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By: J. Eduardo Calonje, MD, DipRCPath

  • Director of Diagnostic Dermatopathology, Department of Dermato-Histopathology, St John's Institute of Dermatology, St Thomas' Hospital, London, UK

Mild behavioural changes symptoms low blood pressure order mildronate 500 mg otc, impairment of memory and errors in judgement develop later z pak medications generic mildronate 250mg mastercard, often in association with signs of neuromuscular irritability symptoms of strep throat order mildronate 500 mg with mastercard, hiccups medications not to be crushed 250mg mildronate with amex, cramps and fasciculations and twitching of muscles. Patients with uraemia usually present to physicians with physical symptoms, but very occasionally the mental changes can be the most prominent manifestation and lead directly to psychiatric consultation. The picture may simulate neurasthaenia with complaints of fatigue after mental effort or body weakness and exhaustion after minimal effort, muscular aches and pains, irritability, sleep disturbance and mood disturbance. Sluggishness, memory impairment and sleep disturbance are not uncommonly seen in patients treated with renal replacement therapies. Psychometric studies have shown deficits in attention/response speed, learning and memory and perceptual coding in patients on both continuous ambulatory dialysis and haemodialysis. Difficulty with concentration is characteristically episodic: a patient may perform well for short periods of time but is unable to sustain mental activity. With further progression the patient may become depressed or emotionally labile, memory becomes obviously impaired, and episodes of disorientation and confusion appear. Frontal lobe symptoms with impaired abstract thinking, listlessness and apathy prevail but anxious restlessness may also sometimes be seen. Gegenhalten (an involuntary, variable resistance to passive movement), grasp, palmomental and other frontal release signs also occur. In the later stages acute confusional states develop in one-third, with visual hallucinations, disorientation and agitation. Both the impairment of consciousness and the changes of mood fluctuate markedly, with lucid periods during which behaviour returns to normal. As in acute confusional states due to other causes the picture changes rapidly and paranoid developments are common. Eventually more profound impairment of consciousness develops, with increasingly sluggish comprehension and reactions, slurring of speech, incontinence and ultimately coma. They are more frequent in acute than chronic uraemia and are usually a late feature. Meningism may be found in one-third and fascicular twitching, coarse postural and kinetic tremor, multifocal myoclonus and asterixis (a form of negative myoclonus) characterise later stages of the encephalopathy. Raised limb tone, hyperreflexia, ankle clonus and extensor plantar responses may also be seen in uraemic coma. Hemiparesis may occur in up to 45%, and curiously may exchange sides during the illness (Fraser & Arieff 1988). On recovery there is patchy or complete amnesia for the periods of disorientation and confusion. Peripheral neurological manifestations Neuropathy occurs in 70% of patients requiring renal replacement therapy, more commonly in men than women (Schaumburg et al. Occasionally, intensely painful paraesthesiae may occur, typically in the feet or as band-like sensations (Mawdsley 1972). Nerve conduction studies may show an axonal pattern of impairment even before clinical signs appear. The most commonly affected cranial nerve is the vestibulocochlear (Burn & Bates 1998). Renal replacement therapy or transplantation Uraemic encephalopathy Uraemic encephalopathy is an organic brain syndrome that occurs in untreated renal failure and in association with renal dialysis. The commonest mental disturbance is progressive torpor and drowsiness with the insidious development of intellectual impairment. Further neurological manifestations include a myopathy, similar to that seen in hyperparathyroidism. Investigation of uraemic encephalopathy Blood urea is raised and electrolyte disturbances including hyponatraemia, hyperphosphataemia, hypocalcaemia and hyperkalaemia are common. There is generalised slowing, most marked frontally with an excess of delta and theta waves.

