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Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial muscle relaxants for tmj pyridostigmine 60 mg cheap. Internetenabled interactive multimedia asthma education program: a randomized trial muscle relaxant names buy cheap pyridostigmine 60mg. A survey of the quality of information leaflets on hayfever available from general practices and community pharmacies spasms nose pyridostigmine 60mg on-line. Association between asthma and rhinitis according to atopic sensitization in a population-based study muscle relaxant chlorzoxazone buy cheap pyridostigmine 60mg on line. Childhood allergic rhinitis predicts asthma incidence and persistence to middle age: a longitudinal study xanax muscle relaxer cheap 60mg pyridostigmine fast delivery. Ciprandi G spasms while high pyridostigmine 60mg without prescription, Cirillo I, Vizzaccaro A, Tosca M, Passalacqua G, Pallestrini E, et al. Seasonal and perennial allergic rhinitis: is this classification adherent to real life Bronchial hyperresponsiveness in young children with allergic rhinitis and its risk factors. Allergic rhinitis and onset of bronchial hyperresponsiveness: a population-based study. Bronchial hyperreactivity and spirometric impairment in patients with seasonal allergic rhinitis. Segmental bronchial provocation induces nasal inflammation in allergic rhinitis patients. Abnormal spirometry in children with persistent allergic rhinitis due to mite sensitization: the benefit of nasal corticosteroids. Once daily intranasal fluticasone propionate (200 micrograms) reduces nasal symptoms and inflammation but also attenuates the increase in bronchial responsiveness during the pollen season in allergic rhinitis. Immunotherapy with a standardized Dermatophagoides pteronyssinus extract, V: duration of the efficacy of immunotherapy after its cessation. Coseasonal sublingual immunotherapy reduces the development of asthma in children with allergic rhinoconjunctivitis. Efficacy and safety of loratadine plus pseudoephedrine in patients with seasonal allergic rhinitis and mild asthma. The comparative actions and adverse effect profile of single doses of H1-receptor antihistamines in the airways and skin of subjects with asthma. Effect of cetirizine, a new histamine H1 antagonist, on airway dynamics and responsiveness to inhaled histamine in mild asthma. The inhibitory effect of terfenadine and flurbiprofen on early and late-phase bronchoconstriction following allergen challenge in atopic asthma. Effects of a cyclo-oxygenase inhibitor, flurbiprofen, and an H1 histamine receptor antagonist, terfenadine, alone and in combination on allergen induced immediate bronchoconstriction in man. Effect of cetirizine, a new H1 antihistamine, on the early and late allergic reactions in a bronchial provocation test with allergen. Similar allergic inflammation in the middle ear and the upper airway: evidence linking otitis media with effusion to the united airways concept. Expression of immunoregulatory cytokines during acute and chronic middle ear immune response. Pregnancy outcome following first trimester exposure to antihistamines: meta-analysis. Fetal safety of drugs used in the treatment of allergic rhinitis: a critical review. A review of pregnancy outcomes after exposure to orally inhaled or intranasal budesonide. Asthma symptoms, severity, and drug therapy: a prospective study of effects on 2205 pregnancies. Meta-analysis finds use of inhaled corticosteroids during pregnancy safe: a systematic meta-analysis review. Use of inhaled steroids by pregnant asthmatic women does not reduce intrauterine growth. Effects of exercise on nasal airflow resistance in healthy subjects and in patients with asthma and rhinitis. Treatment of chronic rhinitis by an allergy specialist improves quality of life outcomes. Consultation and referral guidelines citing the evidence: how the allergist-immunologist can help. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Multiattribute utility function for a comprehensive health status classification system. The Nottingham Health Profile: an analysis of its sensitivity in differentiating illness groups. Two-year bronchodilator treatment in patients with mild airflow obstruction: contradictory effects on lung function and quality of life. The Functional Status Questionnaire: reliability and validity when used in primary care. Reliability and validity of comprehensive health status measures in children: the Child Health Questionnaire in relation to the Health Utilities Index. Parent proxy-report of their childrens health-related quality of life: an analysis of 13,878 parents reliability and validity 640. How young can children reliably and validly self-report their health-related quality of life Development and testing of a new measure of health status for clinical trials in rhinoconjunctivitis. Can the standard gamble and rating scale be used to measure quality of life in rhinoconjunctivitis A questionnaire to measure quality of life in adults with nocturnal allergic rhinoconjunctivitis. Comparison of powder and aerosolized budesonide in perennial rhinitis: validation of rhinitis quality of life questionnaire. Development and preliminary validation of the multiattribute Rhinitis Symptom Utility Index. Assessment of quality of life in adolescents with allergic rhinoconjunctivitis: development and testing of a questionnaire for clinical trials. Sedation with ``non-sedating' antihistamines: four prescription-event monitoring studies in general practice. Histamine skin test reactivity following single and multiple doses of azelastine nasal spray in patients with seasonal allergic rhinitis. Comparison of pharmacokinetics and metabolism of desloratadine, fexofenadine, levocetirizine and mizolastine in humans. Degree and duration of skin test suppression and side effects with antihistamines: a double blind controlled study with five antihistamines. The pharmacokinetics and bioavailability of clemastine and phenylpropanolamine in single-component and combination formulations. A comparison of the in vivo effects of ketotifen, clemastine, chlorpheniramine and sodium cromoglycate on histamine and allergen induced weals in human skin. Effectiveness of clemastine fumarate for treatment of rhinorrhea and sneezing associated with the common cold. Effective prophylactic therapy for cyclic vomiting syndrome in children usig amitriptyline or cyproheptadine. Duration of the inhibitory activity on histamine-induced skin weals of sedative and non-sedative antihistamines. Pharmacokinetics of diphenhydramine in healthy volunteers with a dimenhydrinate 25 mg chewing gum formulation. Pharmacokinetics of promethazine hydrochloride after administration of rectal suppositories and oral syrup to healthy subjects. A retrospective study of promethazine and its failure to produce the expected incidence of sedation during space flight. