By C. Fedor. Muskingum College. 2019.
How- Internal Medicine and Rehabilitation Science buy kamagra super on line amex erectile dysfunction blood pressure medication, Sendai buy generic kamagra super from india erectile dysfunction doctors in colorado springs, Japan cheap kamagra super amex impotence natural cures, 2Sen- ever, the evidence is not strong enough and larger, randomized, dai Medical Center, Department of Rehabilitation, Sendai, Japan, double blind, placebo-controlled, and multicenter trials are needed. This could be attributed to comple- 4 mentary role of electrodiagnostic studies to imaging studies, where neering, Taipei, Taiwan, Chang Gung University, Department of electrodiagnos is as a physiologic evaluation compared to imaging Physical Therapy and Graduate Institute of Rehabilitation Science, studies as anatomic/structural evaluation. Conclusion: This study was the frst to demon- nerve damage and brain trauma as well. Based on our results, brain injury may alter the mented with psychosocial approach for patients and their caretakers. Data of demographic characteristics, etiology and origin of more than 13,000 islands. Due to geographical conditions and dis- referral, and fnal diagnose and payment methods were gathered. Results: Result, in about one third (31%) of cases was rial and Methods: A 3-year-old girl sustained multiple fexor and normal. The most common roots involved in lumbosacral and cer- extensor tendon rupture and median nerve injury of left hand in a vical radiculopathies were L5 (49. All the muscle strength, and sensory), and how to do gentle stretching and doctors were general duty doctors or residents in their respective massage. The areas covered were Rahim Yar Khan, Rojan, Dera the instructions for therapy and supervision were done by text mes- Ghazi Khan, MuzaffarGarh, Rajanpur, Nowshehra, Charsadda and sage and messenger applications with mobile phone. The Doctors reached the food area between instructions how to make hand orthoses from local materials. Re- 1–4 weeks and spent an average of 30 days in the food affected sults: After 16 weeks of the telerehabilitation, there was improve- areas. Gastrointestinal, respiratory and skin Conclusion: Telerehabilitation programs can be delivered even if infections were the commonest ailments followed by conjuncti- there was no sophisticated technology. Hasnan1 rehabilitation services are required in initial days of foods, general 1University of Malaya, Rehabilitation Medicine, Kuala Lumpur, duty doctors trained in common food related ailments are suff- Malaysia cient, however evacuation of previously disabled person residing in the area should be catered for. Conclusion: Higher self-effcacy and independence level evacuees living in temporary housing, and to identify whether the are associated with higher ftness level. It is therefore important amount of physical activity was related to physical ftness and qual- that rehabilitation interventions include strategies to promote and ity of life. Material and Methods: Sixty-four residents of temporary improve self-effcacy and independence. These measures may lead housing in Minamisoma city, aged ≥65 years participated in the to higher physical activity and ftness level. The average daily steps of each participant were measured using a triaxial accelerometer to be representative of the daily phys- ical activity. No relationship was observed between the amount of Aqil, Pakistan physical activity and physical ftness and health-related quality of life except for “physical function”. Conclusion: Physical activity of Introduction/Background: Floods are one of the most frequent nat- the elderly residents of temporary housing complexes was shown ural disasters in recent history. The aim of this study was to analyze to be less compared with the national average of age-matched in- the spectrum of medical issues during foods and to document the dividuals. This decrease in their activity level puts them at risk for needs for medical rehabilitation expertise during foods in Paki- developing lifestyle diseases. Material and Methods: A questionnaire based cross-sectional facilitating the performance of activities of daily living (i. Doctors who provided services in the food ing, laundry, bathing) for the residents in temporary housing may affected areas in the acute phase were interviewed. Orpilla 1 cast for immobilizing the unaffected hand for 5 hour/day and com- Philippine Academy of Rehabilitation Medicine, Manila, Philip- pleted unimanual practice with the hemiplegic hand. Participants were doctors and allied health professionals involved in stroke rehabilitation in the rehabilitation training hospitals in Metro Manila. There were variations in outcomes in