Nimotop

By G. Georg. William Woods University.

Foramen of Monro Occlusion of one foramen of Monro can occur secondary to a congenital membrane order nimotop 30 mg overnight delivery, atresia buy cheap nimotop 30mg line, or gliosis after intraventricular hemorrhage (IVH) or ventriculitis. The result- ing unilateral ventriculomegaly is often occult until early childhood, and may enlarge the ipsilateral hemicalvarium. An iatrogenic functional stenosis of the foramen of Monro can develop in chil- dren with spina bifida whose hydrocephalus has been treated with a ventricular shunt. The contralateral nonshunted ventricle occasionally expands secondary to deformity of the foramen of Monro. If symptomatic, the patient can be treated with a shunt system having two ventricular catheters, each draining a separate lateral ven- tricle or an endoscopic fenestration of the septum pellucidum with one ventricular catheter draining both ventricles. Third Ventricle Cysts and neoplasms within the third ventricle commonly cause hydrocephalus. Col- loid cysts are uncommon neoplasms that present superiorly and anteriorly within the third ventricle, and usually obstruct both foramina of Monro. Considered to Hydrocephalus 27 be congenital lesions, they can become symptomatic at any age. However, they rarely present within the pediatric population, and are commonly symptomatic between the ages of 20 and 50 years. They can cause either intermittent, acute, life-threatening hydrocephalus or chronic hydrocephalus. They are customarily trea- ted with resection via craniotomy, endoscopic resection, or stereotactic aspiration of the cyst. Ependymal and arachnoid cysts within the third ventricle usually present with hydrocephalus in late childhood. Patients may present with bobble-head doll syndrome, a rhythmic head and trunk bobbing tremor at a frequency of two to three times per second. While endoscopic fenestration is a treatment option, they are often treated with a ventricular catheter fenestrated to drain both ventricles and the cyst. The most common pediatric neoplasms that obstruct the third ventricle are craniopharyngiomas and chiasmal-hypothalamic astrocytomas. Hydrocephalus secondary to craniopharyngiomas usually resolves after surgical resection of the tumor. Hydrocephalus secondary to third ventricular region gliomas usually does not resolve after surgical resection, and ventricular shunt placement is often necessary. Cerebral Aqueduct The normal aqueduct of a neonate is 12–13 mm in length and only 0. Thus, it is prone to obstruction from a variety of lesions, including congenital aqueductal malformations, pineal region neoplasms, arteriovenous malformations, and periaqueductal neoplasms. Hydrocephalus secondary to aqueductal occlusion is generally severe and causes distension of the third ventricle and separation of the thalami, thinning of the septum pellucidum and corpus callosum, and compression of the cerebral hemi- spheres. Less than 2% of cases of congenital aqueductal stenosis are the result of the recessively inherited X-linked Bickers–Adams–Edwards syndrome, which is asso- ciated with flexion–adduction of the thumbs (‘‘cortical thumbs’’). Many pineal region tumors, especially germinomas, are highly radiosensitive; and success- ful tumor irradiation as well as surgical resection may adequately treat the obstruc- tive hydrocephalus. Low-grade astrocytomas are the most common periaqueductal pediatric neo- plasms that cause hydrocephalus. Historically, children with neurofibromatosis have often been diagnosed with ‘‘late-onset aqueductal stenosis. Fourth Ventricle In infants, the fourth ventricle is the location for obstruction secondary to Dandy– Walker cysts or obliteration of the basal foramina. Such occlusions result in the dilation of the lateral, third, and fourth ventricles above the obstruction. Dandy–Walker cysts are developmental abnormal- ities characterized by a large cyst in the fourth ventricle lined with pia-arachnoid and ependyma, hypoplasia of the cerebellar vermis, and atrophy of the cerebellar hemi- spheres. Arachnoiditis secondary to either meningitis or subarachnoid hemorrhage can also occlude the basal foramina and cause obstructive hydrocepha- lus. In addition, infants with Chiari II malformations and myelomeningoceles have hydrocephalus secondary to blockage of CSF flow from basilar obstruction.

