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Recommendation: Screening Patients Prior to Initiation of Opioids Screening of patients is recommended prior to consideration of initiating a trial of opioids for treatment of subacute or chronic pain. Screening should include history(ies) of depression, anxiety, personality disorder and personality profile,(683, 718, 719) other psychiatric disorder, substance abuse history, sedating medication use. Those who screen positive, especially to multiple criteria, are recommended to: i) undergo greater scrutiny for appropriateness of opioids (may include psychological and/or psychiatric evaluation(s) to help assure opioids are not being used instead of appropriate mental health care); ii) consideration of consultation and examination(s) for complicating conditions and/or appropriateness of opioids; and iii) if opioids are prescribed, more frequent assessments for compliance, achievement of functional gains and symptoms and signs of aberrant use. Improved identification of more appropriate and safe candidates for treatment with opioids. In cases where someone has elevated, but potentially acceptable risk, this may alert the provider to improve surveillance for complications and aberrant behaviors. For chronic pain patients, theoretical potential to undertreat pain and thus impair function. However, there is no quality literature currently available to support that position. Recommendation: Use of an Opioid Treatment Agreement (Opioid Contract, Doctor/Patient Agreement, Informed Consent) the use of an opioid treatment agreement (opioid contract, doctor/patient agreement, or informed consent) is recommended to document patient understanding, acknowledgement of potential adverse effects, and agreement with the expectations of opioid use (see Appendix 1 of Opioids Guideline). It provides a framework for initiation of a trial, monitoring, treatment goals, compliance requirement, treatment expectations, and conditions for opioid cessation. It should reduce risk of adverse events and opioid-related deaths, although that remains unproven to date. Recommendation: Urine Drug Screening Baseline and random urine drug screening, qualitative and quantitative, is recommended for patients prescribed opioids for the treatment of subacute or chronic pain to evaluate presence or absence of the drug, its metabolites, and other substance(s) use. Federal guidelines recommend at least 8 tests a year among those utilizing opioid treatment programs. Standard urine drug/toxicology screening processes should be followed (consult a qualified medical review officer). In the absence of a plausible explanation, those patients with aberrant test results should have the opioid discontinued or weaned. Such uses are high-risk for opioid events including fatalities (see tables below). Identifies patients who may be diverting medication (those screening negative for prescribed medication). However, it may be a reasonable treatment option among patients with presumptive pyridoxine deficiency. Of the 5 articles considered for inclusion, 3 randomized trials and 2 systematic studies met the inclusion criteria. Duration of use for chronic, localized pain may be as long as indefinitely, although most patients do not require indefinite treatment, as symptoms usually resolve, improve, or require surgery. In the other study, injection was comparable to the patch, yet injections are likely a more effective strategy than naproxen, thus this body of evidence somewhat conflicts. Lidocaine patches are not invasive and have low adverse effects although some patients may experience local reactions such as skin irritation, redness, pain, or sores. Patients should be monitored to ensure that they are receiving benefit and to ascertain if there are any untoward local skin changes as a result of use. Mean demonstrated that patients had other 2006 male) = 20) vs pain scores at 4 weeks: the lidocaine painful diagnoses that electrodiag methylpredn 2.

