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Population impact measures (PIMs) have been developed as tools to help policy-makers with locally relevant decisions over health risks and benefits. This involves estimating and prioritising potential benefits of interventions in specific populations. Using tuberculosis (TB) in India as an example, we examined the population impact of two interventions: direct observation of therapy and increasing case-finding.
PIMs were calculated using published literature and national data for India, and applied to a notional population of 100 000 people. Data included the incidence or prevalence of smear-positive TB and the relative risk reduction from increasing case finding and the use of direct observation of therapy (applied to the baseline risks over the next year), and the incremental proportion of the population eligible for the proposed interventions.
In a population of 100 000 people in India, the directly observed component of the Directly Observed Treatment, Short-course (DOTS) programme may prevent 0.188 deaths from TB in the next year compared with 1.79 deaths by increasing TB case finding. The costs of direct observation are (in international dollars) I$5960 and of case finding are I$4839 or I$31702 and I$2703 per life saved respectively.
Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritise interventions for their populations.
Tuberculosis (TB) is a major global public health problem. Reducing the burden of morbidity and mortality due to TB relies on identifying the treatments and preventive measures of greatest impact, and communicating this information to decision-makers so that the most appropriate policies are implemented.
We have previously described a series of population impact measures (PIMs) to describe the population impacts of risks and benefits [1-3]. These are measures of absolute risk and are based on previous methods for describing clinical and population impacts. They provide local meaning to an otherwise confusing mixture of generic evidence and local statistics, helping policy-makers to identify and prioritise the potential benefits of interventions in their own population. PIMs are simple to compute, and contain the elements to which policy-makers need to pay attention in the commissioning or improvement of services. They are designed as useful additions to the generic measures of illness burden, from which they differ in having event-specific outcomes rather than generic outcomes such as the quality-adjusted life year (QALY) or the disability-adjusted life year (DALY).
The World Health Organization (WHO) has promoted the Directly Observed Treatment, Short-course (DOTS) strategy, which comprises five elements, (political commitment, case detection using sputum microscopy, standardised short-course chemotherapy, regular drug supply, and a standardised recording and reporting system). These elements incorporate direct observation of treatment but exclude active case finding [4]. DOTS programmes may differ in the emphasis placed on the five elements, and may incorporate additional features[5]. In India, the Revised National Tuberculosis Control Programme gives considerable emphasis to directly observed treatment, so that it is now one of the five main elements [6]. Some authors have suggested that case finding is underemphasised as a global TB control strategy [7-11], and that directly observed therapy may be overemphasised[5,12]. Case-finding may be "active" or "enhanced"[11]; we did not specify which of these we include under our general category of increased case-finding, as this will vary according to local conditions. In this study, the utility of using PIMs to describe the population impact of the directly observed component of DOTS was compared with that of increased case-finding, using India, where TB provides a major health burden, as an example[13].
To describe the impact of preventive and treatment interventions, the number of events prevented in a population (NEPP) is defined as "the number of events prevented by the intervention in your population over a defined time period" [2]. NEPP extends the number needed to treat (NNT) beyond the individual patient to a specific population. The components of the calculations (see Appendix for the formulae) are: (i) population denominator (size of the population); (ii) proportion of the population with the disease; (iii) the incremental proportion of the diseased population eligible for the proposed intervention (the latter requires the actual or estimated proportion who are currently receiving, and are compliant with, the interventions, subtracted from best practice goal from guidelines or targets); (iv) baseline risk (the probability of the outcome of interest in this or similar populations); and the(v) relative risk reduction (RRR) associated with the intervention. Confidence intervals (CIs) for the measures were obtained using simulation methods http://www.phsim.man.ac.uk/ webcite. The calculations were made using published data (each source is referenced in the Results section).
Data from the paper by Baltussen et al[14] were used to calculate the costs, which are reported in international dollars (I$). Direct observation of therapy requires 40 clinic visits for supervision (24 in the intensive and 16 in the continuation phase) rather than 4 (1 initial and 3 for progress monitoring) for unobserved treatment. Each clinic visit costs I$3.85. Each TB smear test for those identified by case finding costs I$1.14, and we multiplied this by the prevalence of symptoms in the population (to reflect that increased case-finding would occur among those who are symptomatic). We do not have an estimate of the costs of detecting those who are symptomatic in order for them to have a sputum smear for diagnosis, as the way in which cases are detected will differ depending on the setting and on whether the case finding is "active" or "enhanced"[11]. However, we doubled the cost of the smears to allow for the costs of the case finding to detect symptomatic people who will subsequently have a smear, and also added the treatment costs for the cases of smear-positive TB identified by the case-finding process (drug costs at I$7.84 plus four clinic visits per patient).
The published data show that 45% of identified TB patients in India are covered by the DOTS programme[15] However, only an estimated 50% of smear-positive TB cases in India are identified by the current passive case-finding approach[13]. The benefit of increasing this by a further 20% (or 40% of the currently unidentified cases) was estimated, as this is consistent with the national and global target of detecting 70% of smear-positive cases[6,13], and is a conservative estimate of the proportion of undetected cases that might be found through case finding[11,16]. The added benefit of the directly observed component of DOTS on cure and completion rates has been estimated in a systematic review as 6%, which is the figure used in our study, although this was not statistically significantly different from no benefit[12]. We assumed that this benefit would translate to a similar reduction in case fatality. Six-month case fatality for treated TB was estimated in the original MRC trial of the treatment of TB as 7.3% and for untreated TB 27%, with a reduction of 73% from treatment,[17] and are consistent with a reported global case fatality rate of 23% [9,18]. We also assumed that only 71% of patients with TB would complete treatment in the absence of the DOTS programme, taken from the "cure plus treatment completion" figures of the control groups in the Cochrane review[12]. This is consistent with the 76% quoted elsewhere [19] Table 1 demonstrates that the current direct observation of the DOTS programme would, on average, produce a reduction of 0.188 deaths from TB for each 100 000 people in the population in a year. If the identification rate of TB was increased by 20%, using increased case-finding, and 71% of these people completed treatment, there would be a reduction of 1.79 deaths from TB for each 100 000 people in the population in a year, nearly 10 times the numbers of deaths saved by direct observation of therapy.
Table 1. Number of deaths prevented among 100,000 people in India with direct observation of therapy and increased use of case finding
The cost of direct observation for 36 extra clinic visits is I$138.6 per patient. Table 1 shows that there are 43 smear-positive cases per 100 000 population in a year, thus the cost of direct observation for these 43 cases is I$5960, resulting in a cost of I$31702 per life saved.
For case finding, we estimated that 2% of the population may be symptomatic (from previous figures of 1.2–6.7% symptomatic people in possibly similar populations[11,16]), hence requiring 2000 smears. This may be a conservative estimate, as Baltussen estimates that only 30 smears need to be taken to find one case, whereas we estimated it would take 2000 smears to find 12 cases (40% of the 32 undiagnosed in our population of 100 000), or 167 smears to find one case. The drug costs and 4 clinic visits total I$23.24 for each of the 12 identified cases. The cost of case finding is thus estimated to be I$4839, or I$2703 per life saved (table 2).
Table 2. Costs of direct observation of therapy and increased use of case finding among 100 000 people in India
This study shows that, given the parameters used, increasing case finding by 20% would lead to nearly 10 times the numbers of deaths saved by the current direct observation of therapy in India. This is due to a greater RRR, applied to a higher baseline case-fatality, hence producing a larger absolute benefit. The analysis clearly shows that, based on the assumptions made, improving case-finding for TB will save far more lives than maximizing the use of the directly observed component of DOTS among currently identified cases in India. This has obvious implications for health decision-makers. Although the DOTS program does encourage better case detection, it does not include active or enhanced case-finding [5,6,20]. Our findings concur with those who feel that case finding should receive more attention [7,21,22], and that a careful approach to examining the benefits of different aspects of DOTS programmes should be encouraged[5].
There are several different strategies for increasing case-finding, and the choice should depend on local factors such as disease prevalence, adequacy of training of healthcare workers and willingness of the infected population to seek care for symptoms[11]. The benefits of active, passive or enhanced case-finding among general, high-risk, and symptomatic populations have been reviewed in depth by Golub et al[11].
