EIDON, nº 40 diciembre 2013, 40:25-38 DOI: 10.13184/eidon.40.2013.25-38 Adecuación del esfuerzo terapéutico en los pacientes con alteraciones crónicas de la conciencia José Ramón Ara Callizo Servicio de Neurología, Hospital Universitario Miguel Servet. Zaragoza Los estados de alteración crónica de la conciencia, específicamente el estado vegetativo y el estado de míni
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GraphicSouth Africa is generally sunny and pleasant and the winters are usualy mild. Snow mostly fal s on the high mountain peaks of the Cape and KwaZulu-Natal. The South African seasons are the reverse of those of the Northern Hemisphere. Despite regional climate differences, South Africa generally enjoys a mild climate throughout the year. The areas with the most significant differences in climate are the Western Cape with its Mediterranean climate (warm, dry summers and wet, cold winters), the northern areas (hot summer days and frequent thunderstorms) and the coastal areas of KwaZulu-Natal (subtropical, all year round beach weather and high humidity). Average temperatures in South Africa can vary widely: Summer: October to March, 15° C (60° F) to 35 ° C (96° F). Winter: April to September, below 0° C (32° F) to 20° C South Africa has one of the world’s highest daily sunshine rates and visitors, who are not used to the sun, should take extra care, especial y between 11:00 and 15:00. Sunscreen lotion with a protection factor of at least 15 is advised against the high UV rating of the South African sun. A variety of good quality products are available throughout the country. For summer months, lightweight (cottons and linens), short-sleeved clothes are best, although a light jersey might be needed for the cooler evenings. Umbrellas and raincoats are essential for the summers and the Western Cape winters. Warm clothes will be needed for the winter months. The SA monetary unit is the South African Rand (R) and it equals 100 cents. The international symbol of the Rand is ZAR. Bank notes are issued in denominations of: R 200 (orange), R 100 (purple), R 50 (pink), R 20 (brown), R 10 (green), Coins are issued in denominations of: R 5 (silver), R 2 (silver), R 1 (silver), 50 c (copper), 20 c (copper), 10 c (copper), 5 c Before leaving the customs hall, duty has to be paid on items that are over Cigarettes 200 per/p, Cigars 20 per/p, Cigarette or pipe tobacco 250g per/p, Wine 2 litres per/p, Spirits or other alcoholic beverages 1 litre per/p, Perfume 50 ml per/p Eau de Toilette 250 ml per/p, Gifts, souvenirs and all other goods R 500, A flat rate of 20 percent is charged on gifts in excess of Important note: No person under 18 is entitled to a tobacco or Duty-free goods can be bought at Johannesburg, Cape Town and Durban Drivers must be in possession of a valid driver’s permit containing a photograph and the signature of the holder and it should be printed in English. Should a permit not comply with these requirements, an International Driver’s Permit wil be needed. South Africa has adopted the The legal alcohol limit for drivers is 0,05%. This law is very strictly enforced. Penalties are severe and could even include a prison sentence. Alcohol is not served or sold to any person under 18 years and may not be consumed public places. Al habit-forming drugs are banned in South Africa and prescriptions are necessary for al Schedule 3 to 7 drugs. Al Schedule 8 The Automobile Association (AA) is South Africa’s biggest motoring club and will provide assistance to tourists who experience problems with their vehicles if they can produce a membership card of a motoring association affiliated to the AA through the AIT (Alliance Internationale de Tourisme) or FIA (Fédération de l’Automobile). The emergency number of the AA The wearing of seatbelts is compulsory and strictly enforced by law. South Africans drive on the left-hand side of the road. The speed limit is 60 km/h (35 mph) in urban areas, unless indicated otherwise. The speed limit on national roads is 120 km/h (75 mph), unless indicated otherwise and 100 km/h (60 mph) on rural roads. Road signs are in English and distances Toll fees are payable on some South African roads. The amounts charged vary widely and visitors are advised to have enough cash ready. SA electricity supply: 220/230 volts AC 50 Hz. Exceptions: Pretoria (230 V) and Port Elizabeth (200/250 V). Most plugs have three round pins but some plugs with two smaller pins are also found on appliances. Adapters can be purchased but may be in short supply. US-made appliances may need a transformer, which is available in South Africa. International plugs sold in other countries do not work in