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By C. Sivert. San Jose Christian College. 2018.

The locus is discussed with particular emphasis in relation to Fay and her support for her disabled brother Michael (see Chapter 6) and is identified in Table 2 buy discount sildalis 120mg line. Fay’s experience is also indicative of her own stigmati- sation by school children purchase sildalis 120 mg with amex, displaying disability by association order 120 mg sildalis mastercard. In order to understand the adjustments that children like Fay experience, reference to the stages in the bereavement process is helpful in explaining some typical reactions. Stages in bereavement Understanding of the adjustment which needs to be made to accomodate the effects of stress is aided by Kübler-Ross (1969), who classified the process of adjustment followed by individuals who reacted to the experience of bereavement. Bereavement follows the loss of a loved one and will trigger reflections about missed opportunities; such reflections can be both painful and pleasurable for the bereaved individual. Other models of grief reactions include Parkes (1975) and Worden (1991). All are concerned with individual reactions to bereavement as a significant 32 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES event, and it is suggested that, although all changes do not promote a bereavement reaction, the accumulation of stress resulting from home cir- cumstances for a sibling of a brother or sister with a disability, may in some, if not all cases, produce reactions which are similar to the bereavement process. Kübler-Ross identified five major reactive stages to bereavement: denial, anger, guilt, depression and acceptance. In order to achieve some form of adjustment, a person who is bereaved has to come to terms with their experience. There is a sense of working through each of the stages to achieve a level of acceptance. This mirrored a major theme which emerged from my interviews with siblings of brothers and sisters with disabilities – that they adjusted to different experiences, not especially at home, but at school and with their peers and friends. It seems that different experiences become stressing when the experience is out of the ordinary, but this is dependent on the resilience of the individual to accommodate change (see Chapter 6). The stage of depression identified by Kübler-Ross (1969) is not used as part of a sibling reaction because, following interviews, it emerged that ‘protection’ was a more representative term for the type of reaction that followed the experience of living with childhood disability. The sense too, is not of a linear progression through five stages of reaction; it is more likely to be an adaptation to a particular form of reaction that is identified, fitting a similar finding in my earlier work (Burke and Cigno 1996) which examined the need for family support and identified specific family response types. However, although it suggests a degree of ‘fixation’ according to the behavioural type identified, this is not to say that the char- acteristics are not amenable to change, and each confers some degree of advantage and disadvantage for the child concerned. All names used are invented to protect the identity of the child; also, some minor changes are made to case detail for reasons of confidentiality. Her reaction seems compatible with an internalised anger and an ability to express it. The interactive experiences A FRAMEWORK FOR ANALYSIS: THE RESEARCH DESIGN / 33 Table 2. Negative internal anger Jane & Richard reaction (high) (Ch. Negative external denial John, James & Harry reaction (low) (Ch. Compliant external guilt Joe, David & Daniel behaviour (see (Ch. Positive internal protection Jenny, Paul & reaction (low) Victoria (Ch. Positive external accepting Fay & Michael reaction (high) (Ch. The locus of control will help to decide where control might be initiated. The reality for most individuals is probably a mixture of internal and external control, 34 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES which to some degree determines the type of behaviour followed, whether internal or externally controlled. These observations are based on my professional judgement concerning each case and the need to formulate a problem-solving strategy once the reaction is understood. This is a dependence on expert judgement, which fits within Bradshaw’s (1993) division of social needs, where normative need is determined by professional interpretation. Clearly, there is some element of subjective bias in my categorising behaviours although the qualitative reflection of individual reactions across the range of behaviours reported has validity (Mayntz et al. The thesis concerning disability by association clarifies the reaction type reported, indicating, as clarified by Mayntz et al.

