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Interestingly order olanzapine 10 mg line medicine zyprexa, noise stress-induced en- disorders reveal abnormalities in monoamine systems as well hancement of glutamate release in the LC is abolished by as other neurotransmitter systems buy discount olanzapine facial treatment. Nevertheless proven olanzapine 5mg medicine quiz, it is con- superfusion of the LC with a CRF antagonist (160) purchase cheap olanzapine online medicine vending machine, demon- ceivable that a root cause of depression is a failure or deficit strating an important interaction between CRF and gluta- in a single neurotransmitter system. Because of the intercon- mate systems at the level of the LC (88). It is tempting to nectivity of the monoamine systems, it is likely that failure speculate that a deficit in noradrenergic transmission in in one system to adequately respond to demand would major depression is secondary to a chronic elevation in glu- quickly lead to compensations, or possibly failure, of the tamatergic input into the LC and a resulting depletion of other monoamine systems, as well as changes and/or bio- central NE. At rectly regulated by the pathogenic neurotransmitter system. As is the case for the monoaminergic, as well as nonmonoaminergic, neurotrans- LC, glutamate is excitatory in the raphe nuclei. The activity mitter systems in depression compels us to integrate neuro- of DA neurons in the mesolimbic and mesocortical circuitry transmitter interactions into theoretical models of the neu- can also be modulated by excitatory amino acids (73). This is a difficult neurons in the VTA receive direct glutamatergic innervation undertaking and requires translation and integration of clin- from the prefrontal cortex (73). Glutamate excites DA cell ical, preclinical, and basic research findings. The postulate activity via inotropic and metabotropic receptors (167). That is, depression is associated with reduced GABA function. Petty elevated tyrosine hydroxylase in the LC, as observed in has reviewed this topic (135). To summarize, plasma GABA major depressive suicide victims, can be experimentally pro- Chapter 73: Neurocircuitry of Mood Disorders 1059 duced by pharmacologically depleting NE or chronically in major depression. Plasma and platelet sine hydroxylase in the LC, as can chronic administration excitatory amino acids in psychiatric disorders. Interestingly, CRF is reported to be elevated in 1993;150:1731–1733. Together, these data suggest that elevated CRF in demonstration of increased serotonin 5-HT2 and -adrenergic depression increases demand for NE, probably leading to receptor binding sites in the brain of suicide victims. Quantitative autoradi- also contribute to reduce serotonergic transmission in ography of 1 and 2 adrenergic receptors in the cerebral cortex depression, given the CRF can inhibit dorsal raphe neurons. Furthermore, it is conceivable that other excitatory inputs 5. Fewer pigmented locus to the LC, such as substance P, might also exhibit elevated ceruleus neurons in suicide victims: preliminary results. The 5-HT1A receptor antidepressant actions may elicit their effects on mood, at selective ligands, (R)-8-OH-DPAT and (S)-UH-301, differen- least in part, through actions at the LC. In contrast to excita- tially affect the activity of midbrain dopamine neurons. Naunyn tory transmitters, elevated demand for NE could also result Schmiedebergs Arch Pharmacol 1993;347:353–362. Serotonin selec- GABA provides an inhibitory input to the LC. The brain nucleus locus coeruleus: restricted afferent control of a broad efferent disorders, whereas different mood disorders or subtypes of network. Afferent regula- neuronal input to that particular system. Using the hypothe- tion of locus ceruleus neurons: anatomy, physiology and phar- sis of increased demand for NE in depression as an example, macology. Differential distribution elevated activity of the LC may be a result of elevated CRF of corticotropin-releasing hormone immunoreactive axons in input to the LC in some depressives, whereas others may monoaminergic nuclei of the human brainstem. Neuropsycho- experience elevated LC activity as a result of overactive sub- pharmacology 1997;17:326–341. Distribution, mor- ently, there is little evidence to support the idea of serotoner- phology and number of monoamine-synthesizing and substance P-containing neurons in the human dorsal raphe nucleus. Neu- gic or noradrenergic depressives that respond selectively to roscience 1991;42:757–775. However, NE and 5HT containing neurons may be substance P in stress-induced activation of mesocortical dopa- downstream of disrupted input systems that may actually mine neurones. Suppression of serotonergic neu- ronal firing by -adrenoceptor antagonists: evidence against chemical/neuroanatomic level. Noradrenergic innervation of se- designed to simultaneously measure