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. Home-prepared saline: a safe, cost-effective alternative for wound cleansing in home care. Pregnancy outcome after gestational exposure to loratadine or antihistamines: a prospective controlled cohort study. Pregnancy outcome after gestational exposure to terfenadine: a multicenter, prospective controlled study. The diagnosis of asthma using a self-questionnaire in those suffering from allergic rhinitis: a pharmacoepidemiological survey in everyday practice in France. Increase of asthma, allergic rhinitis and eczema in Swedish schoolchildren between 1979 and 1991. Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. Direct costs of allergic rhinitis in the United States: estimates from the 1996 Medical Expenditure Panel Survey. Health effects of passive smoking, 5: parental smoking and allergic sensitisation in children. On the association between date of birth and pollen sensitization: is age an effect modifier Food hypersensitivity in children: clinical aspects and distribution of allergens. An essential role for dendritic cells in human and experimental allergic rhinitis. The time course of the bilateral release of cytokines and mediators after unilateral nasal allergen challenge. Presence and characterization of prostaglandin D2-related molecules in nasal mucosa of patients with allergic rhinitis. Phenotypic alteration of neuropeptide-containing nerve fibres in seasonal intermittent allergic rhinitis. Nasal allergen provocation induces adhesion molecule expression and tissue eosinophilia in upper and lower airways. Priming effect of a birch pollen season studied with laser Doppler flowmetry in patients with allergic rhinitis. Allergen-specific nasal challenge: response kinetics of clinical and inflammatory events to rechallenge. Defining childhood atopic phenotypes to investigate the association of atopic sensitization with allergic disease. Rhinoconjunctivitis in 5-year-old children: a population-based birth cohort study. School as a risk environment for children allergic to cats and a site for transfer of cat allergen to homes. Pollen allergy in the Bilbao area (European Atlantic seaboard climate): pollination forecasting methods. Seasonal variation in dust mite and grass-pollen allergens in dust from the houses of patients with asthma. Seasonal distribution of Alternaria, Aspergillus, Cladosporium and Penicillium species isolated in homes of fungal allergic patients. The influence of sex, allergic rhinitis, and test system on nasal sensitivity to airborne irritants: a pilot study. Efficacy and safety of fexofenadine hydrochloride for treatment of seasonal allergic rhinitis. Pollen count, symptom and medicine score in birch pollinosis: a mathematical approach. Relationship among house-dust mites, Der 1, Fel d 1, and Can f 1 on clothing and automobile seats with respect to densities in houses. Atypical nasal challenges in patients with idiopathic rhinitis: more evidence for the existence of allergy in the absence of atopy Mucosal T-cell phenotypes in persistent atopic and nonatopic rhinitis show an association with mast cells. Heterogeneity of atopy, I: clinical and immunologic characteristics of patients allergic to cypress pollen. Treatment with intranasal fluticasone propionate significantly improves ocular symptoms in patients with seasonal allergic rhinitis. Ocular symptom reduction in patients with seasonal allergic rhinitis treated with the intranasal cortiocosteroid mometasone furoate. Comparison of ketotifen fumarate ophthalmic solution alone, desloratadine alone, and their combination for inhibition of the signs and symptoms of seasonal allergic rhinoconjunctivitis in the conjunctival allergen challenge model: a double-masked, placebo- and active-controlled trial. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. An evaluation of onset and duration of action of patanol (olopatadine hydrochloride ophthalmic solution 0. Rapid onset of action of levocabastine eye-drops in histamine-induced conjunctivitis. Evaluation of immediate adverse reactions to foods in adult patients, I: correlation of demographic, laboratory, and prick skin test data with response to controlled oral food challenge. Common respiratory manifestations of food allergy: a critical focus on otitis media. Aleman A, Sastre J, Quirce S, de las Heras M, Carnes J, Fernandez-Caldas E, et al. Allergy to kiwi: a double-blind, placebo-controlled food challenge study in patients from a birch-free area.
Almost none of these will lead to serious error in diagnosis if the examining physician is aware of them and attends to them when examining individual patients who are considered brain dead muscle relaxant withdrawal symptoms purchase 60 mg pyridostigmine amex. In fact muscle relaxant comparison chart buy 60mg pyridostigmine otc, there are no reported cases of ``recovery' from correctly diagnosed brain death muscle relaxer 75 pyridostigmine 60 mg online. Conversely muscle relaxant for bruxism order pyridostigmine 60mg overnight delivery, there are several reported cases of recovery from ``cardiac' death spasms compilation order pyridostigmine 60 mg without a prescription,37 the Lazarus phenomenon (not to be confused with Lazarus sign muscle relaxant renal failure cheap 60 mg pyridostigmine with amex, a spinal reflex [see page 334]). A number of case reports describe patients with clinical and electrocardiographic cardiac arrest who, after failed attempts at resuscitation, are pronounced dead, only to be discovered to be alive later, sometimes in the mortuary. Pupils fixed Possible Causes Anticholinergic drugs, tricyclic antidepressants Neuromuscular blockers Pre-existing disease Ototoxic agents Vestibular suppression Pre-existing disease Basal skull fracture Posthyperventilation apnea Neuromuscular blockers Neuromuscular blockers ``Locked-in' state Sedative drugs Sedative drugs Anoxia Hypothermia Encephalitis Trauma 2. In rare instances, the pupils may have been fixed by pre-existing ocular or neurologic disease. More commonly, particularly in a patient who has suffered cardiac arrest, atropine has been injected during the resuscitation process and pupils are widely dilated; fixed pupils may result without indicating the absence of brainstem function. Neuromuscular blocking agents also can produce pupillary fixation, although in these instances the pupils are usually midposition or small rather than widely dilated. Similarly, the absence of vestibulo-ocular responses does not necessarily indicate absence of brainstem vestibular function. Like pupillary responses, vestibulo-ocular reflexes may be absent if the end organ is either poisoned or damaged. For example, traumatic injury producing basal fractures of the petrous bone may cause unilateral loss of caloric response. Some otherwise neurologically normal patients suffer labyrinthine dysfunction from peripheral disease that predates the onset of coma. Other patients with chronic illnesses have suffered ototoxicity from a variety of drugs, including antibiotics such as gentamicin. In these patients, vestibulo-ocular