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An overview of systematic reviews of the effectiveness of opiate maintenance therapies: Available evidence to inform clinical practice and research best vytorin 20 mg cholesterol levels below normal. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence buy vytorin 30 mg amex cholesterol under 100. Rationale for screening and brief intervention for alcohol problems in primary care vytorin 30 mg free shipping cholesterol medication pfizer. American Academy of Pediatrics, Committee on Substance Abuse and Committee on Children With Disabilities. Standards for accreditation of baccalaureate and graduate degree nursing programs. The need for addiction medicine physicians and for addiction medicine residency training programs: A report of The American Board of Addiction Medicine Foundation. Content outline: Pediatric emergency medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Adolescent medicine subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Child abuse pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Neonatal-perinatal medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Developmental-behavioral pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Subspecialty certification examination in forensic psychiatry: 2009 content outline. Subspecialty certification examination in psychosomatic medicine: 2009 content outline. Subspecialty certification examination in geriatric psychiatry: 2010 content outline. Written certification examination in child and adolescent psychiatry (Part 1): 2010 content outline. Report to the Board of Trustees: Background on the organization "Physicians and Lawyers for National Policy": Resolution 425, A-06. Diagnostic and statistical manual of mental disorders, fourth edition: Primary care version. Practice guidelines for the treatment of patients with substance use disorders (2nd ed. Certificate of proficiency in the treatment of alcohol and other psychoactive substance use disorders. Public policy statement on how to identify a physician recognized for expertness in the diagnosis and treatment of addiction and substance-related health conditions. Desperately driven and no brakes: Developmental stress exposure and subsequent risk for substance abuse. The origins of the Minnesota model of addiction treatment: A first person account. Public beliefs about and attitudes towards people with mental illness: A review of population studies. Early intervention for substance abuse among youth and young adults with mental health conditions: An exploration of community mental health practices. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence. Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: Results of a placebo- controlled trial. Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Barriers to enrollment in drug abuse treatment and suggestions for reducing them: Opinions of drug injecting street outreach clients and other system stakeholders. Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Acute cannabis consumption and motor vehicle collision risk: Systematic review of observational studies and meta-analysis. Association of Marital and Family Therapy Regulatory Boards, & Professional Examination Service. Varenicline versus transdermal nicotine patch for smoking cessation: Results from a randomised open-label trial. Adolescent smoking and depression: Evidence for self-medication and peer smoking mediation. Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance. Editorial: Standardizing terminology in addiction science: To achieve the impossible dream. Screening and interventions for alcohol and drug problems in medical settings: What works? Brief interventions for at-risk drinking: Patient outcomes and cost-effectiveness in managed care organizations. Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. Brief cognitive behavioural interventions for regular amphetamine users: A step in the right direction. Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. A 6-month controlled naltrexone study: Combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence. The cost-effectiveness of a smoking cessation program for out-patients in treatment for depression. The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States. Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Increased attributable risk related to a functional mu-opioid receptor gene polymorphism in association with alcohol dependence in central Sweden. Drug abuse treatment entry and engagement: Report of a meeting on treatment readiness. Medicaid reforms in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Outpatient interventions for adolescent substance abuse: A quality of evidence review. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness.

