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You may want to reread this chapter before going on to the next topic purchase dipyridamole 25mg with mastercard, "Nutrition That Affects Our Lives discount dipyridamole 25mg otc. For some of us buy 25 mg dipyridamole fast delivery, balancing a diet and meeting our special needs may be a bit tricky without proper management. In this chapter, I want to share with you the aspects of nutrition that are unique to people with Parkinson’s and some techniques for assur- ing that our bodies get what they really need. The first thing we have to remember is how important it is to maintain a body weight that is appropriate for our size and build. Your doctor should determine the optimum weight for you to maintain, but until you get his or her recommendation, you can use this method of calculation: for women, start with 100 pounds and add 5 pounds for every inch over 5 feet; for men, start with 106 pounds and add 6 pounds for every inch over 5 feet. Adjust 33 34 living well with parkinson’s the total down a bit if you have a very narrow build and up a bit if you have a wide build. Ask your doctor or dietitian to tell you the total daily caloric intake that will maintain your appropriate weight. Pin up a calorie chart and become familiar with the caloric values of the foods you eat. Many people with Parkinson’s lose more weight than they should, which depletes their bodies of protein and muscle, along with fat. They can’t afford that because body protein and muscle are absolutely necessary, not only for strength and endurance but also for responding to physical and emotional stress. Others have difficulty with cutting up food and give up in embarrassment or frustration. Some have a sluggish digestive system and a feeling of fullness that keeps them from eating when mealtime comes. You can overcome a number of obstacles to eating by taking your Sinemet three-quarters of an hour or an hour before you eat. Typically, people who take their Sinemet pill at mealtime are at the end of their last dose. They have lost their appetite because of the struggle to get food to their mouths, chew, and swallow. But someone who takes the pill forty- five to sixty minutes before eating can have a more successful and enjoyable meal because the medication is already working. I remember the first morning I took my Sinemet that way and experienced "morning sickness," although I knew I wasn’t pregnant. Once my body adapted to the medication, I was able to take the pill without milk or food of any kind. It can be absorbed into the bloodstream immediately and can travel to the brain to start working.

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Several factors affect wound healing purchase 100 mg dipyridamole amex, including age buy generic dipyridamole 100mg on-line, the presence of other medical problems dipyridamole 100mg otc, and nutritional state. Avoidance means transferring weight off contact areas at frequent intervals without using pressure, shear, or friction to accomplish the move. Foam rubber pads and sheepskins placed under pressure areas such as the sacrum (tail area) and heels aid in dispersing pressure during movement. The skin must be fre- quently and carefully examined for areas of pressure and break- down. For the bedridden person, a special mattress that takes pressure off the stressed areas may replace the standard bed. It is important to turn once every two hours to avoid continuing pressure to any one area. Cleaning the area (debridement) may be necessary and should be performed by someone who is trained in this technique. The ulcer cavity (opening) with its surrounding scar tissue must be completely 62 CHAPTER 9 • Pressure Sores removed, the bony edge removed, and the wound covered with healthy skin. It should be obvious that care must be taken not to irritate the wound until it has healed. Further attention to prevention is even more important after the wound has healed because the area remains vulnerable to re-injury. If careful attention is paid to the preventive measures described here, the chances of a pressure sore forming will be minimized. Bladder symptoms usually can be controlled with medication or other approaches that minimize any changes in daily activities and life-style. THE URINARY SYSTEM AND ITS CONTROL The following figure shows the urinary system, whose main func- tion is to collect and eliminate bodily wastes in the form of urine. The urinary system includes • the kidneys, which filter the blood to remove waste prod- ucts and produce urine at a rate of approximately one ounce (30 cc) per hour • the bladder, a muscular sac that stretches to store the urine until it is emptied by urination, a process referred to as voiding • the urethra, a hollow tube through which urine passes from the body when voiding occurs • the urethral sphincter, a valvelike muscle that opens and closes to control whether urine remains in the bladder or is voided 64 CHAPTER 10 • Bladder Symptoms Kidney Ureter The urinary system. Bladder Urethral sphincter Urethra When 6 to 8 ounces (180 to 240 cc) of urine is present in the bladder, it becomes sufficiently stretched to stimulate nerve end- ings located in its wall. These nerves send a signal of fullness to an area in the spinal cord that may be thought of as a "voiding reflex center" (Figure A). This center in turn sends the signal on to the brain, and you become aware of the need to urinate. The brain then signals the spinal center, which sends two signals, one to the blad- der telling it to contract and a second to the urethral sphincter mus- cle telling it to relax. This combination of a contracted bladder and a relaxed sphincter permits urine to flow from the bladder. BLADDER PROBLEMS ASSOCIATED WITH MULTIPLE SCLEROSIS The elimination of urine by conscious choice is dependent on the integrity of the spinal cord pathways that connect the brain and the 65 PART II • Managing MS Symptoms voiding reflex center.