the other practices descriptors and auditing guidelines in line with the key 1The University of Hong Kong, Institute of Human Performance, recommendations from the contextualized stroke guidelines. The Hong Kong, Hong Kong- China, 2The Hong Kong Polytechnic Uni- health professionals perceived and valued the guideline implemen- versity, Department of Rehabilitation Sciences, Hong Kong, Hong tation as practical and collaborative. It provided summary of ef- Kong- China, 3The Sixth Affliated Hospital of Sun Yat-sen Univer- fective strategies in stroke rehabilitation and standardized practice. Conclusion: Introduction/Background: This novel study aimed to (1) compare Improvements in some descriptors and quality indicators were seen neuromuscular performance, postural control and motor skills pro- one-year post implementation of recommended guidelines. Three of the six variables for positive reward were toys, snacks, and tablet games and the remaining three for negative were the parents, room and soft pool of balls. Simple percentage was used 1The University of Hong Kong, Institute of Human Performance, to determine the profle of the subjects and mean was used to analyze Hong Kong, Hong Kong- China, 2The University of Hong Kong, the response time on compliance in the reward system. Motor clumsiness is related to sensorimotor defcits and possibly mental 188 attention problems. A multiple regression analysis long-term complications including musculoskeletal disability. Treatment: decrease weight bearing, Ca tion index remained signifcantly associated with the total impair- and vitamin D supplementation. These complications can impair tive Sciences- Department of Physical Therapy, Cebu City, Philip- the survivors’ health-related quality of life. Chen of research, the goal of this study is to determine the effect of positive 1Chang Gung Memorial Hospital- Chiayi, Physical Medicine and and negative reward reinforcements’ response time on compliance to Rehabilitation, Puzih, Taiwan, 2Chang Gung University, School of J Rehabil Med Suppl 55 Short Oral Abstracts 61 Medicine- College of Medicine, Taoyuan, Taiwan, 3Chang Gung be desirable to base forecasts concerning the need for health ser- Memorial Hospital- Chiayi, Traditional Chinese Medicine, Puzih, vices in the future on the model developed during the project. However, com- Hospital Sultan Ismail, Rehabilitation Medicine, Johor Bahru, prehensive information regarding the costs and utilization of reha- Malaysia bilitation for such patients remains scarce. This population-based Introduction/Background: Based on recent data from Malaysian study used a nationwide database to examine the characteristics and Registry of Intensive Care, the incidence of PrU in Hospital Sul- trends of rehabilitation costs and use in Taiwanese patients with tan Ismail, Johor Bharu increased from 8. Material and Methods: Primary ob- hemophilia A who were registered in the National Health Insur- jective: to investigate and analyze the cost of PrU management ance Research Database between 1998 and 2008 were analyzed. Secondary objectives: to Results: The total costs for physical, occupational, and speech/ compare the cost of PrU management between paraplegics and swallowing therapy among patients with hemophilia A during the tetraplegics. Although the rehabilitation costs have increased had their inpatient records reviewed over seven consecutive days since 2004, these values have fuctuated without additional year- based on the most eventful week. They collectively had 55 PrU with an average of 3 PrU per rates for outpatient rehabilitation among all patients with hemo- patient. Conclusion: Higher and encourage these patients to utilize rehabilitation resources to stage of PrU resulted in higher management cost. Bitenc1 ing, thereby increasing patients’ self-reliance and consequently her 1University Rehabilitation Institute Soča, Development centre for dependence on healthcare services. Persons analysis we use data from the Norwegian Patient Registry, Registry with disabilities in Slovenia are mainly employed on the open la- for Individual-based Nursing and Care Statistics, and the Register bour market (80%), social economy represents approximately 20% for Control and Payment of Primary Care Reimbursement Scheme. Work in employment centres is the di- Connecting multiple data records from these sources creates a rect outcome of Slovenian employment rehabilitation services. It allows the analyst to follow an individual’s use of Slovenian thematic study was prepared in 2013 by Development various healthcare services over time. The grounds for the study basis of this formal model combining concepts from micro-eco- are based on the Slovenian Court of Audit Report recommenda- nomic theory, mathematics and statistics, state-of-the-art statistical tions. Material and Methods: Cohort study-retrospective and case- techniques will be used (i) to explain existing data, (ii) to estimate study.
