Celebrex

Jacob P Feigal, MD

• Medical Instructor in the Department of Psychiatry and Behavioral Sciences
• Medical Instructor in the Department of Medicine

https://medicine.duke.edu/faculty/jacob-p-feigal-md

However arthritis in neck back and shoulders buy generic celebrex 200 mg on line, Malaysia is one of few countries offering public funding for rare disease treatment arthritis exercise classes discount celebrex 100 mg with visa. Malaysia has a very high rate of newborn screening of rare diseases with more than 95% of newborns being screened arthritis relief knee pain discount celebrex 100mg with amex. Furthermore rheumatoid arthritis tendonitis purchase 200mg celebrex free shipping, Thailand is a top destination for medical tourism arthritis cramps in feet order celebrex 100mg free shipping, with many patients in neighboring Southeast Asian countries opting to receive treatment in private hospitals in Bangkok arthritis in side of neck celebrex 100mg on-line. Thailand currently has no definition of a rare disease and no specific rare disease policies. The Drug Act requires a company to obtain a license in order to import, sell or manufacture drugs in Thailand. According to the Drug Act, for product registration purposes, pharmaceuticals are divided into three categories: (1) new medicines, (2) generics, and (3) new generics. New drugs are classified as products with new chemicals, chemical combinations, indications, delivery systems or dosage forms. New generics include medicines with the same active ingredients, doses and dosage forms as those of new compounds registered after 1992. New generic drug applications will need to include bioequivalence studies in addition to the requirements for a generic drug application. Samples of products on the market are regularly tested at the Medical Sciences Department laboratory. As in the other South East Asian countries, Thailand’s rare disease patients lack both the essential information on their medical conditions and accessibility to orphan drug treatment. Outside of Bangkok, there is a serious shortage of specialists and drugs, meaning that very few patients have access to medication. Imiglucerase was included despite its exorbitant price as Thai authorities estimated that no more than 5 patients would require treatment per year. Health authorities are slowly developing strategies and approaches to support the importation of orphan drugs, such as a fast-track registration process and the importation of certain orphan drugs prior to product registration. More than 200 foreign pharmaceutical companies are registered in Vietnam, making up over 50% of the country’s market share. In an attempt to improve the overall pharmaceutical market in Vietnam, the country’s National Assembly approved a new Pharmaceutical Law which has come into effect on January 1, 2017. The law is intended to help develop the domestic pharmaceutical industry in Vietnam and also address drug pricing, which has been an issue of constant battle between the drug companies and government in Vietnam for a number of years. There is currently no specific orphan drug legislation in Vietnam, although rare disease management was made a priority in the new Pharmaceutical Law. Regulations are frequently implemented on a case-by-case basis, with little overall coordination. Partially-regulated situations, or regulations that are clearly contradictory, are not unheard of. Moreover, it can be difficult to determine what is permitted in Vietnam and what is illegal. Therefore, foreign companies can face numerous challenges when attempting to navigate the pharmaceutical sector in Vietnam. Foreign companies are more likely to succeed in the market when paired up with a company or personnel who have previous experience in this sector. The definition of “pharmaceutical products” is somewhat ambiguous under Vietnamese law. Some product approval processes will also include product sample analysis, though this occurs only in about ten percent of all application processes. The Institute will analyze the sample and compare the results with the Certificate of Analysis included in the registration application. The applicant is responsible for paying the testing fee; the amount depends on the number and complexity of the test(s). In Vietnam, special import approvals can be granted in some cases for non-registered products. The 2001 Regulation on Drug Registration specifically notes, “In special cases (drugs for epidemic and disasters relief and orphan drugs) the sale and consumption of un-registered drugs shall be specifically considered and approved by the Ministry of Health. As in other Southeast Asian countries, patients with rare diseases often do not seek treatment due to local superstitions. In early 2014, one case involved an 11 year old girl with Lyell’s syndrome, a rare skin disorder. The girl’s parents were persuaded by a local fortune teller to leave her in the jungle because “jungle ghosts have eaten her heart and liver, [and] there’s no way to cure her. In the case of an orphan drug, it is essential that a company determine the potential number of patients and consider other important variables such as competing products, product reimbursement and disease awareness. Product registration costs (Is there a distributor in the country that is willing to absorb these costs? While sales are limited under a named-patient program, the drug company is able to introduce the product to patients and establish relationships with doctors. While Asia’s population is large, suggesting the potential for a large number of patients with rare diseases, these populations tend to lie in poor and less advanced areas in the region. Therefore, the development of in-country support and disease awareness is a crucial aspect of the orphan drug marketing process in Asia. It is often beneficial to conduct market research in order to ascertain how other orphan drugs were introduced into the country and how support was established. Some other ways of increasing awareness are as follows: Copyright © 2017 Pacific Bridge Medical. An orphan drug company should be active in increasing awareness and educating the medical community about the disease their drug treats. If your drug is expensive and the majority of patients diagnosed with the disease would not be able to afford treatment, ensure that charitable institutions would be able to provide significant financial support. Generally, expensive drugs are not sold in Southeast Asia if suitable alternatives already exist. However, each Asian country is unique and has a distinctive orphan drug approval process. Developed Asian countries, including Japan, Korea, Taiwan, Singapore and Hong Kong, have had more experience with rare diseases, orphan drugs and reimbursement for such drugs. In contrast, the developing Asian countries, including the Philippines, Malaysia, Thailand and Vietnam, have had less experience with rare diseases or orphan drugs, and generally do not offer public reimbursement. Disclaimer: the information contained in this report is the opinion of Pacific Bridge Medical, a subsidiary of Pacific Bridge, Inc. It is provided for general information purposes only, and does not constitute professional advice. We believe the contents to be true and accurate at the date of writing but can give no assurances or warranties regarding the accuracy, currency, or applicability of any of the contents in relation to specific situations and particular circumstances. Excessive watering (tearing) of the eyes purifed water, sodium hyaluronate, sodium chloride, potassium chloride. Unusual eye secretions calcium chloride, magnesium chloride and. boric acid and is preserved . If a lens appears to be damaged, do not reapply; consult your to moisturize and refresh tired, dry eyes. If the problem stops and the lenses appear to be discomfort, dryness, blurring and itchiness, which may occur while undamaged, follow the “Directions” below, before reapplying the lens. If any of the above occurs, a serious condition such as dryness, discomfort and irritation that may be associated with lens wear infection, corneal ulcer, neovascularization or iritis may be present. Seek and to cushion lenses by placing a drop on the lens prior to application immediate professional identifcation of the problem and obtain treatment, on the eye. It is recommended that contact lens wearers see their eye care Blink Lid Wipes professional once a year or, if directed, more frequently. For in-eye use chamomile, can be used on children and adults for efective removal of only. Test the temperature of the wipe before applying to the conjunctivitis eyelid to make sure it is comfortably warm. Do not use wipe directly on the eye, only on the eyelid and punctal plugs, which may worsen the patient’s dry eye symptoms. Use of the device in patients with these adult patients to capture, archive, manipulate and store digital images of: conditions may cause injury. Advise patients not not instill oil-based ophthalmic trichiasis, severe ptosis) drops. Wait at least four (4) hours after the epithelial defect, Grade 3 corneal fuorescein staining, or map dot instillation of all other ophthalmic drops prior to device use. Advise pateints to not to treatment efectiveness because these conditions may cause ocular swim for at least 12 hours prior to device use. These conditions include disease, dystrophy, trauma, scarring, D, and 2) cylinder: magnitude of the diference is ≤ 0. Severe eye dryness device should not be used because the risk of use clearly outweighs any may delay healing of the fap or interfere with the surface of the eye after beneft. To reduce the risk of corneal ectasia, the posterior and in the creation of a lamellar cut / resection of the cornea for lamellar 250 microns (μm) of corneal stroma should not be violated. If the estimated residual stromal other treatment requiring the creation of corneal channels for placement/ bed is ≤ 320 microns, an in-the-bed pachymetric measurement should insertion of a corneal inlay device. Complications can include corneal iris, descemetocoele with impending corneal rupture, previous corneal edema, epithelial ingrowth, difuse lamellar keratitis, foreign body incisions that might provide a potential space into which the gas produced sensation, and pain. The lens mitigates the efects of presbyopia by providing an and use by or on the order of a physician or other licensed eye care extended depth of focus. For more information on proper wear, care and safety, talk to comparable distance visual acuity. Although rare, serious repositioning should occur as early as possible prior to lens encapsulation. Follow the wear and replacement schedule can increase your risk of getting an eye infection. In addition, only an eye and the lens care instructions provided by your eye doctor. For more information on proper wear, care and safety, talk to is important to talk to your eye doctor about proper wear and care of your eye doctor, call 1-800-843-2020 or download the Patient Instruction your lenses. Consult your eye care practitioner for will determine whether contact lenses are right for you. To help avoid and without vision correction, so even people without a need for vision these problems, follow the wear and replacement schedule and lens care correction can wear them once they complete an eye exam, are properly instructions provided by your eye doctor. Follow the wear and replacement schedule determine if contact lenses are right for you. If your eye doctor has and the lens care instructions provided by your eye doctor. If one of these conditions occurs, eye problems can develop while wearing contact lenses. Once you have your contact lenses, do not wear them if you have an eye infection, or experience eye discomfort, excessive tearing, vision changes, redness or other eye problems. If you share the same lenses, it can increase your risk of getting an eye infection. In addition, only an eye doctor can determine if the lenses are right for your friend. For more information on proper wear, care and safety, talk to your eye doctor, call 1-800-843-2020 or download the Patient Instruction Guides. This new edition updates the chemical and biological guidance given in the 2006 edition and adds additional material on a range of new and emerging threats in these areas. Additional materials have also been included concerning the health protection elements of response to mass casualty incidents including hearing loss, blood-borne virus transmission, antibiotic prophylaxis for bomb injury wounds and screening for cognitive impairment. The audience for this publication remains to be frst responders, emergency departments and public health and health protection professionals. We have retained the system of keeping the disease, syndrome, or agent specifc advice sheets as being capable of being used as standalone items that can be printed out and used to inform staff responding to identifed threats. This publication is the product of the advice and guidance offered by very many colleagues from the United Kingdom’s National Health Service, Defence Medical Services, and Public Health England. The editors and principal authors wish to thank all of these colleagues, too numerous to list individually, for all their help and support. Casualties should ideally be decontaminated at the scene, but it should be expected that contaminated casualties may also self-present to emergency department. Prompt decontamination after chemical exposure is needed if caustic or irritating injuries are present, or organophosphate (nerve agent) poisoning is suspected. In a radiation incident, treat and stabilise life-threatening injury before decontamination Be alert to the unusual, the unexpected, and the unexplained – and if in doubt, seek expert advice. Undressing should be systematic and consistent with the steps outlined in the disrobe procedure. Consideration must be given to ensuring the welfare and dignity of casualties as far as possible. Improvised decontamination: Improvised decontamination is the use of an immediately available method of decontamination. Training in basic infection control and local policies should be provided as part of your orientation or induction. If you are in doubt about any aspect of infection control, or need training, seek help from your infection control team. Infection control methods are used to prevent contact, droplet and aerosol transmission. Any high consequence infectious diseases spread by droplet or aerosol routes should preferably be assessed initially at a designated infectious disease assessment centre where available. Standard precautions – prevention of contact transmission Practice good basic hygiene with regular hand cleaning. Wear gloves (single use disposable vinyl or nitrile) for: all invasive procedures; contact with sterile sites (including wound care and dressing changes); contact with mucous membranes, and all tasks assessed as carrying a risk of exposure to patients’ blood or body fuids.