In issues of social need discount 120 mg sildalis with visa, it can seem that the disability comes first 120mg sildalis visa, for it is necessary to draw attention to a child’s unequal situation compared with other children order sildalis 120 mg amex. However, there is also a requirement for all children to be treated as children and future citizens without discrimination; otherwise the awareness of difference can be experienced as stigmatising. Family life: Disability by association Living in a family structure is a widely experienced phenomenon. The children within our families experience situations beyond the more ‘ordinary’ family experience: multi-professional and multi-agency contacts are not uncommon and, where uncoordinated, can be oppressive and confusing to consumers. Severely disabled children and their families are more likely to know about respite foster care, time spend in hostels, 124 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES hospitals, even hospices for children with short life expectancies, so that their family life has special features. The family itself and the experience associated with disability service may come to feel ‘disabled’, since others often participate in managing their daily routines over their lifespan. Support is a fundamental need for families when they are coping with stress and disruption, which form part of everyday living. Support is more often provided within the family, although informal care is enhanced when supplemented by professional services. Siblings growing up with disability may then experience a sense of disability by association, as they become known as the brother or sister of a disabled child, a fact some, as I have indicated, may conceal from school friends in an attempt to follow a ‘normal’ life. Such experiences are unfortunately a reflection of the unequal status attributed to disability and essentially a greater integration of children with disabilities may help to educate other children and reduce the stigma of disability. Unfortunately, the structural inequality imposed by adherence to a medical model will perpetuate the sense of disability and its associations, in reaffirming a sense of being different. The social imperative is to redress the lot of disability and like race, cultural and gender issues, insights are slow in coming and slower when attempting to implement attitudinal change. Children’s needs The needs of disabled children and siblings are not identical with those of parents, particularly as children grow up and begin to express their feelings. Although the views of family members may be similar, they are not coterminous. For instance, the parent’s perspective is qualified by their experience and role while the child’s is necessarily more intuitive and malleable. The needs of siblings vary and need to be taken into account, for they may need special help to enable them to manage the differences they perceive in their role and opportunities compared with their friends. Children need to know at a basic level that disability is not contagious or dangerous, so that they will see the person first, otherwise the experience of social exclusion will be reinforced for the child with learning disabilities. CONCLUSIONS: REFLECTIONS ON PROFESSIONAL PRACTICE FOR SIBLING… / 125 Assessments Social workers should appreciate that each individual has different needs and that the family as a unit has needs which may be different for each of its members. I note that an assessment of family needs will often result in conflicting views, which do not have a ready solution. Professionals and families alike experience an ambivalent impulse about the quality and quantity of services: satisfaction and dissatisfaction can exist simulta- neously. The way forward is to listen carefully to how families express their needs and to negotiate the way forward. It is important to have enough knowledge and information to be able to answer parents’ questions on their child’s development and care. Again, holistic assessments need at the very least a multidisciplinary approach, and I refer the reader to the account of its strengths and weaknesses within a multi-agency centre (Burke and Cigno 2000, p. It requires professionals to become involved with siblings, to be able to recognise need at both emotional and practical levels, together with the implications for service provision. A goal at one point may change to another, as need itself varies, and may be articulated differently as circum- stances change. The process of assessment should be subject to monitoring and review, rightly part of management enquiry, to enable an evaluation or re-evaluation of the assessment and intervention undertaken with the client (see Sutton and Herbert’s (1992) ASPIRE model). However, as Middleton (1996) is keen to point out, assessment is not the resolution of the problem; it is the intervention that follows which is important.

