Famvir

Jason Rhee, M.D.

• Transplant Research Fellow
• Department of Surgery
• Tufts Medical Center
• Boston, Massachusetts

Diagnosis: Confirmation of visceral leishmaniasis is made by identifying the par asite hiv infection in zambia purchase famvir 250mg visa. In the form of visceral leishmaniasis that occurs in the Americas hiv infection mouth buy famvir 250 mg overnight delivery, the parasite can rarely be seen in films of peripheral blood; however acute phase hiv infection symptoms discount famvir 250 mg with amex, this technique can yield positive results for kala-azar in India hiv infection rates taiwan buy famvir 250 mg with mastercard. The most sensitive procedure (98% positivity) is splenic aspiration, but this technique entails high risk, especially in patients with anemia and clotting problems. In the early stages of the disease, when parasites are scarce, culture in Novy-McNeal-Nicolle or another appropriate medium or intraperitoneal inoculation in hamsters can be used. Although blood samples on filter paper can be used, the sensitivity of the test increases if lymph node or bone marrow aspirates are used (Osman et al. In dogs and other canids, the parasites can be observed or isolated by culture or hamster inoculation, using material from cutaneous lesions or the viscera of dead animals. When the usual methods for detecting the parasite do not produce results or the media needed to perform them are not available, immunologic tests are generally used. The direct agglutination test to detect visceral leishmaniasis has a sensitivity of over 99% and a specificity of 96% if the appropriate dilution is used (Boelaert et al. However, the reproducibility of the test was not entirely satisfactory (Mauricio et al. Control: Leishmaniasis control measures are directed against the vectors and reservoirs. The incidence of kala-azar in India decreased markedly in the wake of the antimalaria campaign, and the infection has virtually disappeared from the districts that were sprayed. Spraying should not be limited to dwellings, but should also be done around animal dens, stone walls, refuse dumps, and other places where the vector breeds. In regions in which the infection is of zoonotic origin, it is considered important to systematically eliminate infected dogs and, to the extent possible, control the fox population. On the Greek island of Crete, destroying infected dogs brought down the incidence of the disease in humans significantly. However, vigorous campaigns in northeastern Brazil have not borne out the effectiveness of controlling dog popula tions and experimental studies have shown that eliminating dogs does not reduce the incidence of human infection (Dietze et al. In regions in which the infection is of human origin, human cases should be detected and treated. Although vaccination against leishmaniasis is considered impractical because the infection inhibits immunity, experimental stud ies have demonstrated that partial protection was achieved in mice injected with L. The next most effective control method is reduction of host susceptibility through improved nutri tion for children and vaccination of people and dogs. Elimination or treatment of dogs that serve as reservoirs is considerably less effective than either of these meth ods (Dye, 1996). Protection of mice against visceral leishmaniasis by immunization with promastigote antigen incorporated in liposomes. Studies on control of visceral leishmaniasis: Impact of dog control on canine and human visceral leishmaniasis in Jacobina, Bahia, Brazil. Anti-leishma nial IgE antibodies: A marker of active disease in visceral leishmaniasis. Leishmaniasis in Bahia, Brazil: Evidence that Leishmania amazonensis produces a wide spectrum of clinical disease. Visceral leishmaniasis (Kala-Azar) in transplant recipients: Case report and review. A search for leishmania in vertebrates from kala-azar affected areas of Bihar, India. Operational validation of the direct agglutination test for diagnosis of visceral leishmaniasis. Visceral leishmaniasis in a new ecological niche near a major metropolitan area of Brazil. Effect of eliminating seropositive canines on the transmission of visceral leishmaniasis in