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Hemiballism Definition, Symptoms, Causes, Treatment | Hemiballismus vs Chorea

Hemibalism is a form of chorea characterized by rigorous and frequent movements of the limbs on one side of the body. Less often, both sides (biballismus) and legs (paraballismus) can be affected. Unlike chorea, the movements are intermittent during waking and the overwhelming involvement of the proximal muscles in their  their flailing nature.

However, the difference is not obvious because proximal ballismic movements may exist along with distal chorea, symptoms may be intermittent in more severe cases, and in many patients a change of ballismus to chorea can be seen readily or in response to treatment.

Hemibalism is a one sided ballism, a disorder of a frequent hyperkinetic movement that has a large amplitude with vigorous irregular movements. Hemibalism overlaps with clinical hemichorea ("violent chorea"). The hemiballismus-hemichorea is sometimes used to reflect this overlap. Hemiballismic states may cause loss of normal muscle tone.

Neuroanatomically, hemobalism is most commonly associated with lesions of the contralateral subthalamic nucleus of Luys or efferent pathways, although there are separate reports of its outward appearance with diseases of the caudal nucleus, globus pallidus, thalamus, and even with ipsilateral lesions. Neuropathologically, vascular events like ischemia and haemorrhage are common underlying causes of hemibalism.

Hemiballism Definition, Symptoms, Causes, Treatment  Hemiballismus vs Chorea

Hemiballism Symptoms

Ballism is characterized by rigorous, high amplitude, waving like movements primarily by the activity of the proximal appendicular muscles of the shoulder and pelvis. Movements cease during sleep. There is a reduction in muscle tone. These symptoms are exposed unilaterally with a lesion in the subthalamic nucleus in contralateral position.

Since clinical ballism is almost always happening on the one side only and is usually due to a vascular accident, it is also known as hemiballism. Symptoms associated with dysfunction of the basal ganglia are usually observed bilaterally. However, as hemiballism, lesions on one side appear on other side, as the basal ganglia output is directed to the ipsilateral cerebral cortex, whose descending pathways predominantly innervate lower motoneurons on the contralateral side.

Hemiballism Causes

Some causative factors include occupational lesions, inflammation due to encephalitis, systemic lupus erythematosus,  demyelination, metabolic causes like hyperosmolal non ketogenic hyperglycemia, infection like toxoplasmosis , medicines especially oral contraceptives and head trauma.

Pathophysiological, hemibalism is believed to be the result of reduced conduction of the short path within the basal ganglia thalamocortical motor chain (as well as other involuntary movements such as hyperkinetic choreoathetosis). Hemiballismus associated with vascular system improves spontaneously, but drug therapy with neuroleptics may be beneficial. Other drugs that are sometimes useful include anti-psychotic drugs and anticonvulsant drugs.

Hemiballism Treatment

In an acute period when movements are most destructive and potentially harmful, some cases need treatment. Neuroleptics have long been identified as effective and remain the first choice among most clinicians, but no specific drug has been identified as superior to others. Clozapine has been reported to be useful, when other neuroleptics have failed.

Presynaptic dopamine-depleting medications  have also been reported to be beneficial. Others have been reported that are useful for the management of Hemiballism include valproic acid, gabapentin, topiramate, sertraline, and combinations of neuroleptics. Those patients who are not responding to psychotic drugs or other medications functional surgery might be the next option.
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Sialorrhea ICD-10, Definition, Symptoms, Causes, Treatment

Sialorrhea, consisting of the involuntary release of passive saliva from the mouth due to the inability to deal with oral secretions, is often a finding of ALS patients and an important source of social stress. This is not caused by an increase in saliva production that has actually decreased, but due to gradual paralysis and lack of coordination of the muscles related to orofacial and palatolingual area during saliva production.

Sialorrhea is normal in infants and young children. Mild to moderate drooling may continue in infancy and have been reported in children up to 5 years of age. Hyper-salivation or sialorrhea  that goes beyond this period is usually considered pathological and is most common in patients with neurological disorders.

Drooling is often sharpened by a dental malocclusion, poor oral closure or psychogenic control of oral cavity and limited head or trunk control connected with neurological malfunctioning. For example, hyper-salivation is reported in 10% to 37% of children with cerebral palsy. Sialorrhea management is recommended when it represents some kind of clinical implications in a patient.

Sialorrhea or hypersalivation can be part of many diseases. Sialorrheais often a part of parkinson disease, as it has an excessive production of saliva in combination with a reduction in swallowing. Other neurological conditions may also produce hypersalivation such as cerebral palsy, stroke conditions, traumatic brain injuries or neurodegenerative diseases such as ALS.

