Condet

Maria Blasi, PhD

• Assistant Professor in Medicine
• Member of the Duke Human Vaccine Institute

https://medicine.duke.edu/faculty/maria-blasi-phd

Changes reminiscent of the frontal lobe syndrome may occur diabetes test c1a cheap 150mg irbesartan amex, with uninhibited selfish behaviour diabetes mellitus dogs glucose curve irbesartan 300mg online, tactlessness blood sugar 69 order 150mg irbesartan fast delivery, elevation of mood and a decreased tendency to worry diabetes diet type 2 purchase irbesartan 150mg amex. Some of these latter aspects can be construed as improvements in personality, as discussed below. It was most common after rupture of middle cerebral aneurysms, and in general the incidence paralleled that of intellectual impairment and neurological disability. Descriptions of disinhibited behaviour, lessened worry and lessened irritability were commoner in those with anterior aneurysms than other groups, lending support to the classic idea of a frontal lobe syndrome. On the other hand, using the same task a rather different pattern of responding was found in survivors of middle cerebral or posterior communicating artery aneurysms. They showed altered sensitivity to both reward and punishment, and impulsive responding (Salmond et al. However, neither study measured whether there was in fact any personality change in the individuals tested. In both series, therefore, approximately 10% of patients with anterior bleeds showed a favourable outcome of this nature. Two who had been gloomy and readily fatigued became cheerful, vigorous and lost their tension headaches. Two of the 13 showed minor forgetfulness, but in the remainder there was no detectable intellectual impairment. A more recent study found that 13% of patients reported a positive personality change, although the paper gives no further description of what was meant by this (Wermer et al. The improvements consisted mainly of a decreased tendency to worry or get depressed. In three patients there was relief of preexisting endogenous depression, and another showed virtual relief of an obsessional neurosis. Anxiety and depression Walton (1952) emphasised anxiety symptoms in 27% of his cases, half with premorbid neurotic tendencies and half without. The anxiety was often severe and incapacitating, centring largely on fear of recurrence of the haemorrhage. Some patients were afraid for months afterwards to leave the house, or retired to bed immediately they had a headache. In some instances the situation had been worsened by medical advice to avoid exertion. Storey (1972) found symptoms of anxiety or depression in one-quarter of patients, being moderate or severe in 14%. Cerebrovascular Disorders 497 Such symptoms showed an association with indices of brain damage, but depression could also be severe when there was no evidence of brain damage whatever. The depressives without neurological signs had been more neurotic and prone to depression in their premorbid personalities, while those with brain damage had more often been energetic and were therefore perhaps reacting to their loss of function. The patients in whom aneurysms had not been detected appeared to form a special group, with a similar incidence of depression to the remainder despite considerably less evidence of intellectual impairment or neurological disability. Depression was commonest of all, and more liable to be severe and persistent, in patients with posterior communicating aneurysms, where rupture is known to interfere with the fine perforating vessels to the hypothalamus. Patients were recruited consecutively at the time of haemorrhage and rated themselves on the Revised Impact of Events Scale at 3 and 9 months; 30% of patients scored in the clinical range on both subscales (intrusive thoughts and avoidance) at 3 months, falling to 15% at 9 months. Storey (1972) found no examples of psychosis among 261 patients who were studied closely from the psychiatric point of view. One of his patients developed schizophrenia a year later, but the illness seemed unrelated to the haemorrhage. These were persistent and incapacitating in 7 of 56 patients followed by Theander and Granholm (1967), and present in mild degree in many more. Their origin was obscure and showed no relation to the duration of loss of consciousness. Walton (1952) commented on the general similarity between such symptoms after subarachnoid haemorrhage and after head injury, an observation that others have made (Hellawell & Pentland 2001). At 3, 6 and 12 months every patient was assessed by psychiatric interview and classified according to a somewhat idiosyncratic classification of organic mental disorders developed in Sweden (Lindqvist & Malmgren 1993).