Once you have narrowed your search to a few keywords cheap nimotop 30mg otc, you can start to think about the perspective you will take generic nimotop 30mg without prescription. Use question stems (Polit and Hungler 1995) to help define your enquiry. For example; ‘Infection control measures have reduced the incidence of MRSA. Questioning the 196 WRITING SKILLS IN PRACTICE proposition in this way prompts you to start examining relationships. In this case the association between the measures for controlling cross-infection and the incidence of MRSA is under scrutiny. Compare this with a more descriptive account of ‘What is cross-infection? There is no point starting on a topic that will produce only 3000 words when you are required to write 10,000. If you are sure that it will be sufficient you can start thinking about how you will phrase your title. Writing the title You might want to write your title as a question or a statement. Whichever one you choose it must reflect the content of the dissertation and indicate your approach to the topic. Compare ‘The role of infection control mea­ sures in reducing the incidence of MRSA’ with ‘A discussion about the lim­ itations of current infection control measures in reducing the incidence of MRSA’. Remember to keep the wording precise by eliminating any redundant words or phrases. The structure of your dissertation Your dissertation is most likely to be analytical in nature. Use it to demon­ strate your in-depth understanding of the subject matter and your ability to analyse and evaluate the information. The structure of your essay will be based on the keywords used in your title. What do you want to achieve with your work (for example, ‘to explore x’, ‘to evaluate y’ or ‘to analyse z’)? For example: A discussion about the limitations of current infection control measures in reducing the incidence of MRSA. The key words are ‘discussion’, ‘limitations’, ‘current infection control measures’, ‘reducing the incidence’ and ‘MRSA’. The themes are: DISSERTATIONS 197 ° infection control measures ° MRSA (incidence of) ° the relationship between infection control and the incidence of MRSA. The essay will examine the evidence for the effectiveness of infection con­ trol in reducing MRSA. Breaking the essay down into its component parts in this way will help you organise information into a logical sequence. The use of headings is probably advisable considering the length of a dissertation. For example, a section from the above essay might be headed ‘The incidence of methicillin resistant Staphyloccus aureus’. He or she will be able to sup­ port your studies and advise on the writing up of your project. References A dissertation is a reflection of the broad and in-depth reading you have undertaken during your enquiry. They will help distinguish your original thoughts and ideas from those of other researchers. The nature of these ref­ erences will also give an indication of whether the information you have used is current or not and the validity of your source material. Supplying a complete and comprehensive reference list will enable the reader to follow up sources for themselves. There are two main styles of referencing: ° the Harvard style ° the Vancouver style. The Harvard style The Harvard or ‘author–date’ system is well known and widely used within academic institutions. For books, the name of the author and the year of publication are placed in parentheses within the main body of the text, for example: 198 WRITING SKILLS IN PRACTICE Use question stems (Polit and Hungler 1995) to help define your enquiry. However, if there is more than one edition of the book then use the date of the revision or edition you are us­ ing.

Cross References Apathy; Hypermetamorphosis; Hyperorality; Hyperphagia; Hyper- sexuality; Visual agnosia Knee Tremor A characteristic tremor of the patellae buy nimotop 30mg online, sometimes known as knee bob- bing buy nimotop 30mg without a prescription, juddering, or quivering, may be seen in primary orthostatic tremor (POT; “shaky legs syndrome”). It is due to rapid rhythmic con- tractions of the leg muscles on standing, which dampen or subside on walking, leaning against a wall, or being lifted off the ground, with dis- appearance of the knee tremor; hence this is a task-specific tremor. Auscultation with the diaphragm of a stethoscope over the lower limb muscles reveals a regular thumping sound, likened to the sound of a distant helicopter. EMG studies show pathognomonic synchronous activity in the leg muscles with a frequency of 14-18Hz, thought to be generated by a central oscillator (peripheral loading does not alter tremor frequency). A number of drugs may be helpful in POT, including phenobarbi- tone, primidone, clonazepam, and levodopa, but not propranolol (cf. Archives of Neurology 1984; 41: 880-881 - 180 - Kyphoscoliosis K Brown P. Lancet 1995; 346: 306-307 Cross References Tremor Körber-Salus-Elschnig Syndrome - see NYSTAGMUS Kyphoscoliosis Kyphoscoliosis is twisting of the spinal column in both the anteropos- terior (kyphosis) and lateral (scoliosis) planes. Although such defor- mity is often primary or idiopathic, thus falling within the orthopedic field of expertise, it may also be a consequence of neurological disease which causes weakness