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Five Things Physicians and Patients Should Question Don’t prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles arthritis x ray images buy etoricoxib amex, forklifts arthritis back pain relief order etoricoxib 60 mg online, cranes or other heavy equipment rheumatoid arthritis ketogenic diet discount etoricoxib uk. Evidence suggests higher risk with acute opioid use arthritis pain best medication order etoricoxib 60mg, but risk remains elevated throughout treatment with any opioid and reverses on cessation gabapentin for arthritis in dogs cheap etoricoxib 90mg with mastercard. Workers who operate motor vehicles/heavy equipment should be precluded from performing these or other safety-sensitive job functions while under treatment with opioids. Don’t initially obtain X-rays for injured workers with acute non-specifc low back pain. Even when red fags are suspected, it should not be mandatory to order an X-ray in all cases. There is also no reason, either medically or legally, to obtain low back X-rays as a “baseline” for work-related injuries. Don’t order low back X-rays as part of a routine preplacement medical examination. Routine low back X-rays are costly, result in unnecessary radiation exposure, do not address the worker’s abilities and do not predict future injuries. Don’t routinely order X-ray for diagnosis of plantar fasciitis/heel pain in employees who stand or walk at work. Don’t routinely order sleep studies (polysomnogram) to screen for/diagnose sleep disorders in workers sufering from chronic fatigue/insomnia. While a polysomnogram is an essential tool in diagnosing many sleep disorders, it is not usually necessary in assessing insomnia. If lack of sufcient sleep or the job schedule is afecting the patient’s sleep patterns, then behavioral modifcation and attempts to modify the sleep schedule and improve sleep hygiene should be attempted frst. The position paper and the methodology for the development of the Practice Guidelines are available at Elk Grove Village, Ill: 2 American College of Occupational and Environmental Medicine; 2011. Elk Grove Village, Ill: 3 American College of Occupational and Environmental Medicine; 2011. Elk Grove Village, Ill: 4 American College of Occupational and Environmental Medicine; 2011. American College of Physicians Five Things Physicians and Patients Should Question Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary 1 heart disease. In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes. Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology. In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management 5 or improved patient outcomes. The group collaboratively identifed and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. Internists specialize in the prevention, understanding of professionalism and how they can detection, and treatment of illness in adults. Five Things Physicians and Patients Should Question Don’t take a multi-vitamin, vitamin E or beta carotene to prevent cardiovascular disease or cancer. However, there is insufcient evidence to demonstrate beneft from multivitamin supplementation to prevent cardiovascular disease or cancer. Adequate evidence demonstrates that supplementation with vitamin E and beta carotene in healthy populations specifcally have no beneft on cardiovascular disease or cancer. Beta carotene is also associated with increased risks of lung cancer in smokers and people who have been exposed to asbestos. More than 1, 000 symptom-free men need to be screened for prostate cancer in order to save one additional life. As a result, increased harms and medical costs due to widespread screening of asymptomatic men are believed to outweigh the benefts of routine screening. In rare circumstances, such as a strong family history of prostate and related cancers, screening may be appropriate. However, there is no data suggesting that these imaging studies will improve survival or improve the likelihood of fnding a tumor (estimated tumor detection is less 3 than 2% in asymptomatic patients screened). Whole-body scanning is not recommended by medical professional societies for individuals without symptoms, nor is it a routinely practiced screening procedure in healthy populations. Don’t use expensive medications when an equally efective and lower-cost medication is available. Studies estimate that for every 10% increase in the use of generic cholesterol drugs, Medicare costs could be reduced by $1 billion annually. Don’t perform screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease. Health care professionals should not perform cervical cancer screening in women who have had a hysterectomy that removed their cervix and do not have a history of high-grade precancerous lesions or cervical cancer. Screening provides no benefts to these patients and may subject them to potential risks 5 from false-positive results; including physical. In addition, cervical cancer screening should not be performed on women over the age of 65 that are at low risk for cervical cancer and have had negative results from prior screenings. Health care professionals should make this decision on a case-by-case basis, but once a patient stops receiving screenings, in general, they should not re-start screenings. Screening for women in this population provides little to no beneft as the incidence and prevalence of cervical disease declines for women starting at age 40–50 years. Each task force member individually developed 2-3 recommendations and the top ten were selected using an electronic survey by the entire task force. Subsequently, the ten recommendations were prioritized by the task force and rationales with references were produced. