W. Ingvar. Black Hills State University.
When I was seven quality reminyl 4mg, another aunt cheap reminyl 8mg with mastercard, who lived just across the road buy cheap reminyl 8mg on-line, died purchase 4mg reminyl with mastercard, followed in a month by my uncle. With the deaths of so many relatives, I developed many fears, because no one had ever discussed death or the facts about these deaths with me. Because these events were never open to discussion, I never expressed my fears, nor did I receive the reassurance I needed. But his story, too, illustrates the child’s need for explanation and reas- surance. Whenever he visits Maine, he has a won- derful time with them and all of his cousins. On one visit, his grandfather, who had Parkinson’s, was experiencing a serious prob- lem with dyskinesia (involuntary movements). He demanded to know what was wrong, and, in response to explanations, why no one had told him! Any changes in a child’s life need to be made as painless as possible, whether they involve his or her parents’ divorce, a rela- tive’s death, or a grandparent’s Parkinson’s. It’s helpful to explain—in as positive a way as possible—what Parkinson’s means to you and your family. In talking with other families in which a member had Parkin- son’s, I learned that many adults would answer a child’s ques- tion but wouldn’t bring up the subject of Parkinson’s themselves. Many children are born into families that are coping with one problem or another, and they accept the problem as a familiar fact of life. The problems of Parkinson’s can become one of those familiar facts of life for the child. It’s expected that Grandpa takes a long time to shave, just as Billy takes a long time to tie his shoes, and Billy understands. Per- haps Billy has to give Grandpa a hand to help him out of a chair, just as there are many things that Grandpa does for Billy. Of course, the attitude of the whole family influences the child’s atti- tude toward the person who has Parkinson’s. Billy’s attitude will be a good one if the family thinks of every member as a blessing and not a burden. Let your grandchildren be as much a part of your life as they would have been if you had not had Parkinson’s. They will appre- ciate having someone with whom to play a game of checkers, take a walk, or just talk. With openness, the grandparent’s limitations become known, accepted, and even expected. But sometimes the child can be hap- pily surprised, as was Chris, the grandson of a man with Parkin- son’s whom we know. When Chris was born, Gramp had already had Parkinson’s for several years, and when Chris was five, Gramp retired. Gramp taught him how to ride a bicycle and how to skate and shared many other activities with him. Gramp’s slowness didn’t bother Chris, although every once in a while Chris needed to be reassured that Gramp was "all right. One day, Gramp proposed that they play a game of hockey, and they put on their skates. Pleased, because being with Gramp was always fun, Chris (now seven) expected a good but slow game. However, on this day, Gramp’s medication, attitude, and skating rhythm all worked together perfectly, and he surprised everyone by playing a fast, exciting game. Young children’s easy acceptance of problems is not necessar- ily true of teenagers. I’ve talked to a number of grand- parents with Parkinson’s who have similar stories. Their teenage grandchildren behave as if they’re unaware of a problem, but they’re obviously concerned. One grandmother’s observation is typical: her grandson seemed to be unsure of just how to handle the subject of her Parkinson’s and didn’t ask any questions. Never- theless, he was anxious to help, promptly opening doors, extend- ing a hand to help her up from her chair, bringing items she needed.