Material and Methods: A 41-year- ment of General Medicine and Community Health Science purchase kamagra super without prescription erectile dysfunction self treatment, Sasay- old man suffered from subarachnoid hemorrhage (Hunt & Kosnik ama Hyogo purchase discount kamagra super on line what causes erectile dysfunction in diabetes, Japan purchase kamagra super 160mg mastercard erectile dysfunction at 20, 2Sasayama Medical Center Hyogo College of grade 5) due to the rupture of an anterior communicating artery an- Medicine, Department of Rehabilitation, Sasayama Hyogo, Japan, eurysm. He underwent the craniotomy clipping and lumboperitoneal 3Nishinomiya Kyouritsu Rehabilitation Hospital, Department of shunt surgeries for the treatment of hydrocephalus, which he devel- Rehabilitation, Nishinomiya Hyogo, Japan, 4Hyogo College of oped later. He was discharged on the 239thday and returned home, but was admitted in our hospital for further rehabili- Introduction/Background: The evaluation of the spasticity is essential tation on the 256th day. However, there is no established quantitative evaluation of the lower limbs were very diffcult to treat and had limited the knee the spasticity currently. We recorded M-response, H-refex and T-refex ure score improved by 21 points at discharge, compared to that at by tibial nerve stimulation of the affected side before and 4 weeks admission. This is 1 1 1 because Tmax/Mmax refects achilles tendon refex clinically, which C. Introduction/Background: Approximately 20–43% of the post-stroke patients developed spasticity and motor defcit. All the assessment emphasis after acute brain injury is more on life preservation. Tradi- was done at baseline (pre-treatment), one week after treatment and tionally, contracture resulting from spasticity have been managed by at four weeks follow-up. Results: The intervention group showed signifcant improvement spasticity has also role in the pathophysiology of contracture, another in the upper limb motor function and the effect persisted up to one option to treat contracture is by giving local injection procedure such month after treatment. Other than that, there was no signifcant im- as chemical neurolysis using alcohol, phenol or Botolinum Toxin provement in the spasticity and motor evolved potential. High dose of Botulinum improved motor impairment of upper limb with no effect on spasticity. Clinical follow up was obtained at 2 limb amputations treated at Disabled Child Assistance Association weeks, 2 months and 6 month post intervention. Material and Methods: 39 patients answered the question- injection and undergone intensive rehabilitation involving stretching, naire, which included items related to general characteristics, am- functional gait training including ground walking and body weight putation, rehabilitation, activities of daily living, occupation, driv- supported gait training, patient has shown impressive improvement ing and pain in the stump. Beck Anxiety and Depression Inventory in both clinical assessment and outcome measures. Statistical nonparametric tests with equality of two outcome of patient from this case report suggests that Botulinum tox- proportions, confdence interval for mean of 95% e p-value <0. Chung1 Introduction/Background: Interruptions to amputee rehabilitation is 1University of Malaya, Department of Rehabilitation Medicine, a common occurrence. Meikle et al studied the frequency of inter- Kuala Lumpur, Malaysia ruptions in 254 patients admitted for rehabilitation and discovered interruptions in 30% of the patients. It is thought that walking on single limb with endothelial trauma (vascular injury), and the substantial incidence of the support of a walking aids will affect the peak plantar pressure autoantibodies to phospholipid in vascular surgery patients (hyperco- compared to bipedal walking. The purpose of this study is to fnd out agulability) places amputees at high risk. Although interruptions are if there is any difference in peak plantar pressure between normal common and result in longer lengths of stay, these interruptions do bipedal walking and walking on single limb with walking aids. Our case study supports published litera- barefoot on Footscan Pressure Plate using a 2-step protocol. Right ture that return to complete rehabilitation in this scenario can lead and left foot peak plantar pressure of their bipedal walking, walk- to successful prosthetic rehabilitation. Results: A 67-year-old male underwent left below knee test and post