Richard A Lanham, Jr, M.A., Ph.D.

• Assistant Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/6315830/richard-lanham

A true interdisci plinary program is an orientation heart attack diet generic plendil 2.5 mg otc, approach blood pressure ideal buy 10 mg plendil overnight delivery, or philosophy that seeks to go beyond the sum of the parts to build a new enterprise (Figure 9-1) hypertension 10 order plendil 10 mg fast delivery. It is not necessary for sleep medicine to be housed in a stand-alone department or division blood pressure jumping around cheap 5mg plendil otc. However blood pressure chart age 35 discount plendil 10 mg on line, sleep programs that are restricted to a single department that does not allow for interdisciplinary treatment and care tend to struggle hypertension of chronic kidney disease is medicated with discount 5 mg plendil with visa. Further, fragmented programs lack the collaborative spirit nec essary for excellence in clinical care, training, and research. The field of somnology and sleep medicine is an excellent example of an interdisciplinary field because it strives to integrate ideas, to ols, and per spectives from several disciplines in order to advance understanding beyond the scope of a single discipline or field of research practice. The field is being forged from existing fields of cardiology, dentistry, endocrinology, geriatrics, neurology, neuropsychopharmacology, neuroscience, nursing, o to laryngology, pediatrics, psychiatry, psychology, and pulmonology (Box 9-1). Two of the most advanced and successful sleep programs, at Harvard University and the University of Pennsylvania, attest to the productivity and vibrancy of an interdisciplinary approach. The success of the program at the University of Pennsylvania also demonstrates that the success of an interdisciplinary sleep program is not dependent on it being its own stand-alone department. Many types of health professionals are needed to guide the chronic management of sleep disorders. Individuals with sleep loss and sleep disor ders have a multitude of health-related problems that require attention from a number of medical disciplines. However, given the limited number of certified health care professionals in sleep medicine and depending on the size and structure of an interdisciplinary sleep program, an individual often may need to be referred to a specialist in another department who may not be certified in sleep medicine. These physicians come from a variety of medi cal specialties, including internal medicine, pediatrics, o to laryngology, pul monology, neurology, and psychiatry. This large cohort study has shown that sleep apnea is a risk fac to r for hypertension, cardiovascular disease, and insulin resistance (Nie to et al. Endocrinology Cumulative sleep loss led to reduced leptin and increased ghrelin and hence increased appetite (Spiegel et al. This led to the hypothesis that a hormonally mediated increase in appetite may help to explain why short sleep is a risk fac to r for obesity. Neurobiology and Genetics Contributions of neurobiologists led to the demonstration that the rest period in the fruit fly (Drosophila) is analogous to mammalian sleep (Shaw et al. This in strument, which measures functional capacity in relation to sleep, is now used in clinical trials. Other nursing interventions, such as appropriately timed exercise, relaxation, and meditation, have also been shown to have benefi cial effects on sleep in patients with chronic illnesses such as cancer and those in the acute care setting (Davidson et al. Sleep clinicians or researchers often face daunting obstacles and disincentives, most of which arise from the cus to ms and practices of individual academic departments. Yet interdisci plinary programs, even under the best of circumstances, face barriers and impediments within the confines of academic or research institutions (Ehrenberg et al. A recent National Academies report focusing on ways to facilitate interdisciplinary research was unambiguous about the difficulties confronting these programs, de spite their promise. This is a generic problem, regardless of whether the interdisciplinary research program deals with nanotechnology or the perception of pain. The problem of departmental silos permeates interdisciplinary pro grams within any setting: academic health centers, universities, national labora to ries, or industry. The following section presents a series of con straints that to gether limit the achievement of interdisciplinary programs. These constraints were identified on the basis of an analysis of six sleep programs using methods from operations research that the committee commissioned (see below). Several of the other constraints described in the following sections stem from organizational structures that were es tablished prior to the advent of interdisciplinary research: interdiscipli nary programs challenge institutional reward systems; interdisciplinary requirements impose obstacles, different administrative jurisdictions, and lack of appropriately trained staff for sleep studies; and service demand outstrips service supply. Coordi nating all the different types of personnel, lines of authority, policy and procedures, and quality control measures across organizational boundaries is challenging. Who bears the costs and their alignment with benefits and the various revenue streams is neither obvious nor consistent. Interdisciplinary Programs Challenge the Institutional Reward System Most institutional reward systems are organized within traditional dis ciplines or academic departments. These are the units that control what most professionals covet: hiring capacity, tenure and promotion decisions, and space allocation. Interdisciplinary programs challenge this discipline based reward system, as well as the culture accompanying each discipline. The National Academies report on interdisciplinary research con ducted three surveys of different groups either working within or over seeing interdisciplinary programs: individual professionals, provosts, and attendees of a conference on interdisciplinary research. But since these are the only surveys of their kind, it is worth noting that the overwhelming majority of respon dents (70. Interdisciplinary Requirements Impose Obstacles Interdisciplinary sleep programs, at a minimum, require multidis ciplinary participation. As explained earlier, an interdisciplinary program moves beyond being multidisciplinary and is one in which multiple disci plines collaborate in a way that forges a new discipline or endeavor. Provi sion of clinical services in sleep medicine call upon professionals from inter nal medicine and its relevant subspecialties. Similar issues exist in teaching undergraduate, graduate, and phy sicians in their residencies, fellowships, and postdoc to ral work. The unintended consequence is to produce barriers to interdisciplinary patient care, training, and research. Barriers include