Diseases

• Hemangioblastoma
• Biliary malformation renal tubular insufficiency
• Seminoma
• Anencephaly spina bifida X linked
• Encephalomyelitis, myalgic
• Gonzales Del Angel syndrome
• Continuous muscle fiber activity hereditary
• Potter sequence cleft cardiopathy

In addition to registering if you have some kind of specialist support from other professionals or rating systems adapted to a formal integration plan arthritis neck pain treatment buy online celebrex. It is essential to know what furniture you use and the ease or difficulty about this in relation to the sitting posture and upper extremity function arthritis pain in your 30 buy celebrex 200mg online, considering always recording the specific adaptations necessary for the implementation of homework how to improve arthritis in feet purchase cheapest celebrex. It is very important to consider the level of accessibility offered by the educational establishment as well arthritis in the knee in horses order 200mg celebrex free shipping. For this it is necessary to work with different sensory and motor skills that promote learning rheumatoid arthritis big toe best 200 mg celebrex, relearning and improving motor patterns arthritis pain cycle order celebrex 200mg overnight delivery, achieving a better postural adjustment, a more appropriate speed, better directionality and fluidity of movement in relation to the body and different levels in space (Bobath, 2000; Gracies, 1997; Rannie, 2000; Rodríguez, 2011; Rodríguez, et. The lines of treatment can be projected after having clarity about the degree of functional compromise and also knowing the family and social context, which is achieved after a comprehensive evaluation and in conjunction and together with the child and family. This treatment information is projected mainly through frameworks that include sensory stimulation (tactile, propioceptive and vestibular) (Ayres, 2006), neuro-developmental (Bobath, 2000) framework (facilitation based on sequences and normal movement patterns) and rehabilitation framework (to facilitate posture, functionality and independence through activities and elements such as therapeutic aids, orthotics and adjustments) (Creapeac, 2005). Below you can find a description of the therapeutic management used according to the age of the children, the degree of motor impairment and comprehensive level. Children with severe generalized dystonia present difficulties in establishing contact with the environment and/or have cognitive impairments obstruct the understanding of simple instructions. These children will be addressed as multi deficit where the emphasis of the therapeutic management will be placed in relation to family child care. Children with generalized dystonia with moderate motor impairment present a comprehensive level enough to follow simple instructions; this group of children will be described by two distinct age groups, involving them as active participants in the rehabilitation process, with emphasis on motor control and overall functional performance. The more detailed description will be in this group, as we understand that is requiring more therapeutic intervention, highlighting the potential gains to obtain from the functional performance. Children with mild motor impairment and a high level of understanding will be addressed in two separate age groups. This is because the therapeutic action contemplates an intervention plan focused on facilitating normal development and functional performance appropriate to the age and context of the child. Children with a severe motor impairment with a good understanding will also be addressed in two age groups. There are no major changes expected in terms of functional capacity and postural control in short periods of time for this group of children, being important for these cases to enhance the function and prevent complications. It should be considered across the board that in children with a good understanding, the treatment should emphasize the identification of aspects that contribute to optimize the function of the child. It is also important to suggest to the family the self management of aspects that can facilitate the improvement of the child’s performance, such as furniture, or adaptations that optimizes the child’s performance. Ages 0 to 6 year this group of children will benefit from models such as neurodevelopmental and sensory integration, cognitive and behavioral rehabilitation. The intervention aims to normalize psychomotor development facilitating movement sequences and patterns in a more organized, automatic, economical way with a better voluntary control. In this range of age, gross and fine motor demands become more complex and therefore require more postural control to prevent and reduce functional bindings and decrease involuntary movements. Along with this, the sensory aspect is reinforced to provide better input to these stimuli, facilitating the integration and maturation of the systems involved, promoting a favorable adaptive response. Activities are conducted using vestibular and propioceptive sensations and promoting the development of righting and equilibrium reactions, with synergies to promote the organization of movement in relation to body and space (Ayres, 2006). It is also important to generate patterns of controlled and rhythmic breathing, as this has great impact on the voluntary control of movements and spoken language. At this stage, play is the main occupation of the child, which develops through social, emotional, cognitive, sensory, and motor functions. From this, it is essential that play is constantly referred to within the therapeutic activity and according to the therapy goals. Games should also be selected according to the abilities and interests of children, looking to present interesting challenges in order to promote the interest necessary to generate action. The relevance is focused in one punctual aspect: learning will occur to the extent that the activity has both significance and success for the child (Maturana, 2007). Some children will require external support such as furniture, orthotic or adaptation, but these are mostly transitory. In relation to postural control: the child that has interest and contact with the environment initiates movements to go out against gravity spontaneously, developing near-normal patterns. Progressively the child should be dominating higher positions and perform activities according to age. The therapist must accompany this process based on the sequences of normal development, safeguarding that the child does not use fixed resources by setting in abnormal postural patterns learned as functional. Treatment should be focused on correct and facilitate normal motor chain repetition reinforced by activities that bring success in a functional way. From a sensory point of view, treatment should include propioceptive and vestibular elements in order to stimulate the harmonious development of the movements. It is important to address the sitting posture as this is often used for play and influence the stability of hand function. If the child is seated early you may have the need for proximal postural fixation to stabilize the pelvis and trunk, making the transfer of weight and the degrees of freedom more difficult, limiting the possibility of developing movements in different planes which establish harmonic synergy for space exploration. In relation to the role of hands: the function of the hands is largely determined by a stable axial and proximal control, reason why it should be offered a work setting that provide adequate support for the position and sensory registration. In relation to the development of grips you can see a greater mastery of the gross grips, making it difficult or delayed acquisition of fine grips and digital dissociation. To promote the sound development, the child should experience tactile and propioceptive sensation in different games in two motor ways, globally and manipulative. This provides information on weight, texture, shape and size, which determines the progressive development of manual skills necessary for a variety of grasps, dissociated intermediate ranges and movements that will facilitate the execution of increasingly complex tasks according to age of development. The need of proximal fixation to reach stability and distal control needs to be avoided. This fixation reduces the degree of freedom of movement in space of upper extremities. Therefore, it is recommended that activities involving the use of hands are performed in a sitting position. The sitting position should include a stable chair with a rigid seat base and a table with cutout appropriate to the child’s size in order to provide stability to the forearms. For this age group and level it is suggested to postpone the use of orthotics in order to facilitate normal development. Be mindful not to encourage postural proximal fixation, but provide stability and assistance with some element of temporary external support. In relation to the activities of daily living: To carry out these tasks it should be considered to