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In myasthenia gravis buy 200 mg acivir pills fast delivery, fatigue may be elicited in the extraocular muscles by prolonged upgaze caus- ing eyelid drooping; in bulbar muscles by prolonged counting or speech causing hypophonia; and in limb muscles by repeated contrac- tion generic acivir pills 200mg fast delivery, especially of proximal muscles (e 200mg acivir pills visa. Fatigue in myasthenia gravis is understood as a decline in the amount of acetylcholine released from motor nerve terminals with successive neural impulses discount acivir pills 200 mg visa, along with a reduced number of functional acetylcholine receptors (AChR) at the motor end-plates buy discount acivir pills 200 mg line, due to binding of AChR antibodies and/or comple- ment mediated destruction of the postsynaptic folds. This may occur in multiple sclerosis (MS), post-polio syndrome, post-stroke syndromes, and chronic fatigue syndrome (CFS). In MS and CFS, fatigue may be a prominent and disabling complaint even though neurological examination reveals little or no clinical deficit. This type of fatigue is ill-understood: in MS, frequency- - 121 - F Femoral Stretch Test dependent conduction block in demyelinated axons has been sug- gested, as has hypothalamic pathology. Current treatment is sympto- matic (amantadine, modafinil, 3,4-diaminopyridine) and rehabilitative (graded exercise). Fatigue may be evaluated with various instruments, such as the Krupp Fatigue Severity Score. Drugs 2004; 64: 1295-1304 Cross References Dystonia; Hypokinesia; Hypometria; Micrographia; Weakness Femoral Stretch Test The femoral stretch test, or reverse straight leg raising, consists of extension of the hip with the knee straight with the patient lying prone, a maneuver which puts traction on the femoral nerve or L3 root and may exacerbate pain in a femoral neuropathy or L3 radiculopathy, perhaps due to a retroperitoneal hemorrhage. Cross References Lasègue’s sign Fencer’s Posture, Fencing Posture Epileptic seizures arising in or involving the supplementary motor area may lead to adversial head and eye deviation, abduction and external rotation of the contralateral arm, flexion at the elbows, and posturing of the legs, with maintained consciousness, a phenomenon christened by Penfield the “fencing posture” because of its resemblance to the en garde position. To avoid falling and to maintain balance the patient must “chase”the cen- tre of gravity, leading to an increasing speed of gait and a tendency to fall forward when walking (propulsion). A similar phenomenon may be observed if the patient is pulled backward (retropulsion). Festination is common in idiopathic Parkinson’s disease; it is asso- ciated with longer duration of disease and higher Hoehn & Yahr stage. Festination may be related to the flexed posture and impaired postural reflexes commonly seen in these patients. It is less common in sympto- matic causes of parkinsonism, but has been reported, for example in aqueduct stenosis. Festination as the lead- ing symptom of late onset idiopathic aqueduct stenosis. Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 599-600 Cross References Freezing; Parkinsonism; Postural reflexes Fibrillation Fibrillation was previously synonymous with fasciculation, but the term is now reserved for the spontaneous contraction of a single muscle fibre, or a group of fibers smaller than a motor unit, hence this is more appropriately regarded as an electrophysiological sign without clinical correlate. Cross References Fasciculation Finger Agnosia Finger agnosia is a type of tactile agnosia, in which there is inability to identify which finger has been touched when the eyes are closed, despite knowing that a finger has been touched; or inability to point to or move a finger when it is named; or inability to name the fingers (patient’s own fingers or those of another person). This is a disorder of body schema, and may be regarded as a partial form of auto- topagnosia. Finger agnosia is most commonly observed with lesions of the dominant parietal lobe. It may occur in association with acalculia, agraphia, and right-left disorientation, with or without alexia and difficulty spelling words, hence as one feature of Gerstmann syn- drome. Isolated cases of finger agnosia in association with left cor- ticosubcortical posterior parietal infarction have been reported. Since this causes no functional deficit, it may be commoner than reported. Archives of Neurology 1994; 51: 448-450 Cross References Agnosia; Autotopagnosia; Gerstmann syndrome Finger Drop - see WRIST DROP Finger-Floor Distance In patients with leg (+/− back) pain suspected of having lumbosacral nerve root compression, a finger-floor distance of > 25 cm when the patient bends forward and attempts to touch the floor with the fin- gers has been found an independent predictor of radiological (MR imaging) compression. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. Journal of Neurology, Neurosurgery and Psychiatry 2002; 72: 630-634 Cross References Lasègue’s sign “Finger-Nose Test” - see ATAXIA; CEREBELLAR SYNDROMES Fisher’s Sign Fisher’s sign is the paucity of facial expression conveying emotional states or attitudes (emotional facial paresis). It follows nondominant (right) hemisphere lesions and may accompany emotional dysprosody of speech. Cross References Abulia; Aprosodia, aprosody; Facial paresis Flaccidity Flaccidity is a floppiness which implies a loss of normal muscular tone (hypotonia). This may occur transiently after acute lesions of the cor- ticospinal tracts (flaccid paraparesis), before the development of spas- ticity, or as a result of lower motor neurone syndromes. Cross References Hypotonia, Hypotonus; Lower motor neurone (LMN) syndrome Flail Arm Flail arm refers to a severe and symmetric wasting and weakness of the arms without significant functional involvement of other regions, seen in one variant of motor neurone disease, the “flail arm syndrome,” also known as Vulpian-Bernhart’s form.

