By I. Yugul. North Georgia College and State University, the Military College of Georgia.
Gene tests for Alzheimer’s disease are available but are subject to debate cheap 40 mg levitra super active otc. These tests are given to healthy people who have no symptoms but are con- sidered to be at risk because of family medical history order levitra super active 20mg visa. One of their most serious limita- tions is the difficulty in interpreting a positive result because some people who carry a disease-associated mutation will never develop the actual disease levitra super active 20mg low price. A limitation of all medical testing is the possibility of laboratory errors generic levitra super active 40 mg line. Many members of the medical establishment feel that uncertainties sur- rounding test interpretation, the current lack of available medical options for genetic diseases, the potential for provoking patient anxiety, and risks for discrimination and social stigmatization could outweigh any benefits of testing. The promise of human genome research is great, but it will take time to develop inexpensive diagnostic tests for DNA markers. Doctors will need to take the time to understand predisposing factors that may render a patient vulnerable to a disabling condition. Awareness of these factors may eventu- ally allow physicians to unravel complicated diagnostic problems. Reasons for Hope in the Midst of the Diagnostic Dilemma There can be little doubt that the diagnosis dilemma exists and persists despite the best doctors and medical technology in the world. Any one or a combination of factors contributing to this dilemma may be operating in your particular case. We trust you can see the essential need to take a more active role in the search for the diagnostic answers to your unexplained med- The Diagnosis Dilemma 19 ical symptoms. In the next chapter, we’ll define and describe just how easy it is for undiagnosed symptoms to become a mystery malady, and we’ll share some examples and case studies. We will also call your attention to the need to develop a new mind-set as you learn the basics of medical detective work. In Chapter 3, we’ll reveal our revolutionary Eight Steps to Self- Diagnosis. If you’re willing to work through the steps and act as your own medical detec- tive, you can find your way out of the diagnosis dilemma and be well on your way to solving your mystery malady. We hope our per- sonal experiences and the many case studies we present throughout the book will inspire you to work proactively with your doctors to find your diag- nostic solutions. We have dubbed the medical conditions that lead to a diagnosis dilemma “mystery maladies. Definition of Mystery Maladies • Conditions, syndromes, or symptoms that cannot be diagnosed easily or neatly despite advances in medical technology • Misdiagnosed chronic conditions • Symptoms that have no known cause or origin • Conditions or syndromes that are now identifiable but until recently were considered “mysteries” and may still be unfamiliar to many physicians 21 Copyright © 2005 by Lynn Dannheisser and Jerry Rosenbaum. Say, for exam- ple, that you have a persistent cough following what appears to have been a cold. You make an appointment with your primary care physician and tell her your symptoms. She peers in your throat and ears, feels your glands, and listens to your chest. After asking some additional questions, she decides on a treatment plan based on an established protocol. She may prescribe a course of antibiotics, rest, and plenty of fluids, and she might advise you to avoid milk products that can cause mucus. Unfortunately, you don’t get better—and so your mystery mal- ady begins. The following scenario is not atypical for many mystery malady sufferers. You call your physician again; she is somewhat perplexed but suggests a different antibiotic and perhaps an expectorant. Out of concern and in an abundance of caution, she refers you to a specialist, perhaps a pulmonolo- gist, an allergist, or both, and you make the rounds. These physicians, in turn, may send you for x-rays, blood tests, and other medical tests. The end result is a laundry list of possible diagnoses, a fistful of medical bills, and a medicine cabinet full of prescriptions that offer you no relief.
