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He lived to see his technique of anterior the Parisian medical scene hardly could have been spinal correction become accepted throughout unacquainted with one another safe prednisone 20 mg. He undertook several lecture tours overseas and demonstrated his technique of correction of scoliosis at major centers in Mexico discount 20mg prednisone otc, the United States prednisone 5 mg generic, Canada order prednisone 10 mg with mastercard, South Africa and Israel. Many orthopedic surgeons visiting Australia came to his hospital, the Mater at North Sydney, to learn his technique. Despite international acclaim, he remained his modest self, untouched by ostentation; he placed no importance on wealth, social status or patron- age. His interests outside medicine were diverse: he read widely and took a special interest in politics. For several years, he was state president of the Democratic Labor Party. He was also a deeply religious man, who, together with his family, found understanding, affection and support within the Catholic Church. During the last months of his illness, he devel- Allan Frederick DWYER oped an equanimity that gave reassurance and 1920–1975 ease to those most dear to him. Allan Dwyer died in Sydney on February 13, 1975, just 9 months Allan Dwyer’s father was a general practitioner after the onset of the illness that caused the tragic and his mother a warm, perceptive and capable end of an inspiring career. From Christian Brothers School at Lewisham, he secured a scholarship in medicine and a bursary of residence at St. He graduated with honors in 1942 and became resident medical ofﬁcer at St. After war service in Borneo with the Australian Army Medical Corps, he returned to general prac- tice with his father and started as a clinical assis- tant in the orthopedic department of St. This association was to nurture and develop Allan’s life-long enthusiasm for orthope- dic surgery. After obtaining the degrees of FRACS and MS in 1948, he rapidly began to show an outstanding ability for original thought and critical evaluation. His earlier work on the correction of severe defor- mity of the toes gave excellent results and won him countless grateful patients. His more recent work centerd on such formidable problems as scoliosis, the improvement of the rate of spinal 93 Who’s Who in Orthopedics hip resurfacing arthroplasty that he had seen there. This concept, which he developed, became known as the Indiana conservative hip. One of his proudest days was in the summer of 1979, when the American Academy of Orthopedic Surgeons sponsored a course in Indianapolis on resurfacing arthroplasty of the hip. He would internally stabilize intertrochanteric fractures on a standard operating table, using two plain radiographs to verify the correct position after placement of the nail. These nails were not cannulated, and the inferior ﬁn was several millimeters longer than the other two. EICHER lectual stimulation and camaraderie, and traveled 1904–1988 frequently with fellow members to Europe and Canada. Eicher was an associate clinical professor in Berne, Indiana, to Mennonite parents whose of orthopedic surgery at the Indiana University ancestors came from Bern, Switzerland. He was at his fun-loving best attended Indiana University and received his MD with medical students, interns, and residents. After internship at Indianapolis and his wife, Pluma, often entertained students General Hospital, he began the practice of general and house staff in their home, and he greatly medicine, in 1933, in Decatur, Indiana. He repeatedly Had it not been for World War II, he probably insisted that the years of postgraduate training would not have chosen to enter orthopedic train- were the best because of the rapid pace of ing. He joined the United States Army Medical assimilation of knowledge and the absence of Corps in 1942 and served a tour of duty in the the socioeconomic pressures of practice. On returning to the United States, When Pluma died of neoplasia in January he requested assignment to an orthopedic service, 1978, Dr. In even if it meant that he would not receive a 1982, after a bilateral cataract operation, a urinary promotion. He was assigned to the orthopedic tract infection led to a brain abscess. Next came service at Cushing General Hospital, Springﬁeld, a mitral valve replacement and then a mediastinal Massachusetts, of which Nelson Hatt was chief. Hatt for his innovative except the severe visual impairment, which was a ideas.