South Africa, Plugs are obtainable at general supermarkets, hardware and luggage stores Visitors entering South Africa are required to be in possession of a valid passport. Most passport holders need visas to enter South Africa, but some countries are exempt from this arrangement. Check with a travel agent or the nearest SA representative to determine if one is needed. Visas should be obtained in the tourist’s own country and wil not be issued in South Africa. Visas are issued free of charge. A multiple-entry visa is needed if visitors intend to travel to and from neighbouring countries during the time in which the visa is valid. Upon arrival, visitors need to present proof that they have enough money to support themselves and need to be in possession of a valid return ticket or enough money to purchase a return Please ensure that your passport is valid for six months after your visit to South Africa, and that there are two blank pages available for stamps, to All major credit cards such as American Express, Diner’s Club, Visa and MasterCard are widely accepted. Visa and MasterCard are the most popular and cause the least problems. American Express and Diner's Club are not accepted in smaller towns due to high commission fees charged to the retailers. Money can also be withdrawn from these cards at various cash There is a limit of R500.00 per person (local currency) allowed when entering South Africa. There are no limits to the amount of cash (in foreign currency) that visitors can bring into South Africa. However, some countries have limits on the export of bank notes and visitors are therefore advised to convert most of their money to traveller’s cheques. The necessary permit should be obtained from the South African Reserve Bank (the central bank of South Africa) if visitors wish to leave the country with more than R5 000 in cash in their possession. Import of foreign currency is free, subject to declaration. Export of foreign currency is limited to the amount that the visitor declared upon arrival. For more information, contact any Customs South Africa has a sophisticated banking system that can accommodate al international transactions. Banking hours: Monday - Friday, 9:00 to 15:30 Saturday, 8:30 to 11:00 Automatic teller machines are open 24 hours a day. Automatic Teller Machines are only available in some very small towns, and in the rural areas these facilities may be unavailable. Commercial banking services are available two hours before and two hours after the arrival and departure times of international flights, 24 hours a day. Banks, foreign exchange bureaus and certain hotels accept al major foreign currencies, as do most restaurants,businesses and shops. The best currencies to use would be the US Dol ar, the British Pound and the Euro. Traveller’s cheques can also be exchanged at any commercial bank. Most hotels, shops and businesses also accept traveller’s cheques but a fee may be charged for this service. American Express offices and most hotels also have exchange facilities for guests (we recommend this only in emergencies as the rate of exchange is not favourable). We recommend changing currency at the airports where the rate is favourable and the service is quick - service at banks in smaller towns may be slow. Rennies Foreign Exchange Money Line is a toll-free information line, which operates 24 hours per day, 365 days per year. The number is 0861 11 11 77 for rates and 0860 11 11 77 for general information. A touch-tone telephone or cellular phone is needed to access the system from within ¾ ABSA Bank Limited ¾ First National Bank of Southern Africa Limited ¾ Nedcor Bank Limited ¾ The Standard Bank of South Africa Limited Branches of Foreign Banks in South Africa ¾ Banko Espirito Santo e Comercial de ¾ Lisboa ¾ Banque Française du Commerce Exterieur ¾ Credit Suisse ¾ Deutsche Bank ¾ National Bank of Egypt ¾ Standard Chartered Bank ¾ Swiss Bank Corporation There are numerous filling stations in cities, towns and on principal road routes and most of them are open 24 hours a day. Unleaded fuel is available in South Africa but many cars have not been converted for unleaded fuel. Visitors using rental cars are advised to ascertain if the vehicle has been converted before fil ing up on unleaded fuel. Diesel is also readily available. Fuel cannot be bought with an ordinary credit card and should be paid for either in cash or with a special garage card. Please be aware that fuel attendants are at all filling stations to assist in filling your vehicle. It is common, but optional to give them a smal South Africa offers all the excitement and adventure of the African continent but with health and