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Tactile agnosia: underlying impairment and implications for normal tactile object recognition. In ataxic disorders, cerebellar (midline cerebellum, in which axial coordination is most affected) or sensory (loss of proprioception), the ability to tandem walk is impaired, as reflected by the tendency of such patients to compensate for their incoordination by developing a broad-based gait. This may be the earliest indication of a developing temporal field defect, as in a bitemporal hemianopia due to a chiasmal lesion, or a monocular temporal field defect (junctional scotoma of Traquair) due to a distal ipsilateral optic nerve lesion. Cross References Hemianopia; Scotoma Temporal Pallor Pallor of the temporal portion of the optic nerve head may follow atrophy of the macular fibre bundle in the retina, since the macular fibres for central vision enter the temporal nerve head. The belief that Tourette syndrome was a disorder of the basal ganglia has now been superseded by evidence of dysfunction within the cingulate and orbitofrontal cortex, perhaps related to excessive endorphin release. Treatment of tics is most usually with dopamine antagonists (haloperidol, sulpiride) and opioid antagonists (naltrexone); clonidine (central 2 adrenergicreceptor antagonist) and tetrabenazine (dopamine-depleting agent) have also been reported to be beneficial on occasion. The word tic has also been used to describe the paroxysmal, lancinating pains of trigeminal neuralgia (tic douloureux). Cross References Klazomania; Stereotypy Tic Convulsif Tic convulsif is a name that has been given to the combination of trigeminal neuralgia (tic douloureux) with hemifacial spasm. Its specificity has been reported to range between 23 and 60% and sensitivity between 64 and 87%. The differential diagnosis of transient postictal hemiparesis includes stroke, hemiplegic migraine, and, in children, alternating hemiplegia. Cross References Hemiparesis; Seizures Toe Walking Toe walking, or cock walking, is walking on the balls of the toes, with the heel off the floor. A tendency to walk on the toes may be a feature of hereditary spastic paraplegia and the presenting feature of idiopathic torsion dystonia in childhood. Cross Reference Seizure Tonic Spasms Painful tonic spasms occur in multiple sclerosis, especially with lesions of the posterior limb of the internal capsule or cerebral peduncle, perhaps due to ephaptic activation, or following putaminal infarction. Kinetic tremor: present with movement, often with an exacerbation at the end of a goal-directed movement (intention tremor). Task-specific tremor: evident only during the performance of a highly skilled activity. Isometric tremor: present when voluntary muscle contraction is opposed by a stationary object. Psychogenic tremors: these are difficult to classify, with changing characteristics; the frequency with which such tremors are observed varies greatly between different clinics; the coactivation sign (increase in tremor amplitude with peripheral loading) is said to be typical of psychogenic tremor. Essential tremor often responds to alcohol, and this is a reasonable treatment (previous anxieties that such a recommendation would lead to alcoholism seem unjustified); alternatives include propranolol, topiramate, primidone, alprazolam, flunarizine, and nicardipine. Primary orthostatic tremor has been reported to respond to gabapentin, clonazepam, primidone, and levodopa. Cerebellar tremor is often treated with isoniazid, but seldom with marked benefit, likewise carbamazepine, clonazepam, ondansetron, limb weights; stereotactic surgery may be an option in some patients disabled with tremor. Cross References Dystonia; Pseudobulbar palsy Trombone Tongue Trombone tongue, or flycatcher tongue, refers to an irregular involuntary darting of the tongue in and out of the mouth when the patient is requested to keep the tongue protruded. As in the latter, it is suggestive of a corticospinal tract (upper motor neurone) lesion above C5 or C6, especially if unilateral, although it may be observed in some normal individuals. This unusual phenomenon may be associated with perilymph leaks or a defect in the capsule forming the roof of the anterior semicircular canal. The sound sensitivity is probably at the level of the receptors rather than the vestibular nerve. This may be observed with enlargement of the blind spot and papilloedema as a - 353 - T Two-Point Discrimination consequence of raised intracranial pressure or with a compressive optic neuropathy. In nonorganic visual impairment, by contrast, the visual field stays the same size with more distant targets (tunnel vision). A tunnel vision phenomenon has also been described as part of the aura of seizures of anteromedial temporal and occipitotemporal origin. Cross References Aura; Blind spot; Hemianopia; Papilloedema; Visual field defects Two-Point Discrimination Two-point discrimination is the ability to discriminate two adjacent point stimuli. The minimum detectable distance between the points (acuity) is smaller on the skin of the fingertips. Impairments of two-point discrimination may occur with dorsal column spinal cord lesions, in which proprioception (and possibly vibration) is also impaired. Cortical parietal lobe lesions may produce a cortical sensory syndrome of astereognosis, agraphaesthesia, and impaired two-point discrimination. The term has subsequently been applied to exercise and/or temperature related symptoms in other demyelinated pathways. Influence of temperature changes on multiple sclerosis: critical review of mechanisms and research potential. Untersuchungen uber die bei der multiplen Herdsklerose vorkommenden Augenstorungen. The test is not very useful, particularly in chronic, progressive, or partially compensated vestibular lesions. Unterberger stepping test: a useful indicator of peripheral vestibular dysfunction? It may be a sign of acute spinal cord compression, with or without other signs in the lower limbs, or of acute cauda equina compression, for example, with a central L1 disc herniation. Loss of awareness of bladder fullness may lead to retention of urine with overflow. This was first described in multiple sclerosis by Oppenheim in 1911 and reflects plaques in the dorsal root entry zone of the relevant spinal cord segment(s). Cross References Proprioception; Pseudoathetosis; Pseudochoreoathetosis Utilization Behaviour Utilization behaviour is a disturbed response to external stimuli, a component of the environmental dependency syndrome, in which seeing an object implies that it should be used. Another element of the environmental dependency syndrome which coexists with utilization behaviour is imitation behaviour. Utilization behaviour is associated with lesions of the frontal lobe, affecting the inferior medial area bilaterally. Patient behaviour in complex and social situations: the "environmental dependency syndrome". The first phase produces impaired cardiac filling due to impaired venous return as a consequence of elevated intrathoracic pressure, with a fall in cardiac output and blood pressure, inducing peripheral vasoconstriction (sympathetic pathways) to maintain blood pressure. The second phase causes a transient overshoot in blood pressure as the restored cardiac output is ejected into a constricted circulation, followed by reflex slowing of heart rate. In autonomic (sympathetic) dysfunction, reflex vasoconstriction, blood pressure overshoot, and bradycardia do not occur. Cross Reference Orthostatic hypotension Vegetative States the vegetative state is a clinical syndrome in which cognitive function is lost, due to neocortical damage (hence no awareness, response, speech), whilst vegetative (autonomic, respiratory) function is preserved due to intact brainstem centres. Vertigo is often triggered by head movement and there may be associated autonomic features (sweating, pallor, nausea, vomiting). Pathophysiologically, vertigo reflects an asymmetry of signalling anywhere in the central or peripheral vestibular pathways. Peripheral vertigo tends to compensate rapidly and completely with disappearance of nystagmus after a few days, whereas central lesions compensate slowly and nystagmus persists.