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As a result, there can be unique factors that can affect validity at the level of individual assessment, such as deviations from standard administration, unusual testing envi ronments, and variable or poor examinee cooperation. Working knowledge of validity models and the validity characteristics of test scores are a central requirement for responsible and competent test use. From a practical perspective, a working knowledge of validity allows clinicians to chose which tests are appropriate for different uses. For instance, some test scores fail to reach standards for clinical diagnostic purposes of individual patients, but would be perfectly appropriate for research using group data. Validity Models Since Cronbach and Meehl (1955), various models of validity have been proposed. Other validity subtypes, including convergent, divergent, predictive, treatment, clinical, and face validity are subsumed Test Score Validity Content-related Construct-related Criterion-related evidence evidence evidence Convergent Predictive Divergent Concurrent Fig. For example, convergent and divergent validity are most often treated as subsets of construct validity (Sattler 2001), and concurrent and predictive validity as subsets of criterion-validity. Concurrent validity is relevant for tests used to identify existing diagnoses or conditions, whereas predictive validity applies when determining whether a test predicts future outcomes (Urbina 2004). Although face validity is less studied, the extent to which examinees believe a test measures what it appears to measure can affect motivation, self-disclosure, and effort; consequently, face validity can be seen as a moderator variable affecting concurrent and predictive validity that can be operationalized and measured (Bornstein 1996; Nevo 1985). Face validity matters because it encourages rapport between examiner and examinee, as well as openness and acceptance about test results and their implications (Urbina 2004). Again, all these labels for distinct categories of validity are ways of providing different types of validity evidence for test scores, not different types of validity per se. Therefore, validity is never actually finalized because test scores must be continu ally re-evaluated as populations and testing contexts change over time (Nunnally and Bernstein 1994). How to Evaluate the Validity of a Test There are different kinds and degrees of validity attached to different neuropsycho logical test scores, and there are numerous features that neuropsychologists can look for when evaluating a test and reviewing test manuals. Not all will have sufficient evidence to satisfy all aspects of validity, but clinicians should have a sufficiently broad knowledge of neuropsychological measures to be able to select one test over another (and one score over another within the same test), based on the quality of the validation evidence available. Note that there is overlap between the sources of evidence presented in Tables 30. Content-Related Evidence for Validity Content-related evidence for validity provides information on whether the test items actually measure the construct they are intended to measure. One way in which this is accomplished occurs when a test developer conducts a systematic review of the literature before generating test items, and by employing experts in the field to generate items and/or review item content, ideally after consensus. The goal is to refine the item pool while also balancing the need for a sufficiently broad set of items capable of capturing a range of function across the target group, and retaining good face validity. Construct-Related Evidence for Validity Construct-related evidence for validity overlaps with content-related evidence for validity, as both pertain to what is being measured by the test itself (as opposed to what the test might predict, or have utility for clinically). As with content-related evidence, the presence of a theoretical model or theo retical background supported by empirical evidence is important in test item content, test structure, and test format, but equally important is whether that con struct was reliably measured. Examination of reliability evidence therefore becomes crucial for determining construct validity. At the same time, a test that measures a specific construct well should overlap with other tests measuring a similar con struct, and show some differentiation in terms of tests measuring different con structs. Methods such as the multitrait/multimethod matrix, factor analysis, and structural equation modeling are ways in which the construct validity of tests is evaluated. These methods answer specific questions such as, is there sufficient empirical evidence for grouping test items hierarchically into specific levels, such as subscales, index scores for specific domains, and global composites One common method for presenting validity evidence is through intercorrela tions among tests that are believed to measure similar and dissimilar constructs. Realistically, many tests do not yield clear-cut correlation matrices with high cor relations to similar tests and low correlations to dissimilar tests. Whenever large numbers of correlations among measures are presented, there tends to be expected and unexpected relationships between variables, and dissociable relations between tests may not occur in a clear-cut manner. Some of the overlapping variance to consider may be due to global factors such as underlying innate intelligence, or to the fact that most neuropsychological tests require multiple basic abilities.

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There is an inverse relationship between the size of the ascending aorta and pulmonary artery, with a disproportion that is often striking. The finding of increased peak velocities in the pulmonary artery corroborates the diagnosis of Tetralogy of Fallot by suggesting obstruction to blood flow in the right outflow tract. In cases with minor forms of right outflow obstruction and aortic overriding differentiation from a simple ventricular septal defect can be difficult. In those cases in which the pulmonary artery is not imaged, a differential diagnosis between pulmonary atresia with ventricular septal defect and truncus arteriosus communis is similarly difficult. The sonographer should also be alerted to a frequent artifact that resembles overriding of the aorta. The mechanism of the artifact is probably related to the angle of incidence of the sound beam. Careful visualization of the left outflow tract with different insonation angles, as well as the use of color Doppler and the research of the other elements of the tetralogy, should virtually eliminate this problem. Abnormal enlargement of the right ventricle, main pulmonary trunk and artery, suggests absence of pulmonary valve. Unfortunately, these findings cannot be recognized for certain by prenatal echocardiography. When severe pulmonic stenosis is present, cyanosis tends to develop immediately after birth. When there is pulmonary atresia, rapid and severe deterioration follows ductal constriction. Survival after complete surgical repair (which