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Depression may be severe 909 treatment 500 mg mildronate overnight delivery, especially while insight is retained medications prescribed for adhd generic mildronate 250mg otc, and suicide is a considerable risk in the early stages treatment 5th finger fracture order mildronate 500 mg with visa. Eventually symptoms gallbladder problems mildronate 500mg without a prescription, however, the mood is of apathy or fatuous euphoria, and inertia and self-neglect become pronounced. Episodes of restlessness and irritability or outbursts of excitement may occur from time to time, and some patients become difficult to manage on account of spiteful, quarrelsome or violent behaviour. The pronounced apathy that accompanies and develops 580 Chapter 9 along with it is also typical of subcortical dementia. Dementia is usually a relatively late symptom but exceptions are recorded where it is the predominant presenting symptom (Cooper, D. Aggression and violence, usually against the spouse, was the most common change, followed by suspiciousness and outbursts of temper. Affective and psychotic disturbance Affective and psychotic features become obtrusive in many cases, often early in the course or even preceding the onset of chorea or dementia. Most common symptoms are dysphoria, agitation, irritability, apathy and anxiety (Paulsen et al. Major depressive illness is frequent, sometimes recurrent and can be responsive to drugs or electroconvulsive therapy. Delusions of persecution can be pronounced, with religiosity and sometimes grandiosity. Ideas of reference are perhaps accentuated by the attention attracted by the involuntary movements and bizarre facial expressions. Suicide had already been stressed by Huntington (1910), and has been found to account for 7% of deaths among non-hospitalised patients (Reed & Chandler 1958). They describe the typical progression as follows: the patient is overwhelmed by a vague impression of an uncanny change in reality which becomes laden with meaning of an uncertain nature. Delusions and hallucinations distil from this, often welling up suddenly and usually lasting several months. Behavioural change Change of behaviour and/or personality was noted in 42% of 65 patients identified in the Oxfordshire region (Watt & Preclinical changes Autosomal dominant conditions offer the opportunity to unambiguously study the very earliest symptoms, as family members carrying the mutation can be identified and studied in detail prior to obvious manifestation of disease. In one very large study, preclinical symptoms included anxiety, paranoid ideation and psychoticism in one cluster of subjects and depression in another (Marshall et al. Neuropsychometric testing shows deficits in memory prior to executive dysfunction and motor speed in preclinical mutation carriers (Robins Wahlin et al. They conclude that cognitive dysfunction is likely to be due to biological effects and personaility or mood changes to psychological mechanisms. Some of these cognitive impairments are detectable more than 2 years before disease onset (Paulsen et al. Investigations Electroencephalography characteristically shows poorly developed or complete loss of alpha rhythms. There may be generalised low-voltage fast activity or random slow activity, but this too may disappear as the disease progresses. Occasionally, however, a normal record may be obtained even in the presence of advanced dementia. Atrophy of the heads of the caudate nuclei may be clearly apparent, with loss of the normal convex bulging into the lateral walls of the frontal horns. Various linear measures have been proposed for establishing this feature as an aid to diagnosis, but they are not sufficiently specific to be of value in the individual case (Shoulson & Plassche 1980). This, being more widely available, is likely to find clinical application in uncertain cases. For the past 10 years she had shown a slowly progressive dementia, along with increasing motor disorder by way of a stiff unsteady gait, writhing of the hands and choreiform movements of the face. The antecedent family history was at that time uncertain, but her sister in New Zealand was known to suffer from an entirely similar illness. Doubts about the diagnosis were further reinforced when vigorous efforts to trace the family history revealed longevity in the parents and their many siblings, with no evidence of dementia or movement disorder in any of them. It was therefore concluded likely that the illness represented a recessively inherited dementing disorder, with adventitious movements attributable to the neuroleptics that had been administered for many years.

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Classical migraine with aura followed by headache symptoms gonorrhea cheap mildronate 500mg on line, photophobia and nausea seldom causes any diagnostic difficulties treatment action campaign generic 250mg mildronate fast delivery. However symptoms 9 dpo mildronate 250mg with amex, migrainous aura may occur in isolation (acephalgic migraine or migraine equivalent) symptoms emphysema buy mildronate 500mg with mastercard. Visual disturbances are the most common form of aura, but sensory, motor, speech and cognitive disturbance, including clouding of consciousness, are seen occasionally (Al Twaijri & Shevell 2002; Young & Silberstein 2006). The visual aura of migraine typically involve scintillating, monochromatic, zig-zag lines that evolve slowly over tens of minutes. In contrast, visual aura in occipital lobe epilepsy are of sudden onset, brief duration and of coloured, round, often moving shapes. Overall, the characteristic pattern of symptoms, slow onset and gradual resolution help identify the various presentations of migraine. Vertigo is an illusion of rotation due to a disorder of the vestibular system (Halmagyi 2005). True vertigo must be distinguished from symptoms of dizziness and light-headedness, which are non-specific and often reported as prodromal symptoms in epilepsy, and in association with syncope and dissociative seizures. Vertigo has been described with frontal and parietal seizures but is such an uncommon feature of epilepsy that it should immediately call other diagnoses to mind (Altay et al. The underlying disturbance of vestibular function in recurrent vertigo is almost always peripheral, the most common cause being benign positional vertigo. This condition is readily identified by a history of symptoms precipitated by head movement. Consciousness is preserved but the sensation of disorientation can be so profound that patients may report diminished awareness. This refers to a rare group of disorders characterised by an exaggerated involuntary motor response to startle stimuli. The major form presents in the neonate with generalised stiffness that resolves in the first few years of life; an exaggerated startle response, especially to auditory stimuli, that persists throughout life; and a generalised stiffness that follows the startle response and lasts for a few seconds. The minor form of the disorder, which involves only an exaggerated startle response, is less common and less clearly delineated. In particular, minor forms of the disorder have not been as consistently linked to genetic abnormalities as have the major forms (Tijssen et al. Hyperekplexia usually has a genetic basis Paroxysmal neurological disorders Paroxysmal symptoms occurring as part of other psychiatric disorders may be mistaken for epilepsy. The most common problem concerns panic disorder (see Epileptic aura, earlier in chapter). The brief stereotyped nature of affective and perceptual epileptic aura, together with the presence of impaired consciousness and other epileptiform semiology, mean that distinguishing these ictal presentations from primary psychiatric disorder (panic disorder, psychosis, derealisation disorder) is usually straightforward. The rare occurrence of simple partial non-convulsive status with prominent experiential symptoms (aura continua) is discussed under Non-convulsive status epilepticus, earlier in chapter. Juvenile absence epilepsy may present with academic failure and complaints of inattentiveness at school that might raise the possibility of attention deficit disorder. The clinical features of transient ischaemic attacks typically involve a loss of function (as Table 6. The overwhelming majority of affected individuals have the major form of hyperekplexia but there are reports of the minor form of the disorder in some family members, with or without the mutation. The startle response is dramatic, may involve myoclonic movements and be associated with a fall but there is no alteration of consciousness. Non-familial hyperekplexia is rare and may have a sporadic genetic cause (Gaitatzis et al. Exaggerated startle is also seen in the stiff man syndrome and in association with brainstem or severe diffuse cerebral pathology. In the latter condition, epileptic seizures are triggered by sudden stimuli, most commonly auditory. Seizures typically arise in childhood and are often not exclusively related to startle, in which case startle-induced seizures may occur as a transient phase. Some patients have diffuse cerebral pathology and learning difficulties but around half are of normal intelligence without neurological signs. Dysplastic lesions in premotor and perisylvian cortices may account for many of the latter group (Manford et al. Paroxysmal kinesogenic dyskinesia (or choreoathetosis) is the most common paroxysmal movement disorder (Vidailhet 2000). Patients develop sudden brief (usually less than 1 minute) attacks of dystonia or chorea triggered by voluntary movement (Bruno et al.

