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Medical Instructor, California Northstate University College of Medicine

Phobias are generally more common in women with an onset in late second decade or early third decade hiv infection hindi 200mg zovirax mastercard. Social Phobia Typically late hiv infection symptoms purchase zovirax visa, the onset is sudden without any apparent this is an example of irrational fear of activities or cause hiv infection rates increase buy cheap zovirax. The course is usually chronic with gradually increasing restriction of daily activities zinc finger antiviral protein generic zovirax 400mg line. Sometimes, social interaction, characterised by an irrational fear of phobias are spontaneously remitting. The patient is afraid of his Aetiology own actions being viewed by others critically, resulting in embarrassment or humiliation. Psychodynamic Theory There is marked distress and disturbance in rouAs discussed in the aetiology of anxiety disorders, tine daily functioning. Some of the examples include anxiety is usually dealt with the defense mechanism fear of blushing (erythrophobia), eating in company of repression. When repression fails to function of others, public speaking, public performance. By using displacement, anxiety is figures, and urinating in a public lavatory (shy bladtransferred from a really dangerous or frightening der). These two objects are often is used to overcome the anxiety occurring in social connected by symbolic associations. The neutral object chosen unconsciously is the one which can be easily avoided in day-to-day life, Specific (Simple) Phobia in contrast to the frightening object (frightening to the In contrast to agoraphobia and social phobia where the patient only, due to oedipal genital drives). This is an example of separation anxiety have been theorised to contribute irrational fear of objects or situations. When they are forced to face the phobic situbecomes susceptible to anxiety and fear in childhood ation, anxiety mounts and they then seek treatment. The patients with more than one phobia and presence of panic symptoms often seek treatment earlier. Initially, the anxiety provoked by a naturally frightening or dangerous object occurs Psychodynamically oriented psychotherapy is not in contiguity with a second neutral object. This approach happens often enough, the neutral object becomes a is however indicated when there are characterological conditioned stimulus for causing anxiety. Supportive psychoIn 1920, John Watson experimentally produced therapy is a helpful adjunct to behaviour therapy and phobia in an 11 month old boy who came to be know drug treatment. Using classical conditioning, he As stated earlier, cognitive behaviour therapy paired white objects to a loud noise. Behaviour Therapy Although the behavioural theory does not explain all the features of phobic disorders adequately, it is If properly planned, this mode of treatment is usually very helpful in planning systematic treatment. The behavioural therapies are discussed in Chapter 18 and only the names of important techBiological Theories niques are mentioned here. There is also some evidence for the presence of familial factors in the drugs used in the treatment of phobia are: social phobias. Alprazolam is stated Differential Diagnosis to have anti-phobic, anti-panic and anti-anxiety the differential diagnoses include anxiety disorder, properties. So, it is the drug of choice, when panic disorder, major depression, avoidant personality benzodiazepines are used. However, long-term, disorder, obsessive compulsive disorder, delusional double-blind randomised controlled trials are disorder, hypochondriasis, and schizophrenia. Treatment However, long-term use of benzodiazepines is Most patients with phobic disorder rely on avoidance fraught with the dangers of tolerance and dependto manage their fears and anxieties. Fluoxetine has the advantage of Epidemiology, Course and Outcome a longer half-life. This disAs mentioned earlier, multiple approaches are order is commoner in persons from upper social strata usually combined together in treatment of a particular and with high intelligence. An idea, impulse or image which intrudes into the thought to have a steady chronic course, the longituconscious awareness