multiple neurotrans- rotonergic neurons in the dorsal raphe: demonstration by elec- mitter systems. Ultimately, a thorough understanding of tron microscopic autoradiography. Experimental basis for the antidepressant action of the GABA receptor agonist progabide. Neurosci Lett 1984; tems as they relate to the neurochemical pathology of de- 47:351–355. Echogenicity of the ACKNOWLEDGMENTS brainstem raphe in patients with major depression. Ordway has received research support from Eli Lilly, 19. Urinary MHPG in subgroups of Pharmacia-Upjohn, and Merck. In addition, he served as a depressed patients and normal controls. Antidepressant effects of ketamine in depressed patients. Plasma concentrations of sive relapse induced by catecholamine depletion. Arch Gen Psy- excitatory amino acids, serine, glycine, taurine and histidine chiatry 1999;56:395–403. Pimozide GABAergic anatomic relationship in the rat substantia nigra, prevents the development of conditioned place preferences in- locus coeruleus, and hypothalamic median eminence: immuno- duced by rewarding locus ceruleus stimulation. Behav Brain Res cytochemical visualization of biosynthetic enzymes on serial 1992;50:85–92. Current advances and trends in the mRNA coding for D1 and D2 dopamine receptors in the rat treatment of depression [see comments]. A role for the serotonin sion—striatal dopamine D2 receptor SPECT before and after system in the mechanism of action of antidepressant treatments: antidepressant therapy. GABA-mediated inhibition of locus tonin transporter in the midbrain of suicide victims with major ceruleus from the dorsomedial rostral medulla. Stress, antidepressant drugs, and the locus coeruleus.
O nce the glom erular filtration rate has decreased below 25 occur cheap olanzapine 7.5 mg without prescription medicine escitalopram. Late nephrocalcinosis leads to progressive loss of renal function m L/m in the com bination of oxalate overproduction and reduced over several years discount olanzapine 10 mg amex symptoms brain tumor. Rejection episodes are less com m on in patients urinary excretion leads to system ic oxalosis purchase olanzapine 7.5mg symptoms juvenile rheumatoid arthritis, with calcium oxalate receiving com bined liver and kidney grafts than in those receiving deposition in m any tissues buy olanzapine american express medicine world nashua nh. Renal transplantation alone has yielded kidney transplantation alone [3,19]. Acute rejection with renal poor results in the past, with 1-year graft survival rates of only dysfunction, however, causes additional episodes of acute calcium 26%. Com bined hepatorenal transplantation sim ultaneously oxalate deposition in the kidney. Recurrent oxalosis can be seen as replaces renal function and corrects the underlying m etabolic defect. The 1-year liver graft survival rate is 88% , with patient survival of 80% at 5 years. O f 24 renal grafts from the European experience of hepatorenal transplantation, 17 were still functioning at 3 months to 2 years after transplantation. FIGURE 17-14 PATIENT MANAGEMENT IN RENAL OR HEPATORENAL Daily hem odialysis for at least 1 week before transplantation TRANSPLANTATIONS FOR PRIMARY HYPEROXALURIA depletes the system ic oxalate pool to som e extent. Som e centers continue aggressive hem odialysis after transplantation, regardless of the renal function of the transplanted organ. In patients receiving Aggressive preoperative dialysis (and possibly continued postoperatively) com bined hepatorenal grafts, dietary m easures to reduce oxalate Maintenance of high urine output production are not as im portant as they are in patients receiving isolated kidney grafts. In these patients, excess production of Low oxalate, low ascorbic acid, diet low in vitamin D oxalate from glyoxylate still occurs. M agnesium and phosphate Phosphate supplements supplements are powerful inhibitors of calcium oxalate crystallization Magnesium glycerophosphate and should be used in all recipients, whereas thiazide diuretics m ay High-dose pyridoxine (500 mg/d) reduce urinary calcium excretion. Pyridoxine is a cofactor for alanine– Thiazide diuretics glyoxylate aminotransferase and can increase the activity of the enzyme in som e patients. Pyridoxine has no role in com bined hepatorenal transplantation. For m ost patients the ideal option is probably a com bined transplantation when their glom erular filtration rate decreases below 25 m L/m in [8,9]. H owever, increasing num bers of patients these grafts within 2 years of transplantation [20,21]. Patient survival with m yelom a and AL am yloid, or prim ary am yloidosis, are now is reduced, owing to infections and vascular complications, to 68% at receiving peripheral blood stem cell transplantations or bone m ar- 1 year and 51% at 2 years. Recurrence is characterized by proteinuria row allografts. Thus, these patients are surviving long enough to 11 m onths to 3 years after