The calculations made in this study depend on the accuracy of the data used. Each estimate is subject to potential error, and ideally, each population should obtain its own data in order to produce accurate estimates of population impact of risks and interventions. The literature-based estimates of RRR are also open to question. Our use of the baseline risk of death from treated and untreated TB uses old trial data, although the treated risk is consistent with recently published data of death rates of 4.4% among DOTS-registered cases in countries with high TB burden[13]. We applied the cure rate of the systematic review of DOTS therapy to the case fatality, and this may be open to question. An updated Cochrane Review was published in 2006[23], which came to the same conclusion about a non-significant 6% difference in the outcome cured or completed treatment. There were insufficient numbers to allow analysis of case fatality, although four of the included trials did include mortality as an outcome measure. The results of the calculations depend on the various assumptions made. For example, changing the estimate of TB treatment completion would have changed the number of deaths prevented, but is unlikely to have changed the ranking of benefit between increasing case-finding and direct observation of treatment. Thus it is important to obtain relevant local data, apply the approach to different populations and population subgroups, and to test the robustness of the estimates to varying the assumptions. For example, in a population where case finding is already extensive, costs per case detected are likely to be higher, and thus maximizing the use of directly observed therapy could have the greater impact.
The confidence intervals were made taking into account the potential variability of the estimates used; however, changing the estimates used for each of the components of the PIMs themselves has additional potential to influence the results. This can be explored by recalculating the measures using different estimates as appropriate to particular local settings. To assist potential users, we have developed a public access website that automatically calculates both the PIMs and their confidence intervals http://www.phsim.man.ac.uk/ webcite.
We did not include the impact of transmission dynamics on the rest of the population in our calculations, as this would add considerably to the complexity of the approach. In terms of the comparison between direct observation and improved case-finding, the lack of attention to transmission dynamics will underestimate the relative benefit of improved case-finding, as the resulting early intervention is likely to be more effective than the later attempt to improve therapy adherence. The decision to restrict the analysis to smear-positive cases was based on the better accuracy of this measure of disease burden, although it will underestimate the benefit of treatment on extrapulmonary TB. We do not wish to claim false accuracy for the results presented; however, they do use the best available data, are easy to compute and produce results that are easy to understand. The level of accuracy should be adequate for most policy decisions, and is preferable to making decisions in the absence of estimates of population benefit.
If PIMs prove useful where relevant data exist, then this could stimulate better collection and use of health data in situations where there are currently too few data to enable reasonable calculations. Similarly, the use of PIMs with confidence intervals enables policy-makers to be explicit about the uncertainties they face.
The measures can be used to compare between populations, in which case standardization for age, sex, ethnicity and socioeconomic status may be required. The measures can also be used to compare between segments of a population, in which case the potential for an intervention to reduce health inequalities and increase equity within a population can be explored[3].
For ease of presentation, the population denominator we used was 100 000 adults; however, one of the main benefits of these measures is the ability to relate to local context, hence policy-makers can make the calculations for their own population denominator.
The addition of information on costs to the population impact measures will also be important for policy makers, and our estimated costs for the programme will allow costs and their consequences to be calculated[24]. PIMs differ from measures used in cost-effectiveness analyses by not including life expectancy or the utility or valuation of the health outcome. They thus produce outcomes expressed as events rather than generic outcomes such as QALY or DALY gained[25]. We have previously suggested that the valuation of the events prevented should be performed by the policy-maker in relation to the costs of the intervention, once the measures have been produced [26]. Although our cost estimates are prone to error, they were derived using previously published costs applied to this simple model of health gain. They show that the programme costs for the direct observation of therapy and the detection of new cases are similar, although the health gain is much greater for the detection of new cases. In fact, our estimate of the health gain from direct observation may be an overestimate, as the relative risk quoted was not significantly different from no effect.
The data shown on TB control demonstrates the potential benefit to policy-makers from the use of PIMs. There is some evidence that the way in which health benefits are framed impacts on the policy decisions reached[27], although there is debate about the consistency of such an effect[28]. We previously showed that although clinicians were more influenced by benefit expressed as RRR than as PIMs[29], public health professionals were more likely to prioritise interventions based on the use of PIMs than on the basis of more complex demonstrations of health gain [26]. The evidence base on what are the most effective methods of presenting health gains from interventions in order to assist in policy-making is, however, weak. Health policy requires more than merely demonstration of health gain [30-32], as the complexity of policy-making includes social and political drivers of decision-making, as well as the need to take into account issues such equity, total budget impact, total morbidity and disease severity.
Our method is considerably simpler than other modelling exercises that have also examined the potential benefits of case finding[7,8], and may compensate for this simplicity by the increased ease of when making the calculations and understanding the results. Both modelling and the calculation of PIMs have similar reliance on data availability and accuracy. Our method is not intended to replace more complex analyses of TB control[14], nor is it intended to reflect adversely on the DOTS programme, which has many components, of which direct observation is only one. It is intended to show how to use local data to provide simple demonstrations of health benefit, which can then be used in policy-making. We believe that it is worth testing the hypothesis that simple demonstration of the population health-gain consequences of interventions will lead to the introduction of health policies that can provide appropriate priorities to improve health in developing countries. This could be of marked benefit in TB, a major threat to global health.
Increasing case-finding for TB will save nearly 10 times more lives than will the use of the directly observed component of DOTS in India, at a smaller cost per life saved. The demonstration of the population impact, using simple and explicit numbers, may be of value to policy-makers as they prioritise interventions for their populations.
Formula for calculating population impact measure
Number of events prevented in your population (NEPP) [2]
NEPP = n* Pd * Pe * ru * RRR
where n = population size, Pd = prevalence of the disease in the population, Pe = proportion eligible for treatment, ru = risk of the event of interest in the untreated group or baseline risk, and RRR = relative risk reduction associated with the treatment
In order to reflect the incremental effect of changing from current to "best" practice and to adjust for levels of compliance the proportion eligible for treatment Pe is
((Pb - Pt) * Pc
where Pt is the proportion currently treated, Pb is the proportion that would be treated if best practice was adopted and Pc is the proportion of the population that is compliant with the medication.
Competing interests
The author(s) declare that they have no competing interests.
Authors' contributions
RFH, RE and IB were involved in the design and conception of the study, IG and IB in statistical analysis, RFH and SA in data acquisition, RFH, IG, IB and JAV in analysis and interpretation, RFH and IG in initial drafting and all authors in critical revision of the manuscript.
The authors received no funding for this study.
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by Radar Staff
The producers of The Governator animated TV and comic book series have pulled the plug on the highly-touted project.
"In light of recent events, A Squared Entertainment, POW, Stan Lee Comics and Archie Comics have halted production," a statement released Friday night by an A Squared spokesman said.
PHOTOS: Arnold Schwarzenegger & Maria Shriver Through The Years
The obstacles in going forward were massive. The character, who would have been voiced by Arnold himself in the TV series, was a super hero who "leads a double life," according to an outline for the show seen by The Los Angeles Times.
The Governator is also described in the outline as "a devoted family man."
PHOTOS: Maria Shriver And Kids Have Lunch
As RadarOnline.com has been reporting, the former California governor fathered a child with one of his family's housekeepers, and kept it secret for almost 14 years. His son by Mildred "Patty" Baena was born just a week apart from his son by wife Maria Shriver.
Schwarzenegger and Shriver are now separated.
Arnold Schwarzenegger 'Not Willing To Commit' To Any Movies
Arnold Confessed After Maria Confronted Housekeeper About Love Child
PHOTOS: Move Over Arnold, Other Celebs Involved In Baby Scandals!

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The Power of Independent Thinking
Waco, Twenty Years LaterWhat Statism Is All About
Recorded: Wednesday, April 17, 2013
Twenty years ago, Americans witnessed the greatest law enforcement atrocity in modern U.S history. On February 28th, 1993, the ATF raided the Branch Davidian home in Waco, Texas. The stand-off finally ended 51 days later, on April 19th, after the building went up in flames, killing 70 civilians including more than 20 children. Reflections by Independent Institute Research Fellow Anthony Gregory.
Experts: Anthony GregoryType: Independent Institute TVIssues: Civil Liberties/ Human Rights, Culture/ Society, Law Enforcement, Religion
David Theroux Discusses Youths Political Future
Recorded: Friday, April 12, 2013
Independent Institute Founder and President, David J. Theroux discusses libertarianism, politics, and today's youth with host Gary Franchi on the Next News Network.
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Stephen Halbrook Joins the Versus Debates on Firearms and Freedom
Recorded: Tuesday, April 2, 2013
Research Fellow Stephen P. Halbrook joins the Versus Debates on The Right to Bear Arms is a Freedom Too Far.
