Marta A. Miyares, PharmD, BCPS (AQ Cardiology), CACP

• Clinical Pharmacy Specialist, Internal Medicine, Jackson Memorial Hospital
• Director, PGY1 Residency Program, Miami, Florida

Nevertheless herbals shoppe hedgehog products 100 caps geriforte syrup sale, the potential of structured weight loss programs should be exploited in overweight patients to achieve the possible beneficial effects [1 zip herbals mumbai discount geriforte syrup 100 caps fast delivery,4 herbs good for hair 100 caps geriforte syrup overnight delivery,9] kairali herbals generic geriforte syrup 100caps fast delivery. Advice concerning the reduction of high-fat and energy-dense foods, in particular those high in saturated fat and free sugars, will usually help to achieve weight loss. Regular physical activity should also be an important component of lifestyle approaches to the treatment of overweight. Evidence obtained from meta-analyses of randomized controlled trials or at least one randomized controlled trial [1,2]. Evidence obtained from at least one well designed and controlled study without randomization, well-designed quasi-experimental or non-experimental descriptive studies [1,2]. Low fat diets have been traditionally and effectively promoted for weight loss [1,13]; however, recently it has been demonstrated that low carbohydrate, higher fat diets may result in even greater weight loss over short periods of time, up to 6 months [2,10,14]. Such diets eliminate several foods that are important sources of fiber, vitamins and minerals. Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities [1,2]. There is a broad range of possible carbohydrate intake in people with diabetes. This advice is mainly based on recommended restrictions for the intakes of fat and protein. In many European countries, the mean carbohydrate intake of people with diabetes is only around 42% of total energy intake (Table 22. Usually, carbohydrate intake in people with diabetes is lower than recommended by nutrition associations for the general population who receive advice to consume around 50% of total energy intake as carbohydrate. Many people with diabetes tend to reduce their carbohydrate intake because they fear an increase in blood glucose concentrations after the ingestion of carbohydrate-containing foods. In affluent countries, lower carbohydrate diets are usually accompanied by high fat, predominantly an undesirable high saturated fat intake. With such a diet it is also difficult to achieve sufficient fiber intake to meet recommendations [1,24,25]. Having this in mind, it does not appear to be productive to overemphasize the present renaissance of low carbohydrate strategies in diabetes. Furthermore, several recent reports on this topic do not clearly define what is meant by "low" or "high" carbohydrate and whether a carbohydrate intake of around 40% of total energy, which is consumed by many people with diabetes, already corresponds to a low carbohydrate diet [26,27]. Glycemic effects of different carbohydrate Not only the amount of carbohydrate, but also the quality of carbohydrate is important for individuals with diabetes. Vegetables, legumes, fresh fruit, wholegrain foods and low fat milk products should be part of a healthy diet [1,2]. South (n = 1371) Total energy (kcal/day)a Carbohydrate (% of energy) Fiber (g/day)a Total fat (% of energy) Saturated fatty acids (% of energy) Cholesterol (mg/day)a Protein (% of energy) Alcohol (g/day)b Current smokers (n %) Ex-smokers (n %) Vigorous exercise once/week (n %) 2148 43. Southern European Centers (n = 12): Athens, Bari, Cagliary, Lisbon, Milan, Padua, Perugia, Pisa, Rome, Turin, Thessaloniki, Verona. In the process of achieving desirable glycemic control, many individuals with diabetes use either carbohydrate counting, carbohydrate exchanges or experience-based estimation of carbohydrate intake as a helpful means to monitor their consumption of carbohydrate at meals or snacks [2]. For example, eating fresh fruits is superior to a fruit juice with the same amount of carbohydrate. A substantial benefit from these expensive so-called "diabetic" preparations has not been proven. Proper food labeling may help the person with diabetes to make healthy choices from available usual foods. Potential of dietary fiber In many countries, people with diabetes consume only few foods that are rich in dietary fiber and therefore total fiber intake is much lower than recommended (Figure 22. With the relatively low carbohydrate intake in people with diabetes it is not easy to meet recommended quantities of fiber. The degree of evidence for recommended carbohydrate and dietary fiber intakes is shown in Tables 22. Adjustment