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Deaths from soft tissue sarcomas in this time frame were slightly lower, but still accounted for a higher proportion of cancer deaths in the under 35 population (4% and 6%, respectively) than all except bone and joint cancers. At least 75% of surviving bone and joint cancer patients are treated with limb-salvaging surgery. The amputated survivors will require prosthetic limbs, the function of which is clearly limiting in comparison to normal activity. The cost estimate nearly ten years ago was $25,000 per year for artificial limb replacement of an amputated limb in an active 20- to 30-year- old man in 1997 dollars. The cost estimate was $23,500 for implant, rehabilitation, monitoring, and replacement with limb salvaging endoprostheses. Musculoskeletal Cancers of the Aging: Tumors of Bone and Connective Tissue More than 60% of myeloma cases are diagnosed in persons age 65 years and older. This is a similar rate to respiratory and urinary system cancers, both of which disproportionately affect older persons. Soft tissue cancers affect all ages, and in relatively equal proportion in the middle years (ages 35 to 64 years) and older population (65 years and older). As previously discussed, bone and joint cancers affect a disproportionate number of younger persons, and are not considered a major cancer of aging. As a result, poorer outcomes from cancers are expected in the aged due to greater decline in functional status, adaptability and an increase in co-morbid conditions, all of which have been shown to have an effect on survival. Benign Musculoskeletal Tumors In addition to the burden of malignant bone and soft tissue tumors, a plethora of benign tumors and tumor-like conditions disable thousands of Americans annually. No national databases on which to base estimates of the prevalence or incidence of such tumors exist. With the resulting tempering in his experience, accurate incidence estimates could no longer be extrapolated from his personal tumor database. Mirra experience reported in 1989, and the case series reflecting the practice of Dr. Ward during the stated time-period is believed to reflect roughly the general prevalence of bone and soft tissue tumors, since he treated a wide variety of benign and malignant bone tumors in a broad referral practice. It is believed that, with the exception of bone cysts, general orthopaedic surgeons or other musculoskeletal specialists in North Carolina treated few bone tumors over the period the data was collected, as most were referred to orthopaedic oncologists. Practical experience has confirmed that osteosarcoma is the least likely sarcoma to be treated by anyone other than an orthopaedic oncologist. Ward and a small group of orthopaedic oncologists treated nearly all patients with an osteosarcoma in North Carolina for the past 22+ years. This selection process likely excludes small benign tumors, thereby artificially lowering the frequency estimates. Because they never metastasize and are usually quite characteristic on radiographs, many of these are treated by other orthopaedic surgeons, especially pediatric orthopaedic surgeons. The true incidence, therefore, is probably significantly higher than that estimated by extrapolation from Dr. These cystic lesions cause weakening of the bone and the patients may require multiple surgeries to rebuild the bone with bone grafts, injections, and other techniques. They occur in children, and typically recur multiple times until skeletal maturity is achieved. Giant Cell Tumor of Bone Giant cell tumor of bone, with an estimated annual prevalence of more than 750 cases, is the third most commonly encountered benign bone neoplasm, and accounts for significant disability and dysfunction. Smaller tumors can be treated with bone resection and reconstruction with bone grafts or cement filler. Enchondroma A fourth commonly encountered tumor that may require surgery is enchondroma, estimated at more than 725 annual surgical cases. If these achieve sufficient size, they can cause cortical bone erosion and pain or fracture, and may present diagnostic challenges requiring biopsy. These lesions can dedifferentiate into malignant cartilage tumors called chondrosarcomas. Many small enchondromas are seen incidentally, cause no symptoms, and are treated with simple observation; thus, total incidence of enchondromas is much higher than shown in the surgical data. In addition, the burden of enchondromas requiring surgical treatment is very conservatively estimated, as many are treated by general orthopaedic surgeons. If untreated, it can cause collapse and degenerative arthritis in the associated joint and, on rare occasion, can metastasize to the lung. Benign Soft Tissue Tumors As with the benign bone tumors, there is no national registry of benign soft tissue tumors. From this index estimate, a baseline estimate of the national incidence can be calculated. The prevalence and burden in the United States from benign soft tissue tumors is significantly higher than estimated herein. However, depending on the site of involvement and size of the lesion, significant disability of the involved extremity and/or joint can occur. Only patients with larger and more concerning lesions are typically referred to surgeons with a focus in surgical oncology. This misdiagnosis can lead to suboptimal resection of the unappreciated sarcoma by the unsuspecting community surgeon. Lipoblastomas Lipoblastomas are benign fat tumors that occur in infants and young children. Leiomyomas can arise almost anywhere in the body in either men or women because they start in tissues as widespread, for example, as blood vessels or intestine. Skeletal muscle benign tumors Skeletal muscle is the muscle that allows movement of arms and legs and other body parts. An inherited condition called neurofibromatosis, or von Recklinghausen disease, causes people to develop many neurofibromas throughout their body. Tumors of Blood Vessels and Lymph Vessels Hemangiomas are benign tumors of blood vessels. They are rather common, are often present at birth, and can affect the skin or internal organs. It most often develops in the legs, pelvis, and retroperitoneum (the back of the abdominal cavity) and is most common in adults. They rarely spread to distant sites, but tend to recur locally following surgical resection unless very widely excised. Tumors of Fibrous Tissue Fibrous tissue forms tendons and ligaments and covers bones as well as other organs in the body. They frequently recur following resection, and may require additional treatment with repeat surgery, radiation therapy, chemotherapy, or other therapies. Tumors of Uncertain Tissue Type Through microscopic examination and other laboratory tests, doctors can usually find similarities between most soft tissue tumors and certain types of normal soft tissues. However, some soft tissue tumors have not been linked to a specific type of normal soft tissue. Myxoma is a benign tumor that usually is located in muscles but does not develop from muscle cells. Myxoma must be differentiated from myxofibrosarcoma, a malignant neoplasm that can appear very similar under the microscope as well as in gross appearance. Unlike a true tumor, they do not come from a single abnormal cell; they have limited capacity to grow or spread to nearby tissues, and never spread through the bloodstream or lymph system. Examples include nodular fasciitis and myositis ossificans, which involve tissues under the skin and muscle tissues, respectively. The most commonly encountered ones are tophi, often seen in cases of poorly controlled gout. These tumors can achieve massive size, may be mistaken for true tumors, and erode through the skin, causing skin breakdown and infection that may require surgical treatment and antibiotics. They may be painful and may require difficult resection of deposits infiltrated into normal tissue. It behaves essentially the same as the calcium deposition mentioned in association with renal disease. Because of the low number of new cases, incidence is expressed as the number per one million population at risk in this report. Death Rates and 5-Year Relative Survival (Percent) By Primary Cancer Site, Sex and Time Period: Table 1. Death Rates and 5-Year Relative Survival (Percent) By Primary Cancer Site, Sex and Time Period.