is usually carried out in the third month of life) is more than 90% and about 80% of survivors have normal exercise tolerance. The term refers only to the position of the great vessels that is found in association with ventricular septal defects, tetralogy of Fallot, transposition, univentricular hearts. The single arterial trunk is larger than the normal aortic root and is predominantly connected with the right ventricle in about 40% of cases, with the left ventricle in 20%, and is equally shared in 40%. Similar to tetralogy of Fallot, and unlike the other conotruncal malformations, truncus is frequently (about 30%) associated with extracardiac malformations. The main diagnostic criteria are: (a) a single semilunar valve overrides the ventricular septal defect (b) there is direct continuity between one or two pulmonary arteries and the single arterial trunk. A peculiar problem found in prenatal echocardiography is the demonstration of the absence of pulmonary outflow tract and the concomitant failure to image the pulmonary arteries. Prognosis Similar to the other conotruncal anomalies truncus arteriosus is not associated with alteration of fetal hemodynamics. These patients have usually unobstructed pulmonary blood flow and show signs of progressive congestive heart failure with the postnatal fall in pulmonary resistance. Surgical repair (usually before the sixth month of life) involves closure of the ventricular septal defect and creation of a conduit connection between the right ventricle and the pulmonary arteries. Cardiosplenic syndromes are typically associated with abnormal situs, that is abnormal disposition of abdominal and/or thoracic organs. Cardiac anomalies are almost invariably present, including anomalous pulmonary venous return, atrioventricular canal, and obstructive lesions of the aortic valve. One typical and peculiar finding is the interruption of the inferior vena cava, with the lower portion of the body drained by the azygos vein. In normal fetuses, a transverse section of the abdomen demonstrates the aorta on the left side and the inferior vena cava on the right; the stomach is to left and the portal sinus of the liver bends to the right, towards the gallbladder. In polysplenia, a typical finding is interruption of the inferior vena cava with azygous continuation (there is failure to visualize the inferior vena cava and a large venous vessel, the azygos vein, runs to the left and close to the spine and ascends into the upper thorax). Symmetry of the liver can be sonographically recognized in utero by the abnormal course of the portal circulation that does not display a clearly defined portal sinus bending to the right. Associated anomalies include absence of the gallbladder, malrotation of the guts, duodenal atresia and hydrops. As in polysplenia, evaluation of the disposition of the abdominal organs is a major clue to the diagnosis. The spleen cannot be seen and the stomach is found in close contact with the thoracic wall.

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For example, stretching the patella tendon with a pleximeter (reflex hammer) causes a sudden, intense stimulation of the stretch receptors within the femoral nerve, in essence simulating what would happen if we jumped down from a large height. Immediately the muscles innervated by the femoral nerve contact and the knee jerks. An absence of reflex often means there is a lesion of the motor or sensory portion of the femoral nerve or severe disease of the quadriceps muscle. A lesion of the ascending or sensory system causes a disordered gait and postural deficits (see below). The numbered nerves then run to the brachial or lumbar plexus and then exit as named nerves that will then innervate specific muscles. A partial lesion will cause only weakness or paresis but the movement will be ataxic. The absence of ascending information reaching the brain can result in a loss of self reception (proprioception) and consequently spinal cord or proprioceptive ataxia and slow postural reactions. Spinal cord ataxia can take the form of a long-strided gait, the limbs can circumduct, cross midline, and interfere with each other occasionally causing the patient to trip or fall. In addition the patient might stand on the dorsal surface of the paw or stand with limbs too close, too far apart or with limbs crossed. An incomplete lesion causes weakness and the patient will have a short-strided or choppy gait as though they are walking on egg shells. The pelvic limbs will have increased tone and reflex, reduced postural reactions, weakness and ataxia. The long-strided, stiff and ataxic gait in the pelvic limbs is much different than the short-strided gait of the thoracic limbs and sometimes referred to as a two engine gait. T3-L3 Spinal Cord and the Cutaneous Trunci Reflex Disease between the two intumescences is called T3-L3 spinal cord disease and results in upper motor neuron disease to the pelvic limbs. The presence of a cut-off or cessation of the cutaneous trunci reflex can indicate the level of the spinal cord lesion. Once a stimulus is registered the information then ascends in the spinal cord where it synapses motor neurons at the level of spinal cord segment C8 -T2. These nerves form the lateral thoracic nerve that causes contraction of the cutaneous trunci muscle. Functionally a pinch of the skin with hemostats should stimulate contraction of the entire cutaneous trunci muscle along the entire flank of the patient. With a thoracolumbar spinal cord lesion, pinching of the skin behind the lesion will not result in twitching of the skin and thus there appears to be a cut off of this reflex. A cut-off in the cutaneous trunci reflex indicates the lesion is about 2 vertebral bodies cranial to the cut-off. Furthermore, following surgery movement of the cut-off caudally predicts recovery while movement cranially predicts myelomalacia. The patella reflex can be absent in otherwise healthy middle-age and older dogs, presumably from degeneration of the sensory portion of the femoral nerve. Neck pain is often suspected when patient spontaneously yelps out but there is no gait or posture deficits, intermittent thoracic limb lameness (root signature), or stiff neck or decreased range of motion is noted. Palpating muscle spasm laterally at level of transverse process, pain with manipulation or ventral process of C6, or resistance to range of motion can also indicate neck pain. Mid-back pain is often suspected with kyphosis, stiffness and when slow to sit or rise. Palpating and applying pressure to dorsal processes while putting pressure / palpating the ventrum and palpating muscle / rib heads at level of transverse process often allow for detection of back pain. Lumbosacral pain is suspected with abnormal tail carriage and when patient is slow to sit and rise. Pain can often be detected with rectal palpation of the lumbosacral junction (or spondylosis at L7-S1), tail extension or by applying pressure to muscle between dorsal process of L7 and S1. However, hip pain can be discerned by slowly elevating the femoral head about 3-5 mm from acetabulum by lifting up on the medial surface of the femur while the patient is in lateral recumbency.