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Mononuclear osteoclast precursors buy sildalis 120 mg free shipping, stimulated by monocyte colony stimulating factor (M-CSF) order 120mg sildalis with mastercard, initiate osteoclastic activity discount 120mg sildalis, and bone resorp- tion begins. One article also demonstrated that even osteoblasts that become positive for macro- phage marker CD68 might play a role in periprosthetic bone resorption. Osteoblasts present phenotypic differentiation depending on the chemical composition of the debris particles. Particles are usually found in the cytosol of the cells following phagocytosis. Osteoblasts present extensive ruffled cell membranes, less developed endoplasmic reticulum, swollen mitochondria, and vacuolar inclusions. Metallic particles and their side effects are not only limited to the peri-implant site; they are also found in other organs, such as the peripheral blood, liver, spleen, and lymph nodes. Metallic particles in the liver or spleen were more prevalent in patients who had had a 4 Korkusuz and Korkusuz Figure 1 Metal implant–hard tissue interface and the biomaterial-initiated osteolytic and/or adaptive cascade. In one living patient, dissemination of titanium particles from a hip prosthesis with mechanical failure was associated with visceral granulomatosis reaction and hepatospleno- megaly, which required operative and medical treatment [41,42]. Even in well-functioning prostheses the serum and urine concentrations of titanium and chromium were found to be higher than in the normal population. Serum levels of bone-resorbing cytokine GM-CSF level Hard Tissue–Biomaterial Interactions 5 increased significantly in patients with aseptic loosening of hip prostheses. Patients having revision arthroplasty of the hip presented increased chromosome translocations and aneuploidy in their peripheral blood. Although intraarticular testing of titanium and chromium alloys in rats revealed no local tumor development a study of 12 cases on orthopedic implant–related sarcoma revealed using metallic implants as artificial joints might lead to severe end results. Two of the high-grade sarcoma of Keel’s study were located in the soft tissue and 10 in bone. Seven patients were reported to develop osteosarcoma, four malignant fibrous histiocytoma, and one a malignant peripheral nerve sheath tumor. Alloys that contain nickel had higher carcinogenic and toxic potencies. One important aspect of sarcoma arising from artificial joints is the differential diagnosis of infection. Chronic and long-lasting infections may trigger sarcoma. Aggressiveness, high-grade, and metastasis of sarcoma arising from artificial joints need precaution and awareness of the symptoms. Further studies related with this severe complication are essential. It is recommended that surgeons should (1) select prostheses with minimal susceptibility to metal corrosion and wear, (2) replace implanted prostheses when there is evidence of corrosion and mechanical failure, (3) carry out epidemiological studies to quantify cancer risk in patients with various types of metal implants, and (4) improve in vitro assays for carcinogenicity of alloys intended for use in bone tissue. Effectiveness of Metal Coatings Coatings or ion implantation [49–51] are usually used to improve the biocompatibility of im- plants and decrease metallic wear and corrosion. Rough or porous surfaces allow cell attachment. One simple method to allow tissue ingrowth into the implant is to modify its surface by implanting spherical beads or wire mesh. Though manufacturers’ manuals indicate these surface modifications allow bone cells to grow into the implants and increase their mechanical strength and biocompatibility, longitudinal, randomized, prospective clinical studies with long- term follow-up are lacking. A case report concerning bone ingrowth in a porous-coated knee arthroplasty revealed that the prosthesis was held in situ by collagenous tissue, and calcified bone did not appear to interact with the metallic coating. One in vitro experimental study, on the other hand, revealed that rough Ni-Ti surface promoted transforming growth factor beta (TGF- ) expression, a mediator of bone healing and differentiation.