Brazil. Epidemiology of kala-azar in rural Bihar (India) using village as a component unit of study. The signifi cance of blood levels of IgM, IgA, IgG and IgG subclasses in Sudanese visceral leishmania sis patients. The American leishmaniases: Some observations on their ecology and epi demiology. The fox Cerdocyon thous (L) as a reservoir of Leishmania donovani in Para State, Brazil. Clinicoepidemiologic characteris tics, prognostic factors, and survival analysis of patients coinfected with human immunodefi ciency virus and Leishmania in an area of Madrid, Spain. Rapid identification of causative species in patients with Old World leishmaniasis. A cross-sectional serodiagnostic survey of canine leishmaniasis due to Leishmania chagasi. The epidemic of visceral leishmaniasis in western Upper Nile, southern Sudan: Course and impact from 1984 to 1994. Serological diagnosis of visceral leish maniasis by a dot-enzyme immunoassay for the detection of a Leishmania donovani-related circulating antigen. Further evidence incriminating the fox Cerdocyon thous (L) as a reservoir of Amazonian visceral leishmaniasis. Etiology: the agents of this disease are cercariae of avian schistosomes (mainly species of the genera Australobilharzia, Bilharziella, Gigantobilharzia, Microbilharzia, Ornithobilharzia, and Trichobilharzia) or of nonhuman mammals (species of the genera Heterobilharzia, Orientobilharzia, Schistosoma, and Schistosomatium). Man is an aberrant host for these species and does not sustain the development of the parasite beyond its cutaneous site. Although there are differences in the details, all schistosomes share basically the same life cycle (see the chapter on Schistosomiasis). When the egg reaches the water, the miracidium is released and swims in search of an appropriate intermediate host, which is usually a snail belonging to Bulineus, Lymnaea, Nassarius, Physa, Planorbis, Stagnicola, or another genus. The miracidia penetrate the body of the mollusk and invade the digestive gland (hepatopancreas), where they develop into another pre-adult stage, the sporocyst. Another pre-adult stage forms within the sporocyst, the redia, which, in turn, gives rise to yet another pre-adult stage, the cercaria. After several weeks, the fork-tailed cercariae mature and leave the snail, swimming in search of a definitive host. Their infectivity decreases quickly and they generally die if they fail to find a host within 24 hours. The schistosomula penetrate the blood or lymph ves sels and travel to the lungs, where they remain for several days. In man, the cercariae are usually destroyed in the skin before reaching the circulatory system. Of a group of 28 Dutch tourists who became infected with human schistosomes in Mali (West Africa), 10 (36%) had symptoms of cercarial dermatitis (Visser et al. Geographic Distribution and Occurrence: Cercarial dermatitis occurs world wide in all climates, and in all places where people, through their recreational or occupational activities, come into contact with contaminated waters in rivers, lakes, floodlands, irrigation canals, and oceans near the coast. Swimmers, clam-diggers, washerwomen, fishermen, and rice-field workers are the groups most likely to be exposed. As a precise diagnosis is difficult, many cases are probably never recognized as cercarial dermatitis. The Disease in Man: Cercarial dermatitis is basically a defense reaction to an aberrant parasite, which the host almost always successfully destroys, but which causes allergic sensitization. When a person is exposed to cercariae for the first time, the symptomatology is usually mild and may pass unnoticed. Between 10 and 30 minutes after exposure, the affected person feels a transitory itching and macules appear but vanish within 10 to 24 hours. After 5 to 14 days, small papules appear, accompanied by temporary itching where the macules had been. As no immunologic reactions are expected in the first few days of a primary infection and the cercariae are destroyed within approximately 30 minutes in the malpighian layer, the symptoms that occur in the first few days are presumed to be the result of the damage caused by the parasite and the chemical substances it releases.