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Increased risk of neoplasm in appendicitis treated with interval appendectomy: single-institution experience and literature review. The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives. Antibiotics as First-line Therapy for Acute Appendicitis: Evidence for a Change in Clinical Practice. Laparoscopic versus open appendectomy for complicated and uncomplicated appendicitis in children. Meta-analysis of randomized trials comparing antibiotic therapy with appendectomy for acute uncomplicated (no abscess or phlegmon) appendicitis. Pure Transvaginal Appendectomy Versus Traditional Laparoscopic Appendectomy for Acute Appendicitis. Do you need a computed tomographic scan to evaluate suspected appendicitis in young men: an administrative database review. Re-evaluating the sonographic criteria for acute appendicitis in children: a review of the literature and a retrospective analysis of 246 cases. Systematic review and meta-analysis of safety of laparoscopic versus open appendectomy for suspected appendicitis in pregnancy. Discovery and Validation of Urine Markers of Acute Pediatric Appendicitis Using High-Accuracy Mass Spectrometry. Br J Surg (2001) 88: 1387 1391 Diverticulitis: Keys to Management Angenete E, Thornell A, Burcharth J et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis. Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis. Annals of Gastroenterology (2016) 29, 24-32 Mali J, Mentulla P, Leppaniemi A et al. Symptomatic Treatment for Uncomplicated Acute Diverticulitis: A Prospective Cohort Study. Contemporary management of anastomotic leak after colon surgery: assessing the need for reoperation. Predictive factors for colonic resection inpatients less than 49 years with symptomatic diverticular disease. Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy. The Impact of Elective Colon Resection on Rates of Emergency Surgery for Diverticulitis. Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial. Emergency Laparoscopic Sigmoidectomy for Perforated Diverticulitis with Generalised Peritonitis: A Systematic Review. World J Gastrointest Surg (2015) 7(11): 313-318 Bugiantella W, Rondelli F, Longaroni M et al. Left colon acute diverticulitis: An update on diagnosis, treatment and Prevention. Emergency left colonic resections on an acute surgical unit: does subspecialization improve outcomes Operative intervention rates for acute diverticulitis: a multicentre state-wide study. Staging of acute diverticulitis based on clinical, radiologic, and physiologic parameters. Emergency department presentation, admission, and surgical intervention for colonic diverticulitis in the United States. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Outcomes of Percutaneous Drainage Without Surgery for Patients With Diverticular Abscess. Risk of Readmission and Emergency Surgery Following Nonoperative Management of Colonic Diverticulitis: A Population-Based Analysis. Perioperative Fluid Restriction in Major Abdominal Surgery: Systematic Review and Meta-analysis of Randomized, Clinical Trials.