of insulin or insulin secretagogues to carbohydrate intake For people who are treated with insulin or hypoglycemic agents, it is important to match the medication with the amount, type and time of carbohydrate intake to avoid hypoglycemia as well as excessive post-prandial hyperglycemia [1,2]. This advice is now part of many nutrition education programs for people with diabetes who are treated with intensified insulin regimens [18,44]. Self-monitoring of blood glucose offers a helpful means of determining the most appropriate timing of food intake and to make optimal food choices [1]. Individual preferences and the needs of different treatment strategies remain the most important determinants of appropriate meal frequency, portion sizes and carbohydrate intake. Extra carbohydrate may be needed prior to exercise although adjustment of the insulin dosage in those on intensified insulin treatment is often an alternative and preferred choice. Structured training and continuing advice by the diabetes team is needed to enable the people with diabetes to adjust the insulin dosage while considering all three components: blood glucose results, amount and quality of carbohydrate intake as well as the degree of physical activity. Sucrose and other sugars Moderate intake of sucrose (<10% total energy) or other added sugars may be included in the diet of people with diabetes without worsening glycemic control [1,2,25,41]. Although fructose produces a reduction in post-prandial glycemia when it replaces sucrose, this potential benefit is tempered by the fact that fructose may adversely effect serum triglycerides as well as uric acid levels [1,8]. There is no reason to recommend that people with diabetes should avoid naturally occurring fructose. Higher quantities of sugar substitutes may promote undesirable gastrointestinal side effects. Furthermore, it is unlikely that energy-containing sugar substitutes such as sugar alcohols in the amounts likely to be consumed will contribute to an appreciable reduction in total energy intake although they are only partially absorbed from the small intestine [2,8]. Approved non-nutritive sweeteners may also be used by people with diabetes although a special long-term benefit in metabolic control has not been proven. Dietary fat the primary goal concerning dietary fat intake is to restrict the consumption of saturated fatty acids, trans-fats and dietary 351 Part 5 Managing the Patient with Diabetes cholesterol to reduce the risk for vascular disease [1,2,45,46]. Compared with the non-diabetic population, people with diabetes have an increased risk of developing vascular disease. Fat modification in people with diabetes is an established principle to assist in achieving desirable serum lipid concentrations and to avoid vascular lesions in high-risk groups. Although most of this evidence is obtained from studies of people without diabetes, it seems that the recommendations are also relevant in the diabetic population as their risk for vascular disease is even higher than in the general population [1,47]. Even if statins are often needed to meet the treatment goals for serum lipid concentrations, possible lifestyle modifications should always be exploited, and remain the basic therapeutic approach to achieve a desirable lipid profile. The degree of evidence for the recommendations relating to the recommended amounts of fat intake or fat modification, respectively, is shown in Tables 22. Trans-fats and dietary cholesterol Unfortunately, in most countries, the quantity of trans-unsaturated fatty acids is not well documented on many food products. Trans-fats are found in many manufactured products such as biscuits, cakes, confectionery, soups and some hard margarine. Food labeling informs whether hydrogenated fats and oils were added to a food product and the ranking of ingredients on the food label gives at least some information whether high quantities of trans-fats could have a role. Reduction of saturated fatty acids It is suggested that saturated fatty acids could be either replaced by carbohydrate foods rich in fiber or by unsaturated fatty acids, particularly by cis-monounsaturated fatty acids for people on a weight-maintaining diet. In conclusion, fat modification remains an important Omega-3-fatty acids Observational evidence supports the intake of n-3 polyunsaturated (omega-3) fatty acids as they have the potential to reduce serum triglycerides and have beneficial effects on platelet aggregation and thrombogenicity, thus offering cardioprotective effects [52]. Also, the role of folate supplementation in reducing cardiovascular events is not clear and still under further investigation.