Contamination of water by huge 3173 quantities of aluminium may have led to some brain damage cheap 20 mg vytorin with visa cholesterol definition science. Exposure in the workplace (welders generic 20 mg vytorin mastercard vap cholesterol test quest, etc) may lead to tremor buy generic vytorin 30 mg on-line cholesterol ratio nz, impaired balance, reduced recall memory, and slowing of cognition. Cyanocobalmin (B12) deficiency (most often due to pernicious anaemia with antibodies again parietal cells and intrinsic factor) may cause 3174 anaemia, eye problems, spinal cord degeneration , neurasthenia, depression, paranoid psychosis with 3171 May have nodules or skin and knuckle pad thickening. However, some cases of B12 deficiency, especially older subjects, may have normal B12 levels but elevated methylmalonic acid 3176 and homocysteine levels. Always think of B12 deficiency in vegans or in the patient with reduced peripheral vibration sense. Successful treatment is now available with chelating agents such as penicillamine. The commonest psychiatric complications are non- specific affective or behaviour disorders, but schizophreniform or bipolar psychoses can also occur. Menkes’ kinky hair syndrome is a rare sex-linked recessive disorder associated with copper malabsorption. Infants fail to grow, have intellectually disability, brittle hair, anaemia, neutropaenia, and bone lesions. Manganese: Manganese is an essential trace element and is plentiful in the environment. A high manganese level has been associated with psychosis (‘manganese madness’ ) and 3179 Parkinsonism , e. Some cases may walk with their heels in the air and with their elbows flexed (cock-walk). The patient must be removed from sources of contamination although improvement is not guaranteed. This may present in the adult with delirium and seizures, often with associated hypertension. Chronic encephalopathy is characterised by headache, trembling, impaired memory and concentration, poor hearing, and episodic hemianopia and aphasia. Children are particularly badly affected and may develop coma, pareses, papilloedema, meningism, and compression of medullary centres, and those who survive may be brain damaged or blind. Alternatively, the oral chelating agent meso-2,3-dimercaptosuccinic acid may be used. Lead poisoning (plumbism) Sources of lead range from lead toys (common in the author’s childhood), retained bullets (especially in a joint space or a pseudocyst), and illegal whiskey (use of old car radiator) Lethargy Blue line on gum margins (lead sulphide deposition) Lead lines on x-rays of long bones in children Abdominal discomfort or pain, vomiting, constipation 3175 ‘megaloblastic madness’. They may be more sensitive indicators of tissue B12 deficiency than B12 levels themselves. Folic acid and B12 act as co-factors in re-methylation of homocysteine to methionine, deficiency of either vitamin causing increased homocysteine levels. Kim ea (2008) suggest that low B12, low folate and raised homocysteine levels may increase risk for late-life depression. Uptake of fluorodopa is normal in manganese-induced Parkinsonism but reduced in paralysis agitans. Hopes of replacing lithium with rubidium were upset by suggestions of neurotoxicity. Vitamin C converts this to the tetravalent ion, vanadyl (methylene blue has the same effect). Selenium: This is commonly found in skin applications and can cause tremor and loss of appetite if absorbed transcutaneously over a long period of time. Depletion might be a cause of depression and other negative mood states, such as anxiety, confusion and hostility. Well recognised symptoms of zinc deficiency include depression and perverted taste and smell. Low zinc levels are associated with poor nutrition and high phytate levels in bread. Zinc deficiency may also occur in malabsorption states, regional enteritis, hepatic failure, kidney disease, certain drugs (e. High zinc levels have been found in multiple sclerosis and in neural tube defects. Zinc (as acetate or sulphate) is used as a copper depleting agent in Wilson’s disease. Zince supplements given to pregnant poor Bangladeshi women did not confer benefit on their infants’ mental development (Hamadani ea, 2002) although it does seem to reduce mortality in infants from infectious diseases. Electrolytes and acid-base balance disorders Hyponatraemia: symptoms include nausea, vomiting, abdominal pain, anorexia, weakness, dizziness, headache, blurring of vision, sweating, malaise, lassitude, apathy, muscle cramps and twitching, delirium, coma, and hypotension. Patients with psychogenic polydipsia and those with eating disorders who drink water to produce a full feeling are at risk of hyponatraemia. Low sodium (< 125 mmol/L) or a rapid fall in sodium level can lead to agitated delirium whereas more chronic hyponatraemia may be associated