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Patients present with ptosis, diplopia, difficulty in chewing or swallowing, respiratory difficulties, limb weakness, or some combination of these problems Weakness may remain localized to a few muscle groups, especially the ocular muscles, or may become generalized Symptoms often fluctuate in intensity during the day, and this diurnal variation is superimposed on a tendency to longer-term spontaneous relapses and remissions that may last for weeks Nevertheless, the disorder follows a slowly progressive course and may have a fatal outcome owing to respiratory complications such as aspiration pneumonia Clinical examination confirms the weakness and fatigability of affected muscles In most cases, the extraocular muscles are involved, and this leads to ocular palsies and ptosis, which are commonly asymmetric Pupillary responses are normal The bulbar and limb muscles are often weak, but the pattern of involvement is variable Sustained activity of affected muscles increases the weakness, which improves after a brief rest Sensation is normal, and there are usually no reflex changes The diagnosis can generally be confirmed by the response to a short-acting anticholinesterase Edrophonium can be given intravenously in a dose of 10 mg (1 mL), 2 mg being given initially and the remaining 8 mg about 30 seconds later if the test dose is well tolerated; in myasthenic patients, there is an obvious improvement in strength of weak muscles lasting for about 5 minutes Alternatively, 15 mg of neostigmine can be given intramuscularly, and the response then lasts for about 2 hours; atropine sulfate (06 mg) should be available to reverse muscarinic side effects

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A lumbosacral plexus lesion may develop in association with diseases such as diabetes, cancer, or bleeding disorders or in relation to injury It occasionally occurs as an isolated phenomenon similar to idiopathic brachial plexopathy, and pain and weakness then tend to be more conspicuous than sensory symptoms The distribution of symptoms and signs depends on the level and pattern of neurologic involvement

Fluctuating weakness of commonly used voluntary muscles, producing symptoms such as diplopia, ptosis, and difficulty in swallowing Activity increases weakness of affected muscles Short-acting anticholinesterases transiently improve the weakness

Lateral and anteroposterior x-rays of the chest and CT scans should be obtained to demonstrate a coexisting thymoma, but normal studies do not exclude this possibility

the compiler will decide that both a and b should be of type int. But if you were thinking they should be of type double, and later try something like this:

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Electrophysiologic demonstration of a decrementing muscle response to repetitive 2- or 3-Hz stimulation of motor nerves indicates a disturbance of neuromuscular transmission Such an abnormality may even be detected in clinically strong muscles with certain provocative procedures Needle electromyography of affected muscles shows a marked variation in configuration and size of individual motor unit potentials, and single-fiber electromyography reveals an increased jitter, or variability, in the time interval between two muscle fiber action potentials from the same motor unit Assay of serum for elevated levels of circulating acetylcholine receptor antibodies is useful because it has a sensitivity of 80 90% for the diagnosis of myasthenia gravis Certain patients without antibodies to acetylcholine receptors have serum antibodies to muscle-specific tyrosine kinase (MuSK), which should therefore be determined; these patients are more likely to have facial, respiratory, and proximal muscle weakness than those with antibodies to acetylcholine receptors

Keesey JC Clinical evaluation and management of myasthenia gravis Muscle Nerve 2004 Apr;29(4):484 505 [PMID: 15052614] Schneider-Gold C et al Mycophenolate mofetil and tacrolimus: new therapeutic options in neuroimmunological diseases Muscle Nerve 2006 Sep;34(3):284 91 [PMID: 16583368]

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2 Myasthenic Syndrome (Lambert-Eaton Syndrome)

a = 7.4; b = 5.5;

Variable weakness, typically improving with activity Dysautonomic symptoms may also be present A history of malignant disease may be obtained

Myasthenic syndrome (see Table 39 13) may be associated with small-cell carcinoma, sometimes developing before the tumor is diagnosed, and occasionally occurs with certain autoimmune diseases There is defective release of acetylcholine in response to a nerve impulse, caused by P/Q-type voltage-gated calcium-channel antibody, and this leads to weakness, especially of the proximal muscles of the limbs Unlike myasthenia gravis, however, power steadily increases with sustained contraction The diagnosis can be confirmed electrophysiologically, because the muscle response to stimulation of its motor nerve increases remarkably if the nerve is stimulated repetitively at high rates, even in muscles that are not clinically weak Treatment with plasmapheresis and immunosuppressive drug therapy (prednisone and azathioprine) may lead to clinical and electrophysiologic improvement, in addition to therapy aimed at tumor when present Prednisone is usually initiated in a daily dose of 60 80 mg and azathioprine in a daily dose of 2 mg/kg Guanidine hydrochloride (25 50 mg/ kg/d in divided doses) is occasionally helpful in seriously disabled patients, but adverse effects of the drug include marrow suppression The response to treatment with anticholinesterase drugs such as pyridostigmine or neostigmine, either alone or in combination with guanidine, is variable

The designer of Note has opted to make the Read(...) method virtual but not to make the Write(...) method virtual:

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