Face and Head Neuralgias 313 Glossopharyngeal Attacks dipyridamole 100 mg amex, lasting for seconds or minutes 100 mg dipyridamole with visa, of paroxysmal neuralgia pains generic 100mg dipyridamole amex, which are burning or stabbing in nature, and are localized in the region of the tonsils, posterior pharynx, back of the tongue, and middle ear. May be idiopathic, or caused by vascular anatomical aberra- tions in the posterior fossa or regional tumors Occipital neuralgia Attacks of paroxysmal pain along the distribution of the greater or lesser occipital nerve, of unknown etiology Nasociliary neuralgia Paroxysmal attacks of orbital pain, caused or exacer- bated by touching the medial canthus and associated with edema and rhinorrhea. It is of unknown etiology Neuralgia of the Short-lived attacks of pain in the orbit, base of nose, sphenopalatine gan- and maxilla, associated with lacrimation, rhinorrhea glion (Sluder’s neural- and facial flushing. It affects elderly women, and the gia) cause is idiopathic Geniculate ganglion Paroxysmal attacks of pain are localized in the ear, neuralgia caused by regional tumors or vascular malformations Greater superficial Attacks of pain in the medial canthus, associated with petrosal nerve neural- tenderness and pain in the base of nose and maxilla, gia (vidian neuralgia) brought out or triggered by sneezing. The cause is idiopathic or inflammatory Neuralgia of inter- Paroxysmal deep ear pain with a trigger point in the medius nerve ear; of unknown etiology. It may be related to varicella zoster virus infection Anesthesia dolorosa Continuous trigeminal pain in the hypalgesic or anal- gesic territory of the nerve. It occurs after percu- taneous radiofrequency lesions or ophthalmic herpes zoster Tolosa–Hunt syndrome Episodes of retro-orbital pain lasting for weeks or months, associated with paralysis of cranial nerves III, IV, the first division of nerve V, VI, and rarely VII. It is caused by a granulo- matous inflammation in the vicinity of the cavernous sinus Raeder’s syndrome Symptomatic neuralgia of the first division of cranial nerve V, associated with Horner’s syndrome, and possibly ophthalmoplegia from middle cranial fossa pathology Gradenigo’s syndrome Continuous pain in the first and second divisions of cranial nerve V, with associated sensory loss, deafness, and sixth cranial nerve palsy. It particularly affects patients with inflammatory lesions in the region of the petrous apex after otitis media Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Headache: World Health Organization Classification 315 4 Miscellaneous headaches not associated with structural lesions Idiopathic stabbing headache External compression headache Cold stimulus headache – External application of a cold stimulus – Ingestion of a cold stimulus (e. Headache: World Health Organization Classification 317 10 Headache associated with metabolic disorder Hypoxia – High-altitude headache – Hypoxic headache – Sleep apnea headache Hypercapnia Mixed hypoxia and hypercapnia Hypoglycemia Dialysis Headache related to other meta- bolic abnormalities 11 Headache or facial pain associated with disorders of the cranium, neck, eyes, nose, sinuses, teeth, mouth, or other facial or cranial structures Cranial bone Neck – Cervical spine – Retropharyngeal tendinitis Eyes – Acute glaucoma – Refractive errors – Heterophoria or heterotropia Ears Nose and sinuses – Acute sinus headache – Other diseases of nose or sinuses Teeth, jaws, and related struc- tures Temporomandibular joint dis- ease 12 Cranial neuralgia, nerve trunk pain, and deafferentation pain Persistent (contact or tic-like) – Compression or distortion of cranial nerves pain of cranial nerve origin and second or third cervical roots – Demyelination of cranial nerves; optic neuritis (retrobulbar neuritis) – Infarction of cranial nerves; diabetic neuritis – Inflammation of cranial nerves; herpes zoster, chronic postherpetic neuralgia – Tolosa–Hunt syndrome – Neck–tongue syndrome – Other causes of persistent pain