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Relapse rates are high with attempts to taper the steroids and multiple treatment courses may be necessary buy flomax uk man health in pakistan. The side effects of steroids buy cheap flomax 0.2mg line androgen hormone side effects, includ- ing weight gain order cheap flomax on-line prostate surgery procedure, hypertension, immunosuppression and infection, glucose and elec- trolyte abnormalities, cataracts, and avascular necrosis of the hip, often limit continued treatment. Additionally, steroids may significantly worsen behavior, which can be difficult to distinguish from the effects of the underlying disorder. Con- version to an every other day treatment regimen or once per week pulse steroids administered over two days helps to minimize side effects. In isolated reports, intra- venous immunoglobulin and the ketogenic diet have proved beneficial. Benzodiazepines may have a specific role in the treatment of these disorders. Intravenous administration of diazepam can suppress the electrical status epilepti- cus, but the effect is relatively short in duration, usually hours to days. Long-term suppression of the ESES can sometimes be achieved with a relatively high-dose bolus of diazepam followed by prolonged administration of oral diazepam. A suggested protocol that we have used with success is diazepam (1 mg=kg) administered per rectum, followed by oral administration of 0. Benzodiazepines seem to be most effective when administered in conjunction with another antiepileptic medication, such as sodium valproate. Recovery of language func- tion may occur after temporal lobectomy, but due to the risk of removing eloquent cortex, the procedure of multiple subpial transactions (MST) should be considered. The best outcome from surgery for LKS occurs when the child has: (1) normal cog- nitive and language development prior to the onset of symptoms; (2) relative preser- vation of nonverbal cognitive function prior to surgery; (3) evidence of a unilateral focus of the diffuse or bilateral discharges; and (4) duration of CSWS of less than 3 years. PROGNOSIS The long-term prognosis for both LKS and CSWS in guarded, but definitive predic- tions are difficult to make as most of the information comes from case reports and small case series with various treatment regimens. Overall, less than half of all chil- dren regain language function sufficiently to allow return to a regular school envir- onment. Somewhat better outcomes may be associated with surgical treatment, but selection criteria have limited this option to an extremely small subset of children. SUMMARY The LKS and CSWS are rare disorders of young children, characterized by a sub- acute deterioration of language, which tends to be a receptive aphasia in LKS and an expressive aphasia in CSWS. Varying degrees of cognitive, behavioral, and motor dysfunction are associated with the aphasia. Seizures occur in most children with these disorders, but are not the major challenge for treatment. The impaired lan- guage and cognitive dysfunction are correlated with the extent of electrical status epi- lepticus during sleep, which can be difficult to treat. Benzodiazepines given in conjunction with sodium valproate and corticosteroids are currently considered the most effective treatments. Surgery, in the form in multiple subpial transactions, may benefit a highly selected subset of patients. DIAGNOSIS AND TREATMENT OF SUBACUTE LANGUAGE REGRESSION, WITH OR WITHOUT SEIZURES Evaluation: 1. History and physical examination with screening CBC, metabolic studies to evaluate for hepatic, renal, or immunological dysfunction. An EEG, to include a minimum of 30 min of slow-wave sleep, and consider an overnight study to evaluate all stages of sleep. Consider SPECT, PET, MRS, magnetoencephalography for localization of regions of cerebral dysfunction. Coincident with diazepam administration, begin sodium valproate at 5–10 mg=kg=day in 2–3 divided doses, gradually increasing dose over 1–2 weeks to 20 mg=kg=day. If above regimen does not suppress ESES after 1 month, begin prednisone 2–3 mg=kg=day for 1 month with gradual taper over 3 months. If above does not prove beneficial, consider: addition of ethosuximide to sodium valproate; or substitution of lamotrigine or levetiracetam for sodium valproate. If ESES and language dysfunction and ESES persist for greater than 6–12 months, consider referral for surgical evaluation. Epilepsy and epileptiform EEG: association with autism and language disorders. The spectrum of neuropsychiatric abnormalities associated with electrical status epilepticus in sleep. Morrell F, Whisler WW, Smith MC, Hoeppner TJ, de Toledo-Morrell L, Pierre-Pouis SJC, Kanner AM, Buelow JM, Ristanovic R, Bergen D, Chez M, Hasegawa H. Landau– Kleffner syndrome—treatment with subpial intracortical transection. Treatment strategies in Landau–Kleffner syndrome and paraictal psychiatric and cognitive disturbances. Tassinari CA, Rubboli G, Volpi L, Meletti S, d’Orsi G, Franca M, Sabetta AR, Riguzzi P, Gardella E, Zaniboni A, Michelucci R. Encephalopathy with electrical status epilepticus during slow sleep or ESES syndrome including the acquired aphasia. INTRODUCTION Juvenile myoclonic epilepsy (JME) is an idiopathic generalized epilepsy (IGE) syndrome that typically appears in the second decade of life. Herpin wrote the first detailed description of a patient with JME in 1867. In 1957, Janz and Christian pub- lished their article on 47 patients with ‘‘impulsive petit mal. CLINICAL FEATURES There are a number of different epilepsy syndromes within the IGEs (Table 1). JME, childhood absence epilepsy (CAE), epilepsy with generalized