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  • Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

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Cross References Coma; Psychomotor retardation; Stupor Ocular Apraxia Ocular apraxia (ocular motor apraxia) is a disorder of voluntary saccade initia tion; re exive saccades and spontaneous eye movements are preserved cheap 40 mg isoptin amex heart attack referred pain. Ocular apraxia may be overcome by using dynamic head thrusting order isoptin 40mg free shipping hypertension of the eye, with or without blinking (to suppress vestibulo-ocular re exes): the desired xation point is achieved through re ex contraversive tonic eye movements to buy 120mg isoptin blood pressure stroke the midposition following the overshoot of the eyes caused by the head thrust discount 240mg isoptin amex blood pressure 9060. Ocular apraxia may occur as a congenital syndrome (in the horizontal plane only: Cogan’s syndrome), or may be acquired in ataxia telangiectasia (Louis–Bar syndrome), Niemann–Pick disease (mainly vertical plane affected), and Gaucher’s disease (horizontal plane only). Cross References Apraxia; Saccades Ocular Bobbing Ocular bobbing refers to intermittent abnormal vertical eye movements, usu ally conjugate, consisting of a fast downward movement followed by a slow return to the initial horizontal eye position. The sign has no precise localizing value, but is most commonly associated with intrinsic pontine lesions. It has also been described in encephalitis, Creutzfeldt–Jakob disease, and toxic encephalopathies. Its patho physiology is uncertain but may involve mesencephalic and medullary burst neurone centres. Variations on the theme include • Inverse ocular bobbing: slow downward movement, fast return (also known as fast upward ocular bobbing or ocular dipping); • Reverse ocular bobbing: fast upward movement, slow return to midposition; • Converse ocular bobbing: slow upward movement, fast down (also known as slow upward ocular bobbing or reverse ocular dipping). Cross Reference Ocular dipping Ocular Dipping Ocular dipping, or inverse ocular bobbing, consists of a slow spontaneous down ward eye movement with a fast return to the midposition. This may be observed in anoxic coma or following prolonged status epilepticus and is thought to be a marker of diffuse, rather than focal, brain damage. Reverse ocular dipping (slow upward ocular bobbing) consists of a slow upward movement followed by a fast return to the midposition. Cross Reference Ocular bobbing Ocular Flutter Ocular utter is an eye movement disorder characterized by involuntary bursts of back-to-back horizontal saccades without an intersaccadic interval (cf. Ocular utter associated with a localized lesion in the paramedian pontine reticular formation. It has occasionally been reported with cerebellar lesions and may be under inhibitory cerebellar control. Cross References Hypotropia; Lateral medullary syndrome; Skew deviation; Synkinesia, Synkinesis; Tullio phenomenon; Vestibulo-ocular re exes Oculocephalic Response Oculocephalic responses are most commonly elicited in unconscious patients; the head is passively rotated in the horizontal or vertical plane (doll’s head maneou vre) and the eye movements are observed. Conjugate eye movement in a direction opposite to that in which the head is turned is indicative of an intact brain stem (intact vestibulo-ocular re exes). With pontine lesions, the oculocephalic responses may be lost, after roving eye movements but before caloric responses disappear. Cross References Caloric testing; Coma; Doll’s head manoeuvre, Doll’s eye manoeuvre; Head impulse test; Roving eye movements; Supranuclear gaze palsy; Vestibulo-ocular re exes Oculogyric Crisis Oculogyric crisis is an acute dystonia of the ocular muscles, usually causing upward and lateral displacement of the eye. It is often accompanied by a dis order of attention (obsessive, persistent thoughts), with or without dystonic or dyskinetic movements. It occurs particularly with symptomatic (secondary), as opposed to idiopathic (primary), dystonias, for example, postencephalitic and neuroleptic-induced dystonia, the latter now being the most common cause. This is usually an acute effect but may on occasion be seen as a consequence of chronic therapy (tardive oculogyric crisis). It has also been described with Wilson’s dis ease, neuroleptic malignant syndrome, and organophosphate poisoning. Lesions within the lentiform nuclei have been recorded in cases with oculogyric crisis. Treatment of acute neuroleptic-induced dystonia is either parenteral benzo diazepine or an anticholinergic agent such as procyclidine, benztropine, or trihexyphenidyl. Oculogyric