X7c phasized that in this variant the pain episode is selfNote: See note on Cluster Headache (V-6) arthritis in dogs tramadol buy trental 400 mg cheap. Success in treatment Carotidynia (V-4) may arthritis in dogs meloxicam discount trental 400mg overnight delivery, therefore arthritis pain throughout my body discount trental 400 mg free shipping, be confounded with the natural course of the disease arthritis in neck back and shoulders cheap trental 400mg online. Definition Continuous dull aching pain arthritis neck dizzy spells purchase genuine trental online, sometimes throbbing symptoms of arthritis in back trental 400mg for sale, near Pathology Unknown arthritis in back medicine purchase trental 400mg on line. The nosologic status of these headaches rethe upper portion of the carotid arteries and adjoining mains obscure osteoarthritis definition cheap trental american express. Main Features Prevalence: occurrence unknown, depends somewhat upon the criteria used, probably rather rare. Pain Quality: the pain is constant and dull, should accordingly be categorized, whenever possible, aching or throbbing. There is, however, a tendency for the pain episodes to recur after a symptom-free interval. Intensity: moderate, not very severe; apparently less severe Cluster Headache (V-6) than migraine headache. Definition Precipitating Factors Unilateral, excruciatingly severe attacks of pain, princiMoving the head, swallowing, coughing, etc. The carotid artery may on palpation apSite pear enlarged, pulsating, and tender, and externally apOcular, frontal, temporal areas: considerably less freplied pressure against the common carotid artery may quent in infraorbital area, ipsilateral upper teeth, back of the head, entire hemicranium, neck, or shoulder. Regional musmaximum pain is usually in ocular, retro-ocular, or pePage 80 riocular areas. The side may, however, change (in approximately 15% of the patients), even within a Usual Course given cluster period. Age of Onset: most frequently, Social and Physical Disability headaches start between the ages of 18 and 40. Many patients, nevertheless, Quality: the pain is constant, stabbing, burning, or even manage to do their work between attacks. Patients characteristically pace the floor, bang their heads against the walls, etc. Attacks may skip a day or two Differential Diagnosis or more during the cluster period. Nocturnal attacks are Sinusitis, chronic paroxysmal hemicrania, chronic clustypical. The patients tend to smoke and drink rather ter headache, cluster-tic syndrome, and migraine. Incogenic headache and tic douloureux ought not to tensity: at maximum, excruciatingly severe. Note: Although cluster headache is grouped with migraine and similar disturbances, it is doubtful if vascular Associated Symptoms and Signs disturbances are the primary source of these events, and Usually there is no nausea, but some may occur, probathe second code digit refers to alternative possibilities bly with the more severe attacks or at the peak of atfor the origin of the pain. Ipsilateral miosis or ptosis associated with some attacks; occasionReferences ally they persist after attacks and sometimes permaKudrow, L. Ipsilateral conjunctival injection, lacrimation, Oxford University Press, London, 1980. Relief From ergot preparations, oxygen, corticosteroids, lithium, verapamil, methysergide, etc. Slight ipsilateral ptosis or miosis may occur during attacks, and Definition rarely also edema of the upper lid. Photophobia and Multiple daily attacks of severe to excruciating unilateral more rarely phonophobia are occasionally present during head pain, more frequently occurring in females than in attacks. Tinnitus, hypersensitivity in the area of the ophmales, and principally in ocular, frontal, and temporal thalmic division of the Vth cranial nerve, bradycardia, areas by day and night, usually accompanied by ipsilatand extrasystoles occur in some patients during severe eral lacrimation, conjunctival injection, and nasal stuffiattacks. Chronicity denotes an unremitting stage Laboratory Findings Increased nasal secretion and lacrimation (and partly that has lasted more than a year. Ocular, frontal, and temporal areas; occasionally the infraorbital, aural, mastoid, occipital, and nuchal areas. Relief Pain may also be felt in the ipsilateral part of the neck, Immediate, absolute, and permanent from continuous arm, and upper part of the chest. Usual Course System the chronic course may be primary chronic or it may Uncertain. Once chronic, the headand autonomic nervous systems are implicated during ache usually remains chronic. Age of Onset: average around 35 (more than 90% completely during the greater part of pregnancy, to reapare aged 11-60). Characteristically, there is marked fluctuation in the severity of attacks and their frequency. A period of Social and Physical Disability 1-2 moderate attacks per day (occasionally even barely Considerable during the nontreated stage, including suinoticeable) is followed by a period with frequent, severe cidal thoughts. Not infrequently, the patients are Essential Features awakened by the nocturnal attacks. Some patients walk Unremitting presence for at least one year of relatively around during attacks, others sit quietly, still others curl shortlasting repetitive unilateral attacks, associated with up in bed. Intensity: at maximum, the pain attacks are ipsilateral autonomic symptoms and signs. Absolute excruciatingly severe, but there is marked fluctuation in response to indomethacin. Sinusitis, chronic cluster headAttacks may be precipitated in the occasional patient ache, cluster headache, cluster-tic syndrome, hemicrania (around 10%) by bending or rotating the head, particucontinua. The features of the remitting form are the same as for the the differences mainly concern the temporal pattern. Accordingly, for Definition other details, the section on the unremitting variety (V Bouts of excruciatingly severe unilateral pain, usually in 7. Absolute relief from indomales, principally in the ocular, frontal, and temporal methacin. Definition Attacks of unilateral severe or excruciating headache, Main Features occurring more frequently in females than in males, in the chronic form may be primary chronic. The chronic form of cluster headache is more rare period exceeds 12 months, the chronic, unremitting stage than the episodic form (approximately 1:8); the diagnohas been reached). The remitting stage may seemingly sis requires at least two or more attacks per week over a go on indefinitely. Main Features the remitting form seems to be more rare than the unRelief remitting. This is partly due to the not infrequent conthe same measures are effective as for cluster headache, version of the remitting form to the chronic one. Relief Immediate, absolute, and permanent effect of indoEssential Features methacin. The unremitting presence of unilateral, relatively shortlasting, and excruciatingly severe attacks for at least one year. Autonomic symptoms and signs on the symptoEssential Features Frequently occurring, relatively shortlasting attacks of matic side. Absolute reSinusitis, chronic paroxysmal hemicrania, cluster headsponse to indomethacin. Definition Relief the coexistence of the features of cluster headache and the most successful treatment appears to be the use of tic douloureux (trigeminal neuralgia), whether the two carbamazepine or baclofen, or both, rather than the conentities occur concurrently or separated in time. Site Usual Course Pain limited to the head and face; the two parts of the the attacks of cluster headache and tic douloureux may syndrome generally appear on the same side. The cluster start concurrently, or the attacks of tic douloureux may headache element is located in the ocular area as is usual precede those of cluster headache. Quality: a combination of the following: cluster headache Essential Features pain which includes agonizingly severe, longlasting, Coexistence of features of cluster headache