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Spinal facet joint biomechanics and mechanotransduction in normal, injury and degenerative conditions. Cervical facet capsular ligament yield defines the threshold for injury and persistent joint-mediated neck pain. Piriformis syndrom: eine haufige differentialdiagnose des lumboglutaalen schmerzes (Piriformis syndrome: a frequent item in the differential diagnosis of lumbogluteal pain). Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride. In Advances in Pain Research and Therapy: Myofascial Pain and Fibromyalgia, Volume 17. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Routine use of punch biopsy to diagnose small fiber neuropathy in fibromyalgia patients. An in-vitro study of the kinematics of the normal, injured and stabilized cervical spine. Effects of abnormal posture on capsular ligament elongations in a computational model subjected to whiplash loading. Primary fibromyalgia syndrome and myofascial pain syndrome: clinical features and muscle pathology. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. A study of 96 subjects examined both for fibromyalgia and myofascial pain (Abstract). Evidence of abnormal epidermal nerve fiber density in fibromyalgia: clinical and immunologic implications. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Prospective evaluation of somatic and autonomic small fibers in selected autonomic neuropathies. A decreased natural and antibodydependent cellular cytotoxic activities in intravenous drug abusers. Opioid modulation of immune responses: effects on phagocyte and lymphoid cell populations. The case for utilizing Prolotherapy as a promising stand-alone or adjunctive treatment for Over-Manipulation syndrome. Diagnosis and treatment of chronic mycoplasmal infections in fibromyalgia and chronic fatigue syndromes: relationship to Gulf War illness. Role of adrenal cortical activation in the immunosuppressive effects of chronic morphine treatment. Suppression of the induction of delayed hypersensitivity in rats by repetitive morphine treatments. Differential effects of morphine and naltrexone on the antibody response in various mouse strains. Incidence and prevalence of surgery at segments adjacent to a previous posterior lumbar arthrodesis. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. Late degenerative changes after meniscectomy: factors affecting the knee after operation. Patellofemoral osteoarthritis coexistent with tibiofemoral osteoarthritis in a meniscectomy population. Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls. Long term evaluation of disease progression through the quantitative magnetic resonance imaging of symptomatic knee osteoarthritis patients: correlation with clinical symptoms and radiographic changes. Diagnostic accuracy of history taking to assess lumbosacral nerve root compression. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft. Journal of Prolotherapy international medical editorial board consensus statement on the use of Prolotherapy for musculoskeletal pain. Long-term results of arthroscopic partial lateral meniscectomy in knees without associated damage. The case for utilizing Prolotherapy as first-line treatment for meniscal Pathology. Risk assessment for chronic pain and patient satisfaction after total knee arthroplasty. Return to pre-injury level of competitive sports after anterior cruciate ligament reconstruction surgery: Two-thirds of patients have not returned by 12 months after surgery. Abnormality of the contralateral ligament after injuries of the medial collateral ligament. Reflex sympathetic dystrophy: a retrospective epidemiological study of 168 patients. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. The acceleration of articular cartilage degeneration in osteoarthritis by nonsteroidal anti-inflammatory drugs. Prolotherapy as an alternative to surgery: a prospective pilot study of 34 patients from a private medical practice. Treatment of patients with complex regional pain syndrome type 1 with mannitol: A prospective, randomized, placebo-controlled, double blind study. Strain and psychological distress among informal supporters of reflex sympathetic dystrophy patients. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Medicinal and injection therapies for mechanical neck disorders (Review) Cochrane Database Syst Rev. Physician-delivered injection therapies for mechanical neck disorders: a systematic review update (nonoral, non-intravenous pharmacological interventions for neck pain). Utilization of interventional techniques in managing chronic pain in the Medicare population: analysis of growth patterns from 2000 to 2011. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Double-blind controlled study of different myofascial trigger point injection techniques (Abstract). Joint stabilization: An experimental, histologic study with comments on the clinical application in ligament proliferation. Intramuscular oxygen-ozone therapy in the treatment of acute back pain with lumbar disc herniation-a multicenter, randomized, double-blind, clinical trial of active and simulated lumbar paravertebral injection. Intraformainal O2-O3 versus periradicular steroidal infiltrations in lower back pain: randomized controlled study. Subcutaneous Prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Ligament uninhibited reversible antidromic vasodilation in brochiogenic patholophysiologic disease. Fatality after injection of sclerosing agent to precipitate fibro-osseous proliferation. An abstract of a poster presentation (poster #49) at the 59th Annual Assembly of the American Academy of Physical Medicine and Rehabilitation printed in the Archives of Physical Medicine and Rehabilitation. Myofascial trigger point therapy: comparison of dextrose, water, saline, and lidocaine.

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Metamorphopsia and visual hallucinations restricted to the right visual hemifield after a left putaminal haemorrhage. There is a poor correlation between micrographia and the side, severity, or duration of classical parkinsonian features, and its response to levodopa preparations is very variable. These observations, along with reports of isolated micrographia with cortical lesions demonstrated by neuroimaging, suggest that the anatomical basis of micrographia may be at the level of the cortex (dominant parietal lobe) rather than the basal ganglia. Micrographia has also been described following large right anterior cerebral artery infarcts and lacunar infarcts involving the putamen and genu of the internal capsule. It is the most common form of metamorphopsia and is most often associated with lesions of the right temporoparietal cortex, although macular oedema and optic chiasm lesions may also cause micropsia. Hemimicropsia, - 221 - M Microsomatognosia micropsia confined to one visual hemifield, has been recorded. The entirely subjective nature of the disorder may account for the relative rarity of reports. Seeing objects smaller than they are: micropsia following right temporo-parietal infarction. Cross References Chorea, Choreoathetosis; Impersistence; Trombone tongue Miosis Miosis is abnormal reduction in pupillary size, which may be unilateral or bilateral. If only one pupil appears small (anisocoria), it is important to distinguish miosis from contralateral mydriasis, when a different differential will apply. Cross References Agnosia; Neglect Mirror Apraxia Patients with mirror apraxia presented with an object that can be seen only in a mirror, when asked to reach for the real object will reach for the virtual object in the mirror. They are usually symmetrical and most often seen when using distal muscles of the upper limb. Mirror movements are frequently present in young children but prevalence decreases with age. These movements are uncommon after acquired brain lesions with no relationship to specific anatomical 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. A deficit of sustained attention has also been postulated as the cause of mirror movements. Failure to recognize oneself in a mirror may also be a dissociative symptom, a symptom of depersonalization. This may occur spontaneously, 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 device was also used by the author Arthur Ransome in his 1939 novel Secret Water. Jane Austen wrote one letter (1817) to a young niece in which script runs from right to left but with word order reversed within words. Various neural mechanisms are proposed to explain mirror writing, including bilateral cerebral representation of language, motor programmes, or visual memory traces or engrams. The mechanisms may differ between a true mirror writer like Leonardo and someone performing the task for amusement like Carroll. The ability to read mirror reversed text as quickly as normally oriented text has been reported in some autistic individuals. Misidentification Syndromes these are defined as delusional conditions in which patients incorrectly identify and reduplicate people, places, objects, or events. 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. Cross Reference Negativism Mitmachen A motor disorder in which the patient acquiesces to every passive movement of the body made by the examiner, but as soon as the examiner releases the body part, the patient returns it to the resting position. His speech was fluent without paraphasia although impoverished in content, with recurrent themes repeated almost verbatim. Confronted with objects of different colours, he was unable to point to them by colour since all appeared red to him. The features seem to be distinct from erythropsia (persistent) or phantom chromatopsia (normal visual acuity). Monoparesis of the arm or leg of upper motor neurone type is usually cortical in origin, although may unusually arise from a cord lesion (leg more frequently than arm). In clinical usage, the meaning overlaps not only with - 227 - M Motor Neglect that of emotional lability but has also been used in the context of pathological laughter. Cross References Emotionalism, Emotional lability; Pathological crying, Pathological laughter; Witzelsucht Motor Neglect Motor neglect is failure to move the contralesional limbs in the neglect syndrome, a more severe impairment than directional hypokinesia. Cross References Directional hypokinesia; Eastchester clapping sign; Neglect Moving Ear A focal dyskinesia characterized by ear movement has been described. Muscle hypertrophy may be generalized or focal and occurs in response to repetitive voluntary contraction (physiological) or repetitive abnormal electrical activity (pathological. Muscle enlargement may also result from replacement of myofibrils by other tissues such as fat or amyloid, a situation better described as pseudohypertrophy. Cross References Calf hypertrophy; Masseter hypertrophy; Myotonia Mutism Mutism is absence of speech output. Mydriasis Mydriasis is an abnormal dilatation of the pupil, either unilateral or bilateral. If only one pupil appears large (anisocoria), it is important to distinguish mydriasis from contralateral miosis, when a different differential will apply. Such disorders may be further characterized according to whether the responsible lesion lies within or outside the spinal cord: intrinsic or intramedullary lesions are always intradural; extrinsic or extramedullary lesions may be intradural or extradural. It may be possible to differentiate intramedullary from extramedullary lesions on clinical grounds, although this distinction is never absolute because of clinical overlap. Drugs useful in the treatment of myoclonus include clonazepam, sodium valproate, primidone, and piracetam. Cross References Asterixis; Chorea, Choreoathetosis; Dystonia; Fasciculation; Hiccups; Jactitation; Myokymia; Palatal tremor; Tic; Tremor Myoedema Myoedema, or muscle mounding, provoked by mechanical stimuli or stretching of muscle, is a feature of rippling muscle disease, in which the muscle contractions are associated with electrical silence. Myokymia Myokymia is an involuntary, spontaneous, wave-like, undulating, flickering movement within a muscle (cf. Neurophysiologically this corresponds to regular groups of motor unit discharges of peripheral nerve origin. Myokymia is thus related to neuromyotonia and stiffness, since there may be concurrent impairment of muscle relaxation and a complaint of muscle cramps. Neurophysiological evidence of myokymia may be helpful in the assessment of a brachial plexopathy, since this is found in radiation-induced, but not neoplastic, lesions. Cross References Fasciculation; Myotonia; Neuromyotonia; Stiffness Myopathy the term myopathy means a primary disorder of muscle causing wasting and/or weakness in the absence of sensory abnormalities. Clinically, myopathic processes need to be differentiated from neuropathies, particularly anterior horn cell diseases and motor neuropathies, and neuromuscular junction disorders.

