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There is also an increase in venous back-pressure in the brain (due to poor venous drainage), and so the arteriovenous pressure gradient is further reduced, and cerebral perfusion is at risk. For example, in sagittal sinus thrombosis, the impaired venous outflow from the paramedian walls of the cerebral hemisphere may result in bilateral lower extremity hyperreflexia and extensor plantar responses, and sometimes even paraparesis. Thrombosis of the lateral sinus causes pain in the region behind the ipsilateral ear. The thrombosis may be associated with mastoiditis, in which case the pain due to the sinus thrombosis may be overlooked. However, the lateral sinuses are often asymmetric, and if the dominant one is occluded, there may not be sufficient venous outflow from the intracranial space. Infarction in this area may produce little in the way of focal signs, but hemorrhage into the infarcted tissue may produce seizures. Thrombosis of superficial cortical veins may be associated with local cortical dysfunction, but more often may present with seizures and focal headache. Venous thrombosis associated with coma generally has a poor prognosis, whereas awake and alert patients usually do well. However, in many cases of venous sinus thrombosis, there will be little, if any, evidence of focal brain injury. Recorded During the Course of the Disease 61 42 42 33 18 16 11 10 9 9 8 Symptom/Sign Mental changes Headache Coma Focal weakness Seizure Fever Ataxia Aphasia Visual changes (diplopia, amaurosis, and blurring) Tetraparesis Flaccid or spastic paraparesis (with back pain, sensory level, and urinary incontinence) From Younger et al. Vasculitis Vasculitis affecting the brain either can occur as part of a systemic disorder216. Vasculitis causes impairment of consciousness by ischemia or infarction that either affects the hemispheres diffusely or the brainstem arousal systems. Magnetic resonance angiography may demonstrate multifocal narrowing of small blood vessels or may be normal. High-resolution arteriography is more likely to demonstrate small vessel abnormalities. The treatment depends on the cause of vasculitis; most of the disorders are immune mediated and are treated by immunosuppression, usually with corticosteroids and cyclophosphamide. Viral encephalitis, by distinction, is often widespread and bilateral, and hence coma is a common feature. The organisms destroy tissue both by direct invasion and as a result of the immune response to the infectious agent. Although many different organisms can cause encephalitis, including a number of mosquitoborne viruses with regional variations in prevalence (eastern and western equine, St. Louis, Japanese, and West Nile viruses), by far the most common and serious cause of sporadic encephalitis is herpes simplex type I. Personality changes, memory impairment, or seizures focus attention on the medial temporal, frontal, and insular areas, where the infection usually begins and is most severe. There is usually a pleocytosis with a white count of as many as 100 cells and a protein concentration averaging 100 mg/dL. The destruction can initially be unilateral but usually rapidly becomes bilateral. The differential diagnosis includes other forms of encephalitis including bacteria and viruses, and even low-grade astrocytomas of the medial temporal lobe, which may present with seizures and a subtle low density lesion. It is very important to begin treatment as early as possible with an antiviral agent such as acyclovir at 10 mg/kg every 8 hours for 10 to 14 days. Spontaneous sporadic cases are believed to result from a subclinical infectious illness. A pair of magnetic resonance images from the brain of a patient with herpes simplex 1 encephalitis. Note the preferential involvement of the medial temporal lobe and orbitofrontal cortex (arrows in A) and insular cortex (arrow in B). Although there has been no randomized, controlled series, in our experience patients often improve dramatically with oral prednisone, 40 to 60 mg daily.