and tic douburning or throbbing pain, and, concurrently or sepaloureux. These two components of the syndrome may rated in time, sharp, agonizing, electric shock-like stabs appear simultaneously or separated in time. The attack is often prescans may be necessary to rule out tumors in the cerecipitated by speaking, swallowing, washing the face, or bello-pontine region. This happens concurrently with, or temporally separated from, the features of cluster headache. X8h 10-120 minutes, frequently occurring at night, and characteristically occurring in cluster periods lasting 4-8 References weeks, once or twice a year, but at times entering a more Green, M. Page 84 Post-traumatic Headache (V-10) well, and soft-tissue lesions from cervical sprain syndrome. Definition Continuous or nearly continuous diffusely distributed Differential Diagnosis the word concussion is to be avoided because of lack of head pain associated with personality changes involving agreement in definition of term. Confusion with possible irritability, loss of concentration ability, dizziness, visual accompanying depression, post-traumatic stress disoraccommodation problems, change in tolerance to ethyl der, and other accompanying or complicating psychiatric alcohol, loss of libido, and depression, and with or withorganic brain dysfunction disorders is to be avoided. The spouse or family is much more likely to System be aware of the irritability of the victim. Highly of focal neurologic abnormalities, convulsions, or orvarying frequency even in the same person, usually of ganic brain syndrome, indefinite. During one period, the pain may be situated in one area, only to move to another one Social and Physical Disabilities during another period. Usually unilateral at a given time; At worst, left untreated, loss of gainful employment and in the rare case, bilateral. When associated with hemifamily and social status to the point of complete destitucrania continua, etc. In the preheadache phase of chronic paroxysmal Pathology hemicrania, it may appear on the side opposite that of Disruption of central axons and boutons due to angular the pain. Prevalence: probably common, since it appears both on its own and in many combinations. Frequently Social and Physical Disability associated with various types of unilateral headache, In periods with accumulated jabs, the patient may be such as chronic paroxysmal hemicrania, cluster transitorily handicapped. Since several of the headache forms with which it is combined have a clear Essential Features female preponderance (see above), it is likely that within Ultrashort paroxysms in the cephalic area, in multiple some of them there is a female preponderance also of Jabs sites, with no fixed location, and with very varying and Jolts. Pain Quality: Sharp, shortlasting, superficial, frequency, often occurring in bouts. Under such circumstances jabs and jolts seem to increase at the time of the symptomatic Differential Diagnosis episodes and in the related areas. Arteritis) (V-12) Precipitating Factors Neck movements, change of body position, etc. UnderDefinition lying mechanism: occasionally perhaps, mechanical Unilateral or bilateral headache, mainly continuous with irritation from enlarged lymph nodes. In some patients there is a good, incomplete effect from indomethacin (150 mg a day). Site the erratic spontaneous course of this headache makes the pain is maximal in the temporal area on one or both the assessment of drug therapy a most difficult task. Usual Course System Sporadic paroxysms, or bouts with accumulation of Vascular system. Time Pattern: Considerable during the acute stage, and in the case of usually a rather protracted course if untreated. Precipitating Factors Mastication may produce an effect of intermittent clauEssential Features dication. Acute pain, not infrequently unilateral, in the temporal area in an elderly person, with tenderness and irregular Associated Symptoms and Signs shape of the ipsilateral temporal artery and, usually, the temporal artery on the symptomatic side may be raised erythrocyte sedimentation rate. No deficiency signs from the Vth cranial nerve at Other acute unilateral headaches, such as the Tolosarest. Relapse may occur in the early May be frontal, occipital, or global, and not infrequently stage. Impaired chewing in late phase of meals-probably due to Main Features masticatory muscle ischemia, caused by the same disPrevalence: probably rare. Time Pattern: onset is usually insidious, but may occur after a mild trauma, Post-Dural Puncture Headache (V-14) sneezing, sudden strain, or orgasm. Individual headache episodes usually last as long as the patient remains in the upright position. Usual Course Most cases improve spontaneously after a few weeks Main Features and within three months. In Prevalence: occurs in 15-30% of patients who have been some cases, the headache may last for years. Age of Onset: relatively Relief reduced frequency under 13 years and over 60 years. Treatment: Epidural blood patch, epidural Pain Quality: usually dull or aching, but may be throbsaline infusion, high dose corticosteroids have been used bing. Precipitating Factors: the pain is positional, markwith success in a few patients. InComplications tensity: from mild to rather severe, probably never exUsually none. Time Pattern: headache usually starts within Social and Physical Disability 48 hours after lumbar puncture, but it may be delayed up Inability to sit or stay in the upright position because of to 12 days. Lumbar isotope cisternography whereas blurred vision, tinnitus, and vomiting occur has given indications of a leakage through a nerve root more rarely. Treatment: Intravenous caffeine sodium References benzoate, epidural blood patch, epidural saline infusion, Fernandez, E. Page 88 Social and Physical Disability Pattern: the chronic, nonremitting stage so typical of the patient may be unable to sit or stay in the upright this headache is frequently preceded by a remitting stage position because of the pain. During the remitting stage, there may be repetitive, sepaPathology rate attacks lasting hours or days. Intensity: usually moderate to severe, with rather marked fluctuations; patients are usually able to cope with daily Essential Features chores. Precipitating Factors Differential Diagnosis Attacks or exacerbations are not known to be precipiMeningitis (bacterial or aseptic) occurring after lumbar tated mechanically. Associated Symptoms and Signs Photophobia, phonophobia, nausea, conjunctival injecCode tion, and lacrimation (the last two on the symptomatic 023. X l b side) occur in up to half the cases, but these symptoms and signs generally are mild and usually only become References Tourtellotte, W. Usual Course the unremitting course may apparently continue for a long time, perhaps indefinitely. Once the chronic stage Hemicrania Continua (V-15) has been reached, no exceptions to this rule have been observed so far. Definition Unilateral dull pain, occasionally throbbing, initially Complications intermittent but later frequently a continuous headache In a few instances, suicide attempts due to headache. Usually, there are some autonomic Social and Physical Disability symptoms and signs. When atypical Site features occur or when the indomethacin effect is inthe headache is strictly unilateral, and in general withcomplete or fading, such a possibility should be susout change of side. Essential Features System Remitting or nonremitting unilateral headache, occurring Unknown. Prevalence: not known, probably not frequent but may Absolute and permanent indomethacin effect. The other unilateral headache with absolute indomethaAge of Onset: mean about 35, range 11-57 years of age. Considerable fluctuations in pain, even dur(in the remitting stage of hemicrania continua); cervicoing the late, nonremitting stage. Because the structures of the two systems differ significantly, correspondence is often not easy to determine or is definitely not available. Differential diagnosis from local conditions (see above) and general conditions. Definition Signs Pain following trauma in the region of a calcified styloCarotid bruit, transient ischemic episodes. Benign, intractable if styloid process not excised or fractured, partial relief from stellate ganglion local anesMain Features thetic infiltration, and acetylsalicylic acid. Prevalence: among patients with calcified stylohyoid ligament and history of trauma to mandible and/or neck. Start: evoked by swallowing, opening mandible, turning head toward pain and down, with palpation of stylohyoid Social and Physical Disability ligament. Pain Calcified stylohyoid ligament, carotid-external carotid seemingly identical, may be triggered by neck movebranch arteritis. Time Pattern: pain episodes are of greatly Summary of Essential Features and Diagnostic Crivarying duration, from hours to weeks, even intrainditeria vidually, the usual duration being one to a few days. The Presence of calcified stylohyoid ligament, tenderness of varying duration of attacks is a characteristic feature of superficial vessels, history of trauma.
