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Increasingly best nexium 40mg gastritis diet , it appears that dysfunction oglobin to oxyhemoglobin imaged by magnetic resonance of a system of functionally and/or structurally intercon- techniques (the blood oxygenation level dependent [BOLD] nected cortical and limbic brain regions is present to lesser effect) order nexium 20mg on line gastritis y sintomas. This work began in earnest some 50 years ago with or greater degrees order nexium 20mg otc gastritis symptoms weight loss, producing more or less psychopathology the pioneering studies of Seymour Kety and colleagues who in individual patients effective 20mg nexium gastritis zantac, and that certain brain regions, such developed the first reproducible, quantitative technique for as frontal cortex, may play a special role in this larger picture. When this method was applied to ticularly cognitive impairment. Although it is likely that at schizophrenia (1), these investigators found no alteration in least some of the functional abnormalities are generative of the overall average CBF level in patients, a result that has these features and not simply a response to them, clarifica- largely been confirmed by more recent studies; however, tion of this 'chicken versus egg' issue must be a crucial this finding did not rule out the existence of neurophysio- component of any research program in this area, and the logically meaningful changes in specific brain structures. Current functional ment of rigorous methods that could differentiate the func- neuroimaging has much to offer in guiding this quest, par- tional level of specific cortical regions, albeit with only 2- ticularly when combined with new information now avail- cm anatomic accuracy at best (2). This method, administra- able from other fields such as genetics and cognitive science. The resulting findings delineate their relationship to other neurobiological and of functional abnormality in the frontal lobe spurred a shift clinical properties of the illness, discuss conceptual issues in focus throughout many research domains in the field that and controversies, examine methodologic considerations remains a prevailing force today. In the 1980s, the advent (including technical constraints), summarize new tech- of tomographic methods, such as single photon emission computed tomography (SPECT) and PET, which both use radioactive compounds as tracers, brought improved in- Karen Faith Berman: National Institute of Mental Health, Intramural terregional spatial resolution on the order of 5 to 6 mm Research Program, Bethesda, Maryland and allowed measurement of subcortical regional function. A particular advantage ing (fMRI) has emerged as the premier technique for neu- for research in schizophrenia is that neural activity during ropsychiatric functional neuroimaging. By taking advantage correct and incorrect trials can be measured separately and of the differential paramagnetic properties of oxyhemoglo- compared, allowing more incisive study of the mechanism bin versus deoxyhemoglobin and the altered ratio between of cognitive failure and better experimental control of po- them that occurs when blood volume and blood flow change tential confounds based in performance discrepancies that in response to neural activation, BOLD fMRI uses intrinsic often occur between patient and control groups. Event- properties of the blood itself rather than an extrinsic contrast related fMRI has very recently come into wide use in neu- or tracer agent, to generate maps of brain function. It is, roimaging of cognitive systems in healthy subjects, but as thus, entirely noninvasive, and measurements can be re- of this writing has had only limited application to the study peated over time, conferring significant advantage in experi- of schizophrenia. In this approach, blood flow and other measures advance brought further improvements in spatial resolution such as MR spectroscopy, neuroreceptor measurements, and as well as enhanced temporal resolution, which, although electrophysiology (with MEG or EEG) are determined in still slow (several seconds) compared to neuronal signaling the same patients. One example of the richness of the data (on the order of 200 ms), improved to the degree that event- that can be gleaned is the use of PET or fMRI to measure related neural activity could be recorded with anatomic blood flow in conjunction with EEG or MEG. PET and precision heretofore unavailable with electrophysiologic fMRI allow localization of the brain regions that work to- methods. On the other hand, EEG and MEG TECHNICAL PERSPECTIVE have relatively poorer spatial resolution, but provide fine time resolution (i. Combining these meth- As can be seen in the preceding brief history, over the years ods, together with the application of the advanced computa- the sophistication of the questions that could be asked and tional cross-registration and source localization techniques the hypotheses about schizophrenia that could be tested that now exist, provides exponentially more information have paralleled the development of new brain imaging tech- than any of these techniques alone. For example, this allows nologies and analytic methods. This parallel development the determination of the sequence in which various finely is evident in the evolution of the science from the search localized regions are activated during cognition and the test- for regionally specific pathologic function to that in neural ing of the hypothesis that this sequence of events is altered systems, and from measures sensitive only to static patho- in schizophrenia. Although this specific multimodal ap- physiology to explorations of the dynamic interplay among proach has not been applied in schizophrenia, other exam- regions in those neural systems. Therefore, a brief