the length and depth of training in a single field necessary to develop scientists successful at compet ing for funds, the difficulty in forging a successful career path outside the single disciplinary structure, impediments to obtaining research funding for interdisciplinary research, and the perceived lack of outlets for the publica tion and dissemination of interdisciplinary research results. Lack of Appropriately Trained Staff for Sleep Studies By nearly universal consensus, one sleep technician can moni to r at one time two uncomplicated diagnostic studies or one complicated study. Yet, the number of certified technicians nationally is inadequate to meet this need. As with any market in which the supply is less than demand, costs of certified technicians is rising faster than the average rate of inflation or the average rate of medical costs. This has two likely consequences: sleep programs are forced to provide on-the-job training for their technicians; and private-sec to r organizations are able to adjust their payment structures more readily than academic health centers. Thus, academic centers often provide training, but higher salaries in the private sec to r lure the experienced technologists. As discussed in detail in Chapter 6, the predicted number of individuals with sleep disorders greatly outstrips the ability to provide services using trained personnel (Tachibana et al. Analysis commissioned on behalf of the committee indicated that wait times could range by as much as 4 weeks to 4 months. The committee offers principles that can guide development of somnology and sleep medicine programs. For each of these key components and guid ing principles, the committee draws on its experience with programs that have been successful, as well as those that have struggled. If these compo nents and guiding principles are followed, interdisciplinary sleep programs can thrive, whether as a freestanding department or as a program within an existing department or division. Key Components of Interdisciplinary Sleep Programs Strong Linkages from Diagnostic Testing Centers to Comprehensive Care Diagnostic sleep centers need to establish strong linkages with treat ment providers. The committee heard testimony and anecdotal reports that many patients, once tested, are lost to follow-up. Once diagnosed, severe sleep apnea, for instance, optimally should be followed up by a physician certified in sleep medicine. Less severe forms of apnea may warrant watch ing or referral to a dentist for preparation of dental devices, if a dental problem is etiologically related. Components of the model have been demonstrated to lower health care costs or lower use of health care services (Bodenheimer et al. At a minimum, medical students need basic training in sleep disorders, as do pharmacy, public health, dentistry, and nursing stu dents. This training should cover the public health burden of sleep loss and sleep disorders and the importance of diagnosis and treatment throughout the life span. Sleep disorders and sleep medicine should be covered in greater depth in residency and fellowship training programs in all primary care specialties, as well as specialties related to sleep. Clinical, Basic, and Translational Research the field, as an interdisciplinary enterprise, garners momentum from the many clinical and basic disciplines at its core. The coordination and integration of many scien tific fields will maximize these efforts. Participation in Proposed Research Network the committee recommended in Chapter 8 the creation of a National Somnology and Sleep Medicine Research and Clinical Network. The purpose of the proposed network is to advance the field by providing a means to connect individual investiga to rs, research programs, and research centers. The network would provide a resource for education, training, collabora tions, core facilities, data coordination, and access to multisite clinical re search trials. Most sleep programs could benefit greatly from participation in the proposed network. For the network to be successful, all participating programs should be required to submit research and clinical data to what ever joint projects the network undertakes. Guiding Principles of Interdisciplinary Sleep Programs Leadership Leadership, so easily recognizable but elusive to define, is the single greatest success fac to r in forming a new program. The most successful pro grams developed over the past two decades are largely traceable to the con viction, determination, and persistence of committed leaders. These pro grams have served as beacons to others, facilitating their establishment. Revenue Generation and Fiscal Independence Established sleep programs can generate higher revenues than costs, according to the analysis that the committee commissioned. As emphasized throughout this report, there is enormous opportunity both in terms of clinical service and research. Moreover, deans can facilitate interdisciplinary research by specifically giving chairpersons incentives for this type of activity. Such strategies give deans a very specific role in development of and support of somnology and sleep medicine as an interdisciplinary discipline. Transparent Policies and Procedures Sleep programs that are administered as divisions within individual de partments may be at a disadvantage. They are not represented at the level of the school of medicine and hence may not be directly involved in strategic planning initiatives of the academic medical center. Further, the program competes for faculty positions in a structure that is not focused on develop ment of interdisciplinary programs. By studying programs with distinct organi zational structures, the analysis sought to determine which were most con ducive to sustaining or expanding their sleep program. It has identified organizational structure as being associated with success in producing doc to rates (Ehrenberg and Epifantseva, 2001), acquiring grants (Ehrenberg et al. This section of the chapter summarizes the specific questions, methods, and major findings of the commissioned paper. It is important to point out that the choice of programs was meant neither to be representa tive of all sleep programs, nor to cover the question of how to start a pro gram de novo. Specific Questions and Methodology the analysis addresses three specific questions: (1) Can sleep programs generate revenue in excess of their costsfi Parametric analysis applying the principles of operations research was used to examine these three questions. Semistructured inter views were conducted at five academic sleep programs with varying organi zational structures: Emory University, George Washing to n University, Stanford University, University Hospital of Cleveland, and University of Pennsylvania. Financial data were obtained from each program, and direct observations were performed, including the provision of clinical services and the effect of teaching on patient throughput.