place the child in a stable position that allows him to have better resources to perform these activities. It is important that the family favors the development of activities as self-feeding, hygiene and clothing according to their age and thereafter provide environmental support with elements or adaptations to facilitate appropriate and successful implementation. Do not lose of sight that the difficulties in proximal stability and involuntary movements require to modify the pattern and sequence of execution to accomplish the task, since most of the movements’ performed to do these tasks require to go out against gravity which increases involuntary movements. It is suggested that during feeding, forearms are flat on a surface permanently; preventing that the elbow loses contact with the surface, thereby decreasing the involuntary movements. Along with this, if necessary, provide a thickened spoon and always give an indication of moving the head toward the spoon. In these activities the child may need adult assistance or elements that give stability to the plate like an antiskid or an adapted tray. As for hygiene and clothing the child must be an active participant in this routine, to internalize and reinforce appropriate sequences and energy efficiency. It is important to remember the age appropriate tasks watching runtimes to support achievement in the everyday as functional. Also you need to consider the necessary changes in terms of access, items available in the space, utensils and/or some element of temporary or permanent support or adaptation to facilitate the task. In this age self-care activities take on greater relevance with the gain of progressive independence in regards to the activities of basic daily life (Mulligan, 2006). In relation to school activities: It is recommended that this group of children start their schooling in regular school system of selection. Sometimes you need professional support to adapt specific elements related to specific subjects and tasks that require more accuracy or quality of execution. It may also be useful to assess if the furniture provides suitable positions favoring a proper execution of tasks, offering suggestions when necessary. Ages 6 and older Treatment in this group has a profile of progressively making a difference in the development of autonomy, independence and community involvement. After 12 years of age, the self-management of elements of support that foster a better occupational performance are well established. Dystonia and Rehabilitation in Children 127 In relation to the position: At this point it is important to constantly reassess all aspects of the postural adjustment because as growth implies a reorganization of motor schemes, were compensations or patterns may appear abnormal but, in most cases these are temporary. It must be safeguarded that these are not made permanent, damaging in a long-term the postural control and functional performance. In relation to hand function: Insofar as the child progresses through the school system, increasing demands will require greater demands on the quality and speed of execution, which could lead to a decrease in occupational performance, “both given” by the more demanding task and the stress. Assess and define strategies to optimize performance and in some cases it might be required the use of accommodations, furniture and technical assistance. The possible difficulties that might occur should be evaluated and corrected to avoid a significant detriment to the functional performance that has already being achieved. In periods of high growth they may become unstable, so it is recommended to reevaluate constants gait pattern to intervene therapeutically if the case requires so. In relation to activities of daily living: A child this age should increase the autonomy and independence according to age levels in activities of basic daily life, expanding progressively toward the instrumental activities. It must be constantly evaluated to decrease the third-party assistance, providing accommodations or modifications conducive to the attainment of independence. In the instrumental activities daily living it is suggested to increase tasks and responsibilities of intra domiciliary in addition to provide spaces for an active community participation, including documents management, money use, transportation and occupational activities, all age appropriate. In some cases these activities require therapeutic support and training to habituation, as well as to provide strategies, social skills and safety for a satisfactory performance. In relation to school activities: At this point they may demonstrate difficulties in relation to the time of execution, specifically in terms of writing. It is suggested to check if the furniture and tools are providing stability to optimize performance. In many cases, it is required to use support systems or alternative technologies that facilitate the execution of the task. Children older than twelve years should be identifying skills and interests to focus on alternative vocational and employment preferences that must be consistent with the real possibilities of the young. Ages 0 to 6 year this group of children presents clinical signs that can be seen early by a professional in the area. Treatment should be approached from models such as neurodevelopmental, sensory integration, behavioral and cognitive rehabilitation. From early stages when the child tries out against gravity, compensation and abnormal patterns emerge in response to the lack of control and axial synergies. In some cases we observe prolonged primitive reflexes that can be used as a functional resource, transforming it into a learned pattern that is pathological. It becomes important that the development of low postures should take special care and attention as it is on this stage when they begin to strengthen postural and proximal fixation. Managing the child that is less than one year old provides a postural control with elements or implements that help the organization in space, is important to achieve synergies and midline line which are precursors of visual monitoring and of the use of hands. In children over one year, in addition to the above, it begins to favor the functional activity of higher positions such as sitting and bipedal. Parallel to this, it is important to provide vestibular and propioceptive sensory input to enhance and promote afferential information to organize properly a functional motor and adaptive response. Efforts must be placed on patterns of controlled and rhythmic breathing to organize movements to facilitate and promote oral language. In the early stages this work is suggested by the mother who provides rhythmic breathing patterns, after this, the child should work this voluntarily or therapy could help to increase the quality of movement. In children older than three years, gross and fine motor demands become more complex, so the chances of feeling frustration or anxiety increases, making even more difficult the control of movement. This requires special attention when treating and choosing the activity and postural control support which needs to be both static and dynamic. Play and school activities are the main occupation of the child, which develops through social, emotional, cognitive, sensory and motor functions. The therapist must reconcile this with the selected therapeutic activity, not to mention that an activity generates significant and successful learning. Also at this stage the child enters a school system, which sometimes requires guidance or counseling in handling furniture and specific elements of technical assistance. In relation to postural control: In the early stages environmental elements must be conducive to proper posture and the ability to explore spontaneously. Supine flexion should be favored, using elements of containment that provide slight bend of the head and pelvis in order to provide a midline upper extremities, visual and abdominal activity. In prone, use a wedge to allow the right use of forearms or arm support on the surface to weight bearing and allow synergies of shoulder girdle, neck and head. Avoid a pattern of abnormal extension or hyperextension of the neck to be a precursor to every action. Often when turning there is a tendency to one side only and initiated from the head in hyperextension. In this case it will be necessary to facilitate synergies and dissociation in lateral planes. Dystonia and Rehabilitation in Children 129 In managing the sitting posture observe if the overall patterns are initiated from the head and/or pelvis, as this will be a critical control point to consider for the functional use of this position. In the case that the movement originates at the head, descending tactile and propioceptive information must be submitted in the sterna, to stimulate flexor muscles. In the event of involuntary movement generated in the pelvis, hip flexion facilitated greater than 90 degrees is required, in order to shift the weight to this area and reduce the chances of making an involuntary extensor pattern.