Decits in these various functions arthritis in back causes buy generic trental, the dysexecutive syndrome arthritis in fingers surgery cheap trental 400 mg without prescription, are typically seen with lateral prefrontal cortex lesions arthritis names best buy trental. Cross References Attention; Frontal lobe syndromes Dysgeusia Dysgeusia is a complaint of distorted taste perception arthritis knobby fingers generic 400mg trental. It may occur along with anosmia as a feature of upper respiratory tract infections and has also been described with various drug therapies rheumatoid arthritis knee icd 9 buy cheap trental 400mg, in psychiatric diseases rheumatoid arthritis and eyes purchase 400mg trental mastercard, and as a feature of zinc deciency arthritis pain keeps me up at night trental 400 mg line. The term may be qualied to describe a number of other syndromes of excessive movement arthritis in neck solutions buy discount trental on-line. Cross Reference Alexia Dysmentia the term dysmentia has been suggested as an alternative to dementia, to emphasize the possibility of treating and preventing cognitive decline. Cross Reference Dementia Dysmetria Dysmetria, or past-pointing, is a disturbance in the control of range of movement in voluntary muscular action and is one feature of the impaired checking response seen in cerebellar lesions (especially cerebellar hemisphere lesions). Dysmetria may also be evident in saccadic eye movements: hypometria (undershoot) is common in parkinsonism; hypermetria (overshoot) is more typical of cerebellar disease (lesions of dorsal vermis and fastigial nuclei). In cerebellar disorders, dysmetria reects the asynergia of coordinated muscular contraction. Cross References Asynergia; Cerebellar syndromes; Dysdiadochokinesia; Parkinsonism; Rebound phenomenon; Saccades Dysmorphopsia the term dysmorphopsia has been proposed for impaired vision for shapes, a visual recognition defect in which visual acuity, colour vision, tactile recognition, and visually guided reaching movements are intact. These phenomena have been associated with bilateral lateral occipital cortical damage. Dysphagia of neurological origin may be due to pathology occurring anywhere from cerebral cortex to muscle. Neurological control of swallowing is bilaterally represented and so unilateral upper motor neurone lesions may cause only transient problems. Poststroke dysphagia is common, but there is evidence of cortical reorganization (neuroplasticity) underpinning recovery. Dysphagia of neurological origin may be accompanied by dysphonia, palatal droop, and depressed or exaggerated gag reex. Cross References Aphasia Dysphonia Dysphonia is a disorder of the volume, pitch, or quality of the voice resulting from dysfunction of the larynx, i. Hence this is a motor speech disorder and could be considered as a dysarthria if of neurological origin. Flaccid dysphonia, due to superior laryngeal nerve or vagus nerve (recurrent laryngeal nerve) palsy, bulbar palsy. Cross References Aphonia; Bulbar palsy; Diplophonia; Dysarthria; Dystonia; Hypophonia; Vocal tremor, Voice tremor Dyspraxia Dyspraxia is difculty or impairment in the performance of a voluntary motor act despite an intact motor system and level of consciousness. The severity of dystonia may be reduced by sensory tricks (geste antagoniste), using tactile or proprioceptive stimuli to lessen or eliminate posturing; this feature is unique to dystonia. Dystonia may develop after muscle fatiguing activity, and patients with focal dystonias show more rapid fatigue than normals. The genetic characterization of various dystonic syndromes may facilitate understanding of pathogenesis. Other treatments which are sometimes helpful include anticholinergics, dopamine antagonists, dopamine agonists, and baclofen. Drug-induced dystonia following antipsychotic, antiemetic, or antidepressant drugs is often relieved within 20 min by intramuscular biperiden (5 mg) or procyclidine (5 mg). Surgery for dystonia using deep brain stimulation is still at the experimental stage. Patients are asked to clap: those with neglect perform one-handed motions which stop at the midline. Hemiplegic patients without neglect reach across the midline and clap against their plegic hand. This may be observed as a feature of apraxic syndromes such as corticobasal degeneration, as a complex motor tic in Tourette syndrome, and in frontal lobe disorders (imitation behaviour). Synaesthesia may be linked to eidetic memory; synaesthesia being used as a mnemonic aid. Patients 126 Emotionalism, Emotional Lability E may develop oculopalatal myoclonus months to years after the onset of the ocular motility problem. Sometimes other psychiatric features may be present, particularly if the delusions are part of a psychotic illness such as schizophrenia or depressive psychosis. Clinical examination may sometimes show evidence of skin picking, scratching, or dermatitis caused by repeated use of antiseptics. Treatment should be aimed at the underlying condition if appropriate; if the delusion is isolated, antipsychotics such as pimozide may be tried. A distinction may be drawn between the occurrence of these phenomena spontaneously or without motivation, or in situations which although funny or sad are not particularly so. Also, a distinction may be made between such phenomena when there is congruence of mood and affect, sometimes labelled with terms such as moria or witzelsucht. The neurobehavioural state of emotional lability reects frontal lobe (especially orbitofrontal) lesions, often vascular in origin, and may coexist with disinhibited behaviour. Cross References Delirium; Disinhibition; Frontal lobe syndromes; Moria; Pathological crying, Pathological laughter; Pseudobulbar palsy; Witzelsucht Emposthotonos Emposthotonos is an abnormal posture consisting of exion of the head on the trunk and the trunk on the knees, sometimes with exion of the limbs (cf. Cross References Opisthotonos; Seizures; Spasm Encephalopathy Encephalopathy is a general term referring to any acute or chronic diffuse disturbance of brain function. Characteristically it is used to describe an altered level of consciousness, which may range from drowsiness to a failure of selective attention, to hypervigilance; with or without: disordered perception, memory. Although the term encephalopathy is sometimes reserved for metabolic causes of diffuse brain dysfunction, this usage is not universal. Enophthalmos may also occur in dehydration (probably the most common cause), orbital trauma. The temptation to dismiss such bizarre symptoms as functional should be resisted, since environmental tilt is presumed to reect damage to connections between cerebellar and central vestibular-otolith pathways. This may be not only due to a blocked nasolacrimal duct, or irritation to the cornea causing increased lacrimation, but