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By: William A. Weiss, MD, PhD

  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

According to Hansen (1993) , family systems theory is inappropriate for assessing or responding to domestic violence . By conflating conflict and abuse, it attributes domestic violence to “reciprocal interactions” within the family system, ignoring all aspects of families other than communication and interactions between the parents, and between the parents and children. It does not include the legal, social and political systems or contexts within which families exist; differences in size and strength, financial resources, social status, and political power between men and women; or the history of criminal conduct by the abusive spouse. Family systems theory “direct[s] the focus away from the violence and fail[s] to address” the safety needs of weaker family members (Hansen, 1993, p. Furthermore, family systems theory is incompatible with criminal laws that define acts of domestic violence as crimes, including marital rape, and civil protection order remedies that provide protection for victims and restrain the actions of violent spouses. Finally, family systems theory places equal blame for domestic violence on the victim and perpetrator. Gardner proposed that the children needed to be protected from the alienating parent and custody should instead be awarded to the alienated parent. Parental Alienation Syndrome was discredited and is generally not accepted in courts throughout the United States (Hoult, 2006). Nonetheless, the term “parental alienation” is used frequently in regard to children and divorcing parents, is still frequently referenced in custody disputes; the “alienated child” is a subject of concern to the courts and custody evaluators. In concert with the belief that it is best for children to have strong relationships with both parents, the seemingly more benign but conceptually related construct of the “friendly parent” is sometimes incorporated into statutes and case law as one of the factors to be considered under the child’s best interest. Under the “friendly parent” construct, along with other considerations, custody should be awarded to the parent more likely to support the other parent’s role in the child’s life. When applied to domestic violence cases, in which a victimized parent may have legitimate safety reasons for wishing to limit the former partner’s access to the children, a preference for the friendly parent reduces the probability of the victim being granted custody and increases the probability of the abuser being granted custody (Zorza, 1992). These provisions are widespread and routinely applied across the United States with only a small number of states exempting domestic violence cases from the provision (Dore, 2004). Finally, the dominant perspective among advocates for battered women is the “power and control” model. This analysis is attributed the Domestic Abuse Intervention Project 15 this document is a research report submitted to the U. The wheel has spokes with the characteristics of different forms of violence or abusive tactics, including physical and sexual violence; coercion and threats; intimidation and emotional abuse; isolation; minimizing, denying and blaming; using children; using male privilege; and economic abuse. As Pence described it, the prevailing model previously was the “cycle of violence,” which made intimate partner abuse sound episodic. A victim persuaded her that the abuse was ongoing and affected all aspects of the couple’s life. At the center of the wheel are the words “power and control,” denoting the motivation for the abuse. The Power and Control Wheel is pervasive, displayed at programs for victims and offenders across the country and used as a training tool for advocates and law enforcement. The “Duluth Model” (the term actually refers to a coordinated community response to domestic violence, but is often taken to refer to the curriculum of the batterer program) is a gendered theory of intimate partner abuse, finding the causes in institutionalized patriarchy, male entitlement and socialization of boys and girls (Pence and Paymar, 1993). This model finds the source of violence against women in social hierarchies and economic structures rooted in history and found in cultures around the world. In addition to rejecting the conceptualization of intimate partner abuse of women as cyclic, the power and control model is inconsistent with explanations based in mental illness and personality disorders. Typologies have been proposed that are consistent with the power and control model in analyzing