responses may be absent even though other brainstem processes are still functioning. Finally, a variety of drugs, including sedatives, anticholinergics, anticonvulsants, chemotherapeutic agents, and tricyclic antidepressants, may suppress vestibular and/or oculomotor function to the point where oculovestibular reflexes disappear. Pitfalls in the diagnosis of apnea in comatose patients maintained on respirators have been discussed above. Neuromuscular blockers are often used early in the course of artificial respiration when the patient is resisting the respirator; if suspected brain death subsequently occurs, there may still be enough circulating neuromuscular blocking agent to produce absence of motor function when the examination is carried out. If neuromuscular blockade has been recently withdrawn, guidelines require that a peripheral nerve stimulator be used to demonstrate transmission. Therapeutic overdoses of sedative drugs to treat anoxia or seizures likewise may abolish reflexes and motor responses to noxious stimuli. At least two reports document formal brain death examinations in reversible intoxications with tricyclic antidepressant and barbiturate agents. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. Prolonged hemodynamic maintenance by the combined administration of vasopressin and epinephrine in brain death: a clinical study. Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon). The unilateral extension-pronation reflex of the upper limb as an indication of brain death. Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Scientific, philosophic, and emotional uncertainties that attend predictions of outcome from brain damage can intimidate even the most experienced physicians. Nevertheless, the problem must be faced; physicians are frequently called upon to treat patients with severe degrees of neurologic dysfunction. To do the job responsibly, the physician must organize available information to anticipate as accurately as possible the likelihood that the patient will either recover or remain permanently disabled. The financial and emotional costs of caring for those left hopelessly damaged can exhaust both family and medical staff. Physicians must attempt to reduce those burdens, while at the same time retaining an unwavering commitment to do everything possible to treat those who can benefit. In the 26 years since the publication of the third edition of Stupor and Coma, several groups of neurologists and neurosurgeons have initiated studies to identify and quantify early clinical, neurophysiologic, radiologic, and biochemical indicants that might predict outcome in comatose patients. These studies have identified the etiology of injury, the clinical depth of coma, and the length of time that a patient remains comatose as the most critical factors. The bold black line indicates emergence from the minimally conscious state, defined by reliable functional communication. Several limitations, as discussed below, place stringent demands on physicians to carefully consider all available historical details and the reliability of clinical and laboratory evaluations in their consideration of prognosis for an individual patient. Prospective studies of prognosis in adults and children indicate that within a few hours or days after the onset of coma, neurologic signs and electrophysiologic markers in many patients differentiate, with a high degree of probability, the extremes of no improvement or good recovery. Unfortunately, radiologic and biochemical indicators have generally provided less accurate predictions of outcome, with some exceptions discussed below. Accurate prognostication improves over time, but it is still unclear how early one can make accurate predictions within different diagnostic categories. The first section of this chapter details what we now know about prognosis, emphasizing broad outcome categories and shortterm outcomes rather than outcomes beyond a year or longer, although we recognize that rarely, even severely brain-injured patients may improve after many years (see page 371). The second section addresses mechanisms that may underlie recovery, or lack thereof, from coma. Severe cognitive disabilities can arise from at least two fairly different anatomic injuries: (1) extensive, relatively uniform diffuse axonal injury or hypoxic-ischemic damage causing widespread neuronal death and (2) focal cerebral injuries causing functional al- teration of integrative systems in the upper brainstem and thalamus. New studies suggest that physiologic correlates of brain function in some severely disabled patients with relatively intact cerebral structures may ultimately lead to identification of residual cerebral capacities. The third section addresses important ethical considerations in dealing with comatose patients and their families and caregivers. For the two most carefully studied etiologies of coma, traumatic brain injury and cardiopulmonary arrest, mortality ranges from 40% to 50% and 54% to 88%,2 respectively. These statistics have actually improved since the last edition of Stupor and Coma, because of better acute management both in the field and in intensive care. Beyond mortality statistics, very few studies of prognosis in coma have looked at large numbers of patients for careful evaluation of outcomes other than survival or death. These indicate that patients comatose from traumatic brain injury have a significantly better prognosis than patients with anoxic injuries. For example, of 1,000 trauma patients in coma for at least 6 hours, 39% recovered independent function at 6 months,3 whereas only 16% of 500 patients suffering nontraumatic coma made similar recoveries at 1 year. This section reviews efforts to predict outcome from coma for different etiologies. The reader will find that the literature continues to provide little specific information about the kind of outcome enjoyed or suffered by patients. The definitions attempted to identify fairly precisely what was meant by each grade of outcome. Only a small number of outcomes were chosen in the hope that sufficient numbers of patients would fall into each class to allow statistical analysis, but that important differences in medical and social recovery would not be excessively blurred. There still exists a need for further subdivision and consideration of outcomes in the severely disabled group, as discussed below. For example, when using the prognostic data provided below, care should be taken to distinguish indicators of death from those indicating outcomes including severe disability, which remains a very broad category. Where possible, information specific to other etiologies is provided below, but the physician should recognize this general limitation when formulating a prognosis for a comatose patient who has not suffered a traumatic brain injury or cardiac arrest. Consciousness, Mechanisms Underlying Outcomes, and Ethical Considerations 345 a better prognosis than nontraumatic coma, possibly