of paraspinal muscles. Recognized neurological associations of kyphoscoliosis and scol- iosis include: Chiari I malformation, syringomyelia Myelopathy (cause or effect? Skeletal disease, such as achon- droplasia, is more likely to be associated with myelopathy than idiopathic scoliosis) Cerebral palsy Friedreich’s ataxia Neurofibromatosis Hereditary motor and sensory neuropathies Spinal muscular atrophies Myopathies, e. Some degree of scoliosis occurs in virtually all patients suffering from paralytic poliomyelitis before the pubertal growth spurt. Cross References Camptocormia; Stiffness - 181 - L Lagophthalmos Lagophthalmos is an inability to close the eyelid in a peripheral facial (VII) nerve palsy, with partial opening of the palpebral fissure. A sim- ilar phenomenon may be observed with aberrant regeneration of the oculomotor nerve, thought to be due to co-contraction of the levator palpebrae superioris and superior rectus muscles during Bell’s phe- nomenon. Cross References Bell’s palsy; Bell’s phenomenon; Facial paresis Lambert’s Sign Lambert’s sign is gradual increase in force over a few seconds when a patient with Lambert-Eaton myasthenic syndrome is asked to squeeze the examiner’s hand as hard as possible, reflecting increased power with sustained exercise. Cross References Facilitation Lasègue’s Sign Lasègue’s sign is pain along the course of the sciatic nerve induced by stretching of the nerve, achieved by flexing the thigh at the hip while the leg is extended at the knee (“straight leg raising”). This is similar to the maneuver used in Kernig’s sign (gradual extension of knee with thigh flexed at hip). Both indicate irritation of the lower lumbosacral nerve roots and/or meninges. The test may be positive with disc pro- trusion, intraspinal tumor, or inflammatory radiculopathy. Pain may be aggravated or elicited sooner using Bragard’s test, dorsiflexing the foot while raising the leg thus increasing sciatic nerve stretch, or Neri’s test, flexing the neck to bring the head on to the chest, indicating dural irritation. A positive straight leg raising test is reported to be a sensitive indi- cator of nerve root irritation, proving positive in 95% of those with sur- gically proven disc herniation. London: Imperial College Press, 2003: 362-364 Cross References Femoral stretch test; Kernig’s sign - 182 - Laterocollis L Lateral Medullary Syndrome The lateral medullary syndrome (or Wallenberg’s syndrome, after the neurologist who described it in 1895) results from damage (usually infarction) of the posterolateral medulla with or without involvement of the inferior cerebellum, producing the following clinical features: ● Nausea, vomiting, vertigo, oscillopsia (involvement of vestibular nuclei) ● Contralateral hypoalgesia, thermoanesthesia (spinothalamic tract) ● Ipsilateral facial hypoalgesia, thermoanesthesia, + facial pain (trigeminal spinal nucleus and tract) ● Horner’s syndrome (descending sympathetic tract), +/− ipsilateral hypohidrosis of the body ● Ipsilateral ataxia of limbs (olivocerebellar/spinocerebellar fibers, inferior cerebellum) ● Dysphagia, dysphonia, impaired gag reflex ● +/− eye movement disorders, including nystagmus, abnormalities of ocular alignment (skew deviation, ocular tilt reaction, environ- mental tilt), smooth pursuit and gaze holding, and saccades (lat- eropulsion) ● +/− hiccups (singultus); loss of sneezing. Infarction due to vertebral artery occlusion (occasionally poste- rior inferior cerebellar artery) or dissection is the most common cause of lateral medullary syndrome, although tumor, demyelination, and trauma are also recognized causes. Journal of Neuropathology and Experimental Neurology 1961; 20: 103-113 Pearce JMS. London: Imperial College Press, 2003: 233-236 Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Archives of Neurology 1993; 50: 609-614 Cross References Anesthesia; Dysphagia; Dysphonia; Environmental tilt; Gag reflex; Hemiataxia; Hiccup; Horner’s syndrome; Hypoalgesia; Hypohidrosis; Medial medullary syndrome; Nystagmus; Ocular tilt reaction; Oscillopsia; Saccades; Skew deviation; Sneezing; Vertigo Lateral Rectus Palsy - see ABDUCENS (VI) NERVE PALSY Laterocollis Laterocollis is a lateral head tilt; this may be seen in 10-15% of patients with torticollis. Cross References Torticollis - 183 - L Lateropulsion Lateropulsion Lateropulsion or ipsipulsion is literally pulling to one side. The term may be used to describe ipsilateral axial lateropulsion after cerebellar infarcts preventing patients from standing upright causing them to lean to toward the opposite side. Lateral medullary syndrome may be associated with lateropulsion of the eye toward the involved medulla, and there may also be lateropulsion of saccadic eye movements. Laughter - see AUTOMATISM; PATHOLOGICAL CRYING, PATHOLOG- ICAL LAUGHTER Lazarus Sign Various spontaneous and reflex movements are described in brain death, the most dramatic of which has been labeled the Lazarus sign, after Lazarus, raised from the dead by Christ (John 11:1-44). This spinal reflex manifests as flexion of the arms at the elbow, adduction of the shoulders, lifting of the arms, dystonic posturing of the hands and crossing of the hands. Neurology 2000; 54: 221-223 Bueri JA, Saposnik G, Mauriño J, Saizar R, Garretto NS.

