Medical and business documents and records are retained in accordance with the law and our record retention policy back spasms 22 weeks pregnant buy 400 mg skelaxin with amex, which includes comprehensive retention schedules muscle relaxer kidney order 400mg skelaxin fast delivery. Medical and business documents include paper documents such as letters and memos spasms pancreas safe 400 mg skelaxin, computer based information such as e-mail or computer files on disk or tape back spasms 36 weeks pregnant order skelaxin 400mg mastercard, and any other medium that contains information about the organization or its business activities muscle relaxant yellow pill v purchase skelaxin 400 mg without prescription. No one may remove or destroy records prior to the specified date without first obtaining permission as outlined in the Company records management policy spasms hiatal hernia purchase 400mg skelaxin otc. Coding & Billing for Services We have implemented policies spasms near sternum buy 400mg skelaxin amex, procedures and systems to facilitate accurate billing to government payers spasms toddler buy skelaxin 400 mg visa, commercial insurance payers, and patients. These policies, procedures, and systems conform to pertinent Federal and state laws and regulations. In support of accurate billing, medical records must provide reliable documentation of the services we render. It is important that all individuals who contribute to medical records provide accurate information and do not destroy any information considered part of the official medical record. Accurate and timely documentation also depends on the diligence and attention of physicians who treat patients in our facilities. We expect those physicians to provide us with complete and accurate information in a timely manner. Any subcontractors engaged to perform billing or coding services are expected to have the necessary skills, quality control processes, systems, and appropriate procedures to ensure all billings for government and commercial insurance programs are accurate and complete. In addition, third-party billing entities, contractors, and preferred vendors under contract consideration must be approved consistent with the corporate policy on this subject. For technical coding questions in a hospital or ambulatory surgery center contact the 3M Coding Helpline at 1-800-537-1666. These policies and standards require, among other things, that the individual and/or entity be validated and the information be encrypted. Use of due care and due diligence is required to maintain the confidentiality, availability and integrity of information assets the Company owns or of which it is the custodian. This provision does not restrict the right of a colleague to disclose, if he or she wishes, information about his or her own compensation, benefits, or terms and conditions of employment. Improper use or disclosure of confidential information could violate legal and ethical obligations. We comply with Federal and state laws, regulations, and guidelines relating to all cost reports. These laws, regulations, and guidelines define what costs are allowable and outline the appropriate methodologies to claim reimbursement for the cost of services provided to program beneficiaries. Also, we submit our cost report process to internal audits and maintain a peer review process. All issues related to the preparation, submission and settlement of cost reports must be performed by or coordinated with our Reimbursement Department. Electronic Media & Security Requirements All communications systems, including but not limited to computers, electronic mail, Intranet, Internet access, telephones, and voice mail, are the property of the organization and are to be used primarily for business purposes in accordance with electronic communications policies and standards. Users of computer and telephonic systems should presume no expectation of privacy in anything they create, store, send, or receive on the computer and telephonic systems, and the Company reserves the right to monitor and/or access communications usage and content consistent with Company policies and procedures. Colleagues may not use internal communication channels or access to the Internet at work to view, post, store, transmit, download, or distribute any threatening materials; knowingly, recklessly, or maliciously false materials; obscene materials; or anything constituting or encouraging a criminal offense, giving rise to civil liability, or otherwise violating any laws. Also, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction. Colleagues who abuse our communications systems or use them excessively for non-business purposes may lose these privileges and be subject to disciplinary action. Financial Reporting & Records We have established and maintain a high standard of accuracy and completeness in documenting, maintaining, and reporting financial information. This information serves as a basis for managing our business and is important in meeting our obligations to patients, colleagues, shareholders, suppliers, and others. It is also necessary for compliance with tax and financial reporting requirements. All financial information must reflect actual transactions and conform to generally-accepted accounting principles. All funds or assets must be properly recorded in the books and records of the Company. We diligently seek to comply with all applicable auditing, accounting and financial disclosure laws, including but not limited to the Securities Exchange Act of 1934 and the Sarbanes-Oxley Act of 2002. Senior financial officers receive training and guidance regarding auditing, accounting and financial disclosure relevant to their job responsibilities. By signing the acknowledgment card at the end of this Code of Conduct, a colleague specifically agrees to be bound by these provisions of the Code of Conduct. No waiver of this conflict of interest provision may be granted to an Executive Officer. Controlled Substances Some of our colleagues routinely have access to prescription drugs, controlled substances, and other medical supplies. Many of these substances are governed and monitored by specific regulatory organizations and must be administered by physician order only. Prescription and controlled medications and supplies must be handled properly and only by authorized individuals to minimize risks to us and to patients. If one becomes aware of inadequate security of drugs or controlled substances or the diversion of drugs from the organization, the incident must be reported immediately. We make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities. Substance Abuse and Mental Acuity To protect the interests of our colleagues and patients, we are committed to an alcohol and drug-free work environment. All colleagues must report for work free of the influence of alcohol and illegal drugs. It is also recognized individuals may be taking prescription or over-thecounter drugs, which could impair judgment or other skills required in job performance. Colleagues with questions about the effect of such medication on their performance or who observe an individual who appears to be impaired in the performance of his or her job must immediately consult with their supervisor. We are committed to providing an inclusive work environment where everyone is treated with fairness, dignity, and respect. We will make ourselves accountable to one another for the manner in which we treat one another and for the manner in which people around us are treated. We are committed to recruit and retain a diverse staff reflective of the patients and communities we serve. We regard laws, regulations and policies relating to diversity as a minimum standard. We strive to create and maintain a setting in which we celebrate cultural and other differences and consider them strengths of the organization. We do not tolerate harassment by anyone based on the diverse characteristics or cultural backgrounds of those who work with us. Degrading or humiliating jokes, slurs, intimidation, or other harassing conduct is not acceptable in our workplace. This prohibition includes unwelcome sexual advances or requests for sexual favors in conjunction with employment decisions. Workplace violence includes robbery and other commercial crimes, stalking, violence directed at the employer, terrorism, and hate crimes committed by current or former colleagues. Our policies have been developed to protect our colleagues from potential workplace hazards. Colleagues must become familiar with and understand how these policies apply to their specific job responsibilities and seek advice from their supervisor or the Safety Officer whenever they have a question or concern. It is important that each colleague immediately advise his or her supervisor or the Safety Officer of any serious workplace injury or any situation presenting a danger of injury so timely corrective action may be taken to resolve the issue. Hiring of Former/Current Government & Fiscal Intermediary/Medicare Administrative Contractor Employees the recruitment and employment of former or current U. Hiring employees directly from a fiscal intermediary or Medicare Administrative Contractor requires