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Sometimes these repeat services are provided on the same day as the previous service, and without the use of modifier -76, the third-party payer would assume a duplicate bill had been submitted. Modifier -77 reports to the third-party payer that the services are not duplicate services and, therefore, the bill is not a duplicate bill. When modifier -77 has been assigned, documentation must accompany the claim in order to establish the medical necessity for the procedure. If the modifier was not used, the subsequent service would be denied as a duplicate service. If only a portion of the original service or procedure is repeated, you would also assign modifier -52 to indicate a reduced service. Modifier -78 is appended to the subsequent procedure code to indicate to the third-party payer that the second surgery was necessary because of complications resulting from the first operation. For many third-party payers, only the surgery portion (intraoperative) of the surgical package is paid when the -78 modifier is reported. The patient remains within the postoperative period of the first operation for any further preoperative or postoperative care. For example, the patient had an appendectomy and 2 weeks later had a gallbladder episode that necessitates removal of the gallbladder. The diagnosis codes for the two procedures would also be different, further indicating the two procedures were unrelated. If the service is provided during the postoperative period of a major surgical procedure, billing separately for services included in the surgical package is fraudulent. You should receive written directives from the third-party payer before reporting -81 for individuals other than a physician. Usually, the minimum assistant surgeon receives 10% of the usual charge for a surgery. Hospitals that have affiliations with medical schools are considered teaching facilities. Modifier: 5 A patient had a hernia repair and two days later returned to the operating room for a dehiscence of the incision. Smith undergoes an appendectomy on June 8, and then a cholecystectomy is performed on August 16 by the same surgeon, what modifier would be placed on the cholecystectomy code? Modifier: 7 What modifier would you add to a code to indicate that a basic procedure performed by another physician was repeated? Modifier: (Answers are located in Appendix B) -90, reference (outside) laboratory Modifier -90 is used to indicate that services of an outside laboratory were used. If the outside laboratory provides the services, the outside laboratory must report the services. This modifier is correctly assigned when a laboratory test has been repeated so as to produce multiple test results. A full list of codes that can be reported with modifier -95 are listed in Appendix P. Third-party payers vary in terms of how they require multiple modifiers to be reported, so be certain to check with the payer before submitting multiple modifiers. As such, the assignment of this modifier comes under particularly close scrutiny by third-party payers. It takes knowledge and character to adhere to the correct way to do things and not be swayed by other factors, such as how to `get it paid. It provides a listing of headings and subheadings for the categories and subcategories of Evaluation and Management services as illustrated in the table below. Place of service explains the setting in which the services were provided to the patient. Admission is attention to an acute illness or injury that results in admission to a hospital. The four types of patient status are new patient, established patient, outpatient, and inpatient. Established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty in the same group within the past 3 years. The reasons for and results of x-rays, lab tests, and other ancillary services should be clear. A written plan of treatment should include, when appropriate, treatments and medications, specifying frequency and dosage, any referrals or consultations, patient or family education, and any specific instructions for follow-up care. Documentation should report the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of the medical decision making. Figure 11-4 illustrates one example of an audit form that could be used assess E/M services. The components contain a great deal of information that you need to know before you learn about factors. The above categories/subcategories must meet or of three key components. Ancillary staff (nurses, physician assistants, and so forth) are allowed to document some of the history, such as chief complaint and past, family, and social histories, but the physician must authenticate the entries (physician must evaluate the form and indicate in the medical record that the form has been reviewed). Also, a physician can have the patient complete a form composed of questions concerning the review of systems; however, the physician must authenticate the information. In general, an analysis of the subjective findings will indicate the nature and extent of examination required. Problem focused: the physician focuses on the chief complaint and a brief history of the present problem of a patient. A brief history would include a review of the history regarding pertinent information about the present problem or chief complaint. Expanded problem focused: the physician focuses on a chief complaint, obtains a brief history of the present problem, and also performs a problem pertinent review of systems. For example, if the presenting problem or chief complaint is a red, swollen knee, the system reviewed would be the musculoskeletal system. The system review in this history is extended, which means that positive responses and pertinent negative responses relating to multiple organ systems should be documented. For a summary of the elements required for each level of history (according to the 1995 Documentation Guidelines), see. The patient has presented the physician with the subjective information regarding the complaint or problem in the history portion of the encounter; now the physician will do an examination of the patient to provide objective information, "hands-on" (those findings observed by the physician) about the complaint or problem. The examination levels have the same titles as the history levels- problem focused, expanded problem focused, detailed, and comprehensive. The four levels are used to indicate the extent and complexity of the patient examination. Problem focused: Examination is limited to the affected body area or organ system identified by the chief complaint. Expanded problem focused: A limited examination is made of the affected body area or organ system and other symptomatic or related body area(s)/organ system(s). Detailed: An extended examination is made of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive: this is the most extensive examination; it encompasses a general multi-system examination and should include findings about 8 or more of the 12 organ systems. The examination would include the examination elements and the number and extent of elements required for the physician to arrive at the diagnosis. Mother reports that the child has been complaining of pain in right ear with a severity of 8 of 10 for the past 2 days. Plan: Patient was advised to drink fluids, take aspirin as needed for pain, obtain bed rest, and to return if symptoms have not improved in 5 days. According to the 1995 E/M Documentation Guidelines, documentation of management options in the medical record is as follows: 1. For a presenting problem with an established diagnosis, the record should reflect whether the problem is (a) improved, well controlled, resolving, or resolved; or (b) inadequately controlled, worsening, or failing to change as expected. Note: Physician/Provider coders do not code "rule out," "possible," or "probable" diagnosis; rather they code the presenting symptoms and/or complaints unless there is a definitive diagnosis rendered. Treatment includes a wide range of management options, including patient instructions, nursing instructions, therapies, and medications. The results of discussion of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented. The direct visualization and independent interpretation of an image, tracing, or specimen previously interpreted by another physician should be documented. Some basic documentation guidelines for risk of significant complications, morbidity, or mortality include the following: 1. If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure.