Sialorrhea ICD-10, Definition, Symptoms, Causes, Treatment

Symptoms of sialorrhea

Some commonly observed symptoms of sialorrhea are

  • Nausea
  • vomiting
  • Dysphagia
  • change in taste
  • Pooling of saliva in mouth
  • Drooling

Sialorrhea Causes

Mild to moderate kind of sialorrhea might be associated with minor irritation orally or denture  or braces fitting problems. Episodic sialorrhoea can be a treacherous manifestation of a gastroesophageal reflex (GERD). Increased salivation is produced as a protective mechanism for buffering in patients with GERD. This is called  water brash.

A similar saliva state whose underlying cause is unknown called idiopathic paroxysmal salivation. Increased salivary flow consists of episodes occurring 1 or 2 times per week for 2-5 minutes in duration. Episodes are preceded by a multi symptomatic response consisting of nausea or pain in the epigastrium, but without progressing vomiting. These might be variants of the same clinical problem. Hypersalivation may also be associated with obstruction of the esophagus (foreign body, cancer and strictures), infection and nasogastric intubation.

Sialorrhea Treatment

Sialoreia is socially uncomfortable and can interfere with oral hygiene and is a risk factor for bronchial aspiration. Increased saliva management might be done with gum or hard candy to induce swallowing. If this is not enough then injections of toxins like botulinum helps to improve this socially uncomfortable condition. Botulinum toxin injections are considered only effective in the treatment of Parkinson related sialorrhea or hypersalivation.

Sialorrhea ICD-10

ICD-10   H15         Disorders of sclera                      Billable
ICD-10   H15.8      Other disorders of sclera            Billable
ICD-10   H15.89    Other disorders of sclera            Billable
ICD-10   H15.9      Unspecified disorder of sclera    Billable
ICD-10   Q13.5      Blue sclera                                    Billable
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Nulliparity Meaning, Definition, cancer risk | Nulliparity vs Primiparity

nulliparus or nullipara women is one, who never had a child, and this state of non productiveness is called nulliparity. Nulliparity is a recognized risk factor for cervical cancer. Most studies show a double or triple risk for women than those have given birth. The assumption that infertility is a risk factor for cervical cancer is supported by studies that show a higher risk for unmarried women than for married women. Several studies have found that infertile women have an increased risk cancer of reporductive organs due to nulliparity.

Mechanisms that can mediate the risks associated with infertility include anovulatory menstrual cycles (prolonged estrogen exposure without sufficient progesterone), elevated levels of androstenedione (ie, excess androstenedione is available for estrogen conversion) and the lack of monthly sloughing of the lining of the endometrium (i.e the residual tissue can become hyper).

In addition, nulliparity associated with lower levels of globulin bound serum sex hormone (SHBG) causing an increase in bioavailability of estrogen. In most studies, the risk of uterine cancer decreases with increasing parity, especially among women pre-tmenopausal . Several recent studies have shown that past births at the end of reproductive life may reduce the risk of uterine cancer. Although this reflects the unique hormonal profiles of women who can conceive at a later age.

The hypothesis is consistent with the observations that the risk of uterine cancer increases with time as the latest pregnancy . Additional support for this hypothesis comes from several studies that show a reduction in the risk of users of intrauterine devices. However, it is also possible that these devices may affect the risk of causing structural or biochemical changes that alter the sensitivity of the endometrium to circulating hormones.

Nulliparity Meaning, Definition, cancer risk | Nulliparity vs Primiparity

Nulliparity Cancer Risk

In most studies, the risk of uterine cancer decreases with increasing parity, especially in women having pre-menopausal phase. Because pregnancy and breastfeeding reduces the number of women's menstrual cycles in her lifetime, that's why birth is associated with lower cumulative exposure to endogenous hormones.

In addition, pregnancy and breastfeeding make breast cells differentiation and mature them for production of milk. There is a hypothesis, from some researchers, that this differentiation makes breast cells more resistant to transformation in cancer cells than cells that have not undergone such differentiation. Some statistics show that nulliparity (never having had children) is associated with a three times higher risk of breast cancer.

Nulliparity vs Primiparity

A nulliparus or nullipara women is one, who never had a child, and this state of non productiveness is called not nulliparity while Parity is the condition of being able to have children, and when the woman becomes pregnant for the first time enters the state of primiparity, and is called primiparity woman, and primipara or primigravida. Similarly mulitple birth is termed as multiparity.

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Podophyllin Dose, Side effects, Mechanism of action, Uses for warts

Podophyllin has been the basis for the management of external warts since the 1942 Centers for Disease Control recommends the application of external lesion not exceeding 0.5 ml and limited to 10 cm or less per session. After the initial application the patient is re-examined and repeated at weekly intervals. The patient should wash the treated area for 2-4 hours after each topical application.

