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tality rate (due mainly to heart disease) had risen to 21 percent and the incidence of stroke to 13 percent (compared to expected gures of 15 and 3 percent, respectively, in an age-matched population). Of the patients who were alive at the end of the observation period, 43 percent had had no further attacks of amaurosis fugax following the initial episode. Noteworthy also was the nding that among patients with normal carotid arteriograms, only 1 of 35 had had a stroke during the follow-up period, whereas stroke had occurred in 8 of 21 patients in whom the internal carotid artery was occluded or stenotic. These gures are in keeping with those of Ackerman; in his series of 139 patients with amaurosis fugax and normal lumens of the common and internal carotid arteries, only 3 had a subsequent hemispheric stroke (personal communication). As pointed out by Benavente and colleagues, the risk of stroke over the 3 years following an attack is as low as 2 percent if there are no other issues such as diabetes, but it may be as high as 24 percent in older patients with risk factors for atherosclerosis. The age of the patient with amaurosis fugax is of particular signi cance. In the series of Poole and Ross Russell, the youngest patient to have a stroke after amaurosis fugax was 57 years old. Tippin and coworkers reviewed the records of 83 patients with onset of amaurosis fugax before the age of 45 years and found evidence of stroke in none; moreover, 42 of these patients were examined after a mean period of 5.8 years during which no stroke had occurred. It is evident that in this early-onset, good-prognosis group, a mechanism other than atherosclerosis was operative, such as migraine or an antiphospholipid antibody (discussed further on). Brainstem Transient Ischemic Attacks (Vertebrobasilar Circulation) Recurrent TIAs referable to vertebrobasilar disease tend to be less stereotyped and more prolonged than those related to the carotid circulation. They are also more likely to culminate in a stroke. The clinical picture of TIAs in the vertebrobasilar territory is diverse, since this circulation sustains such a varied sensorimotor traf c. Vertigo, diplopia (vertical or horizontal), dysarthria, bifacial numbness, ataxia, and weakness or numbness of part or all of one or both sides of the body (i.e., a disturbance of the long motor or sensory tracts bilaterally) are the hallmarks of vertebrobasilar involvement. Transient vertigo, diplopia, or headache occurring as solitary symptoms should not be interpreted as a TIA. Also, in some patients, the complaint of dizziness will prove, however infrequently, to be part of a carotid TIA; hence this symptom, in our experience and that of Ueda et al, is not a totally reliable indicator of the vascular territory involved. Other manifestations of vertebrobasilar TIAs, in their approximate order of frequency, include staggering, veering to one side, a feeling of cross-eyedness, dark vision, blurred vision, tunnel vision, partial or complete blindness, pupillary change, ptosis, paralysis of gaze, dysarthria, and dysphagia. Less common symptoms include hemiplegia, noise or pounding in the ear or in the head, pain in the head or face or other peculiar head sensations, vomiting, hiccups, sense of tilting, lapse of memory, confused behavior, drowsiness, transient unconsciousness (rare), impaired hearing, deafness, hemiballismus, hallucinosis, and forced deviation of the eyes. So-called drop attacks (page 329), according to Ross Russell, have been recorded in 10 to 15 percent of patients with vertebrobasilar insuf ciency, but we have never observed such attacks as a recurrent ischemic phenomenon or a manifestation of other forms of cerebrovascular disease. Vertebrobasilar TIAs may be identical from one episode to another, or they may vary in detail while maintaining the same basic pattern, the latter occurrence being more typical. For exam-
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The McGraw Hill Companies, 2010
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In addition to changing the value of the BackColor property, change the following as well: Property
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15. Change the ID property to CreateAccount and press ENTER.
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Figure 3-6. Triangulum, the southern triangle; and Apus, the bird of paradise.
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nated as de ciency amblyopia or nutritional optic neuropathy (Chap. 41). The same disorder may be seen under conditions of severe dietary deprivation (Strachan syndrome, page 992) and in patients with vitamin B12 de ciency (page 994). Another cause is Leber hereditary optic atrophy, an inherited disorder of mitochondria, a subject that is reviewed by Newman and discussed in Chap. 37. Subacute optic neuropathy of possible toxic origin has been described in Jamaican natives. It is characterized by a bilaterally symmetrical central visual loss and may have additional features of nerve deafness, ataxia, and spasticity. A similar condition has been described in other Caribbean countries, most recently in Cuba, where an optic neuropathy of epidemic proportions was associated with a sensory polyneuropathy. A nutritional etiology, rather than tobacco use (putatively, cigars in the Cuban epidemic), is likely but has not been proved conclusively (see Sadun et al and the Cuba Neuropathy Field Investigation report). Impairment of vision due to methyl alcohol intoxication (methanol) is abrupt in onset and characterized by large symmetrical central scotomas as well as symptoms of systemic disease and acidosis. Treatment is directed mainly to correction of the acidosis. The subacute development of central eld defects has also been attributed to other toxins and to the chronic administration of certain therapeutic agents: halogenated hydroxyquinolines (clioquinol), chloramphenicol, ethambutol, isoniazid, streptomycin, chlorpropamide (Diabinese), in ixamab, and various ergot preparations. The main drugs reported to have a toxic effect on the optic nerves are listed in Table 13-3 and have been catalogued by Grant. Developmental Abnormalities Congenital cavitary defects due to defective closure of the optic ssure may be a cause of impaired vision because of failure of development of the papillomacular bundle. Usually the optic pit or a larger coloboma is unilateral and unassociated with developmental abnormalities of the brain (optic disc dysplasia and dysplastic coloboma). A hereditary form is known (Brown and Tasman). Vision may also be impaired as a result of developmental anomalies of the optic nerves; the discs are of small diameter (hypoplasia of the optic disc or micropapilla).
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Activity Frequency:
1. David Moschella, IT Professionals Can Help Ease Economic Change, Computerworld (June 26, 2000): 37. 2. Lockheed Martin, Boeing and General Motors Top List of Preferred Employers in Graduating Engineer & Computer Careers Magazine s Biennial Student Survey, PR Newswire (March 17, 2000): Evanston, Ill., Lexis-Nexis. 3. New Internet Website from CASS Communications, Inc. Empowers Engineering and Computer Graduates in the Job Market, PR Newswire (April 2, 1999): LexisNexis. 4. Jay Green, Microsoft: How It Became Stronger than Ever, Business Week (June 4, 2001): 76. 5. Oracle Announces Key Strategic Partnerships to Enhance Product Development Exchange Offering, PR Newswire (October 16, 2000): Lexis-Nexis.
Source: " Will the Bear Market Be With Us for a Long Time " by Dennis Tilley
Sleep, as everyone knows, is an elemental phenomenon of life and an indispensable phase of human existence. It represents one of the basic 24-h (circadian) rhythms, traceable through all mammalian, avian, and reptilian species. The neural control of circadian rhythms is thought to reside in the ventral-anterior region of the hypothalamus more speci cally, in the suprachiasmatic nuclei. Lesions in these nuclei result in a disorganization of the sleep-wake cycles as well as of the rest-activity, temperature, and feeding rhythms. The ancillary role of melatonin and the pineal body in modulating this cyclic activity is described in Chap. 27. Effects of Age Observations of the human sleep-wake cycle show it to be age-linked. The newborn baby sleeps from 16 to 20 h a day and the child, 10 to 12 h. Total sleep time drops to 9 to 10 h at age 10 and to about 7 to 7.5 h during adolescence. A gradual
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