repeatedly. It is recognised as ones own idea, impulse or A summary of long-term follow-up studies shows image but is perceived as ego-alien (foreign to that about 25% remained unimproved over time, 50% ones personality). Predominantly compulsive acts (compulsive rituognised as ones own idea but is not recognised as als), and ego-alien. Depression is very commonly associated with Thought insertion is not thought of as ones own idea, obsessive compulsive disorder. An obsession is usually associated with Premorbidly obsessional or anankastic personality compulsion(s). A compulsion is defined as: disorder or traits may be commoner than in rest of 1. It is aimed at either preventing or neutralising the literature, although admixtures are commoner than distress or fear arising out of obsession. Obsession with need for symmetry or exactness unable to, so washing becomes a ritual. Hoarding/collecting compulsions Any attempt to stop the checking leads to mount15. Several causative factors have been explored in the Pure Obsessions past but no clear aetiology of obsessive compulsive this syndrome is characterised by repetitive intrusive disorder is known yet. Some of the important theories thoughts, impulses or images which are not associated include: with compulsive acts. The distress associated with these obsessions is dealt usually by counter-thoughts (such Sigmund Freud found obsessions and phobias to be as counting) and not by behavioural rituals. This theory can be exA variant is obsessive rumination, which is a preplained in a fiow diagram (Fig. Here, the person repetitively Isolation of Affect: By this defense mechanism, ruminates in his mind about the pros and cons of the ego removes the affect (isolates the affect) from the thought concerned. The affect howPrimary Obsessive Slowness ever becomes free and attaches itself to other neutral A relatively rare syndrome, it is characterised by idea(s) by symbolic associations. Thus, these neutral severe obsessive ideas and/or extensive compulsive ideas become anxiety-provoking and turn into obsesrituals, in the relative absence of manifested anxiety. This happens only when isolation of affect is this subtype is quite difficult to diagnose in the not fully successful (incomplete isolation of affect). Biological Theories this mechanism has been explained in slight detail as this theory attempts to describe the probable 1. However, it must be remembered that this is only omos encephalitis, basal ganglia lesions, Gilles a theory and whether it is true or not, is a matter of de la Tourette syndrome, and hypothalamic and conjecture. The best responders are usually those who have Drug Treatment significant associated depression, although pure 1. The main benefit is the have a limited role in controlling anxiety as marked reduction in associated distress and severe adjuncts and should be used very sparingly. Antidepressants: Some patients may improve the procedures which can be employed are: dramatically with specific serotonin reuptake i. Presence of symptoms or deficits affecting motor by psychiatrists, physicians and non-professionals or sensory function, suggesting a medical or that it no longer has any one meaning. A clear temporal relationship between stressor and matic, and/or seductive behaviour (histrionic development or exacerbation of symptoms. The symptom may have a symbolic relationship plainable in the context of present organic illness with the stressor/confiict. Difficult patient; poor doctor-patient communicain conversion disorder; motor and sensory. The motor disturbance usually involves either paralyEpidemiology sis or abnormal movements. The paralysis may be a Hysteria (comprising of conversion, dissociation and monoplegia, paraplegia or quadriplegia. Females usually outnumber males, but in amination shows normal or voluntarily increased tone children the percentage tends to be similar in boys and normal refiexes. These movements either occur or and other developing countries, though some patients increase when attention is directed towards them, and may present with only a partial, brief unresponsivemay disappear when patient is watched unobserved. The gait disturbance (astasia abasia) is Clearly, differential diagnosis with true seizures usually characterised by a wide-based, jerky, stagis important.