tonic–clonic seizures on awakening (GTCA), and juvenile absence epilepsy (JAE) can present in late child- hood and adolescence. The JME is characterized by myoclonic, generalized tonic– clonic, and=or absence seizures. The typical age of onset is between 12 and 18 years of age (range 8–24). Myoclo- nic seizures occur as the only seizure type in only a small percentage of patients (3–12%). Myoclonic jerks are characterized by sudden, brief, bilateral symmetric, and synchronous muscle contractions that affect predominantly the shoulders and upper extremities. Many patients do not recognize these jerks as seizures until they manifest with a generalized tonic–clonic (GTC) seizure. Prior to diagnosis, the jerks may be interpreted as nervousness, clumsiness, or tics=twitches. A careful history with specific questioning for the presence of myoclonic jerks is critical to making a correct diagnosis of JME, as many patients may not volunteer these symptoms.

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Various surgical • Treat with antibiotics only if systemic symptoms present interventions are available in selected patients (see chapter 7) order flomax 0.2mg with mastercard mens health 55 workout. Patients with high tetraplegia generally have poor balance and have to be hoisted on to a padded shower chair which can be wheeled over a toilet cost of flomax man health news za. In some circumstances bowel evacuation may need to take place on the • Upper motor neurone cord lesion bed with the patient in the left lateral position cheap flomax 0.2 mg overnight delivery prostate oncology specialists inc. Patients who carry out manual evacuation are advised to keep their stools slightly constipated to ease removal. They should be able to transfer themselves onto a toilet, and the seat should be padded to prevent pressure sores from developing due to prolonged sitting. In practice most patients evacuate their bowels daily or on alternate days. When possible, the timing and frequency of bowel evacuation should be made to fit in with the Box 12. Patients are advised to maintain their bowel regime and to avoid • Daily or on alternate days strong oral and rectal stimulant laxatives and enemas. Further • Maintain consistent bowel regime educational principles are described in chapter 8 on nursing. Long-term options which can address chronic bowel management problems include colonic irrigation via the rectum, or through an abdominal stoma (an antegrade colonic enema), or a stoma, such as a colostomy. Autonomic dysreflexia Autonomic dysreflexia is commonly associated with bladder or Box 12. By the time of High lesion patients must: discharge from hospital, patients should be fully aware of the • be aware of the signs and symptoms signs and symptoms of autonomic dysreflexia and be able to • be able to direct care. In the long term, most patients tend to be • Diet of good nutritional standard, to include 5 servings of fruit constipated and will benefit from dietary re-education. A diet of and vegetables per day good nutritional standard but with a controlled calorific • Change of diet affects bowel management content is important. Care needs to be taken in changing the diet if constipation, or more seriously diarrhoea with a risk of bowel accidents, is to be avoided. Teaching the family and community staff When patients are discharged from hospital they should be thoroughly responsible for their own care. If the patient wishes, family members are given individual instruction on how to help in their care and have the opportunity to attend a study day about all aspects of spinal cord injury. If it is envisaged that the patient will require help in the community, district nurses and carers are invited to the spinal unit to work with the primary care teams, thereby enabling them to learn specific aspects of care for their prospective patients. The community staff can also be invited to attend study days which include the subjects of pressure sore prevention, bladder and bowel management, activities of daily living, long-term aspects of spinal cord injury, and psychological support. Most community staff welcome the opportunity to visit the spinal unit as spinal cord injury is not very common. The community liaison staff based at the spinal unit will also visit community staff to give support and advice. Preparation for discharge from hospital Providers of care Patients with high tetraplegia require a substantial amount of care, which will be given by other people. The family should not be expected to take responsibility for the delivery of care, however, especially as it will be required for many years, and they may already have work commitments that are financially Box 12. Usually, people with a high level of disability wish to maintain their independence as much as possible and so • District nurses choose to live independently, therefore it is essential that they • Care assistants • Resident carers/personal assistants: have help to do this. The patient may require the services of Privately employed district nurses and local care agencies. With financial support Employed by disabled person using state benefits the patient may be able to employ their own care such as a • Family live-in carer or personal assistant. Independent living becomes an achievable goal for the patient with the utilisation of these support services. If help and support are not given when the patient goes home from hospital this can increase pressure on the family unit and lead to the breakdown of relationships. Even if the family members are not providing the physical care it is important that they have their own space and time otherwise resentment can occur Box 