with poor attention and falls in older patients. Central pontine myelinolysis is a rare disorder of cerebral white matter and has multiple causes; rapid correction of hyponatraemia (common in beer drinkers, especially when replacing vomited fluids with hypotonic fluids) may be a factor in the aetiology (although not invariably so), the condition presenting a day to a week later. A low sodium diet may be useful in reducing blood pressure in patients with multiple risk factors for the metabolic syndrome. Hypernatraemia: either too much water is lost or too little water is taken in; older people at are highest risk; there can be xerostomia, weight loss, grey complexion, lethargy, confusional state/delirium, and muscular hypertonicity; seizures and central pontine myelinolysis may follow over vigorous rehydration; shrinking of the brain may bleeding from veins; cerebral sinus thrombosis is a known complication; hypernatraemia may occur with anabolic steroid abuse or in diabetes insipidus. Hypokalaemia: this may occur in hepatic cirrhosis, metabolic alkalosis, vomiting, or laxative/diuretic/anabolic steroid abuse; there is reduced intake of potassium, a movement of potassium into cells, or excess potassium loss. Hyperkalaemia: this is chiefly a problem with kidney failure; clinical features include fatigue, muscle weakness (flaccidity in extreme cases), lethargy, confusion and cardiac arrhythmias (bradycardia due to heart block, ventricular fibrillation/asystole). Calcium: High serum calcium (hyperparathyroidism, cancer) causes depression, anxiety, and delirium; low serum calcium (diet low in calcium or vitamin D, hypoparathyroidism, rhabdomyolysis, kidney/liver disease, anticonvulsant drugs, thyroid/parathyroid surgery) can cause cramps, tetany, and seizures. Hypophosphataemia: phosphate may move into cells during management of diabetic ketoacidosis or alcoholism; it is also encountered during refeeding of people who have been starving; clinical features may include anxiety, irritability, delirium, ataxia, slurred speech, breathing irregularities, weakness of extraocular muscles, paralysis, areflexia, myoclonus, and paraesthesiae (in hands and feet). Wernicke’s syndrome or Guillain-Barré syndrome may be mimicked in hypophosphataemia. Any patient who has fluid and other electrolyte imbalance and who unexpectedly develops neurological problems should have magnesium levels checked. Hypomagnesaemia is common and is found in association with alcoholism, medication (e. Severe hypomagnesaemia leads to functional underactivity of the parathyroid glands which responds to magnesium replacement. Other potential manifestations include irritability, depression, vertigo, ataxia, muscular weakness/fasciculation, seizures, myoclonus, choreoathetoid movements, and focal symptoms and signs such as dysphasia and hemiparesis. Endocrinopathies Due to earlier diagnosis, depression and anxiety are the commonest neuropsychiatric phenomena encountered in this group of disorders.

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There is psychic blindness (responds in a similar manner to an orange as to a charging bull - able to see but he is unable to meaningfully discriminate between objects) vytorin 20mg with amex cholesterol in 2 poached eggs. Again buy vytorin 20mg cheap cholesterol particle size chart, parts of the syndrome may occur early in the course of frontotemporal dementia cheap vytorin 30 mg fast delivery cholesterol jones. Diogenes or Plyushkin’s syndrome3168 Diogenes syndrome is named for Diogenes of Sinope,(Wrigley & Cooney, 1992; O’Shea & Falvey, 1997; 3169 Cooney, 1997) a Greek cynic philosopher. Affected persons often refuse help from professionals and they collect all sorts of rubbish (syllogomania). About 50% have a formal psychiatric illness at the time of examination, but far fewer have been admitted to psychiatric care. The death of a close relative may be a precipitating factor in those with no psychiatric illness. Cole ea, 1992) Diogenes syndrome represents a dilemma for psychiatry and for society. Do we let patients live and squalor in case we infringe 3170 human rights (‘rotting with their rights on’)? The stables, unclean and housing many cattle, were cleaned by Heracles (Hercules) who achieved his task in a single day by rerouting rivers. A beggar who admired pverty and decried human achievements, he lived in an Athenian tub and ate onions. The key to diagnosis is the almost simultaneous development of roughly the same symptoms by a number of people inhabiting the same building. Gulf War syndrome (cognitive difficulties, fibromyalgia, depression, anxiety, respiratory problems and chronic fatigue) is not unique to that conflict. Ismail ea (2002) felt that psychiatric disorders did not fully explain self reports of ill health in people with Gulf War syndrome but