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Infants with a shunt malfunction usually present with irritability cheap nizoral 200mg mastercard, poor feeding, increased head circumference, and=or inappropriate sleepiness. Children with a shunt malfunction usually present with headache, irritability, lethargy, nausea, and=or vomiting. However, it is important to inquire if the signs and symptoms that the child is presenting with are the same as those during a shunt malfunction in the past. The child can present with waxing and waning symptoms, or can alternatively present with a progressively worsening picture that does not improve until the shunt is revised. A child complaining of pain with a clinical picture consistent with shunt obstruction should not be given narcotics because of possible respiratory depression or arrest. When a shunt malfunction is suspected, neuroimaging studies should be obtained after a careful history and physical examination. A head CT, as well as anteroposterior and lateral skull, chest, and abdominal radiographs are obtained to evaluate for increased ventricular size and shunt hardware continuity. Even though a majority of children with a shunt malfunction present with increased ven- tricular size on neuroimaging studies, there are those whose ventricular size does not change because of decreased brain compliance (i. In these chil- dren, a shunt tap through the reservoir or valve is indicated to test the adequacy of CSF ﬂow and the intracranial pressure. Children who are diagnosed with a shunt malfunction are taken promptly to the operating room for shunt revision. The presence of a ﬂuid collection in the subcutaneous tissue in proximity to the shunt track is sugges- tive. A collapse of the valve without quick reﬁlling of CSF may indicate a shunt obstruction. Finally, the shunt reservoir can be accessed by a 23- or 25-gauge butterﬂy needle. The presence of spontaneous ﬂow with good respiratory variations up the tubing or in a manometer connected to the butterﬂy indicates patency of the ventricular catheter.
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Combined with pressures from expensive new medical discoveries nizoral 200 mg with amex, future costs may tighten coverage on items outside the acute medical paradigm. Stan Jones (personal communication, 6 February 1998) believes “we’re seeing a retrenchment with regard to buying wheel- chairs and a variety of assistive devices and other services” that aim toward improving daily functioning and quality of life. Competition among health plans based on their premiums is causing more and more conservative decisions and making it harder and harder for people to get these services. Sometimes there’re no crite- ria anywhere deﬁning what’s covered under what circumstances. Sometimes plans just don’t offer it or keep it in the background, not offering it unless the person asks. And if they ask, sometimes it’s hard to get, or it takes a long time, so most people give up. Jones believes that society must decide whether funding mobility aids is a priority, “because we’re heading away from covering them. Patrick O’Reilley runs a neighborhood health center where all his patients are poor. Like Christopher Reeve has a great wheelchair because he’s a professional person; he has money. No in- surance company is going to pay for a scooter for some of my pa- tients. They’d be reading the back of Arthritis Today and say, “Oh, I want that scooter! The fa- ther is a physician, retired from practice but still well connected and vigor- ous. Julie, in her mid forties, had quit working several years ago because of MS. Without respite, it waxes and wanes, bringing disheartening new symp- toms and giving her little peace.
SUGGESTIONS FOR FUTURE RESEARCH Canadian policy researchers have concluded that more research needs to be done prior to inclusion of alternative and complementary therapies within Canadian public health provision (Achilles 2001; Tataryn and Verhoef 2001) buy nizoral 200 mg with visa. I would add that in particular, research on the efficacy of these therapies from the lay perspective is required. Very few studies have examined how lay people assess the effectiveness of the alternative and complementary approaches to health and healing they use. Furthermore, the bulk of this literature does little more than report that people believe that they derive a benefit from their participation in alternative and complementary therapies10 and/or are highly satisfied with their experiences with these therapies. Such research would provide us with a more holistic understanding of what works and also with better evidence to determine which therapies should be included within Medicare. Another direction for future research concerns the following question: To what extent do alternative approaches to health and healing continue to constitute a challenge to biomedical dominance and thus serve as a catalyst for change within allopathic health care? For example, Schneirov and Geczik (1996) argue that the users of alternative therapies are members of a new social movement that presents an institutional challenge to bio- medicine, and Wolpe (1990:922) concludes that alternative practitioners serve as “gatekeepers of orthodox medicine” who have the freedom to experiment with new therapies which can then be incorporated into allopathic practice, thus expanding the range of therapeutic techniques available under public health care provision. However, Schneirov and Geczik (1996:638) also assert that participation in alternative approaches to health and healing constitutes a social network movement that is “submerged within everyday life rather than engaging in visible political Conclusion | 125 activities that confront authorities. Therefore, research should track the influences of the movement towards integration of allopathic and alternative approaches to health and healing, in addition to the inclusion of alternative therapies within public health provision, to determine the effect of these processes on the potential of alternative therapies, as well as on the lay people and practitioners who use them, to continue to play an innovative and revolutionary role within the health care system. Portions of this chapter were previously published in the journal Evidence-Based Integrative Medicine(2003), 1(1):65–76. See also Birch (1997); Calmels (1999); Fitter and Thomas (1997); Gadsby et al. See Barton (2000); Bender (1999); Bossuyt (2001); Calmels (1999); Critchley et al. See Barton (2000); Bossuyt (2001); Drew and Davies (2001); Ernst (2000a,1999, 1997); Ernst and Barnes (1998); Ernst and Fugh-Berman (1999); Gadsby et al. The few authors who critique the RCT method do not suggest that it is inappropriate as a means of assessing the efficacy of alternative and complementary therapies; rather, their critiques centre on refinements of the RCT method (Bossuyt 2001; Thomas and Fitter 1997). Appendix: The Therapies Listed below are brief explanations of the alternative therapies and healing systems mentioned in this book.