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Report of the Quality Standards Subcommittee of the American Academy of Neurology cheap bentyl 10mg amex gastritis diet ��. The clinical problem of Bell’s palsy: is treatment with steroids effective? British Journal of General Practice 1996; 46: 743-747 Cross References Bell’s phenomenon cheap bentyl 10 mg with amex xylitol gastritis, Bell’s sign; Facial paresis; Lower motor neurone (LMN) syndrome Bell’s Phenomenon, Bell’s Sign Bell’s phenomenon or sign is reflex upward, and slightly outward, devi- ation of the eyes in response to forced closure, or attempted closure, of the eyelids. This is a synkinesis of central origin involving superior rectus and inferior oblique muscles. It may be very evident in a patient with Bell’s palsy (idiopathic facial nerve paralysis) attempting to close the paretic eye- lid. The reflex indicates intact nuclear and infranuclear mechanisms of upward gaze, and hence that any defect of upgaze is supranuclear. However, in making this interpretation it should be remembered that per- haps 10-15% of the normal population do not show a Bell’s phenomenon. Bell’s phenomenon is usually absent in progressive supranuclear palsy and is only sometimes spared in Parinaud’s syndrome References Bell C. On the motions of the eye, in illustration of the use of the muscles and nerves of the orbit. Philosophical Transactions of the Royal Society, London 1823; 113: 166-186. Cross References Bell’s palsy; Gaze palsy; Parinaud’s syndrome; Supranuclear gaze palsy; Synkinesia, synkinesis Benediction Hand Median nerve lesions in the axilla or upper arm cause weakness in all median nerve innervated muscles, including flexor digitorum profun- dus. On attempting to make a fist, impaired flexion of the index and middle fingers, complete and partial respectively, results in a hand pos- ture likened to that of a priest saying benediction. A somewhat similar, but not identical, appearance may occur with ulnar nerve lesions: hyperextension of the metacarpophalangeal joints - 54 - Blepharospasm B of the ring and little fingers with slight flexion at the interphalangeal joints. The index and middle fingers are less affected because of the intact innervation of their lumbrical muscles (median nerve). Cross References Claw hand; Simian hand Bent Spine Syndrome - see CAMPTOCORMIA Bielschowsky’s Sign, Bielschowsky’s Test Bielschowsky’s sign is head tilt toward the shoulder, typically toward the side contralateral to a trochlear (IV) nerve palsy. The intorsion of the unaffected eye brought about by the head tilt compensates for the double vision caused by the unopposed extorsion of the affected eye. Bielschowsky’s (head tilt) test consists of the examiner tipping the patient’s head from shoulder to shoulder to see if this improves or exacerbates double vision, as will be the case when the head is respec- tively tilted away from or toward the affected side in a unilateral trochlear (IV) nerve lesion. The test is usually negative in a skew devi- ation causing vertical divergence of the eyes. This test may also be used as part of the assessment of vertical diplopia to see whether hyper- tropia changes with head tilt to left or right; increased hypertropia on left head tilt suggests a weak intortor of the left eye (superior rectus); increased hypertropia on right head tilt suggests a weak intortor of the right eye (superior oblique). Cross References Diplopia; Hypertropia; Skew deviation Bitemporal Hemianopia - see HEMIANOPIA; VISUAL FIELD DEFECTS Blepharoptosis - see PTOSIS Blepharospasm Blepharospasm is a focal dystonia of the orbicularis oculi resulting in repeated involuntary forced eyelid closure, with failure of voluntary opening. The condition typically begins in the sixth decade of life, and is com- moner in women than men. Blepharospasm may occur in isolation or in combination with other involuntary movements which may be dys- tonic (orobuccolingual dystonia or Meige syndrome; limb dystonia) or dyspraxic (eyelid apraxia). Blepharospasm is usually idiopathic but may be associated with lesions (usually infarction) of the rostral brainstem, diencephalon, and striatum; it has been occasionally reported with thalamic lesions. The - 55 - B Blind Spot pathophysiological mechanisms underlying blepharospasm are not understood, but may reflect dopaminergic pathway disruption causing disinhibition of brainstem reflexes. Local injections of botulinum toxin into orbicularis oculi are the treatment of choice, the majority of patients deriving benefit and requesting further injection. Failure to respond to botulinum toxin may be due to concurrent eyelid apraxia or dopaminergic therapy with levodopa. Journal of Neurology, Neurosurgery and Psychiatry 1988; 51: 767-772 Hallett M, Daroff RB. Neurology 1996; 46: 1213-1218 Cross References Blinking; Dystonia; Eyelid apraxia; Gaping; Yawning Blind Spot The blind spot is defined anatomically as the point on the retina at which axons from the retinal ganglion cells enter the optic nerve; since this area is devoid of photoreceptors there is a physiological blind spot. This area may be mapped clinically by confrontation with the examiner’s blind spot, or mechanically. Enlargement of the blind spot (peripapillary scotoma) is observed with raised intracranial pressure causing papilledema: this may be helpful in differentiating papilledema from other causes of disc swelling, such as optic neuritis, in which a central scotoma is the most common field defect. Enlargement of the blind spot may also be a feature of peripapillary retinal disorders including big blind spot syndrome. Cross References Disc swelling; Papilledema; Scotoma Blinking Involuntary blinking rate is decreased in idiopathic Parkinson’s disease (and may be improved by dopaminergic therapy) and progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome).