12. Many patients with a spinal cord injury are young and were already making decisions about their future. It is very difficult for them to make major choices 62 Transfer of care from hospital to community of where to live and with whom and to decide who may be able to help them with their care. It is sometimes necessary to have a Aim for independent living temporary solution, and when they have had more time to To become totally responsible for their own care on discharge from adjust to their injury a more permanent solution can be found. Planning for independent living Many patients with tetraplegia choose to live independently, and initially statutory care facilities in the patient’s home may be used. These services may not be able to meet fully the care needs of someone with a high level of injury so they may need to be supplemented. Many people will prefer to employ a personal assistant to live in to help with personal care and daily living activities. This allows people to take control of their lives but requires them to develop skills in interviewing, financial management, and teaching. Initially, • Effective communication skills—assertiveness patients choosing this option often require additional support —telephone skills from the spinal unit for advice in relation to, for instance, advertising for carers and interviewing. Patients quickly become totally responsible for their own care on leaving the spinal unit. Planning for interim care When their homes have not been adapted for wheelchair use Box 12. Easing transfer from hospital to community The support of the district nursing service is invaluable in easing the transfer from the spinal unit to the community. The families are often reassured to know that there is Community liaison staff from spinal unit (within 6–8 weeks an effective link between the spinal unit and the community. To after discharge from hospital, thereafter on request) maintain this link the initial discharge plan may require a district nurse each morning to provide personal care with help from a care assistant. The early weeks at home The early weeks after discharge can be both physically and emotionally exhausting for all concerned. However well a patient’s community care is planned, problems may still arise. For this reason all patients are visited by the community liaison staff from the spinal unit usually within 6–8 weeks of discharge and at other times as required at the request of the patient, family, carers, district nurse, or general practitioner. Community liaison staff will meet with community staff and visit patients together to educate and further ease the transfer of care from the spinal unit to home. If the patient is travelling to a hot country fluid intake should be increased and catheters adjusted accordingly. Patients are advised to adjust their bowel regime • Telephone support and advice from spinal unit accordingly, and are taught how to carry out bowel care on a • Information resources—Spinal Injuries Association bed, should toilets be inaccessible. Cushions When travelling on a plane, patients are advised to keep their cushions with them and not to allow them to be stored in the hold with the wheelchair, as they can easily get lost.

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The web sites of many universities now carry information about how to use the web carefully and sensibly for your research and it is worth accessing these before you begin your background work flomax 0.2mg without prescription prostate cancer quotes. When you’re surfing the net flomax 0.4mg low price prostate cancer month, there are some extra precau- tions you can take to check the reliability and quality of the information you have found: X Try to use websites run by organisations you know and trust purchase flomax 0.4 mg without prescription prostate and masurbation. X Check the About Us section on the web page for more information about the creator and organisation. X Use another source, if possible, to check any informa- tion of which you are unsure. For example, if you’re interested in medical information you can check the HOW TO CONDUCT BACKGROUND RESEARCH / 43 credentials of UK doctors by phoning the General Medical Council. X You should check the national source of the data as in- formation may differ between countries. X For some topics specific websites have been set up that contain details of questionable products, services and theories. Interlibrary loans If you are a student your institutional library will prob- ably offer an interlibrary loan service which means that you can access books from other university libraries if they are not available in your library. This is a useful service if, when referencing, you find that a small amount of infor- mation is missing (see Example 5 below). EXAMPLE 5: GILLIAN Nobody told me the importance of keeping careful re- cords of my background research. I just thought it was something you did and then that was it, you got on with 44 / PRACTICAL RESEARCH METHODS your own research and forgot about what you’d done. Of course then I had to write my report and in the ‘background’ section I wanted to include loads of things I’d read when I first started the work. Even then I still forgot to write down the name and location of the publisher, so I had to go back to them again. My advice would be to look at how bibliographies are structured and imprint that in your brain so you don’t forget anything. Keeping records When you begin your background research, keep accurate records of what data was gathered from which source as this will save you plenty of time and frustration later, especially when you come to write your research proposal, or