because patients are usually younger and the pathophysiology differs from other types of coma. Recovery after prolonged traumatic coma is well described and, unlike nontraumatic causes, unconsciousness for 1 month does not necessarily preclude significant recovery. Severe head injury causing 6 hours or more of coma still carries a 40% probability of recovering to a level of moderate disability or better. By 6 hours, motor responses no better than abnormal flexor were associated with a mortality of 63%, while abnormal extensor or flaccid responses predicted an 83% mortality. Paradoxically, elderly patients may require a much longer recovery time, so it is risky to predict ultimate recovery early in the course. A meta-analysis of 5,600 patients identified a continuously worsening prognosis with increasing age without a sharp stepwise drop at any point. Data from the Traumatic Coma Data Bank8 reveal an increased incidence of intracranial hemorrhage with age and premorbid medical illnesses, but did not demonstrate a significant statistical association. In one series, 95% of patients who had either bilaterally nonreactive pupils or absent oculocephalic responses at 6 hours after injury died. A single episode of hypotension (arterial line reading) is associated with a doubling of mortality and a significant increase in morbidity. Although length of coma provides a good indication of severity of brain damage, it can be determined only retrospectively when the patient awakens and thus cannot be used for early prognosis of outcome. On the other hand, it can be predicted with some confidence that a patient in prolonged coma is unlikely to recover. The same limitation applies to efforts to correlate outcomes of recovery of cognitive functions with the duration of posttraumatic amnesia. Percentage of patients who recovered full consciousness as a function of duration of coma for several age groups. Other electrophysiologic markers, including cognitive event-related potentials,28 might provide better prognostic value in future studies. Jennett and colleagues in Glasgow, undertook prospective studies of the outcome from coma as caused by medical disorders. All patients over 12 years old, save those with head trauma or exogenous intoxication in acute coma, were identified and repeatedly examined. Meticulous efforts were made to examine every patient in coma using examining techniques that guaranteed consistency of observation. The patients were followed for a minimum of 12 months (unless death occurred first) and many for much longer (only two of the 500 patients were lost to follow-up). This large population provided landmark data on substantial numbers of individuals in each of the major disease categories, permitting correlations between outcome and both the severity of early signs of neurologic dysfunction and the specific etiology of coma. Subsequent studies have largely confirmed the conclusions drawn from this patient population, including larger prospective studies of coma following cardiac arrest. Of the 500 patients, 379 (76%) died within the first month and 88% had died by the end of a year. Some of the patients died during that first month of nonneurologic causes, but the table is constructed so as to indicate the highest possible chance of recovery by the brain. The difference is explained by most of the hepatic and miscellaneous patients having reversible biochemical, infectious, or extracerebral intracranial. By contrast, many patients with stroke or global cerebral ischemia suffered destruction of brain structures crucial for consciousness. Reflecting this difference, the metabolic-miscellaneous group of patients showed significantly fewer signs of severe brainstem dysfunction than did those with vascular-ischemic disorders. For example, corneal responses were absent in fewer than 20% of the metabolic group, but in more than 30% of the remaining patients. Furthermore, when patients with hepatic-miscellaneous causes of coma did show abnormal neuro-ophthalmologic signs (see below), their prognosis was as poor as that of patients in the other disease groups with similar signs. Patients who survived medical coma had achieved most of their improvement by the end of the first month. Among the 121 patients still living at 1 month, 61 died within the next year, usually from progression or complication of the illness that caused coma in the first place. Other cerebrovascular diseases include 76 with brain infarcts and 67 with brain hemorrhage. Miscellaneous includes 19 patients with mixed metabolic disturbances and 16 with infection. Consciousness, Mechanisms Underlying Outcomes, and Ethical Considerations 349 There were seven moderately disabled patients who improved to a good recovery. Of 39 patients severely disabled at 1 month, nine later improved to a good recovery or moderate disability rating. At the end of the year, three patients remained vegetative and four severely disabled. While current patients may have a greater chance of survival with modern therapies, it is unfortunately not likely that they would have a significantly different natural history after 1 month, suggesting that the data from this series remain relevant. The outcome was influenced by three major clinical factors: the duration of coma, neuroophthalmologic signs, and motor function. Of somewhat lesser importance was the course of recovery; a history of steady improvement was generally more favorable than was initially better function that remained unchanged for the next several days. Among patients who survived three days, 60% who were awake and talked made a satisfactory recovery within the first month, compared with only 5% of those still vegetative or in a coma. Contrary to initial expectations, no consistent relationship emerged between age and prognosis either for the study as a whole or for individual illnesses.
Genital tuberculosis presents under two forms spasms eye cheap pyridostigmine 60 mg overnight delivery, either the silent or the active form muscle relaxer jokes buy pyridostigmine 60mg with visa. In the silent forms there are no particular symptoms; there is no pain and no fever muscle relaxant in anesthesia cheap pyridostigmine 60 mg with visa. In the active or advanced forms there are general symptoms and signs of the tuberculous process spasms diaphragm generic pyridostigmine 60 mg otc, meno- or metrorrhagias muscle relaxant cyclobenzaprine dosage discount 60mg pyridostigmine amex, sometimes amenorrhea muscle relaxant vicodin order pyridostigmine 60mg on line. Signs On pelvic examination a fixed retroversion with palpable tubo-ovarian masses may be found. Spontaneous pain and dysmenorrhea may be explained by a pyo- or hydrosalpinx or by a tuberculous pelvioperitonitis. It may, on the other hand, evolve towards a pyosalpinx or an ovarian abscess or to a tuberculous pelvioperitonitis or a general peritonitis. Diagnostic Criteria In advanced cases general symptoms and signs of the tuberculous process, abdominal