Shortly afterward buy 4 mg reminyl with amex, two guidelines for imaging of minor pediatric TBI (excluding nonaccidental trauma) were pub- lished generic reminyl 4mg visa. Management guidelines for minor closed head injury in children were developed by the American Academy of Pediatrics and the American Academy of Family Physicians in 1999 (112) reminyl 8mg without prescription. Patients are categorized by whether or not they had brief loss of consciousness (LOC) buy reminyl 4 mg visa. After the litera- ture review, the authors concluded that skull radiographs have low sensi- tivity and specificity for intracranial injury, and therefore low predictive value. They found no published studies that showed different outcomes between CT scanning early after minor head injury versus observation alone. They also reported no appreciable difference between CT and MRI in detecting clinically significant acute injury/bleeding requiring neurosurgi- cal intervention. Their proposed algorithm recommends observation only if there was no LOC, and allowed a choice of observation versus CT if there was brief LOC. Because CT is more quickly and easily performed and less expensive than MRI, CT was recommended over MRI for the acute evalua- tion of children with minor head injury. An evidence-based clinical practice guideline for management of children with mild traumatic head injury was developed by Cincinnati Children’s Hospital Medical Center in 2000 (113), although a summary of evidence was not detailed. There are fewer studies on the utility of imaging in predicting outcome in pediatric TBI compared to that in adults. Many studies have consisted of relatively small sample sizes and used varying outcome, possibly accounting for conflicting reports regarding outcomes related to TBI in chil- dren. There have been several studies evaluating CT in predicting outcome in children with variable results. Suresh and colleagues (106) (moderate evi- dence) studied 340 children and compared CT findings to discharge GOS outcomes. In addition there was a range of outcomes that were worse with (in descending order) fractures, EDH, contusion, diffuse head injury, and acute SDH. Hirsch and colleagues (114) (moderate evidence) studied 248 children after severe TBI and compared initial CT findings to the level of consciousness (measured by a modified GCS score) at 1 year after injury. They found that children with normal CT or isolated SDH or EDH were least impaired, while children with diffuse edema had the most impair- ment. Those with parenchymal hemorrhage, ventricular hemorrhage, or focal edema had intermediate outcomes. A study of 82 children (moderate evidence) found that unfavorable prognosis (using a three-category Lid- combe impairment scale) was more likely to occur after shearing injury or intracerebral/subdural hematomas, whereas a better outcome was more likely in patients with epidural hematoma (115). Another study of 74 chil- dren (moderate evidence) found that the presence of traumatic subarach- noid hemorrhage on CT was an independent predictor of discharge outcome (p < 0. After stepwise logistic regression analysis, CT find- ings did not have prognostic significance compared to other variables such as GCS and the oculocephalic reflex (104). Another study (moderate evi- dence) compared 59 children and 59 adults and found that a CT finding of absent ventricles/cisterns was associated with a slightly lower frequency Chapter 13 Neuroimaging for Traumatic Brain Injury 251 of poor outcome (6-month GOS) in children, suggesting that diffuse swelling may be more benign in children than in adults unless there was a severe primary injury or a secondary hypotensive insult (67). There have been some studies evaluating MRI for outcome prediction in children with TBI. Prasad and colleagues (103) (moderate evidence) prospectively studied 60 children with acute CT and MRI. Hierarchical multiple regression indicated that the number of lesions, as well as certain clinical variables such as GCS (modified for children) and duration of coma, were predictive of outcomes up to 1 year (modified GOS). Several investigators have studied the correlation between depth of lesion and outcomes, with varying results. Levin and colleagues (116) (moderate evidence) studied 169 children prospectively as well as 82 patients retrospectively with MRI at variable time points, and showed a correlation between depth of brain lesions and functional outcome. Grados and col- leagues (117) (moderate evidence) studied 106 children with a spoiled gradient echo (SPGR) (T1-weighted) MRI sequence obtained 3 months after TBI, and classified lesions into a depth-of-lesion model. Depth and number of lesions predicted outcome, but correlation was better with discharge outcomes than 1-year outcomes.