The key problem identified by Dubos was what became known in the 1970s as ‘the epidemiological transition’ (Omran 1971) generic 10mg bentyl with mastercard gastritis cure. Addel Omran discount bentyl 10mg with mastercard follicular gastritis definition, an American epidemiologist, offered a history of humanity in three ages: ‘pestilence and famine’ (life expectancy 20– 40 years); ‘receding pandemics’ (life expectancy 30–50 years); ‘degenerative and man-made diseases’ (life expectancy more than 50 years). The ‘pandemic’ infectious diseases that had been the main cause of premature mortality, particularly among children and particularly in 133 THE CRISIS OF MODERN MEDICINE the cities created by modern industry, had declined in significance, largely as a result of improvements in sanitation and social conditions, partly as a result of immunisation and antibiotics. Contemporary Western society now faced quite different health problems: heart attacks, strokes and cancer were the major killers, especially of older people, and arthritis, diabetes, asthma were the major causes of ill health. In dealing with this new pattern of disease and disability, the methods of modern medicine appeared to be reaping diminishing returns. One manifestation of the declining efficacy of modern medicine was a slowing in the pace of development of new drugs. According to one estimate, the rate of appearance of genuinely new drugs — rather than modifications of familiar products—declined from around 70 a year in the 1960s to less than 20 a year in the 1970s (Steward, Wibberley 1980). A related development was the recognition of an increasing range of side-effects of drugs that had recently come into use. The most disastrous of these was the sedative Thalidomide produced in Germany in 1956 and first prescribed in Britain two years later. By 1961 it was found to produce limb abnormalties in babies if taken during pregnancy, and it was withdrawn. There were also signs of a growing disillusionment with medical technology. The proliferation of high-tech ‘coronary care units’ in the 1970s was rapidly followed by research that showed that people had just as good a chance of survival if they stayed at home after a heart attack. In the USA, President Richard Nixon had declared ‘war on cancer’ in 1970, but survival rates remained substantially unchanged. Medical research in teaching hospitals was exposed and denounced as ‘a vehicle for self-advancement rather than bettering the patient’s condition’ (Lock 1997:136). In 1971, Macfarlane Burnet, Nobel laureate and founding father of immunology, offered a gloomy prognosis for the discipline he had done much to create, concluding that it had little potential for dealing with the new pattern of disease and arguing that the future lay in the social rather than the biological sciences (Burnet 1971). Up to the early 1970s the problems of the epidemiological transition and the difficulties facing medical science remained for the most part matters of controversy within the world of medicine itself. However, these events unfolded in the context of major social changes affecting all Western societies. By the late 1960s the long post-war economic boom was coming to an end and in the early 1970s all Western economies went into recession, with the return of inflation and unemployment on a scale not seen since the 1930s. The 134 THE CRISIS OF MODERN MEDICINE resulting upsurge in trade union militancy in Europe was linked to a wider youthful radicalisation across the Western world, most conspicuously in the USA, where it was linked to causes of black civil rights, women’s liberation and opposition to the Vietnam War. From the late 1960s onwards, conditions of social stability and political consensus that had prevailed for more than two decades began to break down, with wide-ranging consequences, for doctors and health care systems as for other institutions in society. In terms of the effects of these social forces on medicine, the 1970s can be divided into two phases: an early radical, optimistic, phase and a later phase of conservative reaction in which a more pessimistic outlook became increasingly influential. The radical challenge One of the central principles of the radical upsurge symbolised by the May 1968 events in Paris was the commitment to self-expression and to the assertion of individuality against structures of society perceived as authoritarian and oppressive. In the USA, where the collectivist traditions still upheld by labour movements in Europe were conspicuously weak, and individualistic values were deeply rooted in popular culture, the youthful assertion of individuality took a particularly vigorous form. As the civil rights cause lost momentum as a protest movement in the 1970s, it offered a model for a range of ‘new social movements’ advocating the rights of women, students, gays, children, benefit claimants and many more. In what Starr characterised as a ‘generalisation of rights’ there was a dramatic expansion in both the ‘variety and detail’ of rights demanded: Medical care figured prominently in this generalisation of rights, particularly as a concern of the women’s movement and in the new movements specifically for patients’ rights and for the right of the handicapped, the mentally ill, the retarded and the subjects of medical experiments. No such right had ever been recognised in law, least of all in the USA, where access to health care was strictly 135 THE CRISIS OF MODERN MEDICINE controlled according either to the insurance principle or to strict eligibility criteria for state welfare services. Nevertheless, the claim for health care as a right was ‘for a time so widely acknowledged as almost to be uncontroversial’. Given the universal access to health care offered by the NHS in Britain, the demand for health care as a right had little resonance.