crisis and abnormal magnetic resonance imaging signals in bilateral lentiform nuclei. Fascicular (within substance of midbrain): all muscles or speci c mus cles involved, + other clinical signs expected, such as contralateral ataxia (Claude’s syndrome), hemiparesis (Weber’s syndrome). Orbit: paresis of isolated muscle almost always from orbital lesion or muscle disease. Oculomotor nerve palsies may be distinguished as ‘pupil involving’ or ‘pupil sparing’, the former implying a ‘surgical’, the latter a ‘medical’ cause, but this distinction only holds for complete palsies. Transtentorial (uncal) 250 Onion Peel, Onion Skin O herniation due to raised intracranial pressure may, particularly in its early stages, cause an oculomotor nerve palsy due to stretching of the nerve, a ‘false-localizing sign’. In young patients this is most often due to demyelination, in the elderly to brainstem ischaemia; brainstem arteriovenous malformation or tumour may also be responsible. A vertical one-and-a-half syndrome has also been described, characterized by vertical upgaze palsy and monocular paresis of downgaze, either ipsilateral or contralateral to the lesion. Electro-oculographic analyses of ve patients with deductions about the physiological mechanisms of lateral gaze. A unilateral disorder of the pontine tegmentum: a study of 20 cases and a review of the literature. It re ects the somatotopic sensory representation in the spinal nucleus of the trigeminal nerve: midline face (nose, mouth) represented rostrally, lateral facial sensation represented caudally. A distinction is sometimes drawn between: • External ophthalmoplegia: weakness of the extraocular muscles of central, neuromuscular, or myopathic origin: Supranuclear. The term ‘ophthalmoplegia plus’ has been used to denote the combination of progressive external ophthalmoplegia with additional symptoms and signs, indicative of brainstem, pyramidal, endocrine, cardiac, muscular, hypothalamic, or auditory system involvement, as in mitochondrial disease. Cross References Coma; Decerebrate rigidity; Emposthotonos Oppenheim’s Sign Oppenheim’s sign is a variant method for eliciting the plantar response, by appli cation of heavy pressure to the anterior surface of the tibia, for example, with the thumb, and moving it down from the patella to the ankle. Extension of the hal lux (upgoing plantar response, Babinski’s sign) is pathological. Like Chaddock’s sign, Oppenheim’s sign always postdates the development of Babinski’s sign as a reliable indicator of corticospinal pathway (upper motor neurone) pathology. Although some normal individuals can voluntarily induce opsoclonus, gen erally it re ects mesencephalic or cerebellar disease affecting the omnipause cells which exert tonic inhibition of the burst neurones which generate saccades. Of the paraneo plastic disorders, opsoclonus associated with lung and breast tumours persists and the patients decline from their underlying illness; neuroblastoma associated opsoclonus may be steroid responsive.

They reported that the fundamental frequency and the energy of speech became higher following “obstructive events” such as the destruction of the ship and lower following “conducive events” such as the completion of a game level [Johnstone et al isoptin 120mg lowest price arteria vesicalis. They suggested that the reason could be that physiological arousal order 40mg isoptin overnight delivery blood pressure zero, as indicated by measurements of skin conductance order isoptin 240 mg with mastercard pulse pressure medical definition, was comparatively high following the destruction of the ship 120mg isoptin overnight delivery hypertension heart failure. Vocal expression of emotions elicited during human-computer interaction may be better explored if complemented by the analysis of non-verbal vocal expressions. The investigation of these paralinguistic expressions presents a number of benefits. Because these expressions are not linguistic, they can potentially be used to compare vocal responses to interactive media across different cultures [Belin et al. Moreover, they are “primitive expressions of emotions” [ibid] and are probably better conveyers of the natural emotions and instantaneous responses that usually result from the frustration, stress, anxiety, or excitement of interacting with interactive systems. Computer scientists at Monash University in Australia have already developed a system, SoundHunters, which allows the user to log on to a computer by laughing. SoundHunters logs a user onto networked computers through detecting the sound of the laughing user’s footsteps in order to determine his/her location and activate the nearest computer [Nowak, 2003]. Further