pain or discomfort, signs of a pelvic infection, together with a positive tuberculin test and bacteriological evidence of tuberculosis constitute the basis of the diagnosis. Prevalence: Because histological proof of the diagnosis is usually missing, the prevalence is unknown, but the condition is seen infrequently. It may be found soon after a delivery, especially if the cervix has been torn and infected. Symptoms: the patient complains of lower abdominal pain with or without low backache, and deep dyspareunia. The pain may occur during the premenstrual period and disappear during menstruation, or it may be continuous, with premenstrual exacerbation. Signs A more or less severely torn cervix is found and either an acute or a chronic cervicitis. Pathology Posterior parametritis on chronic cervicitis is believed to be due to extension of a cervical infection along the lymphatics of the parametrium. Diagnostic Criteria and Treatment Diagnosis of cervicitis depends on finding agglutinated leukocytes in the cervical mucus during the periovulatory period. The presence of an infected cervical canal and of a tender posterior parametrium and the absence of a history and of clinical findings suggestive of endometriosis make the diagnosis of posterior parametritis plau- Page 169 phase. Silent cases are usually diagnosed by the presence of tubercular lesions in an endometrial biopsy taken during the evaluation of infertility cases. Treatment Treatment is essentially medical by means of a combined drug regimen with Rifamycin, isoniazid, and ethambutol. Surgery will be resorted to only if pelvic masses persist or increase under medical treatment, if endometrial lesions persist, and if pain or other pelvic symptoms are not alleviated by drug therapy. Main Features Retroversion of the uterus is found in 15 to 20% of adult women, but only a small number of mobile retroversions cause symptoms. In a few cases it may give rise to intermittent pain with or without deep dyspareunia. The pain will be located either in the lower abdomen or in the sacro-gluteal region or in both sites. The pain usually is worse during the premenstrual period and mostly disappears or decreases after the first or second day of the period. On pelvic examination the retroverted uterus is tender and frequently slightly enlarged and softer than normal. Pathology It has repeatedly been observed that the size of a painful retroverted uterus diminishes and that it becomes firmer after anterior reposition. If the pain disappears after correction of the retroversion and insertion of a pessary, it does so gradually during the two to three days following the reposition. These circumstances seem to indicate that circulatory disturbances, probably passive pelvic congestion, cause the pain. Diagnostic Criteria the uterus is said to be retroverted when the axis of the cervix is directed towards the symphysis pubis and the axis of the uterine corpus towards the excavation of the sacrum. A retroversion is said to be fixed when adhesions bind the uterine corpus down in the pouch of Douglas. A mobile retroversion should be considered the cause of the pain only if no other causes of pain are found, such as endo- metriosis or posterior parametritis on a chronic cervicitis, and if the pain disappears after anterior reposition of the uterus. If a patient with a fixed retroversion complains of some symptoms, it is usually impossible to prove which symptoms are due to the retroversion and which are not. Treatment must therefore be directed against the causal disorder, which may be either endometriosis or sequelae of acute pelvic inflammatory disease or of a pelvioperitonitis, or a tuberculous salpingitis. Treatment A mobile retroversion that causes no symptoms does not require any treatment. If the patient complains of pain, reposition of the uterus will be tried and a pessary inserted. If the retroversion is fixed, treatment must be directed against the causal condition and a suspension operation should be performed only when the retroversion itself is probably the cause of the complaint, as in some cases of dyspareunia, or when there are other reasons for surgical intervention. The symptomatology of uterine retroversion and, in particular, pain in uterine retroversion (Dutch), Verhand. If the result of this examination is compatible with a functional cyst, it is recommended to treat it conservatively by means of oral contraceptives. There is a good chance that the cyst and the pain will disappear, whereas surgical exploration with wedge resection of the ovary is Page 170 likely to be followed by a recurrence of the cyst and of the painful episode. Main Features: when a bilateral oophorectomy has been performed in conditions that make it difficult to be sure that all ovarian tissue is removed. Diagnostic Criteria: an ovarian remnant will be suspected when the patient presents evidence of estrogen secretion that persists after a short course of corticoids prescribed to suppress adrenal androstenedione secretion and its peripheral conversion to estrone. It has become clear that formerly many chronic painful conditions have erroneously been classified under the above heading. Associated Symptoms the most important symptom is lower abdominal pain and, less frequently, low back pain. The lower abdominal pain may be felt either in the whole lower abdomen or in both iliac fossae, or in one fossa only. The low back pain may be felt over the whole width of the sacrogluteal zone or over a part of this zone. The pain is usually more severe for several days before menstruation, and its intensity decreases on the first or second day of the period. Medical treatment is not well-defined and is therefore not usually successful in chronic cases. When a chronic pelvic pain syndrome has lasted for several months and has not been cured by medical treatment, it is useful to perform a laparoscopy in order to look for nonpalpable lesions, such as endometriosis or sequelae of chronic pelvic inflammatory disease, which might explain the pain. On gynecological examination the uterus and adnexa may be tender; there is frequently tenderness of the posterior parametrium, and sometimes it is shortened. Pathology Besides lower abdominal pain with or without sacrogluteal pain and the frequent complaint of deep dyspareunia, many patients have several complaints including one or more that are usually considered functional; these patients may therefore be called polysymptomatic. Most oligosymptomatic patients complain merely of spontaneous pelvic pain and deep dyspareunia. During the last decades various conditions have been suspected as possible causes. It has been thought that in a percentage of cases the syndrome is due to traumatic laceration of a sacrouterine ligament or of a posterior leaf of one or both broad ligaments. There is good indirect evidence that circulatory factors may give rise to chronic or intermittent lower abdominal pain. Main Features Chronic pelvic pain without obvious