transplantation. Recurrent light chain consider renal transplantation. O ver 60 patients with renal failure deposition disease is found in half of patients receiving allografts, with resulting from system ic am yloid A (AA) am yloidosis have been graft loss in one third despite plasmapheresis and chemotherapy. Graft survival in these H eavy proteinuria is seen at the onset of recurrence. AL— prim ary patients is the sam e as that of a m atched population. FIGURE 17-16 M icroradioangiography com paring the vasculature of the kidney in a patient with no disease (panel A) and a patient with hom ozygous sickle cell disease (panel B). Despite the frequency of renal dam age in sickle cell disease, only 4% of patients progress to end-stage renal disease, and little experience exists with renal transplantation. Three patients have been reported with recurrent sickle cell nephropathy. In one case, a patient developed renal dysfunction 3. A second study reported recurrent sickle cell nephropathy leading to graft failure in two of eight patients receiving transplantation. Concentration defects were observed within 12 months of grafting. Patients also suffered an increased incidence of sickle cell crises after renal transplantation, possibly associated with the increase in A B hem atocrit. SLE accounts for approxim ately 1% after transplantation, with overall renal and extrarenal recurrence rates of up to 29% and of all patients receiving allografts, and less renal recurrences alone of up to 16%. Graft loss has been reported in up to 40% of than 1% of these will develop recurrent patients with renal recurrence. In the m ost recent data from the H am m ersm ith H ospital, renal disease. Tim e to recurrence has been however, renal recurrences were rare, with only 0. These patients have often been on long courses of im m unosuppres- tion [24,25]. Cyclosporine therapy does not sive therapy before receiving a graft. It is reasonable to can involve the ureter, causing stenosis and obstructive nephropathy. Serial m onitoring of ensure that serologic test results for SLE are antineutrophil cytoplasm ic antibodies after transplantation is im portant in all patients m inim ally abnorm al before transplantation with vasculitis because changes in titer m ay predict disease relapse [28,29]. Patients with lupus anticoagulant and anticardiolipin antibodies are at risk of throm boem bolic events, including renal graft vein or artery throm bosis. These patients m ay require anticoagulation therapy, or platelet inhibi- tion with aspirin. FIGURE 17-19 RENAL COM PLICATIONS OF HEPATITIS C VIRUS Recurrence of both m esangiocapillary glom erulonephritis (M CGN ) AFTER KIDNEY TRANSPLANTATION and, less frequently, m em branous nephropathy is well described after transplantation. N ineteen cases of de novo or recurrent M CGN after transplantation have been described in patients with Clinical: hepatitis C virus (HCV). Almost all had nephrosis and exhibited Proteinuria sym ptom s 2 to 120 m onths after transplantation. Eight patients had dem onstrable cryoglobulin, nine had hypocom plem entem ia, Nephrotic syndrome and m ost had norm al liver function test results. M em branous GN Microscopic hematuria is the m ost com m on de novo GN reported in allografts, and it is Histologic and laboratory findings possible that HCV infection may be associated with its development Mesangiocapillary glomerulonephritis with or without cryoglobulinemia,. Twenty patients with recurrent or de novo m em branous GN hypocomplementemia, rheumatoid factors and H CV virem ia have been reported. In one study, 8% of patients Membranous nephropathy: normal complement, no cryoglobulinemia or rheumatoid factor with m em branous GN had H CV antibodies and RN A com pared Acute and chronic transplantation glomerulopathy with less than 1% of patients with other form s of GN (excluding M CGN ). Prognosis in these patients was poor, with persistent heavy proteinuria and declining renal function. The overall recurrence rate is approximately 20% to 30% [1,4,31]. These numbers, however, may be an underestimate because of biopsy sampling errors.
Nevertheless buy olanzapine once a day treatment hypothyroidism, the abnormal gene prod- aggressive traits (54) order generic olanzapine online medications ranitidine. Importantly olanzapine 10 mg discount medications a to z, stereotypic behaviors uct in PWS may ultimately provide crucial information on may be associated with significant medical complications order 7.5 mg olanzapine with amex medications for ocd, the neurochemistry of the SIB characteristic of these pa- and they may also lead to distressing feelings of shame and tients. Neuroanatomy Neurochemistry Most recently, volumetric magnetic resonance imaging (MRI) and positron-emission tomography (PET) tech- Case reports suggested that the SSRIs may have a role in niques have documented reduced caudate volume and