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changes in the small salivary glands This is a minor of ce procedure in most instances The diagnosis of Sjogren syndrome re quires the detection of at least two collections of 50 or more lymphocytes in a 4 mm2 specimen Some patients have serologic abnormalities such as antinuclear antibodies (anti-Ro, also termed SS-A, and anti-La, or SS-B) or increased monoclonal immunoglobulins, particularly of the IgM subclass The frequency of these speci c Sjogren-speci c antibodies varies greatly between series; they may be useful as screening tests, but the lip biopsy is a far more sensitive diagnostic procedure In our series of 20 cases with salivary gland biopsies that demonstrated in ammatory changes diagnostic of the syndrome, only 6 had serologic evidence of the disease and two had positive serologic tests but a negative biopsy (Gorson and Ropper) The sedimentation rate in our patients was often slightly elevated, however, only 5 of our 20 had a value greater than 40 mm/min The main differential diagnostic entity is a paraneoplastic sensory ganglionitis Mellgren and also Leger and their colleagues have stressed the point that a proportion of unexplained polyneuropathies in middle and late life are caused by Sjogren syndrome The latter authors found typical Sjogren abnormalities in the lip biopsies of 7 of 32 patients with chronic axonal polyneuropathy that could not otherwise be classi ed Several other studies have corroborated this nding of in ammatory disruption of the minor salivary glands in obscure neuropathies, particularly in older women and in some men The diagnosis in our clinics, where lip biopsies are routinely performed in patients with nondescript sensory neuropathies, has not been nearly as frequent Nonetheless, a search for Sjogren disease may be revealing in otherwise obscure sensory neuropathies Nerve biopsies in some cases have revealed a necrotizing vasculitis, in ammatory cell in ltrates, and focal nerve ber destruction Usually, the CSF protein is normal and there is no cellular reaction The few times a dorsal root ganglion has been examined, there were in ltrates of mononuclear cells and lymphocytes and destruction of nerve cells Treatment Treatment of the sicca complex and the neuropathic manifestations is unfortunately largely symptomatic Corticosteroids, cyclophosphamide, and chlorambucil have been used when the neuropathy is severe and are indicated when there is vasculitis involving renal and pulmonary structures We have administered prednisone 60 mg daily, often in tandem with intermittent plasma exchange, with little evidence of response In a few severe cases, monthly intravenous cylcophosphamide has been added Others have recorded more encouraging results The review of the neurologic manifestations of Sjogren syn drome by La tte is recommended Idiopathic Sensory Ganglionopathies (Chronic Ataxic Neuropathy) In addition to the subacute pansensory syndrome described above and paraneoplastic, postinfectious, or toxic processes (page 1128), there is a more chronic idiopathic variety characterized by severe global sensory loss and ataxia We have encountered several such patients with sensory loss and pronounced ataxia resembling the cases described by Dalakas The numbness and sensory ndings progressed over months and spread to proximal parts of the arms and legs and then to the trunk The face and top of the scalp were nally involved Despite severe ataxia and complete are exia, muscular power remained normal Pain was not a problem There are reports of fasciculations in a few patients (but not in the ones we have seen) Within a year, most of these patients became completely disabled from the ataxia, unable to walk or even. data matrix

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The carotid system consists of three major arteries the common carotid, internal carotid, and external carotid As indicated in Fig 34-2, the right common carotid artery arises at the level of the sternoclavicular notch from the innominate (brachiocephalic) artery, and the left common carotid comes directly from the aortic arch The common carotids ascend in the neck to the C4 level, just below the angle of the jaw, where each divides into external and internal branches (sometimes the bifurcation is slightly above or below this point) Common carotid occlusion accounts for less than 1 percent of cases of carotid artery syndrome the remainder being due to disease of the internal carotid artery itself Nevertheless, the common carotid can be occluded by an atheromatous plaque at its origin, more often on the left side Atherosclerotic stenosis or occlusion of the midportion of the common carotid may also occur years after radiation therapy for laryngeal or other head and neck cancer If the bifurcation is patent, few if any symptoms may result, in some cases because retrograde ow from the external carotid maintains internal carotid ow and perfusion of the brain Because the syndromes caused by common carotid occlusion are identical to those of its internal branch, the remainder of this discussion is concerned with disease of the internal carotid artery The territory supplied by this vessel and its main branches is shown in Figs 34-4, 34-5, and 34-6 The clinical manifestations of atherosclerotic thrombotic disease of this artery are among the most variable of any cerebrovascular syndrome Unlike other cerebral vessels, the internal carotid artery is not an end vessel In most individuals it is in continuity with the vessels of the circle of Willis and those of the orbit, and no part of the brain is completely dependent on it Therefore occlusion, which occurs most frequently in the rst part of the internal carotid artery (immediately beyond the carotid bifurcation), is often silent (30 to 40 percent of cases) There are two mechanisms by which strokes arise from atherosclerosis and superimposed thrombotic occlusion of the internal carotid artery (We use the terms atherothrombotic and atherothrombosis here and in subsequent sections of the chapter to indicate this common mechanism of local stenosis, which leads to occlusion of the proximal parts of cerebral vessels or at their origins in the thorax and neck; see page 686) First, occlusion of the carotid may give rise to an embolus that passes distally in the territory of its tributary vessels, downstream from the internal carotid artery (middle and anterior cerebral arteries and their branches, as described further on) This has been termed artery-to-artery embolism Second, and less often, occlusion of the carotid artery may lead to ischemia in the distal eld (watershed or border zone) in the region of lowest perfusion between its major branch vessels. example

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There are many other examples for the Web Intelligence reporting tool for BOBJ including variables, alerts, conditions, filters, and other parameters but these are just a few to offer some basic samples

The clinical picture that results from an occlusion of any one artery differs in minor ways from one patient to another, but there is



Post temporal A Middle cerebral stem Temporal polar A Ant temporal A Lateral geniculate body AUDITORY AREA

Xcelsius is the component with all the bells and whistles for dashboarding in the BOBJ environment This toolset really takes the whole dashboarding process to another level It has all the functionality that is required for a dynamic dashboard and it is very easy to use and understand Now, that being said, it still requires that we configure the underlying source of data correctly so that the different indicators available can read the appropriate information Xcelsius 2008 is a visualization tool for creating interactive visual models based on highly aggregated data sets It uses a point-and-click design time environment that can easily be used by business users No programming skills are necessary for creating Xcelsius 2008 visualizations, but knowledge about dashboarding is still a requirement The following illustration shows the initial workbench for the Xcelsius product As you can see, the object Bar Chart has been dragged and dropped into the worksheet Notice to the right side of the screen you can see that very similar questions are being asked for the development and configuration of this chart type as were asked for the WAD We ve seen this information when we looked at the bar chart in the WAD component So, what comes around goes around and as I mentioned nothing that you learn from the development of the chart types in the WAD will go to waste The information such as subtitles, titles, categories, and so forth are the same and should be treated the same The different categories of charts and types are found on the left side of the screen

Figure 34-4 Diagram of a cerebral hemisphere, lateral aspect, showing the branches and distribution of the middle cerebral artery and the principal regions of cerebral localization Below is a list of the clinical manifestations of infarction in the territory of this artery and the corresponding regions of cerebral damage

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