discussion ples are described in the following. New Vistas in Data Analysis The analytic approaches for the two data collection modali- New Vistas in Data Acquisition ties discussed, event-related fMRI and fusion of spatial and Event-related fMRI is a relatively recent class of experimen- temporal neurofunctional data (i. Another recent set of analytic methods ad- fMRI and PET approaches that blocked together relatively dresses the growing appreciation that the transduction be- long (e. This approach has much in common with tradi- uted components of neural systems (interregional integra- tional evoked-potential electrophysiology and offers advan- tion of neural function). Questions about functional tages in experimental design. Because different trial types integration and coordinated interregional activity are likely can be randomly intermixed and then separated for analysis, to have particular relevance for schizophrenia, as discussed order effects and habituation can not only be controlled in later sections. Although the segregational view can be Chapter 54: Functional Neuroimaging in Schizophrenia 747 tested with univariate statistics (multiple t-tests or ANO- tients tend to be different from normal controls. In particu- VAs), hypotheses about interregional integration require lar, they show abnormal prefrontal activity (8) during tests multivariate approaches. The influence that one brain re- involving working memory (i. They amined via the correlations between brain activity measures show deficits in cingulate cortex as well as alterations in for the two anatomic structures; as an operational definition frontal–temporal and other intracortical functional rela- two brain regions can be considered to be functionally cou- tionships (12,13) during other cognitive tasks, such as cued pled if their activities are correlated (3); however, this ap- verbal recall (9) and the Stroop test (10), and in some studies proach cannot elucidate how other nodes in the network at rest (11). In general, most of these findings have been mediate these relationships. To model this mediation re- reproduced in acute, untreated patients, thus excluding a quires analysis of the covariance matrix of regions studied primary role for medication artifacts. More recent functional brain imaging studies in schizo- These include structural equation modeling (SEM) and phrenia have focused on: (a) further characterization of the eigenimage analysis. SEM, used in conjunction with ac- locales and cognitive and behavioral context of neurophysio- knowledged anatomical models, can characterize and quan- logic deficits in schizophrenia; (b) delineation of the rela- tify the 'functional connectivity' among the multiple com- tionship of the deficits to clinical symptoms and other neu- ponents of neural systems. A model of known or robiological features of the illness; and, most important; (c) hypothesized anatomic pathways is defined first; then a attempts to elucidate the pathophysiologic mechanism(s) of functional model of interest is tested against this model by the deficits. The following section reviews these areas of iterative fitting of the interregional correlational weights. The most enlightening of these re- It should be borne in mind that the regional components sults have emerged from experimental paradigms designed examined are preselected based on putative pathways and to actively engage neural systems in cognitive or other activi- the results from this approach are only as good as the model. Single value decomposition or principal component analysis is used to The frontal lobes have played a prominent role in formula- present the percentage of variance accounted for by different tions of schizophrenia since the conceptualization of the patterns of activity or spatial modes, and canonical variates illness. In earlier times this role was inferred by clinical anal- analysis, conceptually similar to factor analysis, can be used ogy with known frontal lobe disorders and findings in neu- to extract connectivity patterns across the entire brain that ropsychology and nonhuman primate studies. Substantial are most different between the studied groups. Thus, these indirect but compelling evidence from these multiple do- recently developed methods permit characterization of nor- mains conferred the status of best studied and most im- mal and altered neural connectivity using neuroimaging. Changes The explosion of functional neuroimaging studies of schizo- in rCBF in response to cognitive activation were also first phrenia has resulted in many 'findings' and many discrep- observed in these early studies; this approach has been ancies. Nonetheless, several trends spanning the various ex- greatly refined and now has largely replaced the inherently perimental and methodologic techniques were apparent ill-defined and variable resting state as the cornerstone of several years ago (4). First, when brain activity or metabo- functional brain imaging studies in schizophrenia. Second, when scanned during lobe findings (Table 54. Although patients may have Functional Alterations relatively normal regional patterns of resting brain activity, there appear to be associations between specific resting re- The relatively subtle prefrontal functional alterations ob- gional CBF patterns and symptom profiles (5). Changes in served in schizophrenia have been increasingly brought into lateralization of brain function also have been described (6, focus by recent advances in the available neuroimaging ar- 7). Third, when scanned during cognitive activation, pa- mamentarium. FRONTAL LOBE FINDINGS WITH ACTIVATION PARADIGMS IN SCHIZOPHRENIA SINCE 1985 First Author Publication Year Reference Number Imaging Technique Studies Reporting Decreased Frontal Lobe Activation in Schizophrenia Activation Paradigm Berman KF, et al.

