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Instructor: Heather Anderson, MD
The following 10 subjects were chosen for this web module to improve the knowledge and understanding of neurologic conditions critical to the care of geriatric patients.
Parkinsonism is a clinical syndrome characterized by a combination of resting tremor, rigidity, bradykinesia, and postural instability. Typically, the presence of two of these four features is necessary for the diagnosis of parkinsonism. The most common cause of parkinsonism is Parkinson's disease (PD). PD is a chronic, progressive neurodegenerative condition with a slow and relatively selective loss of dopaminergic neurons in the substantia nigra, so dopamine is the main neurotransmitter affected in PD.
Pathologically in PD, there is neuronal loss in the substantia nigra, especially the dopaminergic neurons in the pars compacta, causing loss of neuromelanin pigmentation. Clinical symptoms of PD occur when approximately 50-70% of these neurons are damaged.
The clinical features of PD can be categorized as motor, autonomic and neuropsychiatric symptoms.
Cardinal Motor manifestations
- Resting tremor
- Resting tremor is one of the most easily recognizable and the most common presentation and noticeable features of PD
- In approximately 50% of patients, tremor is the initial symptom and approximately 15% of patients never have tremor throughout the disease course.
- Bradykinesia
- Rigidity
- In later disease stages postural instability
- Postural instability associated with propulsion and retropulsion is one of the most disabling symptoms of PD
Autonomic dysfunction
- Occur in approximately 30% of the PD patients and can occur in all stages of PD
- Autonomic dysfunction early in the disease course, generally suggests Shy Drager syndrome (a form of multiple system atrophy) – see below (MSA in "Parkinson's Plus" Syndromes list)
- Autonomic symptoms seen in PD include
- Orthostatic hypotension
- Constipation
- Dysphagia
- Excessive sweating
- Heat intolerance
- Urinary
- Sexual dysfunction.
Neuropsychiatric symptoms in PD
- Dementia
- Estimated to occur in 30-40% of PD patients.
- Depression
- Prevalence of depression in PD is about 31%.
- Anxiety
- Anxiety has been reported in about 38% of PD patients.
- Psychosis
- Can occur in PD patients on anti-PD medications
- Rarely seen in untreated PD patients
- Psychotic symptoms in PD include
- Hallucinations – the most common psychotic symptom, and these are usually visual
- Delusions (paranoia) and delirium are less common
Motor complications due to levodopa and disease
"Parkinson's Plus" Syndromes
- Freezing of gait
- Freezing consists of a sudden, transient inability to move as if the feet are glued to the ground
- Levodopa induced motor fluctuations including end of dose wearing off, on-off episodes, early morning akinesia
- Dyskinesia including peak dose dyskinesia, biphasic dyskinesia and end of dose dystonia
- Progressive supranuclear palsy (PSP)
- Gait instability, rigidity, no voluntary vertical eye movements but preserved Doll's eyes
- Multiple system atrophy (MSA)
- Shy Drager syndrome – orthostatic hypotension, syncope, autonomic dysfunction, ataxia
- Motor manifestations become less responsive to levodopa as a general rule in Shy Drager syndrome
- Corticobasal ganglionic degeneration – alien hand syndrome, apraxia, dysphasia, cortical sensory loss
- Dementia with Lewy bodies
- Fluctuations in cognitive function, hallucinations, parkinsonism, falls, syncope, sensitivity to neuroleptics making parkinsonism worse
To view this movie clip be sure that your browser popup blocker is turned off to allow popups.
- Parkinsonian Gait Demonstration - This man's gait is bradykinetic and his steps are smaller than usual. There is also the pill-rolling tremor in his hands. He turns en bloc, and there is decreased facial expression
The above movie drawn from the Neurologic Exam and PediNeurologic Exam websites is used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Additional materials for Neurologic Exam are drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, M.D., University of Utah; and Daniel Jacobson, M.D., Marshfield Clinic, Wisconsin. Subsequent re-use of any materials outside of this program, presentation, or website requires permission from the original producers.
A 65 year-old right-handed white male with a 3-year history of tremors in his hands when he is sitting, watching TV. The tremor started on the left initially, but now there is a slight tremor on the right. His wife reports that he is walking more slowly and shuffles his feet. His handwriting has also gotten smaller.
Neurologic Examination:
- Mental Status: Slow to answer. Hypophonic voice.
- Cranial nerves: Masked face. Normal extraocular movement. All other cranial nerves are intact.
- Motor: Resting, pill-rolling tremor, cogwheel rigidity in the arms more than the legs, normal strength
- Sensory: Normal sensory exam
- Reflexes: Normal reflexes
- Cerebellum: No tremor on finger-to-nose testing, and no evidence of dysmetria.
- Gait: Slightly slow gait with reduced arm swing, multi-step turn, and obvious tremor while walking.
Question: What is the diagnosis?
What if this same patient is/has: Click on the correct answer
- Falling A LOT with inability to voluntarily look down, but could overcome this with Doll's eyes maneuver.
- Passing out
- One arm has a mind of its own
- Dementia is rather prominent as compared to motor symptoms, and cognitive dysfunction began within a year of onset of motor symptoms
A stroke occurs when there is ischemia to part of the brain either through an ischemic or hemorrhagic event
- Ischemic strokes – accounts for ~85% of strokes
Source: tinyurl.com/m696kl
- Thrombotic
- Blood clot, ruptured plaque or thrombus forms in a cerebral artery and occludes an intracerebral artery
- Gradual progression of symptoms
- Embolic
- Blood clot forms elsewhere in the body, travels to the cerebral vasculature, and occludes an intracerebral artery
- Rapid onset of symptoms because of the artery
- Usually cardiac source, but could be from carotids or vertebral arteries, or paradoxical emboli from a DVT in the setting of patent foramen ovale (PFO)
- Hemorrhagic stroke – accounts for ~15% of strokes
Source: www.emedicine.com/emerg/topic557.htm
- Leakage from small intracerebral arteries into the brain parenchyma
- Most common cause is chronic hypertension leading to damage of the small intracerebral arteries
- Most common sites for hemorrhagic stroke
- Thalamus
- Putamen
- Cerebelleum
- Brainstem
- Symptoms often accompanied by sudden and severe headache, nausea and vomiting
- Seizures are more common in hemorrhagic than in ischemic strokes and can occur in up to 28% of hemorrhagic strokes
- Hemorrhagic strokes are not to be confused with hemorrhagic transformation of ischemic strokes which are quite common and usually asymptomatic
Stroke symptoms – Acute onset of neurologic deficits
- Hemiparesis
- Hemisensory loss
- Monocular or binocular visual loss
- Visual field deficits
- Diplopia
- Dysarthria
- Ataxia
- Vertigo
- Aphasia (expressive or receptive)
Stroke risk factors
- Age over 55
- Male gender
- African-American
- Diabetes
- Family history of stroke
- Previous stroke or TIA
- High cholesterol
- Hypertension
- Heart disease (coronary artery disease, left ventricular hypertrophy, chronic atrial fibrillation)
- Smoking
Evaluation of a stroke patient
- Time is of the essence – the one and only one treatment for a stroke is tPA (tissue plasminogen activator)
- 3 hour window for administering IV tPA
- 6 hour window for administering intraarterial tPA (angiogram with tPA injected right at the site of the clot)
- CT head without contrast
- Looking for hemorrhage – if there is already a hemorrhage, not a tPA candidate
- DO NOT USE THE CT TO DIAGNOSE THE STROKE – Use your clinical history and exam to diagnose the stroke. A CT that already shows a stroke or edema soon after the stroke occurred indicates a large stroke in which there is an increased risk of hemorrhage with tPA. A CT which is entirely clear, with no infarct or edema or hemorrhage, is the PERFECT situation in which to give tPA.
- Labs
- Fasting lipids
- Fasting blood sugar
- Reserve hypercoagulable work-up for occasion in which no obvious cause of the stroke can be determined (usually performed in young stroke patients)
- Coagulation studies is most helpful if the patient is on anticoagulants
- Urine drug screen in selected patients
- Tests
- EKG – rule-out atrial fibrillation
- Echocardiogram – rule-out cardiac source of emboli, determine ejection fraction
- Carotid ultrasound - Only if the stroke is anterior circulation. If it arose from the posterior circulation, the presence of carotid stenosis is irrelevant since it supplies the anterior circulation. In this situation, MRA (MR angiogram) would be better.
- Only if the stroke is anterior circulation. If it arose from the posterior circulation, the presence of carotid stenosis is irrelevant since it supplies the anterior circulation. In this situation, MRA (MR angiogram) would be better.
- MRI brain once the patient is stable
- tPA if the patient is a candidate
- Implement antiplatelet therapy for secondary stroke prevention, not generally anticoagulation. Heparin just yields increased risk of hemorrhage but no increased benefit after most strokes.
- The American Heart Associate evidence-based guidelines consider ASA alone, Plavix (clopidogrel) or Aggrenox (dipyridamole/aspirin) all reasonable options as first line therapy for secondary stroke prevention.
- Liberal management of hypertension
- Chronic hypertension is a risk factor for stroke, however in the setting of an acute stroke, hypoperfusion makes stroke symptoms worse so liberal management of hypertension is best
- Aggressive treatment of diabetes
- Initiate statin for cholesterol management
- Anticoagulation in only selected cases (atrial fibrillation, low ejection fraction, anterior wall aneurysm, or carotid or vertebral dissection)
- Physical therapy, occupational therapy, and speech therapy
A 70 year-old right handed white male awoke with right-sided weakness and expressive aphasia. He presented to the ER within 45 minutes of discovering the weakness. He has never had a similar event.
Physical Examination:
- Mental status: Awake, alert, and oriented. His comprehension is intact, but he is having difficulty expressing himself with word-finding difficulty.
- Cranial nerves: Right lower facial weakness. Eyes deviated to the left. Right superior quadrantanopia. All other cranial nerves are intact.
- Motor: Dense right-sided hemiplegia. Strength is normal on the left.
- Sensory: Diminished sensation in right face, arm, and leg.
- Reflexes: 2/4 on the left, 3/4 on the right. Toes are downgoing on the left and upgoing on the right.
- Cerebellum: Unable to perform finger-to-nose or heel-to-shin testing on the right.
- Gait: Unable to ambulate.
CT head without contrast is negative for hemorrhage, edema, and infarct.
Question: What is your recommendation to your attending - Should you give the patient TPA? (Click on your choice to see the answers)
Question: What labs should you draw?
Question: What tests should you order?
Question: Assume the patient had slurred speech, trouble swallowing, double vision, and ataxia instead of right-sided weakness, would you still get a carotid Doppler?
Question: The patient is not a TPA candidate, but he has had a big stroke and has major deficits. We should start heparin, right?