of cranial nerve origin Trigeminal neuralgia – Idiopathic trigeminal neuralgia – Symptomatic trigeminal neuralgia; com- pression of trigeminal root or ganglion; central lesions Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Pseudospine Pain Pseudospine pain refers to pain in the back or leg, or both, as the pres- enting symptom of an underlying systemic (metabolic or rheumatologi- cal), visceral, vascular, or neurological disease. Disease Clinical features Vascular disorders Abdominal aortic – Men over 50 years of age (1–4%) aneurysm – Abdominal and back pain (12%) – Pulsatile abdominal mass (50% sensitive; better in thin patients) Visceral disorders Gynecological conditions Endometriosis – Women of reproductive age (10%) – Cyclic pelvic pain (25–67%) – Back pain (25–31%) Pelvic inflammatory dis- – Young, sexually active women ease – Ascending infection: endocervix to upper urogeni- tal tract and symptoms of fever and chills, and leukocytosis – Lower abdominal, back and/or pelvic pain – Vaginal discharge, leukorrhea – Dysuria, urgency, frequency Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Pseudospine Pain 319 Disease Clinical features Ectopic pregnancy – Signs and symptoms of pregnancy: missed period (68%); breast tenderness; morning sickness – Abdominal pain (99. Pseudospine Pain 321 Disease Clinical features Adult scoliosis – Back pain, typically at apex of curve – Pseudoclaudication: spinal stenosis – Thoracic curve: uneven shoulders, scapular promi- nence, paravertebral hump with forward flexion – Lumbar curve: paravertebral muscle prominence Metabolic disorders Osteoporosis – Women over 60 years – Vertebral compression fractures; progressive loss of height and increasing thoracic kyphosis – Pelvic stress fracture: weight-bearing parasacral or groin pain – Chronic mechanical spine pain: increased with pro- longed standing, relieved rapidly in supine position Osteomalacia – Diffuse skeletal pain: back pain (90%), ribs, long bones of the legs – Skeletal tenderness to palpation – Antalgic, waddling gait (47%) – Elevated alkaline phosphatase (94%) Paget’s disease – Bone pain: deep, aching, constant; back pain (10–40%) – Joint pain: accelerated degenerative disease – Nerve root entrapment: hearing loss, spinal steno- sis – Deformities: enlarged skull, bowing of long bones, exaggerated spinal lordosis, kyphosis – Increased alkaline phosphatase – Characteristic radiographic appearance Diabetic poly- – Older patients, over 50 years of age radiculopathy – Unilateral or bilateral leg pain, though diffuse, may resemble sciatica; typically worse at night – Proximal muscle weakness and muscle wasting Malignancy – Patients over 50 years old (75%) – Previous history of malignancy – Constant back pain, unrelieved by positional changes – Night pain – Weight loss: 4. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Developmental dis- orders Spondylolysis, spondylo- listhesis Scoliosis Juvenile kyphosis Scheuermann’s disease Inflammatory disorders Diskitis Vertebral osteomyelitis Sacroiliac joint infection Rheumatological dis- orders – Juvenile rheumatoid arthritis – Reiter’s syndrome Reactive arthritis – Psoriatic arthritis – Enteropathic arthritis Tumors Intramedullary tumors 31% of pediatric spinal column tumors – Astrocytomas 60% of spinal cord tumors – Ependymomas 30% of spinal cord tumors – Drop metastases – Congenital tumors – Hemangioblastomas Extramedullary tumors – Eosinophilic granul- oma – Osteoblastomas – Aneurysmal bone cysts – Hemangiomas – Ewing’s sarcoma – Chordoma – Neuroblastoma – Ganglioneuroma – Osteogenic sarcoma Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Back Pain in Children and Adolescents 323 Intradural extramedul- lary tumors – Nerve sheath tumors – Meningiomas – Mesenchymal chondro- sarcomas Congenital tumors – Teratomas – Dermoid and epider- moid cysts – Lipomas Traumatic and mechan- ical disorders Soft-tissue injury Vertebral compression or end plate fracture Facet fracture and/or dis- location Transverse process or spinous