final report. A useful way to organise your background research is to have two files – one for primary research and one for secondary research. Each file can be divided into topics with the relevant notes slotted into each. Primary research For the primary research file, notes from each contact can be separated by a contact sheet which gives the name of the person, the date and time you met and a contact num- ber or address. Secondary research In the secondary research file, each page of notes can be headed by details of the publication in the same format that will be used in the bibliography – author and initials; date of publication; title of publication; place of publica- HOW TO CONDUCT BACKGROUND RESEARCH / 45 tion and publisher. If it is a journal article, remember to include the name of the journal; the page numbers of the article and the volume and number of the journal. It is also useful to include the location of this publication so that it can be found easily if needed again (website or li- brary shelf location). TABLE 2: SOURCES OF BACKGROUND INFORMATION PRIMARY SECONDARY Relevant people Research books Researcher observation Research reports Researcher experience Journal articles Historical records/texts Articles reproduced online Company/organisation records Scientific debates Personal documents (diaries, etc) Critiques of literary works Statistical data Critiques of art Works of literature Analyses of historical events Works of art Film/video Laboratory experiments SUMMARY X There are two types of background research – primary and secondary research. X Primary research involves the study of a subject through firsthand observation and investigation. X Secondary research involves the collection of informa- tion from studies that other researchers have made of a subject. X Any information obtained from secondary sources must be carefully assessed for its relevance and accu- racy. X Notes from primary and secondary sources should be carefully filed and labelled so that the source can be found again, if required. X When noting details for books, reports or articles which may appear in the final report, include all the details which would be needed for the bibliography. By now you should have decided what type of peo- ple you need to contact. For some research projects, there will be only a small number of people within your research population, in which case it might be possible to contact everyone. However, for most pro- jects, unless you have a huge budget, limitless timescale and large team of interviewers, it will be difficult to speak to every person within your research population. SAMPLING Researchers overcome this problem by choosing a smaller, more manageable number of people to take part in their research. In quantitative research, it is believed that if this sample is chosen carefully using the correct procedure, it is then possible to generalise the re- sults to the whole of the research population. For many qualitative researchers however, the ability to generalise their work to the whole research population is not the goal. Instead, they might seek to describe or explain what is hap- pening within a smaller group of people. This, they believe, might provide insights into the behaviour of the wider re- search population, but they accept that everyone is different 47 48 / PRACTICAL RESEARCH METHODS and that if the research were to be conducted with another group of people the results might not be the same. Market research- ers use them to find out what the general population think about a new product or new advertisement. When they re- port that 87% of the population like the smell of a new brand of washing powder, they haven’t spoken to the whole population, but instead have contacted only a sam- ple of people which they believe are able to represent the whole population. When we hear that 42% of the popula- tion intend to vote Labour at the next General Election, only a sample of people have been asked about their voting intentions. If the sample has not been chosen very care- fully, the results of such surveys can be misleading. Imagine how misleading the results of a ‘national’ survey on voting habits would be if the interviews were conducted only in the leafy suburbs of an English southern city. Probability samples and purposive samples There are many different ways to choose a sample, and the method used will depend upon the area of research, re- search methodology and preference of the researcher. Ba- sically there are two main types of sample: X probability samples X purposive samples. In probability samples, all people within the research po- pulation have a specifiable chance of being selected. These types of sample are used if the researcher wishes to ex- plain, predict or generalise to the whole research popula- tion. On the other hand, purposive samples are used if HOW TO CHOOSE YOUR PARTICIPANTS / 49 description rather than generalisation is the goal. In this type of sample it is not possible to specify the possibility of one person being included in the sample. Within the probability and purposive categories there are several dif- ferent sampling methods. The best way to illustrate these sampling methods is to take one issue and show how the focus of the research and the methodology leads to the use of different sam- pling methods. The area of research is ‘school detention’ and in Table 3 you can see that the focus and sampling techniques within this topic can be very different, depend- ing on the preferences of the researcher, the purpose of the research and the available resources. SAMPLE SIZE Thefirstquestionnewresearcherstendtoaskis‘how many people should I speak to?