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For instance hiv transmission statistics top bottom order zovirax 800 mg otc, Kondratyuk (35) reported that a variation in the intake of microelements was associated with up to hiv infection signs and symptoms buy 800mg zovirax visa six-fold differences in their content in muscular tissue hiv infection rates nigeria cheap 400 mg zovirax overnight delivery. These results were found in a 6-month experiment in which rats were randomized into 4 groups and given: a antiviral journals order generic zovirax pills. Furthermore, a negative effect on the blood formation process was found to be associated with non-supplemented demineralised water. The mean hemoglobin content of red blood cells was as much as 19% lower in the animals that received non-supplemented demineralised water compared to that in animals 153 given tap water. The haemoglobin differences were even greater when compared with the animals given the mineral supplemented waters. However, it is not clear whether the effects observed in these studies are due to the low content of calcium and magnesium or other essential elements, or due to other factors. Lutai (37) conducted a large cohort epidemiological study in the Ust-Ilim region of Russia. Water levels of sulfate, chloride, sodium, potassium, copper, zinc, manganese and molybdenum were also determined. The populations of the two areas did not differ from each other in eating habits, air quality, social conditions and time of residence in the respective areas. The population of the area supplied with water lower in minerals showed higher incidence rates of goiter, hypertension, ischemic heart disease, gastric and duodenal ulcers, chronic gastritis, cholecystitis and nephritis. Children living in this area exhibited slower physical development and more growth abnormalities, pregnant women suffered more frequently from edema and anemia. The author concluded that such water could be considered as physiologically optimum. High loss of calcium, magnesium and other essential elements in food prepared in low-mineral water When used for cooking, soft water was found to cause substantial losses of all essential elements from food (vegetables, meat, cereals). Such losses may reach up to 60 % for magnesium and calcium or even more for some other microelements. In contrast, when hard water is used for cooking, the loss of these elements is much lower, and in some cases, an even higher calcium content was reported in food as a result of cooking (38-41). Since most nutrients are ingested with food, the use of low-mineral water for cooking and processing food may cause a marked deficiency in total intake of some essential elements that was much higher than expected with the use of such water for drinking only. The current diet of many persons usually does not provide all necessary elements in sufficient quantities, and therefore, any factor that results in the loss of essential elements and nutrients during the processing and preparation of food could be detrimental for them. Possible increased dietary intake of toxic metals Increased risk from toxic metals may be posed by low-mineral water in two ways: 1. Such water more readily dissolves metals and some organic substances from pipes, coatings, storage tanks and containers, hose lines and fittings, being incapable of forming low-absorbable complexes with some toxic substances and thus reducing their negative effects. For all three cases, lead had leached from brass fittings and lead-soldered seams in drinking water storage tanks. The three water systems used low mineral drinking water that had intensified the leaching process (42). First-draw water samples at the kitchen tap had lead levels of 495 to 1050 g/L for the two infants with the highest blood lead; 66 g/L was found in water samples collected at the kitchen tap of the third infant (43). Calcium and, to a lesser extent, magnesium in water and food are known to have antitoxic activity. They can help prevent the absorption of some toxic elements such as lead and cadmium from the intestine into the blood, either via direct reaction leading to formation of an unabsorbable compound or via competition for binding sites (44-50). Populations supplied with low-mineral water may be at a higher risk in terms of adverse effects from exposure to toxic substances compared to populations supplied with water of average mineralization and hardness. Possible bacterial contamination of low-mineral water All water is prone to bacterial contamination in the absence of a disinfectant residual either at source or as a result of microbial re-growth in the pipe system after treatment. Bacterial re-growth within the pipe system is encouraged by higher initial temperatures, higher temperatures of water in the distribution system due to hot climates, lack of a residual disinfectant, and possibly greater availability of some nutrients due to the aggressive nature of the water to materials in contact with it. Although an intact desalination membrane should remove all bacteria, it may not be 100 % effective (perhaps due to leaks) as can be documented by an outbreak of typhoid fever caused by reverse osmosis-treated water in Saudi Arabia in 1992 (51). Thus, virtually all waters including desalinated waters are disinfected after treatment. Non pathogenic bacterial re-growth in water treated with different types of home water treatment devices