Experts: Stephen P. HalbrookType: TelevisionIssues: Culture/ Society, Freedom, Gun Control, Public Health/ Consumer Protection
Stephen P. Halbrook on FoxNews: Gun Owner Liability Insurance
Recorded: Tuesday, February 26, 2013
Research fellow Stephen Halbrook discusses the proposed selling of gun owner liability insurance on FoxNews with Judge Jeanine Pirro.
Experts: Stephen P. HalbrookType: TelevisionIssues: Civil Liberties/ Human Rights, Constitutional Law, Crime, Culture/ Society, Gun Control, Law Enforcement, Public Health/ Consumer Protection
Alexander Tabarrok on 3 City Gun Buy-Back Event
Recorded: Friday, February 22, 2013
Alexander Tabarrok, Research Director at the Independent Institute, speaks with Lyanne Melendez of KGO-TV on city gun buy-back programs.
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Alexander Tabarrok on Folly of Gun Buyback Programs
Recorded: Friday, February 8, 2013
Research Director Alex Tabarrok speaks about gun buyback programs on Seattles KIRO-TV.
Type: TelevisionIssues: Crime, Culture/ Society, Law Enforcement
C.S. Lewis, My Godfather: An Evening with Laurence Harwood
Recorded: Wednesday, October 10, 2012
Laurence Harwood, OBE, godson of C.S. Lewis, reflects on his and others relationships with Lewis during his youth. He shares delightful letters and jolly recollections from his book C.S. Lewis, My Godfather: Letters, Photos, and Recollections. Laurence spoke at an evening event sponsored by the C. S. Lewis Society of California.
Type: TelevisionIssues: Culture/ Society, Entertainment, History (International)
Anthony Gregory at P.A.U.L. Festival 2012
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Independent Institute Research Fellow and Student Programs Director Anthony Gregory addresses P.A.U.L. Festival 2012 on Government Power and the Road to Liberty.
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John Lloyd Young dishes on bringing 'Jersey Boys' to the screen
Clint Eastwood didn't just direct "Jersey Boys" — he also gave his Frankie Valli a driving lesson. Like the Broadway hit it's based on, the film chronicles the rise and...
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Watch Joe Biden Discuss Russia-Ukraine Conflict | Watch Aurora Theater Shooting Trial
File photo of Brazilian presidential candidate Eduardo Campos during an event in Brasilia, Brazil, on October 5th, 2013. Campos was killed on August 13th 2014 when a small private plane crashed in a residential area in Santos, in the state of Sao Paulo.
A plane carrying Eduardo Campos, a front runner for the Brazilian presidential elections, crashed on Wednesday morning in the coastal city of Santos.
Brazil's Ministry of Aeronautics confirmed to NBC News that the leader of the Brazilian Socialist Party (PSB) was one of the seven people killed in the plane crash.
According to Brazilian air authorities, Campos' private jet had been traveling from Rio de Janeiro's domestic airport to Guarujá airport. Air traffic control lost contact with the small jet as it was preparing to land in bad weather.
Campos, who led the Brazilian Socialist Party (PSB), was running in third place behind incumbent Dilma Rouseff and Aécio Neves, of the Brazilian Social Democracy Party. A public opinion poll released by Ipobe on August 7th showed Campos winning 9 percent of the votes in the first round of elections; President Dilma Rouseff was unchanged at 38%.
In order for a candidate to be elected in the first round they must obtain more than 50 percent of the votes. This poll indicated that Rouseff was not going to pass in the first round and would likely face Neves in the second round.
Campos' running mate, former senator Marina Silva was not on the plane, a PSB source told Reuters. It's unclear at this time whether or not she will run in Campos' place.
Both Rouseff and Neves announced that they would pause their presidential campaign for a period of mourning and both released statements. "All of Brazil is in mourning," expressed Rouseff "Today we lost a great Brazilian, Eduardo Campos. We lost a great companion."
Neves took to Twitter to express his disbelief: "It's with great sadness that I received the news of the accident that killed the former governor and my friend Eduardo Campos. The loss is irreparable and incomprehensible. At this time, my family and I join in prayer for Eduardo's family, his friends, and millions of Brazilians, who surely share the same confusion and regret."
News of Campos' death caused local financial markets to plunge and threw Brazil's October elections into disarray.
The former Pernambuco governor had just celebrated his 49th birthday three days earlier on August 10th. He leaves behind a wife and five kids.
He was the grandson of Miguel Arraes – a democratically elected governor from the state of Pernambuco who was overthrown in the 1964 military coup. In sad coincidence, Campos died the same day as his grandfather who passed on August 13, 2005.
Emmanuelle Saliba is a social media reporter with NBC News.


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Ring Magazine: October 2012
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Cover: Saul Alvarez, Josesito Lopez, Julio Cesar Chavez Jr., and Sergio Gabriel Martinez
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Home > Archives
Tuesday March 22, 2011
EVERY so often the issue of poorly trained house officers and medical officers crops up. The issue of poor training is not just seen with clinical medicine but research medicine as well.
Often, when a research publication gets retracted for being sub-standard, a junior researcher seems to be the culprit.
Of course some junior doctors have to shoulder their share of blame for their perceived lack of professionalism, but to put the blame solely on them would be an evasion of duty.
There is an explicit obligation on senior clinicians to be effective in their teaching, supervision and assessment of doctors-in-training. For most full-time senior clinicians the daily routine more or less encompasses a few important tasks.
Patient care, teaching and supervision of junior doctors, primary or secondary research and updating professional competency.
Unfortunately, added to this already busy schedule are tasks such as administration and serving on various committees.
In the past, full-time clinicians did some administrative work as these were rather uncomplicated.
Today, however, most medical units are complex organisations with large numbers of staff, dependent on sophisticated technology held together by a complex web of information technology.
Increasingly, hospital administration has been successfully handed over to professional administrators, many of them non-clinicians. It is not that administrative work is not important; indeed it is very important to the delivery of patient care.
It is just that it can now be done by administrators, leaving clinicians with more time to do the things that only a clinician is qualified to do.
Likewise, many senior clinicians may also find themselves sitting on too many time consuming committees.
An under-supervised medical officer left to his own devices while his specialists are busy with their committee work is certain to form unfortunate conclusions.
Senior clinicians must send a clear message to junior doctors that their priority, and most important work, is patient care related. Only then will junior doctors be inspired to be good clinicians themselves. In medicine leadership is definitely by example.
Puchong, Selangor.
Neighbours heard cries of children being beaten
RM1mil reward offer for information on Dr M's alleged misdeeds
Body of child found buried in kitchen
'Wild' party ends for 51 at popular mall
Money down the drain
Image on Google Street View may be that of missing boy
Copyright © 1995-2015 Star Media Group Berhad (ROC 10894D)(Formerly known as Star Publications (Malaysia) Berhad)


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Foxconn reportedly sets aside $6.8 million for a wearable computing startup fund
Taiwanese manufacturer Foxconn is setting up a $6.8 million investment fund targeting startups that are working on producing new kinds of wearable computers.
Foxconn Technology Group, maker of Apple Inc. (AAPL) iPhones and iPads, is launching an investment fund to finance startups developing new kinds of wearable computers, according to two people familiar with the project.
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In French, most written word-final consonants are silent in most contexts. Liaison is the pronunciation of such a consonant immediately before a following vowel sound. For example, the letter s in the word les ("the") is generally silent, but it is pronounced /z/ in the combination les amis ("the friends"). In certain syntactic contexts, liaison is impossible; in others, it is obligatory; and in yet others, it is possible but not obligatory.
Like elision (as in *je aime → j'aime), it can be characterized functionally as a euphonic strategy for avoiding hiatus. If we look at it like this, we are adopting a synchronic approach. This approach does not explain cases where the first word already ends in a consonant, such as tels‿amis, and is therefore already perfectly euphonic.
It is also possible to analyse liaison diachronically. With this approach, the liaison consonant has always been there since the days of Latin, and has merely been elided in other contexts over time. So, the s pronounced in mes amis can be seen as simply preserving the s that was always pronounced in meos amicos. Seen in this way, it is mes frères that is exceptional, having lost the s that was pronounced in meos fratres.
For example, final consonants are pronounced as follows in the case of liaison (the transcription uses IPA; in IPA, liaison is indicated by placing an undertie [‿] between the consonant and the vowel):
Liaisons with [.t‿] and [.z‿] are also found with words ending graphically in -t and -z (e.g. tout "all", venez "come"). Liaisons in [.k‿] with the few words ending in a silent -c are limited to some compound words like porc-épic ("porcupine").
