Clinicians need to be aware of the potential for some AEDs to aggravate sei- zures in JME resulting in increased seizure frequency order 5 mg proscar, increased seizure severity buy 5 mg proscar otc, or the appearance of a new seizure type. Carbamazepine (CBZ) and phenytoin (PHT) both appear to have this potential with CBZ having the strongest aggravating potential, whereas the aggravating effect of PHT appears less prominent. Newer AEDs such as vigabatrin (VGB) and LMT also have the potential to aggra- vate myoclonic seizures and it is important that this potential is discussed with 96 Swink patients when prescribing newer medications. Finally, the ketogenic diet has been shown to be effective in treating all three seizure types common to JME and may be useful in refractory patients but rarely is indicated given the high response rate of JME to AED therapy. In general, I use either VPA or LMT in monotherapy as first-line therapy, followed by the combination in polytherapy. Should these choices fail, I would then consider TPM, ZNS, or LEV as monotherapy as equivalent second-line choices. If unsuccessful, VPA in combination with TPM, ZNS, or LEV may have a role before trying CZP or the ketogenic diet. SUMMARY The JME carries an excellent prognosis for the majority of patients who understand that their disorder is lifelong, requires treatment with antiepileptic medications to control the seizures, and who understand the importance of healthy lifestyle choices to minimize seizure recurrence. With appropriate education, counseling and medical treatment, 86–90% of patients will be seizure free or well controlled on medication. Chronic management of seizures in the syndromes of idiopathic generalized epilepsy. Treatment strategies for myoclonic seizures and epilepsy syndromes with myoclonic seizures. Conry George Washington University School of Medicine, Children’s National Medical Center, Washington, D. INTRODUCTION Progressive myoclonic epilepsy (PME) is a syndrome (not a specific disease) with myoclonic seizures and progressive neurological decline. The diagnosis of PME is based on the presence of a degenerative process which includes myoclonic seizures and progressive neurological dysfunction and which does not fit into any of the other myoclonic epilepsy syndromes. Myoclonic seizures are seen in a variety of epileptic syndromes, some benign and some malignant. All patients with PME at some point in the illness must have myoclonic seizures, which characteristically are brief shock like ‘‘jerks’’ involving the extremities and=or the head=neck and trunk. Myoclonic seizures can also consist of ‘‘negative myoclonus’’ which consist of a brief loss of tone and may be described as a ‘‘drop. In children, a typical cerebellar syndrome of trunkal ataxia, apen- dicular tremor, and hypotonia may be difficult to recognize until late in the disease. Subtle presentations in young children include developmental delay and failure to acquire motor milestones, in addition to a flat affect and nystagmus. An actual loss of milestones and deterioration in neurological function may occur months or even years after ‘‘developmentally delay’’ is diagnosed.