domestic violence as an issue of control exercised through many forms of abuse above and beyond physical violence, and in construing domestic violence not as discrete acts of abuse but as a constant exercise of dominance. Under one construct, true domestic violence follows a pattern of “intimate terrorism,” which is distinguished from “common couple violence. Intimate terrorism is deemed to be more common, to be more likely to be one-sided, to include emotional abuse, and to escalate (Johnson, 1995, 2000; Johnson & Ferraro, 2000). The latter constitutes an abusive relationship with a full range of controlling behaviors, including threats, humiliations and insults, dangerous driving, sexual coercion, social isolation, and financial control and deprivation, which are not prompted by conflict. They contend that custody evaluators and courts must recognize the distinction between a history of conflict and a history of abuse, which involves much more than violence, to construct parenting plans that serve the children. Stark describes the way in which sexual degradation, intimidation, isolation and other forms of regulation of daily life are interwoven with physical abuse to effect domination of the partner. He argues that too much attention has gone to the most injurious physical assaults, undermining the effectiveness of the response to domestic violence (2010). In fact, constant less severe physical abuse – slaps and shoves that may not qualify as crimes but only as lower level offenses – serves to maintain the coercive control by keeping the victim in a chronic state of subjugation and entrapment. When a woman and even her children then respond with fear and depression to a relatively minor incident, they are seen as exaggerating and overreacting. The routine nature of the deprivations (restrictions on food, money, dress, transportation, speech and socializing) is difficult to substantiate in court yet has a cumulative and often devastating psychological impact. It is exactly this sort of more subtle and more difficult to document pattern of control that the legal service organizations that provided the cases in this study factor into their decision to accept a case: the need for legal advocacy is often greater when the abuser has not inflicted severe physical injury. When the abuser has committed severe physical violence and the victim has documented injuries, it requires less skilled and knowledgeable legal representation to persuade the court that the statute governing visitation and custody in domestic violence cases must be applied to the case. The typologies that construct domestic violence as a pattern of behavior involving power and control tend to distinguish between true and dangerous intimate partner abuse and more transient and less serious incidents of violence. Two other distinctions among types of intimate partner abuse have not elicited consensus among experts, particularly in regard to their danger and seriousness. Some would categorize as less serious and not indicative of future danger “situational violence. According to proponents of the distinction, this sort of situation-dependent violence may be mutual and, although usually episodic, may become frequent and physically dangerous. Distinguishing features are that it does not involve pervasive control, nor is it gendered. Under this view, violence that occurs in the context of separation may be situational and therefore not only does it not characterize the history of the relationship, but also it does not indicate that one partner has been unequally victimized and may be incapacitated. Hardesty (2002) adopts Mahoney’s (1991) term of “separation assault” to refer not only to violence that continues or escalates a pattern of abuse during the relationship in the context of separation and afterwards but also to violence that begins with separation.

In a recent study of dogs and cats where only neck pain was noted almost 10% had only a focal brain tumor . The presence of neck pain in a seizure patient should suggest there is a structural cause of the seizure . However an abnormal exam is not always noted and about 30% of patients with a mass lesion will have a normal neurological exam . Conclusion Your client expects a sense of the diagnosis , treatment plan and prognosis when they present with a pet with recent onset seizure. Postmortem evaluation of 435 cases of intracranial neoplasia in dogs and relationship with breed, age and body weight. There are several important questions that a veterinarian must ask during every seizure evaluation. Two, is there an underlying genetic, structural or metabolic cause that can be diagnosed and