With most words whose spellings end in -n and whose pronunciations end in nasal vowels ([ɑ̃], [ɛ̃], [œ̃], or [ɔ̃]), the vowel will be denasalized during liaison:
However, this liaison in -n (and its eventual denasalisation) should not be done before adverbs like ou, et (whose final -t also never produces any liaison).
Liaison with words ending in -er also frequently (but not systematically) leads to a change in vowel quality:
Some rare words ending with a silent -l like persil will also create a liaison in [.l‿], just like words ending in non silent final [l(ə)] (optionally followed by a mute e).
Finally, the words trop [tʁo] ("too") and beaucoup [bo.ku] ("much") productively allow liaison with the final consonant [.p‿]: un prix trop élevé... ("a too high price"), il a beaucoup à apprendre ("he has much to learn'').
The primary requirement for liaison at a given word boundary is of course the phonological or lexical identity of the words involved: The preceding word must supply a potential liaison consonant and the following word must be vowel-initial (and not exceptionally marked as disallowing liaison; see the discussion of "aspirated h" below). The actual realization of liaison, however, is subject to interacting syntactic, prosodic, and stylistic constraints.
Grammatical descriptions of French identify three kinds of liaison contexts: Those where liaison is obligatory, those where it is impossible, and those where it is optional. Pedagogical grammars naturally emphasize what is obligatory or forbidden, and these two categories tend to be artificially inflated by traditional prescriptive rules. Speakers' natural behavior in spontaneous speech shows that in fact relatively few contexts can be said to systematically give rise to, or fail to give rise to, liaison. Any discussion of liaison must take both descriptive and prescriptive perspectives into account, because this is an area of French grammar where speakers can consciously control their linguistic behavior out of an awareness of how their speech diverges from what is considered "correct".
We can identify a small number of contexts where speakers consistently produce liaison in all speech styles, and where the absence of liaison is immediately perceived as an error of pronunciation. These are the contexts where liaison is truly obligatory:
Note that the first two contexts also require obligatory vowel elision for the relevant determiners and pronouns (le, la, me, se, etc.)
The following contexts are often listed as obligatory liaison contexts, but they are more accurately characterized as contexts where liaison is frequent:
Specific instances of these combinations reveal varying tendencies. For certain lexical items (e.g. petit, très), speakers may have a preference for liaison approaching that of the obligatory liaison contexts.
|uninverted form
|inverted form
|elle dort [ɛldɔʁ]
|dort-elle [dɔʁtɛl]
|she sleeps
|il vend [ilvɑ̃]
|vend-il [vɑ̃til]
|he sells
|ils parlent [ilpɑʁl]
|parlent-ils [pɑʁltil]
|they speak
|on parle [ɔ̃pɑ̃ʁl]
|parle-t-on [pɑ̃ʁltɔ̃]
|one speaks
The appearance of this consonant in modern French can be described as a restoration of the Latin 3rd person singular ending -t, under the influence of other French verbs that have always maintained final -t.
The earliest examples of this analogical t in writing date to the mid-15th century, although this practice (and the corresponding pronunciation) was not fully accepted by grammarians until the 17th century (Holbrook 1923).
Grammars mention other contexts where liaison is "forbidden", despite (or precisely because of) the fact that speakers sometimes do produce them spontaneously.
All remaining contexts can be assumed to allow liaison optionally, although exhaustive empirical studies are not yet available. Preferences vary widely for individual examples, for individual speakers, and for different speech styles. The realization of optional liaisons is a signal of formal register, and pedagogical grammars sometimes turn this into a recommendation to produce as many optional liaisons as possible in "careful" speech. The conscious or semi-conscious application of prescriptive rules leads to errors of hypercorrection in formal speech situations (see discussion below).
Conversely, in informal styles, speakers will semi-consciously avoid certain optional liaisons in order not to sound "pedantic" or "stilted". Other liaisons lack this effect. For example Ils ont‿attendu ("they have waited") is less marked than tu as‿attendu ("you have waited"), and neither liaison is likely to be realized in highly informal speech (where one might instead hear [i(l)zɔ̃atɑ̃dy] and [taatɑ̃dy], or simply [taːtɑ̃dy].) On the other hand, the liaison in pas‿encore can be either present or absent in this register.
On the other end, producing a liaison where one is impossible is perceived as an error. For example, pronouncing a liaison consonant instead of respecting hiatus before an aspirated h is taken to indicate an uncultivated or unsophisticated speaker. While all speakers know the rule, they may have incomplete knowledge about which words it must apply to. The effect is less noticeable with rare words (such as hiatus itself), which many speakers may not spontaneously identify as aspirated h words.
Errors due to hypercorrection or euphony are also observed: a liaison is pronounced where it doesn't exist (where it is possible by spelling, but forbidden, as with et‿ainsi, or where it is impossible even by spelling, as with moi-z-avec). This phenomenon is called pataquès. In rare cases, these liaisons may be conserved by the language and become obligatory, such as in donnes-en. Otherwise, they are perceived in the same way as omissions of disjunction, suggesting an "uncultivated" speaker or extremely informal speech. Such an error is sometimes called cuir ("leather") when the inserted consonant is [t], velours ("velvet") when it is [z], although dictionaries do not all agree on these terms:
Careful pronunciation (but without the obligatory reading of "null e's") is necessary in a formal setting. The voice is a tool of persuasion: it reflects, through a pronunciation perceived as correct (according to prevailing norms), intellectual qualities, culture, self-control, and wit. Pushed too far, the over-proliferation of liaisons can render a speech ridiculous. It has been pointed out that French politicians and speakers (Jacques Chirac, for example) pronounce some liaison consonants, independently of the following word, introducing a pause or a schwa afterwards. For example, ils ont entendu ("they heard") is normally pronounced [ilz‿ɔ̃‿ɑ̃tɑ̃dy] or, in more careful speech, [ilz‿ɔ̃t‿ɑ̃tɑ̃dy]. A speaker using this "politician" pronunciation would say (where [ǀ] represents a pause; ils ont'… entendu). One might even hear ils ont décidé ("they decided") pronounced (ils ont'… décidé) or (ils onteuh… décidé). In the first example, we have liaison without enchaînement, not the normal configuration in ordinary speech. In the second, the liaison is completely non-standard, since it introduces a liaison consonant before another consonant.
However, the ancient final [t] of grand did not cease to be pronounced when the following word began with a vowel and belonged to the same tonic cell; It is effectively not at the end of the word anymore, since the ear identifies the stressed group (formed by univerbation), in which the final consonant and the initial vowel appear together, as a new group (or "word") within which the consonant in question has ceased to be final. Bearing in mind that stress in French falls on the last syllable of a word, or a group of words when they are bound grammatically, this situation can be symbolized as follows (the acute represents stress):
This has to do with what the hearer considers to be a word. If grand homme is analyzed as [gʁɑ̃t‿ɔm], the ear in fact understands [gʁɑ̃'tɔm], a continuous group of phonemes whose tonic accent signals that they form a unit. It is possible to make a division as instead of . Then this [t] will no longer be felt to be a final consonant but a pre-stress intervocalic consonant, and therefore it will resist the deletion that it would undergo if it were at the end of a stressed syllable. It can however undergo other modifications thereafter.
The written form, though, was adapted to criteria that are not phonetic, but etymological (among others): where grand is written, [gʁɑ̃t] is pronounced in front of certain vowels, without that being really awkward: the maintenance of the visual alternation -d ~ -de is more productive.
The other cases are explained in a similar fashion: sang, for example, was pronounced [sɑ̃ŋk] (and written sanc) in Old French, but the final -g has replaced the -c in order to recall the Latin etymology, sanguis, and derivatives like sanguinaire, sanguin. Currently this liaison is almost never heard except in one part of the singing of the Marseillaise ("qu'un san(g) /k/ impur") or in the expression "suer sang et eau". Outside those, the hiatus is tolerated.
Finally, the case of -s and -x pronounced [z] in liaison is explained differently. One must be aware, firstly, that word-final -x is a medieval shorthand for -us (in Old French people wrote chevax for chevaus, latter written chevaux when the idea behind this -x was forgotten). The sound noted -s and -x was a hard [s], which did not remain in French after the twelfth century (it can be found in words like (tu) chantes or doux), but which was protected from complete elision when the following word began with a vowel (which effectively means, when it was found between two vowels). However, in French, such [s] is voiced and becomes [z] (which explains why, in words like rose and mise, the s is pronounced [z] and not [s]).
