This document discusses recent advances in the management of extrapyramidal (basal ganglia) disorders. It defines movement disorders and lists various conditions such as Parkinsonism, dystonia, tremor, tics, chorea, tardive syndrome, and myoclonus. It provides details on classification, causes, treatment of these disorders and differential diagnosis of tics. Guidelines for treating tardive syndromes are also mentioned.
Medication-induced movement disorder (Extra-Pyramidal Side Effects, EPSE) occurs due to treatment with antipsychotic medications. It can also be defined as physical symptoms, including tremor, slurred speech, akathesia, dystonia, anxiety, distress, paranoia, and bradyphrenia, that are primarily associated with improper dosing of or unusual reactions to neuroleptic (antipsychotic) medications.
Though they are commonly caused by the typical antipsychotics, but can also be caused by the atypical.
The adverse consequences of these syndromes can be minimized by vigilant clinicians who systematically examine patients at risk for these disorders and who manage them properly when discovered.
The best management is, of course, prevention, which starts with the judicious prescription of neuroleptics, and an awareness of the potential for certain nonpsychiatric medications to cause the same movement disorders.
Medication-induced movement disorder (Extra-Pyramidal Side Effects, EPSE) occurs due to treatment with antipsychotic medications. It can also be defined as physical symptoms, including tremor, slurred speech, akathesia, dystonia, anxiety, distress, paranoia, and bradyphrenia, that are primarily associated with improper dosing of or unusual reactions to neuroleptic (antipsychotic) medications.
Though they are commonly caused by the typical antipsychotics, but can also be caused by the atypical.
The adverse consequences of these syndromes can be minimized by vigilant clinicians who systematically examine patients at risk for these disorders and who manage them properly when discovered.
The best management is, of course, prevention, which starts with the judicious prescription of neuroleptics, and an awareness of the potential for certain nonpsychiatric medications to cause the same movement disorders.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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Recent advances in the mangement of extra pyramidal basal ganglia disorders
1. RECENT ADVANCES IN THE
MANGEMENT OF EXTRA PYRAMIDAL-
(BASAL GANGLIA) DISORDERS
Prof. A.V. SRINIVASAN, MD, DM, Ph.D, F.A.A.N, F.I.A.N,
EMERITUS PROFESSOR
TAMILNADU DR.M.G.R MEDICAL UNIVERSITY
CHENNAI
FORMER PROFESSOR AND HEAD
INSTITUTE OF NEUROLOGY
MADRAS MEDICAL COLLEGE
17th MAY 2009
2. Sir William Osler
To study the phenomenon of disease
without books is to sail an uncharted sea,
while to study books, without patients is
not to go to sea at all.
Sir William Osler Aphorisms
3. DEFINITION
Movement disorders can be defined as
neurologic syndromes in which there is
either an excess of movement or paucity of
voluntary and automatic movements,
unrelated to weakness or spasticity.
7. DEDICATED TO PROF
C.D.MARSDEN- A GENIUS IN
MOVEMENT DISORDERS
•P- PARKINSONISM
•R- RESTLESS LEG SYNDROME
•O- OROFACIAL DYSKINESIA
•F- FIBRILLATION AND FASCICULATIONS
• C –CHOREA INCLUDING HEMIBALISM
• D- DYSTONIA
• M- MYOCLONUS,MYOKYMIA,MYORHYTHMIA,MTAF
• A-ATAXIA,AKATHESIA,ATHETOSIS,ABD.DYS
• R-RETT SYNDROME,
• S-STEREOTYPY,SPASM(HEMIFACIAL),JUMPY STUMPS
• D-DYSKINESIA(PAROXYSMAL)
• E-ESSENTIAL TREMOR, EKPLEXIA(HYPER)
• N-NEUROLEPTIC INDUCED -TARDIVE DYSKINESIA
8. CHOREA
Random, quick Huntington disease
unsustained Neurocanthocytosis
purposeless
movements that have
Postinfectious
an unpredictable chorea
flowing pattern Drug-induced chorea
Vascular chorea
Autoimmune chorea
Chorea gravidarum
9. Ballismus, Chorea, Athotosis
and Dystonia
These should NOT be thought of as
separate entities amenable to specific
definition but rather as a SPECTRUM of
movements that blend into one-another
WHY?