sanitation standards on a par with that of the developed world. Simple common sense precautions will ensure a healthy journey. Food and beverages served in tourist establishments are prepared and served under hygienic conditions and the tourist runs no greater risk of contracting traveller’s diarrhoea than in the south of Europe. Tap water is safe in all cities and towns. Insect-borne diseases occur as anywhere else in the world. The most important diseases for the tourist to take note of are malaria, limited to a small geographic region, and tick bite fever, limited to rural areas and affecting mainly hikers and adventure tourists. South African private sector health-care facilities compare with the best in the world but visitors are urged to take out travel health insurance prior to departure from their respective home countries. Please remember, for your own safety and peace of mind, it is advisable that you consult a travel health practitioner at least two weeks before visiting any country. The Department of Health of the Government of South Africa abides by World Health Organization (WHO) International Health Regulations. Apart from yel ow fever vaccination, there are NO other compulsory vaccines for travellers to South Africa. However, the following vaccines may be recommended by travel health practitioners: Routine Childhood vaccinations All travellers Tetanus toxoid All travellers. Hepatitis A Adventure tourists going off the beaten track. Hepatitis B Contact-sport players, Health care workers. Typhoi d Sometimes long-term rural residents. Meningococcal meningitis Not necessary. Rabies Sometimes veterinarians, game rangers. NOT for the averag e tourist. Polio Not necessary. Bilharzia (Schistosomiasis) is a microscopic organism found in rivers, streams, pools and dams (both stagnant and flowing) in the northern and eastern areas of the country. Visitors are advised not to swim in unchlorinated pools, dams or rivers in these areas. Any water for consumption other than from a tap should be boiled beforehand. There is no immunisation against Bilharzia and symptoms may only present months Isolated cases do occur in disadvantaged communities. However, these areas are not normal y on the standard tourist itinerary. Vaccination is not a statutory requirement in South Africa. South African tap water is safe to drink, except where indicated otherwise. There is a high incidence of HIV/AIDS in South Africa. It is mainly transmitted through sexual intercourse and every precaution needs to be taken to have safe sex. Condoms are readily available from pharmacies, hospitals, clinics and supermarkets. Medical facilities, including injections and blood transfusions are sophisticated and safe; blood is carefully Malaria is caused by a parasite that requires two different hosts during its lifetime: humans and mosquitoes. It is transmitted to humans by the bite of an infected mosquito. Once inside humans, the parasites move to the liver where they develop. After maturing, they move back into the bloodstream where they invade and multiply inside the red blood cells. The infected red blood cells burst, releasing the parasites back into the bloodstream where A malaria risk, predominantly in the malignant form caused by P. falciparum, exists in certain low-veld regions of the country, namely parts of Limpopo, Mpumalanga and the Maputoland coast part of KwaZulu-Natal. Certain areas in the neighbouring countries of Zimbabwe, Mozambique, Swaziland and Botswana are also malaria areas. The warmer months from October to May are the highest risk periods. SA has an extensive anti- malaria programme that has reduced the incidence of malaria by some 81 The incubation period for malaria can be as short as seven days or as long as several months. The majority of P. falciparum-malaria patients develop symptoms and signs within two weeks from being bitten by an infected Any flu-like illness: Headache, fever, ri gors, malaise, weakness, tiredness, dryness in mouth, muscle or joint pain and even diarrhoea. SHOULD BE CONSIDERED TO BE MALARIA UNTIL PROVEN OTHERWISE. Any person returning from a malaria area, who develops the above- mentioned symptoms, should consult a doctor preferably familiar with Blood tests MUST be done to determine whether the parasite is present. Treatment must start immediately, and a blood smear must be carried out, but please remember: One negative smear does not exclude malaria. Smears must be repeated until malaria or another disease is diagnosed. Malaria attacks can occur up to six months after leaving a malaria area. ¾ In all the risk areas, visitors should take precautionary measures to ¾ Wear long-sleeved