work on paralinguistic vocal responses to interactive media is needed in order to improve and enrich the studies on paralinguistic vocal input to interactive media that will be investigated in the rest of this chapter. According to Johnstone, computer games may induce “stronger” and “more varied emotions” than other induction techniques (such as those listed in [Scherer, 1986]) [Johnstone, 1996]. They allow for a degree of immersion that would result in the elicitation of strong and natural vocal reactions [Johnstone, 1996]. The analysis of the characteristics of these expressions may facilitate the development of computers that recognize and react to these vocalizations and their characteristics. Audio-Visual Applications A significant component of my own projects is visual outcomes which correspond in some way to vocal input. It first provides a brief outline of historically-related work and then describes significant contemporary related studies and applications. It then explores the various audio-visual composites used in existing multimedia works. This led him to assign the colors of the spectrum to the seven notes of the musical scale [Collopy, 2000: 357] by way of what is commonly known as the ‘color music wheel’. Since then, there have been many attempts to forge a link between the musical and visual domains. Others who came after Newton used his work as a basis for inventing ‘color organs’. These musical instruments were built to display modulated colored light in some kind of fluid fashion allegedly comparable to music [Moritz, 1997]. In addition, other methods of visualizing sound were devised for scientific purposes. According to Roads: “One method involved modulating a bunsen burner with sound and observing the effect on the flamesRudolf Koenig built precision instruments for generating sound images that he called manometric flames [] More direct images of sound waveforms appeared in the mid nineteenth century. The Wheatstone Kaleidaphone (1827) projected vibrating motions onto a screen” [Roads, 1996:500]. While earlier work in audio-visualization was principally scientific in its motivation (see for example the discussion about spectrograms in section 2. Several developers have attempted to develop audio-visual applications and performances that translate musical cues into graphical feedback or vice versa. Some of them employ novel mapping techniques between visual properties and sound characteristics. Some focus on voice-visualization to establish meaningful correlations between vocal input and visual output. Sound visualization involves developing mappings between graphical parameters (color, height, position, size, shape, etc. One basic example of audio-visual applications is Apple iTunes that includes the display of visual effects associated with various characteristics of the music. Lipscomb and his colleagues’ enquiries among software developers revealed that the designer’s selection of the visual parameters tended to be arbitrary [Lipscomb and Kim, 2004:72]. They conducted an experimental multimedia investigation to find meaningful visual “correlates” for auditory parameters [ibid]. They found that pitch was perceptually matched with vertical location, loudness with size, and timbre with shape. Both pitch and loudness were also found to be best matched with color, while duration did not particularly match any of the characteristics [Lipscomb and Kim, 2004:73]. These findings should be treated with caution because cultural, environmental, and age differences may affect the perception of audio-visual composites. Moreover, such mappings may also depend on the kind of application in which they are implemented and on the level of interactivity required. Programs such as iTunes, for instance, do not require a high level of interaction and the visual output in these programs is mainly incorporated for decorative purposes. In such simple audio-visual applications, the developer may exploit the inherent tendency of the viewer’s brain to coordinate the two sense modalities [Bregman, 1990]. On the other hand, in applications in which the user is not just a passive viewer and/or listener but an active interacting agent, the audio-visual mappings determine the way the user interacts with the interface. In the voice-visual applications that will be investigated in the next section, for instance, forming “perceptually meaningful” [Lipscomb and Kim, 2004] mappings is crucial. Voice-Visual Applications Quite a few developers have focused on voice-visualization to establish meaningful mappings between vocal inputs and visual outputs. Among these developers are Levin and Lieberman who explored a variety of mappings in Hidden Worlds [2002].

