Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.
Objective
To assess the feasibility of recruiting and retaining cancer survivors with lower limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.
Design
Before-after pilot study of 5 months duration.
Setting
University of Pennsylvania
Participants
Cancer survivors with a known diagnosis of lower limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.
Intervention
Twice weekly slowly progressive weight-lifting, supervised for 2 months, unsupervised for 3 months.
Main Outcome Measures
The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.
Results
Interlimb volume differences were 44.4 and 45.3% at baseline and 5 months, respectively (pre-post comparison, p = 0.70). There were 2 unexpected incident cases of cellulitus within the first two months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (p = 0.001 and p = 0.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (p = 0.01). No improvement was noted in self-reported quality of life.
Conclusions
Recruitment of patients with lower limb lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (e.g., a lack of clinically significant interlimb volume increases over 5 months), the unexpected finding of two cellulitic infections among the 10 participants suggests additional study is required before concluding lower extremity lymphedema patients can safely perform weight-lifting.
Many times, family therapists are both the first to learn that a couple may separate and the last to see them in the same consultation room, still relating to each other and the same professional before the adversarial system takes over. Mediation offers a viable alternative to that system because clients are helped to speak directly and craft the decisions that will delineate their move toward separate lives. Mediation is defined and the divorce process demystified, and the similarities and differences between mediation and therapy are discussed. Brief examples and a longer case discussion are provided to illustrate the mediation process. A familiarity with this process will enable therapists to hold more informed discussions about mediation with their clients and invite them to consider a process that is congruent with many of the values of family therapy.
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