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Clinics and of the lower genital tract and order nexium 20 mg free shipping gastritis diet 7 up coupon, if indicated buy nexium 20mg on-line gastritis like symptoms, conduct a health-care providers who ofer cervical screening services but colposcopically directed biopsy nexium 40mg on line gastritis diet underactive thyroid. For women aged <21 cannot provide appropriate colposcopic follow-up of abnormal years buy generic nexium 20 mg line gastritis znacenje, referral to colposcopy for ASC-US and LSIL is not Pap tests should arrange referral to health-care facilities that recommended, because rates of spontaneous clearance are will promptly evaluate and treat patients and report evaluation high in this population; repeat Pap testing at 12 and 24 results to the referring clinic or health-care provider. Colposcopy is appropriate if the provider has con- and results of follow-up appointment should be clearly docu- cerns about adherence with recommended follow-up or mented in the clinic record. Te establishment of colposcopy concerns about other clinical indications. High-grade and biopsy services in local health departments, especially in histological changes (i. If repeat Pap tests are used (instead of prompt colposcopy) to follow ASC-US results, other Management Considerations tests should be performed at 6- and 12-month intervals Te following additional considerations are associated with until two consecutive negative results are noted, at which performing Pap tests: time cervical cancer screening at a normal interval for • Te Pap test should not be considered a screening test age can be resumed. ASC or a more serious condition, follow-up should • All women receiving care in an STD-clinic setting should be conducted according to ASCCP 2006 Consensus be considered for cervical cancer screening, regardless of Guidelines (424). A third strategy for managing patients sexual orientation (i. Whereas conducting • If a woman is menstruating, a conventional cytology high-risk HPV testing might not be possible in some Pap test should be postponed, and the woman should be STD clinics because of resource limitations, such testing advised to have a Pap test at the earliest opportunity. HPV tests that detect low-risk HPV types are not patient might need to have a repeat Pap test after appro- recommended for use in STD clinics, because they are priate treatment for those infections. HPV DNA test is negative, a repeat Pap test should be • Te presence of a mucopurulent discharge should not performed at 12 months. If the test is positive, the patient delay the Pap test. Te test can be performed after care- should be referred immediately for colposcopy, and if ful removal of the discharge with a saline-soaked cotton indicated, directed cervical biopsy. Because many public health clinics (including most STD clinics) cannot provide clinical follow-up of abnormal Pap tests, women with Pap tests demonstrating low- or high-grade SIL Vol. HIV-positive women with other cervicovaginal specimens has not been shown to ASC-H, LSIL, or HSIL on cytologic screening should undergo infuence Pap test results or their interpretation (432). Recommendations for management of • Women who have had a total hysterectomy do not HIV-positive women with ASC-US vary. HHS recommends require a routine Pap test unless the hysterectomy was a more conservative management approach (i. As recommended by ACOG, for women with be managed like HIV-negative women with ASC-US (i. In these situa- tions, women should be advised to continue follow-up Prevalence of HR HPV is high among adolescents aged with the physician(s) who provided health care at the time <21 years (425). Infections in adolescent patients tend to clear of the hysterectomy, if possible. In women whose cervix rapidly, and lesions caused by these infections also have high remains intact after a hysterectomy, regularly scheduled rates of regression to normal. Terefore, ASCCP and ACOG Pap tests should be performed as indicated (433–435). Only those with HSIL at