Elevation of mood is often seen diabetes definition wikipedia purchase irbesartan 300mg without prescription, mainly as an empty and fatuous euphoria rather than as a true elation that communicates itself to the observer diabetes jobs discount irbesartan 150 mg line. In other cases the principal changes are lack of initiative diabetes insipidus urine osm irbesartan 150 mg generic, aspontaneity and profound slowing of psychomotor activity diabetes mellitus hyponatremia order irbesartan 300 mg online, particularly with frontal lobe tumours. This may progress to a state of extreme aspontaneity amounting virtually to stupor. Even with sharply circumscribed frontal lesions, however, the overall picture may at first sight strongly resemble a generalised dementing process. When frontal lesions encroach upon the motor cortex or motor projections there will be contralateral spastic paresis, usually seen earliest in the face and more obvious on voluntary movement than emotional expression. Paresis may be extremely slight, and show only as slowness of repeated movements or falling away of the outstretched arm. Firmer evidence may be found in hyperactive tendon reflexes and a positive Babinski response. Characteristic decomposition of gait may be seen, with trunk ataxia or awkward postures. Posterior lesions of the dominant lobe may produce a primary motor dysphasia, a motor agraphia or an apraxia of the face and tongue. Ipsilateral optic atrophy or anosmia may result from orbital lesions of the lobe, the latter being commonly overlooked in clinical examination. Sphincteric incontinence may occur surprisingly early in view of the reasonable preservation of intellect, and is a valuable added indication. Most characteristic is disinhibition, with expansive over-familiarity, tactlessness, over-talkativeness, childish Parietal lobes Parietal lobe lesions are associated with a rather bewildering variety of complex cognitive disturbances, including defects of language and number sense, defective appreciation of 18 Chapter 1 external space, and disorders of the body image. Where some are concerned it is uncertain how far the lesions of the parietal lobe are alone responsible, or how far adjacent lesions in the temporal and occipital lobes contribute to the total picture. These matters are dealt with in Chapter 2, but the following is presented as a brief clinical guide. Lesions of either parietal lobe may result in visuospatial difficulties and topographical disorientation. Visuospatial difficulties are most readily exposed by asking the patient to copy simple drawings or construct patterns from coloured blocks or matchsticks, tests which reveal the presence of visuospatial agnosia or constructional dyspraxia. Defective performance is seen more commonly with lesions of the nondominant than dominant lobe but may occur with either. Difficulty in locating objects in space, or in describing the relationships between different objects by vision alone, may also be observed. Topographical disorientation is revealed by difficulty in learning or remembering the way about, with the result that the patient mislocates his bed in the ward, fails to find the bathroom or loses himself even in familiar surroundings. Dominant parietal lobe lesions are associated with various forms of dysphasia, primary motor dysphasia being most in evidence with anterior lesions and primary sensory dysphasia with posterior lesions. Motor apraxia similarly accompanies dominant parietal lobe lesions, and usually affects the limbs of both sides of the body. The syndrome is rarely seen in its entirety and individual components often occur along with other parietal lobe symptoms. Bilateral tactile agnosia is occasionally seen, as are various forms of visual agnosia when the lesion lies posteriorly in the parieto-occipital region. Non-dominant parietal lobe lesions may produce disturbed appreciation of the body image and of external space, particularly involving the contralateral side. If paralysed or hemianaesthetic, the disability may be ignored or refuted (anosognosia), a part of the body may be felt to be absent (hemisomatognosia), or in rare cases there may be phantom reduplication of body parts. Neglect of the left half of external space may show in the omission of leftsided details when drawings are copied, or in the crowding of writing into the right-hand part of the paper. In addition to visuospatial agnosia there may be a marked defect of the recognition of faces (prosopagnosia) when the lesion is posterior and involves the occipital lobe. Neurological signs indicative of a parietal lobe lesion include cortical sensory loss and the phenomena of extinc- tion and inattention. Cortical sensory loss consists not of analgesia but of a more complex impairment of sensation and difficulty with discrimination; objects cannot be identified by palpation (astereognosis), figures written on the hand cannot be named (agraphaesthesia), two-point discrimination is impaired, and the localisation of sensory stimuli is inaccurate. Sensory extinction (sensory inattention) is shown when two parts of the body are lightly touched simultaneously and that on the side contralateral to the lesion is not perceived. Visual inattention may be demonstrated by asking the patient to point to moving objects in both halffields of vision; when two objects move simultaneously that in the contralateral half-field is ignored.