certain regulatory notifications. Colleagues should consult with the Corporate Human Resources Department or the Legal Department regarding such recruitment and hiring. Ineligible Persons We do not contract with, employ, or bill for services rendered by an individual or entity that is excluded or ineligible to participate in Federal healthcare programs; suspended or debarred from Federal government contracts and has not been reinstated in a Federal healthcare program after a period of exclusion, suspension, debarment, or ineligibility. A number of Company policies address the procedures for timely and thorough review of such lists and appropriate enforcement actions. Nonpublic, material information may include, among other things, plans for mergers, marketing strategy, financial results, or other business dealings. Regardless of whether our securities are publicly registered or traded, colleagues may not discuss this type of information with anyone outside of the organization. Within the organization, colleagues should discuss this information on a strictly "need to know" basis only with other colleagues who require this information to perform their jobs. These restrictions are meant to ensure the general public has complete and timely information on which to base investment decisions. Even if he or she does not buy, sell, transfer, gift or effect other transactions of such securities based on what he or she knows, discussing the information with others, such as family members, friends, vendors, suppliers, and other outside acquaintances, is prohibited until the information is considered to be public. Information is considered to be public twenty four hours after a general release of the information to the media. It is impossible to foresee all of these, and many do not require explicit treatment in a document like this. While we wish to avoid any strict rules, no one should ever feel compelled to give a gift to anyone, and any gifts offered or received should be appropriate to the circumstances. A lavish gift to anyone in a supervisory role would clearly violate organization policy. Another situation, which routinely arises, is a fund-raising or similar effort undertaken by individual colleagues, in which no one should ever be compelled to participate. Similarly, when the Company or a facility determines to support charitable organizations such as the United Way, no colleague should be compelled to contribute to the charitable organization, nor should there be any workplace consequences of such nonparticipation. License and Certification Renewals Colleagues, individuals retained as independent contractors, and privileged practitioners in positions which require professional licenses, certifications, or other credentials are responsible for maintaining the current status of their credentials and shall comply at all times with Federal and state requirements applicable to their respective disciplines. Each colleague must have evidence of current and valid licensor, certification, registration, accreditation or credential as required by their position description. Each facility must have appropriate processes and procedures to assure documentation of compliance with each position description requirement. This is an umbrella group of the largest healthcare group purchasing organizations in the country intended to promote the highest standards of business conduct in these activities. As in any large organization, once central procurement decisions have been made, it is anticipated that local facilities will utilize the negotiated contracts. We must manage our consulting, subcontractor, and supplier relationships in a fair and reasonable manner, free from conflicts of interest and consistent with all applicable laws and good business practices. Our selection of consultants, subcontractors, suppliers, and vendors will be made on the basis of objective criteria including quality, technical excellence, price, delivery, adherence to schedules, service, and maintenance of adequate sources of supply. We employ the highest ethical standards in business practices in source selection, negotiation, determination of contract awards, and the administration of all purchasing activities. We comply with contractual obligations not to disclose vendor confidential information unless permitted under the contract or otherwise authorized by the vendor. Research, Investigations, & Clinical Trials We follow the highest ethical standards in full compliance with Federal and state laws and regulations in any research, investigations, and/or clinical trials conducted by our physicians and professional staff. Physicians conducting clinical trials of investigational products and services are expected to fully inform all subjects of their rights and responsibilities of participating in the clinical trial. All potential subjects asked to participate in a clinical trial are given a full explanation of alternative services that might prove beneficial to them. They are also fully informed of potential discomforts and are given a full explanation of the risks, expected benefits, and alternatives. The subjects are fully informed of the procedures to be followed, especially those that are experimental in nature. Refusal of a potential subject to participate in a research study or the voluntary withdrawal of his or her participation in an existing study will not compromise his or her access to services or other benefits to which he or she is otherwise entitled. As in all accounting and financial record-keeping, our policy is to submit only true, accurate, and complete costs related to research grants. Competitive Activities & Marketing Practices We operate in a highly competitive environment. Our competitive activities must conform to the high standards of integrity and fairness reflected in this Code of Conduct. Antitrust and Unfair Competition the Company has strict restrictions on communications with competitors, which are set forth in Company policy. Generally, colleagues are not to discuss with competitors nonpublic "competitively sensitive topics" as defined in the policy. Because the antitrust laws are so complex and their application can depend upon the conditions in local markets, it is not practical to adopt written policies to govern all situations. Colleagues should consult with their supervisors or the Legal Department for guidance concerning competitive activities, laws and policies relating to their areas of responsibility. Marketing and Advertising Consistent with laws and regulations that may govern such activities, we may use marketing and advertising activities to educate the public, provide information to the community, increase awareness of our services, and to recruit colleagues. We strive to present only truthful, fully informative, and non-deceptive information in these materials and announcements. This does not prevent fair, non-deceptive competition for business from those who may also have business relationships with a competitor. We comply with all environmental laws and operate each of our facilities with the necessary permits, approvals, and controls. We diligently employ the proper procedures to provide a good environment of care and to prevent pollution. Business Courtesies General this part of the Code of Conduct should not be considered in any way as an encouragement to make, solicit, or receive any type of entertainment or gift. Receiving Business Courtesies We recognize there will be times when a current or potential business associate, including a potential referral source, may extend an invitation to attend a social event in order to further develop a business relationship. The limitations of this section do not apply to business meetings at which food (including meals) may be provided. Perishable or consumable gifts given to a department or group are not subject to any specific limitation. Such business courtesies are addressed in the Extending Business Courtesies to Potential Referral Sources section of this Code and Company policies. Provided that such events are for business purposes, reasonable and appropriate meals and entertainment may be offered. However, all elements of such events, including these courtesy elements, must be consistent with the corporate policy on such events. Meals and Entertainment There may be times when a colleague wishes to extend to a current or potential business associate (other than someone who may be in a position to make a patient referral) an invitation to attend a social event. The purpose of the entertainment must never be to induce any favorable business action. During these events, topics of a business nature must be discussed and the host must be present. These events must not include expenses paid for any travel costs (other than in a vehicle owned privately or by the host entity) or overnight lodging. Moreover, such business entertainment with respect to any particular individual must be infrequent, which, as a general rule, means not more than three times per year. Consult Company policy for events that are expected to exceed $150 or were not expected to but inadvertently do exceed $150. That policy requires establishing the business necessity and appropriateness