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States have varying regulations about how a psychologist reports services provided, and some states require a psychologist to provide and report services only under the supervision of a psychiatrist. The medical record must identify the time spent providing the psychotherapy service. If the time spent providing the service is not recorded on the medical record, the physician should be queried. Crisis psychotherapy (90839, 90840) provides treatment to a patient experiencing a reaction to a more specific event or situation; for example, a drug overdose, attempted suicide, or an episode of severe depression. Crisis psychotherapy focuses on the immediate assessment and treatment of the patient in a crisis and is not intended to treat chronic psychological conditions. Some patients receive psychotherapy only and others receive psychotherapy and medical E/M services. The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive interactions, and interpretation of unconscious motivation, that were applied to produce the therapeutic change. Patients are trained to use biofeedback by a professional and then continue the use of the therapy on their own. Biofeedback training is often incorporated in individual psychophysiologic therapy. The patient is experiencing increased anxiety and insomnia, which is the reason for this visit. Hemodialysis codes (90935 and 90937) are reported for each day the service is provided. The codes in the hemodialysis category are based on the number of times the physician evaluates the patient during the procedure. Peritoneal dialysis Peritoneal dialysis (90945, 90947) involves using the peritoneal cavity as a filter. Dialysis fluid is introduced into the cavity and left there for several hours so cleansing can take place. Few third-party payers allow E/M codes to be reported in addition to dialysis service codes. Most payers consider the dialysis codes to be bundled to include all the treatment necessary for a patient with renal disease, including the E/M services. The reporting of just one code covers all physician visits to the dialysis laboratory during that month. If a hospitalized patient receiving peritoneal dialysis is assessed by the physician, the physician services are reported with 90945 (single visit) and 90947 (multiple visits). Modifier -26 is not used on these codes, as the code descriptions describe only the physician service to the dialysis patient. The monthly service for services provided when the patient was not in the hospital is then reported with 90967-90970, which are per day codes. Ophthalmology is a very specialized field and ophthalmologists treat patients for a variety of diseases and injuries. The codes in this subsection are based on whether the patient is a new or an established patient and on the complexity of service provided. The definitions of the terms "new" and "established" patient are the same as those used in the E/M section. You will recall that those definitions are as follows: New patient: One who has not received professional service from the physician, or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. In fact, should you need to report only one eye from these codes, you add modifier -52 to indicate a reduced service. Special Ophthalmological Service codes are those services that are not normally performed in a general eye examination. For example, an ophthalmological examination under general anesthesia with manipulation of the globe of the eye to determine the range of motion (92018). Other codes that are located in the Ophthalmology subsection under the subheading Spectacle Services report the provision of materials to the patient. The decision to assign an ophthalmology code or an E/M code is determined by the service provided. A comprehensive service (92004, 92014) describes a general evaluation of the complete visual system. The initiation of a diagnostic and treatment program includes the prescription of medication and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures, and radiological services. From the Trenches "Coding is an evolving science; in order to be successful a coder needs to be willing to use every day to the fullest by continuing their education and learning something new and useful. Audiology (hearing) testing is also located in the Special Otorhinolaryngologic Services subsection. Otorhinolaryngologic diagnostic and treatment services are usually reported using codes from the Surgery section. Special services are reported using the otorhinolaryngologic codes from the Medicine section. Cardiovascular the Cardiovascular subsection is discussed in Chapter 17, but there are also some services that are reported with Medicine codes that you have not reviewed yet. The balloon is inflated in the area of occlusion and the occlusive material is pressed back, thereby widening the vessel. Cardiography (93000-93278), Implantable and Wearable Cardiac Device Evaluations (93279-93299), and Echocardiography (9330393355) were reviewed in Chapter 17 of this text. The right side of the heart may be accessed by entering the right femoral vein and advancing through the inferior vena cava or entering the basilic vein in the arm and advancing through the superior vena cava. Right heart catheters are used to measure and record right atrial, right ventricular, pulmonary artery, and pulmonary capillary wedge pressures. Right-sided pressure measurements help diagnose congestive heart failure and right-sided valve disease. A left heart catheterization will help to diagnose coronary artery disease, left ventricular dysfunction, and valve disease. Noninvasive vascular diagnostic studies the codes in this subsection (93880-93998) report procedures that are conducted to study veins and arteries other than the heart and great vessels. These studies use the same devices as are used in heart and great-vessel echocardiography, except that the divisions are based on the location of the vein or artery being studied. Pulmonary function tests monitor the function of the pulmonary system and examine the lung capacity of patients with, for example, emphysema. The number of tests must always be specified for reporting purposes because for most of these codes, payment is made per test. The testing should be based on a complete history and physical examination of the patient and correlated with signs and symptoms related to the presence of possible allergy diagnoses during allergy testing (95004-95071). Code 95076 reports the initial 120 minutes of testing time and 95079 reports each additional 60 minutes. The third subheading is Allergen Immunotherapy and the codes specify three types of services: Injection only, prescription and injection, provision of antigen only. For example, code 95115 reports the injection of antigen only and does not include the extract, but code 95120 reports the prescription, extract, and injection. The professional service necessary to provide the immunotherapy is bundled into the code, so an office visit code would not usually be reported. If the physician provided another identifiable service at the time of the immunotherapy, an office visit may be reported. Allergen Immunotherapy is the repeated administration of allergens to patients for the purpose of providing protection against the allergic symptoms and reactions associated with exposure to these allergens. Immunotherapy (hyposensitization) may extend over a period of months, usually on an increasing dosage scale. Indications for allergen immunotherapy are determined by diagnostic testing appropriate to the individual needs of each patient and his/her clinical history of allergic diseases. The patient records his or her insulin administration, meals, exercise, and any hypoglycemic events during the monitoring period, in addition to performing the usual finger stick glucose four times a day during the 3-day period. The service includes the initial hookup, calibration of the monitor, patient training, removal of sensor, printout of recording, and interpretation and report (95251). Neurology and neuromuscular procedures There are codes in the Neurology and Neuromuscular Procedures (95782-96020) subsection for sleep testing, muscle testing (electromyography), range of motion measurements.

