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Monoclonal antibodies are instru- mental in the performance of sensitive medical diagnostic tests such as: determining pregnancy with chorionic gonadotropin; determining the amino acid content of sub- stances; classifying antigens; purifying hormones; and modi- fying infectious or toxic substances in the body discount cleocin gel 20gm on-line skin care olive oil. They are also important in cancer treatment because they can be tagged with radioisotopes to make images of tumors cleocin gel 20 gm fast delivery acne meds. See also Antibody-antigen purchase 20gm cleocin gel amex skin care by gabriela, biochemical and molecular reac- tions; Antibody and antigen; Immunity, cell mediated; Immunogenetics; Immunologic therapies; Immunological analysis techniques; In vitro and in vivo research ANTIGEN • see ANTIBODY AND ANTIGEN Antigenic mimicryANTIGENIC MIMICRY Antigenic mimicry is the sharing of antigenic sites between microorganisms and mammalian tissue. An immune response Mice used to develop the monoclonal cells that secret a specific can be directed both at the microorganism and at the host site antibody. This autoimmune response due to antigenic mimicry is known to be a crucial factor in the development of certain ailments in humans. A protein, which is made up of a sequence and could, therefore, be crossed with lymphocytes to produce of amino acids strung together, will fold up in various ways, specific antibodies. These hybrid cells are called hybridoma, and they produce monoclonal antibodies. After receiving a doctorate in biochemistry, Proteins that adopt a similar three-dimensional configu- specializing in enzymes, from the University of Buenos Aires ration can stimulate a common response from the immune sys- in 1957, he continued this study at the University of tem. Typically, proteins that have a similar amino acid Cambridge in England. There he worked under the biochemist sequence will adopt the similar folded structures. This protein is similar in amino where Sanger suggested that he work with antibodies. In mice, an immune reac- received his doctorate from the University of Freiburg for tion to Chlamydia triggers a condition known as inflammatory work performed at the Institute for Immunology in Basel, heart disease. To produce the needed antibodies, Milstein and the heart, leading to cardiac malfunction. After shown that a significant number of patients with heart disease extracting the resulting lymphocytes from the mouse’s blood, have antibodies to Chlamydia in their blood, indicative of a they fused one of them with a myeloma cell. As Milstein soon realized, their tech- that is the consequence of an autoimmune reaction. Other bacteria, viruses, fungi and In the example of the injection, alcohol swabbing of the injec- protozoa share the antigenic similarity with the mouse anti- tion site will kill the bacteria on the skin, so that living bacte- genic region. The bacteria include Borrelia burgdorferi (the ria are not carried into the body upon insertion of the needle. Pure alcohol rapidly Antigenic mimicry may also be the basis of the ulcers coagulates surface proteins, producing a coagulated crust formed upon infection of humans with Helicobacter pylori. The acidic environment of the stomach would exacerbate host Another antiseptic is carbolic acid. Antigenic mimicry supports a hypothesis known as the Originally phenol was poured down sewers to kill microor- “infection hypothesis,” which proposes that common human ganisms. If so, then treatment for geon Joseph Lister began using a spray of phenol to disinfect heart disease and stomach ulcers would involve strategies to open wounds during surgery. It is added to household disinfectants more because of its pleas- ant smell than its aseptic power nowadays. In fact, it inclu- ANTISEPTICS sion actually weakens the bacteria-killing power of the Antiseptics household disinfectant. Antiseptics are compounds that act to counteract sepsis, which Lister’s method was supplanted by the adoption of is an illness caused by a bacterial infection of the blood. This approach is known as anti- antiseptic may kill a microorganism, but it does not necessar- septic surgery. The Lister’s era often did not change or clean their operating garb weaker, slower growing microbes may then be more suscepti- between operations. A surgeon would often commence an ble to the defense mechanisms of the host. Yet they do have different mean- sepsis in the operating room, the rate of death following sur- ings. An antiseptic is a chemical or