Both studies involved the same 14 clinical sites and same group of ophthalmologists arthritis pain and inflammation order celebrex 200 mg without prescription. It appears also that there could be an overlap of the patients participating in the two studies rheumatoid arthritis wrist brace celebrex 200 mg sale. The published case series with the larger population size was selected for critical appraisal rheumatoid arthritis gloves 100 mg celebrex fast delivery. Canaloplasty: Circumferential viscodilation and tensioning of Schlemm’s canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults healing arthritis with diet purchase celebrex 100 mg free shipping. The only published studies were 2 relatively small case series arthritis knee pain in dogs buy celebrex amex, conducted in the same centers by the same study group rheumatoid arthritis elbow order celebrex pills in toronto, and possibly with a population overlap. Lewis and colleagues, reported on the one and two-year interim results of canaloplasty with or without corneal phacoemulsification cataract surgery, and Shingleton et al (2008) reported on the results of a subgroup that underwent the two procedures. In their first publication, Lewis and colleagues (2007) reported the one-year interim results of canaloplasty performed on 94 patients with open-angle glaucoma, and in their 2009 publication they reported on the results of the procedure among 127 patients. Back to Top Date Sent: 3/24/2020 186 these criteria do not imply or guarantee approval. Conclusion: There is insufficient evidence to determine that canaloplasty is better than or equivalent to medical treatment in reducing intraocular pressure in adult patients with open angle glaucoma. There is insufficient evidence to determine that canaloplasty is better than or equivalent to filtration surgical procedures as trabeculectomy in reducing intraocular pressure in adult patients with open angle glaucoma. There is insufficient evidence to determine that canaloplasty is safer than filtration surgical interventions as trabeculectomy. No randomized or nonrandomized controlled trials comparing canaloplasty to another treatment or intervention were identified. The use of canaloplasty in the treatment of primary open-angle glaucoma does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 3/24/2020 187 these criteria do not imply or guarantee approval. However, on an individual member basis, Kaiser Permanente and share a copy of the specific criteria document used to make a utilization management decision. Last 12 months of clinical notes from requesting provider &/or specialist (gastroenterology). Most recent lab works Patency Capsule There is insufficient evidence in the published medical literature to show that this service/therapy is as safe as standard services/therapies and/or provides better long-term outcomes than current standard services/therapies. It isBack to Top provided for historical purposes and does not necessarily reflect the most current published literature. Enteroscopy, evaluation of the small bowel, is indicated in many of these patients. Push enteroscopy, sonde enteroscopy and intraoperative enteroscopy are commonly used options. Push enteroscopy is relatively easy to perform but is limited by its inability to examine beyond the mid to distal jejunum in most patients. Sonde-type enteroscopes are longer than push enteroscopes and in some cases can examine as far as the terminal ileum. Disadvantages include long procedure times and a steep learning curve to master the technique. However, this is an invasive procedure that requires a laparotomy (Adrain and Kversky, 1996). It is swallowed by the patient and, as it moves through the digestive tract, it transmits video signals which are stored in a recorder attached to the patient’s belt. The M2A moves through the digestive tract with the aid of peristalsis and is then excreted normally by the patient. At that time there were no studies of health outcomes and no data on patients with unexplained chronic gastrointestinal blood loss. It is most commonly secondary to chronic occult bleeding from the gastrointestinal tract and is one of the common reasons for referral to gastroenterology clinics (Apostolopoulos 2006, Killip 2007). Occult blood loss, on the other hand, is subtle and may only present as iron deficiency anemia or as a positive fecal occult blood test (Triester 2005, Concha 2007, Estevez 2006). Evaluation of the small bowel by conventional endoscopy has the advantage of allowing for intervention if the bleeding site is identified, but may be difficult due to the length, motility, tortuosity, looping, and free hanging course of the small bowel. Enteroscopy is an extension of an upper endoscopy where a longer endoscope that reaches down to the ileum is used. There are different types of enteroscopes including the push type and the sonde-type. Push enteroscopy allows the evaluation of the jejunal mucosa up to 150 cm beyond the ligament of Trietz; however, it is an invasive procedure that requires deep sedation or anesthesia, has a variable diagnostic yield (38-75%), and does not explore lesions in the ileum. The balloons grip the intestinal wall allowing further insertion of the scope and the examination of larger areas of the small bowel reaching up to 300 cm in the oral direction. Back to Top Date Sent: 3/24/2020 189 these criteria do not imply or guarantee approval. Laparotomy with intraoperative enteroscopy is used after all other techniques fail to detect the source of bleeding, when there are adhesions that require lysis via a laparoscopic approach, or and when the risk of bleeding exceeds the risk of the procedure. It is considered the gold standard for a complete endoscopic evaluation of the small bowel. However, intraoperative endoscopy is invasive, risky, and may cause artifacts that could be falsely identified as the cause of bleeding. Moreover, it was reported that intraoperative endoscopy can examine only 50 80% of the small bowel and detect the source of bleeding in up to 40% of undiagnosed cases (Mitchell 2004). Capsule endoscopy (M2A video capsule endoscope, Given Imaging Ltd, Yoqneam, Israel) was introduced in 2001 as a noninvasive direct endoscopic technique for visualization of the small bowel. It is a swallowable wireless capsule endoscope 26 mm in length and 11 mm in diameter. The device consists of an optical dome, 4 light emitting electrodes, a sensor, 2 batteries, and a micro transmitter. The capsule acquires and transmits digital images at the rate of 2/second to a sensory array attached to the patient’s abdomen. It is able to capture video images of the mucosal surface of the entire length of the small intestine directly for 7-8 hours. The images can be downloaded from the recorder to a computer workstation with special software (Hara 2005, Eliakim 2007). However, it lacks the ability to obtain a tissue sample for biopsy, deliver therapy, or treat pathology when it is found. In addition, it was reported that some lesions could be missed due to rapid or delayed small bowel transit. It might also be difficult to identify the precise location of the pathology when it is discovered. Unlike endoscopy, the lesion cannot be washed, and re-examined, and large amounts of intraluminal bile could be mistaken for blood. Interpretation of the small bowel images is highly subjective, and the potential inter-observer variation may compromise the reliability and accuracy of the technology. Moreover, some investigators have reported that the quality of the images taken by the capsule was not satisfactory, and that the duodenum was not effectively visualized. The 8 hour-battery life of the capsule is estimated to be enough time for 85% of the patients to image the entire small intestine. The major potential complication with capsule endoscopy is the risk of capsule retention due to stenosis, stricture, diverticulum, or fistula. The documented incidence of entrapment is 1%, however a retained capsule may potentially lead to intestinal obstruction, and its retrieval may necessitate surgical extraction (Concha 2007, Mazzarola 2007, Enns 2007). The most common application for capsule endoscopy is the evaluation of obscure gastrointestinal bleeding. The second most studied indication is