hoc analysis with Wilcoxon signed-rank tests were amputation on 21/10/2014. We re-established goals, and re-initiated in peak plantar pressure of right and left foot. When comparing right and left foot pressure, only Due to frequent fuctuation in stump volume regular follow-up is es- walking on single limb with crutches had a signifcant difference sential. There is a statistically signifcant positive correlation be- of Physical Medicine and Rehabilitation. Conclusion: The results have shown that single grades: a new population-specifc measure for lower limb amputees. If the result is to be extrapolated to the diabetic patient, it has to be done with caution. Stewart1 motion of the right knee was normal but the patient had pain during 1University of the Witwatersrand, Physiotherapy, Johannesburg, the examination. Magnetic resonance imaging of right knee showed the presence of hyperintense area and increased fat pad Background: It is important to outline the mapping and integration volume compatible with Hoffa’s disease at the lateral side of the of reviewed concepts and ideas to inform studies addressing ampu- knee (Figure 1). We administered diclofenac sodium 75 mg twice tee health in Johannesburg, in order to support the rationale, answer a day for ten days and he was advised for resting, elevation and the research questions, develop, implement, report and evaluate re- cold application. It can the researchers noticed that the current rehabilitation available fol- be diffcult to distinguish this clinical entity from other pathologies. This led to the postulation and expectation that an additional that have pain in the region of knee. Presence of this syndrome may and more supportive intervention is needed if one is to improve prevent prosthesis use. These included 766 problems specifc to developing countries and in particular South Africa. Haga1 problems were addressed in two forms namely, a randomised con- 1Graduate School of Medicine - The University of Tokyo, Depart- trolled trial and an epidemiological study. These problems included ment of Rehabilitation Medicine, Tokyo, Japan, 2The University of mobility, impairment, socioeconomic and psychological challenges. Their introduction is not troublesome, if the patients themselves have requests to use them or know their 768 usefulness. Therefore, it is sometimes diffcult to have young children utilize the prostheses. She then developed a Staph infection which progressed oelectric signals from residual limbs. Results: Several types of into toxic shock syndrome and then necrotizing fasciitis affecting all prostheses and devices were introduced to 12 patients; passive of her extremities causing her to require a bilateral below the knee hands with some function, body-powered prostheses, myoelec- amputation. She spent a total of 3 months in the hospital before be- tric hands, prosthetic hands with sports and recreational devices ing transferred to our Acute Inpatient Rehabilitation Unit where it (S&R), 3D printed robotic prosthesis the ‘Robohand’, three-fn- was noticed she had a locked knee. Material and Methods: A few gered functional hand the ‘Finch’ fabricated by 3D printer, and a different methods were attempted to release the patient’s locked motor-driven plastic toy train the ‘Plarail’ controlled by myoelec- knee. Ten out of 12 patients actively used the main prosthe- a skilled licensed physical therapist was tried. The usages of including anti-infammatory medications and neuropathic medica- prostheses and the Plarail which the ten patients used are shown. A knee injection with cortisone was of- Conclusion: We introduced a variety of prostheses: functional fered but patient refused due to fear of risk of infection. Those functional prostheses also considered but was deferred as the patient had a new skin graft and toys stimulated children’s interest like their toys, contribut- on the anterior aspect of same leg that had a locked knee. Medications didn’t putation pain experience through disinhibition of somatosensory seem to have any affect either. In diabetic limb amputee with option and it was decided to be revisited once the patient’s skin graft distal sensory neuropathy, no pain sensation through ascending sys- had fully healed. Conclusion: In conclusion, this is the frst case in tem will be percept at somatosensory cortical area and there are the literature of a patient s/p amputation after toxic shock syndrome no engram of preamputation pain memory.