For those with more severe injury ganapathy herbals buy 100caps geriforte syrup overnight delivery, unconscious for more than 1 hour herbals in hindi cheap 100caps geriforte syrup mastercard, the inpatient programme did seem to be more effective herbals and diabetes purchase 100 caps geriforte syrup amex. Therefore for many rumi herbals chennai discount geriforte syrup 100 caps with visa, particularly if support is available at home, rehabilitation in the community is appropriate. On the other hand, some will need inpatient cognitive rehabilitation, particularly those with little safety awareness, behavioural problems or limited support at home. Some of these patients will need to move on to a transitional living unit, a halfway house, so that they can Head Injury 249 improve their independent living skills in a more demanding setting, before finally returning to live in the community. This makes it easier to ensure that therapy is tailored to the patient and his situation. A goal-planning approach is likely to be used, with most goals getting the patient doing more with less support. Some of the action plans to achieve these goals will require one-to-one support, with a therapist or care worker being with the patient for perhaps a few hours a day. Once reasonable independent living skills have been mastered, strategies to look at return to work will be an important consideration for many patients. An essential part of rehabilitation lies in the help and guidance offered when the time comes for preparation for return to work (Yasuda et al. The strategies to consider when post-concussional symptoms are present are discussed in the next section. However, the ideal of return to the original occupation may have to be changed on account of persistent physical or mental handicaps. In practice the chief hindrances usually prove to be of a psychological kind: poor timekeeping, inadequacy of memory, slowness and weakness of attention, early fatigue, irritability and poor social judgement. Therefore a thorough assessment will be needed to ensure that employment targets that are reasonably achievable are selected. These are usually day programmes to mimic the demands of getting to work daily (Box 4. Those who are unable to manage under ordinary working conditions may need entry to a sheltered workshop or day centre. A designated case manager should be in a position to establish a continuous link among the various service providers, build up knowledge of what is available locally, and coordinate input to the patient and the family. Post-concussion syndrome Treatments to thwart the development of post-concussional symptoms have already been discussed. There is less research evidence to guide the treatment of symptoms once they have become persistent. Most would agree that a thorough evaluation aimed particularly at understanding the contribution of brain injury, and in addition other causative factors, is the foundation for a therapeutic alliance. This will pay particular attention to the possibility that psychological factors can result in physical and cognitive symptoms; much can be learnt from the reattribution model used in somatisation disorder (Goldberg et al. Once the possibility of brain damage has been fully assessed, further physical investigations are best kept to a minimum. Symptoms will often have deteriorated alongside attempts at returning to work, and the patient is likely to be troubled because the pressure to return to work quickly conflicts with the need to allow symptoms to resolve, sometimes quite slowly. This is likely to include an initial period off work; how long for will depend on clinical common sense, which will be guided by how long symptoms have been present. A firm medical recommendation that the patient requires a prolonged period off work may be needed; if patients are apprehensive about tight deadlines for returning to work, this is 250 Chapter 4 likely to aggravate symptoms. Symptoms that have been present for months are not likely to improve in a few days or weeks, so a medical certificate of 3 months is a starting point, perhaps with guidance to the employers that depending on progress this may need to be extended. It is usually better to overestimate the time that will be needed, so that the employer and the patient are pleased should the latter be fit to start before the target date, rather than disappointed that the target date has passed and the patient has failed to return. On the other hand, it is important not to make blanket recommendations that all patients, including those with mild symptoms, have long periods of convalescence; for some this will cause frustration and may consequently aggravate symptoms, quite apart from the financial problems that may result, or the possibility that the job is jeopardised as a result. The range of organic causes that need to be considered has already been outlined in the Post-traumatic headache section (under Post-concussion syndrome) earlier in chapter. The prognosis of post-traumatic headache that has lasted more than a few months is poor. Pharmacotherapy Cognitive impairment Two main classes of drugs have been used to improve cognition, including memory