For example, the Prayer by Gilles Vaudelin (a document compiled in 1713 using a phonetic alphabet, and introduced in the Nouvelle maniere d'écrire comme on parle en France ["A New Way of Writing as We Speak in France"]), probably representative of oral language, maybe rural, of the time, shows the absence of the following liaisons (Vaudelin's phonetic alphabet is transcribed using equivalent IPA):


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on Feb 02, 2012 Tagged in: General PD Information
By Ron Smith
I was diagnosed with Parkinson's disease (PD) in late 2006. Since then I have put much thought into what this diagnosis means to me and how to cope MOST effectively while living my life as fully as possible and doing things I enjoy doing, especially enjoying life with my wife, Dorothy. It is my sincere hope that what I think has worked for me may also prove helpful to others in dealing and living with the challenge of PD.
The underlying basis of my approach is that I need to have an assertive, action and questioning, pragmatic approach rather than a passive, laid back response to dealing with PD in order to make the best of a complicated, challenging life situation. My somewhat pragmatic approach to this is reflective of my engineering education and work experience. Have an orderly plan, ask questions, seek out the facts, then verify and validate the facts (i.e., get a second professional opinion on your diagnosis-I did and found it helpful, and, I suppose, reassuring in a way). It is important to realize that PD can be overwhelming at first, with a lot of possible symptoms, unique for everyone with some downright depressing complexity. It is different for each of us and a rational plan helps coping, at least for me.
While denial is generally not a very positive response, I believe a certain, healthy denial is helpful insofar as denying the disease control of your life and denying it control of your activities, as much as possible. Give the concept some thought!
The key elements for dealing with the PD diagnosis for me seem to be centered around the following fundamental aspects, based on my 3-1/2 years of experience, observation, and involvement in the local PD community:
Obtaining and using the many excellent and available resources leading to gaining a solid understanding of the disease and its many implications.
Selecting and using a knowledgeable and experienced movement disorder neurologist.
Learning about and understanding how the various meds used work, their side effects, and all vital contraindications.
Implementing lifestyle changes by including a habitual, aggrressive, consistent, regular, aggresssive aerobic and resistence exercise program. Do this if nothing else!
Engagement and active participation with your family in your local MPF support group if available - priceless and worth many times over the cost (0, except for donations!). Dorothy is very active with me. I find this essential.
Family involvement including participation with your loved ones and family in the MPF sponsored two hour orientation program and 6 week Living with PD workshop and repeat if it's been awhile. We found these both very helpful.
Record keeping, communication, and observation. Develop and maintain an up to date clinical history, med list, emergency procedures (for me with another chronic condition this is critical), and observations for your physician on what's going on.
Engagement in volunteer work in the PD community. This is giving back for gifts received in knowledge and interaction with others in the PD community.
Maintaining good nutrition and emotional health. Vital but a bit removed from my knowledge base and experience to permit much comment.
Fortunately there is a myriad of excellent resources readily available including books, brochures, and paper booklets, internet sources, handouts from the MPF, and library materials maintained by the support groups. MPF has a card with PD contraindicated meds that you should get. MPF also has an information and referral program providing names of nearby physicians experienced in treating PD patients. The presentation by MPF in the orientation program is great and the six week MPF workshop also provides useful documentation. The MPF has many separate resources including its newsletter, The Messenger, in addition to its website (www.parkinsonsmi.org), and over 55 support groups in Michigan. Get on their mailing list.
Your neurologist and pharmacist can also provide information and existing patients are likewise good sources for doctor referrals.
Useful PD books are The Parkinson's Disease Teatment Book (overall coverage) by Ahlskog and Making The Connnection Betweeen Brain And Behavior (med effects) by Friedman. Both are excellent and I got my used copies at nominal cost from amazon.com. Other must haves are Parkinson's Disease Resources List (a total resource listing) and Web Resources for People with Parkinson's (web resources available), both available at no cost from MPF or the Parkinson's Disease Foundation. Finally, the National Parkinson Foundation publishes a great set of booklets including coverage on medication, nutrition, fitness, caring/coping, understanding PD, practical pointers, mind/mood/memory, and speech/swallowing.Finally, I subscribe to the Northwest Parkinson's Foundation weekly newsletter and monthly letter (firstname.lastname@example.com). It is provided at no cost and they cover much of the current research and trial info. It keeps me up to date.
I was more comfortable selecting a neurologist who is a movement disorder specialist who primarily treats PD patients, is knowledgeable and experienced (years) in the field and is suggested by other patients and the MPF. If in doubt, seek an interview and go prepared with a list of questions. Get a second opinion of your diagnosis (I did and was happier for it).
Medications (together with exercise) are the cornerstone of treating PD, and every person requires a different combination of medications. What a person takes this year may be changed next year in order to gain more control over the PD symptoms and side effects that all medications have. Keeping on a schedule of taking medications is essential and you need to learn specifics about the medication: what each drug does, when to take it (hours of the day, with or without food), what is supposed to be the positive effect, what are the side effects, and if there are other medications that you should not take with them. It may take a little time to learn about the different drugs and forms - like learning a new language. You can do it with help from others. Get Friedman's book to help in dealing with the side effects.
Maintain an up to date clinical history and a list of your meds and consider an ID alert system such as Medic Alert (which I use). I find it helpful. The med list should contain aspects such as the date, file name, patient name, morning and afternoon protocols, script and over the counter (OTC) medications, med names, dosages, purpose-why being taken, prescribing physician, special precautions and contraindications, any PRN meds and when taken, dates when changes are made, and any other special conditions. Maintain a complete clinical history. Space does not permit a conceptual outline here. Keep it all on flash drive.
Say thanks to the MPF, interact with the organization and other patients, and participate. Help to keep the invaluable services provided by MPF to continue.
Two last thoughts: I believe that every one of us needs to take an active role in managing our Parkinson's disease and the only useful generalization about PD is that there are no generalizations! Each of us is unique.
Ron was an avid runner and long distance bike rider for some 20 years and a 3:28 marathoner. He was diagnosed with myasthenia gravis in 1997 (a rare neurological disease with some similar symptoms to PD including fatigue) and subsequently spent six years trekking in the Alps on summer vacations. He is a double cancer survivor (thyroid & prostate). He completed the megatransect (ultrahike.com) in Lock Haven Pa. in 2005 (not last) and 2007 (last this time), a 25 mile trail walk/run in the Pennsylvania mountains with over 5,000 feet of ascent and descent and big, bad boulder fields to cross. He finished standing in both cases. He welcomes your thoughts and comments on these suggestions (c/o MPF at firstname.lastname@example.com).
Richard Trosch, M.D, Movement Disorder Specialist, Director, Parkinson's and Movement Disorders Center, Southfield, MI, Member, Michigan Parkinson Foundation Professional Advisory Board.
In January, the US Food and Drug Administration approved the use of ioflupane iodine-123 injection or DaTscan,developed by GE healthcare, as an aide in the differentiation of Parkinsonian syndromes from essential tremor. DaTscan is a radionucleotide agent with a high affinity for the dopamine transporter (DaT), a protein found on dopamine neurons. A specific marker for DaT, DaTscan produces images that provide visual evidence based on the density of dopamine transporters. Once injected, DaTscan will bind to or "tag" healthy dopamine neurons in the striatal region of the brain. The radioactivity from this drug may then be visualized by single photon emission computed tomography or SPECT, an imaging technology that is relatively inexpensive and widely available.
DaTscan is now approved in the U.S. for the diagnostic differentiation between Parkinsonism vs. essential tremor. In the European Union, where DaTscan has been available since 2000, it is also indicated for the diagnosis of Lewy Body dementia versus Alzheimer's disease. The projected cost for a DaTscan will be about $1500 to $2000 for the compound, with additional charges of the procedure fee and diagnostic interpretation. Insurance coverage has been established for Medicare and Blue Cross Blue Shield and it is anticipated that coverage by other medical insurers will follow.
Prior to the DaTscan injection, an oral administration of 120 mg potassium iodine is recommended to minimize unnecessary thyroid uptake of radioiodine. The DaTscan agent is delivered as an injection via an intravenous catheter. After three to six hours, the patient is placed in the SPECT scanner and a detector, called a gamma camera, is used to visualize the distribution and quantity of the DaTscan compound within the brain. This procedure will take about 30 minutes to complete.