technique that is used on gery was almost 60%. A disinfectant is a chemical that is applied to an inan- recorded death rate in England dropped to four per cent. An anti- Hand washing has also become standard practice in the septic generally does not have the same potency as a hospital and the home. Otherwise, the chemical would harm the tissues Another antiseptic technique is sterilization. For this reason, an antiseptic should not steam at higher than atmospheric pressure is an effective be used to treat inanimate objects. Likewise, the generally means of killing many types of bacteria, including those that more toxic disinfectant should not be used to treat skin or form spores. In the home, antiseptics are often evident as lotions or While more is known of the molecular basis of antisep- solutions that are applied to a cut or scrape to prevent infec- tic actions, the use of antimicrobial compounds is ancient. For these uses, it is necessary to clean the affected area example, the black eye make-up known as kohl, which was of skin first to dislodge any dirt or other material that could used by the ancient Arabs and Egyptians, is a mixture of cop- reduce the effectiveness of the antiseptic. Indeed, ularly those used in the home, are designed for a short-term the modern cure for trachoma (blindness caused by infection use to temporarily rid the skin of microbes. The skin, being of the eyes by the bacterium Chlamydia trachomatis) is in primary contact with the environment, will quickly remarkably similar in composition to kohl. Long-term use of There are a number of antiseptics and antiseptic pro- antiseptics encourages the development of populations of cedures. In a health care setting, powerful antiseptics are used to Additionally, the skin can become irritated by the long expo- ensure that the skin is essentially sterile prior to an operation. Some people can even develop Examples of such antiseptics include chlorhexidine and allergies to the antiseptic. Alcohol is an anti- Another hazard of antiseptics that has only become septic, which is routinely used to swab the skin prior to an apparent since the 1990s is the contamination of the environ- injection. Antiseptic solutions that are disposed of in sinks and toi- 31 Antiserum and antitoxin WORLD OF MICROBIOLOGY AND IMMUNOLOGY lets can make their way to rivers and lakes. Contamination of Antiserum and antitoxin are obtained from the blood of the aquifer (the surface or underground reserve of water from the test animal. The blood is obtained at a pre-determined time which drinking water is obtained) has become a real possibility. The antiserum constitutes part of the plasma, the clear See also Antibiotics; Infection control component of the blood that is obtained when the heavier blood cells are separated by spinning the blood in a machine called a centrifuge. AAntiserum and antitoxinNTISERUM AND ANTITOXIN Examples of antisera are those against tetanus and rabies. Typically, these antisera are administered if someone Both antisera and antitoxins are means of proactively combat- has been exposed to an environment or, in the case of rabies, ing infections. The introduction of compounds to which the an animal, which makes the threat of acquiring the disease immune system responds is an attempt to build up protection real. The antisera can boost the chances of successfully com- against microorganisms or their toxins before the microbes actually invade the body.
A more commonly used classification differentiates hydrocephalus between communicating or noncommunicating (Table 1) purchase cleocin gel with american express acne tools. Traditionally order 20gm cleocin gel with amex skin care with hyaluronic acid, this classifica- tion was based on whether dye injected into the lateral ventricles could be detected in CSF extracted from a subsequent lumbar puncture discount cleocin gel 20 gm amex skin care images. Currently, the term ‘‘noncom- municating hydrocephalus’’ refers to lesions that obstruct the ventricular system, either at the cerebral aqueduct of sylvius or basal foramina (i. The term ‘‘communicating hydrocephalus’’ refers to lesions that obstruct at the level of the subarachnoid space and arachnoid villi. Lateral Ventricle Choroid plexus tumors are rare in the pediatric population, with an incidence ran- ging from 1. Most choroid plexus tumors are choroid plexus papillomas, which usually present within the first 3 years of life. The CSF production rates three to four times the normal rate have been documented in children with choroid plexus papillomas. Removal of the