of the proposed entertainment. The organization will under no circumstances sanction any business entertainment that might be considered lavish or in questionable taste. We will never use gifts or other incentives to improperly influence relationships or business outcomes. Gifts to business associates who are not government employees must not exceed $75. Federal and state governments have strict rules and laws regarding gifts, meals, and other business courtesies for their employees. With regard to gifts, meals, and other business courtesies involving any other category of government official or employee, colleagues must determine the particular rules applying to any such person and carefully follow them. Government Relations & Political Activities the organization and its representatives comply with all federal, state, and local laws governing participation in government relations and political activities. Those who seek exceptions to this general rule may only do so after obtaining the appropriate approvals required in relevant policies. The conduct of any political action committee is to be consistent with relevant laws and regulations. In addition, political action committees associated with the organization select candidates to support based on the overall ability of the candidate to render meaningful public service. The organization does not select candidates to support as a reflection of expected support of the candidate on any specific issue. The organization engages in public policy debate only in a limited number of instances where it has special expertise that can inform the public policy formulation process. When the organization is directly impacted by public policy decisions, it may provide relevant, factual information about the impact of such decisions on the private sector. In articulating positions, the organization only takes positions that it believes can be shown to be in the larger public interest. The organization encourages trade associations with which it is associated to do the same. It is important to separate personal and corporate political activities in order to comply with the appropriate rules and regulations relating to lobbying or attempting to influence government officials. No use of corporate resources, including e-mail, is appropriate for personally engaging in political activity. A colleague may, of course, participate in the political process on his or her own time and at his or her own expense. If a colleague is making these communications on behalf of the organization, he or she must be certain to be familiar with any regulatory constraints and observe them.
Rarely pathological hyperreflexia may occur in the absence of spasticity yellow muscle relaxant 563 safe 400mg skelaxin, suggesting different neuroanatomical substrates underlying these phenomena muscle relaxant metabolism quality 400 mg skelaxin. Hyper-reflexia without spasticity after unilateral infarct of the medullary pyramid muscle relaxant cz 10 discount skelaxin 400 mg amex. It has also been observed in some patients with frontotemporal dementia; the finding is cross-cultural spasms pregnancy after tubal ligation order skelaxin 400mg visa, having been described in Christians spasms medication buy 400 mg skelaxin visa, Muslims muscle relaxant valium generic 400 mg skelaxin with mastercard, and Sikhs muscle relaxant medication prescription generic skelaxin 400mg free shipping. In the context of refractory epilepsy muscle relaxant youtube discount 400 mg skelaxin mastercard, it has been associated with reduced volume of the right hippocampus, but not right amygdala. Religiosity is associated with hippocampal but not amygdala volumes in patients with refractory epilepsy. Cross References Hypergraphia; Hyposexuality Hypersexuality Hypersexuality is a pathological increase in sexual drive and activity. Sexual disinhibition may be a feature of frontal lobe syndromes, particularly of the orbitofrontal cortex. Clinical signs may include a bounding hyperdynamic circulation and sometimes papilloedema, as well as features of any underlying neuromuscular disease. Sleep studies confirm nocturnal hypoventilation with dips in arterial oxygen saturation. It usually implies spasticity of corticospinal (pyramidal) pathway origin, rather than (leadpipe) rigidity of extrapyramidal origin. Cross Reference Anaesthesia Hypoalgesia Hypoalgesia is a decreased sensitivity to , or diminution of, pain perception in response to a normally painful stimulus. It may be demonstrated by asking a patient to make repeated, large amplitude, opposition movements of thumb and forefinger, or tapping movements of the foot on the floor. Cross References Akinesia; Bradykinesia; Dysmetria; Fatigue; Hypokinesia; Parkinsonism; Saccades Hypomimia Hypomimia, or amimia, is a deficit or absence of expression by gesture or mimicry. Cross References Dysarthria; Dysphonia; Parkinsonism Hypophoria Hypophoria is a variety of heterophoria in which there is a latent downward deviation of the visual axis of one eye. This may be physiological, as with the diminution of the ankle jerks with normal ageing; or pathological, most usually as a feature of peripheral lesions such as radiculopathy or neuropathy. The latter may be axonal or demyelinating, in the latter the blunting of the reflex may be out of proportion to associated weakness or sensory loss. Although frequently characterized as a feature of the lower motor neurone syndrome, the pathology underlying hyporeflexia may occur anywhere along the monosynaptic reflex arc, including the sensory afferent fibre and dorsal root ganglion as well as the motor efferent fibre, and/or the spinal cord synapse. Hyporeflexia may also accompany central lesions, particularly with involvement of the mesencephalic and upper pontine reticular formation. It may be associated with many diseases, physical or psychiatric, and/or medications which affect the central nervous system. Along with hypergraphia and hyperreligiosity, hyposexuality is one of the defining features of the Geschwind syndrome. Cross References Hypergraphia; Hyperreligiosity Hypothermia Hypothalamic damage, particularly in the posterior region, can lead to hypothermia (cf. A rare syndrome of paroxysmal or periodic hypothermia has been described and labelled as diencephalic epilepsy. Non-neurological causes of hypothermia are more common, including hypothyroidism, hypopituitarism, hypoglycaemia, and drug overdose. Cross Reference Hyperthermia Hypotonia, Hypotonus Hypotonia (hypotonus) is a diminution or loss of normal muscular tone, causing floppiness of the limbs. Weakness preventing voluntary activity rather than a reduction in stretch reflex activity appears to be the mechanism of hypotonia. Cross References Ataxia; Flaccidity; Hemiballismus; Hypertonia Hypotropia Hypotropia is a variety of heterotropia in which there is manifest downward vertical deviation of the visual axis of one eye. Improvement of ptosis is said to be specific for myasthenia gravis, perhaps because cold improves transmission at the neuromuscular junction (myasthenic patients often improve in cold as opposed to hot weather). This phenomenon is generally not observed in other causes of ptosis, although it has been reported in Miller Fisher syndrome. A pooled analysis of several studies gave a test sensitivity of 89% and specificity of 100% with correspondingly high positive and negative likelihood ratios. Whether the ice pack test is also applicable to myasthenic diplopia has yet to be determined: false positives have been documented. Illusions occur in normal people when they are tired, inattentive, in conditions of poor illumination, or if there is sensory impairment. They also occur in disease states, such as delirium, and psychiatric disorders (affective disorders, schizophrenia). They are consistent and have a compulsive quality to them, perhaps triggered by the equivocal nature of the situation. There may be accompanying primitive reflexes, particularly the grasp reflex, and sometimes utilization behaviour. Imitation behaviour occurs with frontal lobe damage; originally mediobasal disease was thought the anatomical correlate, but more recent studies suggest upper medial and lateral frontal cortex. Part I: imitation and utilization behaviour: a neuropsychological study of 75 patients. It is most commonly seen with lesions affecting the right hemisphere, especially central and frontal mesial regions, and may occur in association with left hemiplegia, neglect, anosognosia, hemianopia, and sensory loss. Neuropsychologically, impersistence may be related to mechanisms of directed attention which are needed to sustain motor activity. Thus, the anatomical differential diagnosis of neurological incontinence is broad. Moreover, incontinence may be due to inappropriate bladder emptying or a consequence of loss of awareness of bladder fullness with secondary overflow. Other features of the history and/or examination may give useful pointers as to localization. Incontinence of neurological origin is often accompanied by other neurological signs, especially if associated with spinal cord pathology (see Myelopathy). The pontine micturition centre lies close to the medial longitudinal