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causally related to antibodies directed against voltagegated calcium channels in the majority of af icted individuals LEMS is a paraneoplastic disorder in approximately two-thirds of cases Small cell carcinoma of the lung is the underlying malignancy in approximately 90% of these paraneoplastic cases Lymphoproliferative disorders, pancreatic, breast and ovarian carcinomas are other neoplasms reported to associate with LEMS199,200 The LEMS symptoms usually precede tumor recognition by about 10 months (range 5 months to 38 years) Approximately 84% of patients with LEMS are over the age of 40 years, with 54 years being the mean age at presentation Patients with LEMS who are seronegative are clinically indistinguishable from their seropositive counterparts201 In the other third of patients, LEMS occurs in the apparent absence of an underlying cancer Such cases are more common in young females who commonly have other autoimmune disorders Rheumatoid arthritis, systemic lupus erythematosus, in ammatory bowel disease, primary biliary cirrhosis, and even MG may coexist202 210 Other than the risk factors of age and smoking, the paraneoplastic and nonparaneoplastic forms of LEMS are clinically and electrophysiologically indistinguishable Patients with the LEMS usually voice the same complaints as their MG counterparts, that is weakness and easy fatigability, thus explaining its designation as a myasthenic syndrome190,192,193,195 198,211,212 The morbidity and functional impairment associated with these complaints seem to be disproportionate to the severity of objective weakness in many patients This may be in part due to the technique of muscle testing as described below Regardless, it may contribute to the suspicion of a psychogenic disorder, particularly in young women with the nonparaneoplastic form of the disorder The majority of patients present with proximal lower extremity weakness Proximal upper extremity weakness is noted in approximately 80% of patients during the course of the illness A third of patients complain of muscle aching and stiffness during or following physical exertion Approximately 20% of patients note that their weakness and fatigue are exacerbated by hot weather or baths Ocular and bulbar symptoms are not as common or as severe as seen in MG but do occur and may be the initial manifestation213,214 In those with cranial muscle involvement, neck exor, extensor, and facial muscles are among the most commonly affected Ptosis and diplopia are often transient and mild Some patients develop dysarthria or dysphagia Xerostomia and xeroophthalmia may be contributory to these symptoms Cholinergic dysautonomia manifesting in this way or with blurred vision, constipation, decreased sweating, and impotence are common200 Although pulmonary symptoms from lung cancer or associated chronic lung disease may occur, ventilatory issues are rare, although LEMS presenting with ventilatory.

class CUseful : public CBase { public: CONSTRUCTORS_MAY_LEAVE CUseful(); ~CUseful(); };

Though oppy drives are becoming scarce, the use of Recovery Console and some form of accessible, removable media will enable you to semi-automate the restoration of the critical Registry folders Create the following batch le and save it to a oppy disk 1 Open a text editor, type the following lines of code exactly, and save your work as a text le (located on a oppy disk) called MyRegBaktxt

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failure has been described50,215,216 Complaints of numbness and paresthesias in the distal extremities may occur on occasion As previously mentioned, erroneous assessments of muscle strength may result from the potentiation created by the manual muscle testing procedure The patient s strength must be graded from the initiation of contraction, not several seconds later For example, the patient may initially have dif culty maintaining hip exion in the seated position but then demonstrate subsequent recovery This phenomenon may contribute to the perception that the patients are stronger than their histories suggest Potentiation occurs primarily in proximal hip and shoulder girdle muscles The improvement usually dissipates with sustained muscle contraction Repetitive squatting is another means to demonstrate initial weakness, improvement, and then subsequent decline after several minutes Exercise may also be used to evaluate ptosis, which may be improved with sustained voluntary lid elevation in a manner opposite to MG217 In advanced stages of the disease, muscle atrophy can be observed Cholinergic dysautonomia may also be demonstrated by recognition of a sluggish pupillary light reaction or diminished sweating to a provocative challenge Deep tendon re exes may initially be diminished or absent but may amplify once a muscle has been contracted A few patients with LEMS associated with antiHu antibodies (usually seen with small cell carcinoma of the lung) also have clinical ndings suggestive of a sensory neuronopathy, cerebellar ataxia, and/or limbic encephalitis218 The former may explain the paresthesias or sensory loss that can occasionally be reported or recognized A small number of patients will present with what seems to be an MG/LEMS overlap syndrome149,219 227 Most MG cases overlapping with LEMS are based on the presence of AChR antibodies in patients who otherwise appear to have LEMS on a clinical and electrophysiological basis As many as 13% of patients with LEMS have AChR-binding antibodies228 The anti-AChR antibodies may be epiphenomenal rather than pathogenic in at least some LEMS patients147,228 Nonetheless, rare patients may exhibit clinical features of both LEMS and MG.

In an adult, the clinical presentation of botulism is similar, irrespective of whether the disease is acquired through a foodborne, wound, or hidden (ie, suspected gastrointestinal) route113,229 236 The foodborne and infantile varieties are the most common forms of the disease Statistically, different serotypes of Clostridium botulinum may have minor phenotypic differences, which are inconsequential in the evaluation of individual pa-

MD TMP COPY C:\%SYSTEMROOT%\SYSTEM32\CONFIG\SYSTEM C:\%SYSTEMROOT%\TMP\SYSTEMBAK COPY C:\%SYSTEMROOT%\SYSTEM32\CONFIG\SOFTWARE C:\%SYSTEMROOT%\TMP\SOFTWAREBAK COPY C:\%SYSTEMROOT%\SYSTEM32\CONFIG\SAM C:\%SYSTEMROOT%\TMP\SAMBAK COPY C:\%SYSTEMROOT%\SYSTEM32\CONFIG\SECURITY C:\%SYSTEMROOT%\TMP\SECURITYBAK COPY C:\%SYSTEMROOT%\SYSTEM32\CONFIG\DEFAULT C:\%SYSTEMROOT%\TMP\DEFAULTBAK

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