Most strategy for eradication: reproduce by asexual budding arteria zygomatico orbital plendil 5mg low price, although some also exhibit binary fission blood pressure medication makes me pee purchase plendil with visa. Because the vast majority of these rare and emerging species exhibit multicellular forms through the generation of fungal infections involve immunocompromised patients arrhythmia games discount plendil 2.5 mg online, a a string of connected budding cells known as pseudohyphae blood pressure chart log template buy discount plendil 5 mg. At primary strategy for management of these infections with body temperature hypertension benign essential 4011 discount plendil 2.5 mg without prescription, Candida albicans is most commonly present underlying diseases is to maximally reduce immunosup in yeast form hypertension benign essential buy plendil from india. Fdg-pet imaging the use of systemic glucocorticosteroids in the management of selected and the diagnosis of non-small cell lung cancer in a region of high infections. Working group on steroid use, antimicrobial agents commit his to plasmosis prevalence. Menivale F, Deslee G, Vallerand H, Toubas O, Delepine G, Guillou Clin Infect Dis 2000;30:652. Successful treatment of Thoracic Society policy statement: managing confiict of interest in sclerosing cervicitis and fibrosing mediastinitis with tamoxifen. Percutaneous pulmonary artery and and lipid complex formulations of amphotericin B. Endobronchial nary reactions associated with the combined use of amphotericin B findings of fibrosing mediastinitis. Outbreak of his to plasmosis associated with the 1970 Earth Day Moni to ring serum aminoglycoside concentrations in children with activities. Safety and efficacy of liposomal amphotericin B compared with after minimal nephroprotective measures: animal experiments and conventional amphotericin B for induction therapy of his to plasmosis clinical study. Ke to conazole metamorphosis: an antimicrobial becomes of his to plasmosis with itraconazole in patients with the acquired an endocrine drug. Bre to n G, Adle-Biassette H, Therby A, Ramanoelina J, Choudat L, netics of fiuconazole. Successful treatment of cerebral National Institute of Allergy and Infectious Diseases Mycoses Study aspergillosis with a novel triazole (voriconazole) in a patient with Group. His to plasmosis after treatment with anti who are refrac to ry to or in to lerant of conventional therapy: an tumor necrosis fac to r-alpha therapy. Disseminated his to plasmosis: clinical and pathologic correla frac to ry coccidioidomycosis. Voriconazole treatment for less-common, emerging, evidence for a unique gsc-1 subunit mediating beta-1,3-glucan de or refrac to ry fungal infections. In vitro activities of voriconazole, itraconazole, and amphotericin cosis, coccidioidomycosis, and his to plasmosis. Successful treat of a new triazole antifungal agent, schering 56592, with itraconazole ment of cerebral blas to mycosis with voriconazole. A case of disseminated a case series incorporating voriconazole in the treatment regimen. Practice guideline for the treatment of coccidioidomy Blas to mycosis in patients with the acquired immunodeficiency cosis: Infectious Diseases Society of America. Blas to mycosis of the lumbar spine: case report and Coccidioides immitis meningitisfi Fluconazole in the treatment of Vertebral blas to mycosis with paravertebral abscess: report of eight persistent coccidioidomycosis. Treatment of severe pulmonary nonmeningeal coccidioidomycosis: a randomized, double-blind trial. A decade of experience with blas to my Itraconazole treatment of coccidioidomycosis: Naiad Mycoses Study cosis and its treatment with amphotericin B: a national communi Group. Amphotericin B lipid complex for the treatment of recurrent meningitis with voriconazole. The National Institute of Allergy and Infectious Diseases study of oral voriconazole and itraconazole for long-term treatment Mycoses Study Group. Molecular evidence that the range of the Vancouver Island Cavitating pneumonia after treatment with infiiximab and predni outbreak of Cryp to coccus gattii infection has expanded in to the Pacific sone. Fungal infections in transplant recipients receiving neoformans: regulation of capsule synthesis by carbon dioxide. A rare Treatment of cryp to coccal meningitis associated with the acquired genotype of Cryp to coccus gattii caused the cryp to coccosis outbreak immunodeficiency syndrome: National Institute of Allergy and on Vancouver Island (British Columbia, Canada). Rapid respira to ry deterioration and of amphotericin B alone and combined with fiucy to sine in the sudden death due to disseminated cryp to coccosis in a patient with the treatment of cryp to ccal meningitis. Bicanic T, Wood R, Meintjes G, Rebe K, Brouwer A, Loyse A, Bekker coccosis Study Group. Treatment of murine cryp to coc tericin B (ambisome) compared with amphotericin B both followed cosis with cyclosporin-a in normal and athymic mice. Amphoter resistance to calcineurin inhibi to rs by current immunosuppressive icin B colloidal dispersion combined with fiucy to sine with or without regimens. Immune reconstitution cryp to coccosis fiuid pressure in cryp to coccal meningitis: case report and review. Vibhagool A, Sungkanuparph S, Mootsikapun P, Chetchotisakd P, corticosteroids on visual loss in Cryp to coccus neoformans var. An immune active antiretroviral therapy: a prospective, multicenter, randomized reconstitution syndrome-like illness associated with Cryp to coccus study. Itraconazole versus fiuconazole mans: comparison with fiuconazole and effect of human serum. Intravenous and oral itraconazole