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Disk-Caused Nerve Compression in Patients with Acute Low-Back-Pain - Diagnosis with Mr, Ct Myelography, and Plain Ct. Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study. Recurrent lumbar disc herniation after discectomy: Clinical result of repeated discectomy and analysis of factors affecting surgical outcome. A preoperative and postoperative study of the accuracy and value of electrodiagnosis in patients with lumbosacral disc herniation. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility this clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. Anterior lumbar microdiscectomy and interbody fusion for the treatment of recurrent disc herniation. Short-term assessment of periradicular corticosteroid injections in lumbar radiculopathy associated with disc pathology. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review (Structured abstract). An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Unilateral transforaminal lumbar interbody fusion: A review of the technique, indications and graft materials. Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. A primary factor for this delay is a lack of knowledge and awareness regarding rare diseases. The median advantage of correct disease suggestions compared to the time of clinical diagnosis was 3 months or 50% for top five fit and 1 month or 21% for top fit. Wilcoxon signed-rank test shows a significant difference between the time to clinical diagnosis and the time to correct disease suggestion for both top five fit and top fit (z-score -6. Limitations of this study derive from its retrospective and unblinded design, data input by a single user, and the optimization of the knowledge base during the course of the study. Orphanet Journal of Rare Diseases (2019) 14:69 Page 2 of 12 Background By definition, every rare disease is rare. Rare disease diagnosis remains a challenge for patients, doctors, and healthcare systems. Rare disease patients often have diagnostic odysseys, waiting an average of 6 years from onset of symptoms for an accurate diagnosis [3]. During the diagnostic odyssey patients suffer from loss of quality of life, disease progression, incorrect treatment and complications that are sometimes irreversible [5]. People living with rare diseases suffer an even greater loss of quality of life than people with common chronic diseases [5]. Common examples of personal consequences are anxiety, frustration, and impacted relationships [3, 6, 7]. At the same time, unnecessary consultations cause substantial costs for the individual and for healthcare systems. The challenge of diagnosing rare diseases only is the number of known diseases increasing, but the available diagnostic methods and possible interpretations in the medical domain are expanding continuously [9]. In the near future, rapid developments in genetics are likely to lead to an even higher complexity of rare disease diagnoses. These tools can empower physicians in their clinical work by effectively enhancing their cognitive performance. Diagnostic decision support systems Reasons for delayed diagnosis and frequent misdiagnosis of rare diseases are not well understood. Insufficient knowledge and lack of awareness are considered to be the main factors, particularly in primary care [4]. Overall, rare disease diagnosis presents itself as a cognitive challenge due to a combination of factors that characterize rare diseases and limitations of the human brain. Even rare disease specialists will not have in-depth knowledge of every rare disease. Low incidence in combination with a large number of possible rare conditions almost inevitably leads to insufficient disease knowledge and diagnostic errors. Premature closure appears to be among the most common single types of error in medicine [8] and can be assumed to be of major importance in rare diseases. Insufficient knowledge about rare diseases subsequently causes error, for example via fragmentary assessment of history and examination or incomplete diagnostic testing. The exponential growth of knowledge in the medical domain further contributes to the cognitive overload. Alternatively, the system allows physicians to enter findings from a list of suggestions that are ranked by their estimated relevance based on the current symptom constellation, which changes in real time with the addition of each symptom. Contributions of symptoms to disease probabilities are visualized and made transparent via weighted contribution lines. It is easily usable in its current form as a research prototype, however, it has not yet been optimized for everyday use as a product and is therefore not yet publicly available. The knowledge base was built and reviewed by medical doctors in a curated process of knowledge integration from medical literature. Disease models and their related symptoms are added to the knowledge base and modeled according to evidence from peer-reviewed medical literature. The knowledge base is being expanded continuously following this standardized process. It consists of disease models of all common conditions and several hundred rare diseases. Center: Entered symptoms with their attributes, green contribution lines, selected diseases, bars visualizing disease probability (green) and fit (purple). Orphanet Journal of Rare Diseases (2019) 14:69 Page 4 of 12 as well as their corresponding clinical findings. Clinical findings can be further refined with additional attributes, for example intensity or temporality. Epidemiological data is used to derive the prior probabilities of diseases to allow for correct disease probability estimations. The knowledge base is not based on a pre-existing database or publicly available ontology of medical content. Instead, the knowledge base has been specifically designed with the goal of diagnostic accuracy. These test cases comprise all types of diseases from different specialties, including common and rare diseases alike. The set includes cases based on medical literature (published case reports, for example) as well as typical clinical case scenarios that reflect different levels of diagnostic certainty. The aim of this study to respective diagnostic criteria or missing information about the diagnosis visit) were excluded. A secondary aim is to identify key reasons for inaccuracy and current technical limitations. Methods A retrospective study was conducted at the outpatient clinic for rare inflammatory systemic diseases at the Hannover Medical School in Hannover, Germany. Case selection Patients were selected from the pool of patients at the outpatient clinic. Only cases with a confirmed rare disease diagnosis and a documented date of diagnosis in their medical record were included. Cases with a low level of diagnostic certainty (with regard the confirmed diagnosis was assigned to each case. The assignment of diagnoses was based on the most recently specified and validated confirmatory diagnostic information from the medical record. For each patient, all documented visits at healthcare providers were identified in the medical record. The time of the visit of the first documented symptoms relatable to the confirmed diagnosis was identified, as was the time of diagnosis. Clinical evidence including symptoms, examination findings, test results, risk factors and dates of visit were extracted from the medical record for every visit between first documented symptoms and the diagnosis. Information was assigned to the time of the respective visit, but not to earlier visits based on anamnestic information. Previously collected evidence was retained at future visits if not contradicted by other documented information.

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Steinert was an internationally renowned and respected corneal, cataract, and refractive surgeon who pioneered advances in laser surgery techniques and corneal transplantation. He received the 2009 Life Achievement Award from the American Academy of Ophthalmology, the 2015 Distinguished Achievement Award from the New England Ophthalmological Society, and the 2016 Distinguished Clinical Achievement Award from Harvard University, Bert M. Glaser formed a private practice which expanded and later became the National Retina Institute. He also worked in diabetic retinopathy, age-related macular degeneration and retinal detachments. He also received awards from the Macula Society, the Retina Research Foundation and the American Academy of Ophthalmology. Glaser later founded a research and development firm, Ocular Proteomics, for the treatment of ocular diseases. Luce, a pioneering physicist and inventor, earned a PhD in physics from the Massachusetts Institute of Technology. Luce joined Moog Music in 1972 and invented the first commercial polyphonic synthesizer. After Moog closed, Luce embarked on a new career, helping to develop and refine ophthalmic diagnostic instruments at Reichert Technologies. After researching the properties of the cornea, he published a paper that earned him recognition as the "Father of Corneal Biomechanics. This event is family-friendly so purchase tickets for your entire family to join in the fun. The use of Big Data for improving healthcare outcomes and controlling costs shows significant promise. This course will help participants define what Big Data is, describe the Big Data sets available in vision research, explain the analytic methods behind Big Data, and summarize the potential applications of Big Data. Recent advances in genetic engineering, genotyping, high-resolution imaging and biomarker testing have made it easier to deliver the right treatments to the right patients at the right time. The primary goal of this course is to discuss opposing viewpoints related to the various treatment strategies for inherited retinal diseases. Further, learners will be able to identify and debate different clinical and research topics in the area of inherited retinal diseases. Emphasized will be perspectives on the use of stem cells and gene-directed therapy. In addition, the primary mechanism of retinal degeneration in patients with Stargardt disease will be discussed. These discussions highlight current obstacles clinician-scientists are facing in their fight against retinal degeneration. The overall goal of this course is to enhance learner competence in the area of retinal degeneration to utilize in professional practice. McGill Ocular Genetics Laboratory, McGill University Health Centre, Montreal, Quebec, Canada - 1:30 Audience questions and discussion - 8:15 Assessing the potential value of human pluripotent stem cell treatments for retinal degenerative diseases. In fact, the risk of acquiring