fasciculus and local disease may cause an internuclear ophthalmoplegia. However, other signs may be absent in disease of the frontal lobe or cauda equina. Spinal cord pathways: urge incontinence of multiple sclerosis; loss of awareness of bladder fullness with retention of urine and overflow in tabes dorsalis. Cauda equina syndrome; tethered cord syndrome (associated with spinal dysraphism). Approach to the patient with bladder, bowel, or sexual dysfunction and other autonomic disorders. Intermanual conflict is more characteristic of the callosal, rather than the frontal, subtype of anterior or motor alien hand. It is most often seen in patients with corticobasal degeneration, but may also occur in association with callosal infarcts or tumours or following callosotomy. Intrusions are thought to reflect inattention and may be seen in dementing disorders or delirium. The term intrusion is also used to describe inappropriate saccadic eye movements which interfere with macular fixation during pursuit eye movements. Intrusions as a sign of Alzheimer dementia: chemical and pathological verification. The finding of inverted reflexes may reflect dual pathology, but more usually reflects a single lesion which simultaneously affects a root or roots, interrupting the local reflex arc, and the spinal cord, damaging corticospinal (pyramidal tract) pathways which supply segments below the reflex arc. Hence, an inverted supinator jerk is indicative of a lesion at C5/6, paradoxical triceps reflex occurs with C7 lesions; and an inverted knee jerk indicates interruption of the L2/3/4 reflex arcs, with concurrent damage to pathways descending to levels below these segments. The pathophysiological implication is of electrical disturbance spreading through the homunculus of the motor cortex. It may also be used to refer to the restlessness seen in acute illness, high fever, and exhaustion, though differing from the restlessness implied by akathisia. Cross References Akathisia; Myoclonus; Seizures Jamais Entendu A sensation of unfamiliarity akin to jamais vu but referring to auditory experiences. This is suggestive of seizure onset in the limbic system, but is not lateralizing (cf. There is debate as to whether jargon aphasia is simply a primary Wernicke/posterior/sensory type of aphasia with failure to selfmonitor speech output, or whether additional deficits. Others suggest that jargon aphasia represents aphasia and anosognosia, leading to confabulation and reduplicative paramnesia. Both the afferent and efferent limbs of the arc run in the mandibular division of the trigeminal (V) nerve, connecting centrally with the mesencephalic (motor) nucleus of the trigeminal nerve. The reflex is highly reproducible; there is a linear correlation between age and reflex latency and a negative correlation between age and reflex amplitude. Interruption of the reflex arc leads to a diminished or absent jaw jerk as in bulbar palsy (although an absent jaw jerk may be a normal finding, particularly in the elderly). Bilateral supranuclear lesions cause a brisk jaw jerk, as in pseudobulbar palsy. Cross References Age-related signs; Bulbar palsy; Pseudobulbar palsy; Reflexes Jaw Winking Jaw winking, also known as the Marcus Gunn phenomenon, is widening of a congenital ptosis when a patient is chewing, swallowing, or opening the jaw. It is believed to result from aberrant innervation of the pterygoid muscles and levator palpebrae superioris. Cocontraction increases the gain in the monosynaptic reflex arc, as distinct from facilitation or posttetanic potentiation which is seen in Lambert-Eaton myasthenic syndrome following tetanic contraction of muscles involved in the reflex. Facilitation of monosynaptic reflexes by voluntary contractions of muscle in remote parts of the body. This may be confused in neonates with clonic seizures, but in the former there is stimulus sensitivity and an absence of associated ocular movements. However, both may occur in hypoxic-ischaemic or metabolic encephalopathies or with drug withdrawal. Although often visible to the naked eye (difficult in people with a brown iris), they are best seen with slit-lamp examination. There may also be an oculomotor nerve palsy ipsilateral to the lesion, which may be partial (unilateral pupil dilatation). This observation helped to promote the idea that tics were due to neurological disease rather than being psychogenic, for example, in Tourette syndrome. It is due to rapid rhythmic contractions of the leg muscles on standing, which dampen or subside on walking, leaning against a wall, or being lifted off the ground, with disappearance of the knee tremor; hence this is a task-specific tremor. Auscultation with the diaphragm of a stethoscope over the lower limb muscles reveals a regular thumping sound, likened to the sound of a distant helicopter. Although such deformity is often primary or idiopathic, thus falling within the orthopaedic field of expertise, it may also be a consequence of neurological disease which causes weakness of paraspinal muscles. Duchenne muscular dystrophy Stiff person syndrome may produce a characteristic hyperlordotic spine. Some degree of scoliosis occurs in virtually all patients who suffer from paralytic poliomyelitis before the pubertal growth spurt. The test may be positive with disc protrusion, intraspinal tumour, or inflammatory radiculopathy. A positive straight leg raising test is reported to be a sensitive indicator of nerve root irritation, proving positive in 95% of those with surgically proven disc herniation. Crossed straight leg raising, when the complaint of pain on the affected side occurs with raising of the contralateral leg, is said to be less sensitive but highly specific. Infarction due to vertebral artery occlusion (occasionally posterior inferior cerebellar artery) or dissection is the most common cause of lateral medullary syndrome, although tumour, demyelination, and trauma are also recognized causes. Cross Reference Torticollis - 208 - Levitation L Lateropulsion Lateropulsion or ipsipulsion is literally pulling to one side. The term may be used to describe ipsilateral axial lateropulsion after cerebellar infarcts preventing patients from standing upright causing them to lean towards the opposite side. Lateral medullary syndrome may be associated with lateropulsion of the eye towards the involved medulla, and there may also be lateropulsion of saccadic eye movements. This spinal reflex manifests as flexion of the arms at the elbow, adduction of the shoulders, lifting of the arms, dystonic posturing of the hands, and crossing of the hands. Causes include retinoblastoma, retinal detachment, toxocara infection, congenital cataract, and benign retinal hypopigmentation. It is most often seen in corticobasal (ganglionic) degeneration, but a few cases with pathologically confirmed progressive supranuclear palsy have been reported. Pathophysiologically, this movement-induced symptom may reflect the exquisite mechanosensitivity of axons which are demyelinated or damaged in some other way. Conduction properties of central demyelinated axons: the generation of symptoms in demyelinating disease. The neurobiology of disease: contributions from neuroscience to clinical neurology. Ectropion may also be seen with lower lid tumour or chalazion, trauma with scarring, and ageing. The most common cause of the locked-in syndrome is basilar artery thrombosis causing ventral pontine infarction (both pathological laughter and pathological crying have on occasion been reported to herald this event). Bilateral ventral midbrain and internal capsule infarcts can produce a similar picture. The locked-in syndrome may be mistaken for abulia, akinetic mutism, coma, and catatonia. Cross References Echolalia; Festination, Festinant gait; Palilalia; Perseveration Logopenia Logopenia is a reduced rate of language production, due especially to wordfinding pauses, but with relatively preserved phrase length and syntactically complete language, seen in aphasic syndromes, such as primary non-fluent aphasia. Cross Reference Aphasia Logorrhoea Logorrhoea is literally a flow of speech, or pressure of speech, denoting an excessive verbal output, an abnormal number of words produced during each utterance. The term may be used for the output in the Wernicke/posterior/sensory type of aphasia or for an output which superficially resembles Wernicke aphasia but in which syntax and morphology are intact, rhythm and articulation are usually normal, and paraphasias and neologisms are few. Moreover, comprehension is better than anticipated in the Wernicke type of aphasia. Patients may be unaware of their impaired output (anosognosia) due to a failure of self-monitoring. Logorrhoea may be observed in subcortical (thalamic) aphasia, usually following recovery from lesions (usually haemorrhage) to the anterolateral nuclei. Similar speech output may be observed in psychiatric disorders such as mania and schizophrenia (schizophasia). It is often possible to draw a clinical distinction between motor symptoms resulting from lower or upper motor neurone pathology and hence to formulate a differential diagnosis and direct investigations accordingly. It may be seen in cerebellar disease, possibly as a reflection of the kinetic tremor and/or the impaired checking response seen therein (cf. Brief report: macrographia in high-functioning adults with autism spectrum disorder. This may occur because anastomoses between the middle and posterior cerebral arteries maintain that part of area 17 necessary for central vision after occlusion of the posterior cerebral artery. Cortical blindness due to bilateral (sequential or simultaneous) posterior cerebral artery occlusion may leave a small central field around the fixation point intact, also known as macula sparing. Macula splitting, a homonymous hemianopia which cuts through the vertical meridian of the macula, occurs with lesions of the optic radiation. Hence, macula sparing and macula splitting have localizing value when assessing homonymous hemianopia.