papilloma resolves the 25 26 Avellino Table 1 Causes of Hydrocephalus Based on Site of Obstruction Lateral ventricle Choroid plexus tumor Intraventricular region glioma Foramen of Monro Congenital atresia Iatrogenic functional stenosis Stenotic gliosis secondary to intraventricular hemorrhage or ventriculitis Third ventricle Colloid cyst Ependymal cyst Arachnoid cyst Neoplasms such as craniopharngioma, chiasmal-hypothalamic astrocytoma, or glioma Cerebral aqueduct Congenital aqueduct malformation Arteriovenous malformation Congenital aqueduct stenosis Neoplasms such as pineal region germinoma or periaqueductal glioma Fourth ventricle Dandy–Walker cyst Neoplasms such as medulloblastoma, ependymoma, astrocytoma, or brainstem glioma Basal foramina occlusion secondary to subarachnoid hemorrhage or meningitis Chiari malformations hydrocephalus in approximately two-thirds of cases. The remaining third probably suffer from obstruction of the aqueduct and=or basal meninges and require a ventricular shunt presumably secondary to preoperative microhemorrhages or postoperative scarring of the arachnoid villae. Foramen of Monro Occlusion of one foramen of Monro can occur secondary to a congenital membrane, atresia, or gliosis after intraventricular hemorrhage (IVH) or ventriculitis. The result- ing unilateral ventriculomegaly is often occult until early childhood, and may enlarge the ipsilateral hemicalvarium. An iatrogenic functional stenosis of the foramen of Monro can develop in chil- dren with spina bifida whose hydrocephalus has been treated with a ventricular shunt. The contralateral nonshunted ventricle occasionally expands secondary to deformity of the foramen of Monro. If symptomatic, the patient can be treated with a shunt system having two ventricular catheters, each draining a separate lateral ven- tricle or an endoscopic fenestration of the septum pellucidum with one ventricular catheter draining both ventricles. Third Ventricle Cysts and neoplasms within the third ventricle commonly cause hydrocephalus. Col- loid cysts are uncommon neoplasms that present superiorly and anteriorly within the third ventricle, and usually obstruct both foramina of Monro. Considered to Hydrocephalus 27 be congenital lesions, they can become symptomatic at any age. However, they rarely present within the pediatric population, and are commonly symptomatic between the ages of 20 and 50 years. They can cause either intermittent, acute, life-threatening hydrocephalus or chronic hydrocephalus. They are customarily trea- ted with resection via craniotomy, endoscopic resection, or stereotactic aspiration of the cyst. Ependymal and arachnoid cysts within the third ventricle usually present with hydrocephalus in late childhood. Patients may present with bobble-head doll syndrome, a rhythmic head and trunk bobbing tremor at a frequency of two to three times per second. While endoscopic fenestration is a treatment option, they are often treated with a ventricular catheter fenestrated to drain both ventricles and the cyst. The most common pediatric neoplasms that obstruct the third ventricle are craniopharyngiomas and chiasmal-hypothalamic astrocytomas. Hydrocephalus secondary to craniopharyngiomas usually resolves after surgical resection of the tumor. Hydrocephalus secondary to third ventricular region gliomas usually does not resolve after surgical resection, and ventricular shunt placement is often necessary. Cerebral Aqueduct The normal aqueduct of a neonate is 12–13 mm in length and only 0. Thus, it is prone to obstruction from a variety of lesions, including congenital aqueductal malformations, pineal region neoplasms, arteriovenous malformations, and periaqueductal neoplasms. Hydrocephalus secondary to aqueductal occlusion is generally severe and causes distension of the third ventricle and separation of the thalami, thinning of the septum pellucidum and corpus callosum, and compression of the cerebral hemi- spheres. Less than 2% of cases of congenital aqueductal stenosis are the result of the recessively inherited X-linked Bickers–Adams–Edwards syndrome, which is asso- ciated with flexion–adduction of the thumbs (‘‘cortical thumbs’’). Many pineal region tumors, especially germinomas, are highly radiosensitive; and success- ful tumor irradiation as well as surgical resection may adequately treat the obstruc- tive hydrocephalus. Low-grade astrocytomas are the most common periaqueductal pediatric neo- plasms that cause hydrocephalus. Historically, children with neurofibromatosis have often been diagnosed with ‘‘late-onset aqueductal stenosis. Fourth