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after weeks of immobilization A mode of communication should be worked out by the nursing staff, preferably before the patient is intubated Failure to effectively clear the tracheobronchial airways and the need for prolonged mechanical ventilation are the usual indications for tracheostomy In most cases this procedure can be postponed until the end of the third week of intubation However, patients who become rapidly quadriplegic and ventilator-dependent may require tracheostomy earlier Once tracheostomy is performed, careful tracheal toilet and treatment of pulmonary and urinary tract infections by the use of appropriate antibiotics are required Prophylactic antibiotic treatment is not recommended With tracheostomy and intensive care, the mortality from the disease can be reduced to about 3 percent (Ropper and Kehne) (see further on under Prognosis ) The decisions to wean and then discontinue respiratory aid and to remove the endotracheal or tracheostomy tube are based on the degree and timing of recovery of respiratory function The weaning process generally begins when the vital capacity reaches approximately10 mL/kg and comfortable breathing can be sustained for a few minutes The relative merits of the numerous methods of delivering positive pressure volume-cycled ventilation and its gradual withdrawal are too complex to be covered here but the reader is referred to the monograph, Neurological and Neurosurgical Intensive Care, by Ropper and colleagues Physical therapy (passive movement and positioning of limbs to prevent pressure palsies and, later, mild resistance exercises) should begin once they can be comfortably undertaken Plasma Exchange and Immune Globulin Speci c treatment of the presumed immune disorder that underlies GBS includes plasma exchange (PE) and intravenous immunoglobulin (IVIG) Our practice has been to closely observe patients who are still able to walk for several days If the patient has become unable to walk unaided or if he shows a signi cant reduction in vital capacity or signs of severe oropharyngeal weakness, plasma exchange or IVIG (not both) is instituted promptly This typically occurs at the fth to tenth day after the appearance of the rst symptoms but may be as early as one day or as late as 3 weeks Three large randomized trials comprising more than 500 patients have established the usefulness of plasma exchange administered during the evolving phase of GBS In patients who are treated within 2 weeks of onset, there is an approximate halving in the period of hospitalization, in the duration of mechanical ventilation, and in the time required to achieve independent ambulation However, in the largest trial, if the rst plasma exchange was delayed for 2 weeks or longer after the onset of the disease, the procedure was of little value Nonetheless, if a patient continues to progress in the third or fourth week of illness, it is probably still appropriate to institute the exchanges The most important predictors of responsiveness to plasma exchange treatment are the patient s age (responders are younger) and the preservation of motor compound muscle action potential amplitudes prior to instituting treatment (McKhann et al) One study has found that the overall condition of patients was better at 6 and 12 months after treatment as compared to untreated patients; other studies have been equivocal on this point The advised regimen of plasma exchange removes a total of 200 to 250 mL/kg of plasma in four to six treatments on alternate days, or over a shorter period if there is no coagulopathy The replacement uid is saline combined with 5% albumin The need.

J l ^ i r"i l :

Probably the most detailed information as to the effects of age on the nervous system comes from the measurement of cognitive functions In the course of standardization of the original WechslerBellevue Intelligence Scale (1955), cross-sectional studies of large samples of the population indicated that there was a steady decline in cognitive function starting at 30 years of age and progressing into the senium Apparently all forms of cognitive function partake of this decline although in general certain elements of the verbal scale (vocabulary, fund of information, and comprehension) withstand the effects of aging better than those of the performance scale (block design, reversal of digits, picture arrangement, object assembly, and the digit symbol task) However, the concept of a linear regression of cognitive function with aging has had to be modi ed in the light of subsequent longitudinal studies If the same individual is examined over a period of many years, there is virtually no decline in his performance as measured by tests of verbal function until 60 years of age BeTable 29-2 Frequency of neurologic signs in uncomplicated aging (in percent) 65 69

7 8 Table 11-2

( 1 s1 5 )

70 74

To read the entire contents of the /etc/passwd file, you could read and process the individual lines yourself An easier method, however, is to use the getpwent function set:

The secondfinite divided differencewhichrepresents difference two first divided the of generallyas is differences, expressed

75 79

The first call to getpwent returns the user information (as returned by getpwnam) for the first entry in the /etc/passwd file Subsequent calls return the next entry, so you can read and print the entire details using a simple loop:

Glabellar sign (inability to inhibit blink) Snout re ex Limited upgaze Limited downgaze Abnormal visual tracking Paratonic rigidity Unable to recall 3 words Unable to spell world backward

(1516)

while(($name,$dir)=(getpwent)[0,7]) { print "Home for $name is $dir\n"; }

SOURCE:

\n -

11:

10 3 6 8 8 6 24 10

In a scalar context, the getpwent function only returns the user name A call to setpwent resets the pointer for the getpwent function to the start of the /etc/passwd entries A call to endpwent indicates to the system that you have finished reading the entries, although it performs no other function Neither setpwent nor endpwent return anything

( rs 1 7 )

15 8 15 15 18 10 28 12

Along with the password entries, you can also obtain information about the groups available on the system:

';:rl it::ti=;[] :l ii,j':^:),a4t;'^'

27 7 27 26 22 12 25 18

$group = getgrgid($();

37 26 29 34 32 21 55 21

f(x)

or if you are really paranoid, you might try this:

.

Third xl r flxo, xt,x2,

print "Bad group information" unless(getgrnam(getgrgid($()) == $();