Yt teeaen suisw aeaaeo ta hv ewe ead n oo erig e spasms under right rib cage discount 400 mg skelaxin otc, hr r o tde e r wr f ht ae etbihdwehrrwr qatttvl ipoe tert o efcc o salse hte ead uniaiey mrvs h ae r fiay f rbtc-sitdrhbltto muscle relaxant liver disease skelaxin 400 mg discount,adi aatv nuohsooi cagsaeascae ooisasse eaiiain n f dpie erpyilgc hne r soitd wt teehpteie ipoeet muscle relaxer zoloft discount 400mg skelaxin free shipping. Priiat wr rnol asge t a netv uig nl-oois riig atcpns ee admy sind o hg-H)o lwrwr (R gop Tann etie paigavdogm b mvn the ih(R r o-ead L) ru muscle relaxant of choice in renal failure generic 400mg skelaxin. Rsls TeH Gophdfse lann cre spasms left side abdomen 400mg skelaxin fast delivery,sote mvmns rdcd eut: h R ru a atr erig uvs mohr oeet muscle relaxant drugs order skelaxin 400mg without a prescription, eue cnrlsoa fotprea chrneadrdcdseta pwri telf-eprl otaeinl rnoaitl oeec n eue pcrl oe n h ettmoa rgo 3m muscle relaxant generic 400 mg skelaxin mastercard. Gi aayi soe teH gopicesdnnprtcse-eghadtedd ein at nlss hwd h R ru nrae o-aei tplnt n rne twr icesdforwligvlct infantile spasms 8 month old cheap skelaxin 400mg online. W hv f toe e ae eu o olc E uig h uaue hs f toe e ae iiitdsuisi sbct srk t epoebanpatct adtecria ntok ntae tde n uaue toe o xlr ri lsiiy n h otcl ewr cagsascae wt uulcr v. Ipc:Ti wr hsteptnilt hl avnetega o otmzn nuooo mat hs ok a h oeta o ep dac h ol f piiig ermtr rcvr atrnuooia dsaeadijr. Impact: this work has the potential to help advance the goal of optimizing neuromotor recovery after neurological disease and injury. Blast shockwaves with peak overpressures of either 100 or 450 kPa were delivered using a highly reproducible shocktube. Body shielding and head restraint were used to limit pulmonary or acceleration-induced head trauma, respectively. Animals subsequently underwent a battery of behavioral tests to assess motor, emotional, and cognitive dysfunction. Spatial registration of images and voxel-byvoxel statistical testing permitted visualization of the spatially-dependant pattern of brain abnormalities. The ipsilateral cortex and thalamus were significantly abnormal at 4 days post-blast, whereas the injury progressed to include the contralateral cortex and brainstem at 30 days post-blast. At both timepoints, the injury was more pronounced and more extensive following 450 kPa blast compared to 100 kPa. Many individuals have residual deficits even after completion of all conventional rehabilitation therapy. Moreover, increasing evidence suggests that conventional rehabilitation does not provide adequate task-repetitive practice to optimize motor learning and recovery across the continuum of care. The) to Anklebot is capable of independently modulating specific sub-tasks within the gait cycle to better address the heterogeneity of hemiparetic stroke recovery. In this study, we investigate whether a modular, deficit-adjusted approach to using the Anklebot for locomotor training can lead to sustainable gains in selected aspects of gait function in chronic stroke. Training was adaptive in that, training parameters were adjusted across the intervention based on subject performance, and tolerance. This was followed by two 20-min trials of Anklebot-assisted walking during which the Anklebot provided dorsiflexion assistance, commencing immediately following toe-off and peaking during mid-swing. Results: We compared the peak dorsiflexion angle during unassisted walking at admission, discharge, and 6week follow-up. Conclusions: Six weeks of Anklebot-assisted gait training eliminated drop foot and increased overground gait speed in a single stroke subject. We are currently using the approach in subjects with impaired push-off propulsion. Mn fetn n niiuls oiiy n blt o efr vrdy ciiis ay idvdashv rsda dfct ee atrcmlto o alcnetoa rhbltto niiul ae eiul eiis vn fe opein f l ovninl eaiiain teay Mroe,icesn eiec sget ta cnetoa rhbltto de nt hrp. Rbtc myofrapoiigaeu frgi teayb poiig h otnu f ae oois a fe rmsn vne o at hrp y rvdn acsoial mtrlann pafr. I ti suy w ivsiaewehramdlr dfctajse apoc toe eoey n hs td, e netgt hte oua, eii-dutd prah t uigteAkeo frlcmtrtann cnla t ssanbegisi slce o sn h nlbt o oooo riig a ed o utial an n eetd apcso gi fnto i crncsrk. Hr,w dsrb adpeetpeiiaydt set f at ucin n hoi toe ee e ecie n rsn rlmnr aa fo asnl crncsrk srio. Tann ws potnt o utmz ooi upr o niiul at eii rfls riig a aatv i ta,tann prmtr wr ajse ars teitreto bsdo dpie n ht riig aaees ee dutd cos h nevnin ae n sbetpromne adtlrne Tecs sbetetrdtepormwt poone ujc efrac, n oeac. Rsls W cmae tepa drilxo agedrn uasse wliga amsin eut: e oprd h ek osfein nl uig nsitd akn t diso, dshre ad6we flo-p Teewsamre ices i tepa drilxo age icag, n -ek olwu. Cnlsos Sxweso Akeo-sitdgi tann eiiae do fo ad ocuin: i ek f nlbtasse at riig lmntd rp ot n icesdoegon gi sedi asnl srk sbet W aecretyuigte nrae vrrud at pe n ige toe ujc. Educational Learning Objectives: 1) Describe the current state of rehabilitation robotics as applied to functional Objectives recovery after stroke. The variety of percutaneous techniques available for addressing spinal ailments continues to grow. Using both 980-nm (5 discs) and 1470-nm (9 discs) wavelength diode lasers, a part of the nucleus pulposus was vaporized by heat convection. Results the 980-nm wavelength laser caused significant signal decrease on T1- and increase on T2-weighted imaging at the site of the quartz fiber whereas the 1470-nm wavelength laser caused no visible change on T1 and T2 maps. Pathological findings showed a wider carbonization zone and steam-bubble formation related to T1 and T2 changes. With the 1470-nm laser, the carbonization zone was narrower and the bubbles were smaller. Conclusion the effect of the 1470-nm laser was detected in the whole nucleus pulposus, not only at the site of the quartz fiber because of the 40-fold greater absorption rate in water. With the 980-nm wavelength laser, the energy was absorbed in a smaller volume, but caused a greater effect (carbonization, explicit steam-bubble formation). Uigbt 90n (dss ad upss f 4 etba n he rsl avse pns sn oh 8-m 5 ic) n 17-m(dss wvlnt doelsr,apr o tencesplou wsvprzdb 40n 9 ic) aeegh id aes at f h ulu upss a aoie y ha cneto. Rsls eut Te90n wvlnt lsrcue sgiiatsga dces o T-adices o h 8-m aeegh ae asd infcn inl erae n 1 n nrae n T-egtdiaiga test o teqat fbrweeste17-mwvlnt lsr 2wihe mgn t h ie f h urz ie hra h 40n aeegh ae cue n vsbecag o T adT mp. Ptooia fnig soe awdr asd o iil hne n 1 n 2 as ahlgcl idns hwd ie croiainzn adsembbl frainrltdt T adT cags We tewoe abnzto oe n ta-ube omto eae o 1 n 2 hne. Cnlso ocuin Teefc o te17-mlsrwsdtce i tewoencesplou,ntol a the h fet f h 40n ae a eetd n h hl ulu upss o ny t h st o teqat fbrbcueo te4-odgetrasrto rt i wtr Wt the ie f h urz ie eas f h 0fl rae bopin ae n ae. Patients were scanned within 10 days of injury and approximately 1 month post injury. Ptet wr sandwti 1 dy o ijr ad ains ee cne ihn 0 as f nuy n Information i h c r s o p r b e o h o t o s apoiaey1mnhps ijr. We have developed a new technique that allows monitoring of cell delivery in real-time, allowing immediate intervention would cells engraft in undesired locations including the formation of life-threatening microembolisms. Intraarterial cell transplantation was performed in four different experimental models: rat stroke model, normal porcine brain, normal dog brain, and normal dog spinal cord. At the end of the infusion, the cell distribution within the overall infarcted area was quite homogenous. The successful implementation of real-time imaging of cell delivery in rodents prompted us to test this further in a clinically relevant setting using large animals and clinical instrumentation. Developmental coordination disorder and cognitive and language delays may affect an additional 40% of preterm infants at school age. Brain microstructural development at near-term age is not well described but has been identified as an important risk factor for neurodevelopmental problems in children born preterm. Conclusion: Understanding temporal-spatial development of near-term brain microstructure has important implications for identifying aberrations in developmental trajectories, which may signal future motor and cognitive deficits in preterm children. Keywords Diffusion Tensor Imaging (primary keyword) Anatomy Anatomy Diffusion Tensor Imaging Brain mapping/functional imaging