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: U. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. In Medicare Part D plans, low or zero copays and other features to encourage the use of generic statins work, could save billions. The implications of choice: prescribing generic or preferred pharmaceuticals improves medication adherence for chronic conditions. For more information or to see other lists of Five Things Providers and Patients Should Question, visit American College of Radiology Ten Things Physicians and Patients Should Question Don’t do imaging for uncomplicated headache. Imaging headache patients absent specifc risk factors for structural disease is not likely to change management or improve outcome. Those patients 1 with a signifcant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Also, incidental fndings lead to additional medical procedures and expense that do not improve patient well-being. Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. This approach is cost-efective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specifcity of 94 percent. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Imaging of the neck performed to evaluate non-thyroid-related conditions commonly reveals thyroid nodules. Fine needle aspiration often fails to defnitively characterize a lesion as benign owing to the limitations of cytologic evaluation. Consequently, some patients with incidentally-discovered benign nodules undergo unnecessary serial ultrasound imaging and/or surgery. Two published studies reported that the percentage of nodules referred for ultrasound would be reduced by 35–46% using the proposed algorithm. Compare unenhanced with post-contrast to identify enhancement in a mass 7 (2) Adrenal nodule characterization a. Unenhanced scan enables distinction of calcifcation from endoleak when compared to post-contrast images (4) Gastrointestinal bleeding a. If available, dual energy can be used to create a virtual unenhanced dataset and avoid the unenhanced acquisition. In the latter condition, dilated pelvic veins and venous refux account for a range of symptoms, including chronic pain of more than 6-month duration. The diagnostic criteria include the following: 4 or more ipsilateral pelvic 9 varicosities, 1 or more pelvic varicosities measuring more than 4 mm, ovarian (gonadal) vein dilatation > 8 mm in diameter. In patients with dilated pelvic veins that do not meet these criteria, interpretations should not suggest Pelvic Congestion Syndrome. Furthermore, since these criteria were proposed by Coakley et al in 1999, several investigations have confrmed that ovarian vein refux, ovarian vein dilatation and parauterine vein dilatation can be observed in asymptomatic patients, particularly multiparous women. Interpretations should recommend that clinical symptoms guide decision-making with respect to the need for vascular interventional consultation. Don’t routinely recommend follow-up for nonobstructed, asymptomatic, isolated, short-segment jejunojejunal intussusception in adults. In patients without an identifable lead point mass lesion, imaging characteristics that favor the transient variety include short length ( 3. Self-limited jejunojejunal intussusception can occur in the absence of any bowel disease, or the fnding may indicate an infectious or infammatory process, such as enteritis or Celiac disease. Decisions regarding the need for additional work-up and follow up imaging should be made on clinical grounds. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specifc recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the fnal fve things list. How this List Was Created (6 – 10) the Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected fve initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental fndings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging fndings • Pamela T. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. Evidence-Based Guidelines in the Primary Care Setting: Neuroimaging in Patients with Nonacute Headache. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality.

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Occasionally the pregnancy does continue arthritis in dogs today tonight effective etoricoxib 90 mg, there can be serious problems associated bleeding or discharge may last for a few weeks as healing takes with the placenta such as the baby may be small due to arthritis in dogs limping etoricoxib 90mg mastercard poor blood place what does arthritis in back feel like cheap etoricoxib 90 mg mastercard. If there is an increasing amount of bleeding rheumatoid arthritis diet youtube purchase etoricoxib 120mg visa, bright blood fow of oxygen and nutrients arthritis in back icd 9 buy etoricoxib with paypal. Endometrial ablation is therefore only loss, foul-smelling vaginal discharge or increasing pain then you suitable for women who have completed their family. Infections can occur and may require not have an endometrial ablation if there is a