it may also be neurological in origin. Lacrimation is also a feature of trigeminal autonomic cephalalgias such as cluster headache. Cross References Cover tests; Exophoria; Heterophoria Esotropia Esotropia is a variety of heterotropia in which there is manifest inward turning of the visual axis of one eye; the term is synonymous with convergent strabismus. It may be demonstrated using the cover test as an outward movement of the eye which is forced to assume xation by occlusion of the other eye. With lateral rectus muscle paralysis, the eyes are esotropic or crossed on attempted lateral gaze towards the paralyzed side, but the images are uncrossed. Cross References Amblyopia; Cover tests; Diplopia; Exotropia; Heterotropia; Nystagmus Eutonia Kinnier Wilson used this term to describe an emotional lack of concern associated with the dementia of multiple sclerosis. Ewart Phenomenon this is the elevation of ptotic eyelid on swallowing, a synkinetic movement. Cross References Ptosis; Synkinesia, Synkinesis 130 Extinction E Exophoria Exophoria is a variety of heterophoria in which there is a tendency for the visual axes to deviate outward (latent divergent strabismus). Exophoria may occur in individuals with myopia and may be physiological in many subjects because of the alignment of the orbits. Cross References Cover tests; Esophoria; Heterophoria Exophthalmos Exophthalmos is forward displacement of the eyeball. Cross References Lid retraction; Proptosis Exosomaesthesia the sensory disturbance associated with parietal lobe lesions may occasionally lead the patient to refer the source of a stimulus to some point outside the body, exosomaesthesia. Exotropia Exotropia is a variety of heterotropia in which there is manifest outward turning of the visual axis of an eye; the term is synonymous with divergent strabismus. It may be demonstrated using the cover test as an inward movement of the eye which is forced to assume xation by occlusion of the other eye. When the medial rectus muscle is paralyzed, the eyes are exotropic (walleyed) on attempted lateral gaze towards the paralyzed side, and the images are crossed. It is important to show that the patient responds appropriately to each hand being touched individually, but then neglects one side when both are touched simultaneously. More subtle defects may be tested using simultaneous bilateral heterologous (asymmetrical) stimuli, although it has been shown that some normal individuals may show extinction in this situation. A motor form of extinction has been postulated, manifesting as increased limb akinesia when the contralateral limb is used simultaneously. The presence of extinction is one of the behavioural manifestations of neglect and most usually follows non-dominant (right) hemisphere (parietal lobe) lesions. There is evidence for physiological interhemispheric rivalry or competition in detecting stimuli from both hemields, which may account for the emergence of extinction following brain injury. Neural consequences of competing stimuli in both visual hemields: a physiological basis for visual extinction. Clinically there is no visible contraction of orbicularis oculi, which distinguishes eyelid apraxia from blepharospasm (however, perhaps paradoxically, the majority of cases of eyelid apraxia occur in association with blepharospasm). The underlying mechanisms may be heterogeneous, including involuntary inhibition of levator palpebrae superioris. Botulinum toxin A injections improve apraxia of eyelid opening without overt blepharospasm associated with neurodegenerative diseases. Volitional paresis without emotional paresis may occur when corticobulbar bres are interrupted (precentral gyrus, internal capsule, cerebral peduncle, upper pons). Depending on the precise location of the facial nerve injury, there may also be paralysis of the stapedius muscle in the middle ear, causing sounds to seem abnormally loud (especially low tones: hyperacusis), and impairment of taste sensation on the anterior two-thirds of the tongue if the chorda tympani is affected (ageusia, hypogeusia). Lesions within the facial canal distal to the meatal segment cause both hyperacusis and ageusia; lesions in the facial canal between the nerve to stapedius and the chorda tympani cause ageusia but no hyperacusis; lesions distal to the chorda tympani cause neither ageusia nor hyperacusis. Lesions of the cerebellopontine angle cause ipsilateral hearing impairment and corneal reex depression (afferent limb of reex arc affected) in addition to facial weakness. There is also a sensory branch to the posterior wall of the external auditory canal which may be affected resulting in local hypoaesthesia (Hitselberg sign). In primary disorders of muscle the pattern of weakness and family history may suggest the diagnosis. Emotional and nonemotional facial behaviour in patients with unilateral brain damage. Emotional facial paresis in temporal lobe epilepsy: its prevalence and lateralizing value. Clinically, facilitation may be demonstrated by the appearance of tendon reexes which are absent at rest after prolonged (ca. The classic example, and probably the most frequently observed, is abducens nerve palsy (unilateral or bilateral) in the context of raised intracranial pressure, presumed to result from stretching of the nerve over the ridge of the petrous temporal bone. Fasciculations may also be induced by lightly tapping over a partially denervated muscle belly. The term was formerly used synonymously with brillation, but the latter term is now reserved for contraction of a single muscle bre or a group of bres smaller than a motor unit. Persistent fasciculations most usually reect a pathological process involving the lower motor neurones in the anterior (ventral) horn of the spinal cord and/or in brainstem motor nuclei, typically motor neurone disease (in which cramps are an early associated symptom). However, fasciculations are not pathognomonic of lower motor neurone pathology since they can on rare occasions be seen with upper motor neurone pathology. The pathophysiological mechanism of fasciculations is thought to be spontaneous discharge from motor nerves, but the site of origin of this discharge is uncertain. Although ectopic neural discharge from anywhere along the lower motor neurone from cell body to nerve terminal could produce fasciculation, the commonly encountered assumption that this originates from the anterior horn cell body is not entirely supported by the available evidence, which points to an additional, more distal, origin in the motor axons. Denervation of muscle bres may lead to nerve bre sprouting (axonal and collateral) and enlargement of motor units which makes fasciculations more obvious clinically. Cross Reference Micrographia Fatigue the term fatigue may be used in different contexts to refer to both a sign and a symptom. The sign of fatigue, also known as peripheral fatigue, consists of a reduction in muscle strength or endurance with repeated muscular contraction. This most characteristically occurs in disorders of neuromuscular junction transmission. In myasthenia gravis, fatigue may be elicited in the extraocular muscles by prolonged upgaze causing eyelid drooping; in bulbar muscles by prolonged counting or speech causing hypophonia; and in limb muscles by repeated contraction, especially of proximal muscles. Fatigue as a symptom, or central fatigue, is an enhanced perception of effort and limited endurance in sustained physical and mental activities. Current treatment is symptomatic (amantadine, modafanil, 3,4-diaminopyridine) and rehabilitative (graded exercise). Fatigue may be evaluated with various instruments, such as the Krupp Fatigue Severity Score. A similar phenomenon may be observed if the patient is pulled backwards (retropulsion).