posaconazole, fiuconazole, itraconazole, voriconazole, and am versus intravenous and oral fiuconazole for long-term antifungal photericin B against a large collection of clinically important molds prophylaxis in allogeneic hema to poietic stem-cell transplant recipients: and yeasts. Maertens J, Theunissen K, Verhoef G, Verschakelen J, Lagrou K, rarily neutropenic murine model of invasive aspergillosis with an Verbeken E, Wilmer A, Verhaegen J, Boogaerts M, Van Eldere J. Gal itraconazole-susceptible and an itraconazole-resistant isolate of Asper ac to mannan and computed to mography-based preemptive antifungal gillus fumigatus. Efficacy and empirical treatment with liposomal amphotericin b in patients after safety of caspofungin for treatment of invasive aspergillosis in allo-sct. Efficacy Voriconazole versus amphotericin B for primary therapy of invasive and to xicity of caspofungin in combination with liposomal ampho aspergillosis. In vitro activity of the new triazole voriconazole (uk-109, with acute myelogenous leukemia: a study of the eastern cooperative 496) against opportunistic filamen to us and dimorphic fungi and common oncology group (e1490). Groll A, Renz S, Gerein V, Schwabe D, Katschan G, Schneider M, In-vitro activities of amphotericin B, itraconazole and voriconazole Hubner K, Kornhuber B. Fatal haemoptysis associated with invasive against 150 clinical and environmental Aspergillus fumigatus iso pulmonary aspergillosis treated with high-dose amphotericin B lates. The international chronic granuloma to us disease cooperative study terreus, with a head- to -head comparison to voriconazole. Advances in invasive fungal infection and Norris C, Michalski M, Raynor K, Halpern J, Mendrick C, et al. I to h T, Yamada H, Yamaguchi A, Kawamata N, Kakei M, Nozoe S, necrotizing pulmonary aspergillosis: a discrete clinical entity. Chronic necrotizing pulmonary aspergillosis: approach to intracavitary aspergilloma. A chopulmonary aspergillosis without maintenance oral corticoste prospective observational study of candidemia: epidemiology, ther roids: a fifteen-year follow-up. Nosocomial bloodstream infections in us hospitals: bronchopulmonary aspergillosis: a retrospective study of 35 cases. Therapeutic approaches in allergic bronchopulmonary aspergillosis with recombinant anti-ige patients with candidemia: evaluation in a multicenter, prospective, antibody. Otani Y, Yoshida I, Ohki S, Kano M, Kawashima O, Suzuki M, Sa to Y, other forms of invasive candidiasis. Cremaschi P, Nascimbene C, Vitulo P, Catanese C, Rota L, Barazzoni fections in neutropenic patients. Luzzati R, Amalfitano G, Lazzarini L, Soldani F, Bellino S, Solbiati M, a successful treatment in 209 cases of relapse hemoptysis. Babatasi G, Massetti M, Chapelier A, Fadel E, Macchiarini P, Khayat of vascular catheters. Pneumocystis carinii pneumonia during Germany: consensus formed by a panel of interdisciplinary investi maintenance anti-tumor necrosis fac to r-alpha therapy with infiix ga to rs. Successful Should all patients with candidaemia have an ophthalmic examina intermittent chemoprophylaxis for Pneumocystis carinii pneumoni tion to rule out ocular candidiasisfi Empirical marrow transplantation is inferior to other regimens and is associ fiuconazole versus placebo for intensive care unit patients: a ran ated with decreased survival and an increased risk of other in domized trial. Use of Candida pneumonia: experience at a large cancer center and review a cyclophosphamide-induction methotrexate-maintenance regimen of the literature. National Institutes of Health-University of California expert panel for patients with hema to logic malignancy who have zygomycosis. Posaconazole: a potent, extended-spectrum triazole anti therapy for pneumocystis pneumonia in the acquired immunodefi fungal for the treatment of serious fungal infections. A controlled trial of Posaconazole is effective as salvage therapy in zygomycosis: a retro early adjunctive treatment with corticosteroids for Pneumocystis carinii spective summary of 91 cases. Epidemiology, clinical manifestations, and V, Wagels T, Flepp M, Rickenbach M, Furrer H. Godeau B, Coutant-Perronne V, Le Thi Huong D, Guillevin L, center study from Italy and review of the literature. Immunotherapy for invasive fungal infections: from bench tissue disease: report of 34 cases. Gustation Testing time is 2 hours and 50 minutes; there are no separately-timed sections. Neuromodula to rs and Drugs the questions in the Psychology Test are drawn from the core of knowledge most commonly encountered 8. States of Consciousness may require recalling factual information, analyzing relationships, applying principles, drawing conclusions 11. Learning (3-5%) September 2017 yields six subscores in addition to the to tal score: 1. Meaning distributed throughout the test; they are not set aside and labeled separately, although several questions 4. Speech Perception and Processing from a single content area may appear consecutively. Socialization, Family and Cultural skills and knowledge gained over a long period of I. The following Answers recorded in your test book will not be information may be helpful. If you thoroughly the whole test ( to tal correct score) is converted to the understand the directions before you take the to tal reported scaled score. The questions in the practice test illustrate the types In most cases, questions that belong to a particular of multiple-choice questions in the test. When you content area also require some ability in other content take the actual test, you will mark your answers on a areas. By using the to tal correct score, the responses separate machine-scorable answer sheet.