chance that you may antibiotics. It is best to consult your doctor if you think that you have wish to have more children. If you have pain, a foul smelling discharge or a discharge that is green-yellow you should contact your doctor. In fact studies have shown that sexual function improves after endometrial ablation, presumably due to less inconvenience from heavy periods. You can have sex as soon as the bleeding and discharge have stopped or after 4 weeks. Endometrial ablation does not affect the ovaries or the the timing of your cycle is not critical for resection or NovaSure. You will still have normal hormone function and other techniques, it is optimal to perform the procedure in the frst week will go through menopause at the normal time for you. This procedure is not intended as treatment for pelvic pain or When will I know if the procedure has been successful However, studies have shown endometrial It takes between 3 and 6 months for the scarring of the uterine lining ablation is not only likely to reduce the heaviness of your periods, to become effective. Therefore, it is possible that you may have heavy but may also reduce the amount of pain that you suffer experience periods initially, though these become lighter as time progresses. It is unclear as to why it occurs polyps, then these may be removed at the time of an ablation and and treatments are variably successful. In this situation, options may include medications, repeat ablation (by the resection or rollerball techniques only – all other methods are unable to be used a second time) or hysterectomy. Hysterectomy following an endometrial ablation may be for failure of the treatment, or the development of a new problem, such as a fbroid or pain. If you have had a usual caesarean (lower segment incision) any of the endometrial ablation treatments are suitable for you. If you have had a classical caesarean (an up and down incision), then you should not have the NovaSure, Cavaterm or Thermablate procedures. The other procedures are possible and you should discuss this with your doctor further. The information presented should not be relied on as a substitute for medical advice, independent judgement or proper assessment by a doctor, with consideration of the particular circumstances of each case and individual needs. This document refects information available at the time of its preparation, but its currency should be determined having regard to other available information. Executive summary of recommendations What are the risk factors for endometrial hyperplasia Endometrial hyperplasia is often associated with multiple identifiable risk factors and assessment should aim to identify and monitor these factors. What diagnostic and surveillance methods are available for endometrial hyperplasia Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue. Diagnostic hysteroscopy should be considered to facilitate or obtain an endometrial sample, especially P where outpatient sampling fails or is nondiagnostic. Direct visualisation and biopsy of the uterine cavity using hysteroscopy should be undertaken where P endometrial hyperplasia has been diagnosed within a polyp or other discrete focal lesion. Observation alone with follow-up endometrial biopsies to ensure disease regression can be considered, C especially when identifiable risk factors can be reversed. However, women should be informed that treatment with progestogens has a higher disease regression rate compared with observation alone. What should the duration of treatment and follow-up of hyperplasia without atypia be At least two consecutive 6-monthly negative biopsies should be obtained prior to discharge. Women should be advised to seek a further referral if abnormal vaginal bleeding recurs after P completion of treatment because this may indicate disease relapse. When is surgical management appropriate for women with endometrial hyperplasia without atypia Hysterectomy is indicated in women not wanting to preserve their fertility when (i) progression to C atypical hyperplasia occurs during follow-up, or (ii) there is no histological regression of hyperplasia despite 12 months of treatment, or (iii) there is relapse of endometrial hyperplasia after completing progestogen treatment, or (iv) there is persistence of bleeding symptoms, or (v) the woman declines to undergo endometrial surveillance or comply with medical treatment. A laparoscopic approach to total hysterectomy is preferable to an abdominal approach as it is B associated with a shorter hospital stay, less postoperative pain and quicker recovery. Endometrial ablation is not recommended for the treatment of endometrial hyperplasia because D complete and persistent endometrial destruction cannot be ensured and intrauterine adhesion formation may preclude future endometrial histological surveillance. Women with atypical hyperplasia should undergo a total hysterectomy because of the risk of B underlying malignancy or progression to cancer. There is no benefit from intraoperative frozen section analysis of the endometrium or routine C lymphadenectomy. Postmenopausal women with atypical hyperplasia should be offered bilateral salpingo-oophorectomy P together with the total hysterectomy. For premenopausal women, the decision to remove the ovaries should be individualised; however, D bilateral salpingectomy should be considered as