for rehab medicine Abstract Topics Seulae dcmn frcmlt fl wt tofgrsatce. W cnsn the e podd ouet o opee ie ih w iue tahd e a ed h the idvda iaefls i ahge rslto i nee. A Head Injury with Fracture skull will survive whereas One without skull Fracture may prove fatal. The role of the surgeon is very much essential at the Golden Hour 1st 6 hours and still more important in the Platinum hour of 1st 2 hours. Even a General surgeon can do it and then refer that patient to a Neurosurgical Centre. Aiming a better care life will be lost in the transport but only a better care can be given if patient is alive and so transported after decompression. Bitemporal Burr Hole decompression was the treatment of choice in the beginning of the 20th Century and still holds good today though forgotten for some few years before. Results: Of the 42 patients 38 survived and among them atleat 30 were back to normal. Conclusion: Unilateral or Bilateral Temporal Burr hole with Multiple Dural Punctures will save many lives in severe Head Injury. I teC Sa i aalbeta wl b bs t rl otasae soitd nuis f h T cn s vial ht il e et o ue u pc ocpiglso lk Sbua o Etaua co ta rqie asria eauto. Btmoa Br Hl dcmrsinwsteteteto coc i tebgnigo s od ieprl ur oe eopeso a h ramn f hie n h einn f te2t Cnuyadsilhlsgo tdytog frotnfrsm fwyasbfr. Stressors are associated with an increase in sympathetic cardiac control, a decrease in parasympathetic control, or both, and, consequently, an increase in systolic/stroke volume, total vascular impedance/resistance and heart rate, a decrease of baroreflex sensitivity, i. S r s o s a e a s c a e w t a novd n tesreoe adoaclr eciiy tesr r soitd ih n ices i smahtccriccnrl adces i prsmahtccnrl o bt, nrae n yptei ada oto, erae n aayptei oto, r oh additonal ad cneunl,a ices i ssoi/toevlm,ttlvsua n, osqety n nrae n ytlcsrk oue oa aclr 107 meac/eitne n er ae erae f aoelx estvt. Eetonehlgahc ae nomd osn, n tiolgl sus ae en bevd lcrecpaorpi (E)mntrn wspromdfrsft proe. Educational Learn; Transcranial Magnetic Stimulation physical and clinical principles and applications; Brain systems Objectives involved in processing acute stressor-evoked cardiovascular reactivity; Applications of spectrum analysis of Heart Rate Variability Files Submission exists, but was not archived (suffix. Commercially available paclitaxel drugs, Taxol and Abraxane, were similarly tested. Saline and polymer (NanoCarrier 001B) were used as negative control treatments for the xenograft studies. Information J f r y D u h r y (e f d u h r y a p i c c m A P T c n l g e, I c efe oget jf. The entire device is covered with a parilene coating of 7 µm, to ensure maximum biocompatibility. Craniotomy was performed, placing the 16 contacts grid over the left motor cortex (M1). We performed bipolar stimulation by pulses of rectangular shapes with anodal monophasic current pulses of 0. During cortical stimulation of the motor cortex, movements of distinct portions of the right arm were observed with a stimulation intensity of 2 mA. Stimulation with electrode number seven and nine elicited movements of the proximal portion of the right arm, whereas the stimulation with electrodes number one generated movements of the distal portion of the right arm. This fully-integrated system lends itself to be optimized in view of use in a closed-loop systems of electrical stimulation for aborting or blocking promptly detected seizure activity in epilepsy patients. The specific anatomical pattern of pathological changes developing in the brain suggests that once tau pathology is initiated, it propagates between neighboring neuronal cells, possibly spreading along axonal networks. In other words, misfolded aggregated tau protein released by degenerating neurons can mediate and spread toxicity to neighboring cells. This was made particularly evident by the perinuclear localization of aggregates and the re-distribution of vimentin intermediate filament networks and retrograde motor protein dynein. Conclusions: Brain mapping of the spreading of pathological tau aggregation will help therapeutic applications. Ongoing imaging studies will help the visualization of neuropathological features. Functional information about the cortical and subcortical areas at risk is crucial for the avoidance of neurological deficits after tumor surgery. Methods: We describe our initial experience with 14 patients with brain tumors located in or close to eloquent areas. Tegasaet rsc telso a mc a psil, hleg o h ersren h ol r o eet h ein s uh s osbe peevn teptetseitn nuooia fnto. W teatoscnimta tewr peetdi ti mnsrp i oiia,hsntbe e h uhr ofr ht h ok rsne n hs aucit s rgnl a o en pbihdbfr adi ntcretybigcniee frpbiaineswee Al ulse eoe n s o urnl en osdrd o ulcto lehr. Because study population sizes have been generally limited, I will discuss results on genes that have been the focus of independent studies. Keywords Abstract Topics Nanoscience, genomics, computational informatics genetics (primary keyword) Nanoscience, genomics, genetics TeGnmcRsos t TamtcBanIjr h eoi epne o ruai ri nuy the abstarct Rbr H Lpk,P. Files Submission exists, but was not archived (suffix) Reviews 121 Submission 202 home Treatment Effects of Onion (Allium cepa) and Ginger (Zingiber officinale) on Sexual Behavior of Rat after Inducing an Antiepileptic Drug (lamotrigine) Arash Khaki - Dep Pathology,Tabriz Branch,islamic azad university,Tabriz,iran Alireza - Department Clinical Psychiatry Research Center, Tabriz University of Medical Sciences, Farnam Tabriz, Iran Contact: arash khaki (arashkhaki@yahoo. Material and Methods: Wistar rats (n=70) (male=35, female=35) were allocated so that males were divided into seven groups: control (n=5) and test groups (n=35). Onion & Lamotrigine group used both onion juice (3 cc fresh onion juice for each rat/day) and Lamotrigine (10 mg/kg). Ginger & Lamotrigine group used both ginger powder (100 mg/kg/day) and Lamotrigine (10 mg/kg/day). Onion, ginger & Lamortigine group jointly used ginger powder (100 mg/kg/day) and onion juice (3 cc juice for each rat) and Lamotrigine (10 mg/kg/day). For sexual behaviors, Estradiolbenzoate (50 microgram) and 6 hours before test (500 microgram) progesterone was injected to the female rats subcutaneously. Conclusion: Results revealed that administration of (100 mg/kg/day) of ginger powder, and freshly prepared onion juice (3 cc for each rat), significantly lowered the adverse effects of lamotrigine, and can have beneficial effects on sexual behavior in male rat. Department of Biomedical Engineering, the Ohio State University, Columbus, Ohio 43210 2. Developing a non-invasive method of estimating intracranial pressure provides a new option for patients as well as relieves the burden of lumbar punctures on the health care system. The parameters for the circuit were taken from literature values and then modified iteratively based on measured clinical parameters. This model can provide a foundation for more comprehensive investigations of cerebral hemo- and hydrodynamics. Modeling Modulation of Intracranial Pressure by Variation of Cerebral Venous Resistance Induced by Ventilation. To evaluate an electrical analog model for the advancement of applications to more comprehensive Objectives models 2. To establish a first step to a non-invasive method of measuring intracranial pressure Files Submission exists, but was not archived (suffix. The core components of these interventions include exposure, cognitive restructuring, psychoeducation, and relaxation and stress modulation techniques. Some interventions have been manualized and gained popularity, but the essential concept is that their therapeutic effect is based on these core components. The observation that non-invasive electroacupuncture also has this effect is supportive of the possibility that acupoint stimulation can be achieved without the use of traditional acupuncture needles. However, it should be noted that there is not enough evidence to currently support the use of acupoint tapping techniques outside of research settings. Also, because it does not require technical supplies, is non-invasive, and can be selfadministered, it could potentially increase resiliency and be preventive in nature. Sm itretoshv be mnaie adgie pplrt,bt ouain ehius oe nevnin ae en aulzd n and ouaiy u teesnilcneti ta terteaetcefc i bsdo teecr cmoet. Seiial,a ih cpntr ede les h ciiy f h ua ibc ytm pcfcly n ihbtr efc o teaydl hsbe osre. Teosrainta nnivsv n osby leig the ri ra) h bevto ht o-naie eetocpntr as hsti efc i spotv o tepsiiiyta auon lcrauucue lo a hs fet s uprie f h osblt ht cpit siuaincnb ahee wtotteueo taiinlauucuenels I ti tmlto a e civd ihu h s f rdtoa cpntr ede. As,bcuei de ntrqietcncl osby ev s tnaoe nevnin lo eas t os o eur ehia sple,i nnivsv,adcnb sl-diitrd i cudptnilyices upis s o-naie n a e efamnsee, t ol oetal nrae rslec adb peetv i ntr. The impact that a non-invasive self-care technique could have on the psychological wellbeing of veterans. Recent decades have produced significant developments in the capabilities and availability of adjunctive tools in epilepsy surgery. In particular, image-based neuronavigation, electrophysiological neuromonitoring and recording represent versatile and informative modalities that can assist a surgeon in performing safe and effective resections. This group of patients (63 males and 51 females) has a median age of 37 (range 17-78 years). The surface electrode is placed on the brain surface to record the cortical electrophysiological changes. The deep electrode is placed into special area of brain to record electrophysiological changes in related area. If the epileptic focus found, Stage 2 surgery are designed to resect the epileptic focus. Image-guided neuronavigation uses preoperative, intraoperative, or real-time imaging to allow the surgeon to understand spatial relationships within the brain that are not visible by line-of-sight. Accurate localization of eloquent brain regions is of critical importance during resections of nearby epileptogenic foci or lesions. Magnetoencephalography in conjunction with anatomical imaging is a powerful technique that permits the visualization of epileptic spikes within the brain. Results: Among 66 patients, 44 were performed 2 stage of surgery or more, 22 patients were performed only 1 stage which is recording and resection in one time.