Question: If you chose not to anticoagulate, what do we give then?
Question: In what situations would a stroke patient be placed on anticoagulation (heparin, Coumadin)?
Delirium, or mental status change, is very frequent, and very elderly patients and those with preexisting cognitive changes are especially susceptible to prolonged cognitive decline following an acute event.
- Determine the baseline cognitive function of the patient. Does the patient have preexisting dementia or depression or other psychiatric diagnoses?
- What was the course of the presentation?
- An acute change in mental status from baseline is not consistent with dementia and suggests delirium.
- A rapidly fluctuating course (over minutes to hours) and an abnormal level of consciousness are also highly suggestive of delirium
- Delirium is diagnosed with the use of the Confusion Assessment Method (CAM)
- Sensitivity 94%-100%
- Specificity 90%-95%
Reference: Inouye, et.al. Ann Intern Med 1990;113:941-948
- In critically ill patients, on and off the ventilator, who are not able to speak, the CAM-ICU is used
Inouye, et al. Ann Intern Med 1990:113:941-948
Ely, et. al. CCM 2001;29:1370-1379
Ely, et. al. JAMA 2001; 286:2703-2710
Confusion Assessment Method (CAM)
**A diagnosis of delirium is made with Items 1 and 2 and either items 3 or 4 present**
- Acute onset and fluctuating course
- Acute change in mental status from baseline
- Dementia syndromes typically develop over months to years rather than acutely.
- Rapidly fluctuating course (over minutes to hours)
- In delirium, confusion comes and goes or increases and decreases in severity
- Inattention
- Inability to stay focused
- Easily distractable
- Difficulty tracking conversation
- Disorganized thinking
- Rambling or irrelevant conversation
- Unclear or illogical flow of ideas
- Unpredictable switching from subject to subject
- Altered level of consciousness (any of the following count as altered level of consciousness)
- Vigilant
- Hyperalert
- Overly sensitive to environmental stimuli
- Startled very easily
- Lethargic
- Drowsy but easily aroused
- Stupor
- Difficult to arouse
- Coma
- Unarousable
CAM-ICU for critically ill patients
**A diagnosis of delirium is made with Items 1 and 2 and either items 3 or 4 present**
- Acute onset OR fluctuating course (as in CAM above)
- Inattention using the Letters Attention Test – More than 2 errors is considered abnormal
- Directions: Say to the patient, "I am going to read you a series of 10 letters. Whenever you hear the letter 'A,' indicate by squeezing my hand." Read letters from the following letter list in a normal tone 3 seconds apart:
Errors are counted when patient fails to squeeze on the letter "A" and when the patient squeezes on any letter other than "A."
- Altered level of consciousness
- Any level of consciousness other than alert and calm
- Disorganized thinking – Combined number of errors >1 is considered abnormal
- Yes/No Questions
- Will a stone float on water?
- Are there fish in the sea?
- Does one pound weigh more than two pounds?
- Can you use a hammer to pound a nail?
Errors are counted when the patient incorrectly answers a question.
- Command
- Say to patient: "Hold up this many fingers" (Hold 2 fingers in front of patient) "Now do the same thing with the other hand" (Do not repeat number of fingers) *If pt is unable to move both arms, for 2nd part of command ask patient to "Add one more finger"
An error is counted if patient is unable to complete the entire command.
Risk factors
- Predisposing factors
- Advanced age
- Preexisting dementia
- Preexisting functional impairment in activities of daily living
- High medical comorbidity
- Sensory impairment (poor vision and hearing)
- History of alcohol abuse
- Acute precipitating factors
- Medications, especially those that are sedating or highly anticholinergic
- Infections
- Pneumonia
- Urinary tract infection
- Infected decubitus ulcer
- Uncontrolled pain
- Low hematocrit level
- Bed rest
- Use of certain indwelling devices and restraints
Mnemonic for Reversible Causes of Delirium (Geriatrics Review Syllabus, 6th ed.)
Any new additions, increased doses, or interactions
Consider over-the-counter drugs and alcohol
Consider esp. high-risk drugs (anticholingerics, tricyclic antidepressants, some opioids
Electrolyte disturbances
Especially dehydration, sodium imbalance
Thyroid abnormalities
Lack of drugs
Withdrawals from chronically used sedatives, including alcohol and sleeping pills
Poorly controlled pain (lack of analgesia)
Infection Especially urinary and respiratory tract infections Reduced sensory input Poor vision, poor hearing Intracranial
Infection, hemorrhage, stroke, tumor
Rare: consider only if new focal neurologic findings, suggestive history, or work-up otherwise negative
Urinary, fecal
Urinary retention: "cystocerebral syndrome"
Fecal impaction
Myocardial, pulmonary Myocardial infarction, arrhythmia, exacerbation of heart failure, exacerbation of chronic obstructive pulmonary disease, hypoxia
Delirium Treatment/Prevention
- Ensure that the patient is using their hearing aids and glasses if they normally use them
- Check at least a basic metabolic profile (BMP) to rule out and treat any metabolic derangements such as dehydration, hypo- or hypernatremia, etc.
- Check a urinalysis and treat any underlying urinary tract infection
- Assess medication list (prescription and over-the-counter) for high-risk drugs like anticholinergics, tricyclic antidepressants, opioids, etc.
- Evaluate and treat pain
- Ensure that the lights are on during the day, and lights are off at night
- Limit night-time interruptions like scheduled vital signs and medication administration, if possible
- Mobilize with assistance
- Implement a scheduled toileting program
- Reorient the patient at least 3 times daily
- If medication is necessary (risk of injury to self or others, agitation is interfering with patient care, or if patient is distressed and/or appears uncomfortable), use low-dose Haldol (0.5 to 1 mg) IV. Low-dose Haldol may be repeated if initial dose did not fully treat agitation. Use of benzodiazepines should be avoided as they can increase the risk of falls, contribute to confusion, etc.
An 85 year-old woman is brought by her family to the doctor with concern about increasing confusion and agitation over the last day. Her exam is significant for decreased responsiveness, restlessness, and has an odor of urine. There is no focal neurologic deficit. (Click on questions to see the answers)
Source: Image adapted from an image at coachhouserehab.com/images/brain.jpg
Frontal lobe
- Contralateral weakness due to involvement in the motor strip (precentral gyrus)
- Urinary incontinence when bilateral lesions are present because the micturition center is located in the frontal lobes
- Expressive aphasia (Broca's aphasia) involves a lesion in the dominant posterior inferior frontal region (Brodmann's area 44 and 45)
- Executive dysfunction and personality changes when the prefrontal cortex is affected
Parietal lobe
- Contralateral sensory loss due to involvement in the post-central gyrus
- Inferior quadrantanopia – caused by a lesion along the fibers from the superior retina (supplying the lower visual field)
Localization in Clinical Neurology 4th ed. Brazis et al.
Temporal lobe
- Apraxia (dressing, construction, ideomotor) – disorder of skilled movement, not caused by weakness or sensory loss, occur with a lesion in the dominant inferior parietal lobe
- Extinction or simultanagnosia on double simultaneous stimulation occurs with lesions in the left parietal lobe. The individual can sense light touch in both arms, for example, individually, however when both arms are touched simultaneously, only 1 side is felt. Occurs with lesions in the left parietal lobe.
- Neglect - inability to report, respond, or orient to stimuli, generally in the contralesional space. Occurs with a lesions in the right parietal lobe
- Anosagnosia (denial of deficits). The patient clearly has weakness on one side but the patient denies having this deficit occurs with a lesions in the right parietal lobe.
- Gerstmann's syndrome occurs with a lesion in the left parietal lobe.
- Finger agnosia - difficulty naming and differentiating among the fingers of either hand as well as the hands of others
- Agraphia (inability to draw)
- Acalculia (inability to calculate)
- Right-left disorientation
- Balint's syndrome occurs with bilateral parietal lobe lesions
- Inability to voluntarily control the gaze (ocular apraxia)
- Inability to integrate components of a visual scene (simultanagnosia)
- Inability to accurately reach for an object with visual guidance (optic ataxia)
- Receptive aphasia (Wernicke's aphasia) - Brodmann's area 22 occurs with a lesion in the dominant laterosuperior temporal lobe
- Sensory amusia (inability to interpret or appreciate musical sounds) occurs with a lesion in the nondominant laterosuperior temporal lobe
- Sensory aprosodia (imparied ability to comprehend the emotion conveyed in spoken language and impairment of identification of emotional gesturing) occurs with a lesion in the nondominant laterosuperior temporal lobe
- Superior quadrantanopia or "pie-in-the-sky defect" is caused by a lesion along the fibers from the inferior retina (supplying the upper visual field) as they travel through Meyer's loop
Localization in Clinical Neurology 4th ed. Brazis et al.
(Click here for picture)
- Kluver-Bucy syndrome occurs with lesions affecting the tips of the bitemporal lobes
- hyperorality, hypersexuality, flattened emotions, memory loss, inability to recognize faces and objects
- Amnesia can occur when the inferomedial aspect of the temporal lobes are involved, affecting the amygdala and hippocampus (the "memory centers" of the brain)
- Impaired recognition of facial emotional expression occurs with lesions in the nondominant lateroinferior temporal lobe
Occipital lobe
- Homonymous hemianopsia (loss of entire half of visual field).
Localization in Clinical Neurology 4th ed. Brazis et al.
- Macular sparing is present because this is a watershed area, supplied by terminal branches of the Posterior Cerebral Artery (PCA) and Middle Cerebral Artery (MCA). Since occipital lobe strokes are due to PCA occlusion, the macula is spared because of supply by the MCA.
- Wallenberg syndrome-lesion of lateral medulla
- Loss of pain and temperature on ipsilateral face and contralateral limbs and trunk
- Loss of vibrations, proprioception, ataxia in ipsilateral limbs
- Ipsilateral Homer's syndrome, vertigo, nystagmus, hoarseness, and dysphagia are often present
Cerebral Artery Territories
- middle cerebral artery (pink)
- posterior cerebral artery (green)
- anterior cerebral artery (blue)
Deficits can be due to tumors, etc as well as from strokes. If a deficit is due to a stroke, here is a table summarizing the localization and relevant arterial distribution. For more detail on the deficits, please refer to the text below.
Anterior Cerebral Artery
Middle Cerebral Artery
Posterior Cerebral Artery
- Rare (0.6-3%)
- Contralateral weakness affecting leg > arm
- May have lack of initiation or abulia (lack of will or motivation)
- May have sensory loss to contralateral leg
- May have gait and postural disorders
- Most common site of ischemic stroke
- Contralateral weakness affecting face/arm > leg
- May have deviation of the eyes to the side of the lesion
- Dominant hemisphere: Broca's, Wernicke's, conduction, or global aphasia
- May have Gerstmann syndrome (see below)
- Nondominant hemisphere: inattention, neglect, denial, apraxia
- Contralateral homonymous hemianopsia with macular sparing (see below)
The following deficits are found on physical examination of a stroke patient. Based on your knowledge of the neurologic examination and physiology, a lesion in what area of the brain is the most likely to cause these deficits?
