2 English reference Gilles de la Tourette syndrome
3. Summarize Tourette's syndrome (TS) and chronic Tourette's syndrome. Itard( 1825) was first reported, and it was described in detail by French neurologist Gees Gilles de la Tourette in 1885, and later named after it.
This disease is a group of extrapyramidal diseases, which is characterized by sudden and involuntary convulsions of the muscles of the head, limbs and trunk, accompanied by explosive guttural or swearing. Typical manifestations are repeated convulsions, involuntary vocalization, speech and behavior disorders; May be accompanied by obsessive-compulsive disorder, personality disorder, attention deficit hyperactivity disorder. Tourette's syndrome has a family genetic tendency, and the onset age is 2 ~ 18 years old, mostly 4 ~ 12 years old, and gradually decreases after puberty.
Name of disease Tourette's syndrome
English name Gilles de la Tourette syndrome
6. The alias of Tourette's syndrome is chronic multiple; Ticscoprolalia syndrome; Tourette syndrome; Tourette syndrome; Tourette syndrome; Tourette syndrome; Hyperactivity disorder swearing syndrome; Tourette syndrome; Chronic Tourette's syndrome
7 classification neurology >; dyskinesia
8 ICD number G25.8
Epidemiology has been reported in the literature. The annual incidence of Tourette's syndrome is 0.5% ~ 1%, most cases are sporadic, and 35% ~ 50% cases have family history. The onset age ranged from 2 years old to 18 years old, mostly starting from 4 years old to 12 years old, with an average of (12 4) years old, and gradually decreasing after puberty. Boys are more common, and the ratio of male to female is 3 ∶ 1 ~ 9 ∶ 1. The adult prevalence rate is 0.77% for men and 0.22% for women. All studies show that men are more likely to grow hair than women.
The annual incidence reported in the United States is 45/65438+ 10,000, and that reported in Gao Qingyun, China (1984) is 242/ 12. Shapiro( 1978) also found that as many as 22.8% of the patients with this disease are left-handed, while only 5% ~ 10% of the normal population.
10 etiology Tourette's syndrome may be a disease with autosomal dominant inheritance and penetrance variation; Corning and others believe that this is a polygenic genetic disease. A patient has a 50% chance of passing on genetic factors to his/her offspring. The genetic quality of offspring may not completely show Tourette's syndrome. Patients may only show mild TIC and obsessive-compulsive behavior (OCB), or they may only pass on their genes to their offspring without showing clinical symptoms.
The pathogenesis of 1 1 Tourette syndrome is still unknown. Gene defects can lead to abnormal neuroanatomy and neurobiochemical dysfunction. Most scholars speculate that the disease is related to the dysfunction of neurons in basal ganglia, prefrontal cortex and limbic system, and its pathogenesis may be the result of the joint action of genetic factors, neurobiochemical metabolism and environmental factors during development.
1 1. 1 Genetic factors Many studies believe that genetic factors play an important role in the occurrence of this disease. The disease has obvious family tendency. 65% ~ 90% of Tourette's syndrome cases are familial, and the incidence of Tourette's syndrome in identical twins (53% ~ 56%) is significantly higher than that in fraternal twins (8%).
The genetic mode of Tourette's syndrome is controversial, and it is now considered as an autosomal dominant disease with incomplete penetrance. There are gender differences in penetrance, with male penetrance being high (0.5 ~ 0.9) and female penetrance being low (0.2 ~ 0.8). Patients with Tourette syndrome often have obsessive-compulsive symptoms or behavioral disorders, and family history of mental illness is also common. Genetic research suggests that Tourette's syndrome is genetically related to obsessive-compulsive disorder, which may be different manifestations of the same gene abnormality.
There are gene defects in patients with Tourette's syndrome, but so far, the research on gene mapping in patients with Tourette's syndrome has not been conclusive. Simonic's comparative study on 1998 of Tourette's syndrome patients and non-Tourette's syndrome patients in Afrika, South Africa, found that the linkage genes of Tourette's syndrome in Europeans born in South Africa may be located in 2p 1 1, 8q22 and1kloc-0/q23 ~ 24.