If, however, the oxygen deprivation lasts longer than 1 or 2 minutes, or if it is superimposed upon pre-existing cerebral vascular disease, then stupor, confusion, and signs of motor dysfunction may persist for several hours or even permanently. Under clinical circumstances, total ischemic anoxia lasting longer than 4 minutes starts to kill brain cells, with the neurons of the cerebral cortex (especially the hippocampus) and cerebellum (the Purkinje cells) dying first. In humans, severe diffuse ischemic anoxia lasting 10 minutes or more begins to destroy the brain. In rare instances, particularly drowning, in which cold water rapidly lowers brain temperature, recovery of brain function has been noted despite more prolonged periods of anoxia, although such instances are more common in children than adults. Thus, resuscitation efforts after drowning (particularly in children) should not be abandoned just because the patient has been immersed for more than 10 minutes. Equally low arterial blood oxygen tensions have been reported in conscious humans who recovered without sequelae. These laboratory findings suggest that guaranteeing the integrity of the systemic circulation offers the strongest chance of effectively treating or preventing hypoxic brain damage. Much less frequently, transient attacks of vertebrobasilar ischemia can cause unconsciousness. Such attacks may be accompanied by brief seizures, which often present problems in differential diagnosis as seizures themselves cause loss of consciousness. Syncope or fainting results when cerebral perfusion falls below the level required to supply sufficient oxygen and substrate to maintain tissue metabolism. Among young persons, most syncope results from dysfunction of autonomic reflexes producing vasodepressor hypotension, so-called neurocardiogenic, vasovagal, or reflex syncope. Reflex from visceral sensory stimulation (deep pain, gastric distention, postmicturition, etc. Visceral sensory stimulation (tracheal stimulation, glossopharyngeal neuralgia, swallow syncope, etc. Carotid origin emboli in the presence of severe vascular disease of other cervical cranial arteries 2. Condition 3 often is so brief (especially if the head falls below the level of the heart, resulting in improved cerebral blood flow) that neither subject nor observer can be sure whether full consciousness was retained. In conditions 4 and 5, the patient may appear awake and ``conscious' to observers, but has no exact memory of the episode and often recalls it simply as an unconscious attack. Vasodepressor syncope is usually heralded by a brief sensation of giddiness, weakness, and sweating before consciousness is lost. This is an important diagnostic point if present, but about 30% of patients with true syncope may be amnesic from the loss of consciousness and thus report the episode as a ``drop attack'149 (see below). Reflex syncopal attacks almost always occur when the victim is in the standing position, rarely when sitting, and almost never when prone or supine. Asystole, on the other hand, characteristically produces unheralded, abrupt unconsciousness regardless of position. The brevity of the unconsciousness, the rapid restoration of wakefulness when the head is at position equal to or lower than the heart, and the appearance of pallor prior to and during the loss of consciousness differentiate asystolic syncope from transient vertebrobasilar insufficiency. Drop attacks, defined as sudden collapse of the legs in someone who is standing resulting in a fall, generally occur in middle-aged150 and older adults. Others are otologic in origin,152 although the patient is sometimes unaware of vertigo. Occasionally drop attacks occur as a result of bilateral ischemia of the base of the pons or the medullary pyramids, or as a result of transient, positional compression of the upper cervical spinal cord due to atlantoaxial subluxation or fracture of the dens. Brief confusion or amnesic episodes sometimes occur, but stupor and coma are rare, perhaps because ischemia sufficient to affect such a large part of the brainstem bilaterally generally causes additional signs of brainstem ischemia. Basilar ischemia involving the descending motor pathways in the basis pontis or the medullary pyramids sometimes results in drop attacks, which may superficially resemble asystolic syncope. The absence of either unconsciousness or the physical appearance of circulatory failure differentiates the condition from true syncope. Epileptic seizures may occasionally be difficult to distinguish from syncope as a cause of unconsciousness.