Cross References Agnosia; Dysmorphopsia; Graphesthesia; Two-point discrimination Asterixis Asterixis is a sudden purchase levitra super active 20mg visa, brief buy 20mg levitra super active fast delivery, arrhythmic lapse of sustained posture due to involuntary interruption in muscle contraction cheap levitra super active 40mg on line. It is most eas- ily demonstrated by observing the dorsiflexed hands with arms out- stretched (i order levitra super active 20 mg online. Movement is associated with EMG silence in antigravity muscles for 35-200 ms. These features distinguish asterixis from tremor and myoclonus; the phenomenon has previously been described as negative myoclonus or negative tremor. Recognized causes of asterixis include: - 40 - Ataxia A Hepatic encephalopathy Hypercapnia Uremia Drug-induced, for example, anticonvulsants, levodopa Structural brain lesions: thalamic lesions (hemorrhage, thalamo- tomy) Unilateral asterixis has been described in the context of stroke, contralateral to lesions of the midbrain (involving corticospinal fibers, medial lemniscus), thalamus (ventroposterolateral nucleus), primary motor cortex and parietal lobe; and ipsilateral to lesions of the pons or medulla. Unilateral asterixis and stroke in 13 patients: localization of the lesions matching the CT scan images to an atlas. European Journal of Neurology 2004; 11(suppl2):56 (abstract P1071) Cross References Encephalopathy; Myoclonus; Tremor Asynergia Asynergia or dyssynergia is lack or impairment of synergy of sequen- tial muscular contraction in the performance of complex movements, such that they seem to become broken up into their constituent parts, so called decomposition of movement. Dyssynergy of speech may also occur, a phenomenon sometimes termed scanning speech (q. This is typically seen in cerebellar syndromes, most often those affecting the cerebellar hemispheres, and may coexist with other signs of cerebellar disease, such as ataxia, dysmetria, and dysdiadochokinesia. Cross References Ataxia; Cerebellar syndromes; Dysarthria; Dysdiadochokinesia; Dysmetria; Scanning speech Ataxia Ataxia or dystaxia refers to a lack of coordination of voluntary motor acts, impairing their smooth performance. The rate, range, timing, direction, and force of movement may be affected. Ataxia is used most frequently to refer to a cerebellar problem, but sensory ataxia, optic ataxia, and frontal ataxia are also described, so it is probably best to qualify ataxia rather than to use the word in isolation. Cerebellar hemisphere lesions cause ipsilateral limb ataxia (hemiataxia; ataxia on finger-nose and/or heel-shin testing) whereas midline cere- bellar lesions involving the vermis produce selective truncal and gait ataxia. These fibers run in the corticopontocerebellar tract, synapsing in the pons before passing through the middle cerebellar peduncle to the con- tralateral cerebellar hemisphere. Triple ataxia, the rare concurrence of cerebellar, sensory and optic types of ataxia, may be associated with an alien limb phenomenon (sensory type). There are many causes of cerebellar ataxia, including: ● Inherited: Autosomal recessive: Friedreich’s ataxia Autosomal dominant: clinically ADCA types I, II, and III, now reclassified genetically as spinocerebellar ataxias, types 1-25 now described Episodic ataxias: channelopathies involving potassium (type 1) and calcium (type 2) channels Mitochondrial disorders Huntington’s disease Dentatorubropallidoluysian atrophy (DRPLA) Inherited prion diseases, especially Gerstmann-Straussler- Scheinker (GSS) syndrome ● Acquired: Cerebrovascular events (infarct, hemorrhage): usually cause hemiataxia; postanoxic cerebellar