the evaluation of suspected Crohn’s disease. It is also being used to detect polyps, cancers, other causes of chronic inflammation, bleeding, and anemia. Capsule endoscopy is contraindicated in patients with intestinal blockage, strictures or fistulas, pregnant women, patients with swallowing disorders, or those with a cardiac pacemaker or other implanted electromagnetic devices. Patency Capsule the capsule endoscopy is relatively noninvasive, easy to perform, well tolerated, and has a low incidence of complications. The most worrisome complication is capsule retention due to stenosis, stricture, diverticulum, or fistula. Overall, the documented incidence of capsule retention or entrapment is as low as 1% but may be higher in some population at risk. Studies reported retention rates of 5-13% in patients with known Crohn’s disease, and a rate of 21% in suspected bowel obstruction. A retained or impacted capsule may potentially lead to small bowel ileus, intestinal obstruction, or fragmentation of the capsule with potential toxic hazard. Retrieval of a retained capsule requires medical, endoscopic or surgical intervention (Sears 2004, Signorelli 2006, Concha 2007, Enns 2007, Caunedo-Alvarez 2008). Back to Top Date Sent: 3/24/2020 190 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History Due to the risk of capsule retention, wireless capsule endoscopy is contraindicated in patients with suspected small bowel strictures. In most centers, a radiographic evaluation of the small bowel patency is mandatory before performing a wireless capsule endoscopy in patients with a risk of small bowel strictures. They can identify long or medium stenosis with great reduction in their lumen size but may not detect a short intestinal stenosis or obstruction, leading to false negative results (Boivin 2005, Caunedo-Alvarez 2008, Karagiannis 2009). The body is coated with an impermeable cellophane membrane with two wax timer plugs located at each end of the capsule. If there is any kind of stricture hindering its passage for more than 30 hours, the patency capsule starts to disintegrate (except for the identification tag), allowing the insoluble outer membrane to collapse and be excreted deformed or in fragments. It is reported that the Given patency capsule may provide direct evidence of functional patency of the gut lumen, even in those patients showing radiological evidence of small bowel stricture. This information may allow a distinction between rigid fibrotic strictures and flexible ones (Spada 2005, Karagiannis 2009). One of these was a historical piece, one was a letter to the editor describing the use of the technology with 4 cases. There were no studies of health outcomes and no data on patients with unexplained chronic gastrointestinal blood loss. In addition to the studies found on Medline, there were several published abstracts in the Given Imaging reference list. The use of M2A™ (Given Imaging) capsule in the diagnosis of small bowel lesions/chronic bleed sites does not meet the Kaiser Permanent Medical Technology Assessment Criteria 2 for effectiveness. The studies did not use the gold standard evaluation tool, an invasive surgical procedure, so diagnostic accuracy. The ideal study would be an independent, blind comparison of M2A and a gold standard diagnostic test. Back to Top Date Sent: 3/24/2020 191 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History evaluation with push enteroscopy and none of the studies included evaluation with intraoperative enteroscopy, the invasive “gold standard” procedure. The primary outcome in each study was diagnostic yield (the ability to diagnose the source of bleeding) of the two procedures. Results of the studies were similar; all found a higher rate of diagnostic yield with the M2A. Findings were statistically significant in 4 of the 5 studies and did not reach statistical significance in the smallest study. The two largest studies (n=52, n=60) were critically appraised: Mylonaki M, Fritscher-Ravens A, Swain P. Wireless capsule endoscopy: a comparison with push enteroscopy in patients with gastroscopy and colonoscopy negative gastrointestinal bleeding. Diagnostic value of endoscopic capsule in patients with obscure digestive bleeding: Blinded comparison with video push-enteroscopy. See Evidence Table the use of M2A™ (Given Imaging) capsule in the diagnosis of small bowel lesions/chronic bleed sites does meet the Kaiser Permanente Medical Technology Assessment Criteria for effectiveness. Triester’s meta-analysis included studies either published in full or in the abstract form. Hartmann and colleagues’ 2005, study (not included in the meta-analysis) compared capsule endoscopy to the gold standard of intraoperative enteroscopy. This was a highly selected group of patients which may limit generalization of the results. Impact of capsule endoscopy on patient management: the published studies, to date, on the influence of capsule endoscopy on patient management included highly selected groups of patients with wide variations in their baseline characteristics as age, indication of endoscopy, duration of bleeding, number and type of previous investigations undergone, as well as others variables. In addition, the investigators used different diagnostic criteria for the identification of the bleeding pathology, as reflected in the wide range of diagnostic yield. Thus, the published studies with their potential biases and confounding factors, and with the lack of randomized controlled trials, do not provide sufficient evidence to determine that capsule endoscopy would lead to any incremental improvement in the management of patients. The therapies and interventions received by the patients were not standardized and varied between studies. Patients were treated with medical, endoscopic or surgical interventions and complete resolution of bleeding was achieved in 40-85% of cases. This varied according to study, eligibility criteria, patient characteristics, bleeding condition, condition, and treatment received. Randomized controlled trials with long-term follow-up periods are needed to determine the effect of capsule endoscopy on patient management and outcomes. Diagnostic accuracy: There were three meta-analyses (Triester 2005, Triester 2006, and © 2001 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 192 these criteria do not imply or guarantee approval. Diagnostic/therapeutic impact: Articles: the literature search identified several prospective studies on the influence of capsule endoscopy on management decisions and/or treatment outcomes. A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.

Centrally acting β-blockers such as propranolol may also be helpful reversing arthritis in neck discount 200mg celebrex, as may anticholinergic agents arthritis in the feet pictures order celebrex 100 mg, amantadine arthritis swelling feet and ankles discount 200 mg celebrex free shipping, clonazepam arthritis in the back exercises safe celebrex 200 mg, and clonidine arthritis pills for dogs proven celebrex 200mg. Cross References Parkinsonism; Tasikinesia; Tic Akinesia Akinesia is a lack of arthritis upper back exercises discount 100 mg celebrex free shipping, or an inability to initiate, voluntary movements. More usually in clinical practice there is a difficulty (reduction, delay), rather than com plete inability, in the initiation of voluntary movement, perhaps better termed bradykinesia, or reduced amplitude of movement or hypokinesia. These diffi culties cannot be attributed to motor unit or pyramidal system dysfunction. Akinesia may coexist with any of the other clinical features of extrapyramidal system disease, particularly rigidity, but the presence of akinesia is regarded as an absolute requirement for the diagnosis of parkinsonism. Hemiakinesia may be a feature of motor neglect of one side of the body (possibly a motor equivalent of sensory extinction). Bilateral akinesia with mutism (akinetic mutism) may occur if pathology is bilateral. Pure akinesia, without rigidity or tremor, may occur: if levodopa-responsive, this is usually due to Parkinson’s disease; if levodopa unresponsive, it may be the harbinger of progressive supranuclear palsy. Neurophysiologically, akinesia is associated with loss of dopamine projec tions