Medical Disposition the ensuing discussion of medical disposition is reproduced hiv infection from dentist safe 250 mg famvir, essentially unchanged antivirus software discount famvir 250mg on line, from the most recent (1978) edition of the U anti viral pharyngitis buy famvir 250mg overnight delivery. As this revision is being prepared hiv infection graph order famvir 250mg line, medical disposition procedures are being reviewed and we anticipate a substantially simplified and streamlined protocol by late 1990. Before proceeding on the basis of what is printed here, you should ensure that governing directives have not already been revised. As soon as the expected changes are issued, replacement pages for this text will be prepared and distributed. When there is a question of mental competence, there must be three members of the board, and one must be a psychiatrist. A flight surgeon should be a member of all boards on naval aviators and naval flight officers who are returned to full duty or limited duty. Convening Authority for Medical Boards Medical Boards may be convened by the commanding officers of all naval hospitals, the Naval Medical Clinic, Pearl Harbor, or higher authority. The Convening Authority prepares an en dorsement for each Medical Board before forwarding it to higher authority and, in many cases, is authorized to act on the recommendation of the Medical Board without waning for Bureau review, thus avoiding costly delay. There is no longer a requirement that patients be admitted to a hospital for a Medical Board. The opin ions and recommendations of specialty consultations can be incorporated as enclosures to such boards. The narrative must be clear, concise, and sufficiently comprehensive to enable a reviewer who cannot see the patient to render an appropriate decision regarding the recommended disposition. The report consists of three main parts: an introduction, a narrative account, and recommendations. The narrative section should be no more, and certainly no less, than the narrative summary prepared after all hospitalizations and periods of outpatient treatment. A review of the problem, a pertinent background history, and appropriate physical, mental, and laboratory examination data are essential. The member is considered fully qualified for all duties appropriate to his or her rate or rank, without physical or geographic restrictions. A person not fit for full duty is not qualified for special duty, such as aviation. Furthermore, aviation personnel cannot be returned to any flight status by Medical Board action; this requires a separate determination which will be discussed in the section on aviation disposition. The member is considered fit for duty, but this must be restricted commensurate with his or her condition. Within six months following a Medical Board recommending limited duty, another board must be convened which can make any of these four recommendations, including another period of limited duty. If a person is not fit for full duty by that time, it is usually most appropriate to refer his or her case to the Physical Evaluation Board. Occasions for this recommendation arise, for example, when a person must be hospitalized for treatment of a disqualifying condition which he or she fradulently denied having had at the time of enlistment, or when a person who cannot adapt to military service because of a personality disorder is hospitalized because of a manipulative suicide gesture. The member is physically or mentally unfit for continued military service and should be medically separated. The patient will, unless there is felt to be a contraindication to this in regard to his or her physical or mental health, be invited to meet with the members of the board to discuss their findings and recommendations. If he or she is satisfied with these, the member must sign a statement to that effect; if he or she wishes to rebut any of these, five working days will be allowed to prepare a formal exposition of the objec tions. In the latter case, board members have the option of preparing a surrebuttal statement. After endorsement by the Convening Authority, the report is sent for a higher review. It is important, therefore, to include in the report all available information, with adequate documentation, concerning the origin, nature, conduct status, and aggravation by service of any condition discussed. Wherever possible, impairment of function should be reported in terms of objective tests or findings rather than as opinion or conjecture. Sufficient information for proper assessment of overall disability or func tional impairment must be presented. In cases referred to the Physical Evaluation Board, the report must contain information on all rateable conditions, even if some do not represent func tional impairment or lead to unfitness in and of themselves. It is especially important that conjecture regarding disability ratings by members of the Medical Board to the patient or his or her family be avoided. Regardless, the member may present testimony from other military medical consultants or be represented by military attorneys at no cost, or he or she may retain civilian consultants and civilian attorneys at his or her own expense. If he or she remains dissatisfied, appeal is again possible, either with a full and fair or prima facie hearing, before the Physical Disability Review Board. The patient has no formal appeal mechanism at this point, but every effort will have been made to ensure fair and impartial treatment. If the outcome is that the member is not fit for duty and that the disability rating is less than 10 15-7 U. The report of this review is essentially another Medical Board, and it should document clearly the difficulties and successes he or she has experienced in adapting to civilian life. Should the member choose not to return to active duty, the disability compensation and all other benefits would cease and he or she would be separated. These are established by multiplying the current monthly base pay for the rate or rank the member had achieved when medically retired by the percentage of disability established, with the latter limited to 75 percent; the maximum a person could receive in retirement pay after 30 years of service. For example, an O-5 with 16 years active duty who incurred a disability rated at 50 percent would receive 50 percent of the base pay for an O-5 with 16 years service. Had the disability been rated at 100 percent, he or she would receive 75 percent of the same base pay. This would be the case with many enlisted members and some junior officers with 15-8 Disposition of Problem Cases few years of active duty. In either case; medically retired members retain essentially the same rights to the use of base facilities (commissaries, exchanges, etc. All disability compensation for members continuously on active duty since before 25 September 1975 is exempted from Internal Revenue Service taxation. For those whose active ser vice commenced after that date, disability must have been incurred in combat-related cir cumstances in order to qualify for the income tax exemption. As an example, if a member reports a physical disability at the time of examination for retirement after 30 years of service and is awarded a 50 percent disability for this, he or she would receive 75 percent of the base pay of longevity, and two-thirds of this amount (50 percent of the base pay) would be exempted from Federal taxation. General Comments What has been discussed is the disposition of active duty personnel who develop an illness or sustain an injury which renders them unable to continue to function effectively.