As soon as the needle encounters bone it is partly withdrawn prior to reinsertion at a steeper angle spasms cell cancer order skelaxin 400mg line, which will allow the needle (with the bevel facing towards the vertebra) to slide past the vertebral body and through the psoas fascia to lie close to the sympathetic chain back spasms 32 weeks pregnant order 400 mg skelaxin with amex. After aspiration checks for blood (the aorta is on the left muscle relaxant stronger than flexeril generic 400 mg skelaxin with visa, the inferior vena cava on the right) a small volume of contrast medium is injected muscle relaxants knee pain buy generic skelaxin 400mg on-line. Correct placement is indicated by localised linear spread along the vertebral column yorkie spasms buy cheap skelaxin 400 mg line. If the needle is lying within the psoas compartment then the contrast will track away from the vertebral body muscle relaxants for tmj discount 400mg skelaxin visa. Local anaesthetic is then injected muscle relaxant dosage purchase 400 mg skelaxin visa, or if a permanent block is sought either absolute alcohol spasms right side of back order skelaxin 400mg fast delivery, or a dilute solution of phenol (5%) can be used. Direction the viva may take You may be asked the indications for, and complications of, lumbar sympathectomy. It is also used to treat syndromes in which sympathetically maintained pain is a feature, such as the complex regional pain syndrome, and for phantom limb and other neuropathic pain. Some of these complications are associated with mechanical damage caused by the advancing needle, others by the substance that is injected. L1 genitofemoral neuralgia, for example, is much more common after alcohol has been used. Ureteric strictures have also been reported following the use of alcohol and phenol. The lumbar plexus is formed from the anterior primary rami of the first four lumbar nerves, together with a small contribution from the twelfth thoracic nerve. After emerging from the intervertebral foramina the nerves lie just within the substance of the psoas major muscle (and within its sheath). The nerves formed by the plexus include the femoral, the obturator, the iliohypogastric, ilioinguinal, genitofemoral and the lateral cutaneous nerve of the thigh. All except the obturator nerve emerge laterally in the plane between the psoas and quadratus lumborum. Lumbar plexus block (sometimes called psoas compartment block) can provide effective analgesia (as well as motor block) to much of the groin and upper leg. The analgesia afforded by the block is rarely dense enough to allow surgery without general anaesthesia, and nerves such as the femoral and obturator can as readily be blocked at more distal sites. With the patient in the lateral position with the side to be blocked uppermost, a needle is directed perpendicular to the skin to encounter the transverse process of L3. This site is chosen because the process is longer and wider than those of the other lumbar vertebrae. The needle is then walked off superiorly, penetrating first the fascia of quadratus lumborum and then that of the psoas sheath. Some anaesthetists use a nerve stimulator, although as the fibres of the plexus are separated and embedded within the body of the muscle this technique may not always succeed. An alternative is to use a Tuohy epidural needle with a loss of resistance device attached. The loss of resistance as the needle penetrates the sheath is not dissimilar to that which occurs when the epidural space is entered. The advantage of this approach is that an epidural catheter can be inserted in order to provide continuous analgesia. It also allows verification of placement, because an injection of contrast medium will outline the borders of the psoas compartment should the catheter be in the correct place. Coeliac plexus block is no longer a procedure that can be undertaken blind without imaging, and its indications are limited to severe intractable pain. This question, however, remains a perennial favourite despite the fact that most examiners expect only theoretical knowledge. You will, however, need to know the anatomy reasonably well, because even the most sympathetic examiner has no choice but to pursue the topic. The coeliac plexus is most commonly the target for anaesthetists who are treating malignant visceral pain. It is the largest sympathetic plexus and lies anterior to the abdominal aorta where as a dense network of nerve fibres it surrounds the root of the coeliac artery at the level of L1. There are two ganglia, right and left, which are closely related to the crura of the diaphragm. The plexus also receives some filaments bilaterally both from the vagus and the phrenic nerves. Superiorly lie the crura of the diaphragm; posteriorly is the abdominal aorta; laterally are the adrenal glands in the superior poles of left and right kidneys. Direction the viva may take You are likely to be asked about indications for coeliac plexus block. Therapeutic block: the plexus can be blocked in conjunction with intercostal nerves in order to provide analgesia for intra-abdominal surgery. More commonly it is used for the relief of malignant pain, typically that due to carcinoma of the pancreas. Neurolytic blocks give good analgesia in up to 90% of patients, although the effect may only last for a number of months. Diagnostic block: Coeliac plexus block using local anaesthetic alone can be used for diagnostic purposes, and for attempting to break a sympathetically mediated acute pain cycle. Further direction the viva could take You may then be asked how you might perform a block. You are unlikely to be picked up on small details as long as your overall account is plausible and safe. If your examiner does happen to work in chronic pain management they should not allow their specialist knowledge to influence the standard that is expected of you. Neurolytic agents should be injected only under X-ray control, after needle placement has been confirmed by contrast media. It can be very painful on injection, but does not cause the vascular injury that is associated with phenol (which is a potential problem for a block such as this which is para-aortic). The neuritis that can accompany the regeneration of nerves may be as severe as the original symptoms. Complications: these include hypotension (it is a sympathetic block), anterior spinal artery syndrome, subarachnoid, epidural and intrapsoas injection, intravascular injection (the aorta is very accessible on the left, the inferior vena cava is less vulnerable on the right), retroperitoneal haemorrhage, and visceral puncture, most commonly of the kidney. The neurolytic agent may also spread unpredictably, causing paresis, paralysis and dysaesthesia. There is considerable overlap in the arterial supply to areas of the myocardium, and so it is not always possible to diagnose the site of coronary artery occlusion from electrocardiographical or echocardiographical changes. After you have been asked about the anatomy, which you may find easier to explain with the help of a diagram, the viva is likely to move on to the physiology of coronary perfusion. The viva You will be asked to describe the arterial supply and venous drainage of the heart. The right coronary artery passes between the pulmonary trunk and the right atrial appendage to descend in the anterior atrio-ventricular groove. At the inferior border of the heart it effectively divides into the marginal branch which travels along the right ventricle towards the apex and the inferior interventricular artery which continues in the groove of the same name to anastomose with the circumflex artery (the corresponding branch of the left coronary artery). Right main coronary or its branches: these supply the right ventricle and right atrium, part of the interventricular septum, the sino-atrial node (in 65%), the bundle of His, the atrio-ventricular node (80%) and the conducting system (80%). The left coronary artery is larger than the right, and after arising from the posterior aortic sinus, passes between the left atrial appendage and the pulmonary trunk. This