this may reduce the risk of a future ovarian malignancy. How should women with atypical hyperplasia who wish to preserve their fertility or who are not suitable for surgery be managed Pretreatment investigations should aim to rule out invasive endometrial cancer or co-existing ovarian P cancer. Histology, imaging and tumour marker results should be reviewed in a multidisciplinary meeting and P a plan for management and ongoing endometrial surveillance formulated. How should women with atypical hyperplasia not undergoing hysterectomy be followed up Review intervals should be every 3 months until two consecutive negative biopsies are obtained. In asymptomatic women with a uterus and evidence of histological disease regression, based upon a P minimum of two consecutive negative endometrial biopsies, long-term follow-up with endometrial biopsy every 6–12 months is recommended until a hysterectomy is performed. Disease regression should be achieved on at least one endometrial sample before women attempt to P conceive. Women with endometrial hyperplasia who wish to conceive should be referred to a fertility specialist D to discuss the options for attempting conception, further assessment and appropriate treatment. Subsequent management should be as described in the preceding sections of the guideline. How should endometrial hyperplasia be managed in women on adjuvant treatment for breast cancer What is the risk of developing endometrial hyperplasia on adjuvant treatment for breast cancer Women taking tamoxifen should be informed about the increased risks of developing endometrial D hyperplasia and cancer. How should women who develop endometrial hyperplasia while on tamoxifen treatment for breast cancer be managed Subsequent management should be according to the histological classification of endometrial P hyperplasia. Purpose and scope the aim of this guideline is to provide clinicians with up-to-date evidence-based information regarding the management of endometrial hyperplasia. Introduction and background epidemiology Endometrial hyperplasia is defined as irregular proliferation of the endometrial glands with an increase in the gland to stroma ratio when compared with proliferative endometrium. Further information about the assessment of evidence and the grading of recommendations may be found in Appendix I. Endometrial hyperplasia is often associated with multiple identifiable risk factors and assessment P should aim to identify and monitor these factors. Endometrial hyperplasia develops when estrogen, unopposed by progesterone, stimulates endometrial cell growth by binding to estrogen receptors in the nuclei of endometrial cells. This separates D endometrial hyperplasia into two groups based upon the presence of cytological atypia: i. Classification systems for endometrial hyperplasia were developed based upon histological characteristics and oncogenic potential. The association of cytological atypia with an increased risk of endometrial cancer has been known since 1985. B Endometrial surveillance should include endometrial sampling by outpatient endometrial biopsy. Transvaginal ultrasound may have a role in diagnosing endometrial hyperplasia in pre and P postmenopausal women. Endometrial hyperplasia is often suspected in women presenting with abnormal uterine bleeding. However, confirmation of diagnosis requires histological analysis of endometrial tissue specimens obtained either by using miniature outpatient suction devices designed to blindly abrade and/or aspirate endometrial tissue from the uterine cavity or by inpatient endometrial sampling, such as dilatation and curettage performed under general anaesthesia. Endometrial sampling is also fundamental in monitoring regression, persistence or progression. Outpatient endometrial biopsy is convenient and has high overall accuracy for diagnosing endometrial cancer. A small cohort study has shown that up to 10% of endometrial Evidence pathology can be missed even with inpatient endometrial sampling. Hysteroscopy can detect focal lesions such as polyps that may be missed by blind sampling. Directed biopsies can be Evidence taken through the operating channel of a continuous flow operating hysteroscope24, 26 or level 1– blindly through the outer sheath after removing the telescope. A negative or normal hysteroscopy reduced the probability of endometrial disease from 10. It is an expensive test and because of the radiation associated with its application it should not be routinely recommended. Several biomarkers associated with endometrial hyperplasia have been investigated, but as Evidence of yet none of them predicts disease or prognosis accurately enough to be clinically useful. Women should be informed that the risk of endometrial hyperplasia without atypia progressing to B endometrial cancer is less than 5% over 20 years and that the majority of cases of endometrial hyperplasia without atypia will regress spontaneously during follow-up. Progestogen treatment is indicated in women who fail to regress following observation alone and in P symptomatic women with abnormal uterine bleeding. There are two cohort studies and a case–control study describing the natural history of hyperplasia without atypia and its risk for progression to cancer. Two cohort studies have followed up women diagnosed with endometrial hyperplasia who had no treatment.

