leads us to seek an appreciation of the relationship between data and information, and indeed between information and knowledge. Here, data can be processed into information (called data information) through the application of Copyright © 2005, Idea Group Inc. Copying or distributing in print or electronic forms without written permission of Idea Group Inc. Knowledge Cycles and Sharing 105 patterns of meaning that relate to organizational purpose. Data processing is also constrained by criteria of what constitutes a processing need. Information also exists phenomenally, through the very microstructural variety differentiation that exists in a structured situation. The model given in Figure 3 leads to questions about our under- standing of knowledge creation, and has consequences for the way in which we see knowledge development in organizations. For instance, how and through what means are the patterns of meaning formed that enable data to be processed, and information to be coalesced. Further exploration of knowledge processes within organizations can be developed within the context of knowledge management. There is a perhaps a better way than that of Figure 3 to describe the relationship between data, information and knowledge, that comes from an ontological model of viable systems that originates from Schwarz (1997). While data is not information, data classifications or classes can be described as entities that, when woven into a relational pattern can become information when conditioned by knowledge within an action setting. This occurs when information is analyzed, interconnected to other information within a thematic context, and compared to what is already known. A relationship between data, information, and knowledge cannot be considered indepen- dently of an agent that is involved in creating that relationship.

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For example generic 300mg tinidazole visa, patients with severe SAH may not be immediately amenable for either direct neurosurgical intervention tinidazole 1000 mg with visa, such as aneurysm clipping or endovascular treatment (see Chapter 12) purchase tinidazole 1000 mg free shipping, but may still have severe deficits and require ICP monitoring effective tinidazole 1000mg, blood pressure purchase tinidazole 500 mg amex, and volume management (such as hyperdynamic therapy). Common forms of stroke include ischemic stroke, such as major coronary artery occlusion, after which patients often develop severe brain swelling. This swelling can in some cases be ameliorated with ICP monitoring and occasionally by decom- pressive craniectomy. Deep intracerebral hemorrhages due to hypertension often also result in severe neurological deficits requiring intensive management, secondary medical problems, and hydrocephalus. All of these possibilities represent common reasons to stabilize and treat patients in a neuro- science ICU setting. For example, terminal care in patients with poor prognosis or brain death does not require ICU care, nor would patients in a permanent vegetative state who are stable. Also, physiologically stable patients may not require an ICU environment, because no critical treatment issues may exist. In most hospitals ICU are a scarce resource, and such a resource must be managed wisely, considering which patients may optimally benefit from expensive care and resources. Most neuroscience ICUs use detailed flowsheets to help monitor neurological func- tion, including assessment on the Glasgow coma scale for brain function, spinal cord function, and particularly detailed responses to environmental stimuli. Intensive neurological exams are usually performed at least every 2 hours by nurses specialized in neurological assessment. Detection of specific neurological events including sei- zures, herniation syndromes, changes in levels of consciousness and awareness, and spinal cord functions is critical. A key point is that detection of worsening may imply a cascade of pathological alterations that may be prevented by prompt treat- ment and management. In addition to neurological assessment, excellent general medical care is also critical and should include assessment of airway problems, need for continued intubation, nutrition, and methods of diet supplementation. In addition, maintenance of normal temperature, or in some cases lower than normal temperature (as in cooling), requires vigilance and possibly cooling blankets. Since most patients with severe brain alterations typically have intact gastrointestinal function, rapid resump- tion of nutrition is usually possible, initially through an orogastric or nasal tube into the small bowel. Prevention of infection, skin ulceration, and other medical problems is critical because these conditions may significantly slow recovery. Many monitoring functions such as arterial and intracranial pressures are viewed as analog signals and converted to numbers in the case of pulse rate, systolic and diastolic pressures, cerebral perfusion pressures, levels of oxygenation, etc. Typical systemic monitoring functions include cardiac pulse and blood pressure, temperature, weight, cardiac output, ventricular pressures, oxygenation and arterial blood gases, systemic electrolytes, and blood counts. Additional modalities specific to the neuroscience ICU setting include ICP measurement, cerebral oxygen and substrate levels, cerebral blood flow and transcranial Doppler monitoring, cerebral metabolism, electroencephalographic monitoring of seizure and electrical activity of the brain, and level of sedation. While most of these general and neurological modalities of monitoring are common, new methods of monitoring brain function continuously arise. Many monitoring procedures involve an overlap between monitoring and treatment capabilities, for example, ICP moni- toring and drainage. This fact led to the development of waveform analysis to reveal the compliance of the brain in response to incoming cardiac pulsation and to demonstrate whether pathological changes within the brain alter this compliance and lead to increased ICP. The freely diffusible CSF normally equilibrates the ICP around the brain rapidly and buffers the brain mechanically. Because CSF drains into veins with positive pressures (4 to 6 mmHg above sagittal sinus pressure), the usual pressure is 10 to 12 mmHg in a lateral horizontal position. As long as CSF can circulate freely, elevated ICP has no deleterious consequences on brain function, assuming that cerebral perfusion pressure remains in the normal range (65 to 70 mmHg typically). However, secondary systemic hypertension may occur as a reflex in order to maintain cerebral perfusion pressure if the ICP is elevated. This is clearly observed in the example of benign intracranial hypertension (BIH; formerly called pseudotumor cerebri prior to CT and MRI imaging). A CSF absorp- tion deficit is commonly present in BIH, but because normal CSF production con- tinues, CSF pressures can rise. Interestingly, since BIH commonly occurs in young patients with normal ventricular size (rather than hydrocephalus), the ventricles typically do not dilate. Visual loss and headaches are the only discernable abnormalities from high ICP in the absence of a mass, often up to 50 mmHg.