- Loss of pain, temperature on ipsilateral face and contralateral body, loss of vibration, proprioception ipsilateral limbs
- Contralateral sensory loss, inferior quadrantanopia (loss of vision in the right lower quadrant, for example), apraxia
- Homonymous hemianopsia (loss of right half of the visual field of both eyes, for example)
- Receptive aphasia, superior quadrantanopia (pie-in-the-sky defect)
- Contralateral weakness, expressive aphasia
When a patient comes in complaining of neck or back pain, it is important to ask them to describe the pain in as much detail as possible. Ask them if the pain is just located in the neck or back or does it radiate or shoot down a limb. Ask them to point with a finger and show the line of radiation (Click here for "Dermatone Map of the Body"). This will help you localize the pain. Have them hold the arm in the anatomic position, and if the pain radiates into the thumb, then you need to think about a C6 radiculopathy. Also, ask about the characteristics of the pain (sharp, aching, shooting, electrical, burning, tingling). This helps you differentiate the etiology of the pain. If the pain is aching or over a joint, then it is probably musculoskeletal. If it is neuropathic in description (electrical, burning, tingling), then you need to think about a pinched nerve, etc.
What is it? Click here for picture
- Nerve root becomes compressed, usually because of a herniated disc or degenerative disc disease
- Causes pain, weakness, sensory loss, and reflex asymmetry in the distribution of that nerve root
- Disc herniation may not just entrap a nerve root, but may cause spinal stenosis and pressure on the spinal cord (Click here for picture)
- Ask every radiculopathy patient if there has been any change in bowel/bladder or any gait changes. If so, this indicates the presence of spinal stenosis
The neuro exam will help you localize the lesion.
- Myotomal distribution
- Elbow flexion (biceps) is supplied by C5-6
- Elbow and finger and wrist extension – C7
- Finger flexion – C8-T1
- Hip flexion – L3
- Knee extension – L4
- Knee flexion – L5
- Ankle dorsiflexion – L5
- Ankle plantarflexion – S1
- Check pinprick over the dermatomal distributions
- For the arm, I would check this in the lateral aspect of the arm (C5), thumb (C6), middle finger (C7), little finger (C8), and medial aspect of the arm (T1)
- For the leg, I would check this over the medial aspect of the foot (L5) and lateral aspect of the foot (S1). Remember the big toe is bigger than the little toe, and 5 is bigger than 1, therefore, L5 innervates the medial aspect of the foot, and S1 innervates the lateral aspect.
- Check reflexes
- Biceps and brachioradialis are supplied by C5-6
- Triceps is supplied by C7
- Knee jerk is supplied by L2,3,4
- Ankle jerk is supplied by S1
- There is no abnormal Babinski (upgoing toes) with an isolated radiculopathy – Upgoing toes indicates an upper motor neuron lesion such as spinal stenosis.
The most common nerve root to get compressed in the neck is C7 (60%) with C6 being the 2nd most common (25%). The most common nerve roots to get compressed in the lumbar spine are L5 and S1.
Pain originating in the neck or back and "radiating" down the respective limb often represents radiculopathy (nerve root impingement), but not necessarily. If there is normal strength, sensation, and reflexes, then you need to think about hip or other joint pathology.
- Lumbar radiculopathy
- Positive straight leg raise
- Increased pain with increased abdominal pressure (coughing, sneezing, bearing down)
- Weakness or sensory or reflex changes in L5 or S1 distribution
- Hip pathology
- Increased pain when lying on the affected side
- Point tenderness
- Normal sensation, strength, and reflexes
Spinal Stenosis
Hyperreflexia indicates an upper motor neuron lesion at least 1 level above the level of the root supplying the reflex. If a patient has hyperreflexia in both legs with normal reflexes in the arms, the lesion must be above L4 which supplies the knee jerks. The upper motor neuron lesion could be in the upper lumbar spine (very uncommon), in the thoracic spine (exceedingly uncommon), or in the cervical spine (much more likely). So, if you must image a spinal level for a patient with hyperreflexia in the legs and normal reflexes in the arms, start with an MRI of the cervical spine. Perhaps the cervical stenosis is not high enough in the cervical spine to affect the reflexes in the arms. Hyperreflexia in the arms AND legs probably indicates an upper cervical lesion or perhaps a bilateral lesion in the brain.
Spinal Cord Injury
- Surgical stabilization
- Steroids (IV Solumedrol (methylprednisolone)) to prevent further neurologic damage by reducing edema
- Edema in a fixed, rigid column presses normal spinal tissue against the vertebral bodies, causing more neurologic damage
For a patient with bilateral leg weakness and low back pain, be sure to ask about urinary changes (incontinence and retention) and saddle anesthesia. If these are present, you need to check for anal sphincter tone. If this is reduced, the patient needs an emergent MRI of the lumbar spine to rule out cauda equina syndrome.
A 34 year-old man presents with gait difficulty. On examination, he is found to have normal reflexes and strength in his arms and hyperreflexia in his legs with upgoing toes, and his gait is spastic.
Question: If you were to MRI the spine of this patient with normal reflexes in the arms and hyperreflexia in the legs, which level would you MRI first? (Click on your choice to see the answers)
A 45 year-old man presents with neck pain shooting into the lateral aspect of his left arm, into the thumb. He is also having weakness in his left arm when carrying things. On examination, he has weakness of elbow flexion on the left with diminished biceps and brachioradialis reflexes but triceps reflex is normal on the left. Pinprick is diminished over the lateral aspect of his left forearm and hand.
Question: Which cervical nerve root is getting compressed?
Question: Upon further examination, he is found to have hyperreflexia in his legs with upgoing toes, and he is complaining of urinary urgency and retention. (Click on question to see the answers)
67 year-old woman with pain radiating down the lateral aspect of the right leg to the midcalf. Strength, reflexes, and sensation are all normal. There is point tenderness over the lateral aspect of the right hip.
Question: Where is the lesion – right hip or lumbar radiculopathy?
The most common sleep disturbance is insufficient sleep syndrome (sleep deprivation) followed closely by sleep apnea
Neurologic causes of sleep disturbances
- Narcolepsy
- Symptoms
- Cataplexy – loss of muscle tone, not loss of consciousness, in response to strong emotional stimuli (laughter, startle)
- Excessive daytime sleepiness – Narcoleptics fall asleep in dangerous or socially inappropriate situations (while driving, while teaching class, or during sexual intercourse for example)
- Hypnagogic hallucination - episodes of seeing and hearing things as one is falling asleep
- Hypnopompic hallucinations – vivid dreamlike hallucination that occurs as one is waking up
- Sleep paralysis – temporary paralysis of the body shortly after waking up when the brain awakens from a REM state, but the bodily paralysis persists
- Diagnosis
- Multiple sleep latency test (MSLT) – a series of 5 nap opportunities are recorded where the time to drop into REM sleep is measured. Sleep-onset REM (SOREM) is diagnostic of narcolepsy
- Treatment
- Avoid alcohol and drug use, which may exacerbate symptoms
- CNS stimulants
- Ritalin (methylphenidate)
- Provigil (modafinil)
- Anticataplectic agents
- Anafranil (clomipramine)
- Prozac (fluoxetine)
- Xyrem (gamma hydroxybutyrate (GHB))
- Restless legs syndrome
- Symptoms
- Difficulty getting into a comfortable position when trying to go to sleep
- Antsy, creepy-crawly sensation in the legs
- Symptoms are temporarily relieved by walking or repositioning
- Differential diagnosis
- Iron deficiency
- Peripheral neuropathy
- Treatment
- Benzodiazepines
- Levodopa or dopamine agonists such as Mirapex (pramipexole) or Requip (ropinirole)
- Opioids
- Neurontin (gabapentin)
- Periodic limb movement disorder
- Symptoms - stereotyped periodic limb movements during sleep that cause awakening during the night
- Treatment
- Benzodiazepines
- Levodopa or dopamine agonists such as Mirapex (pramipexole) or Requip (ropinirole)
- Neurontin (gabapentin)
- Baclofen (lioresal)
67 year-old woman with a couple of year history of difficulty falling asleep due to discomfort in her legs. She describes this as an antsy sensation, and she needs to keep moving around, trying to find a comfortable position. Her examination is significant for diminished vibration and proprioception in the feet and diminished ankle jerks but normal neurologic examination otherwise. (Click on questions to see the answers)
Cranial Nerve I – Olfactory nerve
- Head injury/shearing of the olfactory nerves at the cribriform plate
- Diminished olfaction in Parkinson's disease and Alzheimer's disease
Cranial Nerve II – Optic nerve
- Evaluation
- Visual acuity using the Snellen eye chart
- Visual field testing
- Light reflex (CN II is the afferent and CN III is the efferent limb of the reflex)
- Fundoscopic examination
- Differential diagnosis
- Optic neuritis
- Papilledema – pressure on the optic nerve from increased intracranial pressure causes enlargement of the physiologic blind spot and can ultimately cause blindness (Click here for Figure)
Cranial Nerve III – Oculomotor nerve
- Evaluation
- Supplies all of the "H" test except for SO4LR6 (superior oblique is supplied by CN IV and the lateral rectus is supplied by CN VI)
- Injury
- Results in diplopia
- Mild ptosis of the ipsilateral eye, failure of the eye to adduct and impaired upgaze
- If the parasympathetic fibers which surround CN III are affected, the pupil will be affected
- Pupillary sparing left CN III palsy (Click here for Picture) is likely due to an infarct of CN III. Note that there is ptosis on the left (so examiner is holding open the left eye), left eye fails to adduct, and pupils are the same size.
- Pupillary involving left CN III palsy is likely due to a compressive lesion such as a mass or aneurysm. Note that the patient is attempting to fixate on an object slightly to the right. There is mild ptosis on the left (so examiner is holding open the left eye), the left eye fails to adduct, and the left pupils fails to constrict and is larger than the right.
Cranial Nerve IV – Trochlear nerve
- Evaluation
- Depression of the eye primarily on adduction
- Injury
- Causes diplopia which is better when tilting the head to the contralateral side, and the diplopia is worse when tilting to the ipsilateral side.
- Example: Left CN IV palsy – diplopia is better when tilting the head to the right and worse when tilting the head to the left
Cranial Nerve V – Trigeminal nerve
- Evaluation
- Assess light touch in the V1, V2, and V3 distributions on the face
- Feel the bulk of the masseter muscle when clenching the teeth. The muscles of mastication are supplied by V3.
