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Compression of the C8 and T1 roots or the lower trunk of the brachial plexus by a cervical rib or band arising from the seventh cervical vertebra leads to weakness and wasting of intrinsic hand muscles, especially those in the thenar eminence, accompanied by pain and numbness in the medial two fingers and the ulnar border of the hand and forearm The subclavian artery may also be compressed, and this forms the basis of Adson s test for diagnosing the disorder; the radial pulse is diminished or obliterated on the affected side when the seated patient inhales deeply and turns the head to one side or the other Electromyography, nerve conduction studies, and somatosensory evoked potential studies may help confirm the diagnosis MRI may be especially helpful in revealing the underlying compressive structure Plain radiographs or CT scanning sometimes shows the cervical rib or a large transverse process of the seventh cervical vertebra, but normal findings do not exclude the possibility of a cervical band Treatment of the disorder is by surgical excision of the rib or band

Patients present with ptosis, diplopia, difficulty in chewing or swallowing, respiratory difficulties, limb weakness, or some combination of these problems Weakness may remain localized to a few muscle groups, especially the ocular muscles, or may become generalized Symptoms often fluctuate in intensity during the day, and this diurnal variation is superimposed on a tendency to longer-term spontaneous relapses and remissions that may last for weeks Nevertheless, the disorder follows a slowly progressive course and may have a fatal outcome owing to respiratory complications such as aspiration pneumonia Clinical examination confirms the weakness and fatigability of affected muscles In most cases, the extraocular muscles are involved, and this leads to ocular palsies and ptosis, which are commonly asymmetric Pupillary responses are normal The bulbar and limb muscles are often weak, but the pattern of involvement is variable Sustained activity of affected muscles increases the weakness, which improves after a brief rest Sensation is normal, and there are usually no reflex changes The diagnosis can generally be confirmed by the response to a short-acting anticholinesterase Edrophonium can be given intravenously in a dose of 10 mg (1 mL), 2 mg being given initially and the remaining 8 mg about 30 seconds later if the test dose is well tolerated; in myasthenic patients, there is an obvious improvement in strength of weak muscles lasting for about 5 minutes Alternatively, 15 mg of neostigmine can be given intramuscularly, and the response then lasts for about 2 hours; atropine sulfate (06 mg) should be available to reverse muscarinic side effects

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Generally, the same value as used for the net value or net price for the item is also used for this rebate basis You may want to have two lines in the pricing procedure, one for the basis of the rebate with sub-total 7, and another for the net value with sub-total 2 The requirement 024 may be assigned to the condition type in the pricing procedure, which determines the condition is only accessed in the billing document Also note when defining the condition types used in rebate processing that our example, B002, must use condition class C (expense reimbursement) As seen in Figure 7-21, the condition types used in rebate processing are slightly different from the standard condition types used, for example, for pricing or discounts, in that there is less data to maintain, while also including two additional rebate settings The two rebate settings used as follows: The rebate procedure indicates if the condition is dependent or independent of sales volume The Provision Con field, which is actually the accruals correction procedure, indicates if accruals must be corrected when a partial rebate payment has been made

A lumbosacral plexus lesion may develop in association with diseases such as diabetes, cancer, or bleeding disorders or in relation to injury It occasionally occurs as an isolated phenomenon similar to idiopathic brachial plexopathy, and pain and weakness then tend to be more conspicuous than sensory symptoms The distribution of symptoms and signs depends on the level and pattern of neurologic involvement

Fluctuating weakness of commonly used voluntary muscles, producing symptoms such as diplopia, ptosis, and difficulty in swallowing Activity increases weakness of affected muscles Short-acting anticholinesterases transiently improve the weakness

Lateral and anteroposterior x-rays of the chest and CT scans should be obtained to demonstrate a coexisting thymoma, but normal studies do not exclude this possibility

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