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Jean Verbrugge died on January 7 generic acivir pills 200 mg mastercard, 1964 after a long and painful illness generic 200 mg acivir pills mastercard, which he bore with courage and stoicism cheap acivir pills 200mg with mastercard. He deserves entirely what he himself hoped for in the case of his late master Lambotte: “that he should still live in our minds acivir pills 200mg for sale. Henning WALDENSTRÖM 1877–1972 Henning Waldenström was born in Stockholm Börje WALLDIUS and began his orthopedic career in the same city generic acivir pills 200 mg on line. In 1936, he became professor of orthopedics at 1913– the Karolinska Institute. In 1938, Waldenström suggested that the term Börje Walldius was born in 1913 in Kristianstad orthopedics be changed to orthopedic surgery, in southern Sweden. In 1909, college in 1932, he attended the medical school Waldenström described a condition of the hip at the University of Lund, receiving his medical joint in children that he called “the upper tuber- degree in 1942. He then process never passed over to the joint and was moved to the department of orthopedics at the prevented from doing this by the joint cartilage, Karolinska Hospital in Stockholm, with which he which formed an impenetrable cover. It was while he was of the condition was enigmatic and controversial, there that he obtained his PhD degree from the and Waldenström suggested the name coxa plana Karolinska Institute in 1957. Gornas Hos- Waldenström in 1938 to the American Academy pital in Stockholm, where he remained active of Orthopedic Surgeons, is one of the first until his retirement in 1978. Waldenström Knee Using an Endoprosthesis,” is an important became an honorary member of the American document because it is the first report of a group Academy of Orthopedic Surgeons, the British of patients treated with a hinged prosthesis. Orthopedic Association, the Société Française de Chirurgie Orthopedique et Traumatologique, and the Deutsche Orthopädische Gesellschaft. Waldenström played an important role in the future development of Swedish orthopedics. In testimony to his leadership, all of his disciples 345 Who’s Who in Orthopedics Frederick Oldfield WARD At this time he also speculated in many small patents and it is said that unsuspecting tradesmen 1818–1877 paid dearly for their infringement of forgotten patent rights of his inventions. In 1854, on the Frederick Oldfield Ward entered the medical recommendation of Lord Palmerston, Ward was school of King’s College in October 1833, when appointed commissioner of sewers and evolved a he was 15 years of age. The theory was time in Camberwell and his early education had acknowledged to be excellent, but was said to be been gained with a Dr. His impossible of execution: it was described as the career as a student appears to have been success- “quart-into pint-pot” plan. Political unrest at this ful enough and we know that he gained a medal period, combined, maybe, with his advanced and in chemistry in 1835 and a silver medal in botany eccentric ideas, caused him to lose his office, in 1837. While still a student, he wrote Human though he apparently continued his investigations Osteology, which was published in 1838. In into the subject of water supply, for in September the preface he said that his book was the result 1856 he addressed the International Congress of “partly of researches in the museum and dissect- Public Health in Brussels and in the same year ing room, prosecuted at intervals during the last prepared the second edition of Human Osteology. Apart from this, nothing is known of his activities for almost 20 years, though Sir John But holding that true brevity consists not in expressing Simons, Medical Officer of Health for London, ideas in a small space but in conveying them in a short who had been a fellow student at King’s College, time, I have not thought it inconsistent with this design mentions in his “Personal Recollections” that to dilate freely upon some obscure and difficult points before his death Ward suffered “enfeeblement. Whatever contradictory statements came under my notice in the course of this comparision Human Osteology. His mental and physical were noted down, and made the subject of careful powers deteriorated to such an extent that he research in several extensive anatomical collections entered St. Ward’s experiments to show the nature and The book is of small dimensions. The pages composition of bone provide interesting conclu- of the first edition measure only two and three- sions. On quarters by four and a half inches, the volume page 370 of Human Osteology, Ward illustrated being one and three-quarters inches thick. Though the triangle in the neck of the femur with which it cannot be said to present the attractions of the his name is still associated. A similar area is to be modern textbook, its text and illustrations achieve found in the calcaneum. He made this observation: qualifying medical examination, but we know that for some years he practiced as a surgeon. His The arrangement of the cancellous tissue in the ends of interests extended far beyond the confines of the femur is very remarkable; and, as it illustrates the medicine. In the lower who introduced him to Edwin Chadwick, both extremity of the bone, it consists of numerous slender of whom were pioneers of the new medicolegal columns, which spring on all sides from the interior group of sanitary reformers. Fired with their surface of the compact cylinder, and descend, con- enthusiasm, Ward wrote at this time a number verging towards each other, so as to form a series of of popular articles in which he criticized water inverted arches, adapted by their pointed form to supply and hygiene and proposed control under sustain concussion or pressure transmitted from below.