- Corneal reflex (CN V is the afferent and CN VII is the efferent limb of the reflex)
- Injury
- Sensory loss in the affected distribution
- Weakness of mastication on the affected side if V3 is affected
- Trigeminal neuralgia – brief, intense lancinating pain in 1 or 2 trigeminal distributions provoked by wind, touch, cold, eating, brushing teeth, etc.
- Treatment = carbamazepine
Cranial Nerve VI – Abducens nerve
- Evaluation
- Abduction of the eye
- Injury
- Causes diplopia which is better when looking to the contralateral side and worse when looking to the ipsilateral side.
Cranial Nerve VII – Facial nerve
- Evaluation
- Muscles of facial expression
- Injury
- Ipsilateral facial weakness
- Central CN VII palsy – Weakness of the lower face on the contralateral side sparing the upper face because portion of the 7th nerve nucleus that supplies the upper face receives bilateral corticobulbar (upper motor neuron) input.
- Peripheral CN VII palsy – Weakness of the entire ipsilateral side of the face, both upper and lower face. You can have as much dual innervation as possible, but if the final common pathway is damaged, the upper face is still going to be weak.
- Differential diagnosis of peripheral CN palsy
- Bell's palsy – ipsilateral upper and lower facial weakness
- Ramsey-Hunt Syndrome – Bell's palsy plus vesicles in the ipsilateral ear caused by Herpes Zoster. Treatment is Acyclovir
Cranial Nerve VIII – Vestibulocochlear nerve
- Evaluation
- Acoustic component
- Whisper or finger rub or clicking next to each ear
- Vestibular component
- Doll's eyes (oculocephalic reflex) – Passive movement of the head to the right and left. The normal intact brainstem response is for the eyes to remain fixated on a spot in space and for the eyes to move within the socket. If the eyes remain "painted on" and don't move with movement of the head, this indicates an absent brainstem response.
- Cold calorics (oculovestibular reflex) – A stronger reflex response than the Doll's eyes maneuver, cold water is injected into an ear. A normal intact brainstem response in a comatose patient is for the eyes to deviate conjugately to the ipsilateral ear until the tympanic membrane temperature returns to normal at which point the eyes return to midline. Injection of cold water into the opposite ear results in conjugate deviation of the eyes to the ipsilateral ear. Failure of the eyes to deviate indicates an absent brainstem response.
- Differential diagnosis of vertigo
- Meniere's disease
- Episodes of vertigo, nausea, vomiting, diminished hearing, and tinnitus
- Treatment: Restrict salt/caffeine/tobacco, use of diuretics, meclizine, benzodiazepines
- Benign positional vertigo
- Recurrent episodes of vertigo lasting ≤ 1 minute and may be associated with nausea and vomiting
- Provoked by looking up while standing or sitting, lying down or getting up from bed, and rolling over in bed
- Typically recur periodically for weeks to months without therapy
- May have evidence of prior inner ear damage
- Diagnosis: Dix-Hallpike maneuver
- Treatment: Epley or Barany maneuvers
- Labyrinthitis
- Prolonged, severe episodes of vertigo accompanied by nausea, vomiting, and disequilibrium caused by inflammation or dysfunction of the vestibular apparatus
Cranial Nerve IX – Glossopharyngeal nerve
- Evaluation: Afferent limb of the gag reflex. CN X is the efferent limb that results in palatal elevation.
Cranial Nerve X – Vagus nerve
- Evaluation: Efferent limb of the gag reflex that causes palatal elevation. The afferent limb is CN IX.
Cranial Nerve XI – Accessory nerve
- Innervates the sternocleidomastoid and trapezius muscles
- Evaluation
- Sternocleidomastoid – Turning the head to one side results from contraction of the contralateral sternocleidomastoid (Click here for Picture)
- Trapezius – Shrugging the shoulder results from contraction of the ipsilateral trapezius
Cranial Nerve XII – Hypoglossal nerve
- Evaluation: Have the patient stick out their tongue and move it side to side
"Bulbar weakness" - Symptoms such as dysphagia, dysarthria, diplopia, dyspnea which localize to the "bulb" or the brainstem
- Differential diagnosis – This is not an exhaustive list, but 2 common conditions to consider include:
- Myasthenia gravis
Horner's syndrome
- Injury to the sympathetic chain resulting in ptosis, meiosis, and anhydrosis
- Differential diagnosis
- Brainstem stroke
- Tumor in lung apex (pancoast tumor)
- Carotid dissection
70 year-old man with a history of hypertension and diabetes develops sudden onset of double vision and pain over the right temple. Neurologic examination reveals mild ptosis of the right eye, failure of the right eye to adduct and impaired upgaze on the right. The pupils are reactive. (Click on your choice to see the answers)
- A lesion in which cranial nerve would cause these exam findings?
- What is the most likely etiology of the cranial nerve dysfunction?
45 year-old man with a 40 pack year smoking history presents with ptosis on the left, and the left pupil is found to be smaller than the right but is reactive. The rest of his exam is otherwise normal.
Temporal arteritis or giant cell arteritis, is caused by an inflammatory response to medium and large arteries of the head and neck primarily and may extend into the carotids and aorta. New-onset headache in any patient older than 50 years prompts consideration of this diagnosis, or if there has been a change in character from a previous headache pattern.
- The pain is typically:
- Unilateral, classically in the temporal region, but may be diffuse or bilateral
- Frequently worse at night
- Burning or jabbing sensation over the scalp and face
- Provoked by combing hair, wearing of a hat or glasses, or resting the head on a pillow
- Other symptoms
- Vision loss
- May occur suddenly and painlessly
- May be transient (amaurosis fugax-type picture) or permanent.
- Blindness eventually occurs in 20-50% of untreated patients
- Jaw claudication when chewing or talking
- Constitutional symptoms include anorexia and weight loss, fever and sweats, and malaise, fatigue, and depression.
- Based on the 1990 American College of Rheumatology criteria for classification of giant cell arteritis, 3 of the following 5 items must be present:
- Development of symptoms in patients older than 50 years
- New onset of headache or localized head pain
- Temporal artery tenderness to palpation
- Decreased pulsations not related to arteriosclerosis of cervical arteries
- Erythrocyte sedimentation rate (ESR) greater than 50 mm/h
- Diagnosis
- Labs
- Most patients with temporal arteritis have an ESR > 80.
- Approximately 10% of patients may have an ESR < 30.
- May be elevated (>2.4)
- CRP level may even be elevated in some patients with a normal ESR
- Definitive diagnosis = temporal artery biopsy.
- Involvement tends to be patchy or segmental so an adequate biopsy needs to be taken (20mm) and pathology needs to perform serial sections
- Steroid therapy may affect results of biopsy, but inflammatory changes usually persist for 2-4 weeks after initiation of treatment
- Treatment
- High dose prednisone or IV methylprednisolone (Solumedrol)
- Ophthalmology consult
- Rheumatology or internal medicine consult to manage care
66 year-old woman with a new onset of headache which began a few weeks ago. The pain is located over the left temporal head region, and the scalp is very tender to palpation. She became frightened because yesterday while shopping, she temporarily lost vision in her left eye as if a curtain came over her vision. She has been experiencing fever and night sweats. (Click on the questions to see the answers)
Damage to the distal nerves in the hands and feet cause a sensation of numbness, pins/needles, burning, and/or electrical pain in the affected areas. The typical peripheral neuropathy is a length-dependent process, so the feet (or "stockings") become affected earlier than the hands (or "gloves"). Not until the symptoms have progressed to above the knees do the hands typically become involved. The patient, however, may have superimposed carpal tunnel syndrome, etc, which could give symptoms in the hands earlier, such as at the onset of the symptoms in the feet. The typical peripheral neuropathy progresses over weeks to months in a gradually progressive manner.
Physical exam findings
- Motor
- Possibly diminished grip strength and/or foot drop if the motor nerves are affected. Toe flexion and extension are frequently weak.
- Sensory
- Diminished pinprick in a distal gradient especially in the feet
- Possible diminished proprioception and vibration in a distal gradient especially in the feet
- Reflexes
- Normal to perhaps slightly diminished reflexes in the arms
- Depressed reflexes at the knees
- Absent ankle jerks
- Electromyogram and nerve conduction studies (EMG/NCS)
Differential diagnosis
- Diabetes - the most common etiology in developed countries.
- B12 deficiency
- Hypothyroidism
- Alcoholism
- Drug induced
- Heavy metal poisoning
- Factoid: The most common worldwide cause of peripheral neuropathy is leprosy
- Neurontin (gabapentin), Lyrica (pregabalin), tricyclic antidepressants, and Cymbalta can help with the pain of neuropathy but do not improve the sensation (i.e. relieve the numbness).
Guillain-Barré Syndrome (GBS)
Rapidly progressive weakness with some sensory loss over the course several days or a week or two. The course of the condition is much faster than that of typical peripheral neuropathy. A mild respiratory or GI illness often precedes the symptoms by 1-3 weeks.
- Symptoms of GBS
- Classically described as an ascending paralysis, however this does not have to be the case
- Respiratory involvement is the most worrisome symptom as death can occur from respiratory failure
- Often describe an achiness in the muscles of the hips, thighs, and back
- Neurological Exam
- Reduced and then absent reflexes
- At an early stage, the arm muscles may be less weak than the leg muscles
- May have facial weakness
- Perhaps diminished vibration more than pain/temperature, but weakness is much more prominent
- Often have autonomic dysfunction
- Diagnosis
- Lumbar puncture
- Look for albuminocytologic dissociation (high protein, which could possibly indicate some sort of infection, however the number of white cells is normal showing that there is no infection). The elevated protein is due to demyelination of the motor nerves.
- Treatment
- Plasma exchange or IVIg
62 year-old man presents with a couple of month history of numbness and tingling and pain which began in his toes and has progressed to mid-foot. He describes a pins and needles sensation with some burning pain. He has also been tripping on his feet somewhat, and his gait has become unsteady.
Neurologic Examination: Normal strength throughout except mild weakness on ankle dorsiflexion and toe extension. Diminished pinprick to the ankles with diminished but present vibration and proprioception at the toes. Reflexes are normal in the arms, diminished at the knees, and absent at the ankles. Toes are mute. The remainder of the neurologic examination is normal except decreased height on heel walk and unsteadiness on tandem gait. (Click on questions to see the answers)
- What is the diagnosis?
- What test would prove the diagnosis?
- What labs would you order to determine the etiology?
- What treatment is available to improve the patient's ability to sense his feet, improve his numbness?
- Which medications are helpful in treating the pain and discomfort?
Dementia: Decline in cognition (memory, executive function (planning / organization), language, or orientation) that interferes with everyday function.