clothing, long trousers and socks when outside at ¾ Use PEACEFUL SLEEP containing insect repellent on exposed skin and ¾ Sleep in a room / tent with mosquito screening in good condition and ¾ Burn mosquito coils / mats in the bedroom. ¾ Sleep under an insect-repellent mosquito net. ¾ Children under five years of age ¾ Pregnant women ¾ Immunocompromised people (e.g. people who have had a splenectomy, or is on immune-suppression medication, such as cancer ¾ People who have used prophylaxis for a prolonged basis. Chloroquine resistance occurs and chloroquine on its own is no longer considered effective. Please consult a travel health consultant, doctor or a pharmacist regarding the recommended preventative medication and adhere to the instructions for taking the medication, otherwise it will not be effective. Malaria prophylaxis should be commenced prior to entering the area, for the duration of your stay and for up to four weeks afterwards. One of the popular medicines being used is Malerone. African tick bite fever is a febrile disease transmitted by ticks that have fed on infected dogs, cattle or game. The same measures to avoid mosquito bites need to be taken to avoid or minimise the risk of tick bites in rural and game watching areas. The disease masquerades as a severe flu but is often accompanied by an eschar (tick bite with a scab/necrotic skin), skin rash and or enlarged lymphnodes. It is very rarely fatal, but is very dangerous to the very young, very old and debilitated persons. It is effectively treated with specific antibiotics. There is no vaccine available. A valid Yellow fever vaccination certificat e is required from ALL travellers over one year of age entering South Africa within six days of leaving a country listed as “Yellow Fever- Endemi c” by the WHO. Visitors who come from, travel through, or disembark in these areas, are advised to be inoculated against yellow fever at least ten days before visiting South Yellow fever does not occur in South Africa and the above measures are intended to protect the South African community from the disease being imported. Yellow fever is a viral disease that is transmitted from infected to susceptible people by a mosquito. Yellow fever is endemic to West, Central and East Africa, as wel as South America. South Africa has 11 official languages but English is spoken well by almost all South Africans and visitors will always be able to have their needs met in English. Road signs and official notices are all in English. Information documents and booklets are also available in English, e.g. maps, telephone directories, forms and tourist brochures. Medical services are readily available in South Africa and are sophisticated and safe for visitors to use. Blood is carefully screened before use. Doctors are listed by their surnames, under Medical, in the telephone directories. Major hotels have an arrangement with doctors and dentists to Hospitals are listed under “H” in all telephone directories and indicated with Most medicines are obtainable at pharmacies, and emergency pharmacies are open at night. Visitors are, however, advised to bring any supplies of specialised medicines they may need, with them. Should visitors carry any prescription medicine on them, it would be best to bring along a letter of authorisation from a doctor, since some medicines might be There is no national health scheme and visitors are advised to take out medical travel insurance for the duration of their stay. South Africa’s peak tourist seasons are between October and February and again between March and April. Touris t accommodation is in high demand during these seasons and visitors are advised to book well in advance to Visitors are advised to take basic safety precautions, – much the same as they would in other major cities around the world. Contact the local tourist ¾ DO NOT walk alone at night, especially in unlit streets. ¾ DO NOT draw unnecessary attention to money or jewellery on your ¾ DO NOT be tempted into pavement games or gambling. ¾ DO NOT buy gold, diamonds or other seemingly valuable items offered for sale on the street - they are often stolen or fake. ¾ DO NOT leave your property unattended in a public place. ¾ DO NOT pick up hitchhikers. ¾ DO NOT travel off the beaten track before informing someone and ¾ DO NOT resist when confronted. ¾ DO NOT accept lifts from strangers. ¾ DO NOT venture into the township areas unless you are part of a tour ¾ DO lock valuables in the hotel safe. ¾ DO check your route before leaving the hotel. ¾ DO lock your hotel door at all times, whether you are in the room or ¾ DO lock your car doors at all times and leave your windows closed. ¾ DO