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More conventional laboratory technologies can also produce There are many reasons behind the spread of biowar- organisms resistant to antibiotics order acivir pills 200 mg on line, routine vaccines purchase acivir pills 200 mg on line, and thera- fare technology purchase 200 mg acivir pills with mastercard. Both technologies can produce organisms that cannot tives; some governments may resort to selling bits of be detected by antibody-based sensor systems buy acivir pills 200mg on-line. In addition discount 200 mg acivir pills otc, scientists in politi- weapons are those that use smallpox (caused by the Variola cally repressive or unstable countries may be forced to par- virus), anthrax (caused by Bacillus anthracis), and plague ticipate in research that eventually ends up in the hands of (caused by Yersinia pestis). With the advent of ful than a conventional weapon because its effects can be far- vaccines and antibiotics, few U. In 1979, after an accident experience to readily recognize these diseases, any of which involving B. The Somalia in 1977, experts suspect that smallpox viruses may be bacilli multiply rapidly and produce a toxin that causes breath- in the biowarfare laboratories of many nations around the ing to stop. At present, only two facilities—one in the United plies adequate to meet the treatment needs following an attack States and one in Russia—are authorized to store the virus. As on a large urban population would need to be delivered and 76 WORLD OF MICROBIOLOGY AND IMMUNOLOGY Bioterrorism, protective measures distributed within 24 to 48 hours of exposure. The National BIOTERRORISM, IDENTIFICATION OF Pharmaceutical Stockpile Program (NPS) is designed to MICROORGANISMS • see GENETIC IDENTIFICATION OF enable such a response to a bioterrorist attack. Preparing a strategy to defend against these types of MICROORGANISMS organisms, whether in a natural or genetically modified state, is difficult. Some of the strategies include the use of bacterial RNA based on structural templates to identify pathogens; Bioterrorism, protective measuresBIOTERRORISM, PROTECTIVE MEASURES increased abilities for rapid genetic identification of microor- ganisms; developing a database of virtual pathogenic mole- In the aftermath of the September 11, 2001 terrorist attacks on cules; and development of antibacterial molecules that attach the United States and the subsequent anthrax attacks on U. Each of government officials, media representatives, and citizens, the these is an attempt to increase—and make more flexible— development of measures to protect against biological terror- identification capabilities. Researchers are also working to counter potential Although the desire to increase readiness and response capa- attacks using several innovative technological strategies. For bilities to possible nuclear, chemical, and biological attacks is example, promising research is being done with biorobots or widespread, consensus on which preventative measures to microchip-mechanized insects, which have computerized arti- undertake remains elusive. These insects can, in a single operation, first half of the twenty-first century, biological weapons will process DNA, screen blood samples, scan for disease genes, surpass nuclear and chemical weapons as a threat to the citi- and monitor genetic cell activity. Defense Advanced Research Project (DARPA) works to rap- Although a range of protective options exists—from the idly identify bio-responses to pathogens, and to design effec- stockpiling of antibiotics to the full-scale resumption of bio- tive and rapid treatment methods. Bees, beetles, and other insects outfitted with Many scientists argue, therefore, that focusing on one specific sensors are used to collect real-time information about the pres- set of protective measures (e. Using fiber optics or electro- against the virus causing smallpox) might actually lower over- chemical devices, biosensors have detected microorganisms in all preparedness and that a key protective measure entails chemicals and foods, and they offer the promise of rapid iden- upgrading fundamental research capabilities. The The array of protective measures against bioterrorism early accurate identification of biogenic agents is critical to are divided into strategic, tactical, and personal measures. Late in 2001, the United States and its NATO (North To combat biological agents, bioindustries are develop- Atlantic Treaty Organization) allies reaffirmed treaty com- ing a wide range of antibiotics and vaccines. In addition, mitments that stipulate the use of any weapon of mass advances in bioinformatics (i. At the tactical level, the United States possesses or virus), the major problem in developing effective counter a vast arsenal of weapons designed to detect and eliminate strategies to bioterrorist attacks involves the breadth of organ- potential biological weapons. For example, researchers are analyzing many pathogens in an effort to identify common options is the use of precision-guided conventional thermal genetic and cellular components. One strategy is to look for fuel-air bombs capable of destroying both biological research common areas or vulnerabilities in specific sites of DNA, facilities and biologic agents. Regardless of whether the pathogens evolve Because terrorist operations are elusive, these large- naturally or are engineered, the