Visual: Occipital epileptic focus causing visual It usually consist of brief myoclonic jerks of the hallucinations arthritis in the knee at 30 purchase 400mg trental with amex. Psychomotor: silent/oral reading and may progress to generalised i Seizure manifests as alteration of mood arthritis foundation neck exercises trental 400mg overnight delivery, tonic clonic convulsion arthritis in dogs paracetamol generic 400 mg trental with mastercard. It is a common form of seizure to produce both *Catamenial epilepsy and epilepsy in concert with sleep partial and secondary seizure treating arthritis joint pain discount trental 400mg visa. Simple partial temporal lobe seizures produce Note: *Associated with menstrual cycle inflammatory arthritis in dogs cheap 400mg trental with mastercard. Automatic movements (lip smacking rheumatoid arthritis unilateral 400 mg trental free shipping, swallowIn petit mal epilepsy arthritis in dogs diet 400mg trental sale, bilateral synchronous spike ing) arthritis names buy generic trental 400 mg on line. Change in the pattern of epilepsy in a known Post-ictal phase a few minutes to hours epileptic. Keep a padded gag or rolled handkerchief between the teeth to prevent tongue bite. During the change to new drug, the initial drug may Immediate Treatment be gradually reduced. Absence seizure in childhood carries good prognosis Precipitating Factors for successful drug withdrawal. To withdraw anticonvulsants in adults is to decrease the dose by 10% every four weeks for carbamazepine, 1. Hyperglycaemia (Nonketotic hyperosmolar coma) of freedom from seizure (Driving is allowed after 2 3. Abrupt withdrawal of antiepileptic drugs in a known Surgery epileptic patient Temporal lobectomy and lesionectomy can be done. Cerebrovascular disease due to venous thrombosis Hemispherectomy and Stereotactic radio-surgery 3. It is defined as a state in which the patient suffers a series of seizures without fully recovering consciousComplications ness between these seizures. The diet before conception should contain adequate inj Phenytoin 20 mg/kg as loading dose, followed amounts of folate. Wait for 15-20 min, if seizure continues give inj monotherapy should be made if possible. If the seizures are still uncontrolled, additional against tonic-clonic, myoclonic, absence, or complex dose of 5-10 mg/kg may be given. In some patients continous Diazepam infusion is toring should be used if necessary. Avoid polytherapy, especially the combination of Epilepsy in Pregnant Women valproate, carbamazepine, and phenobarbital. In cases of valproate treatment, avoid high plasma Guidelines for Counseling Women with Epilepsy levels of valproate. It is characterised by non-physiological events such as progression of twitching from one hand to the other without spread to subjacent ipsilateral face or leg area, twitching of all four extremities without loss of consciousness. It is seen mostly in adolescent girls who have sexual overtones, with pelvic thrusting or genital manipulation. There is no change in the level of serum prolactin (Usually rise during a 30 minutes postictal period in tonic clonic and complex partial seizure). The patient having pseudoseizure will avoid injury by moving away from wall or bed edge during motor 7. Rhabdomyomas of the myocardium All the neurocutaneous syndromes are inherited as autosomal 7. Angiomyomas of the kidneys, liver, pancreas, and dominant except ataxia telangiectasia which is inherited as adrenals autosomal recessive. Cerebrovascular Disorders Von Hippel Lindau Syndrome Inherited as autosomal dominant and the affected Stroke chromosome is 3. Retinal, cerebellar, and spinal haemangioblastoma of vascular pathologic processes which manifest either 2. Embolism from major arteries (aorta, internal tent neurological deficit which does not progress carotid artery, vertebral arteries) beyond 96 hours. Intracerebral (in the presence of hypertension) neurological deficit completely resolves within a b. Frontal pole and a strip of cortex for about 2 cm cranial nerve involvement, with unilateral or bilateral along superolateral surface of frontal lobe hemiplegia. It also supplies cerebellum, medulla, pons, mid Stuttering Hemiplegia brain, subthalamus, and thalamus. First segment: From the site of origin to its entry into the entire cerebrum is supplied by anterior, middle and transverse foramen of C5 or C6 vertebra. It supplies the entire Third segment: Artery winds around atlas and pierces medial surface of cerebral hemipheres including a strip dura mater. Basilar Artery this artery ascends in a groove on the anterior surface of the pons and gives rise to the following branches before dividing into posterior cerebral arteries. Blood Supply to Specific Brain Areas Thalamus: It is supplied mainly by branches of the posterior communicating, basilar and posterior cerebral arteries. Midbrain: It is supplied by posterior cerebral, superior cerebellar, and basilar arteries. Cerebellum: It is supplied by the superior cerebellar, First and fourth segments of vertebral artery and anterior inferior cerebellar, and posterior inferior ceretop of basilar artery are commonly involved. Corpus striatum: It is supplied by medial and lateral Occlusion of Internal Carotid Artery striate central branches of the middle cerebral artery. A nonstenotic or slightly Internal Capsule stenotic carotid lesion in association with a stroke or It can be divided into superior and inferior halves. In nondominant hemisphere affection, patients have Lenticulostriate arteries supply superior half of interapractagnosias, anosognosia, and dysarthria. Patients have profound abulia (delayed motor and verbal response), bilateral pyramidal signs, paraplegia. Nervous System 523 Peripheral Territory (Cortical Branches) Occlusion proximal to posterior communicating artery may be asymptomatic or have only transitory Signs and symptoms Structures involved effects if the collateral flow is adequate. Homonymous hemianopia Calcarine cortex with macular sparing Vertebral Artery Syndromes Bilateral homonymous Bilateral occipital lobe Vertebral arteries are the chief arteries of medulla each hemianopia, cortical with involvement of supplying the lower three-fourths of the pyramid, the blindness, denial of blindparieto-occipital region ness, apraxia of ocular medial lemniscus, lateral medullary region, the restiform movements, inability to count body (inferior cerebellar peduncle), and the posterior Dyslexia without agraphia, Dominant calcarine inferior part of the cerebellar hemisphere. Topographic disorientation Nondominant calcarine and prosopagnosia and lingual gyri, usually Occlusion results in the following features bilateral 1. Pain, numbness, and impaired sensation over half visual cortex the face (descending tract and nucleus of fifth nerve) b. Ataxia of limbs, falling to side of lesion (cerebellum, olivocerebellar fibres, restiform body) Central Territory (Perforating Branches) c. Vertigo, nausea, vomiting, nystagmus, diplopia, Signs and symptoms Structures involved oscillopsia (vestibular nuclei) Thalamic syndrome: All Ventral posterolateral d. Dysphagia, hoarseness, vocal cord paralysis, sias, choreoathetosis, artery), subthalamic diminished gag reflex (ninth and tenth nerves) intention tremor, mild nucleus or its pallidal hemiparesis connections f. Numbness of ipsilateral arm, trunk, or leg Thalamoperforate syndrome: Dentatothalamic tract Crossed cerebellar ataxia with and issuing third nerve (cuneate and gracile nuclei) ipsilateral third nerve palsy h. Patients have movement, skew deviation, third nerve, high midthe following features: sluggish pupillary response to brain tegmentum 1. On the side of lesion light, slight miosis and ptosis ventral to superior colliculus a. Patients may have sense and vibration sense somnolence, memory defects, visual hallucinations, disorder of ocular movements, skew deviation of the eyes, B. Nervous System 525 Differentiating Various Types of Cerebro Vascular Disorders Clinical Features Embolism Thrombosis Haemorrhage Age Younger Middle or old Middle or old Mode of onset Acute Insidious Acute Time of onset Often during day Often during sleep Abruptly