listen to the advice of your host or hotel personnel. ¾ DO park in wel -lit areas when going out at night. ¾ DO lock your personal items and luggage in the boot of the car. ¾ DO contact the police immediately after a crime. ¾ DO make use only of reputable taxi companies. -Ask the hotel for help ¾ DO check whom it is when someone knocks on your hotel door. The South African Police Service (SAPS) can be contacted 24 hours a day. Their vehicles are yellow and blue or white and blue and their uniforms are blue. The police emergency telephone number is 10111 and the Police Crime Stop number is 08600 10 111. Larger cities have Tourist Assistance Government has declared war on crime and criminals to ensure a safer and better South Africa for al . New measures instituted by police have already began to show results and some crime statistics are down from previous ¾ Community co-operation has been encouraged to facilitate early ¾ Specialist squads have been established to investigate specific types of crimes and are receiving training from top international agencies. ¾ Policemen are being deployed on horseback and bicycles to increase ¾ Tourism agencies are involved in working groups with police to investigate measures to keep tourists safe. ¾ The private sector has become involved, e.g. by supplying car guards VAT (Value Added Tax) is currently set at 14% and is included in the marked price of goods. Foreign visitors may claim refunds on goods (with a total value exceeding R 250) that they take out of the country. Note that only goods purchased from shops that are authorised under the export- incentive scheme and that display the VAT logo, qualify for the VAT refund. VAT can be claimed at airports and harbours of departures and customs In order to claim the refund, visitors will need: ¾ A foreign passport; ¾ A VAT-refund control sheet, which can be obtained from international airports, harbours, offices of the Receiver of Revenue, or the offices of ¾ The items on which VAT is being reclaimed; ¾ The original tax invoice, containing the following information: ¾ The words “Tax Invoice”; ¾ The amount of VAT charged or a stat ement that the VAT is included in the price, a tax invoice number. The date of invoice of the receipt. ¾ The seller’s VAT registration number. The cost of goods in Rands. The seller’s name and address, a description of the goods bought, and the Goods consumed or services made use of in South Africa do not qualify for a tax refund. VAT Refund Administrati on offices or Custom Offices are situated at Cape Town, Durban and Johannesburg International Airports, as wel as at Cape Town, Durban, Port Elizabeth and East London Harbours and the Beit Bridge Border Post (Zimbabwe). Refunds are issued by a VAT refund cheque that can be exchanged for foreign currency before leaving the country or that can be deposited in the visitor’s personal bank account. South Africa has a sophisticated telecommunications network. The telephone system is the best developed and has the highest capacity in Africa. Except in remote rural districts, direct dialling connects all centres. Cheaper telephone rates have been instituted from Monday to Friday, 20:00 to 07:00 and Saturday 13:00 until Monday 07:00. The cel ular network in South Africa is well developed and calls can be received almost anywhere. Problems are experienced mostly in the mountainous areas. Cel ular phones are available for hire from most cellular-phone outlets. When using a cellular phone, the dialling code for each area has to be dial ed before punching in the telephone number. The international dialling code for South Africa is +27 but from within South Africa, the +27 should be replaced with 0. Dialling codes should be used when dialling from one metropolitan or municipal area to another. ¾ Police emergency tel: 10111 (Flying Squad) ¾ Police Crime Stop tel: 08600 10 111 ¾ Emergency and Crisis Services: 1022 ¾ Ambulance tel: 10117 (Provincial Ambulance service) ¾ AA breakdown service: 082 16 111 ¾ Electronic Yellow Pages tel: 10118 ¾ Time tel: 1026 ¾ Trunk/Collect Calls tel: 0020 ¾ Phonograms tel: 1028 ¾ Teleconferencing tel: 0020 ¾ Domestic directory enquiries: 1023 International dialling and full telex, telefax and electronic mail facilities are widely available, e.g. at hotels and Postnet outlets. Pay phones can be found in most public places, some operating with phone cards, others with coins. Phone cards can be bought from shops that indicate that they sell these cards. ¾ International Operator tel: 0009 ¾ International Directory tel: 0903 ¾ International direct dial: 09 + the country code. South Africa is two hours ahead of Greenwich Mean Time (GMT), one