either follow-up visit assurance measures are more likely to obtain satisfactory or persistence of ASC-US or LSIL at 24 months should be test results as determined by the laboratory. Counseling Messages for Women • Although evidence supports the option of HPV testing Receiving Cervical Cancer Screening for the triage of women with ASC-US Pap test results, and HPV Testing this option might not be feasible in an STD clinic because When a woman receives abnormal cervical cytology test of limited resources. Furthermore, a positive HPV DNA test result might characteristics. Pregnancy Health-care providers are the most trusted source of infor- mation about HPV and abnormal cervical cytology test results. Pregnant women should be screened at the same frequency Terefore, they have an important role to play in educating as nonpregnant women; however, recommendations for man- women about high-risk HPV and moderating the psychosocial agement difer in this population (83,84,424). Print materials are available at several Several studies have documented an increased prevalence websites (http://www. Department of Health and Human Services (HHS) likelihood of following up with necessary testing or treatment. In counseling women with high-risk HPV infections about • No clinically validated test exists for men to determine if partner management, messages should be tailored to the indi- they have HPV infection. While no evidence supports tion of HPV infection in men is genital warts. High-risk either partner notifcation (PN) or clinical-evaluation referral HPV types seldom cause genital warts. Sexual partners of HPV-infected patients diagnosis with their partners. Tis type of communication can also likely have HPV, even though they might have no foster partner support and ensure the sharing of information signs or symptoms of infection. HPV infection cated to patients receiving cervical screening: can be present for many years before it is detected, and • Te purpose of regular, lifelong cervical cancer screening no method can accurately confrm when HPV infection is to identify cervical cancer precursors, which can be was acquired. Prevention measures for current and subsequent sex part- • A positive high-risk HPV DNA test or an abnormal ners and risk reduction should be discussed. Providers should cervical cytology test is not indicative of cervical cancer. Consistent condom use by male partners abnormalities do not progress. A positive high risk HPV DNA in long-term partnerships might decrease the time required test indicates a HPV infection of the cervix, but does not to clear HPV in the infected woman. A normal cervical cytology test condom remains vulnerable to HPV infection. HPV vaccines indicates that no cellular abnormalities were detected at are available and recommended for girls and young women the time of testing, but women who have HPV infection aged 9–26 years, even those who have been diagnosed with of the cervix have a higher likelihood of developing cell HPV infection. Male partners can be vaccinated with the changes, which could lead to cervical cancer over time. Follow-up evaluation is essential to monitor cervical cytology. Additional testing exposure vaccination with widely available vaccines, including might be required to confrm these results. Tis guidance focuses largely on integrating the use of available Discussion concerning disclosure of a positive high-risk vaccines into STD prevention and treatment activities. HPV test to sex partners might be appropriate and can include Every person being evaluated or treated for an STD the following information: should receive hepatitis B vaccination unless already vac- • HPV is very common. It usually has no signs or should receive hepatitis A vaccination. Even persons with only one lifetime sex partner can get HPV if their Hepatitis A, caused by infection with HAV, has an incu- partner was infected. HAV replicates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of clini- Vol. HAV infection produces a self-limited disease that signs or symptoms of acute liver failure.