process fractures Chronic degenerative mechanical disorders – Facet joint or pars in- terarticularis syndrome – Disk protrusion or her- niation – Postural imbalances, asymmetries, and/or overload on functional spinal elements – Overuse syndrome Nonspinal disorders Iliac fracture, apophyseal avulsion Renal disorder Pelvic/gynecological dis- order Retroperitoneal disorder Conversion reaction Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The back pain (HLD) may be worse when the patient is sitting and stand- ing, and may be relieved when she lies down Symphysiolysis pubis Pain in the groin, symphysis pubis and thigh, which may be increased while rising from sitting to standing, and during walking Transient osteoporosis Pain in the hip and groin areas, increasing when carry- of the hip ing weight, and with a Trendelenburg gait—lateral limp at each step Osteonecrosis of the Groin or hip pain radiating to back, thigh, knee and femoral head aggravated by weight-bearing or passive hip rotation.

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It should be emphasized that none of the immune modulators (as distinguished from immune suppressants) usually has severe side-effects cheap dipyridamole 100 mg fast delivery. The incidence of side-effects forms a bell-shaped curve discount dipyridamole 100mg line, showing some who have no side-effects while others have many dipyridamole 25mg overnight delivery. Its daily subcuta- neous injection usually causes some redness and itching at the injection site when treatment is initiated. One unique side-effect does occasionally occur; it is very infrequent and usually does not recur, but some people may expe- rience a sudden warm or hot sensation throughout the body along with chest tightness, shortness of breath, and a feeling of depres- sion. If an aggres- sive approach with emergency medicine is applied, increased prob- lems occur; thus, it is recommended that if this side-effect is pres- ent, rest for twenty minutes and do not panic. At full dose Avonex® has fewer side- effects because it is given at a lower total dose each week. Knowing this, it is recommended that high dose interferon (Betaseron®, Rebif®) be initiated at a quarter of the final dose each time it is taken 20 CHAPTER 2 • Managing the Disease Process until the side-effects abate. The dose then is increased to a half dose until stable, then three-quarters, then full. Medication that will lower temperature is helpful (ace- toaminophen, ibuprofen, etc. Small needle injections of interferon (Betaseron®, Rebif®) lead to more skin discoloration than the longer needle injection (Avonex®). Common sense tells us that intramuscular injections are best performed by a helper. That is not true for every- one but it holds for most people who have any problems with coor- dination or weakness. If one develops actual skin breakdown, a decision as to whether the treatment can be tolerated must be made. With interfer- on therapy, blood and liver tests should be monitored for a period of time, because sometimes significant changes can occur. In the meantime, there appears to be little relevance to measuring them because they correlate poorly with effect. Mitoxanthrone (Novantrone®) comes with the above mentioned heart concerns but it can also suppress the function of the blood and liver. Care must be taken that the i’s are dotted and the t’s crossed; that may be best done by a physician who is used to administering such chemotherapy agents (an oncologist or cancer doctor). THE TREATMENT OF ACUTE ATTACKS The treatment of acute attacks has changed little in the past decade. Cortisone medication including methylprednisolone, dexamethasone, 21 PART I • The Disease and Its Management prednisone, and others continue to be commonly used to shorten the attack. These potent anti-inflammatory drugs diminish the swelling within the brain and spinal cord that is seen as cells of the immune system invade and attack the nervous system.

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