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These events are linked by sensory fibres of the trigeminal nerve conveying signals from meningeal nociceptors to treatment plan template purchase mildronate 500mg without a prescription the brainstem medicine wheel colors cheap mildronate 500 mg, and efferent fibres of the parasympathetic system controlling meningeal blood vessels treatment wax cheap mildronate 250 mg without prescription, this afferent and efferent loop being part of the trigeminovascular system (Pietrobon & Striessnig 2003) medications dogs can take 500 mg mildronate with mastercard. In animals, spreading depression can be triggered by local application of high concentration of potassium, which then causes a wave of depolarisation to spread outwards. The extracellular con- centrations of potassium, nitric oxide and glutamate are raised. The spread of oligaemia is independent of the territories supplied by the larger cerebral vessels, but like cortical spreading depression may fail to cross prominent cortical sulci. Nitric oxide and inflammatory cytokines released from cortex affected by spreading depression may sensitise overlying meninges and trigger the migraine headache. Activation of nociceptors in the meninges and meningeal vessels is responsible for the headache of migraine, whether or not preceded by aura. Sensitisation of the trigeminal nerve and its sensory nuclei explains why a proportion of patients complain of cutaneous allodynia in the trigeminal distribution (Burstein et al. In those with unilateral headache this effect is lateralised, although one group studying nine patients all with right-sided headache found contralateral brainstem activation (Weiller et al. The activation continues after the headache is controlled by sumatriptan, suggesting that it is not simply a response to painful stimuli coming from the meninges and other intracranial vessels but may play an active role in the pathogenesis of the headache. The lateralised nature of the activation may explain why the headache is lateralised in many patients. These nuclei, which include the trigeminal nucleus pars caudalis on the afferent side and the superior salivary nucleus on the efferent side, modulate sensory input from the meninges and, via their parasympathetic afferents, influence cranial vasculature. The site of the changes responsible for auras must differ widely from one form to another. Teichopsia and homonymous field defects almost certainly originate in the occipital lobes, illusions of altered size, shape and position in the optic radiations, and bitemporal hemianopias from disturbance of chiasmatic vessels. The middle cerebral or internal carotids are likely to be involved in hemiplegic migraine, and the vertebrobasilar system in patients with brainstem manifestations. In fact it is probable that in many attacks a large part of the cerebral vasculature is affected diffusely, the focal symptoms merely reflecting ischaemia in the territory most severely involved, hence the vague but definite symptoms of slowed cerebration and somnolence common in attacks. In the case of prolonged neurological phenomena, as in hemiplegic migraine, local oedema or hypoxia consequent on the spasm may be responsible for the symptoms. Psychiatric aspects Virtually all observers, neurologists and psychiatrists alike, stress the influence that psychological factors may have in migraine and the importance attaching to them in treatment. A considerable literature has accumulated concerning the personality of migraine sufferers and the role of emotions and conflicts in precipitating attacks. Early reports suggested that it was possible to identify a personality type that was particularly prone to suffering migraine. However, the anecdotal observations on which such conclusions were based are vulnerable, not least to ascertainment effects. It has for example been shown that personality type may predict who attends clinic for help rather than who in fact has headache (see below). With more rigorous methods, avoiding ascertainment bias and using reliable measures of personality and other psychopathology, the story is found to be a little more complicated. Mental phenomena are also recognised as common accompaniments of the migraine ictus, and may sometimes assume bizarre expression leading to diagnostic difficulty. Anxiety and depression Patients with migraine are at increased risk of anxiety and depression. Population surveys consistently show that the risk of a person with migraine suffering depression or anxiety is at least twofold to threefold that of somebody without headache (Table 8.


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