Additionally generic reminyl 4 mg with mastercard, this substitution was not confined to the art room or the miniatures buy generic reminyl 4mg. Gre- gory’s interpersonal relationships were fraught with resentment as the in- tensity of his animosity shifted from the father to less intrusive victims generic 4mg reminyl fast delivery. In the early stages of family therapy I utilized quiet listening and clari- fication to establish a safe environment that would foster insight and growth order reminyl 4 mg with mastercard. Gregory’s symptomatic behavior began to reflect the problems sur- rounding the marital dyad as issues related to complementarity (Nichols, 1984) and projective identification (Klein, 1946) came to the forefront. The basic structure of this exercise pairs the family constellation into even teams. Often I will direct specific family members to draw with each other; however, select situations call for a less directive approach and in these cases I allow the individuals to decide for themselves. After each pair appoints a leader, I direct them to think of a drawing they would like to complete. Through verbal communication the leaders help their partners to render an exact duplicate. If you recall the case review on Dion, in Chapter 5, this technique was illustrated through his rendering of Figure 5. The paired communica- tion drawing can be utilized in a multiplicity of ways and with any number of people. If you are in a group setting, or if the family has an uneven num- ber of participants, one individual can take on the role of leader while the remainder of the group members form a horseshoe with their backs turned away from one another. As with the majority of art therapy directives, the mental health professional is hindered only by a lack of creativity. Thus, you can employ numerous variations on this technique to maximize any number of goals or objectives. Due to this family’s dysfunctional interaction patterns, their invisible loyalties (Boszormenyi-Nagy & Spark, 1973), and regressive coping styles, I opted to determine the teams. As is evident from the completed drawings, the parents—the leaders of this communication-driven exercise—did not accomplish the goal of an exact rendering. The differences begin with the physical direction of the 280 Two’s Company, Three’s a Crowd? In the feed- back stage of this directive the family’s spontaneous comments focused on these tangible, visual, and clearly noticeable differences. Although these obvious signs engendered a spirited discussion, as I noted in Chapter 6, without illumination of the process the session will not be generalized because the interrelationships will be ignored. For this rea- son, I initiated a commentary on the interaction, which was fraught with conflict, power, and control issues. Of further note is that while the mother was directing her son, he not only abandoned the task when he did not understand her direction but was verbally cruel and judgmental, blaming his difficulty on her inadequacies. Similarly, the father, while giving instructions to Gregory, became frus- trated with Gregory’s questions and responded in a manner that was no- ticeably vague and distancing. In an effort to clarify, confront, and interpret I directed the discussion by asking the family which suggestions the partners had listened to and which ones they ignored. I followed this question by asking all the family members if they had listened the same way today as they generally did. The responses to both questions ranged from indifference and disregard (manifestation of transference by the younger son and father) to self- justification (a sense of cultural obligation on the mother’s part) and re- 281 The Practice of Art Therapy proach toward both his father and brother (defensive functioning by Gre- gory). This came about because the younger son made the brusque comment that if he had been the leader the results would have been better. Consequently, the father unexpectedly decided to give his son his wish, and the children thus became the leaders. Beyond the placement of the paper (which was perfect in both cases), the younger son did not pro- duce an improved response, as he once again became frustrated and sud- denly discarded the project while attempting to describe the vertical and horizontal lines.