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To improve patency rates after administration of thrombolytics cheap 300 mg tinidazole free shipping, second buy tinidazole 1000 mg lowest price, third order tinidazole 300mg overnight delivery, and fourth generations of rtPA have been introduced discount tinidazole 500 mg line. The newer generations were developed by altering the terminal N units of rtPA and include tenecteplase (TNK) discount 500mg tinidazole mastercard, reteplase, alteplase, monteplase, lanoteplase, and pamiteplase. TNK is a mutant rtPA with higher fibrin specificity and longer plasma half-life due to slower clearance. Staphylokinase, a non-rtPA derivative produced by Staphylococcus aureus, has extreme fibrin specificity and a 6-minute plasma half- life, in comparison to 3 to 4 minutes for rtPA. Specificity to fibrin is thought to correspond to drug efficacy and lower incidence of hemorrhagic complications. The recanalization rate using IV rtPA is less than intra-arterial therapy, and the latter seems to be less with combined therapy. Even with the best strategy, the current pharmacological agents provide modest vessel patency rates and are time consuming to administer. Increasing the doses of therapeutic agents or combining different anti- platelet and fibrinolytic drugs may only lead to increased risk of ICH in stroke patients. This leads us to contemporary microendovascular device designs and innovative techniques that may provide significant advantages over pharmacological approaches. The Microsnare is a simple primitive design reported to capture or disrupt blood clots, but it can be associated with vessel dissection, perforation, or distal clot migra- tion. The © 2005 by CRC Press LLC nitinol corkscrew-like tip on the microwire can be pulled back to an inflated balloon at the tip of a microcatheter when the clot is captured. Ideally, the blood clot, the tips of the microwire, and the microcatheter should be engulfed by the end balloon and should be pulled out as one unit. Initial studies of nine vessels in swine models showed good retrieval and no dissection or perforation. A European trial known as the Neuronet evaluation in embolic stroke disease (NEED) is currently being conducted. The X-ciser uses a dual lumen microcatheter with rotating blades within a central hollow core and vacuum simultaneously to aspirate the debris of a clot. A total of 14 ischemic stroke patients were treated in the North American EKOS trial without any complications and with a 57% recanalization rate using the thrombolysis-in-myo- cardial infarction (TIMI 2–3) scale. A total of 31 vessels were treated with 48% recanalization rate (TIMI 2–3), although 2 vessels were perforated during microcatheter placement and before laser therapy. Embolic materials similar to those used for AVM and AVF therapies may be used to embolize tumor feeders. With enhancement of microbioengineering technology, new microcatheters, wires, and particles will lead to more effective adjunctive tumor embolotherapy. Larger Phase II studies planned Endovascular neurosurgery would be an effective and direct means of administering chemotherapeutic agents to brain tumors locally with fewer unwanted side effects from systemic administration. As the molecular biologies and bases of neoplastic diseases are being uncovered, the endovascular approach may be the choice in some cases to deliver gene therapy or newer and more effective antimitotic agents. The current microcatheter technology allows selective catheterization of small arterial branches to deliver higher concen- trations of therapeutic agents directly to the affected neuronal tissues. As the genetic codes unfold, the endovascular approach may become the preferred method of administering gene therapy to combat various genetic and degenerative diseases. Newer and more bio- compatible devices are becoming increasingly available and the interests of physi- cians and industry will hasten the progress even further. In the field of endovascular intracranial aneurysm therapy, the first and largest randomized control study (ISAT) comparing coiling to clipping was completed and published with positive results. When completed, they are © 2005 by CRC Press LLC expected to clarify the exact role of aneurysm coiling, taking into account the fact that U. Advances in microwire, microcath- eter, and guide catheter technology are also imperative to safer and more successful coiling. Angiography equipment in many endovascular suites includes three-dimen- sional rotational capability that allows better delineation of small vessels, aneurysmal origins, and aneurysmal neck and provides better endovascular guidance. Endovascular microangioscopy or aneurysmoscopy is still in its infancy, but may become the future imaging technique for cerebral aneurysms and AVMs. New nonadhesive embolic agents such as Onyx and Ethibloc allow reuse of microcatheters with fewer complications.

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