was reported by Geldreich et al. The Czech National Institute of Public Health (34) in Prague has tested products intended for contact with drinking water and found, for example, that the pressure tanks of reverse osmosis units are prone to bacterial regrowth, primarily do to removal of residual disinfectant by the treatment. They also contain a rubber bag whose surface appears to be favourable for bacterial growth. Organoleptic characteristics and thirst-quenching capacity were also considered in the recommendations. For example, human volunteer studies (3) showed that the water temperatures of 15-350 C best satisfied physiological needs. Water temperatures above 350 or below 150 C 155 resulted in a reduction in water consumption. The recommendations were based on extensive experimental studies conducted in rats, dogs and human volunteers. These levels were based on health concerns with the most critical effects being hormonal changes in calcium and phosphorus metabolism and reduced mineral saturation of bone tissue. Also, when calcium is increased to 30 mg/L, the corrosive activity of desalinated water would be appreciably reduced and the water would be more stable (3). The report (3) also recommended a bicarbonate ion content of 30 mg/L as a minimum essential level needed to achieve acceptable organoleptic characteristics, reduced corrosivity, and an equilibrium concentration for the recommended minimum level of calcium. Recent recommendations More recent studies have provided additional information about minimum and optimum levels of minerals that should be in demineralised water. For example, the effect of drinking water of different hardness on the health status of women aged from 20 to 49 years was the subject of two cohort epidemiological studies (460 and 511 women) in four South Siberian cities (55, 56). Based on the currently available data, various researchers have recommended that the following levels of calcium, magnesium, and water hardness should be in drinking water: For magnesium, a minimum of 10 mg/L (33, 56) and an optimum of about 20-30 mg/L (49, 57); 156 For calcium, a minimum of 20 mg/L (56) and an optimum of about 50 (40-80) mg/L (57, 58); For total water hardness, the sum of calcium and magnesium should be 2 to 4 mmol/L (37, 50, 59, 60). The maximum protective or beneficial health effects of drinking water appeared to occur at the estimated desirable or optimum concentrations. The recommended magnesium levels were based on cardiovascular system effects, while changes in calcium metabolism and ossification were used as a basis for the recommended calcium levels. The upper limit of the hardness optimal range was derived from data that showed a higher risk of gall stones, kidney stones, urinary stones, arthrosis and arthropathies in populations supplied with water of hardness higher than 5 mmol/L. Long-term intake of drinking water was taken into account in estimating these concentrations. For short-term therapeutic indications of some waters, higher concentrations of these elements may be considered. The first European Directive (62) established a requirement for minimum hardness for softened or desalinated water (fi 60 mg/L as calcium or equivalent cations). The new Directive does not contain a requirement for calcium, magnesium, or water hardness levels. On the other hand, it does not prevent member states from implementing such a requirement into their national legislation. Austria, Germany) included these parameters at lower levels as unbinding regulations, such as technical standards. The Russian technical standard Astronaut environment in piloted spaceships general medical and technical requirements (64) defines qualitative requirements for recycled water intended for drinking in spaceships. The focus is on how to supplement recycled water with a mineral concentrate to make it physiologically valuable (65). Unfortunately, over the two past decades, little research attention has been given to the beneficial or protective effects of drinking water substances. The issue is relevant not only where drinking water is obtained by desalination (if not adequately re-mineralised) but also where home treatment or central water treatment reduces the content of important minerals and low-mineral bottled water is consumed. Drinking water manufactured by desalination is stabilized with some minerals, but this is usually not the case for water demineralised as a result of household treatment. Even when stabilized, the final composition of some waters may not be adequate in terms of providing health benefits. Although desalinated waters are supplemented mainly with calcium (lime) or other carbonates, they may be deficient in magnesium and other microelements such as fluorides and potassium. Furthermore, the quantity of calcium that is supplemented is based on technical considerations. Possibly none of the commonly used ways of re-mineralization could be considered optimum, since the water does not contain all of its beneficial components. Current methods of stabilization are primarily intended to decrease the corrosive effects of demineralised water. Demineralised water that has not been remineralized, or low-mineral content water in the light of the absence or substantial lack of essential minerals in it is not considered ideal drinking water, and therefore, its regular consumption may not be providing adequate levels of some beneficial nutrients.