The most common technique to reduce the effects of diplopia is to have a client wear an opaque eye patch. An alternate strategy would be to use translucent tape or cling-on film that would be less cumbersome, more aesthetic and comfortable and yet allow light stimulation. Prisms are not typically indicated as ocular paresis fluctuates, thus the amount of diplopia is too variable for optical correction. Medication such as cholinesterase inhibitors may also provide improvement with ptosis although it may cause diplopia if the eyelid is lifted and there is a slight amount of ocular muscle weakness (Kaminski, 2003). But one would also consider techniques for specific tasks such as child care or work related tasks. Special consideration needs to be given to the effect of visual impairment as ocular muscle weakness is a hallmark of myasthenia gravis and frequently a first indicator of the disease. While it is possible that any of the three cranial nerves that innervate ocular muscle function can be affected, the oculomotor or third cranial nerve is most often impaired. Subsequently, one might expect ptosis, reduced ocular adduction, upward and downward gaze and reduced diagonal gaze movements. Given this ocular paresis and dysconjugate gaze, the client often reports diOccupational Therapy Issues Regardless if monocular vision is induced by ptosis or an eyepatch, the resulting issue is loss of stereopsis or depth. Typically, the most significant impact is with near tasks such as pouring liquids, accurate reach and grasp, or tool use (Holmes, 2004). Therapist should provide education to help the client learn what to expect and how to compensate. Another significant area of dysfunction is eating and swallowing secondary to muscle weakness. Occupational therapists with advanced training for dysphagia may provide these services (Pendleton & Schultz-Krohn, 2006). In Kaminski H, editor: Myasthenia Gravis and Related Disorders, Humana Press, 2003. In Pendleton & Schultz-Krohn, editors: In Occupational Therapy: Practice Skills for Physical Dysfunction, Mosby, 2006 Trombly C, Radomski M: Occupational Therapy for Physical Dysfunction, Lippincott Williams & Wilkins, 2002. Myasthenia gravis is a disease process that has the potential to disrupt the potential to engage in any or all of these performance areas. It is my hope that this chapter is the beginning of a model that reflects best practice for occupational therapy with clients diagnosed with myasthenia gravis Occupational Therapy Issues 136 9 Speech Pathology and Swallowing Issues Susan G. A reading list is provided and should be consulted for further details about management. Detecting dysphagia early is paramount in managing silent aspiration which can not only lead to aspiration pneumonia but can cause continuous damage to the lungs making rebound from future myasthenic crises more difficult. A swallowing assessment begins with a clinical swallow evaluation and then is followed with an instrumental swallowing evaluation, as indicated. Research has demonstrated that the presence of penetration and/or aspiration is highly correlated with weakness of pharyngeal muscles (Oda, Chiappetta, Annes, Marchesan, Oliveira, 2002). When performing the swallowing assessments described below, testing for weakness and fatigability is a crucial factor. The clinician will note the rate of fatigue for later judgments in how to instrumentally assess speech and swallowing and make therapeutic recommendations. If dysphagia is suspected to any degree, an instrumental swallowing assessment is recommended. Subsequently, an instrumental swallowing exam is necessary, especially in this population which is at a high risk for pulmonary complications where clinician error can not be easily afforded. Following the oral mechanism examination, clinical test boluses may be administered to prepare the clinician as to what to expect and look for during the instrumental assessment. Small test boluses of water are frequently utilized as water has a neutral pH and is relatively benign to the lungs especially if oral care is good. The water test boluses provide an opportunity for the clinician to palpate the larynx and to assess laryngeal elevation. Studies have shown that duration of superior hyolaryngeal elevation is significantly correlated to aspiration (Higo et al. In addition, the clinician will test the fatigability of the facial, lingual and laryngeal functioning by having a patient perform repetitive labial eversion Speech Pathology and Swallowing Point Test) provides information as to what to expect in the instrumental examination. If the patient is already eating, more viscous or solid boluses may be administered to assess masticatory functioning.