impairment, after head injury: drugs that enhance catecholamine transmission and drugs that enhance cholinergic transmission. In both cases it is useful to distinguish early effects to promote concentration and recover and reduce confusion, from late effects once cognitive impairments are static. Over the 6 weeks of the study patients received alternate weeks of methylphenidate or placebo. Using a rigorous methodology they identified three measures of psychomotor speed, concentration and memory that were improved by methylphenidate. Bromocriptine may be able to improve executive function, including dual-task processing (McDowell et al. The newer generation of cholinesterase inhibitors, like donepezil, are much more convenient to administer. Numerous small case series have suggested that they seem safe, and may be effective for both early confusion (Walker et al. The situation of the patient, including his family setting, must be comprehensively reviewed; where litigation is in progress liaison with the lawyers representing the case can be helpful. Antidepressant medication and the minor tranquillisers are valuable aids, but for many patients the mainstay of treatment lies in psychotherapy and in attention to the social problems that exist. Psychotherapy may need to consist of little more than ongoing support, reassurance and the ventilation of anxieties. More sophisticated psychotherapeutic interventions will need to take account of any cognitive impairment (Borgaro et al. Some patients may benefit from relaxation therapy, and this is often used alongside a formal anger management programme for patients with marked irritability and episodic loss of temper. If litigation is present, its speedy resolution is in general to be desired, certainly in cases where brain damage does not play an identifiable part. Post-traumatic headache Long-continued and disabling post-traumatic headache can pose a difficult therapeutic problem. Frequently a number of simple remedies will have been tried without success, and the headache will be found to be inextricably intertwined with a variety of other complaints. Measures of short-term memory and attention improved more quickly during donepezil treatment. A subgroup analysis hinted at improvements in those with more severe memory impairment on rivastigmine. Therefore cholinesterase inhibitors may be useful, but should probably only be carefully tried in those with significant memory impairment. Practical aspects of treatment have been addressed in a useful review (Blount et al. Behavioural problems Although agitation and aggression are common problems after head injury, there is little good evidence to guide the clinician on which drug to use, and indeed whether any are in fact effective (Fleminger et al. The literature is replete with case reports or small case series advocating the effectiveness of different drugs, but given that agitation tends to resolve spontaneously and that aggression is often very changeable, carefully controlled studies are needed. In this setting of uncertainty it is essential to ensure that medication is definitely necessary, to choose drugs with minimum potential for interactions and side effects, and to attend to the principles of drug treatment illustrated in Box 4. Because agitation is often associated with the period of posttraumatic delirium, anything which increases confusion, and that includes almost all psychotropics, may increase agitation. In addition, any akathisia from antipsychotic medication will make agitation worse. There is therefore a good case for waiting, or for trying amantadine or methylphenidate.

Conjugated equine estrogen improves glycemic control and blood lipoproteins in post-menopausal women with type 2 diabetes herbals information safe 100 caps geriforte syrup. Effects of low-dose continuous combined hormone replacement therapy on glucose homeostasis and markers of cardiovascular risk in women with type 2 diabetes herbals wholesale cheap geriforte syrup 100 caps without a prescription. Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women zen herbals purchase geriforte syrup 100caps with mastercard. Thiazide-induced hypokalemia: association with acute myocardial infarction and ventricular fibrillation zain herbals buy geriforte syrup 100 caps on line. Deterioration of glucose tolerance in hypertensive patients on prolonged diuretic treatment. Glucose intolerance in hypertensive patients treated with diuretics: 14 year follow-up. Glucose intolerance during diuretic therapy: results of trial by the European Working Party on Hypertension in the Elderly. Prevention of the glucose intolerance of thiazide diuretics by maintenance of body potassium. Low dose anti-hypertensive treatment with a thiazide diuretic is not diabetogenic. Thiazide-associated glucose abnormalities: prognosis, etiology, and prevention: is potassium balance the key Thiazide diuretics, potassium, and the development of diabetes: a quantitative review. Antihypertensive therapy and insulin sensitivity: do we have to redefine the role of beta-blocking agents Serum glucose levels during long-term observation of treated and untreated men with mild hypertension: the Oslo study. A meta-analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new-onset diabetes mellitus. Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: a randomized controlled trial. Effects of calcium antagonists on glucose homeostasis and serum lipids in non-diabetic and diabetic subjects: a review. Double-blind comparison of the antihypertensive effects of verapamil and propranolol. Calcium antagonists and hormone release, 1: effects of verapamil on insulin release in normal subjects and patients with islet-cell tumour. The effect of nifedipine and nicardipine on glucose tolerance, insulin and C-peptide. Calcium antagonists and hormone release, 6: effects of a calcium antagonist (verapamil) on the biphasic insulin release in vivo. Calcium antagonists and hormone release, 1: effects of verapamil on insulin release in normal subjects and patients with islet-cell tumor. Assessment of hyperglycemia after calcium channel blocker overdoses involving diltiazem or verapamil. Effects of antihypertensive therapy on glucose tolerance: focus on calcium antagonists. Pentamidine-induced derangements of glucose homeostasis: determinant roles of renal failure and drug accumulation. Effects of protease inhibitors on hyperglycemia, hyperlipidemia, and lipodystrophy: a 5-year cohort study. Comparison of hormonal and metabolic effects of salbutamol infusion in normal subjects and insulin-requiring diabetics. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. Influence of small increments of epinephrine on glucose tolerance in normal humans. Effects of octreotide on glycaemic control, glucose disposal, hepatic glucose production and counter-regulatory hormones secretion in type 1 and type 2 insulin treated diabetic patients. Effectiveness and tolerability of slow release lanreotide treatment in active acromegaly: six-month report on an Italian multicenter study. Effects of lanreotide Autogel on growth hormone, insulinlike growth factor 1, and tumor size in acromegaly: a 1-year prospective multicenter study. Long-term safety and efficacy of depot long-acting somatostatin analogs for the treatment of acromegaly. Hypoglycaemia and counterregulatory hormone responses in severe falciparum malaria: treatment with Sandostatin. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Incidence of diabetes mellitus and impaired glucose tolerance in children and adolescents receiving growth-hormone treatment. Posttransplant hyperglycaemia-increased incidence in cyclosporintreated renal allograft recipients. Morphological and functional changes of pancreatic B cells in cyclosporin A-treated rats. Islet cell damage associated with tacrolimus and cyclosporine: morphological features in pancreas allograft biopsies and clinical correlation. Posttransplant diabetes mellitus: increasing incidence in renal allograft recipients transplanted in recent years. Incidence of posttransplant diabetes mellitus in kidney transplant recipients immunosuppressed with sirolimus in combination with cyclosporine. Calcineurin inhibitor avoidance versus steroid 277 Part 4 Other Types of Diabetes avoidance following kidney transplantation: postoperative complications. New-onset diabetes mellitus after kidney transplantation: the role of immunosuppression. Diabetic ketoacidosis induced by alpha interferon and ribavirin treatment in a patient with hepatitis C. Clozapine, diabetes mellitus, weight gain, and lipid abnormalities: a five-year naturalistic study. Stimulation of glycogen synthesis and inactivation of phosphorylase in hepatocytes by serotonergic mechanisms, and counter-regulation by atypical antipsychotic drugs. Incidence of newly diagnosed diabetes attributable to atypical antipsychotic medications. Selective serotonin reuptake inhibitors fluoxetine and fluvoxamine induce hyperglycemia by different mechanisms. Effect of some antidepressants on glycaemia and insulin levels of normoglycaemic and alloxan-induced hyperglycaemic mice. Effects of nortriptyline on depression and glycaemic control in diabetes: results of a double-blind placebo-controlled trial. Risk factors for hyperglycemia in children with leukemia necessitating l-asparaginase and prednisolone. The effect of acipimox in patients with type 2 diabetes and persistent hyperlipidaemia. Gatifloxacin-induced hyperglycemia: a case report and summary of the current literature. Effects of gatifloxacin on serum glucose concentration in normal and diabetic rats. Introduction the primary focus of this chapter is on those endocrine disorders that cause hyperglycemia and where effective treatment of the endocrinopathy can be expected to normalize the blood glucose concentration. These conditions mostly reflect excessive secretion of "counter-regulatory" hormones, the metabolic actions of which oppose those of insulin by inhibiting its secretion, action, or both. It affects approximately 60 people per million [2] and, in 99% of cases, is caused by a pituitary adenoma, most commonly larger than 1 cm in diameter (a "macroadenoma"; Figure 17. Features included: (a) the characteristic facial appearance; (b) a large adenoma (arrow) extending up to but not in contact with the optic chiasm demonstrated by magnetic resonance imaging (R, right; L, left).