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Implicit in such a question could be perceived impact as well as an assessment of behaviour patterns on the governing bodies buy 40mg nexium free shipping gastritis or morning sickness. In both 2014 and 2016 the majority (68% in 2014 and 60% in 2016) of respondents leaned decisively towards the positive end of the spectrum; that is buy nexium 20mg cheap diet during gastritis attack, they said that clinical leaders were central to all discount nexium 40mg visa gastritis diet lunch, or nearly all purchase 40mg nexium with visa gastritis diet 800, redesign initiatives or to a significant proportion of these initiatives. This, in broad terms, might be seen as an overall endorsement of the idea of CCGs. The fall from 68% to 60% in just 2 years might, however, be seen as a matter of concern given the central nature of this question. Most notably, finance officers tended to place much less importance on clinical leadership than did other role holders. GP members of governing bodies and managers (other than accountable officers) were also more circumspect about the role of clinical leaders in service redesign. The chairpersons and accountable officers on the other hand report that clinical leaders are central to nearly all design initiatives or at least involved in a significant proportion of initiatives. As Figure 22 shows, respondents in CCGs rated as inadequate were the least likely to say that clinical leadership was significant in improving or redesigning services; and respondents from good and outstanding CCGs were most likely to say clinical leadership was central or influential in a significant proportion of initiatives. On the face of it, these findings are highly suggestive of the importance of the role of clinical leadership. 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 31 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. Examples of positive impacts by the Clinical Commissioning Groups In the pilot phase in 2014 we had been somewhat surprised to hear the response from accountable officers and chairpersons that the main achievements had been to establish the CCGs and make appointments. In other words, they focused on process aspects and institution building. So, although at that time they were relatively new bodies, they had been in existence for around 2 years in statutory and shadow form and we were expecting to see some more substantial claims about new initiatives and their progress. Therefore, by the time of the survey in 2016, we expected to hear much more about meaningful impacts and service improvements. Some respondents struggled to cite any examples of significant impacts made by their CCG. Most respondents were able to list a few impacts, albeit often the claimed initiatives were in the early stages. The claimed impacts ranged across primary, secondary and community services. Notably, there was very little reference to the use of commissioning and decommissioning as tools for bringing about change. Another notable point is that impact is often perceived in process- improvement terms – such as building positive working relationships, engaging stakeholders and stimulating discussions. 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 33 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. FINDINGS FROM THE NATIONAL SURVEYS As predicted by institutional theory, there appeared to be considerable evidence of imitation. CCGs form a loose community of practice, they have learned a common language, and their ambitions are, in part at least, formed by the wider institutional field. Other comments were responses to national initiatives: use of the Better Care Fund (BCF); co-commissioning. Conversely, some referred to initiatives being stopped by NHSE. A straightforward frequency count of the most-mentioned impacts resulted in the following list of 10 in ranking order: 1. Improving Access to Psychological Therapies (IAPT) self-referral] 3. GP out of hours; federations and practice collaborations 5. Mentioned less frequently were any significant impacts on secondary care or much deployment of the power of commissioning and decommissioning. Indeed, it was also notable and curious that, given all of the talk about prime contractor arrangements and outcome-based commissioning, there was no mention of these in response to the question about the main impact of the CCG to date, or at least not directly. These forms of contracting were implicit in some of the responses about MSK and to a lesser extent in relation to changes in services for the frail elderly, but still there was no explicit mention. It might be suggested that this is because, even where arrangements had been made, it was rather too early to measure actual impact in terms of outcomes. Fortunately, we had a specific question on prime contracting and outcomes-based commissioning. Assessment of service redesign progress The preliminary pilot work had alerted us to the need to distinguish between broad plans and actual activity. However, it does seem to indicate that CCG office holders had a pretty good sense of how well their organisations were performing. There was evidence to support an optimistic view of the worth and importance of CCGs and of the role of clinical leaders, but there was also some evidence to support a more pessimistic view. Likewise, within CCGs, there were indicators of the influence exercised by GPs. They were assessed as broadly as influential as managers. Other data pointing towards an optimistic view can be found in assessments of who sets the compelling vision – a significant indicative role in the context of these bodies. Trends in communication with secondary care clinicians and with patients and the public also offered grounds for optimism. The overall assessment of the influence of clinical leadership was that they were central to nearly all service redesigns (35%) or in a significant proportion of redesigns (25%). Taken together, this suggested that around 60% of respondents claimed a key role for clinical leadership in practice. Positive assessments of CCG influence were more often made by chairpersons and accountable officers (i. In contrast, finance officers and GP board members were much less inclined to offer a positive assessment. Similarly, GPs on governing boards tended to be the least convinced that GPs were influential in the redesign of services. Moreover, GP respondents reported that practice workloads were impeding engagement with clinical leadership and that, as a result, engagement with CCGs was declining. One might expect that at least GPs on the CCG board would be the prime intermediaries and communicators with other primary care clinicians, but only 40% of CCG managers made this assessment, they suggested it was done either by managers or jointly with clinicians.