re- the treatment of skin picking. Indeed, in a series of 30 1748 Neuropsychopharmacology: The Fifth Generation of Progress patients with skin picking, an open trial of sertraline demon- tism were found to have a different range of repetitive symp- strated efficacy (55). They were more likely to demonstrate repetitive or- view of body dysmorphic disorder patients with skin picking dering, hoarding, touching, tapping, or rubbing, and self- indicated that SSRIs were often effective, whereas other injurious behaviors (59). Nevertheless, it may be postulated agents were not (56). Finally, in their controlled study Si- that there are at least some similarities in the underlying meon and colleagues (53) found that fluoxetine was signifi- neurobiological mediation of autism and OCD. Neurochemistry In nail biting, clomipramine appeared more effective There does seem to be evidence of serotoninergic dysfunc- than desipramine, although results were not perhaps as ro- tion in autism (60). Several studies have found elevated bust as those seen in classic OCD (33). The authors empha- platelet serotonin levels in autism. Neuroendocrine chal- sized that there was a high dropout rate at every stage of lenge studies with serotoninergic agents have indicated re- the study, which appeared in sharp contrast to that seen in duced serotoninergic responsivity in autism. They did, however, suggest in a tryptophan depletion study, autism resulted in in- that their data were consistent with the hypothesis that simi- creased SIB, motor stereotypies, and anxiety. However, both open and placebo-controlled and desipramine in a crossover trial of SMD patients. Al- (61) trials with SSRIs have demonstrated efficacy in reduc- though clomipramine appeared promising in a number of ing symptoms such as SIB in autism. Furthermore, the SSRI cases, too few patients completed the trial to demonstrate clomipramine was more effective than the noradren- a clear benefit of clomipramine over desipramine. Neverthe- ergic reuptake inhibitor desipramine in autism (62). Never- less, several case reports suggest that SSRIs may be useful theless, not all studies of these agents have been positive in patients with skin picking, head banging, and other self- (63). Given that dopamine Other neurochemical systems may also play a role in the agonists may result in SIB (57), a possible role for dopamine mediation of self-injurious behaviors in autism. APET blockers, and the new atypical neuroleptics in particular, study demonstrated reduced dopaminergic activity in the also warrants further consideration. Ultimately, controlled anterior medial prefrontal cortex (64). Controlled trials have and long-term studies are needed to formulate rational ap- demonstrated that dopamine blockers (like SSRIs) are effec- proaches to the pharmacotherapy of SMD. Clinical experience indicates Neuroanatomy that where a medication is ineffective in autism, an agent To our knowledge, there have been no studies on the neu- from a different class of medication may be useful (60). The roanatomy of stereotypic movement disorder in normal atypical neuroleptics, with their combined dopaminergic controls. Given the ubiquity of these behaviors, and the and serotoninergic effects, also warrant further study. However, studies of opioid levels in tigating in more detail. Furthermore, despite prom- ising open trials, in controlled studies the effect of opioid blockers on target symptoms including SIB in autism has AUTISM been disappointing. Phenomenology There is promise for delineating the specific albeit multi- ple genetic factors underlying autism (60). Most recently, a possible link to the seroto- actions, communication deficits, and restrictive and stereo- nin-transporter gene has been suggested. Stereotyped SIBs are common in patients ultimately lead to a clearer understanding of the neurochem- with this disorder and may also be seen in other pervasive istry of autism and self-injury and to specific therapeutic developmental disorders that do not meet the narrower cri- interventions. Common forms of SIB in autism include hand/wrist biting, head banging, self- Neuroanatomy scratching, self-hitting, self-pinching, and hair pulling. It has been argued that repetitive behaviors in autism The neuroanatomy of autism has also received increasing cannot simply be subsumed under the banner of OCD. Preliminary postmortem Indeed, compared to patients with OCD, adults with au- studies have found abnormalities in the cerebellum and lim- Chapter 121: Compulsive and Impulsive Aspects of Self-Injurious Behavior 1749 bic system, including the hippocampus and amygdala. Neu- TRICHOTILLOMANIA rophysiologic research has demonstrated various abnormali- Phenomenology ties including aberrant processing in frontal association cortex. Early work with pneumoencephalography suggested The term trichotillomania was coined over a century ago left