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They may also occur occasionally in other oculomotor brainstem disorders such as Miller Fisher syndrome tylenol arthritis pain label discount etoricoxib online amex, but are not seen in normals arthritis diet australia order etoricoxib online from canada. Cogan’s lid twitch sign should not be confused with either Cogan’s syn drome rheumatoid arthritis white blood cells order etoricoxib 120 mg overnight delivery, an autoimmune disorder of episodic vertigo arthritis medication nz buy etoricoxib 120mg low price, tinnitus pregnant with arthritis in back order 90 mg etoricoxib mastercard, hearing loss, and interstitial keratitis; or the oculomotor apraxia of Cogan, a congenital lack of lateral gaze. Myasthenia gravis: a review of the disease and a description of lid twitch as a characteristic sign. A prospective study assessing the utility of Cogan’s lid twitch sign in patients with isolated unilateral or bilateral ptosis. Collapsing Weakness Collapsing weakness, or ‘give-way’ weakness, suggesting intermittent voluntary effort, is often taken as a sign of functional weakness. Although sometimes labelled as ‘volitional weakness’, it is not clear that such weakness is in any con scious sense willed, and it is therefore probably better to use a non-committal 87 C Collier’s Sign term such as ‘apparent weakness’. Such collapsing weakness has also been recorded following acute brain lesions such as stroke. Cross References Functional weakness and sensory disturbance; Spasticity; Weakness; ‘Wrestler’s sign’ Collier’s Sign Collier’s sign (‘posterior fossa stare’, ‘tucked lid’ sign), rst described in 1927, is elevation and retraction of the upper eyelids, baring the sclera above the cornea, with the eyes in the primary position or looking upward. There may be accompanying paralysis of vertical gaze (especially upgaze) and light-near pupillary dissociation. The sign is thought to re ect damage to the posterior commissure levator inhibitory bres. Nuclear ophthalmoplegia with special reference to retraction of the lids and ptosis and to lesions of the posterior commissure. It represents a greater degree of impairment of consciousness than stupor or obtundation, all three forming part of a continuum, rather than discrete stages, ranging from alert to comatose. This lack of precision prompts some authorities to prefer the description of the individual aspects of neurological function in unconscious patients, such as eye movements, limb movements, vocalization, and response to stimuli, since this conveys more information than the use of terms such as coma, stupor, or obtundation, or the use of a lumped ‘score’, such as the Glasgow Coma Scale. Assessment of the depth of coma may be made by observing changes in eye move ments and response to central noxious stimuli: roving eye movements are lost before oculocephalic responses; caloric responses are last to go. Unrousability which results from psychiatric disease, or which is being feigned (‘pseudocoma’), also needs to be differentiated. A number of neurobehavioural states may be mistaken for coma, including abulia, akinetic mutism, catatonia, and the locked-in syndrome. Cross References Abulia; Akinetic mutism; Caloric testing; Catatonia; Decerebrate rigid ity; Decorticate rigidity; Locked-in syndrome; Obtundation; Oculocephalic response; Roving eye movements; Stupor; Vegetative states; Vestibulo-ocular re exes Compulsive Grasping Hand this name has been given to involuntary left-hand grasping related to all right-hand movements in a patient with a callosal haemorrhage. This has been interpreted as a motor grasp response to contralateral hand movements and a variant of anarchic or alien hand. The description does seem to differ from that of behaviours labelled as forced groping and the alien grasp re ex. In its ‘pure’ form, there is a dissociation between relatively preserved auditory and reading com prehension of language and impaired repetition (in which the phenomenon of conduit d’approche may occur) and naming. Reading comprehension is good or normal and is better than reading aloud which is impaired by paraphasic errors. Conduction aphasia was traditionally explained as due to a disconnection between sensory (Wernicke) and motor (Broca) areas for language, involving the arcuate fasciculus in the supramarginal gyrus. Certainly the brain damage (usu ally infarction) associated with conduction aphasia most commonly involves the left parietal lobe (lower postcentral and supramarginal gyri) and the insula, but it is variable, and the cortical injury may be responsible for the clinical picture. Conduction aphasia is most often seen during recovery from Wernicke’s aphasia, and clinically there is often evidence of some impairment of compre hension. Cross References Anomia; Aphasia; Broca’s aphasia; Conduit d’approche; Paraphasia; Transcortical aphasias; Wernicke’s aphasia Conduit d’approche Conduit d’approche, or ‘homing-in’ behaviour, is a verbal output phenomenon applied to patients with conduction aphasia attempting to repeat a target word, in which multiple phonemic approximations of the word are presented, with gradual improvement until the target word is achieved. This phenomenon sug gests that an acoustic image of the target word is preserved in this condition. A similar phenomenon may be observed in patients