Of the paraneo plastic disorders blood pressure 300180 generic plendil 5 mg fast delivery, opsoclonus associated with lung and breast tumours persists and the patients decline from their underlying illness; neuroblas to ma associated opsoclonus may be steroid responsive heart attack photo discount 2.5 mg plendil mastercard. It has sometimes been grouped with associative visual agnosia arrhythmia knowledge a qualitative study discount plendil 2.5mg overnight delivery, but these patients are not agnosic since they can demonstrate recognition of visually presented stimuli by means other than naming hypertension 140 80 buy generic plendil. Objects that are semantically related can be appropriately sorted blood pressure what is normal purchase 2.5mg plendil fast delivery, indicat ing intact semantics arteriogram order plendil 10mg amex. The temporal disc may appear pale in a normal fundus, so that optic atrophy can only be confidently diagnosed when there is also nasal pallor, although temporal pallor may follow damage to the macular fibre bundle with central visual defects. Rotation of the stripe to the left produces leftward pursuit, followed by a compensa to ry saccade to the right, followed by pursuit to the left of the next stripe, with another compensa to ry saccade, and so on. Clinical and imaging studies show a strong correlation between oro-facial dyspraxia and lesions in the frontal operculum; it may also occur with subcortical lesions involving periventricular and/or peristriatal white matter as well as the basal ganglia. Normally there is a drop in blood pressure of lesser magnitude on standing but this is usually quickly compensated for by the barore cep to r refiex. Measuring blood pressure au to matically by passive head-up tilt testing (tilt table) is also helpful in diagnosing orthostatic hypotension if the active standing test is negative, and the his to ry is suggestive, or in patients with mo to r impairment. Non-pharmacological approaches include increased salt and water intake, head-up bed tilt, and wearing elastic s to ckings or a G-suit. Pharmacological therapies include fiudrocortisone (first line), and midodrine, ephedrine, or dihydroxyphenylserine (second line). Cross References Myokymia; Nystagmus; Opsoclonus; Vestibulo-ocular refiexes Oscillucusis Oscillucusis is an abnormal perception of an oscillation in the intensity of ambient sounds, which may occur during a migraine attack. Hypertrophy of the inferior olivary nucleus may be evident neuro radiologically (structural or functional imaging) and pathologically. This is a consequence of a lesion in the denta to -olivary pathway which leads to transsy naptic degeneration and hypermetabolism of the olivary nucleus. Cross References Hemianopia; Illusion; Perseveration; Polyopia; Visual perseveration Pallaesthesia Pallaesthesia is the appreciation of vibration sensation; its loss may be described as pallanaethesia. It may indicate damage to the contralateral paracentral cortex or its connections, but since it is observed in about one quarter of normal adults and is very common in the normal elderly, and may occur in other conditions, both its sensitivity and specificity are low. It may be considered a frontal release sign or primitive refiex, but is less specific than the grasp refiex. A number of stages of papilloedema are described: in the acute stage, the only findings may be oedema at the superior and inferior poles of the disc, absence of spontaneous venous pulsation, and enlargement of the blind spot. The term paradoxical breathing may also be used to describe thorax and abdomen moving in different directions when breathing, as with increased upper airway resistance. Paraesthesia is a feature of neuropathy and may occur in the distribution of a compressed or entrapped nerve, perhaps refiecting the mechanosensitivity of nerves in this situation. Paraesthesia may also be provoked by hyperventilation (especially perioral, hands, and feet [acroparaes thesia]). The use of the word has not been entirely consistent, for example, paral ysis agitans originally used by James Parkinson to describe the disease which now bears his name. Cross References Myo to nia; Plegia Paramnesia Paramnesia is recalling as memories things which have not in fact taken place, hence a dis to rtion of episodic or au to biographical memory. Cross References Amnesia; Confabulation; Reduplicative paramnesia 264 Paraparesis P Paramyo to nia Paramyo to nia is similar to myo to nia in that muscle does not relax normally fol lowing contraction (voluntary, percussion), which may prompt a complaint of muscle aching or stiffness, but differs in that repetitive muscle use. Mutations in the same gene have been documented in hyperkalaemic periodic paralysis and K+-aggravated myo to nia. Cross References Flaccidity; Myelopathy; Paraplegia; Spasticity Paraphasia Paraphasias are a feature of aphasias (disorders of language), particularly (but not exclusively) fiuent aphasias resulting from posterior dominant temporal lobe lesions (cf. Paraphasias refer to a range of speech output errors, both phono logical and lexical, including substitution, addition, duplication, omission, and transposition of linguistic units, affecting letters within words, letters within syllables, or words within sentences. Prevention of this situation may be possible by avoiding spasms, which are often provoked by skin irritation or ulceration, bowel constipation, bladder infection, and poor nutrition. Transient parosmia may presage epileptic seizures of temporal lobe corti cal origin (olfac to ry aura), particularly involving the medial (uncal) region. The clinical heterogeneity of hemifacial atrophy probably refiects patho genetic heterogeneity. The syndrome may result from maldevelopment of au to nomic innervation or vascular supply, or as an acquired feature following trauma, or a consequence of linear scleroderma (morphoea), in which case a coup de sabre may be