treated more specifically than just treating the symptom of seizure. Treatment Challenges About 30% of epileptic dogs will be refractory or drug resistant. Furthermore, in the Border Collie the average life expectancy after the first seizure is 2 years with cluster seizure and status epilepticus being significant risk factors for euthanasia. Secondly, there is very good experimental and some clinical evidence in people to suggest that having a seizure sets-up or facilitates connections in the brain that reduce the seizure threshold. In other words, every seizure can make it a little easier to have another seizure. We know that about 1/3 of veterinary patients with primary epilepsy are difficult to control and delayed treatment may allow a particular patient to be in this category. Thirdly, a recent study surveying owners of dogs with seizure revealed, not surprisingly, that the most acceptable seizure frequency was not once per month, but no seizure. Another study of dogs on bromide or/and phenobarbital found owners reasonably satisfied with seizures less often than every 3 months. Owners have come to the veterinarian not to be told seizures are harmless and that 1 seizure per a month is acceptable, but to have the seizure disorder treated with the goal being no more seizure. Lastly, the balance between side-effect, risk of organ failure, ease of administration and cost vs. These medications have been shown to be effective as add-on medications and clinical experience in human and veterinary patients suggest they are effective for monotherapy as well. However, when Levetiracetam was studied as an add-on to phenobarbital and bromide in a placebo controlled, randomized, crossover design, a significant reduction in seizure frequency was not observed but the quality of life was thought better on Levetiracetam relative to placebo. For the 3 trials evaluated, the average reduction in seizures during placebo administration relative to baseline was 26%. The authors concluded their findings were important because open label studies in dogs that aim to assess efficacy of antiepileptic drugs might inadvertently overstate their results and that there is a need for more placebo-controlled trials in veterinary medicine. There were statistically fewer cluster seizure in the study group and the authors concluded Levetiracetam pulse therapy for cluster seizure is probably effective. Because most patients are already on Levetiracetam or Zonisamide, the author often uses Gabapentin (10-30 mg/kg, Q8 H, and/or Clorazepate (1/2 to 2 mg/kg, Q 8 h) for pulse therapy – given after the first seizure and continued for 24 hours after the last seizure. Bromide is avoided for pulse therapy due to side effects and long elimination half-life. Therefore while therapy can be initiated after a seizure, it can potentially be administered before a seizure, as many owners think they can predict when a seizure will occur. Subcutaneous Levetiracetam 60 mg/kg will reach therapeutic concentrations in 15 minutes or less and last for 7 hours and currently authors at home therapy of choice. The same dose, undiluted can be given as intravenous bolus to rapidly achieve useful serum concentrations without causing any sedation. Diazepam solution at 2 mg/kg per rectum is also advised, however an intranasal injection of 0. Rectal valium suppository formulations have unfavorable absorption and are not recommended for emergency treatment of seizure. Another important consideration is that phenobarbital will increase metabolism of both Levetiracetam and Zonisamide such that the serum concentrations maybe 50% lower than expected. Comparison of phenobarbital with bromide as a first-choice antiepileptic drug for treatment of epilepsy in dogs. Pregabalin as an adjunct to phenobarbital, potassium bromide, or a combination of phenobarbital and potassium bromide for treatment of dogs with suspected idiopathic epilepsy. Pancreatitis associated with potassium bromide/phenobarbital combination therapy in epileptic dogs. Improving seizure control in dogs with refractory epilepsy using gabapentin as an adjunctive agent. Epilepsy in Border Collie: clinical manifesations, outcome, and mode of inheritace. Double-masked, placebo-controlled study of intravenous levetiracetam for the treatment of status epilepticus and acute repetitive seizures in dogs. Serum triglyceride concentration in dogs with epilepsy treated with phenobarbital or with phenobarbital and bromide. Apparent acute idiosyncratic hepatic necrosis associated with zonisamide administration in a dog. Effects of long-term phenobarbital treatment on the thyroid and adrenal axis and adrenal function tests in dogs.