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Drowsiness blood glucose monitor precision xtra purchase irbesartan 150 mg with amex, worsening of neurological symptoms and transient cognitive deficits consisting of short-term memory and attentional deficts are seen blood sugar conversion chart safe irbesartan 300mg. It may take the form of local radionecrosis or diffuse leucoencephalopathy and cerebral atrophy (Taphoorn & Klein 2004) diabetes diet exercise control order irbesartan 150 mg with mastercard. There is an association between the severity of cognitive deficits and imaging abnormalities such as cerebral atrophy and leucoencephalopathy (Postma et al pendulum blood sugar buy discount irbesartan 150 mg. Memory, attention and new learning, as well as processing speed are sensitive to radiotherapy. Common neurological sequelae include urinary incontinence, ataxia, and pyramidal as well as extrapyramidal signs. More than half of the patients had difficulty in learning new information and 80% displayed accelerated forgetting over time. Additionally, one-third of the patients displayed deficits of visuomotor speed, frontal lobe 304 Chapter 5 executive function and fine motor coordination. Two of the patients had severe necrosis with ensuing dementia and blindness (Meyers et al. Improvements in technology aim to deliver high doses of radiation to the tumour while significantly sparing the surrounding healthy structures. Stereotactic surgery combines the principles of stereotactic localisation with precise delivery of radiation to an imaging-defined target. The gamma knife uses emitted photons that are directed precisely through circular channels drilled into a high-density metal helmet. These methods are all efficacious and offer a more circumscribed approach to the treatment of brain tumours (Brown & Pollock 2005). New therapeutic modalities Novel therapeutic approaches targeted at the aetiological factors that may be responsible for tumours, especially gliomas, have been developed. These are all promising strategies in the earlier stages of development for clinical practice. In: Transactions of the American Neurological Association, 71st Annual Meeting, pp. Although a diagnosis of epilepsy implies that symptoms are the result of abnormal electrical activity, this may in turn have many different causes. The current classification of epilepsy (Commission on Classification and Terminology of the International League Against Epilepsy 1981, 1989) approaches the subject at two levels: (i) there is a system for classifying seizures based on clinical signs and symptoms. The latter is derived from the classification of seizures, but in addition takes into account patterns of signs and symptoms, age at onset, electrophysiological findings, natural history and factors of potential aetiological significance, including background and family history and pathology where known. It represents an attempt to define syndromes that are homogeneous with respect to aetiology and which have practical implications for treatment and prognosis. With advances in our understanding of pathophysiology, and perhaps the genetics of epilepsy in particular, future refinements to this system are both inevitable and desirable. Mellers Maudsley Hospital, London the manifestations of epilepsy include facets of equal importance to the psychiatrist and the neurologist. The seizure itself may take the form of the classic motor convulsion or consist instead of complex abnormalities of behaviour and subjective experience. Associated disorders may sometimes include cognitive difficulties, personality disturbances or psychotic illnesses of various types and durations. In all these respects the study of patients with epilepsy has played an important part in advancing our knowledge of brain function and dysfunction, and in indicating something of the pathophysiological basis for certain forms of psychological disorder. The accent in this chapter is on those aspects most relevant to the work of the psychiatrist. It is now clear that the great majority of people with epilepsy suffer little or no mental disturbance, but those who do can present difficult and complicated problems. Psychosocial and organic factors are often inextricably mixed in causation, and assessment of all the evidence available in the individual patient can be a complex and time-consuming matter. This definition conveys three important principles: (i) that the core presenting feature, the seizure, is a transient abnormality of neurological function that is highly uniform from one episode to the next; (ii) that the diagnosis depends primarily on clinical judgement; and (iii) that the underlying mechanism of an epileptic seizure is an abnormal cortical discharge. The most important division distinguishes between seizures that arise from epileptic discharges beginning in a circumscribed brain region (partial seizures) and seizures that have no detectable focal onset and seemingly involve the cortex bilaterally from the start (generalised seizures).