Active wrist extension is achieved cheap prednisone 40 mg fast delivery, by transferring the brachioradialis into the insertion of extensor carpi radialis brevis discount prednisone 20 mg visa. Relative factors in selection: Further surgical procedures include implantation of the • Adequate sensation in hand NeuroControl Freehand system (see below) cheap prednisone 10 mg mastercard, which is an upper • Minimal or no spasticity limb neuroprosthesis suitable for C5 and upper C6 spinal cord • Minimal or no contractures injured patients buy prednisone 20mg cheap, and procedures to achieve an intrinsic balance and improve hand function in lower cervical injuries. Functional electrical stimulation Following spinal cord injury, lower motor neurone pathways may remain intact and have the potential to be electrically stimulated. Functional electrical stimulation (FES) of paralysed muscles to restore function is becoming more commonly used, although only a few systems are commercially available, such as the NeuroControl Freehand system, the Handmaster, and the 71 ABC of Spinal Cord Injury ODFS. Eight electrodes are attached to specific muscles to Attempts to replace or improve missing functions, using the body’s achieve hand opening, lateral pinch, and hand grasp. The own muscles, through: implant is controlled by moving the opposite shoulder, which is • External devices connected by a lever to a “joystick” located on the central chest. Functional grasp patterns improve the user ability to perform specific activities of daily living. The forearm and wrist are held in a neutral position by the splint, on the inner surface of which are saline-soaked electrodes. These are placed over finger and thumb extensors and a thumb abductor, using pre-set patterns of stimulation to open and close the hand. Handmaster available from NESS (Neuromuscular Electrical Stimulation Systems Ltd), 19 Ha-Haroshet Street, PO Box 2500, Ra’anana 43654, Israel. ODFS available from Department of Medical Physics and Biomedical Engineering, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ, UK Tel: 01722 429065. Self-adhesive electrodes are placed over the common peroneal nerve as it passes over the head of the fibula. Stimulation is timed to the gait cycle using a pressure switch placed in the shoe. Trials of the ODFS have shown that walking can be less effort, faster, and safer. The benefits of FES include an increase in muscle bulk and blood flow in the legs. This may be at the expense of spasms becoming stronger as muscular strength increases, but the majority of people find that their spasms are more predictable and less frequent, especially in the period immediately after FES. Re-training muscles calls for a long-term commitment, and places great demands on the patient’s time. Ambulation remains a distant goal for people with complete injuries, although cycling on recumbent tricycles is feasible. Systems in incomplete injuries can significantly improve walking speed and performance. Ageing with spinal cord injury The spinal cord injury population is ageing, partly because survival rates following injury have improved, and partly Figure 14. Bottom: a C6 because the percentage of older people sustaining spinal cord tetraplegic patient at work using the Freehand system. The ageing spinal cord injured patient may present with several problems. In the case of people injured at a young age, if their parents are the carers, they will eventually be unable to cope, and may need care themselves. The majority of patients will put increased strain on their upper limbs due to propelling their wheelchair, transferring or walking with crutches and orthoses, and often after 15–20 years will have increasing pain and discomfort in the joints of the upper limb, particularly the shoulders. They may then become less independent and have to consider using additional aids such as transfer boards, hoists, and mechanical aids to lift their chairs into their car. They may have to change from a manual to a motorised wheelchair, and have a vehicle which they can drive from their wheelchair. A change in lifestyle to reduce the number of transfers, further domestic modifications, and an increased level of care may be necessary. For those in employment, a reduction in the number of hours worked or the taking of early retirement may be inevitable. Right: patient has previously coped well with a severe disability for most of with incomplete spinal cord injury using the dropped foot stimulator. Prognosis It is important to indicate the probable degree of recovery at an early stage to both patient and relatives to make planning for the future realistic.
At this time order prednisone 5 mg fast delivery, the diagnosis remains clinical: unilateral progressive epilepsy in the setting of atrophying brain prednisone 10 mg cheap. Aggressive medical management with anticonvulsant medication is uniformly unsuccessful order 10 mg prednisone with mastercard. Seizures can be contained to some degree buy prednisone 40 mg online, but they cannot be stopped; it is imperative that the physician pays careful attention to the amount of side effects produced by the medications, often for very little additional beneﬁt. Certainly, with the concern that RS may be viral- related, numerous attempts to treat with antiviral agents have been made with little success. The use of immunomodulatory therapy has increased over the last decade, inﬂuenced by the further understanding of the pathogenesis of the condition. Plas- mapheresis may produce a rapid, but unsustainable, improvement in the child’s con- dition and this may be important to the immediate management of devastating seizures. Various steroid protocols have been suggested, but again, none appear to offer sustained relief and there are the obvious problems inherent in the prolonged use of such treatment. Intravenous immunoglobulin (IVIg) is also a reasonable, albeit again short-term approach, for most individuals. There are various protocols suggested, including: monthly cycles of high-dose IVIg (0. Unfortunately, the only therapy that has shown