hour ahead of Central European Winter Time, eight hours behind Australian Eastern Standard Time and seven hours ahead of Eastern Standard Winter Time, USA. There is no daylight saving. There are no time-zone changes between South Africa and its neighbouring countries, or between the nine Restaurants normaly do not include the service charge in the account and it is customary to include an extra amount of 10 to 14 percent as a tip for the waiter, depending on the quality of the service. Some hotels keep a staff-box at reception where tips for the staff can be left; otherwise tips may be given to individual staff members personal y. South Africa has three international airports: Johannesburg International Airport, Durban International Airport and Cape Town International Airport. Of these three, Johannesburg is the largest and most popular. All three have duty-free facilities and bus links with the city centre and the major hotels. Their facilities also include taxi ranks, restaurants, car rental offices, tourist information desks and hotel booking desks. Apart from these, there are several national and smaller airports and airfields. The national airline (SAA) and the other smaller airlines combine to create an excellent air network. Charter companies operate widely. Visitors will be able to rent and pilot light aircraft’s if they can produce a valid pilot’s licence. South Africa has a well-developed rail infrastructure. However travel by train is mostly not recommended for tourists because the system is not geared for it and safety is a concern. Cape Town is the only city with a suburban network but it is not considered safe to use it after dark. There are, however, luxury rail companies th at offer the tourist high levels of comfort and safety, such as Rovos Rail and the Blue Train. An aspect of rail travel that is very popular with visitors is the luxury passenger trips and South Africa has an excellent road infrastructure. The traffic is relatively light, except during peak hours, which sometimes tempts drivers to speed. The accident rate is therefore high, especially during peak holiday seasons. Pedestrians are also apt to jaywalk, even on freeways, and drivers should be careful, especially at night. Some rural roads are not in peak condition but road signs will warn drivers of danger. Another danger on rural roads is the presence of people and animals such as sheep and goats and, in some areas, wild animals. Drivers need to be extremely careful, especially in areas where rural communities are established. There are a few long-distance coach companies that provide transport between cities but visitors need to book well in advance. Information can generally be gained from the city railway station or the company offices. There are a few national car rental companies who have outlets that are very conveniently placed, e.g. at airports. A car can be col ected from one outlet and dropped at another, for a premium. Local firms offer a cheaper but more limited service. A large variety of vehicles are available for rent but vehicle rental in South Africa is relatively expensive. South Africa does not have a well-developed public transport system. All the cities have a municipal bus service, which runs according to an established schedule, but only until a certain time of night. The service is infrequent and even more limited over the weekends and public holidays. Towns do not offer a municipal bus service. There are mainly two types of taxis in South Africa. Metered taxis are more expensive and to be found mainly in the cities although some small towns may have a limited number. They cannot be hailed from the street and must either be ordered by phone or at the taxi ranks, which are scarce. Minibus taxis are the cheapest but also the most uncomfortable. Violence connected with minibus taxis and a relatively high accident rate make this Tap water in South Africa, in major citi es as well as in most game reserves, is purified and 100 percent safe to drink. However, bottled water is also ¾ South Africa operates on the metric system. ¾ Distances are measured in metres and kilometres (1 mile = 1, 621 km). ¾ Weight is measured in grams and kilograms. ¾ Liquids are measured in litres. ¾ Temperature is measured in degrees Celsius (10 ° C = 50 ° F; 20 ° C =
Experimental Neurology 192 (2005) 73 – 78Continuous dopaminergic stimulation reduces risk of motor complicationsFrancesco Bibbiania, Lauren C. Costantinib, Raj Patelb, Thomas N. Chasea,*aExperimental Therapeutic Branch, Building 10, Room 5C103, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD 20892-1406, USAbTitan Pharmaceuticals, Inc., South San Francisco, CA