The DaTscan agent works by binding to or "tagging" the DaT protein, located on dopamine brain cells. This is used to visualize the location and density of dopamine brain cells, which "light up" on the image. If the parts of the brain where dopamine cells should be remain dark on the scan, an expert reader may diagnose early Parkinson's disease or Parkinsonism. DaTscan has been shown to have a 97.5% diagnostic sensitivity, meaning that it will be abnormal in 97.5% of patients with Parkinson's disease. Because other Parkinsonian syndromes, including Progressive Supranuclear Palsy (PSP), Multiple Systems Atrophy (MSA) and Corticobasal Degeneration (CBD) also have a dopaminergic loss, similar to Parkinson's disease, DaTscan will not be able to discriminate between these disorders.
Reported adverse effects from the DaTscan agent include headache, dizziness, nausea, vertigo, dry mouth, and injection site pain and hypersensitivity reactions. In the European experience, with over 300,000 doses dispensed, no serious adverse effects have been reported. DaTscan in contraindicated in patients with a know sensitivity to iodine, in women who are pregnant or breastfeeding, and in patients with impaired kidney or liver function. Also, certain prescription medications will need to be stopped prior to this study. Although this agent is a radiopharmaceutical, the minimal amount of radiation exposure is considered clinically insignificant.
Currently, there is no definitive test for PD. Establishing a diagnosis of Parkinson's disease remains a clinical process, hinging on the patient's description of their symptoms and the physician's findings on neurological examination. The accuracy of a diagnosis of PD is dependent upon the skill and experience of the examining physician and remains a "best guess". Studies examining the accuracy of this guess have found an error rate of about 25 to 30%. Improved diagnostic accuracy can be achieved by following a patient's clinical course over time and by demonstrating an improvement with levodopa treatment. A diagnosis of "definite" Parkinson's disease, however, requires pathologic confirmation. During life, if the classic Parkinson's disease symptoms, signs and response to levodopa are present, a diagnosis of "probable PD" may be made. Clearly, objective measures to aide in the diagnosis of PD are needed and much work is being done to discover biomarkers for this illness.
DaTscan will serve as a diagnostic adjunct, meaning it can provide additional information about a patient's condition. It cannot be used to establish a diagnosis of PD, however, it may provide additional information to help establish or refute a particular diagnosis. The utility of DaTscan in the diagnosis of PD will be limited to special circumstances. If you have already received a diagnosis from an expert and are responding well to dopaminergic therapy, PET and SPECT scans would not add any new information and therefore likely to be unnecessary. Several experts have suggested that approximately 5% of Parkinsonism/PD cases may be DaTscan candidates, with the majority of Parkinson's disease patients not requiring this test. Instead, DaTscan will be reserved for cases where there is diagnostic uncertainty, for atypical cases of tremor, when the distinction between PD and essential tremor is unclear, in psychogenic Parkinsonism, and for patients who have a difficult time accepting the diagnosis of Parkinson's disease.
Within the neurologic community, skeptics have voiced concerns about the potential for inappropriate testing, overuse and/or misinterpreted testing. Whether an internist or general neurologist should ever order a DaTscan has been the subject of considerable debate. Clearly, most Parkinson's disease patients will not benefit from a DaTscan and the non-specialist may not be trained to recognize when this test is required. A less expensive alternative, a consult with a movement disorders specialist, provides greater diagnostic accuracy and will prevent unneeded testing.
Roger L. Albin, MD, Anne B. Young Collegiate Professor of Neurology, University of Michigan Medical School, Past MPF Advisory Board Member
The evaluation and diagnosis of Parkinson's disease (PD) and related conditions is based almost completely on a careful history and physical examination. There are no radiological or laboratory measures that contribute significantly to the evaluation of PD and related disorders. The point of departure for establishing a specific diagnosis is identification of the syndrome of parkinsonism.
A syndrome is a constellation of related symptoms and examination findings that point to dysfunction of a specific organ or part of an organ. Syndromes usually have several causes. In the case of parkinsonism, all the key features stem from impaired production or action of the brain chemical dopamine. Parkinsonism can result from degeneration of dopamine producing nerve cells, blockade of dopamine action by certain types of drugs, or loss of the nerve cells that are the targets of dopamine action.
The key clinical features of parkinsonism are bradykinesia (slow movement), rigidity (an increase in the resistance of an affected body part to passive movement of that body part by an examiner), resting tremor (rhythmic involuntary movements when the affected body part is relaxed), and loss of postural reflexes (impairment of the body's ability to maintain an erect posture when displaced rapidly by an examiner) (Table 1). Discovery of two or more of these findings by a competent examiner indicates an abnormality of dopamine mediated signaling within the brain. If these features are not present, then PD and related disorders are excluded. An important corollary point is that these clinical features and symptoms should exhibit insidious onset and slow worsening. Sudden onset of these features would be very unusual for PD or any related disorder.
Difficulties with diagnosis of PD arise in two specific contexts; (1) initial diagnosis, and (2) individuals thought to have PD whose clinical course is atypical. When an individual is initially found to have parkinsonism, there are 3 major possible explanations.
The first is PD itself.
The second is drug-induced parkinsonism, a situation in which a prescribed drug impairs the action of dopamine and results in parkinsonism. Many drugs used in psychiatric practice have this side effect. Some drugs used for treatment of nausea can also have this side effect. These side effects do not usually occur after short-term use of these drugs but generally follow weeks to months of administration.
The third possible explanation is one of the PD related disorders (see below).
A fourth possibility that should be mentioned is Benign Essential Tremor (ET), even though this disorder does not exhibit parkinsonism. ET is a very common entity among older Americans. It is distinct from parkinsonism in that the tremor is not present at rest but occurs with use of the arms and there is no bradykinesia, rigidity, or loss of postural reflexes. Inexperienced physicians sometimes confuse these entities.
A definite diagnosis of PD is possible only after death with pathologic examination of the brain and detection of characteristic abnormalities. Clinical diagnosis of PD is based on the presence of two or more features of parkinsonism, the exclusion of other causes of parkinsonism (such as drug-induced parkinsonism), and the presence of significant improvement with a dopamine-like drug, either in the form of an L-dopa preparation or a dopamine agonist. PD responds well to treatment with these agents while the other neurologic diseases causing parkinsonism do not. Despite the apparent imprecision of this approach, it is actually very successful and studies comparing clinical diagnosis by expert clinicians with pathological diagnosis have shown clinical diagnosis to be quite accurate.
If these conditions are satisfied, the diagnosis is almost certainly PD. Difficulties occur in diagnosis when one of the other neurologic disorders causing parkinsonism is present.
BradykinesiaRigidityResting TremorLoss of Postural Reflexes
Drug InducedDopamine Antagonists; Anti-Psychotics, Anti-EmeticsCatecholamine Depleters; Reserpine, TetrabenazineFalse Transmitters; a-Methyl-TyrosineEssential Tremor - Not Really a MimicOther Neurodegenerations Affecting the Basal GangliaProgressive Supranuclear PalsyMultiple Systems AtrophyCorticobasal DegenerationIdiopathic Parkinson's Disease
Atypical Presenting Features- Lack of Tremor- Symmetrical Onset- Early Autonomic Dysfunction- Early Cognitive Dysfunction- Unusual Eye Movement Findings on Examination- Atypical Movement Control Problems of Affected LimbsRapid ProgressionLack of Response to Dopamine Replacement
Progressive Supranuclear Palsy (PSP)Multiple System Atrophy (MSA)Corticobasal Degeneration (CBD)Lewy Body Dementia (LBD, DLB)
The most important clue that another neurologic disorder is present is lack of significant response to a dopaminelike drug. These drugs must, however, be tried at adequate doses and for proper lengths of time. A short trial at a low dose may simply not be adequate to assess response.
Some other clinical features may point away from PD. Most, but not all PD patients, have resting tremor. The PD-like disorders usually lack tremor. PD typically begins on one side of the body where most of the PD-like disorders have symmetric onset (for an important exception, see below). Rapid progression of parkinsonism is another important clue. We expect PD patients (with appropriate treatment) to do well and progress slowly for at least 3-5 years after diagnosis. Finally, each of the PD-like disorders has characteristic features that assist in the diagnosis.