advanced age-related macular degeneration increases from 2% for those ages 50-59, to nearly 30% for those over the age of 75. Potential new therapies that could interrupt these pathways will also be explored. Its clinical presentation, pathology, current treatment options, and key clinicopathologic indicators for basic research. A0048 - A0086 A0103 - A0129 A0246 - A0262 A0263 - A0277 B0029 - B0076 B0317 - B0343 C0001 - C0018 C0019 - C0057 C0106 - C0127 C0170 - C0201 C0234 - C0270 A0001 - A0033 A0034 - A0046 A0087 - A0102 A0221 - A0245 A0288 - A0309 A0310 - A0353 B0001 - B0028 B0137 - B0149 B0150 - B0174 B0175 - B0190 B0191 - B0212 B0270 - B0279 B0280 - B0299 C0062 - C0073 C0202 - C0233 C0271 - C0310 A0130 - A0173 A0174 - A0220 A0278 - A0287 B0077 - B0086 B0087 - B0136 B0213 - B0240 B0241 - B0269 B0300 - B0316 B0344 - B0371 C0074 - C0085 C0086 - C0105 C0128 - C0169 Poster board numbers correspond to poster location in Exhibit Hall; A = Poster Area A, B = Poster Area B and C = Poster Area C. The cellular machinery that underpins Proteostasis integrates complex, multi-layered regulatory networks affecting global protein synthesis, protein trafficking and processing, folding, aggregation and degradation rates. Given the functional and structural heterogeneity and diversity of ocular cells/tissues, the mechanisms by which Proteostasis is coordinated within and between cells are central to understanding and managing the eye diseases. Recent findings concerning mechanisms of action of various risk factors and disease related variants of proteins with different primary functions increasingly point to failure of Proteostasis as a unifying pathway for ocular pathogenesis. This symposium will enable participants to discuss the pathways, translational opportunities and challenges for the management of eye diseases offered by targeting Proteostasis networks. Gorbatyuk and Astra Dinculescu - 8:15 Introduction 1 - 8:20 An Emergent Paradigm for Vision Research: Proteostasis, Variation and Precision Management of Human Disease. This symposium will allow participants to consider how circadian rhythms and diurnal patterns affect the eye and other systemic processes that are important in basic research and clinic. Gamlin - 8:15 Introduction & Welcome 6 - 8:20 Molecular Architecture of the Mammalian Circadian Clock. Examples of normal and pathological retinal architecture will be given illustrating the multiple, newly identified roles of bipolar cells, and their exquisite stratification in the inner retina; the unique features of the human fovea; remodeling and corruption of retinal architecture in degenerative diseases; the unique contribution of glial cells to retinal physiology and pathological conditions. Destined to everyone with interests in the retina as part of the brain, either using basic or applied approaches. Moderator: Ulrike Grunert - 8:15 Introduction 12 - 8:25 Comparative connectomics of the mammalian retina. Computational Neuroethology, caesar, Bonn, Germany - 8:43 Discussion 13 - 8:47 the functional organisation of bipolar cell pathways. Birch 17 - A0048 Cell surgery in retinitis pigmentosa: restoration and visual prognosis. Hamamatsu University School of Medicine, Hamamatsu, Japan 21 - A0052 Association between Macular Blood Flow and Choroidal Structure and their Relationships to Visual Function in Retinitis Pigmentosa. Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Kyoto, Japan 25 - A0056 Relationship of visual field sensitivity in central 10-degrees to thickness of different retinal layers in eyes of patients with retinitis pigmentosa. Fyodorov Eye Microsurgery Federal State Institution, Moscow, Russian Federation 96 - A0259 the use and viability of two autologous grafts as anterior and posterior lamellar spacers in eyelid reconstruction. Ophthalmology, Royal Hospital for children, Glasgow, Glasgow, United Kingdom 105 - A0268 Cost Comparison of Different Treatment Approaches to Dacryocystitis and Dacrocystocele. Fukuoka University, Fukuoka, Japan 123 - B0037 Rapamycin attenuates Th2driven experimental allergic conjunctivitis. Zhongshan Ophthalmic Center, Guangzhou, Guangdong, China 129 - B0043 Decision Making Model for the Operation Method and Prognosis in Pterygium. Ophthalmology, Chung-Ang University, Seoul, Korea (the Republic of) 130 - B0044 Impact of pterygium in the ocular surface parameters and tear cytokine profile. Asocornea, Bogota, Colombia 132 - B0046 Electrospun silk fibroin/poly(Llactic acid-co-caprolactone) scaffolds for conjunctival tissue engineering. Department of Ophthalmology, University Hospital Duesseldorf, Duesseldorf, Germany 119 - B0033 Evaluation of adenovirus amplified detection kit using tears including conjunctival exudate. Department of Frontier Medical Science and Technology for Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan 142 - B0056 Molecular characterization of pterygium fibroblasts in an enhanced serial explant culture technique. Ophthalmology, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Pathumwan, Bangkok, Thailand f 146 - B0060 Biophysical interactions of gamma-linolenic acid with tear lipids at an air-tear interface. School of Optometry and Vision Science, Queensland University of Technology, Kelvin Grove, Queensland, Australia 150 - B0064 Medial Canthus Hyperpigmentation in Ocular Allergy. Zhongshan Ophthalmic Center, Guangzhou, China 160 - B0074 the presentation of patients with psoriasis to opthalmology accident and emergency. Universtity Eye Hospital, Mainz, Germany 174 - B0328 Clinical characteristics of children with Ahmed glaucoma valve implantation in a reference center in Mexico. State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guanghzou, China 176 - B0330 the effect of the history of delivery on the development of open-angle glaucoma. Discipline of Orthoptics, University of Technology Sydney, Ultimo, New South Wales, Australia 186 - B0340 Retinopathy of Prematurity in Rwanda: setting up a screening system. Miyata Eye Hospital, Miyakonojo, Miyazaki, Japan 254 - C0113 Impact of residual astigmatism on optical and visual performance for toric intraocular lenses. Chuncheon Sacred Heart Hospital, Chuncheon, Korea (the Republic of) 259 - C0118 Long-term Performance of a one-piece acrylic hydrophilic intra-ocular lens. David J Apple Center for Vision Research, Heidelberg, Germany 266 - C0125 Optical Pathway Imaging and Straylight Evaluation of Opacified Intraocular Lenses. Apple Center for Vision Research, Heidelberg, Germany 267 - C0126 Unfolding efficiency and time for optic recovery of a novel hydrophobic acrylic material as compared to currently available intraocular lens materials.

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In females, peak height velocity occurs about 2 years after the growth spurt begins and averages about 9 cm per year. This is also around the time when the nipple and areola have developed but before any other significant breast development (7), and about 6 to 12 months prior to menarche. After menarche, females will usually not grow more than 5 cm, with epiphyseal closure occurring about 2 years after. Males are taller because of this greater velocity of height in addition to having about 2 more years of prepubescent growth over females (8). Growth normally starts to slow down at about 12 to 15 months of age, which is reflected in the growth chart. The periods of rapid growth occur during the first 12 months of age, and from puberty until adulthood. Calculation of weight gain in grams per day also allows more precise estimation of growth rate as can be seen in the table below. Approximate Daily Weight Gain 30 g 20 g 15 g 12 g 8g 6g Approximate Monthly Weight Gain 1 kg (2 lb) 0. For example, if a 10 year old female weighs 18 kg, this weight is below the 5th percentile for a 10 year old; and, it is at the 50th percentile for a 5 year old. One could state that her weight age is 5 years, which is a better quantitative description of the growth abnormality. The weight for height curves exceeding 120% of the median weight for height can also be an indicator for obesity. The problem with the weight for height curves is that they are applicable only from 2 years to 11. However, since the cutoff values for children differ with age and sex, they therefore must be based on percentiles, with the 85th percentile being suggested as the cutoff point for being overweight. Fat-free mass increases with age in both sexes, but increases are more rapid in boys than in girls after age 13. Likewise, total body fat increases from 8 to 18 years in girls but decreases after age 14 in boys. This helps predict those individuals who are at risk for obesity later in childhood and adulthood. Although percent body fat is the best measure of obesity, its measurement requires complex laboratory procedures. Common student and board examination questions include the growth chart patterns for various diseases and conditions such as constitutional growth delay, familial short stature, nutritional insufficiency, and congenital pathologic short stature. Congenital pathologic short stature: these infants are born small and growth gradually tapers off throughout infancy. Constitutional growth delay: In this type of delay, these patients enter puberty later; therefore, their growth spurt occurs later in adolescence. The growth curve has the following appearance: weight and height drop in their percentiles near the end of infancy, parallel the norm through middle childhood, and accelerate toward the end of adolescence. Adult size is normal or often taller than average because their duration of growth is longer than others. Frequently, one or both parents may have a history of short stature during childhood, delayed puberty, and eventual normal adult height. Delayed puberty can be identified by asking about age of menarche in mother and age at which father first started shaving. Tanner staging is also useful in evaluating these patients because of their delayed puberty. How do the growth curves for congenital pathologic short stature, constitutional growth delay, and familial short stature look like? Those who rebound before 5 years have a higher risk of obesity in childhood and adulthood. It does not provide an accurate index of adiposity since it does not differentiate between lean tissue and bone from fat. Congenital pathologic short stature: infant born small and growth gradually tapers off throughout infancy. Constitutional growth delay: weight and height drop in their percentiles near the end of infancy, parallel the norm through middle childhood, and accelerate toward the end of adolescence. All three children superficially appear normal, growing well on their growth