with optic aphasia attempting to name a visual stimulus. A similar behaviour is seen in so-called speech apraxia, in which patients repeatedly approximate to the desired output before reaching it. The term may also be used to refer to a parapraxis in which patients attempt to perform a movement several times before achieving the correct movement. Cross References Aphasia; Conduction aphasia; Optic aphasia; Parapraxia, Parapraxis; Speech apraxia 90 Congenital Nystagmus C Confabulation the old de nition of confabulation as the falsi cation of episodic mem ory occurring in clear consciousness, often in association with amnesia (in other words, paramnesias related as true events), has proven increasingly de cient, not least because most amnesic patients, suffering from medial temporal lobe/hippocampal lesions, do not confabulate, and poor memory alone cannot explain confabulation. Schnider has developed a fourfold schema of intrusions, momentary confabulations, fantastic confabulations, and behaviourally sponta neous confabulations, of which the latter are clinically the most challenging. Anterior limbic structures are thought culpable, and the pathogenesis includes a wide variety of diseases, which may include associated phenomena such as amnesia, disorientation, false recognition syndromes including the Capgras delu sion, and anosognosia. Psychophysical and neuroimaging studies suggest that confabulators have reality confusion and a failure to integrate contradictory information due to the failure of a ltering process, 200–300 ms after stimulus presentation and before recognition and re-encoding, which normally permits suppression of currently irrelevant memories. Cross References Amnesia; Asomatognosia; Cortical blindness; Delusion; Paramnesia Confusion Confusion, understood as the inability to think with one’s customary clarity and coherence, is a feature of not only delirium, but also of other situations (encephalopathies, attentional disorders). Moreover, as there is a lack of corre lation of meaning when this term is used by different health professionals, it is regarded by some as an unhelpful term. Cross Reference Delirium Congenital Nystagmus Congenital nystagmus is a pendular nystagmus with the following characteristics: • Usually noted at birth or in early infancy; sometimes may only become apparent in adult life; • Irregular waveforms; • Conjugate; • Almost always horizontal; 91 C Consensual Light Re ex • Accentuated by xation, attention, anxiety; • Decreased by convergence, active eyelid closure; • Often a null point or region; • No complaint of oscillopsia; • It may appear with blindness of childhood onset. Acquired pendular nystagmus may be a result of neurological disease which may present in childhood, such as Pelizaeus–Merzbacher disease, mitochondrial disease, multiple sclerosis, and Whipple’s disease. This may be due to a variety of factors, including prolonged muscle spasticity with or without muscle brosis. This often occurs in the context of limb immobilization or inactivity, for example, in a exed posture. Injections of botulinum toxin to abolish muscle spasticity may be required to assess whether there is concurrent ligamentous restriction, and thus to plan opti mum treatment, which may involve surgery. This may be • Vocal: involuntary utterance of obscenities; • Mental: compulsion to think obscenities. The former is a complex vocal tic most characteristically seen in Tourette syndrome although it actually occurs in less than half of affected individuals. Other recognized disease associations are as follows: • Lesch–Nyhan syndrome; • Postencephalitic parkinsonism; • Neuroacanthocytosis; • Cingulate cortical seizures. The pathophysiology of coprolalia is unknown but may be related to frontal (cingulate and orbitofrontal) dysfunction, for which there is some evidence in Tourette syndrome. Cross Reference Tic Copropraxia Copropraxia is a complex motor tic comprising obscene gesturing, sometimes seen in Tourette syndrome. Cross References Coprolalia; Tic Corectopia Corectopia is pupillary displacement, which may be seen with midbrain lesions, including transtentorial herniation and top-of-the-basilar syndrome, peripheral oculomotor nerve palsies, and focal pathology in the iris. Corneal Re ex the corneal re ex consists of a bilateral blink response elicited by touching the cornea lightly, for example, with a piece of cotton wool. As well as observing whether the patient blinks, the examiner should also ask whether the stimulus was felt: a difference in corneal sensitivity may be the earliest abnormality in this re ex. The bres subserving 93 C Corneomandibular Re ex the corneal re ex seem to be the most sensitive to trigeminal nerve compression or distortion: an intact corneal re ex with a complaint of facial numbness leads to suspicion of a non-organic cause. Trigeminal nerve lesions cause both ipsilateral and contralateral corneal re ex loss. Cerebral hemisphere (but not thalamic) lesions causing hemiparesis and hemisensory loss may also be associated with a decreased corneal re ex. The corneal re ex has a high threshold in comatose patients and is usually preserved until late (unless coma is due to drug overdose), in which case its loss is a poor prognostic sign. Cross References Blink re ex; Coma; Cerebellopontine angle syndrome; Corneomandibular re ex; Facial paresis