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The committee assesses the mechanistic evidence regarding an as sociation between acellular pertussis vaccine and seizures as weak based on knowledge about the natural infection. The committee assesses the mechanistic evidence regarding an as sociation between diphtheria toxoid or tetanus toxoid vaccine and seizures as lacking. Kubota and Takahashi (2008) did not provide evidence of causality beyond a temporal relationship of 2 days between vaccine administration and development of cerebellar symptoms leading to a diagnosis of acute cerebellar ataxia. This one study (Geier and Geier, 2004) was not considered in the weight of epidemiologic evidence because it pro vided data from a passive surveillance system and lacked an unvaccinated comparison population. Four publications did not pro vide evidence beyond temporality, one of which was deemed too short based on the possible mechanisms involved (Abdul-Ghaffar and Achar, 1994; Bolukbasi and Ozmenoglu, 1999; Hamidon and Raymond, 2003; Rogalewski et al. Eight years prior the patient developed neurological symptoms 15 days after receiving a diphtheria toxoid, tetanus toxoid, whole cell pertussis vaccine, and an oral polio vaccine. Mechanistic Evidence the committee identifed four publications reporting the development of transverse myelitis after the administration of vaccines containing diph theria toxoid, tetanus toxoid, and acellular pertussis antigens alone or in combination. In addition, three publications reported the concomi tant administration of vaccines, making it diffcult to determine which, if any, vaccine could have been the precipitating event (Cizman et al. Furthermore, Cizman and colleagues (2005) reported that one patient had a concomitant infec tion with Epstein-Barr virus. The odds ratio for ever vaccinated with tetanus toxoid or combined tetanus toxoid and diphtheria (Td) before optic neuritis diagnosis was 0. The authors concluded that tetanus toxoid vaccination does not appear to be associated with an increased risk of optic neuritis in adults. Weight of Epidemiologic Evidence the committee has limited confdence in the epidemiologic evi dence, based on one study that lacked validity and precision, to assess an association between diphtheria toxoid or tetanus toxoid vaccine and optic neuritis. The epidemiologic evidence is insuffcient or absent to assess an association between acellular pertussis vaccine and optic neuritis. Mechanistic Evidence the committee identifed one publication reporting the development of optic neuritis after the administration of vaccines containing tetanus toxoid antigens. See Table 10-3 for a summary of the studies that contributed to the weight of epidemiologic evidence. Adverse Effects of Vaccines: Evidence and Causality 552 Copyright National Academy of Sciences. In addition, the patient was vaccinated against hepatitis B, hepatitis A, and poliovirus concomitantly, making it diffcult to determine which, if any, vaccine could have been the precipitating event. The immunization status was obtained from telephone questionnaires and confrmed with vaccina tion records or written confrmation from the physician. Tetanus toxoid vaccina tions were given alone or in combination with poliovirus or diphtheria or both. The risk period was defned as any time within 2 months before the relapse, and the four control periods were outlined as 2-month intervals prior to the risk period (2 to 10 months before the relapse). In all but one case, tetanus toxoid vaccination was combined with other vaccinations: tetanus toxoid, diphtheria, and polio (98 cases); teta nus toxoid, diphtheria, pertussis, and polio (45 cases); and tetanus toxoid, diphtheria, pertussis, polio, and Haemophilus infuenza B (22 cases). The immunization status was obtained from vaccination certifcates, and telephone interviews were used for six participants that did not provide certifcates. The participants exposed to tetanus toxoid vaccine signifcantly differed from those without the vaccination. In particular, those who were vaccinated were more likely to have had infections during the month before a frst episode, more frequently from low socioeconomic status families, younger at frst episode, and less likely to have a frst epi sode after 1997.