from the substantia nigra to the putamen. Parkinson’s disease, progressive supranuclear palsy (Steele–Richardson–Olszewski syndrome), and multiple system atrophy (striatonigral degeneration); akinesia may occur in frontotemporal lobar degeneration syndromes, Alzheimer’s disease, and some prion diseases;. However, many parkinsonian/akinetic-rigid syndromes show no or only partial response to these agents. Cross References Akinetic mutism; Bradykinesia; Extinction; Frontal lobe syndromes; Hemiakinesia; Hypokinesia; Hypometria; Kinesis paradoxica; Neglect; Parkinsonism Akinetic Mutism Akinetic mutism is a ‘syndrome of negatives’, characterized by a lack of vol untary movement (akinesia), absence of speech (mutism), and lack of response to question and command, but with normal alertness and sleep–wake cycles (cf. Frontal release signs, such as grasping and sucking, may be present, as may double inconti nence, but there is a relative paucity of upper motor neurone signs affecting either side of the body, suggesting relatively preserved descending pathways. Akinetic mutism represents an extreme form of abulia, hence sometimes referred to as abulia major. Pathologically, akinetic mutism is associated with bilateral lesions of the ‘centromedial core’ of the brain interrupting reticular-cortical or limbic-cortical pathways but which spare corticospinal pathways; this may occur at any point from frontal lobes to brainstem. Frontodiencephalic: associated with bilateral occlusion of the anterior cere bral arteries or with haemorrhage and vasospasm from anterior communi cating artery aneurysms; damage to the cingulate gyri appears crucial but not sufficient for this syndrome. Pathology may be vascular, neoplastic, or structural (subacute communicating hydrocephalus), and evident on structural brain imaging. Akinetic mutism may be the final state common to the end-stages of a number of neurodegenerative pathologies. Akinetic mutism from hypothalamic damage: successful treatment with dopamine agonists. This sta tokinetic dissociation may be known as Riddoch’s phenomenon; the syndrome may also be called cerebral visual motion blindness. Such cases, although excep tionally rare, suggest a distinct neuroanatomical substrate for movement vision, as do cases in which motion vision is selectively spared in a scotomatous area (Riddoch’s syndrome). Cross References Acalculia; Aphasia; Riddoch’s phenomenon Alalia Alalia is now an obsolete term, once used to describe a disorder of the mate rial transformation of ideas into sounds. Stendhal’s aphasic spells: the first report of transient ischemic attacks followed by stroke. Cross References Aphasia; Aphemia Alexia Alexia is an acquired disorder of reading. The word dyslexia, though in some ways equivalent, is often used to denote a range of disorders in people who fail to develop normal reading skills in childhood. Peripheral: A defect of perception or decoding the visual stimulus (written script); other language functions are often intact. Patients lose the ability to recognize written words quickly and easily; they seem unable to process all the elements of a written word in parallel. They can still access meaning but adopt a laborious letter-by-letter strategy for reading, with a marked word length effect. Patients with pure alexia may be able to identify and name individual letters, but some cannot manage even this (‘global alexia’). Alexia without agraphia often coexists with a right homonymous hemianopia, and colour anomia or impaired colour perception (achromatopsia); this latter may be restricted to one hemifield, classically right-sided (hemiachromatopsia). Pure alexia has been characterized by some authors as a limited form of associative visual agnosia or ventral simultanagnosia. Patients tend to be slower with text than single words as they cannot plan rightward reading saccades. The various forms of peripheral alexia may coexist; following a stroke, patients may present with global alexia which evolves to a pure alexia over the following weeks. Pure alexia is caused by damage to the left occipitotemporal junction, its afferents from early mesial visual areas, or its efferents to the medial temporal lobe. Global alexia usually occurs when there is additional damage to the splenium or white matter above the occipital horn of the lateral ventricle. Hemianopic alexia is usually associated with infarction in the territory of the posterior cerebral artery damaging geniculostriate fibres or area V1 itself, but can be caused by any lesion outside the occipital lobe that causes a macular splitting homonymous field defect. Neglect alexia is usually caused by occipitoparietal lesions, right-sided lesions causing left neglect alexia. Alexia with aphasia: Patients with aphasia often have coexistent difficulties with reading (reading aloud and/or comprehending written text) and writing (alexia with agraphia, such patients may have a complete or partial Gerstmann -16 Alexithymia A syndrome, the so-called third alexia of Benson). The reading prob lem parallels the language problem; thus in Broca’s aphasia reading is laboured with particular problems in reading function words (of, at) and verb inflections (-ing, -ed); in Wernicke’s aphasia numerous paraphasic errors are made. From the linguistic viewpoint, different types of paralexia (substitution in reading) may be distinguished: Surface dyslexia: Reading by sound: there are regularization errors with exception words. The term transcortical alexia has been used to describe patients with Alzheimer’s disease with severe comprehension deficits who nonetheless are able to read aloud virtually without error all regular and exception words. Cross References Acalculia; Achromatopsia; Agnosia; Agraphia; Aphasia; Broca’s aphasia; Gerstmann syndrome; Hemianopia; Macula sparing, Macula splitting; Neglect; Prosopagnosia; Saccades; Simultanagnosia; Visual agnosia; Visual field defects; Wernicke’s aphasia Alexithymia Alexithymia is a reduced ability to identify and express ones feelings. It may be measured -17 A ‘Alice in Wonderland’ Syndrome using the Toronto Alexithymia Score. There is evidence from functional imag ing studies that alexithymics process facial expressions differently from normals, leading to the suggestion that this contributes to disordered affect regulation. Alexithymia is a common finding in split-brain patients, perhaps resulting from disconnection of the hemispheres. Alexithymia: an experi mental study of cerebral commissurotomy patients and normal control subjects. It has subsequently been suggested that Charles Lutwidge Dodgson’s own experience of migraine, recorded in his diaries, may have given rise to Lewis Carroll’s descriptions of Alice’s changes in body form, graphically illustrated in Alice’s Adventures in Wonderland (1865) by Sir John Tenniel. Some authors have subsequently interpreted these as somes thetic migrainous auras whereas others challenge this on chronological grounds, finding no evidence in Dodgson’s diaries for the onset of migraine until after he had written the Alice books. Moreover, migraine with somesthetic auras is rare, and Dodgson’s diaries have no report of migraine-associated body image hallucinations. Other conditions may also give rise to the phenomena of microsomatognosia or macrosomatognosia, including epilepsy, encephalitis, cerebral mass lesions, schizophrenia, and drug intoxication. Alien Grasp Reflex the term alien grasp reflex has been used to describe a grasp reflex occurring in full consciousness, which the patient could anticipate but perceived as alien. These phenomena were associated with an intrinsic tumour of the right (non-dominant) frontal lobe. It was suggested that the grasp reflex and alien hand syndromes are not separate entities but part of the spectrum of frontal lobe dysfunction, the term ‘alien grasp reflex’ attempting to emphasize the overlap. Cross References Alien hand, Alien limb; Grasp reflex Alien Hand, Alien Limb An alien limb, most usually the arm but occasionally the leg, is one which man ifests slow, involuntary, wandering (levitating), quasi-purposive movements. An arm so affected may show apraxic difficulties in performing even the simplest tasks and may be described by the patient as uncooperative or ‘having a mind