The four major disorders that can mimic PD are Progressive Supranuclear Palsy (PSP), Multiple System Atrophy (MSA), Corticobasal Degeneration (CBD), and Lewy Body Dementia (LBD).
PSP is characterized by certain types of eye movement abnormalities, particularly difficulty with voluntary movements of the eyes in the vertical plane.
MSA is distinguished by difficulties with the autonomic system, the part of the nervous system responsible for maintaining blood pressure and similar functions. MSA patients frequently have difficulties with maintaining an appropriate blood pressure when standing, have problems with control of their bladders, may have sweating changes, and in men, impotence is common.
CBD is a rare disorder which typically presents with asymmetric abnormalities of limb function. There may be a combination of clinical findings suggesting parkinsonism and abnormalities of limb use reflecting dysfunction of the cortex; the so called thinking part of the brain.
LBD is quite common but does not usually present with parkinsonism, but rather with dementia. Dementia is uncommon in patients with early PD but when dementia occurs prior to or approximately coincident with the development of parkinsonism, LBD is the likely diagnosis.
These PD-like disorders are individually rare but their aggregate prevalence is significant. Perhaps as many as 15% of patients presenting to Movement Disorder Clinics for evaluation of parkinsonism turn out to have one of these PD-like disorders. Making a specific diagnosis of one of these disorders is often quite difficult. The characteristic clinical features may not appear until months to years after the emergence of parkinsonism and prolonged clinical follow-up is necessary often to confirm a specific diagnosis. There is no effective primary medical or surgical therapy for any of these disorders. The emphasis is on assistive care with physical therapy, occupational therapy and interventions that palliate some of the symptoms. Making a specific diagnosis as early as possible is important to improve patient and family comprehension, reduce unnecessary medication trials and diagnostic studies, and to focus attention of appropriate assistive interventions.
on Feb 01, 2012 Tagged in: General PD Information , coping with PD
by Ray Buch (from Lansing Area Parkinson Support Group Newsletter, June 2011). Ray has been a clinical social worker, flat-water paddler and kite flyer through his entire adult life. He delights in his wife and lifelong companion, Lindy, his two adult offspring, his 93 year old dad and an insatiable curiosity.
What does it take to stay upbeat in the face of a siege on one's health (or on one's self). When every day is a battle and no matter how many battles are won, the chances of winning the war are nil. Under these circumstances, we should find that nearly everyone is depressed or despondent. The fact that everyone is not depressed or despondent is worth understanding.
We often begin to understand something difficult by studying an extreme example of the issue. One of the most difficult chronic situations to "get through" is being a prisoner. In 1946, Viktor Frankl wrote Man's Search for Meaning. A survey by the Library of Congress and the Book of the Month Club in 1991 deemed it "one of the ten most influential books in the United States." Frankl searches for the reasons some survived the German concentration camps and some did not. He learned that aside from the harshness of the situation, if a person retained the belief that he had freedom to choose (whether to be sad, despondent, angry or not), his chances of survival went up remarkably. Sometimes it was the belief that others were worse off, or a moment of camaraderie; at other times it was an imagined image of a beloved person (wife, lover, parent even God).
I've talked with some of the individuals who have had PD or other chronic conditions over a longer period of time. They indicate that the essential element for managing one's self is to choose to "stay in the present," "be occupied with what can be rather than what might be," and "prepare for tomorrow, but live in today." The guidance is to maintain one's mind in the present. Some psychologists believe that increased levels of anxiety come from trying to solve the future problems of one's life without having enough information. The idea is that the mind continues to cycle back over the same unresolved questions because no new information has been acquired to help resolve the problem. The obvious answer is to provide new information, which is why many people with PD spend a great deal of time reading aboutevery aspect of the disease. However, there is little possibility of getting much information about how things end up for them.
A.J. Heschel, one of the most prominent religious thinkers of the 20th century, used the term radical amazement to denote being constantly aware of the large and small things, processes and events as a means to being aware of and in contact with God. This is very close to many of the meditative aspects of yoga: constantly being in the present. The many forms of yoga and the preoccupation with practice attest to both the difficulty and reward that comes from "staying in the present."
Perhaps a less ethereal and more common example of "staying in the present" might be useful to many of us. Consider for a moment the idea of celebration. The dictionary has two common definitions.
• To celebrate a holiday or commemorate a special day like Christmas, Independence Day or Thanksgiving where we spend some time thinking about the special issue being commemorated and enjoy a certain amount of revelry.
• To proclaim, publish, praise or make a ceremony to acknowledge.
It is this second type of celebrating with which we are familiar that is similar to radical amazement. Imagine if we were able to maintain the awareness of not just one idea or situation or beautiful thing every day, but maintain that same level of delight, joy and awareness of many, many things every day. We certainly wouldn't have much "brain time" to be over-concerned about what might happen five or ten years in the future.
on Jan 13, 2012 Tagged in: PD Glossary , General PD Information
Akinetic-rigid syndrome: A syndrome, or collection of systems, consisting of lack of movement (akinesia) or reduced movements (hypokinesia), slow movements (bradykinesia), and stiffness or rigidity (involuntary resistance to movement). The rigidity is of a type called cogwheel rigidity.
Basal ganglia: A group of nuclei, or clusters of nerve cells, near the base of the brain that is important in regulating both movements and emotions.
Bradykinesia, hypokinesia & akinesia: Bradykinesia means slow movements. Hypokinesia means reduced movements and generally refers to making smaller movements than intended, such as the small steps seen when a Parkinsons patient walks, or the small size of a Parkinsons patient's handwriting (called micrographia). Akinesia means lack of movement.
Cogwheel rigidity: " A type of rigidity in which, when a patient's limb is moved by the examiner, it resists and gives way in small, step-like movements as if it was being controlled by a cog-wheel.
Dopamine: One of a number of chemicals used by nerve cells as neurotranmitters. Messages are carried electrically along individual nerve cells but signalling from one nerve cell to another is usually accomplished by releasing a neurotransmitter chemical. Dopamine is the main neurotransmitter of the nerve cells which die off in Parkinson's disease.
Dysarthria: soft voice or inarticulate speech.
Dyskinesia: Abnormal writhing movement of voluntary muscles.
Dystonia: Involuntary spasms of muscle contraction that cause abnormal movement and posture.
Epidemiological studies: Statistical studies of the occurence of diseases in populations and environments.
Familial Parkinsons: Some unusual forms of Parkinson's disease run in a few families. Abnormal genes have been identified in some of these families, but abnormalities in these genes are NOT found in most patients with Parkinson's disease. Alpha-synuclein and parkin are the proteins coded for by genes identified as being abnormal in some familial forms of atypical Parkinson's disease. Normal alpha-synuclein is also the major protein in Lewy bodies, the pathologic inclusions found in typical Parkinson's disease. The normal functions of alpha-synuclein and parkin are not yet clearly established.
Freezing: Temporary inability to move.
Levodopa: Levodopa was the first major breakthrough in the treatment of Parkinson's disease. Levodopa is used by the brain to produce the chemical dopamine, which is deficient in persons with PD. The neurotransmitter is converted by the neurons in the brain into dopamine, which is stored within the cells until needed by the body.
Neurodegenerative Disease: A disease in which nerve cells in the brain or spinal cord (central nervous system, CNS) progressively die or degenerate.
Neuron: a cell that generates or conducts electrical impulses to carry information from one part of the brain to another.
On-off phenomena: sudden, unpredictable changes in motor performance by people on levodopa therapy.
Parkinson's Plus diseases: These are neurodegenerative diseases which cause the akinetic-rigid syndrome or parkinsonism PLUS additional symptoms not usually seen in Parkinson's disease. These diseases are progressive supranuclear palsy or PSP, corticobasilar ganglionic degeneration or CBGD, and multiple system atrophy or MSA, which includes Shy-Drager Syndrome, olivopontocerebellar atrophy or OPCA, and striato-nigral degeneration.
Pathology of Parkinson's disease: Examination of brain tissue from Parkinson's disease patients under the microscope shows loss of the dark-colored dopamine-producing nerve cells in the substantia nigra pars compacta and appearance of Lewy bodies, abnormal small round clumps of protein and other materials which are rarely seen except in Parkinson's disease.
Postural reflexes: Postural reflexes are the involuntary movements people automatically make to maintain their balance when standing and walking. Impairment of the postural reflexes causes poor balance and a tendency to fall.