Moreover hiv infection rate in new york buy cheap zovirax line, a properly executed evacuation reduces time spent exposed to antiviral kit buy zovirax 200 mg radiation; the goal hiv infection from mosquitoes buy zovirax 400 mg with mastercard, of course hcv hiv co infection rates buy zovirax on line, is to minimize total exposure. The objectives of guidance in this chapter are as follows: Protect the public from the acute effects of high radiation exposure associated with fallout in the initial 72 hours after a nuclear explosion. The potential for acute radiation effects increases with higher radiation doses, and above 200 rad (2 Gy), medical treatment will likely be needed. The highest priority in managing sheltering and evacuation responses following a nuclear detonation is to reduce the number of people exposed to life-threatening acute radiation. Treating life-threatening injuries and not interfering with critical life saving operations must also be high priority planning factors. The radiation protection principles, however, are the same regardless of the potential dose or circumstances. In the case of a nuclear explosion, priority must be given to preventing acute-level radiation exposures. They should also be applied during the intermediate phase of the incident, when relocation would be considered as a protective action. As stated earlier, the primary means of protecting the public from radiation associated with fallout following a nuclear explosion is to shelter and/or to evacuate. Secondary protective actions include removal of fallout particles from ones clothing and body (decontamination) and avoiding inhalation and ingestion of fallout particles. Planners should consider what actions are to be recommended to the public, where those actions would apply, how they would be communicated, how they would be supported and implemented by responders, and what resources are needed for successful implementation. One special consideration to acknowledge in planning is recommendations to the public for their animals. No single protective action will be adequate for all locations and times; therefore, planners should consider the following three tiers of protective action recommendations: 1. Generic recommendations issued in advance of an incident that are coupled with public education and outreach Pre-designated public shelters may be part of this strategy for communities that do not have abundant, adequate shelter options. Initial recommendations issued as soon as possible after an incident, which are based on little or no incident data Generally, the recommendation would be for the public to take shelter immediately in the most protective, readily available shelter. Follow-up recommendations issued once additional data and information become available these recommendations may include continued shelter for a set period of time followed by evacuation, and specific evacuation instructions for selected areas or populations, such as heavily impacted areas or for vulnerable populations. Shelter Recommendations Sheltering in the most accessible and sufficiently protective building or structure is the best initial action immediately following a nuclear explosion. This includes Shelter-in-place, which means staying inside or going immediately indoors inside the nearest yet most protective structure. During that time, the intensity of the fallout radiation will decrease significantly, allowing for less hazardous egress from dangerous fallout areas. Sheltered individuals should not selfevacuate prior to 24 hours following the detonation unless instructed by authorities. Earlier evacuation may be beneficial in some cases (for example after 12 hours), such as to attend to medical needs. Even in areas where fallout is not apparent, sheltering is advised until the fallout areas are clearly known. Otherwise, evacuees could be caught outside when the fallout arrives or flee unaffected areas and unknowingly enter into a fallout area. The adequacy of shelter is a function of initial radiation dose rates when fallout arrives and the dose rate reduction afforded by the structure. The primary risk from nuclear fallout is penetrating radiation that needs to be reduced as much as possible by shielding using dense building material and increased distance from deposited fallout, including on roofs that may be afforded by large buildings. Cars and other vehicles are not adequate shelters because they lack good shielding material. Good shielding materials include concrete, brick, stone and earth, while wood, drywall, and thin sheet metal provide minimal shielding. Large buildings can have thick walls of concrete or brick, but also provide the benefit of increased distance from deposited fallout materials when people gather away from exterior walls. This distance from exterior walls and roofs can substantially reduce radiation dose to those sheltering. Shelters such as houses with basements, large multi-story structures, and parking garages, or tunnels, can generally reduce doses from fallout by a factor of 10 or more. These