during waking hours History of 1. Lateral Localisation of Site of Lesion Symptoms Structures involved Site of lesion Localising clinical features Paralysis of muscles of Nucleus of 5th nerve Cortex Aphasia mastication and impairment Bladder involvement of sensation over face Cortical sensory loss Contralateral loss of pain and Spinothalamic tract Denial temperature Epilepsy (focal fits) Flaccid mono or hemiplegia Inferior Pontine Syndromes Internal capsule Hemiplegia, hemianaesthesia (most common site) hemianopia A. Medial Spasticity marked Symptoms Structures involved Thalamus Fleeting hemiparesis or hemiplegia in the side opposite to the lesion. Protein C, S deficiency (lateral) and inferior pontine (medial and lateral) syn3. Collagen vascular disorders Systemic lupus erythematosus Antiphospholipid syndrome Spontaneous dissection of cartoid. To decide the line of management (to decide on therapy with anticoagulants or antiplatelet drugs). Angiography: It is not usually indicated but indicated only to rule out specific causes such as arterial dissection. To confirm diagnosis (haemorrhage can be detected mass effect resolves immediately whereas it may take 48 hours for infarcts Months to years Encephalomalacic change, volume to be detected). Vasogenic oedema refers to the influx of fluids and solutes into the brain, due to incompetent bloodI. However, oral antiManagement hypertensive drugs are indicated in persistent or 1. Mannitol is contraindicated in cardiac failure and A patients blood pressure at presentation should renal failure. Pressor therapy to maintain adequate mean arterial as the ischaemic penumbral tissue will infarct with pressure to ensure cerebral perfusion pressure of even minor drop in systemic blood pressure, because more than 70 mmHg. Avoid glucocorticoids in trauma, ischaemia and dissection of carotid artery) haemorrhagic stroke. Stroke evolving over hours or days especially in In refractory cases posterior circulation stroke 7. Onset of symptom to time of drug administration Alteration of perfusion/diffusion < 3 hr. Lacunar infarcts are small deep infarcts (usually 3 mm2 cm in diameter) secondary to disease of the small. These are used in the primary as well as secondary the major risk factor is age and hypertension, which prevention of stroke. Aspirin: It is given in a dose of about 150 mg/day of the tiny penetrating vessel. The side effects are skin weakness of one side of body involving the whole or rash, diarrhoea, reversible neutropenia, and theretwo out of three body areas (face, upper limb, leg). Attend to bladder, bowel, back, base of lungs and paresis and ipsilateral cerebellar ataxia often marked eyes with dysarthria, clumsiness of hand and b. Lesion is in the base of pons or genu position if unconscious to prevent aspiration of internal capsule. Corona radiate, cortical this occurs due to stenosis or occlusion of the subclavian lesion artery proximal to the origin of the vertebral artery. Control of hypertension should be done only after bruit over supraclavicular fossa over the affected subthe progression of the disease ceases, i. Aspirin in a dose of 60 to 150 mg per day advancing motor (paraplegia) and sensory (cortical 3. Tumour invasion of dural sinuses hypodensity of the white matter; compression of 6. Cavernous sinus: Proptosis, ptosis, headache, external and internal ophthalmoplegia, papilloedema, reduced sensation in ophthalmic division of triFig. Clinical Features General Treatment Males below 40 years of age are predominantly affecti. There are signs and symptoms of raised intracranial tension (headache, Prognosis vomiting, seizures and papilloedema) and neck stiffness (if there is extension of blood into the ventricles Recovery is good; prognosis is better than arterial occland sub-arachnoid space). Hemiparesis or hemiplegia and to a lesser degree, are: hemisensory deficit, opposite to the side of 1. Nonfluent aphasia with intact repetition and variably impaired comprehension with lesions of the dominant thalamus. Convergence-retraction nystagmoid movements, impairment of vertical gaze and pupillary lightconvergence dissociation. Downward and inward deviation of the eyes (sometimes skew deviation of the eyes may be seen). Conjugate gaze palsy to the side of lesion; patient looks to the side of the hemisensory loss and away from the side of haemorrhage. Monitoring of blood pressure (diastolic pressure not to be lowered below 110 mmHg in the first 48 hours). Surgery: It is indicated in cerebellar haemorrhage, whereby the haematoma can be surgically removed. This is not recommended in haemorrhage at other sites, as this may result in permanent neurological deficit. In general, immediate prognosis in the acute phase is grave and in minimal haemorrhage, once the patient tides over the initial phase, prognosis is good. Acute (few hour onwards) Deoxyhaemoglobin Moderately hypointense Profoundly hypointense 3. Early subacute (few weeks) Intracellular methaemoglobin Hyperintense Hyperintense 4. At the bifurcation of middle cerebral artery from meningeal irritation and loss of consciousness. At the origin of posterior inferior cerebellar and this is characterised by fall in the level of conscioussuperior cerebellar arteries from basilar artery. Congenital defect in the media of the blood vessels characterised by increase in severity of headache and at the point of bifurcation. Hyperdense areas are ophthalmic division of the V cranial nerves may be seen in anterior interhemispheric fissure, both involved due to compression by the aneurysm of sylvian fissures, in the ventricular system and internal carotid artery within the cavernous sinus. Hereditary haemorrhagic telangiectasia Do angiography as early as possible after ictus 9. In the acute phase, the patient is treated for signs Clinical Features and symptoms of raised intracranial tension. Association Intracranial saccular aneurysms may be associated with: Brain Death 1. Cervical artery dissection Brain death occurs from irreversible brain injury that is 3. Fibromuscular dysplasia of arteries sufficient to eliminate all cortical and brainstem function 4. Because the vital centers in the brainstem Nervous System 537 sustain cardiovascular and respiratory functions, brain 3. Before confirming brain death, exclude reversible Headache conditions like hypothermia, drug intoxication, metabolic disorders like hypoglycaemia, acidosis, and Headache is one of the most common and frequent electrolyte imbalance. No response to visual, auditory, or painful les about the head, neck and shoulder girdle suggest stimulation activation of intra and extracranial arteries and skeletal 3. Pain commonly results from activation of peripheral Ancillary Diagnostic Supportive Tests nociceptors in the presence of normally functioning 1.