there is no evidence that it is caused by neurological problems. Examples of the latter include improving ventilation systems and reducing any contaminant exposure. The patient may need counselling, medication, career guidance/change/retirement – or whatever is appropriate, keeping in mind the necessity of non-reinforcement. Humidifier fever is due to contamination of humidifying systems in air conditioners in factories and office blocks with bacteria, thermoactinomyces or amoebae. It may present with the symptoms of extrinsic allergic alveolitis: fever, cough, dyspnoea etc. The head is suddenly and unexpectedly jolted whilst the head moves freely, as when one car hits another from behind. Claims for persistent symptoms make up a large percentage of all personal injury claims. Are these people physically injured, psychologically traumatised, or ‘on the make’? In the Karlsborg ea (1997) series of 39 patients there are 6 cases of whiplash in females for every 4 cases in males. Moderate to severe pain was reported by 27% of whiplash sufferers at 1 year and by slightly more (30%) at 3 years. Accident-associated and post-accident psychosocial variables predicted pain severity at 12 months. Whilst whiplash was especially associated with compensation seeking, the authors suggested that this was explained by ‘the high proportion of innocent victims, the physical symptoms and the ease of legal definition’. This research was based on case notes and self-reports at follow-up, and response rates declined over the follow-up period. Like Cassidy ea (2000), Thomas (2002) emphasises the potential of litigation (as distinct from no fault compensation) to worsen and prolong suffering and reduce functioning. Electrical stimulation of this part of the brain can evoke illusions of elevation, rotation, lightness, flying, and limb shortening or movement. Fibrosis may also occur on the soles of the feet (plantar fibromatosis), knuckle pads, and penis (Peyronie’s disease). Trace elements Trace elements occur in living tissues in extremely small quantities. The association between trace elements and mental illness is circumstantial at present. Reducing the amount of aluminium in the water for dialysis prevents this encephalopathy. Contamination of water by huge 3173 quantities of aluminium may have led to some brain damage. Exposure in the workplace (welders, etc) may lead to tremor, impaired balance, reduced recall memory, and slowing of cognition. Cyanocobalmin (B12) deficiency (most often due to pernicious anaemia with antibodies again parietal cells and intrinsic factor) may cause 3174 anaemia, eye problems, spinal cord degeneration , neurasthenia, depression, paranoid psychosis with 3171 May have nodules or skin and knuckle pad thickening. However, some cases of B12 deficiency, especially older subjects, may have normal B12 levels but elevated methylmalonic acid 3176 and homocysteine levels. Always think of B12 deficiency in vegans or in the patient with reduced peripheral vibration sense. Successful treatment is now available with chelating agents such as penicillamine. The commonest psychiatric complications are non- specific affective or behaviour disorders, but schizophreniform or bipolar psychoses can also occur. Menkes’ kinky hair syndrome is a rare sex-linked recessive disorder associated with copper malabsorption. Infants fail to grow, have intellectually disability, brittle hair, anaemia, neutropaenia, and bone lesions. Manganese: Manganese is an essential trace element and is plentiful in the environment. A high manganese level has been associated with psychosis (‘manganese madness’ ) and 3179 Parkinsonism , e. Some cases may walk with their heels in the air and with their elbows flexed (cock-walk). The patient must be removed from sources of contamination although improvement is not guaranteed. This may present in the adult with delirium and seizures, often with associated hypertension. Chronic encephalopathy is characterised by headache, trembling, impaired memory and concentration, poor hearing, and episodic hemianopia and aphasia. Children are particularly badly affected and may develop coma, pareses, papilloedema, meningism, and compression of medullary centres, and those who survive may be brain damaged or blind. Alternatively, the oral chelating agent meso-2,3-dimercaptosuccinic acid may be used. Lead poisoning (plumbism) Sources of lead range from lead toys (common in the author’s childhood), retained bullets (especially in a joint space or a pseudocyst), and illegal whiskey (use of old car radiator) Lethargy Blue line on gum margins (lead sulphide deposition) Lead lines on x-rays of long bones in children Abdominal discomfort or pain, vomiting, constipation 3175 ‘megaloblastic madness’. They may be more sensitive indicators of tissue B12 deficiency than B12 levels themselves.