structures would generally provide adequate shelter, and individuals with ready access to these structures would protect themselves effectively even where initial unshielded fallout dose rates would result in lethal radiation dose levels. Where adequate shelter is available, sheltering for periods even longer than 24 hours may be desirable if the appropriate resources. Emergency response officials may have to issue supplemental orders to those sheltering in wood frame structures. If acceptable early evacuation options are available, authorities may advise evacuation for some occupants of inadequate shelters. However, early evacuation without adequate knowledge of the highest fallout hazard areas, even from poor shelters, can be extremely hazardous. A dose reduction factor of 10 indicates that a person in that area would receive 1/10th of the dose of a person in the open. A dose reduction factor of 200 indicates that a person in that area would receive 1/200th of the dose of a person out in the open. The need for reunification is especially true for parents who are separated from their children at the time of the event. Communications aimed at families and those who want to evacuate will be critical to successfully keeping people inside. After a nuclear detonation, people will need to understand why they and their families are safest staying sheltered. Specifically, schools should develop preparedness plans for shelter-in-place in their settings. These should be shared with parents to ensure existing safely procedures for children when there is a need for shelter-in-place. Sheltering is implicitly short term; everyone sheltering may need to be evacuated at some point until the safety of the area can be confirmed by officials. The duration of time spent in shelter may range from short, on the order of hours, to several days, depending on the fallout dose rates, adequacy of shelter, local factors and operational factors, and individual circumstances. Recommended shelter departure times for individuals will depend on several factors, including dose rate at the shelter and along the evacuation path, adequacy of the shelter, impediments during evacuation, interference with other response operations, and individual circumstances. Sheltering for the first 12 hours following detonation is particularly critical due to the high fallout dose rates and uncertainty in the fallout hazard areas initially following the detonation. It is important to continuously communicate and update community members about sheltering; otherwise, individuals may break from shelters due to lack of available information or because of assumptions about safety over time. Evacuation Prioritization Sheltering should be followed by staged, facilitated evacuation for those in fallout-impacted areas. Evacuations should be prioritized based on the fallout pattern and radiation intensity, adequacy of shelter, impending hazards. Evacuations should be planned so as not to obstruct access to transportation routes that are critical for ongoing life-saving missions. The staging of evacuations should be driven by the hazard to members of the public and logistical considerations. Prioritization of early evacuation of at-risk populations should be balanced against responder risk, modes of transport, ease of access and egress, control of fires in the area, the ability to communicate with them, etc. Uninjured individuals with adequate shelter conditions should not be the highest priority for early evacuation. When evacuations are executed, travel should be at right angles to the fallout path (to the extent possible) and away from the plume centerline, sometimes referred to as lateral evacuation. The rapid identification of populations and areas that could benefit from priority evacuation should be a goal of responders. However, identifying such populations and facilitating timely, safe transport is a challenging task. The following are critical steps in planning and implementing an early evacuation effort. Situational Awareness: the first step in establishing evacuation priorities is to develop an accurate understanding of fallout distribution and radiation dose rates. Plume models (either local and/or Federal) can project the hazardous area based on the best available information on attack parameters and local 72 weather conditions.

Diseases

  • Adducted thumb club foot syndrome
  • Braddock Jones Superneau syndrome
  • Motor neuron disease
  • Hypotonic sclerotic muscular dystrophy
  • Hypogonadism hypogonadotropic due to mutations in GR hormone
  • Arthrogryposis ophthalmoplegia retinopathy

