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Table 9-2 Examination features of the peripheral and spinal cord sensory syndromes (see text and also Chap. 46) Polyneuropathy Symmetrical distal sensory loss Sensory loss may affect one modality preferentially Are exia or hypore exia Weakness, if present, symmetrical Polyradiculopathy Asymmetrical sensory and motor loss Proximal and distal parts of limb differentially affected Re ex loss limited to region of affected root(s) Ganglionopathy Implicates all sensory modalities Proximal body parts affected Ataxia Tabetic syndrome Prominent loss of vibratory and postion sense in feet Romberg sign Secondary (Charcot) joint deformities Are exia Myelopathy Complete transverse lesion: loss of all sensory modalities below level of lesion Syringomyelia: loss of pain and thermal sense with prevervation of touch and joint position/vibration over restricted region of neck, cape, arms, hands Anterior spinal artery syndrome: loss of pain sense with preservation of vibration and joint position below level of lesion Posterior column: same as tabetic but re exes preserved Hemicord (Brown-Sequard): loss of pain sense opposite to the lesion and beginning several levels below it; loss of vibration and joint position sense on the side of the lesion and below it
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administrators in the organization. The focus of these solutions is the act of integrating security information and actions across multiple systems and applications. If you are a security architect or engineer facing challenges around integrating identity information among multiple systems or integrating authentication session across applications (for example, a web portal authentication scenario) or dealing with setting up role-based access control of your databases using LDAP servers, you are more of less at a tactical maturity level for your security architecture. Keep in mind that working through these types of pains that come at this level is a prerequisite to solving the problems posed in subsequent maturity levels. Once again, the simple litmus test for categorizing as tactical is in the answer of whether the architects are mainly solving data and system integration problems.
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Figure 6.2 A&B An underprojected chin position leads to an unfavorable obtuse cervicomental angle. A chin implant increasing chin projection can improve the cervicomental angle on postsurgical healing are well documented in the literature and should be explicitly explained to patients currently using tobacco products. Patients should discontinue the use of all tobacco and nicotine at least 1 month before and after cosmetic surgery.4 All medications or supplements that increase the risk for bleeding, including anticoagulant medications such as aspirin, nonsteroidal anti-in ammatory drugs (NSAIDs), warfarin sodium (Coumadin), steroid medications, as well as some vitamins and herbal supplements, should be reviewed by the surgeon and discontinued prior to surgery. In addition, a history of easy bruising, bleeding gums, frequent epistaxis, a family history of bleeding dyscrasias, heavy alcohol use, or liver disease can increase the risk for postoperative bleeding and should be evaluated before surgery.
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The choose from list dialog box comes with a Cancel button on the left and an OK button on the right. You can t change the behavior or position of these buttons, but you can change their names to make their function more obvious (though OK and Cancel are pretty clear) or to make the dialog box conform to your company s or organization s house style. To change the button names, use the OK button name parameter and the Cancel button name parameter, as in this example and Figure 8-18:
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V. Preparing and Printing a Drawing
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Physicians are often consulted by patients who suffer some derangement of sleep. Most often the problem is one of sleeplessness, but sometimes it concerns excessive sleep or some peculiar phenomenon occurring in connection with sleep. Certain points concerning normal sleep and the sleep-wake mechanisms are worth reviewing, since familiarity with them is necessary for an understanding of disorders of sleep. A great deal of information about sleep and sleep abnormalities is now available as a result of the development, in relatively recent years, of the subspecialty of sleep medicine and the creation of a large number of centers for the diagnosis and treatment of sleep disorders. Most disorders of sleep can be readily recognized and managed if one attends closely to the patient s description of his sleep disturbance. Only complex or odd cases or those requiring the documentation of apneic episodes or seizures and other motor disorders during sleep need study in special sleep laboratories.
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As a rough guide to the relative frequency of the various causes of syncope, the large amount of information from the Framingham Heart Study accumulated by Soteriades and colleagues can be taken as representative; the leading cause was vasovagal, 21 percent, a cardiac cause was established in 9 percent, and orthostatic hypotension in 9 percent; fully 40 percent could not be categorized. Also notably, 7 percent of cases were attributed to medications, mainly those that interfered with sympathetic tone. The three main types of syncope and several others that cannot readily be included within these categories can be further subdivided by their pathophysiologic mechanism, as follows: I. Neurogenic vasodepressor reactions A. Elicited by extrinsic signals to the medulla from baroreceptors 1. Vasodepressor (vasovagal) 2. Neurocardiogenic 3. Carotid sinus hypersensitivity
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The symptom complex of incomplete or insuf cient development of mental capacities and associated behavioral abnormalities (variously referred to as mental retardation, mental subnormality, or formerly, oligophrenia) combines many of the developmental abnormalities already discussed. Mental retardation stands as the single largest neuropsychiatric disorder in every civilized society. Its overall frequency cannot be stated precisely. Rough estimates are that in a group of children between 9 and 14 years of age, about 2 percent or slightly more will be unable to pro t from public education or to adapt socially and, when fully grown up, to live independently. Using any one of a number of indices of social and psychologic failure, two somewhat overlapping groups are recognized: (1) the mildly impaired (IQ 45 to 70), and (2) the severely impaired, corresponding to an IQ below 45. The second group, also called the pathologic mentally retarded, makes up approximately 10 percent of the subnormal population. The more mildly affected rst group, which was formerly referred to as the subcultural, physiologic, or familial mentally retarded, is a much larger group. Because of the objectionable implications of the previously used terms idiot, imbecile, and moron, the American Association on Mental De ciency proposed that the mentally retarded be grouped instead into four categories: (1) those with profound de ciency, incapable of self-care (IQ below 25); (2) those with severe de ciency, incapable of living an independent existence and essentially untrainable (IQ 25 to 39); (3) those with moderate de ciency, trainable to some extent (IQ 40 to 54); and (4) those with mild de ciency, who are impaired but trainable and to some extent educable. The above terms, while in common use, satisfy neither neurologists nor psychologists because of their generality, embracing as they do any lifelong global de cit in mental capacities. The terms convey no information of the particular type(s) of intellectual impairment, their causes and mechanisms, or their anatomic and pathologic bases. Moreover, they express only one aspect of impaired mental function the cognitive and ignore the inadequate development of personality, social adaptation, and behavior. Spe-
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