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Muscle weakness and wasting are generalized but the hands are often particularly affected The myotonia shows itself in two ways: 1 The patient has dif culty in rapid relaxation of tightly contracted muscle, contraction myotonia, and this is best seen by asking the patient to open the hand and ngers quickly after making a st 2 Percussion myotonia is the tendency for muscle tissue to contract when it is struck by a tendon hammer, and this is best seen by light percussion of the thenar eminence whilst the hand is held out at A sustained contraction of the thenar muscles lifts the thumb into a position of partial abduction and opposition From its appearance in early adult life, the illness runs a variable but slowly progressive course over several decades The associated cardiomyopathy is responsible for some of the early mortality in myotonic dystrophy.

The precise aetiology of bone demineralisation in patients with AN and BN remains unclear. The development of osteopenia and osteoporosis can be characterised by two major mechanisms that supplement and reinforce each other. Due to the early onset of the eating disorder, often during puberty, the patients fail to reach their peak bone mass, a process which is normally nished at the end of puberty or early adulthood. Second, there is premature and increased bone destruction in patients suffering from these disorders (Ruegsegger et al., 1991). The greatest risk factor for the development of osteoporosis is an oestrogen de ciency, which is re ected by the secondary (sometimes primary) amenorrhea. However, case reports have demonstrated that male anorexic patients can also suffer from osteoporosis, most likely due to testosterone de ciency. In addition, glucocorticoid excess, malnutrition, reduced body mass, and hyperactivity further in uence bone turnover in both sexes. Previous studies on recovery from osteoporosis have yielded con icting results. Some studies conclude that in many cases recovery is possible (Herzog et al., 1993), while others suggest that only partial improvement of BMD can be achieved (Ward et al., 1997).

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Secondary brain injury The four additional insults will show their adverse influence on the brain by : declining performance in Glasgow Coma Scale observations an epileptic fit impaired brainstem function observations

Offered to employees without regard to eligibility for retirement benefits, these programs often include benefits that are more attractive to one segment of the employee population. For example, eligibility for retiree health coverage after 10 years of service, commencing at age 50, instead of age 55, would appeal to the segment of the employee population in that age range who would not otherwise be eligible for this benefit. Most voluntary termination programs include severance pay, either as a lump sum or as salary continuation. Severance pay is often determined based on years of service (for example, two weeks severance for every year of service, up to a predetermined maximum) or employment category (exempt employees receive six months of pay; nonexempt, three months, for example). Other possible severance benefits are employer-subsidized COBRA continuation coverage or other health benefits, continued group health coverage, employer-provided outplacement services, prorated partial-year bonuses, and vesting benefits in retirement, stock, profit-sharing, or savings plans.

Some children of females with myotonic dystrophy may show the disease from the time of birth Such babies may be very hypotonic, subject to respiratory problems (chest muscle involvement) and feeding problems (facial muscle involvement) Mental retardation is a feature of these children Frequently, the birth of such a child is the rst evidence of myotonic dystrophy in the family, since the mother s involvement is only mild..

for providing his son with the behavioral reward for school attendance, which consisted of driving his son once or twice a week to play cards at a game store In addition, Miguel Jr and his mother continued some contact through the joint babysitting of his niece and nephew Third, Miguel Jr s need to help take care of his family was accomplished by his attending an alternative high school program that was afternoons only Thus, he provided day care for his sister s children in the morning and was paid for his help Generalization Phase In the generalization phase, the focus of attention turns from changing current patterns of couple or family functioning to anticipating the future and helping the couple utilize multiple systems to maintain and enhance the positive changes within the family There are three primary goals in this phase.

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