High concentrations of oxygen cause alveolar collapse purchase 160mg kamagra super overnight delivery erectile dysfunction vs impotence, as oxygen is absorbed rapidly cheap 160mg kamagra super with visa relative impotence judiciary. Respiratory Failure 103 Handbook of Critical Care Medicine Mechanical ventilation Mechanical ventilation is often required in critically ill patients who develop respiratory failure purchase cheap kamagra super on line erectile dysfunction new zealand. While it is a valuable tool to assist ventilation, it can be dangerous if used inaccurately or unnecessarily. Junior doctors often find ventilators and ventilation threatening and shrouded in mystery, with strange bits and pieces of equipment, numerous unfamiliar settings and confusing parameters and values to be monitored. In reality, if one understands the basic concepts of ventilation, it is quite simple. The respiratory system has two components: x The gas transfer mechanism: the lungs -airways, alveoli, and circulatory system supplying the lungs x The pump which ventilates the lungs: diaphragm, accessory muscles of respiration, and the respiratory centre. Similarly, in acute asthma, the work of breathing increases, and this together Ventilation 104 Handbook of Critical Care Medicine with poor oxygenation results in exhaustion of the respiratory muscles. The disadvantages of invasive ventilation are: x Higher risk of nosocomial pneumonia x Loss of cough reflex x Inability of the patient to speak x Possible late complication of tracheal stenosis with long duration of ventilation Early ventilators were simple pumps. The tidal volume and rate could be adjusted to achieve the necessary minute ventilation. At the start of the inspiratory cycle of ventilation, the valve opens, and a fixed volume of air is delivered into the lungs by positive pressure. At the end of inspiration, the expiratory valve opens and the inspired air is expired by the elastic recoil of the lungs. Since the patient’s own breaths would interfere with the ventilators breaths, patients had to be Ventilation 105 Handbook of Critical Care Medicine paralysed using a neuromuscular blocking agent. Ventilation occurs continuously irrespective of whether the patient is breathing or not. Modern ventilators nearly always synchronise the delivered breaths to the patient’s own breaths. The components of a ventilator A ventilator has several basic components x A source of pressurised gas with a mechanism for mixing air and oxygen to the desired concentration of oxygen x A ventilator circuit, with an inspiratory valve and an expiratory valve x A control system, with a control panel together with monitoring and alarms x A system to synchronise the ventilator to the patients breathing’ The ventilator is connected to an oxygen supply. This is called the FiO ,2 Ventilation 106 Handbook of Critical Care Medicine or fraction of inspired oxygen, and is correctly given as a fraction, i. The ventilator circuit consists of an inspiratory tube and an expiratory tube, which are connected to the patient using a Y shaped connector. Ventilators usually have a synchronisation system to sense the patient’s own breathing, and synchronise the machines breaths accordingly. Sensors within the ventilator circuit sense the patient’s inspiratory effort, and trigger opening of the inspiratory valve. When inspiratory flow falls below a certain level, the inspiratory valve closes and the expiratory valve opens. The size of the external ventilator circuit must be adequate for the patient, and in an adult, the inner diameter should be 22mm. Modern ventilators display most of the required ventilator and patient parameters, sometimes in graphical form. In addition the control panel has various alarms which can be set according to requirements. For example, if the tidal volume drops below a certain level, an alarm would sound. The control panel also allows for certain manoeuvres which are used to assess various respiratory parameters such as peak and plateau pressures, airway resistance and lung compliance. The gas delivered to the patient must be adequately heated to body temperature and humidified. This is achieved by using either a heat and moisture exchanger mounted at the Y-piece, or an Active Heated Humidifier in the inspiratory line. They have the disadvantage of not being very effective if the tidal volume and minute ventilation are high, and tend to increase dead space. Active humidifiers are more effective and have an active heating device with temperature control and sensors to maintain the correct humidity and temperature. As mentioned above, modern ventilators attempt to supplement and support the patient’s own respiration as far as possible. In pressure control ventilation, a fixed inspiratory pressure is applied during inspiration. Expansion of the lung is limited by the pressure Ventilation 108 Handbook of Critical Care Medicine which is applied. When the recoil pressure of the lung equals the applied pressure, or