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The statistician of the trial will provide information for the Data Monitoring and Safety Committee (for detailed information see chapter 11) arthritis in feet remedies order genuine trental on line. A further follow-up period of two years will be required in order to capture the vast majority of events rheumatoid arthritis herbs best order trental, which are expected to occur within 18 months of diagnosis arthritis in fingers lumps cheap trental 400 mg on-line. Data on long term survival arthritis in back and stomach pain purchase trental australia, side effects of treatment and quality of survival will be collected for at least a further 5 years from end of treatment arthritis pain relief gloves reviews discount trental 400 mg without prescription. Since recurrence of germinoma may occur later than this rheumatoid arthritis cream order trental no prescription, clinical follow-up for at least 10 years is advised arthritis in neck and face cheap trental 400 mg mastercard. Recommendations can be found in appendix C (Follow-up investigations) and chapter 5 arthritis in knee sports purchase 400 mg trental free shipping. The potential bias of historical comparisons will be considered in the interpretation of results. Since this therapy modification may increase the risk of relapse, this group of patients will be monitored closely (see chapter 10. Patients with teratoma will be registered but no therapeutic question will be asked, but an evaluation of QoS will be performed. For both groups (germinoma and non-germinoma) an analysis will also be performed on a per-protocol basis in addition to the main intent-to-treat analysis. Patients, who died during treatment will be analysed in the per protocol analysis. If there are conflicting results for the per-protocol and the intent-to treat analysis, the steering committee and the data monitoring committee will have to decide about the implication on conclusions from the main analysis. With a study duration of 5 years the total patient accrual will be 250 for all germinoma (and 150 for pooled patients with non-Germinoma. All other tests conducted for the analysis of further results and subgroup analysis will be descriptive and explorative. Based on previous studies, the expected percentage of cases lost to follow-up is negligible (less than 5%), and therefore not included in the sample size calculation; calculations were done according to Freedman (Freedman, 1982). The boundary proposed in such rules requires very strong evidence of an effect to terminate at the first interim test, whereas the criteria at the final test are rather close to those for a single sample design (that is, a design with no interim testing). The p-values will then be based on a Lan-DeMets spending function approach with OBrien-Fleming type spending function. Final analysis will be performed three years after recruitment of the last patient. The rate of toxic deaths observed in each diagnostic subgroup (Germinoma and Non-Germinoma) will be compared to a reference rate in order to detect an absolute excess of toxic deaths with a Wald sequential plan. Based on this previous experience, we choose the following parameters: p0 = 1% and p1 = 5%, with = 5% and = 1%. This means that the risk to wrongly conclude that there is an excess of toxic deaths (whereas the real rate is equal to p0 1%) is equal to = 5%. On the other hand, the power to detect an excess of toxic deaths (if the real rate is equal to p1 = 5%) is equal to 1- = 99%. If the test is not significant, this group cannot be included in the test of the main study question for Germinoma. Three interim analyses are planned to monitor the possibility of higher risk of relapse in patients with non-metastatic low-risk Germinoma when 25, 50 and 75% of the patients have a potential follow up of 6 months. Treatment on the study cannot be commenced until written consent has been obtained. If results of staging are pending at time point of registration, the primary inquiry should be sent as soon as possible after all results are present. In patients, who have undergone initial tumour resection, a copy of the surgical report and the histopathological report (local pathologist and reference pathologist) are additionally required. For definite risk stratification tumour marker, imaging before surgery, surgical report and a local as well as a central histological report are mandatory. Preferably, imaging in 3 dimensions should be done for diagnosis and as well as a postoperative imaging to define resection status. The histological diagnosis is supported by the information regarding tumour markers and reference histopathological evaluation. The final assignment to the specific risk group will be made at the national coordination centre. Additionally, the national chief investigator can be asked for therapy recommendation. For this purpose, the required information must be forwarded to the national coordination centre in written form. A written therapy recommendation will not be provided on the basis of oral information. In every patient, a follow-up status form will be sent to the clinic once a year until at least 5 years after diagnosis or five years after the last relapse, respectively, in order to document long-term survival. A lateevent and quality-of-life documentation form will therefore be distributed to the clinic at the following time points: at diagnosis, after radiotherapy, 1,and 5 years after diagnosis. If the patient discontinues follow-up in the treating centre, the clinic should either provide the follow-up information in conjunction with the new physician that will take care of the patient, or should provide the national coordination centre with the name and full address of the new physician, depending on national practice. A patient is considered lost to follow-up, if the contact between the follow-up physician and the patient is lost during the planned follow-up period of ten years and cannot be restored. Please take care that all documentation forms are filled in complete and legible in printed characters. Because this is an international study, plain text fields and comments have to be completed in English language. The incorrect entry should be crossed through with a single line (correction fluid must not be used) and should still be legible. If the paper form has already been sent to the national coordination centre, the amended page must be sent (by fax) again. If the doubtful data concerns arguable or missing results of examinations according to risk stratification. Exception: if examinations are already done or planned but the results are still outstanding. Not documented variables are entered as not done Please ensure that all mandatory examinations for risk stratification and response evaluation are performed and results are available as soon as possible If you are not sure how to fill in any of the questions, do not hesitate to contact the data manager of the national coordination centre. Additionally, data managers or research nurses who are also mentioned in the collaboration agreement or delegation log are allowed to fill in the documentation and sign them (national responsibilities). For example, national law in Germany requires that trial documents are stored for at least 10 years. The data will be stored in the international database when all information required for risk stratification is available. Only on the registration fax, the full name of the patient is asked for to allow a consulting service with the national coordination centre. Every incoming documentation will be checked for accuracy, legibility and completeness and will be compared with information already received before transmission to the international coordination centre and final entry into the data base. A copy of the operation note and histology report is required for quality assurance of risk stratification. Missing documentation or values concerning risk stratification will be requested at regular intervals until receipt. If information for risk stratification is not available for a long time and after repeated reminders, the study committee reserves the right to remove the patient from the study. If an entry has to be corrected (after review or additional query), it will be crossed out with a single line on the form and furnished with date, initials and short statement. Additionally to the completeness and plausibility controls by reading, there will be plausibility controls inside the data base and statistical program. Further standardization of internal actions within the national coordination centre and its reference institutions will be achieved. Cooperation of additional countries will be welcomed by the study committee in order to enlarge the number of patients to be recruited. The Chief Investigator must be qualified for this position as required by the national laws and regulations of the respective country. The National Chief Investigator is required to comply with European and national legal regulations. This includes the certification of all cooperating hospitals and may include patient insurance. For each country, the patient