temporal horn dilatation, and an early MRI study found to describe patients with hair pulling. Hair pulling most hypoplasia of the posterior cerebellar vermis, but later stud- frequently occurs from the scalp, although it can occur from ies have been inconsistent. Functional brain imaging studies a wide range of body areas, including the eyebrows, eye- are also so far inconsistent, although perhaps suggestive of lashes, beard, axillae, and pubis (70). Plucking may be con- dysfunction in association cortex. Clearly, much remains to fined to a single patch, may involve different areas, or may be done to understand the neuroanatomy of SIB, and in- cover the entire scalp. Some patients also report pulling hair deed to integrate behavioral and biological findings in this from a child, significant other, or pet. Patients with hair pulling may demonstrate a range of other stereotypic and self-injurious behaviors (70,71). Indeed, both the personal and the economic costs of this disorder may Compulsive self-injurious behavior is only rarely seen in be significant. Awide range of behaviors may be seen, particularly head banging and self-punching or slapping, but also including lip biting and tongue biting, Neurochemistry eye poking, skin picking, and self-punching or -slapping. Research on the neurobiology of hair pulling was boosted Medical complications have included subdural hematoma by a seminal trial comparing clomipramine and desipramine and vision impairment. As in OCD, trichotillomania re- In a large study, SIB in TS was not correlated with intel- sponded selectively to the SSRI. Nevertheless, although the lectual function, but was significantly associated with sever- SSRIs have seemed effective for trichotillomania in a num- ity of motor tics and with scores of hostility and obsession- ber of open trials, these agents have proved disappointing ality (68). Furthermore, SIB has been described as one of in placebo-controlled trials (72). Thus, although the neurobiology of SIB trichotillomania response to clomipramine may be sustained per se in TS has not been well studied, it is possible that over time, there are also reports that initial response to SSRIs this overlaps with that underlying tics and compulsions. Taken together, this work indicates that it may be premature to overly emphasize the specific role of Neurochemistry serotonin in trichotillomania. Several neurochemical systems have been implicated in TS, Indeed, few studies of trichotillomania patients have di- most notably the dopamine system, but including also the rectly assessed monoamine concentrations. Ninan and col- serotoninergic, noradrenergic, opiatergic, hormonal, and leagues (73) obtained CSF from a small group of patients immunologic systems (see Chapter 117). However, to our with trichotillomania and found that CSF 5-HIAA levels knowledge little of this work has focused specifically on the did not differ from normal controls. This finding is redolent of some work on OCD and suggests that in both disorders response to SSRIs may Neuroanatomy be accompanied by a fall in CSF 5-HIAA levels.
This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed discount olanzapine 7.5 mg with mastercard symptoms thyroid cancer, the full report) may be included in professional journals 39 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising 7.5 mg olanzapine with mastercard medications not to mix. Applications for commercial reproduction should be addressed to: NIHR Journals Library purchase 20mg olanzapine with amex treatment 1 degree av block, National Institute for Health Research discount olanzapine online american express symptoms kidney failure dogs, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. When the child started school and therapies were being delivered in that setting, parents often expressed confusion about what they should still be doing, if anything. Finally, parents agreed that guidance on what to prioritise would be extremely helpful. Variation in advice and prescribing Some parents reported that they had experienced receiving different advice regarding the implementation of a particular technique or exercise, or the way a piece of equipment should be used, or for how long. In one case, when the use of a standing frame over long periods had been causing a child considerable discomfort, an inconclusive discussion with the physiotherapist left the parent wondering whether even the therapist knew what the appropriate dose or intensity should be. This included practising exercises related to motor or speech/communication, splinting and the use of sleep systems. The reasons why children resisted included the fact that the therapy restricted them doing other activities, that it was painful and that it disturbed their sleep. Various ways of managing this were reported, both between parents and on a situation-by-situation basis. Sometimes it led to a treatment being