Alzheimer's disease
- Most common cause of dementia (60-80%)
- Usually occurs in patients age 65 or older
- Marked by early memory impairment and executive dysfunction
- Examples of memory impairment
- Forgetfulness (conversations; appointments; medicines; names)
- Repetition of questions, statements
- Misplacement of items
- Examples of executive dysfunction
- Managing household finances
- Driving
- Meal preparation
- Operating appliances
- Must have deficits in at least 2 of the following areas of cognition
- Memory
- Orientation
- Judgment and Problem Solving
- Community Affairs
- Home and Hobbies
- Personal Care
- Gradual onset and progressive decline over months or years. The average life expectancy after onset of symptoms is approximately 8 years, but progression may occur as short as 3 years or as long as 20 years.
- Treatment
- Acetylcholinesterase inhibitor such as donepezil (Aricept), rivastigmine (Exelon), or galantamine (Razadyne)
- NMDA receptor antagonist such as memantine (Namenda)
Dementia with Lewy Bodies
- Clinical diagnosis
- Dementia
- Two of the following
- Fluctuations in cognition
- Visual Hallucinations
- Parkinsonism
- Supportive features: falls, syncope, neuroleptic sensitivity, delusions, loss of consciousness
Frontotemporal Dementia (Pick's disease = FTD syndrome with Pick bodies at autopsy)
- Clinical features
Vascular Dementia (multi-infarct dementia) (Click here for Picture)
- Focal neurologic signs
- Stepwise progression
- Gait difficulties, urinary incontinence, parkinsonian features
- Subcortical dementia
- Slowing of thought
- Apathy
Normal Pressure Hydrocephalus
- Clinical triad:
- Wet (urinary incontinence)
- Early on, urgency and frequency
- Later, true incontinence
- Wobbly (gait disorder)
- Bradykinetic
- Broad-based
- Shuffling
- Apraxic, "magnetic" (like the feet are stuck to the floor)
- Marked difficulty taking the first step (start hesitation) or turning
- Wacky (dementia)
- "Normal pressure" is actually a misnomer since there is probably intermittent transient elevations in intracranial pressure with the pressure returning to normal transiently after ventricular dilatation
- Causes
- Head injury
- Subarachnoid hemorrhage
- Meningitis
- CNS tumor
- Diagnosis
- Imaging
- Ventricular enlargement out of proportion to sulcal atrophy (Click here for Picture)
- High-volume lumbar puncture (30-50cc of CSF is removed) with timed walk before and after to determine if the patient is a shunt candidate
- Prior to LP, have the patient walk a set distance, time the walk, count the steps, and describe the gait in detail
- Immediately following the LP, repeat the timed walk. If the patient is a shunt candidate, there should be improvement in the gait
- 3 hours after the LP, again repeat the timed walk. There is usually mild worsening of the gait compared to immediately after the LP
- Repeat the timed walk the next morning. The gait usually returns to baseline by this time.
- If there is improvement in the gait following a high-volume LP, consult neurosurgery for consideration of shunt placement
Creutzfeldt-Jakob (CJD)
- Symptoms
- Rapidly progressive form of dementia, usually with death within 1 year
- Over the course of a few months, the patient becomes lost in their own home and has significant changes in memory and judgment
- Develop myoclonus or involuntary muscle jerks
- Visual disturbances
- Diagnosis
- MRI brain can show hyperintensities in the cortex and cortical ribboning in the basal ganglia
- Definitive diagnosis is made at autopsy, showing spongiform changes in the cortex
- EEG may show periodic complexes
Wernicke's encephalopathy
An acute confusional state, ophthalmoplegia, and ataxia caused by thiamine deficiency.
The following are descriptions of paitents with dementia. Which type of dementia is best characterized by the following descriptions? (Click to see correct answer)
- 72 year-old woman with 2 year history of gradually progressive memory loss, repeating herself, mild disorientation to time.
- 68 year-old woman with several month history of urinary incontinence, gait difficulties, and memory loss.
- 55 year-old man with a 1 year history of disinhibition and word-finding difficulties
- 49 year-old woman with a couple of month history of rapidly progressive memory loss, now getting lost in her own home, with associated movement disorder and periodic complexes on EEG
- 83 year-old man with a history of diabetes and hypertension with a 2 year history of step-wise progression of memory loss
- 69 year-old man with frequent falls, shuffling gait, memory loss, and visual hallucinations


text:
I just want to give the Maine Geocaching community a heads up that I have a new cache waiting to be approved in Acton. I hope that some of you will try for it in the next few days. It is the PINE TREE POST. I hope you enjoy it. Also, when and if it gets approved I would like some feed back on it. SO, feel free to contact me.
Black Burn

subset: commoncrawl


text:
Beat writer Jerry McDonald graded the Raiders performance in their 26-16 victory over the Kansas City Chiefs on Sunday at Arrowhead Stadium:
Pass offense
After an interception on his first pass to Stanford Routt, Carson Palmer was mistake free and threw touchdown passes of 9 yards to Denarius Moore and 32 yards to Darrius Heyward-Bey. Maximum protection schemes were excellent as Palmer wasn't sacked and barely touched. Too many dropped passes — at least four. Grade: B
Run offense
Darren McFadden had his second 100-yard game on the strength of a 12-carry, 73-yard fourth quarter. Ideally, it's the way a zone blocking system is supposed to work — running with a lead. He finished with 29 carries and 114 yards. Need to run better earlier in the game, however. Grade: B-minus
Pass defense
Free safety Matt Giordano had his first interception of the season, a classic read of Brady Quinn, and Pat Lee halted a Chiefs drive deep in Raiders territory with an acrobatic interception of Matt Cassel. The Raiders pass rush was very good as Rolando McClain, Philip Wheeler and Richard Seymour had sacks. Grade: B
Run defense
The only flaw was allowing Quinn and Cassel the opportunity to exploit an open middle when pressured from the outside as quarterbacks gained 53 yards on nine carries. The rest of the running game was stuffed as the Broncos finished with 22 attempts for 102 yards. Jamal Charles had just five carries and 4 yards. Grade: B-plus
Special teams
The game swung on a special teams hustle play, with long-snapper Jon Condo getting downfield to recover a muffed punt return attempt by Javier Arenas late in the first half. It set up the Palmer-to-Moore touchdown and gave the Raiders permanent momentum. Sebastian Janikowski was 4-for-4 kicking field goals, flawless as usual in Arrowhead. Grade: B-plus
Raiders were much better prepared for a team coming off a bye than the previous week against Jacksonville, and were ready to play from the outset. Good mix of defensive play-calling kept Chiefs guessing all day. Offensive coordinator Greg Knapp placed a priority on pass protection and it paid off, as did sticking with a sluggish running game in the fourth quarter. Grade: B-plus


text:
Junior middle hitter Alex Kelly and junior setter Stefine "Jake" Pease were playing together on club teams long before they ever wore the purple and gold of the Lipscomb Lady Bisons. Kelly is the 2009 and 2008 Atlantic Sun Player of the Year. Pease was the Atlantic Sun Freshman of the Year in 2007 and was also the Atlantic Sun Tournament Most Valuable Player that same year.
This year both Kelly and Pease are also members of the Atlantic Sun All-Conference First Team. And while the Lady Bisons have earned the No. 1 seed in the Atlantic Sun Tournament with a 20-0 record as a team, 26-3 overall, the dual engines that drive the success are Kelly and Pease.
The Lady Bisons, who have won their last 23 matches in a row, will face Belmont in the semifinals of the tournament Friday at 4 p.m. Belmont, the No. 4 seed, beat Kennesaw State 3-0 (25-17, 25-15, 25-17), in the opening round here Thursday at the Alico Arena on the campus of tournament host Florida Gulf Coast.
Belmont is 18-14 overall.
"Belmont's experience in the tournament was probably a little too much for Kennesaw State in this match," said Lady Bisons coach Brandon Rosenthal. "Kennesaw had a great season.
"It is kind of scary how Belmont is playing. I equate it to a couple of years ago when we were the No. 4 seed and won in 2007. They are playing very good volleyball right now."
The Lady Bisons beat Belmont 3-0 Sept. 8 to open the A-Sun portion of the season and then followed up with a 3-1 win Oct. 13. Belmont is one of three conference teams to win a set against the Lady Bisons this season. ETSU won three and Campbell won one.
The Lady Bisons are 1-2 overall in tournament play against Belmont. The Lady Bisons won the title in 2007.
"It is a little strange to come all this way to play Belmont," said Rosenthal. "At some point we expected to play them.
"There is nothing to do about the conference and where everybody finishes. Our girls know their players very well. It is going to come down to a match between two good teams. The winner will be the one that executes better."
The Lady Bisons fell to Belmont in 2008 in the tournament championship game in Macon, Ga. Rosenthal will be counting on Kelly and Pease, who captain the team along with senior opposite Erin Pierce to lead the Lady Bisons to even higher heights.
Their leadership approaches are extensions of their personalities.
"They are very different in terms of personalities," said Rosenthal. "A common misconception is that because they have known each other for so long that they are the same. They're not.
"The best thing about the two of them is the way they deal with each other. They each allow the other to be herself. Jake understands Alex and allows her to be Alex. Alex understands Jake and allows her to be Jake."
The ease in which Kelly and Pease take on their leadership roles without stepping on each other's toes is an exception.
"I don't know how they did it, but both of them figured out that they need each other and don't need to fight this," said Rosenthal. "I don't think one way or the the other is right. I think is a good combination with the girls hearing things from different perspectives.
"On the court Alex is going to let her emotions show a lot more. I think that is what makes her successful. Jake takes a `let's go about our business' approach. It is kind of fun to see the both of them push each other and push the team."
As individuals each one possesses almost unlimited talent. On the court they choose to combine those talents rather than compete against each other.
"I think they understand the power that they have together," said Rosenthal. "They are a great combination."
This is the fifth appearance for the Lady Bisons in the Atlantic Sun Conference Tournament. They have a 6-3 record overall.
Mark McGee, Senior Publisher/Media Relations Director


text:
Ductal Carcinoma In Situ (DCIS) of the Breast
I have just been diagnosed with breast cancer - labeled DCIS (Ductal Carcinoma In Situ). I understand this means that the cancer is still in the milk ducts and hasn't spread to other parts of my body. I have no family history of breast cancer, but now I am anxious that I am more likely to develop cancer in other parts of my body especially in the other breast. How worried should I be? Does this mean my chances of, say, ovarian or cervical cancers go up?
Kenneth Blank, MD and John Han-Chih Chang, MD, Editorial Assistants for Oncolink, respond:
Dear OncoLink Reader:
Thank you for your question.