Attempts at immobilisation commonly lead to bruising and chafing elchuri herbals proven 100caps geriforte syrup, and any benefit is promptly lost on removal of the restraint herbs and rye geriforte syrup 100 caps low price. Anticholinergics such as trihexyphenidyl are sometimes helpful but less so than in the dystonias which set in during childhood herbals on demand down buy discount geriforte syrup 100caps. Adults are more prone to side effects herbals teas safe during pregnancy 100 caps geriforte syrup with amex, and often cannot tolerate the high dosage required for therapeutic response. Benzatropine, diazepam and neuroleptics such as phenothiazines or haloperidol may help a proportion of patients in the early stages, but benefits are often transient. The treatment that has emerged as most useful is injection of botulinum toxin (Botox, Dysport) into the affected muscle groups (Tsui et al. The use of botulinum A and botulinum B has been reviewed by the Cochrane Collaboration (Costa et al. This should be undertaken only in clinics which have special experience of using the technique. It leads to relief from the neck deviations and associated pain in a high proportion of patients. Careful choice of injection sites is important, the aim being to weaken the most active muscles from among the sternomastoid, splenius capitis and trapezius. Mild neck weakness may be experienced for some days after the injections, also dysphagia that may persist for a week or two and nausea (Jankovic & Schwartz 1991). The affected neuromuscular junctions are permanently inactivated, the waning of effect resulting from the establishment of new junctions by a process of sprouting from presynaptic axons. Experience has shown the feasibility of continuing treatments over many years, although antibodies to the toxin may ultimately develop and lead to unresponsiveness. The toxin appears to act by cleaving a membrane-bound protein required for release of acetylcholine. Studies have shown that in most cases treatment can be given success- Movement Disorders 785 fully over many years (Brashear et al. Botulinum toxin exists in a number of serotypes: type A and type B both block the action of acetylcholine, but by binding to different receptors. Alternative approaches have included intensive behaviour therapy employing massed practice, aversion techniques or systematic desensitisation to the anxiety induced by the head movements (Agras & Marshall 1965; Brierley 1967; Meares 1973). Biofeedback may meet with substantial success in certain patients, either as an aid to simple relaxation or more directly by electromyographic feedback from the offending muscle groups (Korein & Brudny 1976; FischerWilliams et al. Psychotherapy directed at the exploration of conflicts, or analysis of the settings in which the movements first appeared, has been reported to produce improvement and even complete relief in occasional patients (Whiles 1940; Paterson 1945). Surgical approaches have included selective division of cervical nerve roots, peripheral denervation, thalamotomy and even sternomastoid myotomy in very disabled patients, but the advent of treatment with botulinum toxin should reduce the need for such invasive procedures. Blepharospasm and oromandibular dystonia (cranial dystonia, orofacial dystonia) Blepharospasm consists of an uncontrollable tendency to spontaneous and forcible eye closure. It may begin unilaterally but both eyes are usually soon affected (Malinovsky 1987). Repeated contractions of the orbicularis oculi can progress to almost constant involuntary spasm, sometimes rendering the patient virtually unable to see. Spasms are provoked by bright light, embarrassment, attempts at reading or looking upward. Some patients fi nd tricks that help: yawning, humming, touching the eyelids or eyebrows, neck extension or forced jaw opening. It is most common in middle-aged or elderly women, with onset particularly in the sixth decade. For some considerable time, even years, it may be intermittent, and the aggravation by emotional influences may give a strong impression that psychological factors are operative. A considerable proportion of patients show depression around the time of