seen. Pathological laughter and crying following stroke: validation of a measurement scale and a double-blind treatment study. Brainstem find ings include oculomo to r disturbances, dysarthria, ataxia, and impaired arousal. Cross Reference Myo to nia Periodic Alternating Nystagmus Periodic alternating nystagmus is a horizontal jerk nystagmus, which damps or s to ps for a few seconds and then reverses direction. Treatment of the associated lesion may be undertaken, otherwise periodic alternating nystagmus usually responds to baclofen, hence the importance of correctly identifying this particular form of nystagmus. Cross References Coma Perseveration Perseveration refers to any continuation or recurrence of activity without appro priate stimulus (cf. The term was coined by Weir Mitchell in the nineteenth century, but parts other than limbs (either congenitally absent or following amputation) may be affected by phan to m phenomena, such as lips, to ngue, nose, eye, penis, breast and nipple, teeth, and viscera. Phonagnosia is the equivalent in the audi to ry domain of prosopagnosia in the visual domain. Cross References Agnosia; Audi to ry agnosia; Prosopagnosia; Pure word deafness Phonemic Disintegration Phonemic disintegration refers to an impaired ability to organize phonemes, the smallest units in which spoken language may be sequentially described, resulting -277 P Phonetic Disintegration in substitutions, deletions, and misorderings of phonemes. Noise-induced visual phosphenes have also been reported and may be equivalent to audi to ry-visual synaesthesia. Cross References Aura; Hallucination; Photism Physical Duality A rare somaesthetic metamorphopsia occurring as a migraine aura in which individuals feel as though they have two bodies. These may be helpful in ticklish patients who object to having their feet stroked. Cross Reference Winging of the scapula Poriomania A name sometimes given to prolonged wandering as an epileptic au to matism, or a fugue state of non-convulsive status epilepticus. Postural and righting refiexes depend not only on the integration of labyrinthine, proprioceptive, exteroceptive, and visual stimuli, mostly in the brainstem but also involve the cerebral cortex. Presbycusis Presbycusis is a progressive sensorineural hearing loss, especially for high fre quencies, developing with increasing age, which may reduce speech discrimina tion. There are also non neurological causes, such as haema to logical conditions (sickle cell anaemia, polycythaemia rubra vera) which may cause intrapenile thromboses. Developmental refiexes: the reappearance of foetal and neonatal refiexes in aged patients. Proprioceptive information is carried within the dorsal columns of the spinal cord (more reliably so than vibration sensation, though not necessarily exclu sively). Venous angioma of the orbit may cause an intermittent prop to sis associated with straining, bending, coughing, or blowing the nose. Alexia and achroma to psia may also be present, depending on the exact extent of the underlying lesion. Ana to mically, prosopagnosia occurs most often in association with bilateral occipi to -temporal lesions involving the inferior and mesial visual association cortices in the lingual and fusiform gyri, sometimes with subjacent white mat ter. Unilateral non-dominant (right) hemisphere lesions have occasionally been associated with prosopagnosia, and a syndrome of progressive prosopagnosia associated with selective focal atrophy of the right temporal lobe has been reported. Progressive prosopagnosia associ ated with selective right temporal lobe atrophy. There is some experimental evidence that olfac to ry stimuli can cue au to biographical memories more effectively than cues from other sensory modal ities. The pattern of cognitive deficits in individuals with depression most closely resembles that seen in so-called subcortical dementia, with bradyphre nia, attentional, and executive deficits. Memory loss for recent and distant events may be equally severe -293 P Pseudodiplopia (cf. The recognition of pseudodementia is important since the deficits are often at least partially reversible with appropriate treatment with antidepressants. Psychomo to r retardation in dementia syndromes may also be mistaken for depression. Some patients with dementia with Lewy bodies certainly realize that their percepts do not correspond to external reality and similar experiences may occur with dopamine agonist treatment. Cross Reference One-and-a-half syndrome Pseudopapilloedema Pseudopapilloedema is the name given to elevation of the optic disc that is not due to oedema. This may result simply from a redundant tarsal skin fold, especially in older patients, or be a functional condition. The term pseudop to sis has also been used in the context of hypotropia; when the non-hypotropic eye fixates, the upper lid follows the hypotropic eye and appears p to tic, disappearing when fixation is with the hypotropic eye. This is a stereo-illusion result ing from latency disparities in the visual pathways, most commonly seen as a 298 Pupillary Refiexes P consequence of conduction slowing in a demyelinated optic nerve following uni lateral optic neuritis. It is frequently related to previous occupation or hobbies but is seldom pleasurable. It is thought to be related to dopamin ergic stimulation and may be associated with impulse control disorder such as pathological gambling and hypersexuality. The contralat eral (consensual) response results from fibres crossing the midline in the optic chiasm and in the posterior commissure at the level of the rostral brainstem. Paradoxical constriction of the pupil in darkness (Flynn phenomenon) has been described. In coma to se patients, fixed dilated pupils may be observed with central diencephalic herniation, whereas midbrain lesions produce fixed midposition pupils. A dissociation between the light and accommodation reactions (light-near pupillary dissociation, q.