Ductal carcinoma in situ of the breast (DCIS) means that the cancer has not spread through the epithelium of the milk ducts. Let us explain: The milk ducts of the breast are covered by a lining called the epithelium. The epithelium is a very thin layer of tissue in which most breast cancers arise. When the cancer has spread through the epithelium into the surrounding breast tissue it is called invasive breast cancer. If the cancer remains confined within the epithelium it is termed DCIS.
The chance of having cancer return in other parts of your body is extremely small. Because, by definition, DCIS has not spread through the epithelium, the cancer cells cannot gain access to the lymph nodes or blood system, which could potentially carry them to other parts of the body. The risk of developing a breast cancer on the other side is also low, but having had a cancer in one breast does slightly increase the chance of having a second cancer arise in the other breast. For this reason, it remains critical for you to have yearly mammograms and physical examinations as well as perform a self-examination monthly.
Finally, the fact that you had DCIS does not increase your risk of getting ovarian or cervical cancers. There exist familial cancer syndromes in which affected women are prone to get breast and ovarian cancers, but your negative family history precludes this possibility.


text:
Author: TH (co-colspgs-4-u1-b5-248.clspco.adelphia.net)
Date: 05-07-04 15:33
I'm looking for a poem entitled "Columbus" It goes:
In fourteen hundred and ninty two,
Someone sailed the ocean blue.
Someone borrowed the fare in Spain
For a business trip on the bounding main.
I am also looking for the words to the poem "Opportunity"
"This I beheld or dreamed it in a dream."
It's about the prince who finds the broken sword of the craven and wins the battle.
Thank you.
Look What You Did, Cristopher!
In fourteen hundred and ninety-two,
Someone sailed the ocean blue.
Somebody borrowed the fare in Spain
For a business trip on the bounding main,
And to prove to the people, by actual test,
You could get to the East by sailing West.
Somebody said, Sail on! Sail on!
And studied China and China's lingo,
And cried from the bow, There's China now!
And promptly bumped into San Domingo.
Somebody murmured, Oh dear, oh dear!
I've discovered the Western Hemisphere.
And that, you may think, my friends, was that.
But it wasn't. Not by a fireman's hat.
Well enough wasn't left alone,
And Columbus was only a cornerstone.
There came the Spaniards,
There came the Greeks,
There came the Pilgrims in leather breeks.
There came the Dutch,
And the Poles and Swedes,
The Persians, too,
And perhaps the Medes,
The Letts, the Lapps, and the Lithuanians,
Regal Russians, and ripe Roumanians.
There came the French
And there came the Finns,
And the Japanese
With their formal grins.
The Tartars came,
And the Terrible Turks -
In a word, humanity shot the works.
And the country that should have been Cathay
Decided to be
The U.S.A.
And that, you may think, my friends, was that.
But it wasn't. Not by a fireman's hat.
Christopher C. was the cornerstone,
And well enough wasn't left alone.
For those who followed
When he was through,
They burned to discover something, too.
Somebody, bored with rural scenery,
Went to work and invented machinery,
While a couple of other mental giants
Got together
And thought up Science.
Platinum blondes
(They were once peroxide),
Peruvian bonds
And carbon monoxide,
Tax evaders
And Vitamin A,
Vice crusaders,
And tattletale gray -
These, with many another phobia,
We owe to that famous Twelfth of Octobia.
O misery, misery, mumble and moan!
Someone invented the telephone,
And interrupted a nation's slumbers,
Ringing wrong but similar numbers.
Someone devised the silver screen
And the intimate Hollywood magazine,
And life is a Hades
Of clicking cameras,
And foreign ladies
Behaving amorous.
Gags have erased
Amusing dialog,
As gas has replaced
The crackling firelog.
All that glitters is sold as gold,
And our daily diet grows odder and odder,
And breakfast foods are dusty and cold -
It's a wise child
That knows its fodder.
Someone invented the automobile,
And good Americans took the wheel
To view American rivers and rills
And justly famous forests and hills -
But someone equally enterprising
Had invented billboard advertising.
You linger at home
In dark despair,
And wistfully try the electric air.
You hope against hope for a quiz imperial,
And what do they give you?
A doctor serial.
Oh, Columbus was only a cornerstone,
And well enough wasn't left alone,
For the Inquisition was less tyrannical
Than the iron rules of an age mechanical,
Which, because of an error in '92,
Are clamped like corsets on me and you,
While Children of Nature we'd be today
If San Domingo
Had been Cathay.
And that, you may think, my friends, is that.
But it isn't - not by a fireman's hat.
The American people,
With grins jocose,
Always survive the fatal dose.
And though our systems are slightly wobbly,
We'll fool the doctor this time, probly.
( this was emailed to my by his daughter ... )
OPPORTUNITY by Edward R. Sill
This I beheld, or dreamed it in a dream:
There spread a cloud of dust along a plain;
And underneath the cloud, or in it, raged
A furious battle, and men yelled, and swords
Shocked upon swords and shields. A prince's banner
Wavered, then staggered backward, hemmed by foes.
A craven hung along the battle's edge
And thought, "Had I a sword of keener steel --
That blue blade that the king's son bears -- but this
Blunt thing -- !" He snapt and flung it from his hand,
And, lowering, crept away and left the field.
Then came the king's son, wounded, sore bestead,
And weaponless, and saw the broken sword,
Hilt-buried in the dry and trodden sand,
And ran and snatched it, and with battle shout
Lifted afresh, he hewed his enemy down,
And saved a great cause that heroic day.
I DREAM by K. Campbell
(In life, as in fencing, you need a mental sword with which to fight your dragons.)
I dream.
In silvered shadows my hero arrives,
Not on a white horse,
But only walking.
He comes
Without a sword to slay the dark dragon.
His weapon mere words;
I hear him talking.
"It's nothing special. It's no big deal."
Odd things for a warrior to say.
Where is the poetry, the flourish?
Is this truly one who will win the day?
He falls silent. He offers his hand.
The dragon draws closer and I'm afraid.
Then, a shifting, adn the beast is gone.
We're dancing on mist in a forest glade.
I know.
Morpeus has sent a message by way
Of this strange champion,
"Dragons are real."
"They come.
You face them and they dissolve into mist.
They're nothing special.
They are no big deal.


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Pearly beige with a delicate metallic finish.
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Memphis, Tenn.-based Thomas & Betts is celebrating 50 years of Ty-Rap, the original cable tie. Each tie is a small, lightweight, one-piece, self-fastening plastic strap that can be used to securely bundle cables and wire.
"We're proud to be the company that brought this innovation to the world," says Dominic Pileggi, CEO, Thomas & Betts. "Over the past 50 years, Ty-Rap has become an indispensable part of everyday life."
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Earlier today in Beirut as I made my way to Sassine for brunch with my 15-month old we passed yet another high-rise construction site called Embassy II. The floor plans show the usual cluster of vast living rooms, en suite bathrooms and tiny maid's rooms. They're accompanied by the tag-line "Your passport to luxury city living."
An hour after leaving Sassine, I was back home, thinking about Lebanese business concepts which have filled a real gap in the market, like Beirut.com and Zawarib. You can't think about business or any kind of investment in Beirut without pondering the instability of investments in a country which one pundit or another invariably puts on the brink of war. Ironic then that my thoughts are interrupted by a huge blast followed by the wail of ambulances. Soon the land line, the mobiles, and Skype were alive with friends and family checking for our vital signs. A couple of hours later, Naharnet, the source which seems to get news out the fastest, put the toll at 8 dead and 78 wounded in a car bomb just off Sassine. Then their website got too overloaded to load. I'm glad I abandoned the idea of staying at Sassine to shop after kneife because my Beirut baby was so sleepy.
Yesterday I was sent this article in The Spectator on why one Lebanese has had enough of the frailty of life in Beirut. Unlike him, I haven't lived through three wars. I was only on holiday here in May 2008 when gun fights sprang up like leaks in a plastic bag and Hizbollah took control of West Beirut. I don't get war jitters like some who have lived through it. In fact that was my only trip here before deciding to move here and it didn't put me off in the slightest. I didn't even learn the Arabic for bomb until today – a good sign to be sure. But I'm no longer seized by the desire to head straight back up to Sassine to check the situation out. I have Beirut baby to think about. Frankly, worrying about her tripping as she toddles about on her little legs so soon after her first steps is as much as I want to handle.
The news now is that the head of the Intelligence Bureau of the Internal Security Forces was the target of the car bomb. The BBC says its the deadliest attack since May 2008. Still, on a purely selfish level it's almost a relief to know that it was, as always in Lebanon, an attack with a specific target, a typical assassination. Doesn't that make it less likely for innocent bystanders and their babies to get caught up in the violence than in countries where terrorism is more random? It's not a relief for Lebanon though.
Some may be willing to put a million dollars into the Embassy II development, and maybe it will prove to be their passport to luxurious city living. But it might just as well give them a better view than they ever wanted over a brand new conflict on their doorstep. As Michael Karam points out in his very personal article, the third world affords certain luxuries which are hard to come by in the West, such as live-in home help at laughably low rates. But I think a lot of dual-citizen Lebanese out there are wondering whether they should be using their back-up nationality, their non-Lebanese passport, to get themselves a normal life elsewhere, instead of the sometimes luxurious but unstable life they lead in Lebanon. Others may be gritting their teeth as they knuckle down to a difficult period from which they have no escape.


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A Collaboration between Roger Williams University
and the Rhode Island International Film Festival
April 26-28, 2009
Sun Apr 26 2009
Screening Location: RWU School of Architecture, ARCH*132
4:00 p.m.
A First Look Premiere Presentation of the Rhode Island International Film Festival
Interrogate This: Psychologists Take on Terror
Directed by Maryanne Galvin, USA, 2008
90 mins.
Presents a troubling and deeply human story illustrating the complexities encountered when national security, psychology, politics, ethics and morality collide. Until this past September when the American Psychological Association voted on a referendum requiring policy adjustments regarding psychologists' work in national security sites that prohibits their further involvement in interrogations of detainees, the mental health profession's involvement in the war-on-terror had not been widely publicized. Yet, for years psychologists and other professionals involved in the war on terror have gone head to head debating their continued involvement as consultants to those conducting the interrogations of suspected terrorists in detention centers throughout the globe.
POST SCREENING PANEL DISCUSSION (Roundtable):
Dr. Matt C. Zaitchik is a clinical and forensic psychologist. He is an Associate Professor of Psychology at Roger Williams University. From 1988 to 2004 he was Co-director of the Forensic Service at UMass Medical School/Worcester State Hospital, where he conducted criminal evaluations and supervised pre-doctoral interns, post-doctoral fellows, psychiatry fellows and doctoral level clinicians. He is a Designated Forensic Professional and Designated Forensic Supervisor for the Commonwealth of Massachusetts and a Diplomate (ABPP) in Forensic Psychology. He is President-Elect (2009-2010) of the American Academy of Forensic Psychology. Dr. Zaitchik is also currently on the Community Access Board at the Massachusetts Treatment Center (for Sexually Dangerous men).