The prestabilization this increased rating will be effective 50-percent rating is not to be used in the first day of continuous hospitaliza any case in which a rating of 50 percent tion and will be terminated effective or more is immediately assignable the last day of the month of hospital under the regular provisions antiviral aids discount 250 mg famvir overnight delivery. An authorized absence of They will continue for a 12-month period fol 4 days or less which results in a total of lowing discharge from service hiv infection nail salon generic famvir 250 mg without a prescription. However hiv infection female to male buy famvir 250mg with visa, more than 8 days of authorized absence prestabilization ratings may be changed to a during the first 21 days of hospitaliza regular schedular total rating or one author tion will be regarded as the equivalent izing a greater benefit at any time jiangmin antivirus guard purchase 250mg famvir with amex. Such total other provisions of the rating schedule, rating will be followed by appropriate and consideration will be given to the schedular evaluations. When the evi propriety of such a rating in all in dence is inadequate to assign a sched stances and to the propriety of its con ular evaluation, a physical examina tion will be scheduled and considered tinuance after discharge. A little used part of the ination will be scheduled prior to the musculoskeletal system may be ex end of the total rating period. This consideration, or the ab does not provide a zero percent evalua sence of clear cut evidence of injury, tion for a diagnostic code, a zero per may result in classifying the disability cent evaluation shall be assigned when as not of traumatic origin, either re the requirements for a compensable flecting congenital or developmental evaluation are not met. When possible, this system is primarily the inability, due should include complete neurological to damage or infection in parts of the and psychiatric examination, and other system, to perform the normal working special examinations indicated by the movements of the body with normal physical condition, in addition to the excursion, strength, speed, coordina required general and orthopedic or sur tion and endurance. The ualize the nature and extent of the functional loss may be due to absence service connected disability. The with deformity throwing abnormal lumbosacral articulation and both sac stress upon, and causing malalignment roiliac joints are considered to be a of joint surfaces, should be depicted group of minor joints, ratable on dis from study and observation of all avail turbance of lumbar spine functions. The direction of angulation and within the Department of Veterans Af extent of deformity should be carefully fairs. Inquiry will be directed combined with a peripheral nerve pa to these considerations: ralysis rating of the same body part, (a) Less movement than normal (due unless the injuries affect entirely dif to ankylosis, limitation or blocking, ferent functions. Service de verely disabled, the evaluation of the partment record of superficial wound shoulder joint under diagnostic code with brief treatment and return to 5200 will be elevated to the level for un duty. No cardinal signs or symptoms of signed, but the muscle groups them muscle disability as defined in para selves will not be rated. No impairment of the evaluation for unfavorable anky function or metallic fragments re losis of that joint, except in the case of tained in muscle tissue. Through and through or (e) For compensable muscle group in deep penetrating wound of short track juries which are in the same anatom from a single bullet, small shell or ical region but do not act on the same shrapnel fragment, without explosive joint, the evaluation for the most se effect of high velocity missile, residu verely injured muscle group will be in als of debridement, or prolonged infec creased by one level and used as the tion. Some loss of with muscle or tendon damage will be deep fascia or muscle substance or im rated as a severe injury of the muscle pairment of muscle tonus and loss of group involved unless, for locations power or lowered threshold of fatigue such as in the wrist or over the tibia, when compared to the sound side. Service de strain or demonstrable tenderness, is a partment record or other evidence congenital abnormality which is not showing hospitalization for a prolonged compensable or pensionable. In crepitation within the joint structures severe cases there is gaping of bones on should be noted carefully as points of the inner border of the foot, and rigid contact which are diseased. Exercise involved should be tested for pain on with undeveloped or unbalanced mus both active and passive motion, in culature, producing chronic irritation, weight-bearing and nonweight-bearing can be an aggravating factor. In the ab and, if possible, with the range of the sence of trauma or other definite evi opposite undamaged joint. Amputation, pensation, will be held to exist when no or injury to an upper extremity, is not