pathology is the name given recently to a syndrome that has been known and described for more than a century under many different names, some of them being: parametropathia spastica, pelvic congestion and fibrosis, pelipathia vegetativa, and pelvic sympathetic syndrome. However, the morphological or functional basis of this tenderness remains to be elucidated. All those who studied the psychological characteristics of these patients found definite psychopathological anomalies or stress situations in most, although not all, of the patients examined. At one end, there are patients with very little peripheral noxious stimulation whose complaints will, to a large extent, have a psychological explanation. The other extreme is made up of persons with rather intense peripheral noxious stimulation: either pelvic circulatory disturbances or tenderness of the posterior parametrium and, less often, uterine cramps or a real tear in a sacro-uterine ligament, and little or no psychological factor. In between these extremes there are apparently a number of mixed cases with less pronounced peripheral noxious stimulation and one or more of the psycho-physiological mechanisms that may induce complaints and care-seeking behavior. Some patients have been helped with cyclic estroprogestogens; others have had hypo-estrogenic amenorrhea induced by continuous administration of oral progestogens. Main Features the pain can occur immediately after the operation but not infrequently occurs after months or years. The pain is burning or lancinating and radiates to the area supplied by the sensory nerve. For the iliohypogastric nerve the pain radiates to the midline above the pubis but also laterally to the hip region. For the ilio-inguinal and the genito-femoral nerve the pain radiates from the groin into the anterior part of the labia major (or the scrotum and the root of the penis) and on the inside or the anterior surfaces of the thigh, sometimes down to the knee. Usually the pain is continuously present, but it can be intensified by forcible stretching of the hip joint, coughing, sneezing, sexual intercourse, or general tension in the abdominal muscles. The patient frequently adopts a posture that eases discomfort, with a slight flexure of the hip and a slight forward inclination of the trunk. Signs On examination the pain can be triggered in a narrowly circumscribed area of the operative scar. Usually, there is a tenderness along the course of the nerve from near the anterior superior iliac spine to the external genitalia; when the genito-femoral nerve is involved, the internal ring of the inguinal canal can be very painful. As a rule, cutaneous sensibility is more or less impaired in the region innervated by the affected nerve. Usually, there is an increased threshold for touch and prick sensation in combination with hyperalgesia; the hypoesthesia is some times best demonstrated with cold stimuli. In some cases scratching the skin induces less reddening or an absence of it on the affected side as compared to the intact side, indicating the degeneration of afferent C-fibers. Although motor impairment of abdominal muscles can be present, this is hard to evaluate because the motor tests usually exacerbate the pain. If the iliohypogastric nerve is damaged, the lower abdominal skin reflex may be absent. Typically, with involvement of the genital branch of the genito-femoral nerve in man, the cremaster reflex is absent on the affected side. Usual Course Without treatment, the pain may persist for several years without tendency to improvement. Pathology If the nerve was sectioned during surgical intervention, histological examination may show a neuroma. Diagnostic Criteria Typical pain radiation with sensory impairment and pain relief by local anesthetic. Treatment the pain can be relieved by injection of a local anesthetic proximally from the injury side; for the iliohypogastric and ilio-inguinal nerve the injection is done two finger-widths medially from the anterior superior iliac spine, where they leave the internal oblique muscle. Burning pain with occasional superimposed paroxysms in the distribution of the involved nerve. Differential Diagnosis Inguinal and femoral hernia; lymphadenopathy; periostitis of pubic tubercle. When that happens the rectal pain is usually associated with severe depressive or schizophrenic illness but may also be associated with conversion symptoms. X9f Delusional Conversion Depressive Precipitating Factors A bowel movement, sexual activities, stress, heat, or cold may precipitate an attack. Usual Course the frequency of episodes tends to fall with age, and usually stops by the age of 70. Social and Physical Disabilities Between episodes of pain, the sufferer is completely well. Marital disharmony due to the fear of sexual intercourse precipitating an attack has been described. Pathology or Other Contributing Factors Proctalgia is thought by some to occur more commonly in sufferers from irritable bowel symptoms. Others report that patterns submitted to psychiatric assessment and personality tests were perfectionist, anxious, tense, and hypochondriacal. Diagnostic Criteria Episodic pain in the rectal area occurring in otherwise well subjects. Proctalgia fugax has been attributed to spasm of the sigmoid colon or levator ani. Main Features the pain is severe, episodic, and usually located in the midline somewhere above the anal sphincter. The pain is sudden in onset, without warning, lasting from several seconds to 20 minutes. It may occur at any time of day, or may waken the sufferer from a deep sleep at night. Prevalence the pain occurs in 14-19% of healthy subjects and is somewhat more common in women (17. For explanatory material on this section and on section D, Spinal and Radicular Pain Syndromes of the Cervical and Thoracic Regions, see pp. Diagnostic Features Radiographic or other imaging evidence of a fracture of one of the osseous elements of the lumbar vertebral column. Clinical Features Lumbar spinal pain with or without referred pain, associated with pyrexia or other clinical features of infection. Diagnostic Features A presumptive diagnosis can be made on the basis of an elevated white cell count or other serological features of infection, together with imaging evidence of the presence of a site of infection in the lumbar vertebral column or its adnexa. Diagnostic Features A presumptive diagnosis may be made on the basis of imaging evidence of a neoplasm that directly or indirectly affects one or other of the tissues innervated by lumbar spinal nerves. Absolute confirmation relies on obtaining histological evidence by direct or needle biopsy. Diagnostic Features Imaging or other evidence of metabolic bone disease affecting the lumbar vertebral column, confirmed by appropriate serological or biochemical investigations and/or histological evidence obtained by needle or other biopsy. Similarly, the condition of "spondylosis" is omitted from this schedule because there is no positive correlation between the radiographic presence of this condition and the presence of spinal pain. There is no evidence that this condition represents anything more than agechanges in the vertebral column.