ataxia Inflammatory: demyelination: multiple sclerosis, Miller Fisher variant of Guillain-Barré syndrome, central pontine myelinolysis - 42 - Ataxic Hemiparesis A Inflammatory: infection: cerebellitis with Epstein-Barr virus; encephalitis with Mycoplasma; HIV Neoplasia: tumors, paraneoplastic syndromes Neurodegeneration: one variant of multiple system atrophy (MSA-C); prion diseases (Brownell-Oppenheimer variant of sporadic Creutzfeldt-Jakob disease, kuru); idiopathic late- onset cerebellar ataxia Drugs/toxins: for example, alcohol, phenytoin Metabolic: vitamin E deficiency, thiamine deficiency (Wernicke’s encephalopathy), gluten ataxia, hypothyroidism (debatable) References Klockgether T (ed. Neurology in clinical practice: principles of diagnosis and management (3rd edition). Boston: Butterworth-Heinemann, 2000 309-317 Cross References Alien hand, Alien limb; Asynergia; Balint’s syndrome; Cerebellar syndromes; Dysarthria; Dysdiadochokinesia; Dysmetria; Head tremor; Hemiataxia; Hypotonia, Hypotonus; Macrographia; Nystagmus; Optic ataxia; Proprioception; Pseudoathetosis; Rebound phenomenon; Rombergism, Romberg’s sign; Saccadic intrusion, Saccadic pursuit; Scanning speech; Square-wave jerks; Tandem walk- ing; Tremor Ataxic Hemiparesis Ataxic hemiparesis is a syndrome of ipsilateral hemiataxia and hemi- paresis, the latter affecting the leg more severely than the arm (crural pare- sis). This syndrome is caused by lacunar (small deep) infarction in the contralateral basis pons at the junction of the upper third and lower two-thirds. It may also be seen with infarcts in the contralateral thala- mocapsular region, posterior limb of the internal capsule (anterior choroidal artery syndrome), red nucleus, and the paracentral region (anterior cerebral artery territory). Sensory loss is an indicator of cap- sular involvement; pain in the absence of other sensory features of thalamic involvement. Stroke 1998; 29: 2549-2555 Cross References Ataxia; Hemiataxia; Hemiparesis; Pseudochoreoathetosis - 43 - A Ataxic Nystagmus Ataxic Nystagmus - see INTERNUCLEAR OPHTHALMOPLEGIA; NYSTAGMUS Athetosis Athetosis is the name sometimes given to an involuntary movement dis- order characterized by slow, sinuous, purposeless, writhing movements, often more evident in the distal part of the limbs. Athetosis often coex- ists with the more flowing, dance-like movements of chorea, in which case the movement disorder may be described as choreoathetosis. Indeed the term athetosis is now little used except in the context of “athetoid cerebral palsy. Athetosis and William Alexander Hammond, a founder of American neurology. London: Imperial College Press, 2003: 413-416 Cross References Chorea, Choreoathetosis; Pseudoathetosis; Pseudochoreoathetosis Atrophy Atrophy is a wasting or thinning of tissues. The term is often applied to wasted muscles, usually in the context of lower motor neurone pathology (in which case it may be synonymous with amyotrophy), but also with disuse. Atrophy develops more quickly after lower, as opposed to upper, motor neurone lesions. It may also be applied to other tissues, such as subcutaneous tissue (as in hemifacial atrophy). Atrophy may sometimes be remote from the affected part of the neu- raxis, hence a false-localizing sign, for example wasting of intrinsic hand muscles with foramen magnum lesions. Cross References Amyotrophy; “False-localizing signs”; Hemifacial atrophy; Lower motor neurone (LMN) syndrome; Wasting Attention Attention is a distributed cognitive function, important for the opera- tion of many other cognitive domains; the terms concentration, vigi- lance, and persistence may be used synonymously with attention.