Ventricle In infants, the fourth ventricle is the location for obstruction secondary to Dandy– Walker cysts or obliteration of the basal foramina. Such occlusions result in the dilation of the lateral, third, and fourth ventricles above the obstruction. Dandy–Walker cysts are developmental abnormal- ities characterized by a large cyst in the fourth ventricle lined with pia-arachnoid and ependyma, hypoplasia of the cerebellar vermis, and atrophy of the cerebellar hemi- spheres. Arachnoiditis secondary to either meningitis or subarachnoid hemorrhage can also occlude the basal foramina and cause obstructive hydrocepha- lus. In addition, infants with Chiari II malformations and myelomeningoceles have hydrocephalus secondary to blockage of CSF flow from basilar obstruction. Arachnoid Granulations Sclerosis or scarring of the arachnoid granulations can occur after meningitis, sub- arachnoid hemorrhage, or trauma. The subarachnoid spaces over the convexities enlarge, thus forming a condition often referred to as ‘‘external hydrocephalus. Symptomatic external hydrocephalus is treated with a subdural= subarachnoid to peritoneal shunt. CLINICAL FEATURES Premature Infants Hydrocephalus in premature infants is predominantly caused by posthemorrhagic hydrocephalus (PHH). Because the poorly myelinated premature brain is so easily compressed and the skull is so distensible, premature infants can develop consider- able ventriculomegaly before their head circumference increases. Infants with PHH may have no symptoms or may exhibit increasing spells of apnea and bradycardia. Poor feeding and vomiting are uncommon signs of hydrocephalus in premature infants. If ventriculomegaly progresses and ICP increases, the anterior fontanelle becomes convex, tense, and nonpulsatile; and the cranial sutures splay and the scalp veins distend. As ventriculomegaly persists, the head develops a globoid shape, and the head circumference increases at a rapid rate. Table 2 Signs and Symptoms of Hydrocephalus in Children Premature infants Infants Toddlers and older Apnea Irritability Headache Bradycardia Vomiting Vomiting Tense fontanelle Drowsiness Lethargy Distended scalp veins Macrocephaly Diplopia Globoid head shape Distended scalp veins Papilledema Rapid head growth Frontal bossing Lateral rectus palsy Macewen’s sign Hyper-reflexia-clonus Poor head control Lateral rectus palsy ‘‘Setting-sun’’ sign (From Elsevier from: P. Signs include macrocephaly, a convex and full anterior fontanelle, distended scalp veins, cranial suture splaying, frontal bossing, ‘‘cracked pot’’ sound on skull percussion over dilated ventricles (Macewen’s sign), poor head control, lat- eral rectus palsies, and the ‘‘setting-sun’’ sign, in which the eyes are inferiorly deviated. Paralysis of upgaze and Parinaud’s sign herald dilation of the suprapineal recess (Table 2).
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When using flipchart sheets remember to: ° Check that all the students have a clear view of the flipchart purchase cheap cleocin gel line acne rash. Either mask with paper or leave blank pages in between your prepared sheets purchase 20gm cleocin gel amex acne quizlet. PREPARING MATERIALS FOR TEACHING 149 ° Fold back sheets rather than tearing them off purchase cleocin gel 20gm mastercard acne on chin, as you may need to refer to them later. Start writing or drawing about a third of the way in so your body is not obstructing the audience’s view. Use the first two thirds of the chart (the part furthest away from you). These are handy for preparing material in advance, but their small size restricts their use to groups of ten or less. Some are designed for use in preparing for a session, for example a list of preparatory reading or a document containing introductory material. Many are for use during the session, for example a gapped handout to be completed by the student during the lecture, while others are to promote further individual study by the student after the session, for example a reading list. Use handouts to: ° provide preparatory reading, for example background information, glossary of terms or ‘stop and think’ activities ° provide complex information such as detailed numerical data or diagrams ° give evidence in support of the main arguments, for example research studies, detailed case studies and explanations ° aid note-taking by supplying copies of essential acetates or illustrations ° encourage active listening by supplying gapped handouts to be completed during the lecture, for example labelling a diagram or filling in key terms ° encourage