effective function remains other than considered as a causative factor with that which would be equally well subsequently developing arthritis, ex served by an amputation stump at the cept in joints subject to direct strain site of election below elbow or knee or actually injured. This arms, and, in the matter of postural 40 percent rating may be further com stability, by a special appliance. Dis hand, of an ambidextrous individual ability is manifest from erector spinae will be considered the dominant hand spasm (not accounted for by other pa for rating purposes. To qualify more major joints or 2 or more minor joint for the 10 percent rating, 2 or more episodes groups. At this point, if there For chronic residuals: has been no local recurrence or metastases, For residuals such as limitation of motion or an the rating will be made on residuals. Limitation of motion must be ob tional stress or by overexertion, but that jectively confirmed by findings such as swell are present more than one-third of the ing, muscle spasm, or satisfactory evidence of time. Para plegia with loss of use of both lower extremities and loss of anal and bladder sphincter control qualifies for subpar. With metacarpal resection (more than (e) Combinations of finger amputations one-half the bone lost). With an even Without metacarpal resection, at proxi number of fingers involved, and adja mal interphalangeal joint or proximal cent grades of disability, select the thereto. Motion lost beyond last quarter of arc, the hand does not approach full pronation. The position of function of the between the fingertip(s) and the hand is with the wrist dorsiflexed 20 to 30 proximal transverse crease of the degrees, the metacarpophalangeal and palm, with the finger(s) flexed to proximal interphalangeal joints flexed to the extent possible, evaluate as 30 degrees, and the thumb (digit I) ab favorable ankylosis. Normal forward flexion of the Forward flexion of the cervical thoracolumbar spine is zero to 90 degrees, exten spine 15 degrees or less; or, fa sion is zero to 30 degrees, left and right lateral vorable ankylosis of the entire flexion are zero to 30 degrees, and left and right cervical spine. The com Forward flexion of the bined range of motion refers to the sum of the thoracolumbar spine greater than range of forward flexion, extension, left and right 30 degrees but not greater than lateral flexion, and left and right rotation. The normal ranges of motion for 30 degrees; or, the combined each component of spinal motion provided in this range of motion of the note are the maximum that can be used for cal thoracolumbar spine not greater culation of the combined range of motion. Fixation of a spinal segment in nal contour; or, vertebral body neutral position (zero degrees) always represents fracture with loss of 50 percent favorable ankylosis. Not to be combined with 5257 Knee, other impairment of: other ratings for fracture or faulty union in the Recurrent subluxation or lateral instability: Severe. Extrinsic muscles of shoulder girdle: condyle of humerus: Flexors of the carpus (1) Trapezius; (2) levator scapulae; (3) and long flexors of fingers and thumb; serratus magnus. Intrinsic muscles lumbricales; 4 dorsal and 3 palmar of shoulder girdle: (1) Pectoralis major I interossei. Intrinsic muscles of shoulder Rat girdle: (1) Supraspinatus; (2) infraspinatus ing and teres minor; (3) subscapularis; (4) 5310 Group X. Function: Elbow supination or digiti minimi brevis; (9) dorsal and plantar (1) (long head of biceps is stabilizer of interossei. Posterior and lat support of body steadying pelvis upon head of eral crural muscles, and muscles of the calf: (1) femur and condyles of femur on tibia (1). Spinal 4, 5); simultaneous flexion of hip and flexion of muscles: Sacrospinalis (erector spinae and its pro knee (1); tension of fascia lata and iliotibial longations in thoracic and cervical regions). The evaluation for the cessation of any surgery, radiation treatment, antineoplastic chemotherapy or other therapeutic visual impairment of one eye must not procedures. Six months after discontinuance of exceed 30 percent unless there is ana such treatment, the appropriate disability rating tomical loss of the eye. Ex tance corrected vision and an expla amination of visual acuity must in nation of the reason for the difference. For mine the average concentric contrac phakic (normal) individuals, as well as tion of the visual field of each eye by for pseudophakic or aphakic individ measuring the remaining visual field uals who are well adapted to intra (in degrees) at each of eight principal ocular lens implant or contact lens cor meridians 45 degrees apart, adding rection, visual field examinations must them, and dividing the sum by eight. If there has been all other clinical conditions that may no local recurrence or metastasis, rate on re produce similar symptoms; and siduals. Rate residuals such as liver damage or lymphadenopathy under the appropriate system. Rate residuals such as skin lesions or peripheral neuropathy under the appropriate system.