information leaflets should be translated into the native language. Every 3 months, data will be send from the national to the international coordination centre. Regulations on detail regarding international cooperation and data exchange are determinded in a cooperation agreement. The Ethics committee will be informed about any changes and amendments to the protocol. The study coordinators will inform the committee about the (scheduled or premature) closure of the study. In addition, the protocol is distributed according to national requirements to the responsible Ethics committees at all participating institutions (see Appendix J) prior to patient recruitment. For this purpose, the protocol includes information leaflets appropriate for different age groups as well as guidelines for patient information (see appendix A). In addition, patients have to give their consent to participation in associated scientific projects including collection of tumour tissue and blood for molecular genetic analysis. Paper copies will be stored at the national coordination centres, including copies of original documents such as surgical notes, histopathological reports, medical reports and correspondence. Consequently, these paper files will necessarily include patient identifiers (full name, date of birth). However, international electronic data storage will be performed by unique trial number only. Consent for data management, storage and transmission will be required from the patient or their legal guardian in addition to the consent into study participation. At any time, the patients or their legal guardians may withdraw from their trial participation by revoking their informed consent and patients data will be deleted. The national legal regulations (see appendix K) have been considered wherever appropriate. The national chief investigators have more than two years of experience in clinical studies. After opening of the protocol and prior to the enrolment of the first patient, each participating clinical centre has to announce the study participation to the responsible local authority as required by national regulations. The data monitoring committee will advise whether the data generated during the trial or data generated in other relevant trials allow further patient recruitment. Assuming that further patient recruitment is indicated, the data monitoring committee will also determine the frequency of future reviews based on the patient accrual and event rates. Final report: After the closure of the clinical trial and the evaluation of the biometric data, the study co-ordinators will summarize all relevant information in a final report that will include the clinical data, the statistical evaluation, evaluation of specific subgroups and the conclusions based on these data. Aoyama H, Shirato H, Ikeda J, Fuijeda K, Miyasaka K, Sawamura Y: Induction Chemotherapy followed by low dose involved firld radiotherapy for Intracranial Germ Cell Tumours. Harms D, Gottschalk I, Janig U: Pathologische Anatomie der Keimzelltumouren (besonders Hodentumouren) bei Kindern. Congenital intracranial teratoma: prenatal diagnosis and postnatal successful resection. Intensive cisplatin and cyclophosphamide-based chemotherapy without radiotherapy for intracranial germinomas: failure of a primary chemotherapy approach. Kumabe T, Kusaka Y, Jokura H, Ikeda H, Shirane, Yoshimoto T: Recurrence of intracranial germinoma initially treated with chemotherapy only. Journal of Neuro-Oncology 54, 2001: 311-316 Matsutani,-M; Sano,-K; Takakura,-K; Fujimaki,-T; Nakamura,-O; Funata,-N; Seto,-T: Primary intracranial germ cell tumours: a clinical analysis of 153 histologically verified cases. Improved prognosis of intracranial non-germinoma germ cell tumours with multimodality therapy. Journal of Neurooncology 1997, 32: 71-80 Schild,-S-E; Scheithauer,-B-W; Haddock,-M-G; Wong,-W-W; Lyons,-M-K; Marks,-L-B; Norman,-M-G; Burger,-P-C: Histologically confirmed pineal tumours and other germ cell tumours of the brain. Epidemiological Analysis of 1442 Children and Adolescents Registered in the German Germ Cell Tumour Protocols. Cancer Res 2001; 61:7268-7276 Shinoda J, Yamada H, Sakai N, Ando T, Miwa Y: Placental phosphatase as tumour marker for primary intracranial germinoma. Incidence of Contralateral Germ Cell Tumours in South Europe: report of the Experience at 2 Spanish University Hospitals and Review of the Literature. The histogenetic-embryologic basis for reappearance of alpha-fetoprotein in endodermal sinus tumours (yolk sac tumours) and teratomas. Weiner,-H-L; Finlay,-J-L: Surgery in the management of primary intracranial germ cell tumours. To describe the ocular signs and symptoms associated with selected systemic diseases and their serious ocular sequelae. To review the important features of diabetic retinopathy and the current screening guidelines 3. To be familiar with the important ocular features of hypertension, thyroid disease, sarcoidosis and inflammatory conditions, malignancy and acquired immunodeficiency syndrome. Patent Application: 2018/0156787 A1, Publication Date: 7 June 2018; (OmniGridAccent). Harro, Barbara DeNearing, Jessica Brubaker, David A Sack, A Louis Bourgeois, Philip L Felgner, Xiaowu Liang, Sachin Mani, Heather Wenzel, R Reid Townsend, Petra E Gilmore, Michael J Darsley David A Rasko, James M Fleckenstein the Journal of Infectious Diseases, 24 May 2018; ahead of print. Inventors: Kay Klausing, Min-Jui Richard Shen, John Moore, Vincent Peter Smith, and Kevin Hall. Shu-Hong Huang, Yu-Shin Chang, Jyh-Ming Jimmy Juang, Kai-Wei Chang, Mong-Hsun Tsai, Tzu-Pin Lu, Liang-Chuan Lai, Eric Y. Analyst, 21 March 2018; 143(6): 1367-1377 Label-free biosensors in the field of stem cell biology. Yang Yang, Tian-Wei Jia, Fei Xu, Wei Li, Shun Tao, Li-Qiang Chu, Yun He, Yu Li, Suri S. Methods and Compositions For the Diagnosis And Treatment Of Cancer and Autoimmune Disorders. Luna Coronell, Khulan Sergelen, Philipp Hofer, Istvan Gyurjan, Stefanie Brezina, Peter Hettegger, Gernot Leeb, Karl Mach, Andrea Gsur, and Andreas Weinhausel. Campo, Andre Lin Ouedraogo, Lisette Meerstein-Kessel, Isabelle Morlais, Dari Da, Anna Cohuet, Sandrine Nsango, Colin J. Sutherland, Marga van de Vegte-Bolmer, Rianne SiebelinkStoter, Geert-Jan van Gemert, Wouter Graumans, Kjerstin Lanke, Adam D. Singh, Michael Theisen, Phil Felgner, Matthias Marti, Chris Drakeley, Robert Sauerwein, Teun Bousema, and Matthijs M. Patent Application: 2018/0016299 A1, Publication Date: 18 January 2018; (OmniGrid 100) patents. Stefania Parlato, Teresa Chiacchio, Debora Salerno, Linda Petrone, Luciano Castiello, Giulia Romagnoli, Irene Canini, Delia Goletti, and Lucia Gabriele. Joyner, Sunny Ketchum, Rie Nakajima, Algis Jasinskas, Li Liang, Rich Fong, Christopher King, Bryan Greenhouse, Maxwell Murphy, Jason Bailey, Mary R. Patent Application: 2017/0009306 A1, Publication Date: 12 January 2017; (OmniGrid 100). Patent Application: 2017/0023586 A1, Publication Date: 26 January 2017; (OmniGrid 100). Lindow, Arlo Randall, Elsio Wunder, Jozelyn Pablo, Rie Nakajima, Algis Jasinskas, Jaqueline S. Emmanuel Dotsey, Irina Ushach, Egest Pone, Rie Nakajima, Algis Jasinskas, Donovan A. Patent Application: 2017/0051349 A1, Publication Date: 23 February 2017;. Inventors: Guangdan Zhu, Cindy Wang, Tanya Moreno, Andrew Hellman, Alok Tomar, Svetlana Ivanova Gramatikova, Aditi Chawla, Russell Kuo-fu Chan, Adriana Del Tredici, Adrian Vilalta, K. Patent Application: 2017/0051350 A1, Publication Date: 23 February 2017;. Patent Application: 2017/0081659 A1, Publication Date: 23 March 2017; (OmniGrid 100). Patent Application: 2017/0107583 A1, Publication Date: 20 April 2017;. Jiin Felgner, Aarti Jain, Rie Nakajima, Li Liang, Algis Jasinskas, Eduardo Gotuzzo, Joseph M. Vinetz, Fabio Miyajima, Munir Pirmohamed, Fatimah Hassan-Hanga, Dominic Umoru, Binta Wudil Jibir, Safiya Gambo, Kudirat Olateju, Philip L. Patent Application: 2017/0175123 A1, Publication Date: 22 June 2017; (OmniGrid 100).