In a much less degree similar changes could be felt in Paget’s Disease of the Nipple the lower half of the left femur buy bentyl 10mg low price gastritis diet ����. This limb was occa- sionally but never severely painful bentyl 10mg with amex gastritis diet ��, and there was no In 1874, Paget published a paper in St. The left femur and tibia Bartholomew’s Hospital Reports on “Disease of became larger, heavier, and somewhat more curved. At the same time, I believe it has not yet been published that certain or later, the knees became gradually bent, and as if by chronic affections of the skin of the nipple and areola rigidity of their fibrous tissues, lost much of their are very often succeeded by the formation of scirrhous natural range and movement. I have seen about fifteen ally larger, so that nearly every year, for many years, cases in which this has happened, and the events were his hat, and the helmet that he wore as a member of a in all of them so similar that one description may Yeomanry Corps needed to be enlarged.... The patients were all women, various in age and habitual posture of the patient were thus made from 40 to 60 or more years, having in common strange and peculiar. In all of them the lowered, so that the neck was very short, and the chin, disease began as an eruption on the nipple and areola. The short narrow intensely red, raw surface, very finely granular, as if chest suddenly widened into a much shorter and broad nearly the whole thickness of the epidermis were abdomen, and the pelvis was wide and low. The arms removed; like the surface of very acute diffuse eczema, appeared unnaturally long, and, though the shoulders or like that of an acute balanitis... But it has happened were very high, the hands hung low down by the thighs that in every case that I have been able to watch, cancer and in front of them. Altogether, the attitude in stand- of the mammary gland has followed within at the most ing looked simian, strangely in contrast with the large two years, and usually within one year.... In January 1876 he tion of cancer has not in any case taken place first in began to complain of pain in his left forearm and elbow the diseased part of the skin. But it grew substance of the mammary gland, beneath or not far worse, and swelling appeared about the upper third of from the diseased skin, and always with a clear inter- the radius and increased rapidly, so that, when I saw val of apparently healthy tissue. After this time however, together with rapid Paget’s Disease of Bone increase of the growth upon the radius, there were gradual failure of strength and emaciation, and on the In 1876, Paget wrote the most famous of all his 24th of March, after two days of distress with pleural papers, “On a form of Chronic Inflammation of effusion on the right side, he died.... Holding then the disease to be an inflammation of bones, I would suggest Bones (Osteitis Deformans),” which was read that, for brief reference and for the present, it may be before the Royal Medical and Chirurgical Society 7 called after its most striking character: Osteitis Defor- of London. Abetter name may be given when more is known description of the disease; detailed postmortem of it. He noted But more than a century later, no more is the evolution of the disease in a patient during the known of the origin of the disease, nor of its cure. The borders of the loose body were of bone occurring as the result of trauma without smoothly rounded off.... These loose bodies are inflammatory reaction; he offered the same expla- sequestra, exfoliated after necrosis of injured portions nation for the presence of certain loose bodies of cartilage, exfoliated without acute inflammation. In 1870, he read a paper before Paget described certain fibromata, in connec- the Clinical Society of London on “A case of tion with aponeuroses, fasciae, and tendons, Necrosis of the Femur, without External Inflam- which recur with shortening intervals after mation. The pathology of tumors was of What seemed more important was that a hard swelling, continuous interest to him. The name fibroplastic of which the patient knew nothing, surrounded the had been given to a certain bone tumor that on middle of the shaft of the femur. The swelling felt of the continent had been separated from others as nearly ovoid form about six inches in length, it was in being different in kind. Paget proposed the name every part