Men who sexually molest their own prepubertal children occasionally approach other children as well antiviral breakfast purchase famvir 250mg without prescription, but in either case their behaviour is indicative of paedophilia hiv transmission facts statistics discount 250mg famvir with amex. If the individual prefers to be the recipient of such stimulation this is called masochism; if the provider hiv infection rates by demographic purchase famvir 250 mg fast delivery, sadism antiviral kleenex side effects purchase discount famvir. Often an individual obtains sexual excitement from both sadistic and masochistic activities. Mild degrees of sadomasochistic stimulation are commonly used to enhance otherwise normal sexual activity. This category should be used only if sadomasochistic activity is the most important source of stimulation or necessary for sexual gratification. Sexual sadism is sometimes difficult to distinguish from cruelty in sexual situations or anger unrelated to eroticism. Where violence is necessary for erotic arousal, the diagnosis can be clearly established. These include such activities as making obscene telephone calls, rubbing up against people for sexual stimulation in crowded public places (frotteurism), sexual activity with animals, use of strangulation or anoxia for intensifying sexual excitement, and a preference for partners with some particular anatomical abnormality such as an amputated limb. Erotic practices are too diverse and many too rare or idiosyncratic to justify a separate term for each. Swallowing urine, smearing faeces, or piercing foreskin or nipples may be part of the behavioural repertoire in sadomasochism. Masturbatory rituals of various kinds are common, but the more extreme practices, such as the insertion of objects into the rectum or penile urethra, or partial self-strangulation, when they take the place of ordinary sexual contacts, amount to abnormalities. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual, or bisexual in orientation, or in individuals who after a period of apparently stable sexual orientation, often within a long-standing relationship, find that their sexual orientation is changing. An attention-seeking (histrionic) behavioural syndrome develops, which may also contain additional (and usually nonspecific) complaints that are not of physical origin. The patient is commonly distressed by this pain or disability and is often preoccupied with worries, which may be justified, of the possibility of prolonged or progressive disability or pain. Dissatisfaction with the result of treatment or investigations, or disappointment with the amount of personal attention received in wards and clinics may also be a motivating factor. Some cases appear to be clearly motivated by the possibility of financial compensation following accidents or injuries, but the syndrome does not necessarily resolve rapidly even after successful litigation. For physical symptoms this may even extend to self-infliction of cuts or abrasions to produce bleeding, or to self-injection of toxic substances. The imitation of pain and the insistence upon the presence of bleeding may be so convincing and persistent that repeated investigations and operations are performed at several different hospitals or clinics, in spite of repeatedly negative findings. The motivation for this behaviour is almost always obscure and presumably internal, and the condition is best interpreted as a disorder of illness behaviour and the sick role. Individuals with this pattern of behaviour usually show signs of a number of other marked abnormalities of personality and relationships. Malingering, defined as the intentional production or feigning of either physical or psychological symptoms or disabilities, motivated by external stresses or incentives, should be coded as Z76. The commonest external motives for malingering include evading criminal prosecution. Malingering is comparatively common in legal and military circles, and comparatively uncommon in ordinary civilian life. F70-F79 Mental retardation Overview of this block 174 F70 Mild mental retardation F71 Moderate mental retardation F72 Severe mental retardation F73 Profound mental retardation F78 Other mental retardation F79 Unspecified mental retardation A fourth character may be used to specify the extent of associated behavioural impairment: F7x. However, mentally retarded individuals can experience the full range of mental disorders, and the prevalence of other mental disorders is at least three to four times greater in this population than in the general population. In addition, mentally retarded individuals are at greater risk of exploitation and physical/sexual abuse. Adaptive behaviour is always impaired, but in protected social environments where support is available this impairment may not be at all obvious in subjects with mild mental retardation. A fourth character may be used to specify the extent of the behavioural impairment, if this is not due to an associated disorder: F7x. The presence of mental retardation does not rule out additional diagnoses coded elsewhere in this book. However, communication difficulties are likely to make it necessary to