continues in the atrio-ventricular groove to anastomose with the inferior interventricular artery as above. Left coronary artery or its branches: these supply the left ventricle and left atrium, part of the interventricular septum, the sino-atrial node (in 35%), the atrio-ventricular node (20%) and the conducting system (20%). The innermost part of the endocardium receives oxygen directly from the blood within the ventricle. Venous drainage: As much as a third of cardiac venous blood drains directly into the cardiac chambers via the venae cordis minimae (a network of small veins). The remainder is drained by larger veins, which tend to accompany the coronary arteries. Most of the remaining venous blood drains into the right atrium via the coronary sinus, which is located to the left of the opening of the inferior vena cava, and which lies in the posterior atrio-ventricular groove. At rest about 250 ml min 1, or 5% of the cardiac output is supplied to the myocardium through the coronary arteries. In the absence of a stenotic lesion the main variable that determines flow is the calibre of the blood vessels. Vasodilatation occurs mainly in response to the presence of local metabolites, such as hydrogen ions, adenosine, potassium, phosphate, carbon dioxide and prostaglandins. Autonomic control of vascular tone is present but is a negligible influence in comparison. Myocardial tissue has a high oxygen extraction ratio (80%), which limits its capacity for anaerobic metabolism. Increased oxygen demand, therefore, has to be met by an increase in coronary perfusion. During systole the sub-endocardial pressure in the left ventricle exceeds that in the outer part of the myocardium, and so in the main, arterial flow occurs through the arteries only in diastole. There is, however, some flow to the outer areas of the left ventricle throughout the cardiac cycle. In the right side of the heart, which is a lower pressure system, coronary perfusion persists throughout systole and diastole. High heart rates can compromise ventricular perfusion as well as ventricular filling. Further direction the viva could take You may be asked about the factors that determine the balance between myocardial oxygen supply and demand. The technique is regaining popularity, particularly in obstetrics, and together with epidural analgesia is a central area of anaesthetic practice. Ignorance of its main aspects potentially can put patients at grave harm, and so you will be expected to demonstrate that your knowledge is sound. The spinal subarachnoid space communicates freely with the ventricular system of the brain. Dura mater: this is the strongest of the meningeal coverings and consists of fibro-elastic connective tissue. The cranial dura has two layers: an outer endosteal layer which lines the skull, and a meningeal layer which invests the brain. These two layers are closely applied, except where they separate to accommodate the large venous sinuses. At the spinal level the endosteal layer continues down the vertebral canal as a lining of periosteum. The width of the dura varies with the spinal level: in the lumbar region it is between 0. The spinal dura also provides a cuff for nerve roots, which thins as each nerve approaches the intervertebral foramen. Arachnoid mater: this is a fine non-vascular membrane, which is closely applied to the dura. The subdural space between these two layers is a potential capillary space, containing a small amount of lubricant serous fluid. It is widest in the cervical region, and laterally, adjacent to the nerve roots themselves. Pia mater: this is a fine vascular membrane, which invests the spinal cord itself. Its lateral projections form the dentate ligament, which attach to the dura and support the cord. The filum terminale is the terminal extension of the pia mater which runs from the end of the spinal cord to attach to coccygeal periosteum. It is formed by secretion and ultrafiltration from the choroid arterial plexus in the lateral third ventricles and the fourth ventricle. These demonstrate a gradient between the ventricles, where the concentration is low, and the lumbar region where they are highest. The adult spine has a number of natural curves, the high points of which (in the supine position) are the fifth cervical and the second or third lumbar (C5 and L2/L3) vertebrae, and the low points of which are the fifth and sixth thoracic and the second sacral (T5/T6 and S2) vertebrae. The spinal cord in the adult ends at the level of the intervertebral disc at L1/L2. There is some variation and in up to 10% of subjects the cord may end as high as T12/L1 or as low as L2/L3. It can, however, be difficult to identify this point clinically, which is why neurosurgeons operating on the back identify the level radiologically prior to operation. Anaesthetists must aware of this potential for inaccuracy, because a spinal needle which is advanced too high, or is advanced without finesse, risks penetrating the conus medullaris with permanent neurological deficit. The lowest rib (which is palpable only in very thin subjects) is at the level of T12. The first spinous process which is clearly palpable is C7, which is the vertebra prominens (although the spinous process of T1 below it, is actually more prominent still). The inferior angle of the scapula in the neutral position is at the level of T7/T8. Further direction the viva could take There are various ways in which a viva on spinal anaesthesia may develop. You may be asked about complications, but this is relatively straightforward, and so it is more likely that you will be asked the factors that influence intrathecal spread, about which there are common misconceptions. Level of injection: In the supine patient with a normal spine the maximum height of the lumbar lordosis is at L2/L3. Less local anaesthetic will move rostrally if the injection is made below that level. In practice the final block height is similar, except it that it takes longer to achieve. In the supine patient with a normal spine, hyperbaric solutions tend to pool in the thoracic kyphosis at T5/T6, and produce blocks which generally are higher but which are claimed to be more predictable than those produced by isobaric solutions. Solutions which pool in the lumbosacral area may have a relatively enhanced effect because the nerves of the cauda equina have large surface area and only a thin layer of pia mater. If the patient is in the decubitus position the curves of the spine have no influence. Trendelenberg positioning clearly will increase the rostral spread of a hyperbaric solution. Patient age: There may be increased cephalad spread with advancing age, although again the block height cannot reliably be predicted. Pregnancy (and multiple pregnancy): Term pregnancy is said to be associated with greater block height, which is made higher still with multiple pregnancy. The mechanism may relate to the relative smaller volume of the dural sheath because of encroachment in the epidural space by the engorged venous plexus. Needle direction and speed of injection: Rostral facing injection or forceful injection shortens the onset time but does not influence the final height of block. Barbotage, weight of patient, gender of patient, adjuvant drugs, vasoconstrictors: None of these factors has any significant effect on block height. In many hospitals the numbers of epidurals that are now inserted for surgical analgesia exceed those that are given to relieve the pain of labour. Thus quite detailed knowledge will be expected: you will be required to demonstrate a good three-dimensional grasp of the anatomy as well as being aware of all the material complications. The extradural (epidural) space is the area surrounding the dural sheath as it lies within the vertebral canal. It extends from the foramen magnum superiorly (where the dura is fused to the skull) to the sacral hiatus inferiorly. It is traversed by the dural sheath, whose thickness in the lumbar region is about 0. The filum terminale is an extension of the pia mater, which runs from the conus medullaris to the coccyx. Anteriorly the epidural space is bounded by the bodies of the vertebrae and by the intervertebral discs, over which lies the posterior longitudinal ligament. Ligamenta flava: There are two ligaments which meet in the midline and which connect the laminae of adjacent vertebrae. Each extends from the lower part of the anterior surface of the lamina above to the posterior surface of and upper margin of the lamina below. Their fibres run in a perpendicular direction, but when viewed in the sagittal plane the ligaments are triangular in shape with the apex of the triangle formed at the upper lamina. At the level of a typical lumbar vertebra, for example L4, the space contains the spinal nerves, each of which is invested with a cuff of dura, with loosely packed fat, areolar connective tissue, lymphatics and blood vessels. The depth of the posterior epidural space (between the ligamenta flava and the dura) varies with the vertebral level. The list is long, and so once you have volunteered as many complications that you can recall, it is probable that the viva will concentrate on the recognition and management of one or two of them.