when the inspiratory time ends, inspiration ends. The volume of air entering the lungs during the inspiratory phase will depend on the compliance of the lung. If the compliance is low, the lung will expand to a lesser degree than if the compliance is high. Volume control ventilation is more widely used in critically ill patients, because the lung volumes are more predictable, and will be discussed here. Before we discuss the commonly used modes, there are two other important settings that are briefly mentioned. Pressure support: this is the amount of pressure applied at the start of the inspiratory cycle, i. Pressure support makes it easier for the patient to breathe in, and takes away the dead space. Pressure support is not present in ventilator timed breaths, only in spontaneous breaths. It helps to keep the airways open, since if the pressure within the airways fall to zero, the airways will collapse. Paralysis is required in certain circumstances; however, in general the ventilator supplements and assists the patient’s natural breaths. Ventilator breaths are usually triggered by the inspiratory effort made by the patient. When the patient makes a respiratory effort, a negative pressure is applied to the inspiratory valve. When this negative pressure exceeds a certain value (usually around negative 2mmHg), inspiration is ‘triggered’ - the valve opens and inspiration begins. When the inspiratory flow falls below a certain value, the inspiratory valve closes, and expiration begins. Ventilation 109 Handbook of Critical Care Medicine Assist control ventilation In this mode, a tidal volume and respiratory rate are set on the machine. Every inspiratory effort triggers the machine to deliver a full breath of the set tidal volume. If the patient’s own respiratory rate is less than the set respiratory rate, the ventilator will ensure that the required breaths are given. Let us take an example where the set rate is 14 breaths per minute, and the tidal volume is 500ml. Each time the patient attempts to take a breath, the ventilator will deliver a tidal volume of 500ml. The disadvantage is that if the patient’s respiratory rate is high, the minute ventilation can be significantly high, resulting in respiratory alkalosis.
The degree of transient cortical dysfunction appeared to relate directly to the intensity of early organic symptoms 160 mg kamagra super for sale erectile dysfunction los angeles. Severed neurones may 3110 heal but develop incorrect connections generic kamagra super 160mg on-line erectile dysfunction treatment exercises, which may cause persistent sensory abnormalities and major problems in processing multiple stimuli cheap kamagra super 160mg on-line erectile dysfunction doctor montreal, e. The most troublesome long term morbidity after head injury is caused by behavioural and emotional consequences, including sexual inhibition, aggression, apathy, anxiety, and lability of mood. Syndromes that may follow local injury (McClelland, 1988) Frontal - disinhibition, euphoria, reduced vitality Temporal – aggressiveness Basal - reduced spontaneity and vitality Other psychological changes - anxiety, depression, tension, fatigue, irritability, obsessionality, and hypochondriasis According to Fleminger (2009a, p. Lack of confidence, hopelessness, and self-deprecation may be more reliable symptoms than biological complaints (e. Post-traumatic seizures can be divided into immediate (seconds/minutes), early (within 7 days), and late seizures. The earlier the seizure onset the more benign is the prognosis for epileptic progression. Penetrating injuries and injuries affecting multiple cerebral lobes are more likely to lead to epilepsy than are closed injuries or unilobular injury. The risk of epilepsy following mild or severe brain injury or skull fracture in children and young adults is increased and lasts for years; a family history of epilepsy increases the risk of epilepsy following mild or severe brain injury. Antiepileptic drugs are poor at preventing seizures after head injury and phenytoin may even slow recovery. Information form evoked potentials provide helpful prognostic indicators: the degree of recovery of these central conduction times correlates with clinical improvement. Increased age is associated with a reduced chance of returning to work, increased memory problems, an increased incidence of anxiety and fears, and an increased mortality rate. Legal liability should be decided early, or a ‘no fault’ system of compensation should be introduced. Fleminger (2003) warns that haloperidol is overused and can cause akathisia and worsening of confusion. Minimum effective doses should be used and the need for continued prescribing should be reviewed frequently. Reactive