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The familial nature of the process may not be appreciated because genetic penetrance is not complete until after 60 years of age On MRI scans, clinically unaffected family members may show substantial changes in the white matter well before strokes or dementia arises In some cases, particularly in Japan, early alopecia and lumbar spondylosis have been associated with CADASIL The MRI and CT appearance of multiple con uent white matter lesions of various sizes, many quite small and concentrated around the basal ganglia and periventricular areas, is similar to that in Binswanger disease When these are asymmetrical and periventricular, they are dif cult to distinguish from the lesions of multiple sclerosis In the autopsy cases studied by Jung and colleagues, numerous partially cavitated infarctions were found in the white matter and basal ganglia.

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These are mostly behind-the-scenes people in instruction, nance and business, personnel, public relations, and other areas who keep the schools open, operating, and, ideally, advancing Some, such as supervisors of science or home economics, oversee the content and the methods of schooling Others manage such responsibilities as the school district s payroll, purchasing, budgeting, and accounting; its hiring, promotion, evaluation, and other personnel matters; its relations with the state and federal governments; and its relations with the local community Still others focus on services and logistics, like plant maintenance, transportation, and food 5 examines the roles of the professionals who address particular aspects of young people s growth and development, such as reading skills, expressiveness, appreciation of the arts and humanities, social and psychological development, mental health, physical functioning, general welfare, educational future, and speech and hearing abilities.

In the regions of these infarctions were small vessels, 100 to 200 mm diameter, in which the media contained basophilic granular deposits with degeneration of the smooth muscle bers Attribution of the white matter degeneration to these vascular changes presents the same problems as in Binswanger disease, particularly in view of patency of most of the many small vessels in the material Again, the relation of the vascular changes to lesions in the brain has not been studied in serial sections Nevertheless, CADASIL is probably the main cause of sporadic instances of what otherwise passes for Binswanger disease but without the obligate hypertension of the latter Also, migraine headaches are not a component of Binswanger disease..

toimmune diseases Elmquist and Lambert, from a series of studies of excised muscle, deduced that there is a defect in the release of ACh quanta from the presynaptic nerve terminals, akin to the effects of botulinum toxin, magnesium excess, and neomycin (see further on) The presynaptic vesicles themselves appear to be normal in electron micrographs Also in contrast to myasthenia gravis, the extent of the receptor surface in this syndrome is actually increased (A G Engel) The physiologic mechanism in Lambert-Eaton myasthenic syndrome is not fully delineated; however, a fundamental defect is a loss of voltage-sensitive calcium channels on the presynaptic motor nerve terminal The calcium channels become cross-linked and aggregated by IgG autoantibodies, ultimately reducing the number of functioning channels (Fukunaga et al).

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Examples of this type of personnel are art, music, and special education teachers; school counselors and psychologists; librarians and media specialists; nurses; occupational and physical therapists; and social workers These specialists may work with students directly, but they also may help students indirectly, by consulting with teachers, principals, parents, and other school personnel Careers in two- and four-year colleges and universities are discussed in 6 In all three types of institutions, the roles of teacher and administrator are prominent At the four-year college and university level, the roles of teacher-researcher and researcher emerge These roles are not wholly absent in elementary and secondary schools or two-year colleges; they are simply rarities in those contexts Roles analogous to some of the.

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In other words there are antibodies against a speci c component of the presynaptic membrane that have the effect of reducing the presynaptic release of ACh, virtually the opposite of myasthenia gravis A serologic test for these antibodies is available and is performed to con rm the diagnosis Even in patients without detectable antibodies against voltage-gated calcium channels, passive transfer indicates the presence of a circulating factor with similar activity Muscle biopsy is normal or shows only the same slight, nonspeci c changes as in myasthenia gravis The thymus is, of course, normal Recognition of the Lambert-Eaton syndrome should lead to a search for an occult tumor, particularly of the lung A PET scan of the body may be useful in this regard, although CT of the lungs is usually adequate If found, it should of course be treated; this alone may result in improvement in the neurologic syndrome.

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