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Mechanisms of brain injury Risk factors: hypertension is the most common risk after intracerebral haemorrhage discount 20 mg vytorin mastercard cholesterol in shrimp vs meat. Recommendations neurosurgical intensive care unit is associated with for the management of intracranial haemorrhage – reduced mortality rate after intracerebral hemorrhage vytorin 20mg low cost cholesterol levels ratio. Functional outcome of American Stroke Association Stroke Council; High ischemic and hemorrhagic stroke patients after Blood Pressure Research Council; Quality of Care and inpatient rehabilitation: a matched comparison order vytorin 30 mg amex cholesterol and saturated fat in shrimp. The genetic intracerebral hemorrhage in adults: 2007 update: a architecture of intracerebral hemorrhage. American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of 21. Aspirin and risk of haemorrhage in the Oxfordshire community stroke hemorrhagic stroke: a meta-analysis of randomized 163 project, 2: prognosis. Apolipoprotein E genotype for differential clinical diagnosis of intracranial and cerebral amyloid angiopathy-related hemorrhage. Fazekas F, Kleinert R, Roob G, Kleinert G, Kapeller P, enlargement in spontaneous intracerebral hemorrhage. Relative edema volume subgroup analyses and standards for study design and is a predictor of outcome in patients with hyperacute reporting. Intracerebral hemorrhage: pathophysiology and associated with hypertensive stroke by echo-planar therapy. Magnetic hemorrhage: correlations with coagulation parameters resonance imaging detection of microbleeds before and treatment. Chapter Cerebral venous throm bosis 1 Jobst Rudolf which eventually drain into the cerebral sinuses. Cerebral veins do not possess diagnosis in the pre-angiograph era was usually made valves and therefore allow blood flow in both direc- post-mortem. In contrast, the deep veins that drain traditionally assumed, and that its prognosis is much the basal ganglia and other deep subcortical structures better than is generally accepted, provided that the do not possess the diversity of the superficial venous diagnosis is suspected, the respective neuroimaging network. The basal veins of Rosenthal and the internal examinations are performed in a timely manner, cerebral veins drain into the great cerebral vein of and therapy is initiated early, i. The variety of verse and sigmoid sinuses, finally reaching the vena clinical signs and symptoms renders the diagnosis cava via the jugular veins. Diagnosis is still lum and brainstem is drained from the posterior fossa frequently overlooked or delayed due to the wide by veins reaching the vein of Galen, the petrose or the spectrum of clinical symptoms and the often subacute lateral sinus. Thus, there is no mind in stroke cases that present with a fluctuating possibility of influencing venous blood flow by means course, headache, epileptic seizures or disturbances of of vasoconstriction or vasodilatation. The 165 groups – the superficial and the deep cerebral veins – infectious agents reach the cerebral sinuses ascending Section 3: Diagnostics and syndromes Table 11. Potential causes of and risk factors associated with cerebral venous thrombosis [3, 4, 14]. In venous congestion, disturb- Steroids ances of neuronal functional metabolism are tolerated Cytotoxic drugs (e. Motor symptoms may initially present as a re-opened by endogenous fibrinolysis will result in a monoparesis that gradually develops into a full-blown lowering of venous and capillary pressure. As a rule, extended thrombosis of cortical sinuses will result in symptoms and signs of general- Clinical features ized brain dysfunction (headache and other signs of Abrupt occlusion of a cerebral artery results in the increased intracranial pressure, impairment of the acute manifestation of focal neurological symptoms level of consciousness, generalized seizures), while due to ischemia of the brain tissue perfused by this isolated cortical venous thrombosis will result in focal artery. Eventually, (veins of Rosenthal, great vein of Galen, straight failure of collateral venous drainage will result in the sinus, etc. Most cases of cavernous sinus throm- (> 70%) or the most common (75–90%) symptom bosis