Corneomandibular Re ex the corneomandibular re ex, also known as the corneopterygoid re ex or Wartenberg’s re ex or sign, consists of anterolateral jaw movement following corneal stimulation. Cortical blindness may result from: • Bilateral (sequential or simultaneous) posterior cerebral artery occlusion; • ‘Top of the basilar syndrome’; • Migraine; • Cerebral anoxia; 94 Coup de Sabre C • Bacterial endocarditis; • Wegener’s granulomatosis; • Following coronary or cerebral angiography (may be transient); • Epilepsy (transient); • Ciclosporin therapy. Patients with cortical blindness may deny their visual defect (Anton’s syn drome, visual anosognosia) and may confabulate about what they ‘see’. Cross References Anosognosia; Confabulation; Macula sparing, Macula splitting; Optokinetic nystagmus, Optokinetic response; Prosopagnosia; Pupillary re exes; Visual agnosia Cotard’s Syndrome A delusional syndrome, rst described in the 1890s, characterized by the patient’s denial of their own existence, or of part of their body. The patient may assert that they are dead and able to smell rotten esh or feel worms crawling over their skin. Although this may occur in the context of psychiatric disease, especially depression and schizophrenia, it may also occur in association with organic brain abnormalities, speci cally lesions of the non-dominant temporoparietal cortex, or migraine. Some envisage Cotard’s syndrome as a more pervasive form of the Capgras syndrome, originating similarly as a consequence of Geschwindian disconnection between the limbic system and all sensory areas, leading to a loss of emotional contact with the world. Cross References Capgras syndrome; Delusion; Disconnection syndromes Coup de Poignard Coup de poignard, or dagger thrust, refers to a sudden precordial pain, as may occur in myocardial infarction or aortic dissection, also described with spinal subarachnoid haemorrhage. Subarachnoid haemorrhage presenting as acute chest pain: a variant of le coup de poignard. Coup de Sabre Coup de sabre is a localized form of scleroderma manifest as a linear, atrophic lesion on the forehead which may be mistaken for a scar. This lesion may be associated with hemifacial atrophy and epilepsy, and neuroimaging may 95 C Cover Tests show hemiatrophy and intracranial calci cation. Whether these changes re ect in ammation or a neurocutaneous syndrome is not known. Cross Reference Hemifacial atrophy Cover Tests the simple cover and cover–uncover tests may be used to demonstrate manifest and latent strabismus (heterotropia and heterophoria), respectively. The cover test demonstrates tropias: the uncovered eye is forced to adopt xation; any movement therefore represents a manifest strabismus (heterotropia). The cover–uncover test demonstrates phorias: any movement of the cov ered eye to re-establish xation as it is uncovered represents a latent strabismus (heterophoria). The alternate cover or cross-cover test, in which the hand or occluder moves back and forth between the eyes, repeatedly breaking and re-establishing xa tion, is more dissociating, preventing binocular viewing, and therefore helpful in demonstrating whether or not there is strabismus. It should be performed in the nine cardinal positions of gaze to determine the direction that elicits maxi mal deviation. However, it does not distinguish between tropias and phorias, for which the cover and cover–uncover tests are required. Cross References Heterophoria; Heterotropia Cramp Cramps are de ned as involuntary contractions of a number of muscle units which results in a hardening of the muscle with pain due to a local lactic aci dosis. Cramps are not uncommon in normal individuals but in a minority of cases they are associated with an underlying neurological or metabolic disorder. Recognized associations of cramp include • Normal individuals: Especially during periods of dehydration with salt loss; pregnancy. Symptomatic treatment of cramps may include use of quinine sulphate, vitamin B, naftidrofuryl, and calcium channel antagonists such as diltiazem; carba mazepine, phenytoin, and procainamide have also been tried. Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the Therapeutics and Technology Subcommittee of the American Academy of Neurology. Cross References Fasciculation; Myokymia; Neuromyotonia; Spasm; Stiffness Cremasteric Re ex the cremasteric re ex is a super cial or cutaneous re ex consisting of con traction of the cremaster muscle causing elevation of the testicle, following stimulation of the skin of the upper inner aspect of the thigh from above downwards. The cremasteric re ex is lost when the corticospinal pathways are damaged above T12 or following lesions of the genitofemoral nerve. It may also be absent in elderly men or with local pathology such as hydrocele, varicocele, orchitis, or epididymitis. Cross References Abdominal re exes; Re exes Crocodile Tears Crocodile tears, gustatory epiphora, or Bogorad’s syndrome re ect inappropri ate unilateral lacrimation during eating, such that tears may spill down the face (epiphora). Cross References Bell’s palsy; Epiphora; Synkinesia, Synkinesis Crossed Adductor Re ex Contralateral adductor muscle contraction in response to a tap on the adductor tendon may be found with a pyramidal lesion above L2, although it is a normal nding in infants.

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