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• International Classification of Vestibular • Internal (self) or external (surround) • Feeling of postural instability (e.g., swaying or • Disturbed sense of spatial orientation Bisdorff, et al., J Vest Research, 2009 1871 Westphal - Die Agoraphobie (fear of squares) Patients find it impossible to cross open squares and walk along certain – Legrande du Saulle - concept of ‘fear of fear’ streets. Fear restricts their mobility, [but] they insist that they are not aware of any reasons for their anxiety. It seems to arise as an alien force as soon as a square is crossed or approached. With the anxiety, – Lannois and Tournier - agoraphobia occurs in as part of one process, occurs the thought of not being able to cross individuals with pre-existing psychic anxiety, and is and a perception of an enormous expanse of space.
elicited by otologic diseases causing vertigo Kuch and Swinson, Can J Psychiatry, 1992 Balaban and Jacob, J Anxiety Disord, 2001 – Dizziness or subjective imbalance with normal exam – Fluctuating unsteadiness or illusory body perturbations – Provocative stimuli - bridge, street, crowds – Accompanied by anxiety and autonomic arousal – Obsessive-compulsive personality, mild depression – Onset after periods of stress, medical illness, or vestibular disorder – A neurologic syndrome, NOT panic or agoraphobia – Uneasiness about balance or spatial orientation – Feelings of swaying or rocking when still – Heightened awareness of normal movement – Environments with inexact or potentially conflicting visual and somatosensory cues (bridges, open spaces) – Dizziness in environments with complex visual stimuli Jacob, et al., J Psychopath Behav Assess, 1993; Am J Psychiatry, 1996; Bronstein, JNNP, 1995; J Neurol, 2004 Anxiety, Depression, and Dizziness in 132 Patients • Slower on a high versus low platform • Walk on a walkway • Gait slowest on high narrow walkway • Stride shortest on high narrow walkway • Greater sway for subjects with high anxiety (eyes open). No differences (eyes closed). • Shorter response latencies, more postural corrections for subjects with high anxiety. • Subjects with anxious traits were more strongly affected by erroneous visual stimuli. Adkin, et al., 2002; Brown, et al., 2002; Ohno, et al., 2004; Staab and Ruckenstein, Laryngoscope, 2003 Carpenter, et al., 2004; Viaud-Delmon, et al., 2000 Vestibular Neuronitis and Anxiety in 75 Patients • Prospective study of physical outcomes – lightheadedness, heavy headedness, “swimming” • Hypersensitivity to motion stimuli (SMD) – Movement of objects in the environment • A 21st century integrated clinical syndrome Godemann, et al., J Psychiatric Res, 2005 Staab and Ruckenstein. Arch Oto-HNS, 2005, 2007 • Normal physical exam and head imaging – Exam may provoke symptoms, but not signs of vestibular • e.g., dizziness, not nystagmus • Non-specific vestibular test findings – Isolated peripheral abnormalities are common • Peripheral deficits ≠ constant dizziness Staab and Ruckenstein. Arch Oto-HNS, 2005, 2007 • Vestibular laboratory (basic reflex tests) • A test of integrated balance function • Misinterpretations of this test continue to be Cevette, et al., Otolaryn Head Neck Surg, 1995 Allum, et al., Gait Posture, 2001; Jacob, et al., Psychosom Med, 1997; JNNP, 2009; Huweler, et al., Behav Res Ther, 2009; Endo, et al., Spine, 2008 Ödman & Maire, Acta Oto-Laryngol, 2008


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Ereção sem hora marcada é a nova meta dos fármacos São José do Rio Preto, 3 de agosto de 2007 Cecília Dionizio Nova dosagem do medicamento comercializado como Cialis, do laboratório Eli Lilly, chega às farmácias da Europa este semestre, com a proposta de atender a demanda de mais de 50% dos homens, entre 40 e 70 anos, que têm preocupação em manter ou atingir uma ereção. S

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