Intact perception is sometimes used as a sine qua non for the diagnosis of agnosia , in which case it may be questioned whether apperceptive agnosia is truly agnosia . However , others retain this category , not least because the suppo sition that perception is normal in associative visual agnosia is probably not true. Moreover, the possibility that some agnosias are in fact higher-order perceptual decits remains: examples include some types of visual and tactile recognition of form or shape. The difculty with denition perhaps reects the continuing problem of dening perception at the physiolog ical level. Other terms which might replace agnosia have been suggested, such as non-committal terms like ‘disorder of perception’ or ‘perceptual defect’, or as suggested by Hughlings Jackson ‘imperception’. Theoretically, agnosias can occur in any sensory modality, but some author ities believe that the only unequivocal examples are in the visual and auditory domains. Anatomically, agnosias generally reect dysfunction at the level of the association cortex, although they can on occasion result from thalamic pathol ogy. Cross References Agraphognosia; Alexia; Amnesia; Anosognosia; Aprosodia, Aprosody; Asomatognosia; Astereognosis; Auditory agnosia; Autotopagnosia; Dysmorphopsia; Finger agnosia; Phonagnosia; Prosopagnosia; Pure word deafness; Simultanagnosia; Tactile agnosia; Visual agnosia; Visual form agnosia Agrammatism Agrammatism is a reduction in, or loss of, the production or comprehension of the syntactic elements of language, for example articles, prepositions, conjunc tions, verb endings. Despite this impoverishment of language, 10 Agraphia A or ‘telegraphic speech’, meaning is often still conveyed because of the high infor mation content of verbs and nouns. Agrammatism is encountered in Broca’s type of non-uent aphasia, associated with lesions of the posterior inferior part of the frontal lobe of the dominant hemisphere (Broca’s area). Whether this is a perceptual decit or a tactile agnosia (‘agraphognosia’) remains a subject of debate. Agraphias may be classied as follows: • Central, aphasic, or linguistic dysgraphias: these are usually associated with aphasia and alexia, and the decits mirror those seen in the Broca/anterior/motor and Wernicke/posterior/sensory types of aphasia. Centrally acting -blockers such as propranolol may also be helpful, as may anticholinergic agents, amantadine, clonazepam, and clonidine. Cross References Parkinsonism; Tasikinesia; Tic Akinesia Akinesia is a lack of, or an inability to initiate, voluntary movements. More usually in clinical practice there is a difculty (reduction, delay), rather than com plete inability, in the initiation of voluntary movement, perhaps better termed bradykinesia, or reduced amplitude of movement or hypokinesia. Akinesia may coexist with any of the other clinical features of extrapyramidal system disease, particularly rigidity, but the presence of akinesia is regarded as an absolute requirement for the diagnosis of parkinsonism. Hemiakinesia may be a feature of motor neglect of one side of the body (possibly a motor equivalent of sensory extinction). Neuroanatomically, akinesia is a feature of disorders affecting • frontal–subcortical structures. Neurophysiologically, akinesia is associated with loss of dopamine projec tions from the substantia nigra to the putamen. Parkinson’s disease, progressive supranuclear palsy (Steele–Richardson–Olszewski syndrome), and multiple system atrophy (striatonigral degeneration); akinesia may occur in frontotemporal lobar degeneration syndromes, Alzheimer’s disease, and some prion diseases; • Hydrocephalus; • Neoplasia. Cross References Akinetic mutism; Bradykinesia; Extinction; Frontal lobe syndromes; Hemiakinesia; Hypokinesia; Hypometria; Kinesis paradoxica; Neglect; Parkinsonism Akinetic Mutism Akinetic mutism is a ‘syndrome of negatives’, characterized by a lack of vol untary movement (akinesia), absence of speech (mutism), and lack of response to question and command, but with normal alertness and sleep–wake cycles (cf. Akinetic mutism represents an extreme form of abulia, hence sometimes referred to as abulia major. Pathologically, akinetic mutism is associated with bilateral lesions of the ‘centromedial core’ of the brain interrupting reticular-cortical or limbic-cortical pathways but which spare corticospinal pathways; this may occur at any point from frontal lobes to brainstem. Two forms of akinetic mutism are sometimes distinguished: • Frontodiencephalic: associated with bilateral occlusion of the anterior cere bral arteries or with haemorrhage and vasospasm from anterior communi cating artery aneurysms; damage to the cingulate gyri appears crucial but not sufcient for this syndrome. Pathology may be