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In order to complete its main functions, the kidneys perform complex processes within the nephron. This includes glomerular filtration, tubular secretion and tubular re-absorption of water, electrolytes and metabolic waste (Lewis, Heitkemper & Dirksen, 2004). The composition of the filtrate is similar to that of blood however it does not contain larger molecules like blood cells and proteins that are retained in the capillaries (Lewis, Page 8 of 57 the Continuous Renal Replacement Education Package Heitkemper & Dirksen, 2004). This is considered to be a mean arterial pressure above 60 mmHg (Huether and McCance, 2007). On average a normal glomerular filtration rate is 125 mls per minute (Elliot, Aitken et al. As the filtration occurring in the glomerulus is primarily done by the size of the molecules, the majority of the blood volume becomes the filtrate so in the next parts of the nephron extensive secretion of non-essential molecules and re-absorption of essential molecules is done to maintain normal levels in the body (Huether & McCance, 2006). Re-absorption is the movement of molecules from the tubules (containing the filtrate) to the nearby capillaries and secretion is movement of molecules out of the capillaries (containing blood) into the tubules. These processes occur in specific parts of the tubular system depending on the different concentrations of molecules in the blood (Lewis, Heitkemper & Dirksen, 2004). When the filtrate enters the proximal tubule active re-absorption of all the glucose, small proteins and amino acids, with 80% of electrolytes (Sodium Chloride, Potassium ions, Bicarbonate and Phosphate) occurs (Lewis, Heitkemper & Dirksen, 2004). Some molecules are also secreted into the filtrate; including hydrogen ions, foreign substances and creatinine (Huether and McCance, 2006). In the descending loop water is reabsorbed that causes sodium chloride to diffuse back into the blood while urea is being secreted (Huether & McCance, 2006). In the ascending loop chloride ions are reabsorbed via active transport which passively brings across more sodium ions. The distal convoluted tubule is important in final water and acid-base balances (Lewis, Heitkemper & Dirksen, 2004). Here the tubule is affected by several substances to regulate what is excreted or retained. It is released from the posterior pituitary gland in reaction to high serum osmorality or decreased blood volume and relates to the hydration status of the patient. It is excreted from the adrenal cortex based upon blood volume and the plasma concentrations of sodium Page 9 of 57 the Continuous Renal Replacement Education Package and potassium and acts on the distal convoluted tubule. Aldosterone causes re-absorption of sodium ions while excreting potassium ions in a process where they literally swap places (Lewis, Heitkemper and Dirksen, 2004). Acid-base regulation is related to blood pH and the kidney will manage this by re-absorption of bicarbonate (base) and the excretion of hydrogen ions(acid) to maintain pH between 7. This forms the metabolic management of acid-base reactions and is generally slower to take effect than respiratory measures. Blood pressure is maintained by the kidney via the instigation of several systems. These monocytes measure the blood pressure within the atrium and secrete this hormone if it is too high (Huether and McCance, 2006). The kidney is integral in the all-important Renin-angiotensin-aldosterone system; the affect of aldosterone on the kidney has already been discussed however the initiation of this system also begins in the kidney. Renin is the trigger for this system, produced and released from the juxtaglomerular apparatus which is connected to the afferent arteriole next to the glomerulus. The juxtaglomerular apparatus monitors the sodium levels in the blood passing through it. This system forms an important part of the sodium and water balancing of the body when blood pressure is high or low.

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The spinal cord extends from the brain stem, through a very large opening (the fora men magnum) in the base of the skull, and down the spine. At the level of each vertebra in the spine, nerve bers arise from the spinal cord and emerge through openings between the vertebrae. These are the spinal nerves, which carry messages to and from various regions of our bodies. These are the membranes (meninges), which completely sur round the brain and spinal cord. Your efforts were felt and I believe that the association is moving in a direction that will really, serve our community, our tribe, our family. There are four in all: the two lateral ventricles, the third ventricle and the fourth ven tricle. From the third ventricle it ows down a long, narrow passage way (the aqueduct of Sylvius) into the fourth ventricle. From the fourth ventricle it passes through three small openings (foramina) into the subarachnoid space surrounding the brain and spinal cord. Once in the bloodstream, it is carried away and ltered by our kidneys and liver in the same way as are our other body uids. The obstruction may de velop from a variety of causes, such as brain tumors, cysts, scarring and infection. He was 1 year old when he was diagnosed with hydrocephalus, but the cause is not known. Lucas is very active, has many friends, loves sports and is teaching himself to play piano. Because the ventricles remain open and communicate with each other, this type of hydro cephalus is called communicating hydrocephalus. The scalp may appear thin and glistening, and the scalp veins may appear to have unnatural fullness (prominence) as well. Toddlers whose sutures have not yet closed also show the signs of head enlargement. Often these symptoms include headache, nausea, vomiting and sometimes blurred or double vision. The child might have problems with balance, delayed development in such areas as walking or talking, or poor coordination. The child may show a change in personality or be unable to concentrate or remember things, and their school performance may decline. While at times the symptoms are very noticeable, other times they can be very subtle and progress so slowly that only in retrospect are they appre ciated. Most cases of congenital hydrocephalus are thought to be caused by a complex interaction of genetic and environ mental factors. Hydrocephalus that develops later in life in some chil dren, and even in adults, but is caused by a condition that existed at birth, is still considered a form of congenital hydrocephalus. When hydrocephalus develops after birth and is caused by a factor such as head injury, meningitis or a brain tumor, it is termed acquired hydro cephalus. Aqueductal obstruction may result from Solan was diagnosed with hydrocephalus and aqueductal stenosis at 11 months.

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