nursing (nurse only gives attention if patient disturbed) may 3117 reinforce the problem. According to Fleminger (2003) early transfer to a specialised rehabilitation unit leads to better outcome than delayed stays on medical or surgical units. The availability of such units, especially ones with a high tolerance for disturbed behaviour, may be less than the ideal. The boxer can look forward to a worsening of all these until he finally quits the ring. Blows damage the cortical (especially frontal and temporal) surface and cause multiple disruptions of neuronal networks (Strich lesions). Bleeding may occur, especially in the substantia nigra and deep periventricular tissues. Head guards do not protect from rotational injuries, only making the head a bigger target. Loosemore ea (2007) found no evidence for chronic traumatic brain injury in the literature on amateur boxing although the ‘quality of evidence was generally poor’. McCrory (2003) concluded that head to ball contact in soccer is unlikely to cause brain injury but head to head contact, which is difficult to prevent, might do so. The environment of head-injured patients may need modifying in order to minimise disturbed behaviour. Routine, structure, task simplification, modification of environmental stimulation, and removal of annoyances may be needed. Realistic hope should be instilled, mourning should be assisted, strengths should be identified, and self-esteem bolstered. Memory aids, use of concrete communications, and short psychotherapeutic sessions may help. The patient should be taught skills that assist coping, relaxation, and stress management. Problem-solving skills and breaking down goals into achievable ones will assist progress. Mittenberg ea (1996) reported that participating in education programs aimed at normalising reactions can improve post-concussional symptoms. They will need to learn the middle road between excessive protection and risk-taking if the patient is to achieve optimal independence and competence. Headache3118 Childhood headache, which is associated with psychosocial adversity, may be a risk factor for adult headache and psychiatric symptoms in adulthood. Structures above the tentorium are innervated by the ophthalmic division of the V cranial nerve, whilst structures below the tentorium are innervated by C2 and C3. Cerebellar lesions usually cause pain posteriorly, and pain from occipital lobe lesions is felt anteriorly. However, because of a contribution from the caudal nucleus of V nerve, pain from upper cervical spine or posterior fossa can also be referred to the front of the head. Chronic renal failure may be associated with headache, emesis, and left ventricular failure. Many cases of bacterial meningitis suffer headache for months after the initial illness. It tends to be symmetrical, have a particular distribution (bifrontal, bioccipital, and nuchal), be of mild to moderate intensity, to have a stable intensity, to get worse as the day progresses, to lack features of migraine, and is often of high frequency (sometimes daily). It responds to reduction in stress, psychotherapy, environmental manipulation, alcohol, tranquillisers, etc. Sufferers (migraineurs) have been characterised as ‘anxious and neurotic’, but, whilst they do suffer an excess of anxiety and depression (probably more than other headache sufferers: Fleminger, 2009b, p. Rasmussen (1992) found that people with tension headache rather than migraine had high neuroticism scores on the Eysenck Personality Inventory. Indeed, previous descriptions of migraineurs as being particularly ‘neurotic’ may have been due to confinement of studies to clinic samples. Migraine with aura is more likely to be familial than is migraine without aura, but the likelihood of a latter case having a similarly affected close relative is increased nonetheless. The risk of a child developing migraine is, respectively, 45% and 70% if one or both parents have the disorder. Being pregnant may relieve migraine and two-thirds of cases improve with physiological menopause, the opposite number worsening with surgical menopause. The same phenomenon can be induced in animal studies by applying a strong solution of potassium. The wave may be preceded by a brief hyperaemic phase, possibly the cause of the lights that occur during an aura. Digitolingual paraesthesias (cheiro-oral syndrome) are a common part of the aura – numbness and pins and needles start in the fingers of one hand and extend into the arm and face, especially the nose and mouth area ipsilaterally; this usually follows the visual disturbance but uncommonly occurs without it. Teichopsia consists of visual hallucinations, especially of battlements, and is characteristic of migraine.