Increased ICP can arise from the structural lesions mentioned above buy nimotop 30mg online, as well as hydrocephalus nimotop 30mg on line, meningitis, and pseudotumor cerebri. The retinoids cis-retinoic acid and fenretinide, used in neuroblastoma, and all-trans retinoic acid, utilized in acute promyelocytic leukemia, can cause pseudotumor. The clinician should maintain an orderly approach to the urgent and emergent treatment of increased ICP (Table 4). SEIZURES Seizures in children with cancer may arise from primary brain tumors or metastatic disease, leukemic meningitis, stroke, CNS infection, metabolic abnormalities, or treatment sequelae. Intrathecal methotrexate can cause seizures 7–10 days after administration, while high-dose intravenous methotrexate can lead to seizures more acutely. Standard neu- rologic management of status epilepticus and seizures, described elsewhere in this book, should be followed. For the child undergoing chemotherapy, special consid- eration should be given to the choice of antiepileptic agent. Recent data have shown marked reduction in bioavailability of chemotherapy metabolized by the cytochrome P450 mono-oxygenase system, when patients concurrently receive the enzyme- inducing anticonvulsants phenytoin, phenobarbital, or carbamazepine. For these children, if chronic anticonvulsant therapy is warranted, selection of a non-enzyme-inducing agent, such as gabapentin, levetiracetam, lamotrigine, or topiramate, is preferable to avoid this complication. Furthermore, carbamazepine and valproic acid are avoided owing to their potential bone marrow myelosuppression. MYELOPATHY The neurologist should always think beyond cerebral processes and consider myelo- pathy to explain motor loss, sensory deficit with a dermatomal level, or autonomic (i. Spinal irradiation, months to years after its administration, can lead to myelopathy, often symmetric. Intrathecal agents, 258 Fisher Neurologic Effects of Cancer 259 260 Fisher Table 3 Differential Diagnosis for Stroke in the Child with Cancer Acute promyelocytic leukemia Chemotherapeutics BCNU (carmustine) intra-arterial Cisplatin intra-arterial l-Asparaginase Hyperleukocytosis, in leukemia Intratumoral hemorrhage—high-grade astrocytoma, medulloblastoma Methotrexate-associated stroke-like events days to a week plus after intravenous high dose Neuroblastoma metastatic to the dura or torcula Platelet-resistant thrombocytopenia such as cytarabine, methotrexate, and thiotepa, can cause acute to subacute spine necrosis, specifically when these drugs distribute unevenly in the subarachnoid space because of blockage from tumor. Nuclear medicine studies with technetium or indium can often demonstrate blockage in the presence of leptomengineal disease, even when spine MRI appears to show patent spaces. SPINAL CORD COMPRESSION The most alarming cause of myelopathy in the oncology patient is compression of the spinal cord by tumor. Tumor most often infiltrates through intervertebral foramina, unlike in adults where vertebral body involvement is more often found. Epidural tumor spread through the foramina is seen most frequently with Ewing sarcoma, neuroblastoma, osteosar- coma, rhabdomyosarcoma, Hodgkin disease, and non-Hodgkin lymphoma. Spinal subarach- noid tumor can develop with leukemia and ‘‘drop metastases’’ from the primary brain tumors medulloblastoma, embryonal tumors, ependymoma, and astrocytoma. In addition to the signs of myelopathy already described, these patients com- monly have exquisite back pain and localized tenderness to percussion over the spine. For children suspected to harbor pathology of the inferior cord, spending con- siderable time distinguishing between localization to the conus medullaris (i. Instead, to expedite diagnosis for any child suspected to have spinal cord compression, spine MRI is always the study of choice. Emergent treatment of spinal cord compression should commence with dexa- methasone 1 mg=kg intravenously. In suspected cases of lymphoma, the oncolytic effect of steroids can be so profound that biopsy should be performed immediately to confirm diagnosis. For some tumors, laminectomy and posterior decompression may suffice as initial therapy, along with steroids. Surgery is particularly recom- mended as initial therapy when the primary tumor is unknown and another easily accessible disease site cannot provide the diagnosis, all or most of the neoplasm can be removed, or relapse occurs during or after maximal radiotherapy. Thrombo- cytopenia and coagulopathy should be corrected before surgery (or before lumbar puncture, as described above) is attempted. If the diagnosis is known and the tumor radioresponsive, then radiotherapy is the therapy of choice. A few reports of initial chemotherapy for young children with spinal cord compression and newly diagnosed neuroblastoma, Ewing sarcoma, germ cell tumors, and osteo- sarcoma have shown efficacy, but the symptomatology of these patients is often minimal and the choice of therapy nonrandomized. ATAXIA As ataxia connotes simply incoordination, the clinician should exclude cerebral or spinal processes already described before localizing the process to the cerebellum.