They also occur in disease states hiv infection symptoms discount zovirax 800 mg fast delivery, such as delirium hiv infection kinetics cheap 200mg zovirax with visa, and psychiatric disorders (affective disorders antiviral trailer buy zovirax with american express, schizophrenia) hiv infection via eye buy 400 mg zovirax visa. Examples of phenomena which may be labelled illusory include Visual: illusory visual spread, metamorphopsia, palinopsia, polyopia, teleopsia, Pulfrich phenomenon, visual alloaesthesia, visual perseveration; Auditory: palinacusis; Vestibular: vertigo. They are consistent and have a compulsive quality to them, perhaps triggered by the equivocal nature of the situation. There may be accompanying primitive refiexes, particularly the grasp refiex, and sometimes utilization behaviour. Imitation behaviour occurs with frontal lobe damage; originally mediobasal disease was thought the anatomical correlate, but more recent studies suggest upper medial and lateral frontal cortex. A distinction has been drawn between naive imitation behaviour, which ceases after a direct instruction from the examiner not to imitate his/her gestures, which may be seen in some normal individuals; and obstinate imitation behaviour which continues despite an instruction to stop; the latter is said to be exclusive to frontotemporal dementia. Obstinate imitation behaviour in differentiation of frontotemporal dementia from Alzheimers disease. It is most commonly seen with lesions affecting the right hemisphere, especially central and frontal mesial regions, and may occur in association with left hemiplegia, neglect, anosognosia, hemianopia, and sensory loss. Impersistence of tongue protrusion and handgrip may be seen in Huntingtons disease. Neuropsychologically, impersistence may be related to mechanisms of directed attention which are needed to sustain motor activity. Neurological pathways subserving the appropriate control of micturition encompass the medial frontal lobes, a micturition centre in the dorsal tegmentum of the pons, spinal cord pathways, Onufs nucleus in the spinal cord segments S2S4, the cauda equina, and the pudendal nerves. Thus, the anatomical differential diagnosis of neurological incontinence is broad. Moreover, incontinence may be due to inappropriate bladder emptying or a consequence of loss of awareness of bladder fullness with secondary overfiow. Other features of the history and/or examination may give useful pointers as to localization. Incontinence of neurological origin is often accompanied by other neurological signs, especially if associated with spinal cord pathology (see Myelopathy). The pontine micturition centre lies close to the medial longitudinal fasciculus and local disease may cause an internuclear ophthalmoplegia. However, other signs may be absent in disease of the frontal lobe or cauda equina. Causes of urinary incontinence include Idiopathic generalized epilepsy with tonicclonic seizures; however, the differential diagnosis of loss of consciousness with incontinence also encompasses syncopal attacks with or without secondary anoxic convulsions, non-epileptic attacks, and hyperekplexia. In addition there may be incomplete bladder emptying, which is usually asymptomatic, due to detrusor sphincter dyssynergia; for postmicturition residual volumes of greater than 100 ml (assessed by inout catheterization or ultrasonography), this is best treated by clean intermittent self-catheterization. Approach to the patient with bladder, bowel, or sexual dysfunction and other autonomic disorders. A compulsive grasping hand syndrome has been described which may be related to intermanual confiict, the difference being grasping of the contralateral hand in response to voluntary movement. Intermanual confiict is more characteristic of the callosal, rather than the frontal, subtype of anterior or motor alien hand. It is most often seen in patients with corticobasal degeneration, but may also occur in association with callosal infarcts or tumours or following callosotomy. Cross References Alien hand, Alien limb; Compulsive grasping hand; Diagonistic dyspraxia Intermetamorphosis A form of delusional misidentification in which people known to the patient are believed to exchange identities with each other (cf. This may be obvious with pursuit eye movements, but is better seen when testing refiexive saccades or optokinetic responses when the adducting eye is seen to lag behind the abducting eye. A similar clinical picture may be observed with pathology elsewhere, hence a false-localizing sign and referred to as a pseudointernuclear ophthalmoplegia, especially in myasthenia gravis. Cross References Diplopia; False-localizing signs; One-and-a-half syndrome; Optokinetic nystagmus, Optokinetic response; Oscillopsia; Pseudointernuclear ophthalmoplegia; Saccades; Skew deviation Intrusion An intrusion is an inappropriate recurrence of a response (verbal, motor) to a preceding test or procedure after intervening stimuli. Intrusions are thought to refiect inattention and may be seen in dementing disorders or delirium. The term intrusion is also used to describe inappropriate saccadic eye movements which interfere with macular fixation during pursuit eye movements. Intrusions as a sign of Alzheimer dementia: chemical and pathological verification. The finding of inverted refiexes may refiect dual pathology, but more usually refiects a single lesion which simultaneously affects a root or roots, interrupting the local refiex arc, and the spinal cord, damaging