The utility of testing tactile perception of direction of scratch as a sensitive clinical sign of posterior column dysfunction in spinal cord disorders spasms left rib cage 60mg pyridostigmine sale. A reappraisal of "direction of scratch" test: using somatosensory evoked potentials and vibration perception spasms with cerebral palsy pyridostigmine 60mg on line. Seizure morphology may be helpful in establishing aetiology and/or focus of onset muscle relaxant trade names generic pyridostigmine 60mg on line. Otherwise muscle relaxant gabapentin generic pyridostigmine 60 mg visa, as for idiopathic generalized epilepsies muscle relaxant yellow pill v generic pyridostigmine 60mg on-line, various antiepileptic medications are available spasms jerks order pyridostigmine 60 mg without prescription. Best treated with psychological approaches or drug treatment of underlying affective disorders; antiepileptic medications are best avoided. The differentiation of epileptic from non-epileptic seizures may be difficult; it is sometimes helpful to see a video recording of the attacks or to undertake in-patient video-telemetry. This pattern is highly suggestive of a foramen magnum lesion, usually a tumour but sometimes demyelination or other intrinsic inflammatory disorder, sequentially affecting the lamination of corticospinal fibres in the medullary pyramids. Cross References Hemiparesis; Paresis; Quadriparesis, Quadriplegia Setting Sun Sign the setting sun sign, or sunset sign, consists of tonic downward deviation of the eyes with retraction of the upper eyelids exposing the sclera. Setting sun sign is a sign of dorsal midbrain compression in children with untreated hydrocephalus. Metallic poisonings (mercury, bismuth, lead) may also produce marked salivation (ptyalism). Recently, the use of intraparotid injections of botulinum toxin has been found useful. Botulinum toxin treatment of sialorrhoea: comparing different therapeutic preparations. Cross References Bulbar palsy; Parkinsonism Sighing Occasional deep involuntary sighs may occur in multiple system atrophy. Sighing is also a feature, along with yawning, of the early (diencephalic) stage of central herniation of the brainstem with an otherwise normal respiratory pattern. Recognition of single objects is preserved; this is likened to having a fragment or island of clear vision which may shift from region to region. There may be inability to localize stimuli even when they are seen, manifest as visual disorientation. Ventral: A limitation in the number of objects which can be recognized in unit time, i. Ventral simultanagnosia is most evident during reading which is severely impaired and empirically this may be the same impairment as seen in pure alexia; otherwise deficits may not be evident, unlike dorsal simultanagnosia. This is thought to reflect damage to otolith-ocular pathways or vestibulo-ocular pathways. Skew deviation has been associated with posterior fossa lesions, from midbrain to medulla. Ipsiversive skew deviation (ipsilateral eye lowermost) has been associated with caudal pontomedullary lesions, whereas contraversive skew (contralateral eye lowermost) occurs with rostral pontomesencephalic lesions, indicating that skew type has localizing value. Skew deviation with ocular torsion: a vestibular brainstem sign of topographic diagnostic value. Dysarthria, facial paresis, hemiparesis with or without hemihypoaesthesia, and excessive laughing with or without crying were common accompanying features in one series. Sensory nasal trigeminal afferents run to a putative sneeze centre, localized to the brainstem based on lesions causing loss of sneezing following lateral medullary syndrome and medullary neoplasm. Integration of inputs in this centre reaches a threshold at which point an expiratory phase occurs with exhalation, forced eye closure, and contraction of respiratory musculature. Cross Reference Lateral medullary syndrome Snoring Reduced muscle tone in the upper airway during sleep leads to increased resistance to the flow of air, and partial obstruction often results in loud snoring. Cross Reference Hypersomnolence Snouting, Snout Reflex Sometimes used interchangeably with pout reflex, this term should probably be reserved for the puckering or pouting of the lips induced by constant pressure over the philtrum, rather than the phasic response to a tap over the muscle with finger or tendon hammer. Cross References Frontal release signs; Pout reflex; Primitive reflexes Somatoparaphrenia Ascription of hemiplegic limb(s) to another person. For example, flexor spasms in patients paraplegic due to upper motor neurone lesions are sudden contractions of the flexor musculature, particularly of the legs, either spontaneous or triggered by light touch. Spasm may also refer to a tetanic muscle contraction (tetany), as seen in hypocalcaemic states. Infantile seizures consisting of brief flexion of the trunk and limbs (emposthotonos, salaam or jack-knife seizures) may be known as spasms. This is usually a benign idiopathic condition, but the diagnosis should prompt consideration of an optic pathway tumour. Spasmus nutans-like nystagmus is often associated with underlying ocular, intracranial, or systemic abnormalities. The excessive resistance evident at the extremes of joint displacement may suddenly give way, a phenomenon known as clasp-knife (or, confusingly, clasp-knife rigidity). The amount and pattern of spasticity depends on the location of the lesion and tends to be greater with spinal cord than cortical lesions. Scales to quantitate spasticity are available (Ashworth, modified Ashworth, pendulum test of Wartenberg) but have shortcomings. Spasticity may also vary in distribution: for lesions above the spinal cord it typically affects the arm flexors and the leg extensors to a greater extent (hemiparetic posture). Slow, laboured speech, with slow voluntary tongue movements, may be referred to as spastic dysarthria, which may occur in the context of a pseudobulbar palsy. The pathogenesis of spasticity has traditionally been ascribed to damage to the corticospinal and/or corticobulbar pathways at any level from cerebral cortex to spinal cord. Treatment of severe spasticity, for example, in multiple sclerosis, often requires a multidisciplinary approach. Urinary infection, constipation, skin - 330 - Spinal Mass Reflex S ulceration, and pain can all exacerbate spasticity, as may inappropriate posture; appropriate management of these features may ameliorate spasticity. Intrathecal baclofen given via a pump may also be of benefit in selected cases, and for focal spasticity injections of botulinum toxin may be appropriate. For painful immobile spastic legs with reflex spasms and double incontinence, irreversible nerve injury with intrathecal phenol or alcohol may