vascular, neoplastic, or structural (subacute communicating hydrocephalus), and evident on structural brain imaging. Akinetic mutism may be the nal state common to the end-stages of a number of neurodegenerative pathologies. Akinetic mutism from hypothalamic damage: successful treatment with dopamine agonists. This sta tokinetic dissociation may be known as Riddoch’s phenomenon; the syndrome may also be called cerebral visual motion blindness. Stendhal’s aphasic spells: the rst report of transient ischemic attacks followed by stroke. Cross References Aphasia; Aphemia Alexia Alexia is an acquired disorder of reading. Alexia may be categorized as: • Peripheral: A defect of perception or decoding the visual stimulus (written script); other language functions are often intact. Patients lose the ability to recognize written words quickly and easily; they seem unable to process all the elements of a written word in parallel. Alexia without agraphia often coexists with a right homonymous hemianopia, and colour anomia or impaired colour perception (achromatopsia); this latter may be restricted to one hemield, classically right-sided (hemiachromatopsia). Patients tend to be slower with text than single words as they cannot plan rightward reading saccades. The various forms of peripheral alexia may coexist; following a stroke, patients may present with global alexia which evolves to a pure alexia over the following weeks. Pure alexia is caused by damage to the left occipitotemporal junction, its afferents from early mesial visual areas, or its efferents to the medial temporal lobe. Global alexia usually occurs when there is additional damage to the splenium or white matter above the occipital horn of the lateral ventricle. Hemianopic alexia is usually associated with infarction in the territory of the posterior cerebral artery damaging geniculostriate bres or area V1 itself, but can be caused by any lesion outside the occipital lobe that causes a macular splitting homonymous eld defect. Central (linguistic) alexias include • Alexia with aphasia: Patients with aphasia often have coexistent difculties with reading (reading aloud and/or comprehending written text) and writing (alexia with agraphia, such patients may have a complete or partial Gerstmann -16 Alexithymia A syndrome, the so-called third alexia of Benson). The reading prob lem parallels the language problem; thus in Broca’s aphasia reading is laboured with particular problems in reading function words (of, at) and verb inections (-ing, -ed); in Wernicke’s aphasia numerous paraphasic errors are made.


  • Cortisol
  • Wakes you up from sleep
  • Sinus infection (sinusitis)
  • How much is the eye swollen?
  • Follow a low-salt diet, which may reduce fluid buildup and swelling.
  • Sweating
  • Hyperviscosity
  • Puncture of the heart muscle, coronary artery, lung, liver, or stomach

Splinting Hemostasis Splinting results in preservation of normal ana Hemorrhage control is frst attempted with focal tomical alignment and improved perfusion , and direct pressure and elevation of the affected limb . In immobilization of the affected part provides pain cases of inadequately controlled arterial bleeding , control . Common splints used include thumb spica, a temporary proximal tourniquet may be placed. Tourniquet time should always be documented and In general, the hand is immobilized in the intrinsic should not exceed 2 to 3 hours. A glove “ring” tourniquet is an effective method to Skin And Soft-Tissue Injury Treatment achieve adequate hemostasis during wound explo Laceration ration in the digits. Patients with lacerations associated with devitalized tissue, removal of foreign contaminants, a high risk of infection should receive prophylactic and gentle scrubbing, when necessary. Level I evi 35-mL syringe is superior to low-pressure irrigation dence demonstrates no effect upon wound infection techniques for reducing infection rates. A prospective randomized controlled tri Many studies have reported no beneft of pro al by Karounis et al of 95 pediatric patients with lac phylactic antibiotics in hand and extremity lacera erations at various sites (except the scalp) compared tions that are at a low risk for infection. Small linear lacerations in Zone I injuries, in which no bone is exposed, areas of low skin tension (such as the dorsum of the undergo wound care followed by placement of a non hand) may be amenable to a tissue adhesive. Lamon et al performed a study of 25 consecutive able sutures versus traditional nonabsorbable sutures patients with zone I injuries who underwent conser in pediatric lacerations. This patient group is associated bone and closure should be guided by emergency with a signifcant burden of psychiatric disease and clinician familiarity with the