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Headache may occur in hypoglossal lesions due to its connection with the ansa cervicalis buy generic sildalis 120 mg online. Signs Unilateral lesion leads to wasting of the ipsilateral side of the tongue and excessive furrowing buy 120 mg sildalis with mastercard. Deviation occurs towards the side of the lesion when the tongue is protruded buy cheap sildalis 120 mg on-line. Bilateral lesions cause difficulty in tongue protrusion, speech, and the ability to move food in the oral cavity. Patients are hardly able to eat, and have difficulty pronouncing “d” and “t” (see Fig. Pathogenesis This cranial nerve is rarely affected, except in disorders of the base of the skull and neck. Vascular: Vertebral basilary aneurysm, dissection of internal carotid artery. Infection: Basal meningitis, infections: mononucleosis, granulomatous meningitis, post vaccination mononeuropathy. Inflammatory/immune mediated: Rheumatoid arthritis: subluxation of odontoid process in rheumatoid arthritis, Paget’s disease. Iatrogenic: Surgery of the oral cavity and neck, carotid endarterctomy. Radiotherapy, in association with other cranial nerves. Compression of lateral part of tongue (with lingual nerve). Neoplastic: Schwannoma, primary nerve tumors (neurofibroma, neuroma). Metastasis to the base of the skull, meningeal carcinomatosis. Affection of hypoglossal canal by glomus jugulare tumors, meningioma, chordoma (some- times in association with other cranial nerves). Lymph node enlargement with Hodgkin’s disease and Burkitt’s lymphoma. Trauma: Head injury, penetrating head wound (often with other CN injuries), or dental extraction. Malformation: Chiari malformation Glossodynia: Burning pain in tongue and also oral mucosa, usually occuring in middle aged or elderly persons. Motor neuron disease Differential diagnosis Pseudobulbar involvement Treatment is based on the underlying cause. Therapy Agnoli BA (1970) Isolierte Hypoglossus- und kombinierte Hypoglossus-Lingualis-Paresen References nach Intubation und direkter Laryngoskopie. HNO 18: 237–239 Berger PS, Batini JP (1977) Radiation-induced cranial nerve palsy. Cancer 40: 152 Keane JR (1996) Twelfth nerve palsy: analysis. Arch Neurol 53: 561 Schliack H, Malin JC (1983) Läsionen des Nervus hypoglossus. Akt Neurol 10: 24–28 Thomas PK, Mathias CJ (1993) Diseases of the ninth, tenth, eleventh, and twelfth cranial nerves. In: Dyck PJ, Thomas PK, Griffin JP, Low PA, Poduslo JF (eds) Peripheral neuropa- thies. Saunders, Philadelphia, pp 867–885 80 Cranial nerves and painful conditions – a checklist CN Base of Sinus Neuralgic Other the skull cavernosus pain lesions lesions Optic nerve + Temporal arteritis, headache Oculomotor Metastases, + Tolosa Diabetes, giant cell arteritis, metastatic tumor, nerves meningeal Hunt lymphoma, leukemia, mucormycosis carcinomatosis syndrome Orbital disease: pseudotumor, sinusitis, ophthalmoplegic migraine Posterior fossa aneurysm: posterior cerebellar artery (PCA), basilar Trigeminal Metastasis, V 1 + V 1 Tolosa Hunt syndrome, jaw mastication nerve meningioma, Trigeminal ganglion gasseri neuralgia syndrome Glosso- + + Neck pain pharyngeal nerve Accessory Shoulder pain nerve Hypoglossal + Pain, connection via cervical plexus nerve Parasellar Trauma syndrome Neoplastic: adenoma, craniopharyngioma, epidermoid, ganglion Gasseri meningioma, neurofibroma, pituitary sarcoma Vascular: carotid artery aneurysm, PCA, carotid cavernous fistula, thrombosis, intracerebral venous occlusion Primary tumors: chordoma, chondroma, giant cell tumor Metastases: nasopharyngeal, squamous cell carcinoma, lymphoma, multiple myeloma Inflammatory: Fungal: mucormycosis mucocele, periostitis, sinusitis Viral: herpes zoster, spirchochetal Bacterial: mycobacterial Others: eosinophilic granuloma, sarcoid, Tolosa Hunt syndrome, Wegener’s Cervical + Cervical operations, surgery plexus References Kline LB, Hoyt WF (2001) The Tolosa Hunt syndrome. J Neurol Neurosurg Psychiatry 71: 577–582 Stewart JD (2000) Peripheral neuropathic pain. Lippincott Williams Wilkins, Philadelphia, pp 531–550 81 Cranial nerve examination in coma Genetic testing NCV/EMG Laboratory Imaging Biopsy Blink and + + Jaw Reflex Endocrine Structural Brainstem evoked potentials Metabolic Edema Motor evoked potentials Toxic (Magnetic stimulation) Somatosensory evoked potentials CN examination in coma Pupil Metabolic and toxic causes often spare the light reflex. Lids must be passively held open: anisocoria, examine consensual light reaction Early manifestation of herniation syndrome-decline of pupil, usually on the side of the mass.

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