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Second buy cheap flomax 0.4mg man health trend, the most up-to-date information is then available to any health professional accessing the health record of the client order cheapest flomax and flomax prostate 84. Clinicians must also be aware that evidence for use in court must be from a record that is contemporaneous with the event to which it relates (Quantum Development 2000) purchase flomax in india mens health vitamin guide. The Department of Health recommends recording information as soon as possible after the con­ tact and at least within the same working day. Any delay in recording notes may reduce the credibility of the professional in any complaint. HOW TO RECORD INFORMATION 33 Summary Points ° Information needs to be accurate, complete, relevant and accessible if it is to be of use to the health professional, whether this is a clinician, manager or administrator. It is not meant to be a definitive account, and the reader is advised to refer to the relevant legislation, health service circulars and guidance notes for a full and com­ plete account. Professional bodies and employers also provide standards in relation to health records management. There are four main issues to be considered in the management of health information: 1. Accountability A health record is a document that contains information about the physical or mental health of an identified individual, which has been made by or on behalf of a health professional in connection with the care of that individ­ ual (Data Protection Act 1998). Although the majority of records are pa­ per based (manual records), there are an increasing number of computer-based notes (electronic records). Health information may also be recorded in other ways such as on audio or visual cassette and CD-ROM. All NHS records are deemed public records under the Public Records Act (1958), and there are various levels of accountability relating to their management. The clinician is responsible for any records he or she creates 34 THE LEGAL FRAMEWORK 35 or uses. However, it is the NHS Trust or health authority that usually has ownership and copyright of these records (NHS Executive 1999). Chief executives and senior managers in these organisations are personally ac­ countable for the quality of the systems for managing records. Use and protection of client information A clinician has always had a common-law duty of confidentiality to his or her clients. In addition health records are covered by the Data Protection Act (1998), which stipulates that all processing of data must be fair and lawful within the context of common law. Therefore clinicians, NHS or­ ganisations and so on must comply with the common law of confidential­ ity when processing personal health information. Clinicians also have a duty to uphold their professional ethical code to keep client information confidential. A review of how the NHS manages and protects client information used for non-clinical purposes was carried out by a committee chaired by Dame Fiona Caldicott. Its report in 1997 made a number of recommenda­ tions for improving confidentiality and ensuring that access to personal health data was strictly on a need to know basis. Caldicott guardians have been appointed in all NHS organisations with the remit to oversee the safeguarding of confidentiality. The role is mainly advisory but the guard­ ian may help in the implementation of improvements. Clients must be informed about the different purposes for which infor­ mation is collected about them and with whom it may be shared (NHS Ex­ ecutive 1996). Information is gathered primarily to plan and deliver optimum health care to the client. However there are a number of other important uses that include ensuring effective health care administration (for example, clinical audit and risk management), teaching and research. The Department of Health recommends that clients are told how in­ formation might be shared before they are asked to provide it. This might be through the use of general information contained in leaflets and specific discussions between the client and the clinician as part of joint care plan­ ning. However, it is recognised that in health care it would be impracticable and unnecessary to obtain the client’s specific consent each time informa­ tion needed to be passed on. Health professionals must be able to respond to the needs of clients promptly. Personal health information needs to be readily available so that the most appropriate and effective care is deliv­ ered. Therefore health organisations need to advise clients that their per­ sonal information may need to be shared amongst health staff and with associated agencies, in order to plan and co-ordinate care. The client has a right to refuse permission for information to be passed on (subject to the exceptions detailed below). Clinicians will need to re­ spect the wishes of the client in such cases. However it is important that cli­ ents are made aware of the likely implications of this decision for their own health care and the impact on effective management of health services in general. Children and young people There is often some confusion regarding the rights of children and young people with regard to consent and confidentiality when receiving health care. THE LEGAL FRAMEWORK 37 ° Young people aged 16 or 17 years of age have the right to consent to treatment unless there is evidence of a lack of capacity (the Family Law Reform Act 1969). Consequently such young people also have the same rights to confidentiality as adults. In other cases the person with parental responsibility, who has consented to treatment on behalf of the child, would be involved in decisions about passing on information. There are certain exceptions to the duty of confidentiality where informa­ tion may be disclosed. Below are some examples: ° Where there is a statutory requirement to pass on information, for instance notification of communicable disease, the Public Health (Control of Disease) Act 1984, the Mental Health Act (1983), the Prevention of Terrorism Act (1989). It may therefore be necessary to share information with specific professionals and agencies. This often relates to the prevention of serious crime but can include such matters as a public health risk. Any unwanted paperwork containing personal details about clients must be disposed of using processes that protect confidentiality. For instance, they should not reveal passwords or allow others access to the computer under their identity and password. Care should be taken that computer screens are not left unattended or in view of public areas. THE LEGAL FRAMEWORK 39 ° Clinicians need to ascertain, when sharing information about clients with other professionals, that they have the same requirements regarding confidentiality (Shaw 2001). Access to health records Clients have had the right to have access to automatically processed health records since the first Data Protection Act in 1984. This has now been re­ placed by the Data Protection Act (1998), which came into force on 1 March 2000.

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