Short ciliary nerves contain parasympa- thetic impulses from ciliary ganglion (Chapter 17) discount reminyl 8 mg mastercard. Continues as external nasal nerve supplying cutaneous sensation to anterior aspect and tip of nose order 8mg reminyl overnight delivery. The nerve impulses pass thus: cornea buy 8 mg reminyl with mastercard, nasociliary nerve discount 8mg reminyl mastercard, Va, principal sensory nucleus of V, brain stem interneurons,facial motor nucleus,VII,orbicularis oculi muscle. This may lead to displacement of the The ophthalmic nerve (Va) 55 orbital contents causing proptosis and squint, and sensory loss over the anterior nasal skin. The isolated area of palate and lip in these cases are supplied by Va through its external nasal branch which enters from above. In a unilateral cleft, Vb of one side is able to innervate the area in an asymmetric fashion. Some of its branches transmit postganglionic parasympathetic fibres from the pterygo- palatine ganglion which pass to the lacrimal, nasal and palatine glands (see Section 17. The maxillary nerve (Vb) 57 Trigeminal ganglion Foramen rotundum Zygomatic nerve with Pons parasympathetic fibres to lacrimal gland Infraorbital nerve Nasal, palatine and Pterygoid canal, pterygopalatine superior alveolar ganglion (parasympathetic fibres branches distributed with Vb as shown) Cutaneous distribution Zygomaticotemporal Zygomaticofacial Vb Infraorbital Fig. Infraorbital nerve – infraorbital skin, upper lip Passes anteriorly between orbit and maxillary antrum in infraor- bital groove. Two small cutaneous branches penetrate zygoma: zygomaticofacial and zygomaticotem- poral. Conveys postganglionic parasympathetic fibres from pterygo- palatine ganglion to lacrimal gland (see Chapter 17). Branches also convey postganglionic parasympathetic fibres from pterygopala- tine ganglion to nasal glands (see Chapter 17). Superior alveolar (dental) nerves Branches of infraorbital and palatine nerves pass directly through maxilla to maxillary teeth, gums and sinus. Branches also convey postganglionic parasympathetic fibres from pterygopalatine ganglion to minor saliv- ary glands in the palatal mucosa (see Chapter 17). Pharyngeal branch Passes posteriorly to contribute to sensory supply of nasopharynx. Note: sensory fibres travers- ing pterygopalatine ganglion, for example those from palate and nose, do not synapse there. Taste (visceral sensory) fibres: nucleus of solitary tract From scattered taste buds on palate. Axons ascend in palatine nerves, through pterygopalatine ganglion (no synapse), pterygoid canal, greater petrosal and facial nerve (cell bodies in geniculate ganglion). Central processes enter brain stem through nervus intermedius,pass- ing to nucleus of solitary tract (see Chapter 17). The maxillary nerve (Vb) 59 Parasympathetic fibres: superior salivatory nucleus Superior salivatory nucleus, nervus intermedius,VII, lacrimal, nasal and palatal glands (see Chapter 17). It transmits sensory fibres from the skin over the mandible, side of the cheek and temple, the oral cavity and contents, the external ear, the tympanic membrane and temporomandibular joint (TMJ). It is motor to the eight muscles derived from the first branchial arch: • temporalis, masseter • medial, lateral pterygoids • mylohyoid, anterior belly of digastric • tensor tympani, tensor palati As an aid to memory, note the four groups of two: tensors, ptery- goids, big muscles and the last two in the floor of the mouth. Some of its distal branches also convey parasympathetic secreto- motor fibres to the salivary glands, and taste fibres from the anter- ior portion of the tongue. The mandibular nerve (Vc) 61 Sensory fibres from Pons mandibular nerve, cell bodies in trigeminal ganglion Foramen ovale Trigeminal motor nucleus giving Buccal nerve rise to branchiomotor fibres passing in mandibular nerve to Lingual nerve first branchial arch muscles Inferior alveolar nerve Auriculotemporal nerve formed by two rootlets clasping middle meningeal artery Cutaneous distribution: Note: other branches of mandibular nerve are small twigs to muscles Auriculotemporal branches of buccal Mental, continuation of inferior alveolar Fig. Inferior alveolar nerve: lower teeth, skin, mylohyoid, digastric Enters mandibular foramen, supplies lower teeth. Just before man- dibular foramen, gives off nerve to mylohyoid and anterior belly of digastric, running in groove on medial aspect of mandible. Mental nerve emerges from mental foramen on anterior aspect of mandible to supply skin. Lingual nerve: tongue sensation Lingual nerve immediately below and medial to the third lower molar (wisdom) tooth. Passes forwards in floor of mouth, winding 62 Trigeminal, facial and hypoglossal nerves around submandibular duct. Conveys parasympathetic fibres from superior salivatory nucleus, and taste fibres to VII; these pass between lingual nerve and VII in chorda tympani (see Chapter 17). Auriculotemporal nerve: skin of temple, TMJ, external ear Arises beneath foramen ovale by two rootlets on either side of mid- dle meningeal artery.