procedure and hand substance abuse. Three-view radiographs of the hand are recommended to identify fracture or retained Nail Plate And Nail Bed Injury Treatment foreign body. Subungual Hematoma Although it often appears innocuous, fght bite A subungual hematoma is a collection of blood be injury is associated with a high risk of structural and tween the nail plate and nail bed matrix. Following the introduc radiographs are recommended for injuries suspi tion of oral and skin commensal organisms into the cious for distal phalanx fracture. Until relatively wound, the bacterial inoculum is dragged proxi recently, it was common practice to perform nail mally into the joint, tendon sheath, and deep soft plate removal and exploration of the nail bed for all tissue. Infectious complications include tenosynovi subungual hematomas > 50% of the nail plate. Patients with cellulitis and/or abscess in delayed presentation require admission for surgical debridement and intravenous antibiotics. The Infectious Diseases Society of America guidelines recommend empiric therapy with amoxi cillin/clavulanate to cover oral commensal bacteria (eg, Eikenella corrodens and beta lactamase-producing anaerobes) and skin fora (eg, Staphylococcus aureus and Streptococcus species). The dominant ring fnger is Open nail bed matrix injuries are associated with most commonly affected due to its relative anatomic nail plate deformity and functional impairment of weakness and degree of protrusion in the grasping the fngertip. Tendon Injury Treatment Strain Injury A strain is an injury of a tendon and/or muscle Figure 7. Injury Ultrasonography ranges from mild tearing to complete disruption of the musculotendinous unit. Flexor Tendon Injury the 2 most common mechanisms of fexor tendon injury are laceration from a sharp object, followed by forced extension during fnger fexion. When possible, specifc follow up instructions should be discussed with the hand surgeon on call and they should be given to the patient. The name originates from the initial description assessed through full range of motion. View B: Ultrasound longi in 1977 of rugby players who sustained fnger injury tudinal view of fexor tendon (a), middle phalanx (b), and proximal by holding on to the jerseys of their opponents as interphalangeal joint (c). Closed extensor tendon injuries require should be guided by emergency clinician familiarity volar splinting in extension and follow-up with a with the procedure and hand surgeon availability. The third, fourth, and ffth digits of the dominant hand are most commonly affected. Mallet Finger Splint View A: intrinsic plus position, with wrist dorsifexion at 30°, metacar pophalangeal joint fexion at 80°-90°; View B: intrinsic plus and volar splint. Radiographs are advised to Gamekeeper’s thumb is an injury of the ulnar col exclude fracture and confrm dislocation. In select patients, with rapid deceleration while grasping an object (eg, after counseling and consent, a single rapid joint a ski pole or a steering wheel). Patients should be risk stratifed for scaphoid fracture, as the typical mecha nism of injury is similar. Patients with scapholunate diastasis > 3 mm,75,66 or clinical suspicion of scapholunate dissociation with equivocal imaging are placed in a thumb spica splint and referred to a hand surgeon. Scapholunate dissociation may require nonemergent surgical in tervention to decrease the risk of severe and debili tating wrist dysfunction. Perilunate Dislocation And Lunate Dislocation Perilunate dislocation and lunate dislocation are typically discussed together. Physical examination may dem onstrate swelling and deformity of the wrist, point Application of radial stress on the thumb (arrow) with the metacarpo tenderness over the dorsal aspect of scapholunate phalangeal joint in mild fexion assesses ulnar collateral ligament lax joint, and decreased range of motion. The unaffected side should Posterior-anterior radiographs of the wrist also be assessed. Careful radiographic Fractures Of Phalanges 2, 3, 4, 5 review (with particular attention to the lateral view) Distal Phalanx should be undertaken because missed injuries occur Distal phalanx fractures are classifed into 3 catego frequently. A 1993 study by Herzberg et al of 166 ries: (1) tuft, (2) shaft, or (3) base factures. Focused patients with perilunate dislocation reported a rate physical examination should identify point tender of missed injury of 25%. Emergent consultation with a hand surgeon is recommended to coordinate closed reduction versus 78 A B open reduction and fxation in the operating room. Plain Radiograph In Lunate Dissociation Posterior-anterior wrist radiograph with > 3 mm of scapholunate A B diastasis marked.

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