10. Because……..
• They often co-exist
• Even neurologists may often not be
able to agree as to how a particular
movement should be classified!
• They often ( with some notable
exceptions ) have the same
significance in terms of aetiology.
11. The spectrum
Ballismus Chorea Athetosis Dystonia
Movements become - Less violent / explosive / jerky
- Smoother and more flowing
- More sustained
They differ from tics in that they cannot be suppressed by
voluntary control
12. Ballismus
• Violent “flinging” movement of entire limb
• Almost always unilateral and therefore
use term “ HEMIBALLISMUS”
• Involves proximal musculature and is
sometimes thought of as a
“ proximal unilateral chorea ”
• Usually due to a CVA in contralateral
subthalamic nucleus
15. Secondary to medical
disorders
(A SHEEP)
• Anoxic brain damage ( post – CPR )
• Systemic lupus erythematosis
• Hepatic failure
• Endocrine - Thyrotoxicosis
- Addisons
• Electrolyte - Low Ca, Mg,
- High Na
• Polycythemia rubra vera
16. Chorea ( “dance” in Greek)
• Rapid irregular muscle jerks
• May affect limbs, head, face and tongue
• In the limbs chorea refers more to distal
movements ( as proximal movements usually
called ballismus)
• Patients often attempt to conceal involuntary
movements by superimposing voluntary
movements onto them e.g. an involuntary
movement of arm towards face may be adapted
to look-like an attempt to look at watch
17. Sydenham’s chorea
• Mainly children / adolescents
• Complication of previous group A
streptococcal infection
• Usually no recent history of infection
• Acute / subacute onset
• May have behavioural problems
• Usually remits spontaneously
18. Chorea gravidarum
• Chorea of any cause that begins in
pregnancy
• May represent recurrence of
Sydenham’s chorea.
• Most commonly associated with anti-
phospholipid syndrome +/- SLE
• Usually resolves spontaneously
19. Athetosis “ changeable” in Greek
• Slow, flowing, often twisting movements
• Occurs mainly distally ( hands, fingers)
• Can also affect face and tongue
• Often use term “ choreoathetosis ” due
to overlap between syndromes ( chorea
referring to less smooth , more jerky
movements)
21. TREATMENT OF MYOCLONUS
Drug Initial Adult Dose
Clonazepam 0.5 mg / day
Levetiracetam 250 mg / day
Piracetam 400 mg 3 times a day
Primidone 25 mg / day
Valporate 125 mg 2 times a day
22. TREATMENT OF MYOCLONUS
Indication
Usual Effective Dose
Posthypoxic myoclonus Spinal
2 mg/day divided myoclonus Progressive myoclonic
3 times a day
epilepsy Essential myoclonus
1000-1500 mg/day Posthypoxic myoclous Cortical
myoclonus Spinal myoclous
1200-16,000 mg/day divided 3 Posthypoxic myoclonus Cortical
times a day myoclonus Progressive myoclonic
epilepsy Essential myoclonus
500-750 mg/day Cortical myoclonus
750-1000 mg/day divided 2 Most forms of myoclonus
times a day
24. TREATMENT OF ESSENTIAL TREMOR
Drug Initial Adult Usual Effective
Dose Dose
Propranolol 20 mg/day 80-240 mg/day
Primidone 12.5-25mg 50-300 mg/day
at bed time divided Bio or
at bedtime
Topiramate 12.5=25mg/day 400 mg/day
maximum dose
divided Bio
26. TIC
Stereotyped, Tourette syndrome
automatic Celebral palsy or
purposeless developmental delay
movements and syndromes
vocalizations Autism
Huntington disease
27. PRIMARY TIC DISORDERS
DIAGNOSTIC CRITERIA
DISORDER Presence of multiple motor and
Tourette syndrome vocal tics
Age at onset <21 y
Tics must occur many times daily,
nearly every day, over a period
of >1y
Disturbance causes marked
distress or significant
impairment in daily functioning
Condition cannot be ascribed to
known neurological disorder
(symptomatic or secondary tic
disorder)
Duration of tic disorder <1 y
Transient tic disorder
28. Primary tic disorders
Diagnostic Criteria
Disorder
Chronic motor or chronic vocal
Chronic tic disorder tics (but not both of >1y
Chronic single motor or chronic
single vocal tic