A neuroimaging study (Adisetivo et al order nexium 40mg otc gastritis diet bland, 2013) which was careful to exclude children with co-morbid disorders reports that in pure ADHD (compared to healthy controls) showed abnormal grey and white matter changes in bilateral frontal and parietal lobes order 40mg nexium otc gastritis causes, insula buy generic nexium 20 mg online gastritis nsaids, corpus callosum generic 40mg nexium gastritis symptoms diarrhea, and right external and internal capsules. Parents and teachers need to be educated about the disorder and involved in the designing and provision of management strategies. Where symptoms interfere with learning or social integration and family life, psychostimulants (methylphenidate and dexamphetamine) may be useful, as they enable children to participate in other aspects of management. Debate continues about the place of medication in ADHD. Ghuman and Ghuman (2013) contend that no information is available about long term safety and effects of psychopharmacologic agents on the rapidly developing brains of pre-schoolers. Usage differs from one region to another, for example, use is five times higher in Iceland than Sweden (Zoega et al, 2010). DSM-5 criteria Autism spectrum disorder Persistent deficits in social communication and social interaction across multiple contexts 1. Deficits in social reciprocity – reduced sharing and conversation 2. Deficits in nonverbal communication – abnormalities of eye-contact, body language 3. Deficits in developing, maintaining and understanding relationships A. Restricted, repetitive patterns of behaviour, interests – at least 2 of below 1. Stereotyped or repetitive motor movements of speech – motor stereotypies, echolalia 2. Insistence on sameness, inflexible adherence to routines – change=distress. Highly restricted, fixated interests of abnormal intensity and focus 4. Hyper- or hypo-reactivity to sensory input –indifference to pain, fascination with lights or movement. Autism The term autism is derived from Greek word “autos” meaning self, and was coined to reflect the fact that autistic children seem to lack interest in other people. It was first described by Dr Leo Kanner (USA) in 1943. Autism is a neurodevelopmental disorder which manifests as markedly abnormal social interactions and communication ability, abnormal patterns of interest and patterns of behaviour. The disorder should be present before 3 years of age. The prevalence appears to be 1 in 150-200 (ADDM, 2007), much higher than previously estimated, and the disorder is highly heritable. Head circumference (HC) is greater th than the 97 percentile in 20% of autistic children. However, HC is apparently normal at birth (Hobbs et al, 2007) suggesting an increased rate of head growth in the post- natal period. Unaffected co-twins have a similar head size, suggesting macrocephaly may represent an endophenotype (Froehlich et al, 2013). Advanced paternal age is reported to be associated with childhood autism in offspring (Lampi et al. Autistic children prefer objects to faces, they avoid eye contact and have difficulty learning to engage in social interaction. This may be apparent in the first few months of life. These children appear to prefer being alone and seldom seek comfort from others. Autistic children have been described as lacking a “theory of mind” (see Chapter 33), by which is meant they are unable to understand the world from the perspective of others. If they know where something is which is out of sight (lost car keys) they assume that everyone knows the location of that thing. They prefer predictable routines and familiar environments. If overwhelmed by change or adversity they may respond with anger, self-injury or withdrawal. There are difficulties in sensory integration, and such people may have difficulty tolerating normal sensory input. People with autism tend to be clumsy, have poor body awareness and difficulty learning new movements. There are often delays in speech, language and motor skills. Such people may remain mute throughout life, communicating using images, sign language or typing. Some develop large vocabularies but nevertheless have difficulty sustaining a conversation. Social situations are usually highly stressful for people with autism. However, companionship is important to them, and they are often conscious of being outcasts and this is distressing rather than desired. Autistic people often engage in self-stimulation, which is observed by others as repetitive behaviours, such as spinning objects. They may flap their hands or arms or wiggle their toes for long periods. They often arrange toys in rows rather than play with them in the usual manner. They may become preoccupied with certain subjects, such as computers, numbers, symbols or particular aspects of science. Eduction presents difficulties, as could be expected from the above. Difficulty understanding gestures leads to difficulty understanding and communicating with teachers and peers. Autistic savants are autistic people with extraordinary talent in a certain area. There is controversy regarding the best ways of treating people with autism. It celebrates the work of Hans Asperger (Austrian; 1906-1980) who had described the condition decades earlier. As he travelled little and published in German, his work was late to be “discovered”. They are at greater risk of depression or poverty than members of the general population. These are social difficulties and stereotyped behavioural features, but there is not delayed and deviant language development.

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