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There is growing concern that growth suppression may be an iatrogenic effect of stimulants that will reliably accompany long-term use buy isoptin 120mg free shipping arrhythmia pvc treatment. As discussed above buy discount isoptin 120 mg line heart attack 720p kickass, very little is known about the long-term risks of stimulants in other domains order 240 mg isoptin overnight delivery blood pressure chart new zealand. With regard to generic isoptin 240mg amex heart attack telugu movie online use over a period of 2 to 3 years, the risk–benefit analysis of stimulant medication does not appear to be favorable because beneficial effects appear to dissipate while side effects. Thus, the risk–benefit of behavioral treatment over this time period would be Report of the Working Group on Psychotropic Medications 52 favorable. At the 2-year follow-up, children in combined treatment had the same outcomes as those in behavioral treatment alone, and they had growth suppression, as did the medicated children (albeit less because of lower doses). Thus, the use of combined treatments for 2 to 3 years would not appear to have a favorable risk–benefit ratio. For this regimen to have a favorable risk–benefit ratio, it would have to produce incrementally beneficial improvements relative to behavioral treatment alone without a corresponding increase in side effects. There is some indication from a single short-term study that such an outcome might be attainable with very low dosages of stimulants (Pelham, Burrows-MacLean, et al. This would be particularly true for antidepressants, which have lower efficacy and greater side effects than stimulants. Should medication be employed as the first-line treatment—the most common practice and the preference of many, if not most, physicians If so, how long should it be tried and at what doses before—and if—behavioral interventions are added Alternatively, should behavior modification be employed first, and if so, how should the components (parent training, school intervention, and peer intervention) be sequenced How long should behavior Report of the Working Group on Psychotropic Medications 53 modification be tried and at what intensity before medication is added Might a behavioral treatment-first sequence result in lower societal use of stimulants or lower doses with fewer side effects when employed Or should the two major modalities begin simultaneously so that all children receive both modalities Which components can be time limited, and how does treatment need to be modified as children move through different developmental stages Given the minimal impact of medication and psychosocial interventions on academic achievement, particularly over the long-term, what academic interventions are efficacious with this population, and how can these be delivered feasibly along with behavioral strategies in school settings These are questions practitioners and parents face on a daily basis that beg answers. Home-based behavior modification typically involves parents receiving training in both antecedent-based. Similarly, school-based behavior modification approaches include the use of contingent teacher praise and/or reprimands, token reinforcement, response cost, time out from positive reinforcement, and self-management. Most school-based interventions are implemented directly by classroom teachers; however, contingencies can also be delivered by peers (Cunningham & Cunningham, 1998) and/or parents. Home and school-based contingency management interventions are associated with significant improvements in compliance and concomitant reductions in aggression and disruptive behavior (Walker, Colvin, & Ramsey, 1995; Webster-Stratton, 1994), although these effects are less pronounced in adolescents, and generalization of effects across settings and time is limited. Behavioral parent training is associated with a medium effect size for reduction of externalizing behaviors (Maughan, Christiansen, Jenson, Olympia, & Clark, 2005). Multisystemic treatment provides problem-focused treatment within families and also supports family members in managing the interconnected systems of family, peer, neighborhood, and school in order to reduce risks. Various forms of residential treatment have been studied with multidimensional treatment foster care (Chamberlain, Fisher, & Moore, 2002) and the teaching family model (Friman et al. Perhaps because behavioral strategies require consistent implementation across time and caregivers, treatment adherence rates typically are under 50% unless ongoing feedback is provided to the adult. Strength of Evidence Contingency management interventions implemented at home and school have resulted in moderate to large effect sizes for reduction in conduct problems (DuPaul & Eckert, 1997; Maughan et al. Cognitive-behavior therapy and multisystemic therapy have also resulted in moderate effect sizes (Brestan & Eyberg, 1998). Although one does not often think of psychostimulants as a treatment for aggression in the context of disruptive behavior disorders, there are several Report of the Working Group on Psychotropic Medications 61 modest-sized studies attesting to a moderate effect in some children (Aman & Lindsay, 2002). Controlled and open trials of classical antipsychotic medications such as haloperidol. Only one well-controlled study has been conducted to date (Steiner, Petersen, Saxena, Ford, & Matthews, 2003), although there are several small controlled and poorly controlled studies and/or case series attesting to some beneficial effects (see Steiner et al. One controlled study suggests that atomoxetine may also reduce symptoms of both disorders, especially at higher dosages (Newcorn, Spencer, Biederman, Milton, & Michelson, 2005). Side Effects All of the medications used to treat aggression and conduct problems are associated with potential adverse side effects that, although rare, can be relatively serious. Side effects of lithium can include polyuria, polydipsia, motor tremor, increase in appetite, dryness of mouth, general muscular weakness, and memory reduction (Henry, 2002; Luby & Singareddy, 2003). Risperidone, haloperidol, and other neuroleptic medications can be associated with serious extrampyramidal side effects. Divalproex sodium can lead to a variety of side effects, including abdominal pain, headache, dizziness, drowsiness, and memory difficulties. Possible side effects of clonidine include sedation, lethargy, dryness of mouth, and low blood pressure (Connor, 2005). Stimulants can be associated with a range of side effects, including loss of appetite, sleep disturbance, headaches, stomach aches, and possibly motor tics (Connor & Barkley, 2006). Atomoxetine can lead to stomach aches, nausea, decreased appetite, and weight loss (Christman, Fermo, & Markowitz, 2004).

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