self-assessment by using true/false or multiple-choice questionnaires 150 WRITING SKILLS IN PRACTICE ° facilitate learning activities, for example instructions for practical tasks, data sets and case studies for problem solving ° give students the opportunity to apply new concepts or principles, for example analysing data sets ° promote further study by giving lists of references, further reading or a set of questions to focus students’ reading and note-taking. When using handouts remember to: ° Decide on a system for distribution as giving out paper to a large group is time-consuming and may disrupt the flow of your presentation. Some ideas are to: ° Place handouts on chairs before the audience arrives. PREPARING MATERIALS FOR TEACHING 151 Evaluation Monitor the cost-effectiveness and efficacy of your teaching materials. Summary Points ° Additional written materials, such as acetates, slides, flipcharts or handouts, are used to support teaching. Al though notes are traditionally associated with lectures, students will be re quired to record information from a variety of sources. These will include books, journal articles, audiovisual material, demonstrations and the stu- dent’s own clinical experience. In common with other skills it requires practice, and it is not as straightforward as it might seem at first. This section reviews the purpose of note-taking, and looks at how study notes facilitate the learning process. It also offers students some practical suggestions on how to improve their skills in note-taking. Purpose of notes There are several reasons for taking notes as a student. They can be used as both a learning tool and as a study aid for revision. They will contain information that will help you understand the theoretical background and 153 154 WRITING SKILLS IN PRACTICE practical applications of your subject. Good notes will also contain your thoughts, opinions and ideas, making them a true reflection of the devel opment in your learning. A framework Your notes are a way to organise both your past and your current learning. They provide a framework that makes it easier to assimilate new informa tion with what you have already learnt. You will also be able to gauge how well you comprehend current stud ies. Gaps or sketchy notes indicate that further reading or more in-depth study is required. A reference source Notes contain information that will be of use to you in preparing essays. This may be data that can be included in your assignment, or it may be ref erences to other sources. Reading through your notes may even inspire you about topics that you would like to study in more depth. An aide-mémoire Notes will help to remind you of facts, figures, theories and practical appli cations that would otherwise be forgotten. Their permanent and personal nature means that you will be able to return to them at any point – so you can find information you have collected from journal articles, books and audiovisual material without the need to seek out the original texts or tapes. A learning tool Notes are a way of organising information, which will help you make sense of what the lecturer or author is trying to convey. In good notes, the key in formation will be highlighted and clearly distinguished from supporting examples and explanations. The link between topics will be clear, and you will be able to see how smaller details fit into the whole picture. A revision aid Your notes as a whole will provide you with an overview of the areas around which to plan your revision. They can also be used to help you re member key facts and identify themes. The actual task of note-taking itself is one way of starting to memorise the material. Rereading notes at regular intervals helps to consolidate the retention of this information. They are not usually placed under ex ternal scrutiny, nor do they form part of any assessment. There is no direct system for evaluating the ability of a student to make relevant and useful notes. How ever, this does not help students identify ways to improve their skills or how to make the most of the information they have recorded. Some students are uncertain about which pieces of information they should be noting. In order not to miss anything they conscientiously re cord every utterance of the lecturer, or neatly précis a chapter or article. This results in over-detailed notes where it is difficult to identify the key points or get a perspective of the topic as a whole. It is also extremely te dious for the student and does not promote active listening or critical thought. This may miss out some of the key points and make it difficult to use the notes for revision. The amount and type of information that needs to be recorded will vary between students. It depends very much on what individuals need in order to make sense of what is being presented to them. Different styles of note-taking Have you ever considered the way in which you record information? Most of us tend to follow the style of note-taking shown to us at school. The fol lowing section describes several different methods of note-taking.