abandoned altogether. Parents described strategies they developed to overcome these difficulties. Valued therapy practices and approaches Within the data gathered from parents are some clear themes about the therapy practices and approaches that parents valued. Child-focused approaches Parents particularly appreciated therapists who clearly appeared to value their child and want the best for them. Why should our children not be pushed to reach their full potential? Goals-focused approaches It was clear in discussions with parents that there was a preference for goals-focused approaches. As we reported in an earlier section, many parents did not report this experience. Some parents did not feel a longer-term view was in the minds of the therapists working with their child, or that it had certainly not been overtly expressed to parents in those terms. This approach was regarded as leading to a focus on functional outcomes, rather than identifying alternative ways and means by which goals related to participation and well-being could be achieved. I feel it would be better to work on her upper arm strength so she can use a wheelchair. Many parents stressed the need for greater clarity about the aims of therapy interventions. For example, one parent described a situation when their child had identified riding a bicycle as her goal, but instead she was offered a tricycle. Parents who had accessed private provision often identified this as one of the most valued aspects of using private providers. In addition, parents valued feeling well informed about the therapy options available to their child. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 41 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. As this parent described: My OT [occupational therapist] and physio communicate. Often during these discussions reference was made to a perceived lack of attention and resources available for speech and communication support. Parents consistently valued therapists who took a wider interest in the child and family and who were able and prepared to offer, where appropriate, wider advice. Within this, parents welcomed therapists speaking with colleagues in other therapy teams or services to ensure co-ordinated and consistent approaches to the care and management of the child. Working in partnership with parents Finally, we would note and reiterate material reported earlier in this chapter regarding the way therapists worked with parents, in particular whether or not there was a sense of partnership, respect and shared objectives. There is increasing recognition of the importance of detailed and accurate reporting of the active ingredients of pharmacologic interventions in reports of evaluations and 27–29 intervention manuals. Referred to as complex interventions,31 they may well have one or more of the following features: l involve several interacting components l require many different behaviours from health-care professionals or participants for successful delivery l be aimed at different levels within an organisation l be tailored to different contexts or settings. A recent review comparing reporting of the active ingredients for pharmacologic interventions and non-pharmacologic interventions found it significantly poorer for the latter. The complexity of such interventions, and a lack of understanding or evidence regarding the mechanisms of change, are likely contributors to this. Before moving on to do so, we briefly discuss three overarching issues: levels of complexity, understandings of the active ingredients of therapies and therapist versus therapy. Levels of complexity All interviewees agreed that physiotherapy, occupational therapy and speech and language therapy are complex interventions. It was also argued that because the interventions are being delivered to children, and a diagnosis of neurodisability is present, the level of complexity increases. This was particularly the case when the neurodisabilty resulted in multiple and severe impairments. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 43 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. I1 We are dogged in therapy by multiple, sometimes not that plausible, hypothesised change mechanisms that are rarely explicitly articulated. The best way to work is multidisciplinary, but to show the contribution of SLT [speech and language therapy] there is very, very difficult. I2 This was the case even for longstanding techniques. The following quotation is on the use of standing frames in physiotherapy:. Is it getting children to stand at the same height as their peers? People also report a benefit in breathing, and bladder and bowel function. And so you may well [need] a series of different outcome measures for each individual child for one intervention. One way of presenting or understanding this is set out in Box 4.
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