The Ayre’s T-piece with the open-ended bag (Jackson Reece modification) is not recommended because it requires specialist training to be able to operate it safely and effectively buy nimotop 30mg on-line. Management protocols for advanced life support Having established an airway and effective ventilation with high inspired oxygen purchase nimotop 30 mg on-line, the next stage of the management depends on the cardiac rhythm. The infant or child must therefore be attached to a cardiac monitor or its electrocardiogram (ECG) monitored through the paddles of a defibrillator. Laerdal face masks 46 Resuscitation of infants and children Non-ventricular fibrillation/non-ventricular tachycardia Two arrest rhythms Asystole is the commonest cardiac arrest rhythm in infancy and childhood. It is the final common pathway of respiratory or ● Non-VF/VT: asystole or pulseless electrical activity circulatory failure and is usually preceded by an agonal ● Ventricular fibrillation or pulseless bradycardia. Care must be taken to ensure that the electrocardiograph leads are correctly positioned and attached and that the monitor gain is turned up. Effective basic life support and ventilation with high-flow oxygen through a patent airway are essential. Having established a secure airway and intravenous or intraosseous access, 10mcg/kg (0. If asystole persists, further three-minute sequences of CPR with adrenaline (epinephrine) at doses of 10-100mcg/kg (0. Alkalising agents are of unproven benefit and should be used only after clinical diagnosis of profound acidosis in patients with respiratory or circulatory arrest if the first dose of adrenaline (epinephrine) has been ineffective. The dose of bicarbonate is 1mmol/kg and is given as a single bolus by slow intravenous injection, ideally before the second dose of adrenaline (epinephrine). If an alkalising agent is used then the cannula must be thoroughly flushed with normal saline before any subsequent dosing with adrenaline (epinephrine) because this drug will be chemically inactivated by the Asystole in an infant or child alkalising agent. Subsequent treatment with alkalising agents should be guided by the blood pH. A bolus of normal saline should follow the intravenous or intraosseous injection of any drug used in resuscitation, especially if the injection site is peripheral. When cardiac arrest has resulted from circulatory failure a larger bolus of fluid should be given if no response or only a poor response to the initial dose of adrenaline (epinephrine) is seen. Examples PEA of such cases are children with hypovolaemia from blood loss, ● Absence of cardiac output with normal or gastroenteritis, or sepsis when a profound distributive near normal ECG hypovolaemic shock may occur. These children require ● ECG evidence in pulseless patient 20ml/kg of a crystalloid (normal saline or Ringer’s lactate) or a colloid (5% human albumin or an artificial colloid). Pulseless electrical activity Formerly known as electromechanical dissociation, pulseless electrical activity (PEA) is described as a normal (or near normal) ECG in the absence of a detectable pulse. If not treated, this rhythm will soon degenerate through agonal bradycardia to asystole. It is managed in the same way as asystole, with oxygenation and ventilation accompanying basic life support and adrenaline (epinephrine) to support coronary Broad and slow rhythm is associated with pulseless electrical activity and cerebral perfusion. Ventricular fibrillation and pulseless ventricular tachycardia Ventricular fibrillation is relatively rare in children, but it is occasionally seen in cardiothoracic intensive care units or in patients being investigated for congenital heart disease. In contrast to the treatment of asystole, defibrillation takes precedence. Defibrillation is administered in a series of Ventricular fibrillation and pulseless three energy shocks followed by one minute of basic life ventricular tachycardia support. The defibrillation energy is 2J/kg for the first shock, ● Characteristic ECG in pulseless patient 2J/kg for the second rising to 4J/kg for the third and all ● Relatively rare in children subsequent defibrillation attempts. For defibrillators with ● Treatment is immediate defibrillation 47 ABC of Resuscitation stepped current levels the nearest higher step to the calculated energy level required should be selected. Ventilation and chest compressions should be continued at all times except when shocks are being delivered or the ECG is being studied for evidence of change. Paediatric paddles Endotracheal tube should be used in children below 10kg, but in bigger children Oral Internal the larger adult electrode will minimise transthoracic length diameter (cm) (mm) Length 5060 80 100120 140 150 cm impedance and should be used when the child’s thorax is 14 18-21 7. One paddle should be placed over the 8 apex of the heart and one beneath the right clavicle. Therefore, it is important to seek endotracheal out and treat the initial cause of the cardiorespiratory collapse. It is important to become familiar with and to use one rectal of these systems. Non-standard drug concentrations may be available: from paediatric resuscitation attempts.