corticospinal (pyramidal tract) pathways which supply segments below the refiex arc. Hence, an inverted supinator jerk is indicative of a lesion at C5/6, paradoxical triceps refiex occurs with C7 lesions; and an inverted knee jerk indicates interruption of the L2/3/4 refiex arcs, with concurrent damage to pathways descending to levels below these segments. The pathophysiological implication is of electrical disturbance spreading through the homunculus of the motor cortex. Cross Reference Seizures Jactitation Jactitation is literally throwing about, but may also imply restlessness. The term has been used in various ways: to refer to jerking or convulsion of epileptic origin; or jerking of choreic origin; or of myoclonic origin, such as hypnagogic jactitation (physiological myoclonus associated with falling to sleep). It may also be used to refer to the restlessness seen in acute illness, high fever, and exhaustion, though differing from the restlessness implied by akathisia. Cross References Akathisia; Myoclonus; Seizures Jamais Entendu A sensation of unfamiliarity akin to jamais vu but referring to auditory experiences. This is suggestive of seizure onset in the limbic system, but is not lateralizing (cf. There is debate as to whether jargon aphasia is simply a primary Wernicke/posterior/sensory type of aphasia with failure to selfmonitor speech output, or whether additional deficits. Others suggest that jargon aphasia represents aphasia and anosognosia, leading to confabulation and reduplicative paramnesia. Cross References Anosognosia; Aphasia; Confabulation; Echolalia; Logorrhoea; Pure word deafness; Reduplicative paramnesia; Transcortical aphasias; Wernickes aphasia Jaw Jerk the jaw jerk, or masseter refiex, is contraction of the masseter and temporalis muscles in response to a tap on the jaw with the mouth held slightly open. Both the afferent and efferent limbs of the arc run in the mandibular division of the trigeminal (V) nerve, connecting centrally with the mesencephalic (motor) nucleus of the trigeminal nerve. The refiex is highly reproducible; there is a linear correlation between age and refiex latency and a negative correlation between age and refiex amplitude. Interruption of the refiex arc leads to a diminished or absent jaw jerk as in bulbar palsy (although an absent jaw jerk may be a normal finding, particularly in the elderly). Bilateral supranuclear lesions cause a brisk jaw jerk, as in pseudobulbar palsy. Cross References Age-related signs; Bulbar palsy; Pseudobulbar palsy; Refiexes Jaw Winking Jaw winking, also known as the Marcus Gunn phenomenon, is widening of a congenital ptosis when a patient is chewing, swallowing, or opening the jaw. It is believed to result from aberrant innervation of the pterygoid muscles and levator palpebrae superioris. Cross References Ptosis; Synkinesia, Synkinesis Jendrassiks Manoeuvre Jendrassiks manoeuvre is used to enhance or bring out absent or depressed tendon (phasic stretch) refiexes by isometric contraction of distant muscle groups. Cocontraction increases the gain in the monosynaptic refiex arc, as distinct from facilitation or posttetanic potentiation which is seen in LambertfiEaton myasthenic syndrome following tetanic contraction of muscles involved in the refiex. Facilitation of monosynaptic refiexes by voluntary contractions of muscle in remote parts of the body. This may be confused in neonates with clonic seizures, but in the former there is stimulus sensitivity and an absence of associated ocular movements. However, both may occur in hypoxicfiischaemic or metabolic encephalopathies or with drug withdrawal. This produces Dysphagia, dysphonia, palatal droop, impaired gag refiex; ipsilateral reduced taste sensation on the posterior one-third of the tongue, and anaesthesia of the posterior one-third of the tongue, soft palate, pharynx, larynx, and uvula, due to glossopharyngeal and vagus nerve involvement. Cross References Dysphagia; Dysphonia; Gag refiex Junctional Scotoma, Junctional Scotoma of Traquair Despite the similarity of these terms, they are used to refer to different types of scotoma: Junctional scotoma: Unilateral central scotoma with contralateral superior temporal defect, seen with lesions at the anterior angle of the chiasm. Such lesions have been said to damage the ipsilateral optic nerve plus the crossing loop of fibres (Wilbrands knee) originating from the inferonasal portion of the contralateral eye, although it may be noted that some authors have questioned whether such a loop in fact exists. Cross References Scotoma; Visual field defects 202 K KayserFleischer Rings KayserFleischer rings are deposits of copper, seen as a brownish discoloration, in Descemets membrane. Although often visible to the naked eye (difficult in people with a brown iris), they are best seen with slit-lamp examination. Since they are a highly reliable sign of intracerebral copper deposition in Wilsons disease (hepatolenticular degeneration), any patient suspected of this diagnosis.

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