The patient is a 57-year old female, right-handed, who presented with one-week history of cough and progressive shortness of breath few hours before arrival to the emergency room (ER). In the ER, her blood pressure was 130/100mmHg. She was tachycardic at 140 beats per minute with new-onset atrial fibrillation. She was tachypneic with a respiratory rate of 28cycles per minute and with an oxygen saturation of only 82% at room air. She was afebrile at 36.5 degrees Celsius. She was agitated and inconsistently followed commands. Arterial blood gases revealed severe metabolic acidosis with a pH of 6.898, carbon dioxide of 20.5, oxygen of 261.6, bicarbonate of 4, and oxygen saturation 99.4% with a high anion gap of 20. The patient was intubated, started on amiodarone and bicarbonate drip, and was sedated with dexmedetomidine. The initial assessment at the ER level was thyroid storm. However, the laboratory findings were consistent with only subclinical hyperthyroidism. A red flag noted in the patient's history was the chronic intake of multiple supplements mostly consisting of herbal extracts. Intoxication with any of these drugs was then considered. To the Editor: Fluoxetine, the selective serotonin reuptake inhibitor first introduced for clinical use in the United States in 1988, was discovered in the early 1970s. The long half-life of the drug and its metabolite contribute to a 4-week period to reach steady-state concentrations. As with all available antidepressants, the effects of fluoxetine are seen in the first 1-3 weeks, but the clinician should wait until the patient has been taking the drug for 4-6 weeks before evaluating its antidepressant activity. Fluoxetine is available in 10-mg and 20-mg capsules and as a liquid (20 mg/5 ml) (1– 5). Her er en parasol til altan velegnet, da den netop er designet til at stå på en altan. Du kan få en altanparasol i forskellige varianter – både med fod til at stå på altangulvet og i en udgave, hvor parasollen sættes fast på altangelænderet. Du kan også få en altanparasol formet som en trekant, der skal placeres op mod muren, så den ikke skygger på hele altanen, men kun under den. Vælger du en parasol med tilt, kan du også selv styre, hvor skyggen rammer på din altan. Få en parasol der kan tåle det danske sommervejr Selvom parasollerne er både robuste og vejrbestandige, er det alligevel en god idé at tage sine forholdsregler. Hvis det blæser kraftigt, er det eksempelvis ikke en god idé at slå parasollen op. Så er det bedre at søge læ på anden vis. Hvis parasollen har fået et ordentligt regnskyl, mens den har været slået sammen, anbefaler vi, at du slår parasollen ud, så den kan tørre, når det igen er blevet tørvejr. På den måde minimerer du risikoen for, at parasollen får skjolder eller bliver jordslået. Ligeledes er det en god idé at sikre sig, at parasollen er nogenlunde tør, inden den slås sammen. D. budgeted cash disbursements for operating expenses (other than cost of goods sold) during the month of April is

Cranial MRI. Axial DWI (A) and FLAIR (B, C) images during admission show restricted diffusion in the intraorbital segment of both optic nerves (arrows) and confluent hyperintense signal in the central pons. Follow-up DWI (D) and FLAIR (E, F) images after two months show resolution of the restricted diffusion in the optic nerves and less confluent signal abnormality in the pons with interval demonstration of hyperintense foci in the bilateral cerebral subcortical white matter. T1 - Finding a solution to the problem of pain: Conceptual formulation and the development of the Pain Solutions Questionnaire (PaSol)

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Optic disc haemorrhages at baseline as a risk factor for poor outcome in the Idiopathic Intracranial Hypertension Treatment Trial

Additionally in our patient, there was another finding of hyperintense signal involving the central pons. Pathology in the pons was reported in a case where it was demonstrated that foci of T2 hyperintensity in the bilateral pontine tegmentum was one of the imaging findings in severe methanol intoxication [ 10]. Further, in a case series of 17 patients who died of methanol intoxication, pontine hemorrhage was documented in 2 cases on autopsy [ 11]. The susceptibility of the pons to methanol is worth investigating, as its vulnerability with the optic nerve may not be a coincidence. In the follow-up imaging of our patient, the less confluent appearance of central pontine hyperintensity coincided with the resolution of diffusion restriction of both optic nerves. The interval appearance of T2 hyperintensity in the bilateral subcortical cerebral hemispheres on repeat MRI is consistent with previously reported imaging findings in the chronic stage of methanol toxicity [ 5]. These subcortical changes can be consequences of the toxic metabolites of methanol [ 10]. These are not specific for methanol toxicity but should always be considered in association with other MRI findings [ 5]. Det smarte ved en hængeparasol er, at den kan placeres et lille stykke væk fra havebordet eller loungemøblerne og alligevel give rigtig god skygge over hele området. Dermed undgår du at have en parasol akavet placeret mellem to af de personer, der sidder rundt om havebordet. Derudover er det nemt at justere på vinklen på selve parasollen, så du let kan tilpasse parasollen i takt med at solen bevæger sig over himlen. Når du vælger en hængeparasol, er det vigtigt, at du kombinerer den med en god tung parasolfod, så du ikke risikerer at parasollen vælter. Altan parasol til byboerne Mr. A responded to sublingually administered fluoxe­tine, and his depressive symptoms resolved within 4 weeks; he had improvements in mood, affect, and the activities of daily living as well as social interactions. Four weeks after the treatment was initiated, his plasma fluoxetine and norfluoxetine levels were measured and found to be in the lower end of the therapeutic range (fluoxetine=47 ng/ml and norfluoxetine=52 ng/ml). Mr. A was maintained with sublingual fluoxetine treatment for 9 weeks, but he was switched to oral administration of the medication as a result of improvement in his medical condition. Mr. A remained psychiatrically stable during the rest of his hospital stay, and he was eventually discharged while receiving oral fluoxetine treatment with outpatient instructions.

Methanol is a clear and colorless chemical that can usually be seen in household cleaning products, antifreeze, varnishes, and fuel [ 1, 2]. Methanol intoxication is a significant cause of neurologic morbidity and mortality if it is unrecognized and left untreated. Acute methanol toxicity may present with mild symptoms such as headache, altered mentation, blurring of vision, abdominal pain, and vomiting. However, in more severe cases, patients may develop blindness, severe metabolic acidosis, and coma [ 1]. Intake of adulterated alcoholic beverages is the primary cause of poisoning outbreaks of this substance [ 2]. Although ingestion is the most commonly implicated route of toxicity, methanol can be absorbed by inhalation and dermal exposure and these serve as uncommon routes of acute and chronic intoxication. Studies on chronic exposure to methanol particularly through dermal and inhalational routes are all the more rare and seen only on limited case reports. Chronic methanol toxicity can have neurologic sequelae such as vision loss that can potentially be irreversible. Vision loss is brought about by the affinity of the toxic metabolite of methanol, formic acid, to the optic pathway [ 1]. As such, methanol toxicity is an important differential diagnosis in unexplained vision loss. On cranial MR imaging, the most characteristic imaging feature of methanol poisoning is bilateral symmetric basal ganglia necrosis [ [3], [4], [5], [6], [7] ] . Hvis du gerne vil passe ekstra godt på dine parasol, kan du købe et smart parasolovertræk, der beskytter dugen mod regn og sol, når den ikke er i brug. Køb parasoller på tilbud hos ILVA