identification of common traits scale military responses offer protection against only the will assist in developing counter measures (i. When laboratories capable of producing Biological warfare; Contamination, bacterial and viral; Genetic low-grade weaponizable anthrax-causing spores can be estab- identification of microorganisms; Public health, current issues lished in the basement of a typical house for less than $10,000, 77 Bioterrorism, protective measures WORLD OF MICROBIOLOGY AND IMMUNOLOGY Bioterrorist attack on the U. The NPS stockpile is designed to be rapidly extreme of potential military responses, the formal resumption deployable to target areas. For example, in response to poten- of biological weapons programs—even with a limited goal of tial exposures to the Bacillus anthracis (the bacteria that enhancing understanding of potential biological agents and causes anthrax) during the 2001 terrorist attacks, the United weapons delivery mechanisms—is unneeded and possibly States government and some state agencies supplied Cipro, the detrimental to the development of effective protective meas- antibiotic treatment of choice, to those potentially exposed to ures. In addition to increasing funding for the NPS, Biological Weapons Convention to which the United States is additional funds have already been authorized to increase a signatory and which prohibits such research, opponents of funding to train medical personnel in the early identification such a resumption argue any such renewal of research on bio- and treatment of disease caused by the most likely pathogens. Nonethless, advocates of increased research capabilities develop protective measures against biological attack.

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Responsibilities to the speakers Speakers invariably fall into one of three types acivir pills 200 mg overnight delivery. The well-organised speakers: they will tell you exactly what they are going to do and what they require buy 200mg acivir pills with visa. If you ask them how long they are going to speak cheap acivir pills 200mg mastercard, they will tell you in minutes and seconds! You will need to have little concern for these speakers buy cheap acivir pills 200mg online, but they will expect you be as well prepared and organised as themselves acivir pills 200 mg low price. The apprehensive speakers: they will generally be the younger and less experienced. They will often have a well- prepared paper to present but are in danger of not doing themselves justice. You can assist such speakers greatly by familiarising them with the facilities before the session and encouraging them to practise operating the audio-visual equipment. If this seems beyond them, you may be able to take on this task yourself. They will not seek advice and will deny having received detailed instructions about their presenta- tion. When you ask them how long they expect to speak, you will receive an off-hand response. They will tell you that they have not rehearsed their presentation and will almost certainly go over time. There is little you can do to help such people because they are certain they have everything under control. Prior to the session you must convince them you are serious about cutting them off if they speak over time. Unfortunately this strategy will often fail and you must be prepared to act immediately the first time a speaker goes over the allotted time. If the hint is not immediately taken, you have no option but to politely but firmly stop the speaker. Examples can be cited of such speakers being physically led off the stage still talking, but such extremes should not arise. Fortunately, you will only have to intervene in such a way once in a session and, should it happen, your future as an invited chairperson is assured. Do not allow a questioner to make long statements or commence a mini-presentation of their own work. Suggest any significant differences of opinion be explored informally at the subsequent coffee break. Responsibilities to the audience The audience has a right to expect several things. They must be reassured that you will keep the speakers to time to protect their opportunity to ask questions and to allow them to move to any concurrent sessions. Speakers going over time is the commonest complaint of participants and the chair is usually held to blame. During the question period you should ensure that the time is not monopolised by the intellectual heavies in the front rows. On the other hand you must also be prepared to ask the first question if none is immediately forthcoming from the audience. You may also have been asked to transmit information from the organisers. Particularly important would be to obtain completed evaluation forms for the session if these had been provided. GUIDED READING The book we can still recommend for further reading is J. This pocket-sized do-it-yourself guide is not only valuable but also entertaining. It contains many useful illustrations and good advice about the preparation of visual aids. Race’s Conference Presentations and Workshops, University of Northumbria, 1986 (available through Amazon. Those interested in the organisation and evaluation of medical meetings are referred to a series entitled Improving Medical Meetings, written by D. Richmond and his colleagues, published in the British MedicalJournal (1983), 287, pp.

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