Resting tremor: Tremor is a rythmic movement or shaking of any part of the body. The tremor of Parkinson's disease is called a "resting tremor" because it is present when a limb is at rest and may be reduced or go away when the limb is held up or otherwise used by the patient. Most other types of tremor are reduced or absent when the limb is at rest and relaxed.
Striatum: A region of the brain made up of two nuclei, or clusters of nerve cells, the globus pallidus (which means "white ball") and caudate (which means "tailed"). These two nuclei are part of a group of nuclei called the basal ganglia, which is important in regulating both movements and emotions.
Substantia nigra: This literally means "the black substance" and is a region in the brainstem (where the spinal cord joins the brain) where there is a group of dopamine-producing nerve cells, which appear darker than the surrounding tissue. The dopamine-producing nerve cells are in the pars compacta (meaning "compact or dense part"). There is another part called the pars reticulata ("speckled part").
Edwin B. George, MD, PhD., Wayne State University School of Medicine, 2003
on Jan 12, 2012 Tagged in: Neuro Exam , General PD Information
When you visit your neurologist, there are several things that regularly occur: forms to fill out, lots of questions and, usually, a neurologic examination.
Do you ever wonder what neurologists are really doing to you during your physical exams and what they are looking for?
In general, the neurologic exam concentrates on several specific areas: mental status, cranial nerves, motor function, sensation and reflexes.
Depending on whether it is your first visit or a routine follow-up visit, the exam's length and complexity may vary. It actually begins before you realize it!! The neurologist checks the forms you filled out to see if the handwriting is small or shaky, then closely observes you during the initial interview - is there a lack of facial expression, a lack of movement of one arm or leg, a tremor and is the voice loud or indistinct? Often the diagnosis of Parkinson's disease is reached within the first minute or two the neurologist is in the room.
Then the neurologic examination begins. Although the exams performed by different neurologists vary widely, and also from one visit to the next, there are certain things a neurologist checks to determine the diagnosis (is it Parkinson's disease?) or to see how well you are responding to medication.
Mental Status: During the interview, and often with additional questioning, us¬ing standardized tests of cognitive function, the neurologist assesses your memory, concentration skills, language skills and orientation.
Gait: Usually you are asked to walk back and forth, on your toes and heels, then in a straight line. Observing whether you swing your arms normally or not may provide an early tip-off to the diagnosis of Parkinson's disease. You may be pushed or pulled to see how well you can maintain your balance (postural stability). You also watched to see if you have trouble rising from a chair and whether you stand straight or stooped.
Cranial Nerves: The cranial nerves are those that supply the eyes, face, ears, mouth/tongue and neck. A lack of facial expression (masked facies) may be noted, but there can be certain abnormalities that indicate a diagnosis of something other than typical Parkinson's disease (an inability to normally move the eyes, for example).
Motor Function: During this portion of the examination, your doctor checks your strength, pulling or pushing your arms and legs, comparing one side of the body to the other, and seeing if there is a difference between the upper and lower limbs. Your doctor will also move your arms and legs while you relax, to decide if there is increased tone or stiffness. (In Parkinson's disease we are looking for "cogwheeling," which is a type of stiffness with a "ratchety" feeling.) The speed of your movements is also examined: you are often asked to hold your arms in front of you and rapidly move them from "palm up" to "palm down," something called "rapid alternating movements." Additional maneuvers may be performed, such as finger tapping and repetitive "hand opening-closing," looking for bradykinesia (slowness of movement). The speed of these rapid movements often helps in making the diagnosis. It is important to note whether the abnormalities are worse on one side or the other.
The search for tremor actually continues throughout the entire time with your doctor. A tremor observed while a person is sitting quietly is known as a resting trem¬or and is the most typical type seen in PD. Often, this tremor is visible while you are walking, and is also called a "pill-rolling" tremor, named after the movement that an old-time pharmacist would make as he created a pill between his fingers. Tremor can also be seen with certain activities (holding objects, writing, etc.), and may or may not be seen in PD. Often you are asked to hold your arms outstretched, or to touch your finger to your nose.
Sensation: The sensory exam consists of being poked with a pin, lightly brushed with cotton/tissue, or asked whether you feel a vibrating tuning fork, or if a finger or toe is moved upward or downward. Again, the physician wants to know whether you feel these sensations equally on both sides of the body and whether it differs between how it feels in your feet/hands (distal sensation) or closer portions of the limbs (proximal sensation). This portion of the exam is probably the least important in the diagnosis of PD. However, certain abnormalities might be clues to a different neurologic disorder.
Reflexes: Here the doctor observes how your limbs react to being tapped with a reflex hammer (deep tendon reflexes). In particular, are the responses equal on both sides and are they increased or decreased in a particular pattern? Another very important reflex commonly tested is the plantar reflex, when the bottom of your foot is stroked unpleasantly to see what direction your toes move. This is one of the most important tests in neurology. If the toes move upward in a specific way, it is known as a "Babinski sign." This is not usually seen with PD, but may indicate another disorder.
The neurologic examination remains the most accurate way to diagnose Parkinson's disease, coupled with the history that you give. Testing is generally not required to make a diagnosis, but is occasionally ordered to rule out a different diagnosis, if there are unusual features noted during the exam. Remember: the length of the neurologoc exam may vary from visit to visit, with the initial consultation generally being the most extensive examination, and follow-up visits being shorter. When it is only a brief office visit, only a few things may be tested to decide if medication is helping, or if changes are required. While the examination is very informative and can usually result in a definite "yes" or "no" to the question of whether you have PD, some of you may have experienced exams where the neurologist is not certain and asks you to return in a few months or a year to see if your physical exam changes.
Despite all the advances that have been made in the field of neurology, the examination remains essential.
Neurologist Dr. Glen Ackerman, M.D., is a past Chairman of the Michigan Parkinson Foundation Professional Advisory Board and is a cur¬rent Member. He is Assistant Professor of Neurology, Michigan State University School of Human Medicine and School of Osteopathic Medicine, and is Head of its Movement Disorders Clinic.


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Follow along with step-by-step beading projects and share your designs with beaders around the world—it's quick & easy!
- "Souvenirs in Resin": on
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- "Souvenirs in Resin": on
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"Oh Monica...you are so creative!! I just love what you have done with the shells!…" read »
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- "Matching Bracelet": on
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- "The Sandcastle Necklace": on
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About this design:
I did this in 2 versons because I liked how it turned out. :)
Components:Czech glass flowers and beads, Vintaz brass headpins, antique gold leaf chain, chain, toggle. Most or all from LB !
Read the comments (or add your own)
Detail and movement and texture… all in a Keep It Simple style. You know I'm going to have to steal the earring idea!
ME TOO!! Lovely blue with an earthy edge!
Straight to my favs, Becky!
Super cute design. Love the leaves added in for movement too. The green is very nice too, but this one is my favorite!
Oh yes the blue is my favorite also.
Both versions have a lovely antique feel about them. Very sweet and feminine!
You're right, there is more contrast in this blue necklace, so technically it is the more attractive… but it's not green!
This is so graceful, Becky – - and the earrings have perfect balance. Fabulous design idea and smart of you to "repeat" it !
So pretty and dainty! Love both sets!
You guys are too kind!
So beautiful!
I don't blame you! Both are adorable!!
Super beautiful and adorable
Still loving this design, and good for you! You figured out how to use the whitish-turquoise flowers that kept intriguing me, though I wasn't sure what to pair with them.
So adorable and perfect for spring or any season, have to do something like that
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It started as a vacation: Israel.
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Telstar 28
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Umm...if you ever have to go forward and try and tame a flogging genny...you'll regret having a shackle on the clew. That turns it from an annoyance which leaves bruises to a deadly weapon that can crack your skull open.
The Larkshead doesn't really present anything to hang up on the shrouds, but requires you to have one long sheet. If you switch headsails, the larkshead is a lot more of a PITA than two bowlines.
Originally Posted by
So what's wrong with shackles instead of larks heads or bowlines. The obvious objection to 1/4 metal objects flying around aside ( a dip in liquid rubber, and not being forward during flailing periods fixes that) isn't that actually better, a slimmer 'connection' to the clew so it gets hung up on the shrouds during a tack etc..
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Telstar 28
New England
You know what the first rule of sailing is? ...Love. You can learn all the math in the 'verse, but you take
a boat to the sea you don't love, she'll shake you off just as sure as the turning of the worlds. Love keeps
her going when she oughta fall down, tells you she's hurting 'fore she keens. Makes her a home.
Cpt. Mal Reynolds, Serenity
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