This observation indi- cated to Babinski the peripheral (facial nerve) origin of hemifacial spasm order 20gm cleocin gel amex skin care store. It may assist in differentiating hemifacial spasm from other craniofacial movement disorders buy 20 gm cleocin gel fast delivery acne varioliformis. Journal of Neurology discount 20gm cleocin gel amex acne drugs, Neurosurgery and Psychiatry 2001; 70: 516 Cross References Hemifacial spasm Babinski’s Trunk-Thigh Test Babinski’s trunk-thigh test is suggested to be of use in distinguishing organic from functional paraplegia and hemiplegia (Hoover’s sign may also be of use in the latter case). The recumbent patient is asked to sit up with the arms folded on the front of the chest. In organic hemiple- gia there is involuntary flexion of the paretic leg; in paraplegia both legs are involuntarily raised. In functional paraplegic weakness neither leg is raised, and in functional hemiplegia only the normal leg is raised. Cross References Functional weakness and sensory disturbance; Hemiplegia; Hoover’s sign; Paraplegia “Bag of Worms” - see MYOKYMIA Balaclava Helmet A pattern of facial sensory loss resembling in distribution a balaclava helmet, involving the outer parts of the face but sparing the nose and mouth, may be seen with central lesions, such as syringobulbia which progress upwards from the neck, such that the lowermost part of the spinal nucleus of the trigeminal nerve which serves the outer part of the face is involved while the upper part of the nucleus which serves the central part of the face is spared. This pattern of facial sensory impair- ment may also be known as onion peel or onion skin. Cross References Onion peel, Onion skin Balint’s Syndrome Balint’s syndrome, first described by a Hungarian neurologist in 1909, consists of: ● Simultanagnosia (q. Not all elements may be present; there may also be coexisting visual field defects, hemispatial neglect, visual agnosia, or prosopagnosia. Balint’s syndrome results from bilateral lesions of the parieto-occip- ital junction causing a functional disconnection between higher order visual cortical regions and the frontal eye fields, with sparing of the primary visual cortex. Brain imaging, either structural (CT, MRI) or functional (SPECT, PET), may demonstrate this bilateral damage, which is usually of vascular origin, for example due to watershed or border zone ischemia, or top-of-the-basilar syndrome. Balint syndrome has also been reported as a migrainous phenome- non, following traumatic brain injury and in association with Alzheimer’s disease, tumor (butterfly glioma), radiation necrosis, progressive multifocal leukoencephalopathy, Marchiafava-Bignami disease with pathology affecting the corpus callosum, and X-linked adrenoleukodystrophy. Cambridge: MIT Press, 2003: 27-40 Cross References Apraxia; Blinking; Ocular apraxia; Optic ataxia; Simultanagnosia Ballism, Ballismus Ballism or ballismus is a hyperkinetic involuntary movement disorder characterized by wild, flinging, throwing movements of a limb. These movements most usually involve one half of the body (hemiballismus), although they may sometimes involve a single extremity (monoballis- mus) or both halves of the body (paraballismus). The movements are often continuous during wakefulness but cease during sleep. Clinical and pathophysiological studies suggest that ballism is a severe form of chorea. It is most commonly associated with lesions of the contralat- eral subthalamic nucleus. Cross References Chorea, Choreoathetosis; Hemiballismus; Hypotonia, Hypotonus Bathing Suit Sensory Loss - see SUSPENDED SENSORY LOSS - 52 - Bell’s Palsy B Battle’s Sign Battle’s sign is a hematoma overlying the mastoid process, which indi- cates an underlying basilar skull fracture extending into the mastoid portion of the temporal bone. Beevor’s Sign Beevor’s sign is an upward movement of the umbilicus in a supine patient attempting either to flex the head onto the chest against resist- ance (e. It indicates a lesion causing rectus abdominis muscle weakness below the umbilicus. Lower cutaneous