The majority of allegations of educator sexual misconduct are not reported to the police by the school districts. District policy should require that the allegation be reported to both the police and child protection agencies. Ensure that investigations are completed within 48 hours and reports are presented to school authorities, students, and parents. Define the roles of all parties in the investigation including their notification responsibilities. Complete investigation and file report internally, with criminal justice authorities, and with state licensing entities. With rare exceptions, sexual abuse prevention training for educators and school staff-whether preprofessional or while on the job- does not include educator sexual misconduct. These programs focus on what to do when sexual or any other kind of abuse or maltreatment is suspected from a source outside the school. Therefore, additional training for educators and other staff about educator sexual misconduct is important. Training outlines the behaviors that are not acceptable so that everyone-both those who abuse and those who do not abuse-are working from the same set of expectations. By making expectations explicit and public, school decision makers are also helping educators understand their own responsibility in reporting behavior that does not conform to those expectations. Thus, the training will educate employees about unacceptable behavior and to remind them of their responsibility to report abuse. Like staff, students need to understand the boundaries that educators should not cross. This is important both for students who might be targeted and for students who observe such behaviors. Both sets of students need to know that such behavior is prohibited and that there is a person to whom they can and should report such incidents. Materials and programs that have been developed to protect students from sexual abuse rarely include examples of predators who are educators. Students need to know that educators might cross boundaries and what to do if this happens. State certification requirements for educators need to include required training on educator sexual abuse. New entrants to the field need to understand the professional expectations and ethics in regard to student relationships. In most cases where educators cross boundaries, the educator does not lose her or his license. Therefore, a national list of educators by state who sexually abuse, which is maintained by the state certification office, would be a place where future employers or parents can turn to check backgrounds. Currently there is no electronic federal registry that can be accessed to search for educators who have had certification and licenses suspended. State laws which prohibit educators who abuse their positions of trust should be implemented to include any student, no matter what age, in an educational institution. State laws should require school officials to report any alleged sexual misconduct or the resignation or suspension of educators accused of sexual misconduct to state education officials. Laws protecting school officials from lawsuits for job references given should be in place in every state. The age of consent should be standardized across states as should the definition of what constitutes child sexual abuse. State laws that protect employers who give good-faith references on former employees will help increase the information exchange across districts. Although state personnel laws already protect former employers in this process, additional laws will increase feelings of security.

This means that most devices designed for detecting the urinary metabolites will not be useful for oral fluid testing. For roadside testing in law enforcement, an advantage of oral fluid is that drug detection relates more directly to current subject impairment than does drug presence in urine, with its longer detection periods for metabolites. Collection procedures and devices for collection are not standardized, and drug concentration can differ, depending on collection method (55). Adsorption of the drug of interest to the collection device (to the filters or absorbent material contained in some devices) is also of issue. In 1 study, interference from foods, drinks, poppy seeds (n 1), and mouthwash were assessed as not compromising test results based on an unclear number of samples (56). Results were reported to correlate well with urine results from samples collected at the same time as the saliva samples. While some criticize saliva as a medium (57), the evidence suggests that saliva is a feasible alternative and an aesthetically more acceptable matrix than urine. In some settings, adulteration/manipulation of the sample by users to circumvent positive results (13, 38, 39, 41, 53) is a major issue. A number of issues, such as invasion of privacy, many methods of manipulation, and cross-reactions, have led to interest in alternative matrices. As previously discussed, the antibodies used in the devices target the same drug and/or metabolites detected with urine laboratory screens. The labeling of these devices with respect to what is measured or detected is perhaps even more important because many users may not fully understand that most of these tests are designed to detect classes or groups of drugs. This mislabeling may lead to interpretational false positives or negatives when testing personnel do not understand the specificity. The immunochromatographic test strip used with the DrugWipe system in these studies is based on the Frontline urine test strip (Roche Diagnostics/Boehringer Mannheim GmbH, Germany). This study also reported differences in results, based on experience of the analyst. The authors concluded that the strips were useful for "rule-out" of ethanol use but not for "rulein. Evidence-Based Practice for Point-of-Care Testing Sweat There are 2 different approaches to sweat collection. One is a sweat patch worn by the subject for a period of time, resulting in an integrated collection of drugs in sweat over a period of time. In the other, the skin is wiped (DrugWipe) and the collected sweat has been used in roadside testing. Findings similar to those from oral fluid have been published with laboratory-tested sweat samples (59, 64), with the parent drug predominating. The elimination of a drug through the skin is reported to be delayed for many days, and drugs may bind to various skin fractions (65). Drugs in sweat were found to be present in a wide concentration range, requiring laboratory analytical techniques (65). An alternate sweat collection device, DrugWipe, has been used for sweat collection in Europe. Sweat is prone to external contamination of the skin, such as passive exposure to smoke (66). Sweat concentration of several drugs differs according to the collection site (58). Time intervals between drug administration and excretion of the drug in sweat are variable and have not been extensively studied. As with oral fluid specimens, obtaining adequate sample with breath alcohol testing is a constant issue (50), especially with very intoxicated individuals. The breath analysis was affected by body temperature and breathing patterns at time of sample collection. They reported that the primary reasons given for trauma centers not routinely performing alcohol tests were that results are considered "clinically not important" or legal concerns.