of its own’ (hence alternative names such as anarchic hand sign, le main étranger, and ‘Dr Strangelove syndrome’). These phenomena are often associated with a prominent grasp reflex, forced groping, intermanual conflict, and magnetic move ments of the hand. Different types of alien hand have been described, reflecting the differing anatomical locations of underlying lesions: Anterior or motor types: Callosal type: characterized primarily by intermanual conflict. Frontal type: shows features of environmental dependency, such as forced grasping and groping, and utilization behaviour. A paroxysmal alien hand has been described, probably related to seizures of frontomedial origin. Functional imaging studies in corticobasal degeneration, along with the evi dence from focal vascular lesions, suggest that damage to and/or hypometabolism of the medial frontal cortex (Brodmann area 32) and the supplementary motor area (Brodmann area 6) is associated with alien limb phenomena. More gen erally, it seems that these areas are involved in the execution of learned motor programs, and damage thereto may lead to the release of learned motor programs from voluntary control. Cross References Alien grasp reflex; Apraxia; Ataxia; ‘Compulsive grasping hand’; Forced groping; Grasp reflex; Intermanual conflict; Levitation; Magnetic movements; Utilization behaviour Alienation Du Mot A loss of the feeling of familiarity with a word, part of the comprehension deficit seen in semantic dementia. Slowly progressive aphasia in three patients: the problem of accompanying neuropsychological deficit. Alloacousia Alloacousia describes a form of auditory neglect seen in patients with unilateral spatial neglect, characterized by spontaneous ignoring of people addressing the patient from the contralesional side, failing to respond to questions, or answering as if the speaker were on the ipsilesional side. Cross Reference Neglect Alloaesthesia Alloaesthesia (allesthesia, alloesthesia) is the condition in which a sensory stim ulus given to one side of the body is perceived at the corresponding area on the other side of the body after a delay of about half a second. The trunk and proximal limbs are affected more often than the face or distal limbs. Visual alloaesthesia, the illusory transposition of an object seen in one visual field to the contralateral visual field, is also described, for example in ‘top of the basi lar’ syndrome or with occipital lobe tumours. Tactile alloaesthesia may be seen in the acute stage of right putaminal haemorrhage (but seldom in right thalamic haemorrhage) and occasionally with anterolateral spinal cord lesions. The author has seen a patient report sensation below the stump of an amputated leg follow ing stimulation of the contralateral remaining leg, a phenomenon which might be termed ‘phantom alloaesthesia’. The mechanism of alloaesthesia is uncertain: some 20 Allodynia A consider it a disturbance within sensory pathways, others consider that it is a sensory response to neglect. Cross References Allochiria; Allokinesia, Allokinesis; Neglect Allochiria Allochiria is the mislocation of sensory stimuli to the corresponding half of the body or space, a term coined by Obersteiner in 1882. There is overlap with alloaesthesia, originally used by Stewart (1894) to describe stimuli displaced to a different point on the same extremity. Cross References Alloaesthesia; Allokinesia, Allokinesis; Neglect; Right–left disorientation Allodynia Allodynia is the elicitation of pain by light mechanical stimuli (such as touch or light pressure) which do not normally provoke pain (cf. Examples of allodynia include the trigger points of trigeminal neuralgia, the affected skin in areas of causalgia, and some peripheral neuropathies; it may also be provoked, paradoxically, by prolonged morphine use. Various pathogenetic mechanisms are considered possible, including sensi tization (lower threshold, hyperexcitability) of peripheral cutaneous nociceptive fibres (in which neurotrophins may play a role); ephaptic transmission (‘cross talk’) between large and small (nociceptive) afferent fibres; and abnormal central processing. The treatment of neuropathic pain is typically with agents such as carba mazepine, amitriptyline, gabapentin, and pregabalin. Interruption of sympa thetic outflow, for example with regional guanethidine blocks, may sometimes help, but relapse may occur. Cross References Hyperalgesia; Hyperpathia -21 A Allographia Allographia this term has been used to describe a peripheral agraphia syndrome character ized by problems spelling both words and non-words, with case change errors such that upper and lower case letters are mixed when writing, with upper and lower case versions of the same letter sometimes superimposed on one another. These defects have been interpreted as a disturbance in selection of allographic forms in response to graphemic information outputted from the graphemic response buffer. A model of writing performance: evidence from a dys graphic patient with an “allographic” writing disorder. Cross Reference Agraphia Allokinesia, Allokinesis Allokinesis has been used to denote a motor response in the wrong limb. Others have used the term to denote a form of motor neglect, akin to alloaesthesia and allochiria in the sensory domain, relat ing to incorrect responses in the limb ipsilateral to a frontal lesion, also labelled disinhibition hyperkinesia. Altitudinal field defects 22 Amblyopia A are characteristic of (but not exclusive to) disease in the distribution of the cen tral retinal artery. Central vision may be preserved (macula sparing) because the blood supply of the macula often comes from the cilioretinal arteries. Cross References Hemianopia; Macula sparing, Macula splitting; Quadrantanopia; Visual field defects Amaurosis Amaurosis is visual loss, with the implication that this is not due to refractive error or intrinsic ocular disease. The term is most often used in the context of amaurosis fugax, a transient monocular blindness, which is most often due to embolism from a stenotic ipsilateral internal carotid artery (ocular transient ischaemic attack). Giant cell arteritis, systemic lupus erythematosus, and the antiphospholipid antibody syndrome are also recognized causes. Gaze-evoked amaurosis has been associated with a variety of mass lesions and is thought to result from decreased blood flow to the retina from compression of the central retinal artery with eye movement. Amblyopia Amblyopia refers to poor visual acuity, most usually in the context of a ‘lazy eye’, in which the poor acuity results from the failure of the eye to establish nor mal cortical representation of visual input during the critical period of visual maturation (between the ages of 6 months and 3 years). Amblyopic eyes may demonstrate a relative afferent pupillary defect and sometimes latent nystagmus. Amblyopia may not become apparent until adulthood, when the patient sud denly becomes aware of unilateral poor vision. The finding of a latent strabismus (heterophoria) may be a clue to the fact that such visual loss is long-standing. The word amblyopia has also been used in other contexts: bilateral simulta neous development of central or centrocaecal scotomas in chronic alcoholics has often been referred to as tobacco–alcohol amblyopia, although nutritional optic neuropathy is perhaps a better term. This is a component of long-term (as opposed to working) memory which is distinct from memory for facts (semantic memory), in that episodic memory is unique to the individual whereas semantic memory encompasses knowledge held in common by members of a cultural or linguistic group. Episodic memory generally accords with the lay perception of memory, although many complaints of ‘poor memory’ represent faulty atten tional mechanisms rather than true amnesia. A precise clinical definition for amnesia has not been demarcated, perhaps reflecting the heterogeneity of the syndrome. Amnesia may be retrograde (for events already experienced) or anterograde (for newly experienced events). Retrograde amnesia may show a temporal gradi ent, with distant events being better recalled than more recent ones, relating to the duration of anterograde amnesia.

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