Chronic single tic Tic order that begins > age 21
disorder Two temporal patterns:
- De novo adult-onset tic
- Recurrent childhood tic – a tic
Adult-onset tic discorder disorder than goes into
remission and recurs during
adulthood
29. DIFFERENTIAL DIANOSIS OF TICS
lassification
C Diffenential
Diagnosis
Simple Motor Tics
Clonic Myoclonus
Chorea
Seizures
Dystonia Dystonia
Athetasis
Tonic Muscle spasms and
cramps
Complex Motor Tcs
Mannerisms
Stereotypies
Restless legs syndrome
Seizure
Phenomenology
Abrupt Myoclonus
Chorea
Hyperekplexia
Paraxysmal dyskinesia
Seizures
Sensory phenomenon Akathisia-stereotypy
(urge relief) Restless legs syndrome
30. Classification
Diffenential
Diagnosis
Perceived as voluntary Akasthisia
Suppressibility All hyperkinesias but less than tics
Decrease with distraction Akasthisia
Psychogenic movements
Increase with stress Most hyperkinesias
Increase with relaxation Parkinsonian tremor
(after a period of stressA)
Multifocal migrate Chorea
Myoclonus
Fluctuate spontaneously Paraxysmal dykinesias
Seizures
Present during sleep Myoclonus (segmental)
Periodic movements
Painfullegs / moving toes
Other hyperkinesias
SEizures
35. General guidelines for treating
tardive syndromes
• Taper and slowly eliminate causative medications, if clinically possible.
Avid sudden cessation of these drugs, which can exacerbate symptoms
• If treatment of tardive movements is necessary, the drugs of first choice
are the dopamine-depleting drugs reserpine, tetrabenazine, and a-
methylparatyrosine. Monitor for the development of depression,
hypotension sedation, and parkinsonism.
• If dopamine-depleting agents are ineffective, consider a trial of clozpine
or quetiapine.
• Dopamine receptor-blocking agents can be used as medications of last
resort for patients with tardive syndromes despite the risk of worsening
the syndrome over the long term.
• Consider globus pallidus stimulation if pharmacotherapy is ineffective.
36. NEUROLEPTIC INDUCED
MOVEMENT DISORDERS
1. Acute reaction
a. Acute dystonia
b. Acute (Subacute) akathisia
2. Toxicity state (over dosage)
a. Drug-induced parkinsonism
3. Neuroleptic malignant syndrome (NMS)
4. Tardive stbdrines
a. Withdrawal emergent syndrome
b.Classic fardive dyskinesia
c. Tardive dystonia
d. Tardive akathisia
e. Tardive myoclonus
f. Tardive tremor
g. Tardive tics
h. Tardive Chorea
i. (?) Tardive parkinsonism
37. TERMINOLOGY OF THE TARDIVE SYNDROMES
Description Equivalent
CommonNames
Tardive syndromes Tardive syndrome
as a group Tardive dykinesia
Repetitive, rhythmic Classic tardive
Movements, usually in dyskinesia
The oral-buccal-lingual Tardive setreotypy
Region Rhythemic chorea
Dystonic movements
and postures
restlessness and the Tardive akasthisia
movement that occur
as result
Myoclonus Tardive myoclonus
Tremor Tardive tremor
Tucs Tardive tics
Tardive tourettism
Chorea Withdrawal emergent syndrome
Tardive chorea
Oculogyria Tardive oculogyric crisis
Parkinsonism Tardive Parkinsonism (if it exists)
39. NATURE HISTORY OF
TOURETTE SYNDROME
• Excerbation Remission ?
• Obsessive-compulsive behavior
• Vocal tics (simple complex)
• Motor tics (rostrocaudalprogession)
• Attention deficit with hyperactivity
40. Summary
• Movement disorders are often difficult to define precisely, but
have similar differential diagnoses.
• They are often a manifestation of a more widespread
neurological or internal medical problem.
• Other than the specific treatments mentioned, most details of
therapy are beyond the scope of this course.
• In some cases treatment includes treatment of underlying
cause e.g. Wilson’s disease
43. READ not to contradict or confute
Nor to Believe and Take for Granted
but TO WEIGH AND CONSIDER
THANK YOU
My sincere thanks to Faculty of Madras
Institute of Neurology and Madras Medical
College for giving this opportunity to speak
in the CME Program