be advocated to relieve symptoms. This, or a very similar, constellation of features has also been known as cortical dysarthria, aphemia, or phonetic disintegration. Speech apraxia has been associated with inferior frontal dominant (left) hemisphere damage in the region of the lower motor cortex or frontal operculum; it has been claimed that involvement of the anterior insula is specific for speech apraxia. The syndrome is thought to reflect disturbances of planning articulatory and phonatory functions, but is most often encountered as part of a non-fluent aphasia. If not deliberate, it presumably reflects a left hemisphere dysfunction in the appropriate sequencing of phonemes. A variant of this foraminal compression test involves rotation, side bend, and slight extension of the neck with the application of axial pressure to the head. Cross Reference Radiculopathy Square Wave Jerks Square wave jerks are small saccades which interrupt fixation, moving the eye away from the primary position and then returning. This instability of ocular fixation is a disorder of saccadic eye movements in which there is a saccadic interval (of about 200 ms; cf. Very obvious square wave jerks (amplitude > 7) are termed macrosquare wave jerks. Their name derives from the appearance they produce on electrooculographic recordings. Although square wave jerks may be normal in elderly individuals, they may be indicative of disease of the cerebellum or brainstem. In the strike phase, there is a characteristic slapping down of the foot, again a consequence of weak ankle dorsiflexion. Proprioceptive loss, as in dorsal column spinal disease, may also lead to a gait characterized by high lifting of the feet and also stomping (stamping with a heavily accented rhythm) or slapping of the foot onto the floor in the strike phase. This may lead to falls as a consequence of tripping over the foot, especially on up-hill gradients, and a characteristic pattern of wear on the point of the shoe. Whole areas of the body may be involved by stereotypies and hence this movement is more complex than a tic. Examples include patting, tapping, rubbing, clasping, - 333 - S Sternocleidomastoid Test wringing, digit sucking, body or head rocking or banging, grimacing, smelling, licking, spitting, and mouthing of objects. Stereotypies are common in patients with learning disability, autism, and schizophrenia. The term has also been used to describe movements associated with chronic neuroleptic use; indeed adult-onset stereotypy is highly suggestive of prior exposure to dopaminereceptor-blocking drugs. The recurrent utterances of global aphasia are sometimes known as verbal stereotypies or stereotyped aphasia. Reiterated words or syllables are produced by patients with profound non-fluent aphasia. Stiffness may be primarily of muscular origin (myotonia) or of neural origin (myokymia, neuromyotonia). Accompanying signs may prove - 334 - Strabismus S helpful in diagnosis, such as slow muscle relaxation (myotonia), percussion irritability of muscle (myoedema), and spontaneous and exertional muscle spasms. Review of 23 patients affected by the stiff man syndrome: clinical subdivision into stiff trunk (man) syndrome, stiff limb syndrome, and progressive encephalomyelitis with rigidity. Cross References Foot drop; Steppage, Stepping gait; Wasting Stork Manoeuvre the patient is asked to stand on one leg, with arms folded across chest, and the eyes open. Absence of wobble or falling is said to exclude a significant disorder of balance or pyramidal lower limb weakness. Hence the thumb remains straight when the patient attempts to grasp something or make a fist. If visual fields are full, the patient will point to the approximate centre; if there is a left field defect, pointing will be to the right of centre, and vice versa for a right field defect. Altitudinal field defects may be similarly identified by holding the string vertically. Cross Reference Visual field defects Stupor Stupor is a state of altered consciousness characterized by deep sleep or unresponsiveness, in which patients are susceptible to arousal only by vigorous and/or repeated stimuli, with lapse back into unresponsiveness when the stimulus stops. Stupor is a less severe impairment of conscious level than coma, but worse than obtundation (torpor). Cross References Coma; Delirium; Encephalopathy; Obtundation Stutter Stutter, one of the reiterative speech disorders, is usually a developmental problem, but may be acquired in aphasia with unilateral or bilateral hemisphere lesions. Unlike developmental stutter, acquired stutter may be evident throughout sentences, rather than just at the beginning. Cessation of developmental stutter following bilateral thalamic infarction in adult life has been reported, as has onset of stutter after anterior corpus callosum infarct. Stuttering without callosal apraxia resulting from infarction in the anterior corpus callosum. Cross References Aphasia; Echolalia; Palilalia Sucking Reflex Contact of an object with the lips will evoke sucking movements in an infant. In dementia, there may be complete reversal of sleep schedule with daytime somnolence and nocturnal wakefulness. Although this syndrome may relate to worsening of visual cues with increasing darkness, it may also occur in well-lit environments. This may reflect intrinsic or intramedullary spinal cord pathology, in which case other signs of myelopathy may be present, including dissociated sensory loss, but it can also occur in peripheral neuropathic disease such as acute porphyria. Cross References Dissociated sensory loss; Myelopathy Swan Neck this term has been applied to thinning of the neck musculature, as in myotonic dystrophy type 1, for example. Swearing Swearing is not, in sensu strictu, a part of language, serving merely to add force of emotion to the expression of ideas; hence it is within the same category as loudness of tone or violence of gesticulation. Cross Reference Coprolalia Sweat Level A definable sweat level, below which sweating is absent, is an autonomic change which may be observed below a spinal compression. Swinging Flashlight Sign the swinging flashlight sign or test, originally described by Levitan in 1959, compares the direct and consensual pupillary light reflexes in one eye; the speed of swing is found by trial and error. Normally the responses are equal but in the - 339 - S Syllogomania presence of an afferent conduction defect an inequality is manifest as pupillary dilatation. The test is known to be unreliable in the presence of bilateral afferent defects of light conduction. Subjective appreciation of light intensity, or light brightness comparison, is a subjective version of this test. Synaesthesia Synaesthesia is a perceptual experience in one sensory modality following stimulation of another sensory modality. Known synaesthetes include the composers Messiaen and Scriabin, the artist Kandinsky, and the author Nabokov.
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