Teal Rothschild, Ph.D. is an Associate Professor of Sociology at Roger Williams University.
Jon W. Shelburne serves as a Visiting Assistant Professor of Law at Roger Williams University.
Maryanne Galvin is a documentary filmmaker as well as a practicing forensic psychologist in Boston, Massachusetts. Over the past several years, she chronicled the heated debate amongst her colleagues about their work as consultants to interrogations in U.S. national security detention centers. Interrogate This: Psychologists Take on Terror, premiered in September 2008 at The Thin Line Film Festival in Texas.
Her films have won awards at numerous independent film festivals and have been broadcast and distributed widely. Galvin has also written, directed, and produced three educational training videos for mental health and law enforcement professionals. She holds a doctorate in psychology from UMass Amherst and is a licensed and Board Certified (ABPP/Counseling) psychologist. She also earned the MFA in Creative Writing from Emerson College, Boston.
7:00 p.m.
Escape from Luanda:
Directed by Phil Grabsky,
72 mins.
In Luanda, one of the world's poorest and most dangerous places, three students from Angola's only music school work towards their end-of-year concert. The Music School is Angola's first and only school of its kind. It houses some 80 students, most of them desperately poor. Many face disapproval and outright rejection from their families who can't see a future in music. This film asks if, despite the ravages of 27 years of civil war, musical passion can overcome terrible hardships. The three characters are: Joana, 23. Her ambition is to be Angola's first female rock drummer. Her husband left her because of the school – and took her two children with him. She struggles to stay at school while wanting to reclaim her children. Domingas, 42. Mother of five, her husband also left her when she started the school. She had been a money-changer on the dangerous streets of Luanda – and was so depressed she considered suicide. The school "saved her life". The oldest student at the school, she is determined to see it through. Alfredo, 21. He is considered the bright hope of the school – perhaps the most likely to succeed. He has had to face down a disapproving father who thought a career in music a ridiculous idea in post-war Angola. Now he faces new obstacles in achieving his aim of becoming Angola's first-ever classical pianist.
Mon Apr 27 2009
Location: MNS*200
5:00 p.m.
The Last Word:
Directed by Jesse Quackenbush
90 mins.
The inevitable story of failure every American has anticipated but hoped would never have to be told. This documentary takes the 'Innocent Man on Texas Death Row' tale to a dark corner feared by all - - proving that an innocent man has been executed by the State. A clash between good and evil strikes up on the High Plains of Texas, when Johnny Frank Garrett, a 17 year old retarded boy is arrested, convicted and ultimately executed for the Halloween night rape, mutilation and murder of Sister Tadea Benz. The 76 year old nun was attacked while she slept in her room at the St. Francis Convent in Amarillo, Texas. Garrett claimed his innocence from the time of his arrest until his dying breath. Sixteen years after Garrett's execution new evidence rose up from the cold case grave of the Amarillo Police Department proving they executed the wrong man! In Garrett's final statement he professed his innocence one last time but did so in a voice driven by hate and vengeance. In his chilling conclusion Garrett promised those responsible for his murder that someday he would have the last word and they would pay for what they had done. For or against the death penalty, The Last Word compels viewers to feel not only the collective pain our societal conscience suffers for executing the innocent but also the individual fear of not knowing what margins of error our judges, jurors and executioners will find acceptable tomorrow.
7:00 p.m.
A First Look Premiere Presentation of the Rhode Island International Film Festival
Transcending: The Wat Misaka Story:
Directed by Bruce Alan Johnson and Christine Toy Johnson
86 mins.
TRANSCENDING The Wat Misaka Story is a documentary film about Wat Misaka, the first person of color to be drafted into what is now the NBA. A Nissei who was born, raised and is still living in Salt Lake City Utah, he was the very first draft pick of the New York Knicks, in 1947. Overcoming the national political climate during World War II, Wat was a star player for the University of Utah 1944 and 1947 championship teams, taking 2 years off in between to serve in the U.S. Army. His perseverance and loyalty to his teammates, other Nissei friends (including those interned at Topaz) and his family, are a testament to the unflappable Japanese American spirit. This film includes in depth interviews with Wat and his family, teammates from his championship teams (including Arnie Ferrin, Herb Wilkinson, Fred Lewis and Glynn Peterson), sports authorities, and many who continue to look up to him as both a role model and personal hero. The film also has video clips from his 1944 and 1947 college games, rare footage from a visit to the Topaz Internment Camp, and countless photos of his triumphant career. Co-directed by award-winning filmmakers Bruce Johnson and Christine Toy Johnson, this project was awarded two consecutive grants from the California Civil Liberties Public Education Program.
The Directors will be in attendance.
8:30 p.m.
Accelerating America
Directed by Timothy Hotchner
90 mins.
Education has traditionally been the first step towards fulfilling the American dream and escaping a life of poverty. But in the United States today, one-third of all students who enter high school do not graduate. ACCELERATING AMERICA follows a group of inner-city students fighting for their last chance to realize this dream from Providence, RI. At the center of the film is a revolutionary school, UCAP, founded by inspiring principal Robert DeBlois. Despite his own physical limitations as a quadriplegic, he tirelessly devotes himself to saving his 130 students. His school, the only one of its kind, offers failing middle school kids confronted with poverty, drugs, gangs and jail a chance to catch-up to their peers by completing two grades in one year. Director Timothy Hotchner spends a year following Mr. DeBlois, his staff and three students, America, Yazmine and Jason, as they attempt to overcome their chaotic home lives and troubled pasts. Of the three, only two of the kids make it. With its intimate look at the complex lives of inner-city youth and their fearless principal, ACCELERATING AMERICA is a highly engaging story of survival and redemption despite the odds.
Winner Grand Prize Best Documentary Film, Rhode Island International Film Festival 2008.
Screening Location: CAS*157
7:30 p.m.
A First Look Premiere Presentation of the Rhode Island International Film Festival
58 Harrison Lane
Directed by Sprague Theobald, 2008
38 mins.
"58 Harrison Lane" is a story about The Woodhall School in Connecticut,
a small secondary school for boys who have not experienced success in traditional educational settings. Most often, they have struggled because of learning differences such as ADD, ADHD, PDDNOS, Aspergers, Tourettes and Dyslexia. In many cases, this school is their last hope. The majority of the boys end up at Woodhall only after their families, previous mainstream schools, and often rehabs, have simply given up on trying to work with them. The students are a diverse group from around the world with a similar profile in common: a long history of difficulty in school, low self-esteem and no sense of hope. Individual academics are a cornerstone in Woodhall's great success story. With classes of three to four students, teachers are able to work one-on-one to meet the student's strengths and weaknesses. Woodhall has an astounding record of getting boys that society once called "lost" or "hopeless" back on their feet and into college. Each and every young man brings a tragic history of failure with him to the school and the "miracle" behind Woodhall is that they leave the school with wisdom, self-esteem and hope. These qualities are achieved by means of three very simple acts: self-reflection, accountability and responsibility. The students development these skills through working with their peer groups, with the guiding hand of Woodhall's trained faculty and staff.
About the Director: Sprague Theobald of Hole In The Wall Productions lives and works out of Newport, RI . His production resumé is wide and varied. For several years, he worked for an NBC affiliate both in front of and behind the camera producing segments and news stories of regional interest, while working on his independent productions. Recently, he has been concentrating his efforts on more detailed story telling, and "58 Harrison Lane" is Hole In The Wall's most recent project. Sprague's efforts haven't gone unnoticed in that he's received both national and international recognition for his writing, producing, cinematography and editing. Of his many awards and notices, he's the most proud of his Emmy award for "The 26th Defense; The End of An Era". Currently, Sprague and Hole In The Wall are in production on "The Pearl Farmers of Fumba" and in pre-production for "Arctic Grail; The Northwest Passage."Sprague is now in production for "Arctic Grail..." and will be leaving on my boat this June 15th for five months into and through the Northwest Passage, Hopefully arriving in Seattle late November: www.bravingit.com
The Director will be in attendance for a Q&A
Tue Apr 28 2009
Screening Location: CAS*162:
4:30 p.m.
A First Look Premiere Presentation of the Rhode Island International Film Festival
Art & Copy
Directed by Doug Pray
86 mins.
ART & COPY is about advertising and creativity, and its profound effects on modern culture. Like Dorothy pulling the curtain back on the Wizard of Oz himself, the film intimately reveals the relatively unknown personalities and stories of the most influential advertising creatives of our age: Lee Clow, George Lois, Mary Wells Lawrence, Hal Riney, Dan Wieden and David Kennedy, Phyllis K. Robinson, Jeff Goodby and Rich Silverstein, plus others, who have shaped our daily lives with their ideas for selling us cars, clothes, computers and presidential campaigns. Directed by Doug Pray ("Surfwise," "Scratch") the film interweaves stunning cinematography of TV satellites being launched and billboards being erected with some of the greatest ad campaigns of all time, resulting in an inspiring synthesis of art, commerce and human emotion.
6:00 p.m.
THE MAKING OF A DOCUMENTARY FILM: FROM LOCAL TO GLOBAL (Roundtable)
From African refugees to a clinic that treated tuberculosis; from the media in Palestine to the impact of an LGN refinery located at a port in the Narragansett Bay; documentary filmmakers have told us stories about ourselves and the world in which we live. Just what makes up a documentary film? What inspires its creation? Who are the people behind the camera? This panel investigates the art and craft of documentary filmmaking from the perspective of successful regional artists.
• David Bettencourt is a Rhode Island-born filmmaker and adjunct professor at the University of Rhode Island. He earned a Master of Fine Arts degree from Boston University's graduate film program in 2001 and has since produced and directed more than a dozen short films and videos. David's first feature film, the award-winning documentary "You Must Be This Tall: The Story of Rocky Point Park," garnered five stars from the Providence Journal this past September. His second feature documentary, "On the Lake: Life and Love in a Distant Place," is currently airing on PBS stations across the country.
• G. Wayne Miller, Writer, Producer. is a 1976 graduate of Harvard College and has been a staff writer for more than 27 years at The Providence (R.I.) Journal. He has won many awards in journalism; along with other writers at The Journal, he was a finalist for the 2004 Pulitzer Prize in Community Service for coverage of The Station nightclub fire that killed 100 people and injured more than 200 in February 2003. Miller is the author of a novel and six critically acclaimed works of narrative non-fiction, including Toy Wars, Men and Speed, King of Hearts, Coming of Age, The Work of Human Hands, and The Xeno Chronicles, a two-year chronicle of the transplantation work of Dr. David H. Sachs. He and David Bettencourt formed a creative partnership founding Eagle Peak Media, specializing in movie-making, Internet content and distribution, and the printed word: mainly books, short stories and essays.