Cross Reference Torticollis 208 Levitation L Lateropulsion Lateropulsion or ipsipulsion is literally pulling to one side blood pressure healthy range buy plendil 10mg free shipping. This spinal refiex manifests as fiexion of the arms at the elbow blood pressure is low buy plendil 5 mg fast delivery, adduction of the shoulders blood pressure chart symptoms buy discount plendil 2.5 mg, lifting of the arms ulterior motive synonym best buy plendil, dys to nic posturing of the hands arrhythmia graphs buy generic plendil pills, and crossing of the hands blood pressure monitor walmart order generic plendil online. It is most often seen in corti cobasal (ganglionic) degeneration, but a few cases with pathologically confirmed progressive supranuclear palsy have been reported. Pathophysiologically, this movement-induced symp to m may refiect the exquisite mechanosensitivity of axons which are demyelinated or damaged in some other way. Les douleurs a type de decharge electrique consecutives a la fiexion cephalique dans la sclerose en plaques: un case de forme sensitive de la sclerose multiple. The locked-in syndrome: what is it like to be conscious but paralyzed and voicelessfi Patients may be unaware of their impaired output (anosognosia) due to a failure of self-moni to ring. It may be seen in cerebellar disease, possibly as a refiection of the kinetic tremor and/or the impaired checking response seen therein (cf. Cortical blindness due to bilateral (sequential or simultaneous) posterior cerebral artery occlusion may leave a small central field around the fixation point intact, also known as macula sparing. Hence, macula sparing and macula splitting have localizing value when assessing homonymous hemianopia. This constellation of clinical signs refiects underlying pathology in the frontal lobe and subjacent white matter, most usually of vascular origin, and is often associated with a subcortical vas cular dementia. Cross References Hypomimia; Parkinsonism Masseter Hypertrophy Masseter hypertrophy, either unilateral or bilateral, may occur in individuals prone to bruxism. A number of other, eponymous, signs of meningeal irritation have been described, of which the best known are those of Kernig and Brudzinski. Rarely, they are long lasting or permanent, for example, following brain infarction (most commonly involving the occipi to -parietal or temporoparietal cortex: lesions on the right are more likely than those on the left to give metamorphopsia) or tumours. Retinal disease causing displacement of pho to recep to rs may produce metamorphopsia: micropsia due to recep to r separation in retinal oedema, macropsia due to recep to r approximation in retinal scarring. Metamorphopsia and visual hallucinations restricted to the right visual hemifield after a left putaminal haem orrhage. These observations, along with reports of isolated micrographia with cortical lesions demonstrated by neuroimaging, suggest that the ana to mical basis of micrographia may be at the level of the cortex (dominant parietal lobe) rather than the basal ganglia. They are usually symmetrical and most often seen when using distal muscles of the upper limb. Mirror move ments are frequently present in young children but prevalence decreases with age. These movements are uncom mon after acquired brain lesions with no relationship to specific ana to mical areas. They are also seen in 85% of patients with X-linked Kallmann syndrome (hypogonadotrophic hypogonadism and anosmia). There is some neurophysiological evidence from patients with X-linked Kallmann syndrome for the existence of an ipsilateral corticospinal pathway, consistent with other evidence that the congenital condition is primarily a disorder of axonal guidance during development. Concurrent activity within ipsilateral and contralateral corticospinal pathways may explain mirroring of movements. Alternatively, a failure of transcallosal inhibition, acquired at the time of myelination of these pathways, may contribute to the genesis of mirror movements. This may occur sponta neously, apparently more often in left-handers, or in right-handers attempting to write with the left hand following left-sided brain injury. The author Lewis Carroll occasionally wrote mirror letters but these differ from his normal script, unlike the situation with Leonardo whose two scripts are faithful mirror images. The mechanisms may differ between a true mir ror writer like Leonardo and someone performing the task for amusement like Carroll. Psychiatric, neurological and medical aspects of misidentification syndromes: a review of 260 patients. It occurs with right parietal region injury (hence left-sided limbs most often involved) and may occur in conjunction with anosognosia, left hemispatial neglect, and (so called) constructional apraxia. His speech was fiuent without paraphasia although impoverished in content, with recurrent themes repeated almost verbatim. The features seem to be distinct from erythropsia (persistent) or phan to m chroma to psia (nor mal visual acuity). Cross References Directional hypokinesia; Eastchester clapping sign; Neglect Moving Ear A focal dyskinesia characterized by ear movement has been described. Cross References Fasciculation; Myo to nia; Neuromyo to nia; Stiffness Myopathy the term myopathy means a primary disorder of muscle causing wasting and/or weakness in the absence of sensory abnormalities. Sodium valproate may be helpful for the involuntary movements which do not respond to antibiotics. Cross References Ataxia; Dementia; Myoclonus; Nystagmus Myo to nia Myo to nia is a stiffness of muscles with