onset (Marsden 1976a). The affected patients are typically stable, however, and without precipitants that could explain the disorder (Bender 1969). Oromandibular dystonia has a similar range of onset and also more frequently affects women than men. Prolonged spasms affect the muscles of the mouth, jaw and sometimes the tongue (lingual dystonia). The jaw may be forced open or abruptly closed, the lips purse or retract, and the tongue protrudes or curls within the mouth. The picture can at first sight resemble the orofacial dyskinesias seen as a late effect of neuroleptic medication (see Tardive dyskinesia, under Drug-induced disorders/ Clinical pictures, earlier) but in essence the movements are different (Marsden 1976a,b). Orofacial dystonia consists of repetitive prolonged spasms rather than the incessant flow of choreiform lip smacking, chewing and tongue rolling movements seen in tardive dyskinesia. The spasms are typically provoked by embarrassment, fatigue or attempts at speaking, chewing or swallowing. Certain tricks may be learned to abort them, such as grasping the lower jaw firmly or shaking the head. While each of these two disorders can be seen in isolation, there is a strong tendency for them to be coupled together. In a later series of 264 patients with blepharospasm, 188 (71%) also showed oromandibular dystonia (Grandas et al. When both are present they usually begin contemporaneously, although sometimes the blepharospasm antedates the oromandibular dystonia by several years. Ben Simon and McCann (2005) suggest that isolated blepharospasm occurs only in a minority of patients. Most have a combination of blepharospasm with oromandibular dystonia or a segmental cranial dystonia. Patients may also exhibit frowning, torticollis titubation, or hyperexcitable trigeminal reflex blinks (Mauriello et al. The course is usually chronic and protracted, but can be intermittent over many years. Aetiology the aetiology of both conditions remains obscure, but they are now firmly included within the dystonia spectrum. Blepharospasm was formerly often considered to be psychological in origin, but its frequent association with oromandibular dystonia has served to dispel this view. Functional neuroimaging has demonstrated increased metabolism in the thalamus and striatum (EsmaeliGutstein et al. Several authors focus on basal ganglia abnormalities as the cause of blepharospasm (Berardelli et al. Continuous chronic blepharospasm has also been reported after head injury or subarachnoid haemorrhage, or in association with cerebral tumours, degenerative conditions or cerebral arterial disease. Rostral midbrain lesions appear to be particularly closely related to its development (Poewe et al. In all such settings blepharospasm can sometimes resemble a psychogenic disorder but for the history and abnormal findings on neurological examination. A family history suggestive of blepharospasm or dystonia elsewhere was found in almost 10% of cases, suggesting a genetic predisposition. These include talking, singing, yawning, whistling, coughing, humming, or placing a finger on the lateral margin of the orbit (Anderson et al. Although there is now overwhelming evidence of an organic basis for blepharospasm, it is also clear that symptoms may be triggered or exacerbated by psychological factors, and that comorbid psychiatric diagnoses are common. Treatment Treatment can raise very considerable problems as responses to drug treatment are often ill-sustained. With both blepharospasm and oromandibular dystonia there may be a good response to anticholinergic medication provided this can be tolerated in adequate dosage. Tetrabenazine, lithium, benzodiazepines or neuroleptics such as haloperidol and pimozide are also often tried. Severe cases of blepharospasm may require section of branches of the facial nerve, or muscle-stripping operations to remove selected parts of the orbicularis oculi muscles. Injection of botulinum toxin into the orbicularis oculi muscle is now the first-line treatment for blepharospasm. The mean duration of benefit is approximately 3 months but can be as long as 6 months (Dutton & Buckley 1988).

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