Physician’s assistants and nurse practitioners are midlevel practitioners, meaning that their responsibilities lie somewhere between those of a nurse and those of a physician. Midlevel practitioners assess medical problems, order tests, and recommend treatments. They work with varying degrees of independence, depending on state laws, the medical problems they care for, and their relationship with the other health care providers.     Midlevel practitioners often have specialized training in one area of medical care, including care of people with HIV infection. They are especially valuable in highly specialized areas of medical care because they have often acquired, through training and experience, an expertise not usually found among physicians who care for people with many different diseases. Many comprehensive care programs for people with HIV infection rely heavily on midlevel practitioners.     Physician’s assistants have two years of specialized training, must pass a board exam every six years, are required to have at least one hundred hours of postgraduate education every two years, and are licensed. Physician’s assistants must practice under the supervision of a physician. They may prescribe drugs in some states but not in others.     Nurse practitioners are registered nurses who have nine additional months of advanced training or have received a master’s degree in nursing. Nurse practitioners do much of what physician’s assistants do, but they are not required to serve under direct supervision of a licensed physician.*164\191\2*

It is hard to tell how common such problems are, since there are biases in all studies. Children with psycho-social problems are far more likely to be identified and included in studies than those without problems. Also, children with continuing seizures are more likely to be identified than the 80 percent whose seizures are completely controlled or outgrown.Whatever the true incidence, such problems are sufficiently common that they should be monitored. Problems with learning and even with retardation are usually caused by brain injury rather than the seizures themselves. Learning problems, as well as hyperactivity and behavioral problems, may be caused by medication. Close monitoring of your child’s school performance should be your responsibility and if you have concerns, you should discuss them with your physician.Depression is not uncommon in children. It may be hard to identify. Symptoms of depression include sleep disturbances, school problems, fatigue or listlessness, lack of enthusiasm, easy crying, and irritability, among others. Depression can be due to medication, particularly phe-nobarbital. But depression also may be a consequence of a child’s or family’s reaction to the seizures and their treatment. If you are concerned about these problems, you should discuss them with your doctor. Early identification of depression can lead to earlier help.In general, psycho-social problems are sufficiently common in children with epilepsy that families and physicians should be alert to them. Preventive discussions with members of the family and the school may avoid problems and permit early identification. Psycho-social problems should not be allowed to become a handicap.*216\208\8*

Another consequence of thrombophlebitis, especially in the deep veins of the legs, is damage of the valves in the affected veins. These valves prevent backward (downward) flow of blood in the veins when you stand up. Because veins do not have muscle in their walls to help “pump” the blood back to the heart, they are affected by gravity and the gentle squeezing provided by the surrounding skeletal muscle. To improve the flow of blood back to the heart, veins have valves. These valves work like safety cogs on mountain trains, which prevent them from rolling backward if they lose power while climbing up a steep mountain slope. In much the same way, the valves in the veins prevent the blood from “flowing back” as it is gradually pushed uphill toward the heart.When the valves in the veins do not work properly, several problems can occur. The pooling of blood can lead to ballooning of the vein, resulting in varicose veins. In some cases the pooling gets so bad that the leg swells. This condition is commonly referred to as venous insufficiency. With chronic swelling and the associated increase in pressure on the skin, discoloration called stasis pigmentation can develop in some people, and in severe cases, actual skin ulceration can develop.*210\252\8*