abdomi- nal reflexes are also absent, having the same localizing value. Downward movement of the umbilicus (“inverted Beevor’s sign”) due to weakness of the upper part of rectus abdominis is less often seen. Oxford: Butterworth Heinemann, 1999: 222-225 Cross References Abdominal reflexes Belle Indifférence La belle indifférence refers to a patient’s seeming lack of concern in the presence of serious symptoms. This was first defined in the context of “hysteria,” along with exaggerated emotional reactions, what might now be termed functional or somatoform illness. Some patients’ coping style is to make light of serious symptoms; they might be labeled stoical. Patients with neuropathological lesions may also demonstrate a lack of concern for their disabilities, either due to a disorder of body schema (anosodiaphoria) or due to incongruence of mood (typically in frontal lobe syndromes, sometimes seen in multiple sclerosis). Journal of Neurology, Neurosurgery and Psychiatry 2002; 73: 241-245 Cross References Anosodiaphoria; Frontal lobe syndromes; Functional weakness and sensory disturbance Bell’s Palsy Bell’s palsy is an idiopathic peripheral (lower motor neurone) facial weakness (prosopoplegia). It is thought to result from viral inflammation - 53 - B Bell’s Phenomenon, Bell’s Sign of the facial (VII) nerve. In the majority of patients with Bell’s palsy (idiopathic facial pare- sis), spontaneous recovery occurs over three weeks to two months. Poorer prognosis is associated with older age (over 40 years) and if no recovery is seen within four weeks of onset. The efficacy of steroid treatment remains uncertain, but it is often prescribed; it may improve facial functional outcome. Practice parameter: steroids, acyclovir, and surgery for Bell’s palsy (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. The clinical problem of Bell’s palsy: is treatment with steroids effective? British Journal of General Practice 1996; 46: 743-747 Cross References Bell’s phenomenon, Bell’s sign; Facial paresis; Lower motor neurone (LMN) syndrome Bell’s Phenomenon, Bell’s Sign Bell’s phenomenon or sign is reflex upward, and slightly outward, devi- ation of the eyes in response to forced closure, or attempted closure, of the eyelids. This is a synkinesis of central origin involving superior rectus and inferior oblique muscles. It may be very evident in a patient with Bell’s palsy (idiopathic facial nerve paralysis) attempting to close the paretic eye- lid. The reflex indicates intact nuclear and infranuclear mechanisms of upward gaze, and hence that any defect of upgaze is supranuclear. However, in making this interpretation it should be remembered that per- haps 10-15% of the normal population do not show a Bell’s phenomenon. Bell’s phenomenon is usually absent in progressive supranuclear palsy and is only sometimes spared in Parinaud’s syndrome References Bell C. On the motions of the eye, in illustration of the use of the muscles and nerves of the orbit. Philosophical Transactions of the Royal Society, London 1823; 113: 166-186. Cross References Bell’s palsy; Gaze palsy; Parinaud’s syndrome; Supranuclear gaze palsy; Synkinesia, synkinesis Benediction Hand Median nerve lesions in the axilla or upper arm cause weakness in all median nerve innervated muscles, including flexor digitorum profun- dus. On attempting to make a fist, impaired flexion of the index and middle fingers, complete and partial respectively, results in a hand pos- ture likened to that of a priest saying benediction. A somewhat similar, but not identical, appearance may occur with ulnar nerve lesions: hyperextension of the metacarpophalangeal joints - 54 - Blepharospasm B of the ring and little fingers with slight flexion at the interphalangeal joints. The index and middle fingers are less affected because of the intact innervation of their lumbrical muscles (median nerve). Cross References Claw hand; Simian hand Bent Spine Syndrome - see CAMPTOCORMIA Bielschowsky’s Sign, Bielschowsky’s Test Bielschowsky’s sign is head tilt toward the shoulder, typically toward the side contralateral to a trochlear (IV) nerve palsy. The intorsion of the unaffected eye brought about by the head tilt compensates for the double vision caused by the unopposed extorsion of the affected eye. Bielschowsky’s (head tilt) test consists of the examiner tipping the patient’s head from shoulder to shoulder to see if this improves or exacerbates double vision, as will be the case when the head is respec- tively tilted away from or toward the affected side in a unilateral trochlear (IV) nerve lesion.