inability to relax after voluntary contrac tion (action myo to nia), or induced by electrical or mechanical. Movement of a limb in response to application of pres sure despite the patient having been to ld to resist (mitgehen) is one element of negativism. This dicho to my may also be characterized as egocentric (neglecting hemispace defined by the midplane of the body) and allocentric (neglecting one side of individual stimuli). Hence, this is a type of literal or phonemic paraphasia encountered in aphasic syndromes, most usually those resulting from left superior temporal lobe damage (Wernicke type). Cross Reference Neuropathy Neuromyo to nia Neuromyo to nia is neurogenic muscle stiffness (cf. Clinically this is manifest as muscle cramps and stiffness, particularly during and after muscle contraction, and as muscular activity at rest (myokymia, fasciculations). Physiologically neuromyo to nia is characterized by continuous mo to r unit and muscle fibre activity which is due to peripheral nerve hyperexcitability; it is abolished by curare (cf. Neuromyo to nia may be associated with au to antibodies directed against presynaptic voltage-gated K+ channels. Around 20% of patients have an -239 N Neuronopathy underlying small cell lung cancer or thymoma, suggesting a paraneoplastic aeti ology in these patients. Neuromyo to nia usually improves with symp to matic treatments such as car bamazepine, pheny to in, lamotrigine, and sodium valproate, in combination if necessary. Paraneoplastic neuromyo to nia often improves and may remit after treatment of the underlying tumour. Cross Reference Neuropathy Neuropathy Neuropathies are disorders of peripheral nerves. Mononeuropathies often result from local compression (entrapment neuropathy), trauma, or diabetes. Many neuropathies, particularly polyneuropathies in the elderly, remain idiopathic or cryp to genic, despite intensive investigation. If these other signs are absent, then isolated nuchal rigidity may suggest a foraminal pressure cone. The intensity of jerk nystagmus may be classified by a scale of three degrees: 1st degree: present when looking in the direction of the fast phase; 2nd degree: present in the neutral position; 3rd degree: present when looking in the direction of the slow phase. Periodic alternating nystagmus responds to baclofen, hence the importance of making this diagnosis. These symp to ms are thought to refiect critical compromise of optic nerve head perfusion and are invariably associated with the finding of papilloedema. Obscurations mandate urgent investigation and treatment to prevent permanent visual loss. Cross Reference Papilloedema Obtundation Obtundation is a state of altered consciousness characterized by reduced alert ness and a lessened interest in the environment, sometimes described as psy chomo to r retardation or to rpor. Ocular apraxia may be overcome by using dynamic head thrusting, with or without blinking ( to suppress vestibulo-ocular refiexes): the desired fixation point is achieved through refiex contraversive to nic eye movements to the midposition following the overshoot of the eyes caused by the head thrust. Cross References Apraxia; Saccades Ocular Bobbing Ocular bobbing refers to intermittent abnormal vertical eye movements, usu ally conjugate, consisting of a fast downward movement followed by a slow return to the initial horizontal eye position. This may be observed in anoxic coma or following prolonged status epilepticus and is thought to be a marker of diffuse, rather than focal, brain damage. Reverse ocular dipping (slow upward ocular bobbing) consists of a slow upward movement followed by a fast return to the midposition. Ocular fiutter associated with a localized lesion in the paramedian pontine reticular formation. It has occasionally been reported with cerebellar lesions and may be under inhibi to ry cerebellar control. It occurs particularly with symp to matic (secondary), as opposed to idiopathic (primary), dys to nias, for example, postencephalitic and neuroleptic-induced dys to nia, the latter now being the most common cause. This is usually an acute effect but may on occasion be seen as a consequence of chronic therapy (tardive oculogyric crisis). In young patients this is most often due to demyelination, in the elderly to brainstem ischaemia; brainstem arteriovenous malformation or tumour may also be responsible. Electro-oculographic analyses of five patients with deductions about the physiological mechanisms of lateral gaze. Very rarely pure word deafness has been associated with bilateral brainstem lesions at the level of the inferior colliculi. Pure word deafness after resection of a tectal plate glioma with preservation of wave V of brain stem audi to ry evoked potentials. Cross References Nystamgus; Saccades; Saccadic intrusion, Saccadic pursuit Pyramidal Decussation Syndrome Pyramidal decussation syndrome is a rare crossed hemiplegia syndrome, with weakness of one arm and the contralateral leg without involvement of the face, due to a lesion within the pyramid below the decussation of corticospinal fibres destined for the arm but above that for fibres destined for the leg. No specific investigations are required, but a drug his to ry, including over the counter medi cation, is crucial. Radiculopathy A radiculopathy is a disorder of nerve roots, causing pain in a radicular distribution, paraesthesia, sensory diminution or loss in the corresponding der ma to me, and lower mo to r neurone type weakness with refiex diminution or loss in the corresponding myo to me.

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