very firm and tense, hard pressure on it was “myeloid” for this tumor because of its multinu- painful especially in its middle part... In 1849, he conducted a series of experi- through down to the outer surface of the periosteum ments on rabbits. Contrary to the opinion of appeared perfectly healthy; there was not in any of previous workers in this field, he concluded them the smallest sign of inflammatory change.... The central point of interest in this case is I think in the fact gradually formed, where at first there had been a of necrosis, leading to separation of bone, being uniform and seemingly purposeless infiltration of unattended with inflammation of any of the textures the whole space left by the retraction of the external to the periosteum or with more than a scarcely tendon. How unlike this is to the ordinary course Bone-setters Cure,” delivered in 1867, attracted of necrosis I need not declare. Bartholomew’s imitate what is good and avoid what is bad in Hospital Reports for 1870. The patient was sixteen, active, athletic, and Paget received all the highest honors.

Slides made from printed materials frequently contain too much detail and fine line work to enable them to be projected satisfactorily discount 10mg bentyl fast delivery gastritis esophagitis diet. This means that you may need to have artwork redrawn and new lettering added purchase bentyl 10mg mastercard chronic gastritis medicine. A useful rule of thumb is that a slide which can be read without a magnifier is generally satisfactory. A better method is to go with a colleague to a large lecture theatre, project your slides and check to see if all details are legible and understandable at the rear of the auditorium. When making slides, avoid the temptation to put all the details into the slide. If it is important for students to have all the details, provide these in a handout so that they can refer to it and keep it for reference. Photographers will advise you on the different processes available to produce your slides. These processes will usually include simple black-on-white slides, colour slides and diazo slides (white against blue, green or red 172 backgrounds, the blue being preferred for clarity). Your institution may also be able to help you produce computer- generated colour slides of high quality. Another attractive and inexpensive way to prepare slides is to obtain negatives (white-on-black) and colour the white sections in by hand using coloured marking pens. The possibility exists for using separate colours to highlight different points on the slide. Whatever you choose, try to achieve a degree of consistency by sticking to one type of slide. Guidelines for the preparation of effective slides are given in Figure 9. Setting up and using the slide projector Slide projection equipment is normally part of the standard fixtures in a lecture theatre or seminar room so the question of setting up does not usually arise. If it does, locate the projector and screen with care to give the best view to students and so that it is convenient for you to operate the projector and room lights with a minimum of fuss. Slide projection Before loading your slides into a carousel, carefully plan the sequence of their use. If your teaching is to be interspersed with slides, consider using black slides to separate your material and to avoid having to keep turning the projector on and off or leaving an inappropriate slide on view. Black slides are simply pieces of opaque film mounted in a slide frame to block off light to the screen and can be easily made from exposed film. If you plan to use the same slide on more than one occasion during a 173 presentation, arrange to have duplicates made to save you and your students the agony of having to search back and forth through a slide series. It is essential to have your slides marked or ‘spotted’ for projection (see Figure 9. When showing your slides, it is rarely necessary to turn off all the lights. Remember that students may wish to take notes and so you should plan to leave some lights on or to dim the main lights. Further advice on using slides is given in Chapter 4 on presenting a paper at a conference. THE VIDEO PROJECTOR This exciting device enables you to project a variety of materials from a computer onto a screen for large and small group viewing. These materials include videos, broadcast television, slides and overheads, multi-media presentations, computer output, and Internet displays. When it is professionally set-up, supported, and used, the video projector is an outstanding presentation tool. In our view, the current situation with video projectors is one that must be approached with caution as it is a good example of the embarrassing immaturity of much educational technology. If you doubt this judgement, have a close look at the systems currently in use with cords and cables every- where, the need for backup computers, incompatible software and systems, the risk of system crashes, and so on! It is probably unwise to rely on a video projector system unless you are very familiar with its use and even then be well prepared with back-up resources.