• John Lavall started Devlo Media, a film and video production company in 1997 with a goal of producing original and honest portrait films in a documentary-style. Whether that film is a documentary, an educational film, a corporate profile or a public service announcement our main focus is to present a straightforward visual representation of that particular journey.
• Joseph Sousa is an Emmy-nominated producer, writer, and director with four years experience working in public and commercial television. He has produced programming that has aired on PBS, ABC, NBC, Spike TV, and Portuguese satellite network RTP International. Sousa is currently segment producer on Conversations with Carlos Watson, a cutting edge new talk show with former CNN commentator Carlos Watson. Sousa's most recent documentary film, Festa, is a 30-minute independently produced film focusing on the Portuguese immigrant community of New Bedford, Massachusetts. Festa premiered domestically on PBS and internationally on RTP and has been nominated for a 2007 New England Regional Emmy.
Films And Excerpts To Be Screened:
Home Across Lands
Directed by John Lavall
HOME ACROSS LANDS chronicles the journey of these newly arrived Kunama as they strive to become self-reliant, invested participants in their new home. Guiding their transition is the resettlement agency, International Institute of Rhode Island that connects them to the resources they need as they work to establish a new community and a better life for their families.
Live from Bethlehem
Directed by Joseph C. Sousa
Live From Bethlehem chronicles the struggles, failures and triumphs of the Ma'an
News Network, the only major independent news source in the Palestinian Territories.
Following the lives of the station's reporters, producers and photographers, this
documentary provides an in-depth, balanced look into the challenges of making news
in one of the world's most combative regions. A highly observational film, Live From
Bethlehem focuses more on people than politics while still engaging with questions of
gender equality and freedom of expression in the evolving Palestinian mediascape.
On the LAKE: Life and Love In a Distant Place
Directed by David Bettencourt
A century ago, tuberculosis was the number-one killer in America. Today, it's the world's second most deadly infectious disease, after HIV/AIDS. And now, acclaimed filmmakers David Bettencourt and G. Wayne Miller bring this story to life in a one-hour documentary featuring never-before-seen images and interviews. This is a medical story, a chronicle of loss and despair -- but also an emotionally powerful true-life tale of friendship and love in tragic circumstances, a triumph of the human spirit for those who survived.
8:00 p.m.
EASY RIDER, RAGING BULLS: How the Sex, Drugs and Rock 'N' Roll Generation Saved Hollywood
Directed by Kenneth Bowser
119 mins.
Based upon Peter Biskind's book of the same name, this BBC-produced documentary traces the rise of a generation of Hollywood filmmakers who briefly changed the face of movies with a more personal approach that pushed the boundaries of what was acceptable on-screen. Influential directors who appear include Arthur Penn ("Bonnie and Clyde"), Dennis Hopper ("Easy Rider"), Francis Ford Coppola ("The Godfather"), John Schlesinger ("Midnight Cowboy"), Bob Rafelson ("Five Easy Pieces") Martin Scorsese ("Taxi Driver"), Peter Bogdanovich ("The Last Picture Show"), and Jonathan Demme ("Crazy Mama"). Narrated by William H. Macy, the documentary features vintage clips of Coppola, Scorsese, Beatty, George Lucas, Sam Peckinpah, Roman Polanski, Robert Altman, and Pauline Kael. It also includes original interview material with Penn; Roger Corman; Bogdanovich; Hopper; David Picker; writer/directors John Milius and Paul Schrader; actresses Karen Black, Cybill Shepherd, Margot Kidder, and Jennifer Salt; actors Peter Fonda, Kris Kristofferson, and Richard Dreyfuss; producers Jerome Hellman, Michael Phillips, and Jonathan Taplin; editor Dede Allen; production designer Polly Platt; writers David Newman, Joan Tewksbury, Gloria Katz, and Willard Huyck; cinematographers Laszlo Kovacs and Vilmos Zsigmond; agent Mike Medavoy; and former production executive Peter Bart. Among the films discussed are "Rosemary's Baby," "The Wild Bunch," "Mean Streets," "American Graffiti," "The Rain People," "Midnight Cowboy," "M*A*S*H," "McCabe and Mrs. Miller," "The Last Picture Show," "Shampoo," and "Taxi Driver."
This program will be hosted by visiting guest professor, Ron Tippe.
For more information about films, dates, and venues
for the Roving Eye Film Festival™,
please call 401-861-4445, email firstname.lastname@example.com
See last year's 2008 Festival Schedule, click here.
This program is free to the general public. Seating is on a first-come, first-served basis.
From Newport: Take 114N over the Mount Hope Bridge and take the first right off the bridge onto Old Ferry Road. Take the first right into the parking lot.


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NEW YORK -- Looking at photos of Iraqi children maimed by the war makes the conflict unforgettable. Reflecting on the causes that led to that war makes it unforgivable. Slowly but steadily new information is coming out on the effects of the war on children, and how it has affected not only their health but also their quality of life and prospects for the future.
One child dies every five minutes because of the war, and many more are left with severe injuries. Of the estimated 4 million Iraqis who have been displaced in Iraq or left the country, 1.5 million are children. For the most part, they don't have access to basic health care, education, shelter or water and sanitation. They carry on their shoulders the tragic consequences of an uncalled for war.
"Sick or injured children, who could otherwise be treated by simple means, are left to die in the hundreds because they don't have access to basic medicines or other resources. Children who have lost hands, feet and limb are left without prostheses. Children with grave psychological distress are left untreated." That is the assessment of 100 British and Iraqi doctors.
Never mind that according to United Nations Security Council Resolution 1483, the U.S. and Great Britain are recognized as Iraq's occupation powers and as such are bound by The Hague and Geneva Conventions that demand that occupying powers are responsible not only for maintaining order but also for responding to the medical needs of the population. Tragedies like that don't have parents.
In the meantime, malnutrition levels among children continue to increase, and they are now more than double what they were before the U.S.-led invasion. Iraq malnutrition rates are now on a par with Burundi, a central African country torn by a brutal civil war, and higher than Uganda and Haiti. The number of Iraqi children who are born underweight or suffer from malnutrition continues to rise, and is now higher than before the invasion, according to a report by OXFAM and 80 other aid agencies.
Almost a third of the population -- 8 million people -- needs emergency aid, and more than 4 million Iraqis depend on food assistance. The collapse of basic services affects the whole population. For example, 70 percent of Iraqis lack access to adequate water supplies and 80 percent lack effective sanitation, both conditions breeding grounds for a parallel increase in intestinal and respiratory infections that predominantly affect children.
"Children are dying every day because of lack of essential medical support. The bad sewage system and lack of purified water, particularly in suburbs, has been a serious problem which might take years to solve," warns Ahmed Obeid, an official at the Ministry of Health.
The media landscape is changing fast
Our news team is changing too as we work hard to bring you the news that matters most.
Change is coming. And we've got it covered.
At the same time, a variety of environmentally related chronic diseases are emerging among children because of their exposure to environmental contaminants. Many cases of congenital malformations and cancer among children are believed to be the consequence of exposure to chemicals and radioactive materials that have significantly increased during the war. And this without counting what is euphemistically called "collateral damage," the hundreds of children killed by roadside bombs, during suicide attacks or attacks by the occupation forces.
I look again at the face of an anonymous child, a photograph by Dan Chung for The Guardian newspaper in Britain, his features burned almost beyond recognition, whose sad eyes seem to be telling the viewer, "What did I do to deserve this?" And I cannot but think how miserable those adults are who destroy children's lives with total impunity.
Despite all evidence, some political leaders continue to insist that the situation is improving, as though the brutal TV images of the war did not exist, as if they were a fantasy invented by evil spirits. The chasm between the people's view of reality and that of their leaders has rarely been greater.
The editor of The Lancet, Dr. Richard Horton, stated recently: "Our collective failure has been to take our political leaders at their word." Sen. John McCain, speaking to cadets at the Virginia Military Institute, affirmed that to continue the war is, indeed, to pursue the right road.
And, added McCain, one of the contenders for the Republican presidential nomination, "it is necessary and just." The above-mentioned facts should prove to him that it is neither.
César Chelala, a co-winner of an Overseas Press Club of America award, is the foreign correspondent for the Middle East Times International (Australia).
© 2007 The Seattle Post-Intelligencer


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Spine Rehabilitation
More than 80% of adults experience some form of back pain that will limit their ability to perform daily activities at home, at work or at leisure. In fact, back pain is one of the most common reasons for missed work and accounts for $$ in lost wages and productivity. Back pain can be caused by injury, trauma or degeneration as a person ages. It can be dull or sharp, intermittent or constant. But for those who suffer from back pain, it can be a debilitating, frustrating and difficult condition to deal with.
Kessler's Spine Rehabilitation Program focuses on providing manual therapy, therapeutic exercise, postural correction exercises and functional training to help alleviate pain and restore function. Patient education, a key component of this program, emphasizes proper posture and body mechanics to prevent re-injury.
Our Approach
At Kessler, our interdisciplinary team of rehabilitation specialists focuses on individual needs and rehabilitation goals. We understand that each patient brings a unique set of symptoms. Pain may occur when sitting, standing, walking and/or going about daily chores. Pain may be in the lower back and/or or extend into the legs. Some may also experience numbness or tingling in the leg or foot. And whether your pain is short-term or more chronic in nature, we will work closely with you and tailor your treatment accordingly.
Patients will receive a thorough evaluation from a Kessler physiatrist, a physician who specializes in physical medicine and rehabilitation. Our orthopedic physical therapists work closely with our physicians to develop and implement an individualized physical therapy treatment program. Treatment may include:
- McKenzie-based treatment for neck and back pain
- Lumbar stabilization/core strengthening
- Stretching and flexibility exercises
- Progressive lower extremity strengthening exercises
- Manual Therapy and mobilization techniques
- Muscle energy techniques
- Therapeutic modalities
- Pilates exercises
- Postural exercises and training
- Body mechanics and functional training
In addition, your physician may prescribe medications or perform fluoroscopically-guided selective spinal injections that can help to diagnose and treat the spinal pain generator. Other services available include functional capacity evaluations/work hardening and pain management, including both diagnostic and therapeutic spinal injection procedures.
Technology & Research
At Kessler, you'll find both the proven therapies and latest technologies to help address your pain. In addition, the physicians and therapists of our rehabilitation team are actively involved in a wide range of research studies that may offer new avenues of treatment for individuals with low back pain.
Studies have shown that a highly integrated program of care, like that offered at Kessler Institute for Rehabilitation, is more likely to resolve an individuals symptoms than if treatment is administered in isolation.