If no improvement is noted after one month, it should be considered as alternative treatments. However, the most successfully treated lesions respond in two to four days. The effectiveness of the treatment varies between 22-98%. Topical podophyllotoxin as 0.5% Solution or gel (Podoillox) is one of the most commonly used ablation therapy for genital warts which is also a major use of podophyllin resin.

But because of the potential Toxicity of this Podophyllotoxin is a ligand present in an active crude podophyllin resin and exhibits activity at concentrations of 0.5 to 10.0% in the treatment of genital HPV infection. The ability to apply a particular concentration according to a chemical ingredient leaves treatment for patients administered as a way to treat genital warts.

The reported 0.5 mg solution of podophyllotoxin is effective in the treatment of penile warts and is well tolerated in the self-administered regimen. It also offers the potential benefits in terms of safety and cost in relation to the treatment of genital warts, podophyllin resin.

Podophyllotoxin is applied to external warts twice daily for three consecutive days. Treatment is then performed for four days, and the cycle is repeated up to four weeks. Patient's instructions should include the following burning of the application may be expected but excessive burning, pain or swelling should be reported, wash hands after use and avoid contact during treatment days.

Podophyllin Dose, Side effects, Mechanism of action, Uses for warts

Podophyllin Side effects

  • Burning
  • Meatitis
  • Systemic toxicity
  • pain at application site
  • Redness
  • Skin irritation
  • Skin allergy

Podophyllin Mechanism of action

Podophyllotoxin is a purified podophyllin derivative with cytolytic effects. Its mechanism of action includes antimitosis, inhibition of nucleoside transport, stimulation of macrophage proliferation, and production of IL-1 and IL-2. Podophyllotoxin is prescribed as a treatment.

Podophyllin Uses/Indications

Podophyllin is recommend  to treat warts like perigual warts, plantar wrats etc. It should not be used on irritated on wounded skin as it may cause intense burning. Moreover, it is not suitable to apply over urethral warts.
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Corpectomy ICD-10, cage, recovery, complications | Lumbar & Cervical Corpectomy

A corpectomy is an operation that removes all or part of the vertebral body (Latin: corpus vertebrae, therefore called corpectomy), usually as a way of decompressing the spinal cord and nerves. Corpectomy is often performed in conjunction with some form of discectomy.

When the spinal vertebrae has been removed, the surgeon performs a spinal fusion. As the space in the column left after operation, it needs to be filled with a block of bone taken from the pelvis or one of the legs of the bone or manufactured. This bone graft keeps separation between these vertebrae and holds them firm and tight. As it heals, the vertebrae develop together and fuse.

Anterior cervical corpectomy and fusion (ACCF) is performed in patients with symptomatic progressive cervical spinal stenosis and myelopathy. It is done to remove large arthritic osteophytes  that are causing compression of the spinal cord and spinal nerves. However, in order to do this it is usually removed spinal body and the disc that need to be replaced by a part of the bone graft and connected together to firmly to maintain stability.

The operation is performed by means of general anesthesia. A breathing tube (endotracheal tube) is placed and the patient inhales through artificial ventilation system during surgery. Preoperative antibiotics are given intravenously. Patients are lying down (lying on the back), usually using a standard flat table. The surgical zone (neck) is cleaned with a special cleansing solution. Sterile drapes are placed and surgically sterile surgical gowns and gloves are used to keep the bacteria-free environment.

Corpectomy ICD-10, cage, recovery, complications | Lumbar & Cervical Corpectomy

Corpectomy Recovery

Recovery after corpectomy may take months but it highly depends upon surgical approach being uitilized at the time of operation, incision size, number of vertebral disc removed etc. Post-operative care is much important in this whole scenario because of  infection risk and spine comfortability. Moreover, right body posture and improved diet may be required to speed up the process of recovery.

Corpectomy Complications

Some commonly observed post-operative complications of corpectomy are

  • Infection
  • Dysphagia
  • Graft dislocation
  • Screw losening
  • Injury to spinal cord
  • Cervical malalignment
  • postoperative epidural hematoma
  • Pseudoarthrosis

Corpectomy Cages

Several types of inter body cages are used in spinal surgery e.g the titanium mesh cage, stackable cage systems and expandable cages . The use of expandable cages has increased in popularity due to their ease of placement and ability to correct segmental deformity. After selecting an appropriate size, the expandable cage cell is placed in the disk and the ends of the cage are aligned with the frontal planes of the spinal vertebral body above and below the corpectomy level.

Corpectomy ICD-10

M43.22 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes
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