curves. The children have no dysmorphic features or other abnormal signs on physical exam. The physicians in the clinic are mandated to do a check of development but they do this somewhat differently from physician to physician. Another physician asks questions to her parents but does not use any formal developmental screening instrument. She is suspected to have autism, and is referred to a Developmental Behavioral Pediatrician who confirms the diagnosis after more elaborate evaluation. The physician who asks questions directly to families, finds the parents of the third child slightly worried at the 18 month visit about the child not being cuddly and not seemingly not very attached to them. The school psychologist evaluates the child and relates to the parents their child has autism. The parents become angry as they find that many characteristics they have seen in the past two to three years are noted by the school psychologist as signs of autism. They tell the psychologist that they feel that their physician should have figured this out earlier. An important aspect of caring for children in a medical context is that they grow in multiple ways over time. Page - 22 Unfortunately, there are a variety of medical conditions that are derangements in proper child development. There are many more problems that are rare, such as most of the developmental disabilities with genetic etiologies. Other medical conditions, such as cancer, may impact child development because of the effects of chemotherapy on the brain, or because of child and parental stress. Developmental or behavioral conditions are thought to occur in 12 to 16% of children in the United States (1). Families expect physicians to identify developmental problems in their children and then help manage these concerns (2). It is therefore particularly important for physicians to carefully and routinely evaluate children for problems in development and behavior. Physicians such as pediatricians and family practitioners have essential roles because of their frequent contact with children and their families. They have knowledge of normal and abnormal development unlike other professionals who are in touch with families. Physicians commonly encounter children in well child visits, in the emergency room, and in the hospital. In the emergency room or in the hospital, a child may show developmental regression. Directly observed developmental behavior may be different than when the child is well (3). Families also have more trust with someone who gets to know their child and family well. Identifying children with cognitive, behavioral, social or motor problems can be difficult. Obvious and severe problems are actually rare compared to more commonly seen but subtle problems. A child that appears completely normal as an infant or toddler may not develop skills expected in the preschool or school age group periods. But because a moderate percentage of children have developmental or behavioral problems, a physician requires solid strategies for determining if a child has an important lag or problem in development. The majority of children with developmental problems are not detected without standardized screening tests. Informal "eyeballing" of children and informal questioning of parents do not work well. There is a good chance of missing problems because of the need of looking at multiple domains in development. A physician asking about walking and other motor skills may miss language and other cognitive deficits. Research from Great Britain where clinical impression is used rather than screening tests is revealing.

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Care should be taken to make sure the planting bed is slightly deeper than the surrounding terrain. This will hold the water whenever it rains so that it will not run off and carry the good soil and seedlings with it. With the method described it is possible to grow vegetables even during prolonged periods of drought. In areas not too far from the sea, the night-time dew suffices to provide enough moisture for plants, but if there is no dew, the vegetables require weekly watering. While reading this book, you may have realised that mere knowledge about eyes is not enough if you want to be a good primary eye care worker. If you want to prevent xerophthalmia you should know how to grow green vegetables in your area. There is also another reason for not using fertiliser: most people use too much for too long. In questions of child nutrition she has become more confident because of all the information she received at the hospital. It is her own concern and she is determined to take the Carer group along with her to solve the problem of growing vegetables in their poor soil and dry climate. Few of them have enough money to make a solid fence to keep goats and chickens out. If they had got together to make a communal garden, good fencing would have been affordable. They have not done so because they 137 Hanyane Part 1: Community eye care were afraid one or the other might steal the vegetables. If you want to know more about working in groups, the three volumes of Training for Transformation by Anne Hope will give you excellent guidance. As an eye health worker, you have to know about more than eyes: toilets, refuse pits, clean water supply and vegetable growing are all essential to prevent unnecessary blindness. Joyce helped Lerisa to overcome some of these fears at a big party held on her return. She explained what the villagers could expect from their village health worker and what kind of illnesses she would have to refer to the clinic. She wanted to have this very clear from the start to avoid misunderstandings and unhappiness on both sides. Proudly she opened her little suitcase which contained a first aid kit, a baby scale, Road To Health Charts, some aspirin, malaria tablets and tetracycline eye ointment. The long journey to the clinic would only be necessary if there were problems she could not solve. The people of Hanyane were delighted to hear this and were surprised at what Lerisa could now do. But Lerisa was still nervous about how the Carers would react to her in her new, paid position. But you must be careful not to become too proud of yourself and start acting like those nurses at the hospital. They were surprised to hear that the training included a lot of useful home crafts how to cook vegetables and prepare a healthy baby porridge which could almost replace milk. Everybody wanted to have such a wonder stove and to cook on it for their children. The group would be busy for a long time with the new things Lerisa could teach them. This was arranged with the doctor and Joyce was given some time to prepare a course for village health workers on eye care (see Part 2). What fears do you have when you return to your place after a long absence for study? How do you support and supervise your village health workers in their work in your area? The people of Hanyane have known Lerisa since childhood They knew that she attended school for only two years. For these reasons, village health workers working in their own community have more difficulty starting work than do outsiders. However, once established they are usually more committed and more stable than a person from somewhere else who may change jobs as he/she pleases. Lerisa has her family in Hanyane and is unlikely to leave her home village in the foreseeable future. This makes Hanyane independent from outside assistance and promotes its self-reliance. Being a village health worker, Lerisa should now replace Joyce for almost everything concerning the group. How would the group accept that she, Lerisa, was now paid for her work while the group members remained unpaid volunteers? In many primary health care programmes the role of the village health worker is restricted to preventive and promotive work. Many primary health care projects go wrong because the field workers are left without support. The post of a village health worker is a lonely and isolated one, usually miles away from a clinic. If you will be in charge of village health workers, make a point of taking enough time 141 Hanyane Part 1: Community eye care when you visit them. Do not just hurry past with a quick glance at the records or an unfriendly remark when you find mistakes. Sit down with your village health worker and listen first to what he/she has to say. This benefits manufacturers of powdered milk who, by promoting their products with glossy advertisements reap financial reward. Most mothers who need food supplements for their babies would have to spend the greater part of their household budget on milk powder. Lerisa learned to prepare weaning food as follows: take 2 parts of maize flour, 1 part bean flour and 1 part ground peanuts. The advantage of this food is that it is about 20 times cheaper than milk, the ingredients can be grown at home, and it tastes delicious. Microbes which cause diarrhoea grow fast if the porridge is allowed to stand for more than an hour, even if you protect it from flies. Village health workers from their own community have more difficulty starting work than outsiders. The tasks of village health workers should be well defined and explained to the community to avoid wrong expectations. Hanyane people, and many from neighbouring villages, were eager to buy fresh vegetables directly from the fields. Naturally, quarrels occurred, especially about who was allowed to take part in the cooperative and who was not. However, the group had grown in the spirit of cooperation and learned how to settle their own differences. Neighbouring communities had heard of the Hanyane Carers for some time but never bothered to go there and find out more. Now that they knew they could buy fresh vegetables at a fair price, they came to Hanyane and met the Carers. A whole network of Health Carer groups developed, linking together and learning many things from one another. What could be the reasons in your area for malnutrition remaining a serious problem? They learn to see which essentials of life they are lacking and what they can do about them for themselves. Their experience in development activities enables them to be more self-assured about making their demands on health matters to those in control. Her 147 Hanyane Part 1: Community eye care own training experience had been to be ordered from above, so she did the same to those in her care.

References:

  • https://uhs.berkeley.edu/sites/default/files/iud_non-hormonal.pdf
  • https://www.fiorentini.com/media/files/143_204_reflux_819_us_print.pdf
  • https://www1.aaoinfo.org/wp-content/uploads/2019/03/sleep-apnea-white-paper-amended-March-2019.pdf