rely more than usual for the diagnosis upon objectively observable symptoms such as, in the case of a depressive episode, psychomotor retardation, loss of appetite and weight, and sleep disturbance. Diagnostic guidelines Intelligence is not a unitary characteristic but is assessed on the basis of a large number of different, more-or-less specific skills. Although the general tendency is for all these skills to develop to a similar level in each individual, there can be large discrepancies, especially in persons who are mentally retarded. This presents problems when determining the diagnostic category in which a retarded person should be classified. Associated mental or physical disorders have a major influence on the clinical picture and the use made of any skills. The diagnostic category chosen should therefore be based on global assessments of ability and not on any single area of specific impairment or skill. The categories given below are arbitrary divisions of a complex continuum, and cannot be defined with absolute precision. Without the use of standardized procedures, the diagnosis must be regarded as a provisional estimate only. F70 Mild mental retardation Mildly retarded people acquire language with some delay but most achieve the ability to use speech for everyday purposes, to hold conversations, and to engage in the clinical interview. Most of them also achieve full independence in self-care (eating, washing, dressing, bowel and bladder control) and in practical and domestic skills, even if the rate of development is considerably slower than normal. The main difficulties are usually seen in academic school work, and many have particular problems in reading and writing. However, mildly retarded people can be greatly helped by education designed to develop their skills and compensate for their handicaps. Most of those in the higher ranges of mild mental retardation are potentially capable of work demanding practical rather than academic abilities, including unskilled or semiskilled manual labour. In a sociocultural context requiring little academic achievement, some degree of mild retardation may not itself represent a problem. However, if there is also noticeable emotional and social immaturity, the consequences of the handicap. In general, the behavioural, emotional, and social difficulties of the mildly mentally retarded, and the needs for treatment and support arising from them, are more closely akin to those found in people of normal intelligence than to the specific problems of the moderately and severely retarded. An organic etiology is being identified in increasing proportions of patients, although not yet in the majority. Understanding and use of language tend to be delayed to a varying degree, and executive speech problems that interfere with the development of independence may persist into adult life. Associated conditions such as autism, other developmental disorders, epilepsy, conduct disorders, or physical disability are found in varying proportions. Includes: feeble-mindedness mild mental subnormality mild oligophrenia moron F71 Moderate mental retardation Individuals in this category are slow in developing comprehension and use of language, and their eventual achievement in this area is limited. Achievement of self-care and motor skills is also retarded, and some need supervision throughout life. Progress in school work is limited, but a proportion of these individuals learn the basic skills needed for reading, writing, and counting. Educational programmes can provide opportunities for them to develop their limited potential and to acquire some basic skills; such programmes are appropriate for slow learners with a low ceiling of achievement. As adults, moderately retarded people are usually able to do simple practical work, if the tasks are carefully structured and skilled supervision is provided. Generally, however, such people are fully mobile and physically active and the majority show evidence of social development in their ability to establish contact, to communicate with others, and to engage in simple social activities. Discrepant profiles of abilities are common in this group, with some individuals achieving higher levels in visuo-spatial skills than in tasks dependent on language, while others are markedly clumsy but enjoy social interaction and simple conversation. The level of development of language is variable: some of those affected can take part in simple conversations while others have only enough language to communicate their basic needs. Some never learn to use language, though they may understand simple instructions and may learn to use manual signs to compensate to some extent for their speech disabilities. An organic etiology can be identified in the majority of moderately mentally retarded people. Childhood autism or other pervasive developmental disorders are present in a substantial minority, and have a major effect upon the clinical picture and the type of management needed. Epilepsy, and neurological and physical disabilities are also common, 178 although most moderately retarded people are able to walk without assistance.

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