consistently favorable results is surgery. There are a variety of approaches that appear to be useful, ranging from the hemidecorticectomy procedure used at Hopkins to functional hemispherectomy and the recently described hemispherotomy technique. Results appear quite similar with 80–90% of children experiencing either complete relief from seizures or negligi- ble auras. There is morbidity and mortality associated with this surgery and it should not be minimized. Problems include infection in about 5–10% and a need for shunt placement in about 20% of patients. This is clearly related to the elimination of seizures, but in addition, motor function also may actually improve in spite of the dense hemiplegia. This per- haps relates to the stability and predictability of the deﬁcit, rather than the unpre- dictability of motor function in the setting of recurring seizures. Postoperatively, the decline in intelligence appears to stabilize and some children actually improve. This may depend considerably on whether the right or left hemisphere is involved and the ultimate impact on language. It is perhaps also related to the extent of reha- bilitation services available to the child. We believe it is important for children and parents to participate in a network of other families in order to better understand the problems and solutions that may arise. THE FUTURE Improvement in care for patients with RS lies along many avenues. Certainly, a bet- ter understanding of the pathogenesis will lead to better therapies. This may include novel strategies such as immunoablation with high-dose cyclophosphamide, in which 124 Vining one attempts to eliminate the entire host population of ‘‘sensitized’’ T cells, or the use of other immunosuppressive agents such as tacrolimus. Improved neuroimaging may provide us with additional strategies to assess the impact of therapy. Surgical strategies need constant reﬁning, in order to eliminate the 10–20% of children who appear to be left with residual tissue or ‘‘nondisconnected’’ tissue. Finally, rehabilita- tion must improve with better strategies to improve gait; programs that might involve computer-assisted devices to improve hand and ﬁnger function; and ﬁnally improved understanding of the cognitive, language, and behavioral problems these children face so that they can function as productive, capable, and happy adults. Bien CG, Bauer J, Deckwerth TL, Wiendl H, Deckert M, Wiestler OD, et al. Destruction of neurons by cytotoxic T cells: a new pathogenic mechanism in Rasmussen’s encephalitis. Improvement in adult-onset Rasmussen’s encephalitis with long-term immunomodulatory therapy.
Anticonvulsants Divalproex has been approved by the FDA for migraine prophylaxis in adults prednisone 40mg generic. Starting dose is 5–10 mg=kg=day divided BID discount 10 mg prednisone, and is increased to a dose of 15–20 mg=kg=day discount 20 mg prednisone mastercard. It is available as an extended release preparation that can be used once daily buy 5mg prednisone amex. Common side effects include nausea, 228 Stephenson fatigue, weight gain, tremor, and alopecia. Rare side effects include thrombocytope- nia, hepatic dysfunction, and pancreatitis. Topiramate is a good choice for overweight patients with headache because of the often-coveted side effect of decreased appetite. Starting dose is 1–2 mg=kg (15 or 25 mg) qhs, and is increased by 15 or 25 mg increments weekly to the target dose, not usually to exceed 200 mg. Common side effects include digital and perioral parethesias, fatigue, concentration problems, word-ﬁnding difﬁculties, and weight loss. The incidence of kidney stones due to carbonic anhydrase inhibition is approxi- mately 1%, and is increased in those with a family history of kidney stones. There is an increased risk of oligohydrosis and heat stroke in patients taking topiramate. Zonisamide may be a suitable alternative to topiramate in those using oral contra- ceptive medications as topiramate can interfere with the efﬁcacy of estrogen contain- ing contraceptive medications. ALTERNATIVES Other agents effective in migraine prophylaxis include calcium channel blockers, selective serotonin reuptake inhibitors, gabapentin, zonisamide, and tizanidine. Botulinum toxin injections to the frontal and posterior neck muscles have been well studied in adult migraine, and have an extremely low risk of adverse effects. Never- theless, it remains a relatively unappealing option for both pediatric patients and families. Feverfew is a popular herbal remedy for fever and inﬂammation and more recently for headache prevention. There are little data on its use in pediatric patients and its safety proﬁle is not well established. The dose for young patients (up to 6 years) is 100 mg daily, 6–8 years 200 mg daily, 8–13 years 300 mg, and 13 years and up 400 mg. It tends to have a strong odor and taste and produces bright yellow urine. Magnesium at doses of 200–400 mg daily usually produces no side effects. Stress reduction techniques such as biofeedback yoga, counseling for stress management techniques, and exercise are complimentary to pharmacologic therapy. LONG-TERM CONTROL Although prophylactic medication is often necessary to break the cycle of chronic headache, optimal management of most chronic headache syndromes will rely on identiﬁcation and avoidance of trigger factors. Once headaches are well controlled on preventative medication, the dose should be slowly tapered off. Often headaches remain under reasonable control, especially if patients begin to adopt lifestyle changes to avoid headache triggers. A comprehensive treatment plan including realistic patient expectations, patient education, and judi- cious use of abortive and preventative medications is necessary for successful long-term control of migraines. The efﬁcacy of divalproex sodium in the prophylactic treatment of children with migraine. Effectiveness of amitriptyline in the prophylactic management of childhood headaches. INTRODUCTION While migraine is a well-recognized phenomenon in adults, it is often overlooked or minimized in children and adolescents.