Jean VERBRUGGE 1896–1964 Henk VERBIEST The Belgian medical world discount levitra super active 20mg with visa, and especially its 1909–1997 orthopedic surgeons buy generic levitra super active 20mg, mourn the passing of an eminent surgeon levitra super active 20 mg generic, a good man cheap 40 mg levitra super active, and an incompara- Henk Verbiest was born in Rotterdam in 1909. After brilliant intermediary studies at student, Verbiest did research in pigeons on Antwerp, he graduated and gained his degree, in several neurological problems. After graduation, 1921, as a doctor of medicine, surgeon, and obste- Verbiest worked in the department of neurology trician from the University of Brussels, with the until 1937. He was almost immediately this period, he was granted a doctoral degree in awarded a scholarship as a Fellow of the Com- 342 Who’s Who in Orthopedics mittee for Relief in Belgium (CRB Educational stances that could and, indeed, would lead to Foundation) and spent 2 years, up to 1924, at the forgiveness. Instead, almost fessor Putti in Italy and Professor Leriche in embarrassed, he would say “I do not think that I France. As early as 1925, he started his career at would have set about it that way. For many years, he involved duties and contacts of every description, worked in trusted collaboration with this univer- but the young surgeon fresh from the university sally recognized surgeon, who may be said to received as kind and as amicable a welcome as have been the founder of the modern technique of the VIP. Orthopedic science as well as orthopedic Another characteristic of the man we mourn surgery owes a great deal to Jean Verbrugge, as was the price he attached to friendship. People of evidenced by his numerous books, papers, his generation and younger ones can bear witness reports, lectures—about 175 publications in all. All sorts of render a service, chat with his friends, meet them, honors naturally rewarded his brilliant efforts tease them in a good-natured fashion, such and, as was only to be expected, he was a member appeared to be one of his principal aims in life. In fact, how could such a man have anything but On several occasions, he represented Belgium friends? He was called to the his colleagues of the Société Belge de Chirurgie; presidency of the Belgian Orthopedic Association his attitude was in no way that of a president, stiff no less than three times. He presided over many and solemn, discharging an obligation toward the a congress in Belgium and in other countries in a members of a society: quite the opposite, in fact, smiling good-natured manner, which did not he behaved like a man affectionately surrounded exclude firm action when necessary. The reception was full of to meet socially as he was captivating to listen to warmth and a total success and, each time he and fascinating to follow as a scientist. Tact, spoke to his guests, he called them his “dear frankness, modesty, devotion, honesty, indul- friends,” which was, indeed, the term he used gence, kindness, I do not know which of these when speaking from the platform of a scientific qualities could best be cited as characteristic of society, since he never could imagine that one the man when describing him, for he was blessed could address one’s colleagues differently. But, above all, I think that he was His career and his works, which I have re- naturally of a kind disposition and that, to his rela- called, are not sufficient, however, to depict the tions, his students, his friends, and his colleagues, man of science; the most that one can say is that he was kindness personified. He was kind to his they enable one to sum up his contribution to patients, his friends, his assistants, his colleagues, science. Better still, teacher was clarity: in a few words, he simplified when somebody hurt him, he did not show his dis- a problem and a few movements sufficed to turn tress but confided in some close friend. For in keeping with his honest and indulgent outlook instance, in a clinical case discussion, he would on life and he always sought attenuating circum- enumerate five possibilities and, from that 343 Who’s Who in Orthopedics moment, one could be quite certain that there were no more. He then rejected progressively one after another of the four possible solutions and, finally, there remained only one, which his con- science, his common sense, and his experience told him was the best. Similarly, at scientific meetings, it was almost a relief to see Jean Verbrugge stand up after a somewhat labored exposé or a heated debate: in a few words, he would stress the principal points, which had either escaped notice or were hardly apparent, and everything became simple and comprehensible. He was outstanding in this field when a young speaker, intimidated by his audience or by ill- natured questioners, showed signs of losing his head. One could be sure that, at this moment, Ver- Richard Von VOLKMANN brugge would stand and say “I have been very interested (and this was true) by what my young 1830–1889 friend has said. He studied at several and, here again, one could be certain that the three universities and graduated at the age of 24. Two observations would clarify the question and rid it years later he became deputy professor of surgery of all that was superfluous. Professor Verbrugge rarely stood up and spoke He instituted Lister’s antiseptic methods at without teaching me something and I find it hard the hospital; it had previously been subject to to visualize our next meetings without him. Simone and Simon- He wrote poems and fairy stories with the pen ette Verbrugge mourn the passing of a loving name Richard Leander, which were very popular, husband and an exemplary father. Jean Verbrugge died on January 7, 1964 after a long and painful illness, which he bore with courage and stoicism. He deserves entirely what he himself hoped for in the case of his late master Lambotte: “that he should still live in our minds. Henning WALDENSTRÖM 1877–1972 Henning Waldenström was born in Stockholm Börje WALLDIUS and began his orthopedic career in the same city. In 1936, he became professor of orthopedics at 1913– the Karolinska Institute.