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The second goal is inform- ing policymakers about counterproductive health insurance and other public policies that are barriers to improving mobility generic proscar 5mg line. I primarily emphasize health-care delivery and payment policy order proscar 5 mg with mastercard, but the concept of “health” in- evitably extends broadly, reaching into homes, workplaces, communities, and the public spaces in which we all live. For individuals, restored independent mobility offers joy, empower- ment, and renewed hope. For society, “designing a flexible world for the many,” accessible to all regardless of their mobility ability, will serve everybody well (Zola 1989, 422). But significant personal, societal, health- system, and innumerable other hurdles impede the way. To examine these issues, I addressed three major questions in a project funded by the Robert Wood Johnson Foundation: How many adults living in communities have difficulty walking be- cause of chronic progressive diseases and disorders, and what are these health conditions? How do mobility difficulties affect people—their physical comfort, feelings about their lives, relationships with family and friends, and daily activities at home and in their communities? How do policies, especially for health-care delivery and payment, help and hinder people’s ability to maximize independent mobility, through enhancing the ability to walk pain-free and safely, modify- ing home and community environments, and providing assistive technologies? Mobility Limits / 3 These questions assume that getting out in the world is worth striving for, and that strategies exist to help us do so. Some approaches focus on individuals: reducing pain, obtaining assis- tive technologies, and redesigning daily activities. Making our public and private environ- ments and policies—homes, workplaces, educational settings, legal system, communal spaces, transportation networks, health-care providers, and re- imbursement policies—easier for and better suited to people with mobility difficulties will improve things for everybody. I concentrate here on certain people, defined by the extent of mobility dif- ficulties, underlying physical cause, and age. First, mobility limitations cover a broad spectrum, ranging from persons who still walk independently but more slowly and less surely than before to those who require complete assis- tance with all mobility tasks, such as turning in bed. With the most severe limitations, people need extensive or round-the-clock personal assistance at home or live in nursing homes or institutional settings, raising many com- plex and important issues. Here, however, I focus on the vast majority of peo- ple at the less limited end of the spectrum: persons living in the community without intensive personal assistance at home. Although these people have less severe mobility limitations, their walking difficulties nonetheless affect their daily lives. They rarely identify with others who have mobility diffi- culties or use services targeting people with impaired mobility. Like the saleslady’s mother, they therefore risk feeling alone and unsure of what to do. Second, I consider persons with chronic progressive diseases or disor- ders, not people with congenital or acute, generally traumatic conditions, such as spinal cord injury. The experience of growing up with limited mo- bility or suddenly losing mobility differs from the slow, progressive march of increasing impairment. Persons with congenital conditions such as cerebral palsy, spina bifida, and muscular dystrophy often enter (along with their parents) a bewildering and specialized health and social service labyrinth; these service systems frequently fall apart as children become adults. Persons with spinal cord and serious injuries have obvious needs for assistive tech- nologies and various rehabilitative services.

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Currently order 5 mg proscar mastercard, only metallic devices can be manufactured with thin-walled one-piece cementless sockets and excellent wear properties order proscar 5 mg line, especially for large femoral heads [18,19], making MOM the bearing of choice for resurfacing. Introduction Hip resurfacing with MOM bearings is the fastest growing procedure in the world and is playing a major role in the treatment of osteoarthritis (OA), especially for young patients [20–24]. However, most of the results published to date relate to resurfacing in a population essentially composed of patients treated for idiopathic or “primary” OA. In Asia, primary OA is extremely rare [25,26], and hip arthroplasty essentially applies to degenerative changes secondary to developmental dysplasia of the hip (DDH), osteonecrosis (ON), posttrauma (PT), slipped capital femoral epiphysis (SCFE), Legg–Calve–Perthes (LCP) disease, and inflammatory diseases (rheumatoid arthritis, etc. The purpose of the present study was to review the indications and assess the clini- cal results of a current metal-on-metal hip resurfacing design in a population of patients treated for nonprimary OA. Materials and Methods From a series of more than 950 hips treated with metal-on-metal hybrid resurfacing (Conserve Plus; Wright Medical Technology, Arlington, TN, USA), 208 patients (238 hips) underwent the procedure between November 1996 and June 2005 for a diagnosis other than primary OA. The degeneration of the articular cartilage was secondary to DDH in 82 hips (34. The surgical technique employed in this series has been described in detail in previous publica- tions [28–30], and the effects of the modifications made from the initial surgical technique have been evaluated. The patients were evaluated preoperatively, immediately after surgery, at 3 to 4 months, at 1 year, and then at yearly intervals. Radiographic data consisting of a low anteroposterior pelvis view, a modified table down-lateral, and a Johnson lateral view were collected at each visit. The radiographic analysis was similar to that reported in our previous publications. The clinical outcome of the surgeries was evaluated pre- and postoperatively using the University of California at Los Angeles (UCLA) hip scoring system and the Short-Form 12 questionnaire (SF-12). The Harris hip score was calculated postoperatively as an overall assessment of success comparable to other studies. The Surface Arthroplasty Risk Index (SARI) was calculated for each hip to evaluate the suitability of the group to be treated with a resurfacing procedure. A statistical analysis was performed using Kaplan–Maier survivorship curves and log-rank tests for comparison of survivorship data. Paired Student’s t tests were used for comparison of preoperative to postoperative clinical scores, and two-sample equal-variance t tests were used for comparisons of clinical scores with other groups of patients. Only one of these was associ- ated with clinical symptoms of loosening in a patient who was lost to follow-up. A narrowing of the femoral neck of 10% or more at the junction with the femoral component was observed in ten hips, but no definite association could be made with femoral component failure.

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