are due to ascending infection from the orbita, of cortical venous thrombosis. Headache, as well as the paranasal sinuses or other structures of the nausea, papilledema, visual loss or sixth nerve palsy, is viscerocranium and are accompanied by signs of local 167 due to increased intracranial pressure. Aseptic thrombosis of the cavernous sinus leading to painful uni- or bilateral ophthalmoplegia has to be differentiated from the Tolosa-Hunt syndrome. Chapter 11: Cerebral venous thrombosis intravenous application of iodinated contrast media, brain edema. The main indication is to rule out the dura mater of the sinuses will show a distinct other conditions. Magnetic resonance imaging (T1-weighted images after intravenous injection of paramagnetic contrast media) in a patient 169 with thrombosis of the superior sagittal, straight and right transverse sinus. During the second suspicion cannot be corroborated by other neuroima- week after clot formation, red blood cells are des- ging techniques. After 2 weeks, the thrombus becomes hypointense on T1- and hyperintense on T2-weighted images, and recanalization may occur with the re-appearance Other diagnostic findings of flow void signaling. They allow direct imaging of the thrombus; the Most routine laboratory findings in the acute signal intensity depends on clot age. However, elevated D-dimers just indicate active structures after intra-arterial injection of iodinated thrombosis (anywhere in the body), and normal contrast media (Figure 11. Digital subtraction angiography in a patient with isolated thrombosis of the right inferior anastomotic vein of Labbe (right), in contrast to physiological imaging of the cerebral vein findings of the contralateral hemisphere (left). Impaired consciousness and cerebral hemorrhage on Anticardiolipin IgG and IgM antibodies admission are associated with a poor outcome. The first study was ter- The advantage of dose-adjusted intravenous heparin minated after inclusion of 10 patients in each group, therapy, particularly in critical ill patients, may be the as an interim analysis documented a beneficial effect fact that the activated partial thromboplastin time of heparin treatment on morbidity and mortality. Both studies were tory effect of heparin may be immediately antagonized criticized for inadequately small sample size [8]or with protamin, while such an antidote is not available baseline imbalance favoring the placebo group [6]. Immediate anticoagulation is recommended, even A meta-analysis of the studies on immediate anti- in the presence of hemorrhagic venous infarcts. Chapter 11: Cerebral venous thrombosis According to current guidelines [1], oral anti- complications. Acetylsalicylic Thrombolysis acid should be avoided, as the patients’ bleeding risk may be increased due to the concomitant anticoagu- Despite immediate anticoagulation, some patients lation treatment. Severe headache may require treat- show a distinct deterioration of their clinical condi- ment with opioids, but dose titration should be tion, and this risk seems to be especially high in performed cautiously in order to avoid over-sedation. A potential publication bias in the For the treatment of headaches, paracetamol current published work has been assumed, with pos- should be preferred over acetylsalicylic acid 173 sible under-reporting of cases with poor outcome and because of the patients’ bleeding risk. One study identified focal sensory deficits rapid improvement of headache and visual function. A hemorrhagic lesion diuretic drugs are not as quickly eliminated from in the acute brain scan was the strongest predictor of the intracerebral circulation as in other conditions post-acute seizures [22]. Osmodiuretics common in patients with early symptomatic seizures may thus reduce venous drainage and should there- than in those patients with none. Increased intracranial pressure in most cases Epileptic seizures should be treated with paren- responds to improved venous drainage after anti- terally administered antiepileptic drugs (phenytoin, coagulation. Chapter 11: Cerebral venous thrombosis occluded cerebral veins, but also in order to prevent Infectious thrombosis the recurrence of intra- or extracerebral thrombosis.

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