The usual caveat diabetes test when pregnant discount 300mg irbesartan otc, that none of these studies have yet had replications published diabetes mellitus type 2 etiology buy generic irbesartan 300mg on-line, remains diabetes blog buy irbesartan 300 mg line. In some studies this was due to an effect of education on non-Alzheimer dementia (Fratiglioni et al diabetes type 2 weekly meal plan order irbesartan 300mg free shipping. There is an interaction between gender and education in that it is only in women that an effect is seen (Letenneur et al. Quite what cognitive reserve equates to in the brain is pure conjecture, presumably networks, neurones or synapses. In this context it is both intriguing and perhaps surprising that head circumference is also associated with risk of dementia, a larger head offering some measure of protection (Schofield et al. Perhaps big heads mean big brains, which in turn means more brain to lose before dementia becomes apparent. Nevertheless, the increase in incidence was only apparent in the very elderly in at least one large prospective study (Ruitenberg et al. Assuming that there is a true increase in incidence for women, what might this be due to The most obvious mechanism is the loss of protection of estrogen and related hormones after the menopause and there is ample evidence that estrogen has some neuroprotective properties, particularly against amyloid-induced neurotoxicity (Green et al. Nonetheless, this suggests that a low incidence of dementia in Africa may be due to some protective factor. Jorm and colleagues identify six possible mechanisms for this association (Jorm 2000), none of which can be confidently excluded. Perhaps the explanation needing fewest radical speculations is the one that depression represents a very early prodromal symptom. Dietary intake of vitamin C or vitamin E has been raised as possible risk factors but the results from epidemiology are inconsistent (Engelhart et al. It may well be that only trials will determine whether these antioxidants offer any protection. It has long been clear that there is a group of individuals who are somewhat impaired but who do not have a full dementia syndrome. The difficulty with nosology has been what impairment means: impaired in relation to all adults, young adults, agematched controls Attempts have been made to group these people in various categories, including benign senescent forgetfulness, age-associated memory impairment, and others. However, common to all criteria are (i) that the patient should not meet criteria for dementia; (ii) that there should be some report of cognitive impairment by either the patient or an informant; (iii) that there should be objective evidence of cognitive impairment or decline; and (iv) that there should be no substantial evidence of functional impairment. Some criteria refine these elements, suggesting for example that objective evidence for cognitive impairment should be a score more than 1. However, one of the difficulties common to all criteria relates to the upperlevel criteria that the patient should not have dementia. While there are excellent scales and measures for assessing function in more advanced dementia, doing the same in very early dementia is difficult and rests entirely on a careful, detailed and sometimes lengthy history. Often functional impairment is specific to an individual and is both culture and gender bound. At least for currently elderly cohorts this example illustrates a probable gender bias and neither functional impairment is detectable without considerable effort. When combined with very mild cognitive impairment and other features, some clinicians would give a diagnosis of dementia; others would not. In a systematic review we found rates of conversion to dementia ranged from 2% to 30% per year (Bruscoli & Lovestone 2004). However, diagnostic differences did not seem to account for all this substantial variability. When considering a variety of variables that might account for these different conversion rates, the one that stood out was the origin of the subjects of the study. Where subjects were recruited from a community-based study annual conversion rate was 7. It seems that there is something about people who manage to negotiate the care pathway to a memory clinic that is different from those people identified with the same symptoms in the community.

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