1 1.2 The imaging changes of the brain in patients with Tourette's syndrome are mainly in the basal ganglia. Organic brain injury in children caused by dystocia, asphyxia, premature delivery, convulsion and head trauma may be the risk factors of Tourette's syndrome. About 50% of Tourette's syndrome patients have nervous system signs such as slight muscle tone changes or fine motor defects, and non-specific abnormal changes can be seen in EEG, which support that the disease may be an organic disease.
1 1.3 Abnormal central neurotransmitter system (1) Dopamine hyperactivity or dopamine receptor hypersensitivity: Because most patients with Tourette's syndrome have a good therapeutic effect on haloperidol, a selective central dopamine D2 receptor antagonist, most scholars believe that the mechanism of Tourette's syndrome is dopamine hyperactivity in basal ganglia and cerebral limbic cortex, or dopamine receptor hypersensitivity after synapse.
(2) The role of sex hormones and excitatory amino acids: Recent studies suggest that the abnormal development of brain regions with basic reproductive functions such as basal ganglia and limbic system may be related to Tourette's syndrome. The abnormal development of these special brain regions is controlled by sex hormones. The twitching of patients with Tourette's syndrome, such as touching, rubbing, sucking, sniffing, pelvic stretching, foul language, etc., may be improper manifestations of reproductive behavior, while foul language and explosive guttural sounds, such as dog barking and wheezing, may also be improper manifestations of reproductive behavior.
(3) Hypothesis of norepinephrine (ne) dysfunction: Low dose clonidine can relieve the symptoms of Tourette's syndrome, so it is considered that the pathological mechanism of this disease is related to the participation of NE energy system, and low dose clonidine has the effect of * * * presynaptic α2 receptor, thus feedback inhibiting the synthesis and release of NE in locus coeruleus and relieving TIC symptoms.
1 1.4 Mental factors This disease may be related to social and psychological factors. Mental trauma, life events (such as bad family environment, incorrect education methods, disharmony between parents and children), excessive mental stress, stress or emotional fluctuation can all induce or aggravate TIC symptoms. Seizure may be a manifestation of repressed desire and resistance.
1 1.5 patients with lethargic encephalitis accompanied by oculomotor nerve crisis and herpes encephalitis may have clinical manifestations of Tourette's syndrome. Pathological anatomy and imaging examination of these patients showed that there were lesions around the temporal lobe, basal ganglia, thalamus, midbrain lid and midbrain aqueduct, suggesting that viral infection in basal ganglia or limbic system may be related to Tourette's syndrome. The autoimmune process after streptococcus infection may be related to children's TIC and obsessive-compulsive symptoms. It was also found (Muller et al., 200 1) that the antibody titers of Streptococcus M 12 and M 19 in adult patients with Tourette's syndrome increased.
Main pathological changes: There are few reports about the neuropathology of Tourette's syndrome. Balthasar (1957) found an abnormal type of cells in the dopamine-rich cell group in the striatum in the autopsy of 1 case of Tourette's syndrome, which may be the pathological basis of Tourette's syndrome.
Haber's immunohistochemical study of 1 autopsy brain samples of Tourette's syndrome showed that dynorphin-positive villi fibers in the posterior part of lateral segment of globus pallidus and ventral part of globus pallidus were completely missing or significantly reduced, suggesting that the nerve fibers projected from striatum fibers to globus pallidus were abnormal.
12 The clinical manifestation of Tourette's syndrome is 1. The onset age of the disease is 2 ~ 18 years old, mostly 4 ~ 12 years old, and it gradually decreases after puberty. Symptoms are fluctuating and can change within weeks or months. The course of the disease is long and chronic, lasting at least 1 year. Tourette's syndrome is the main symptom in the early stage, which generally starts from the face and gradually develops to the upper limbs, trunk or lower limbs. It is characterized by repeated and rapid irregular convulsions (movement spasms) of eye muscles, facial muscles, neck muscles or upper limb muscles, such as blinking, pouting, frowning, twitching nose, grimacing, shaking head, nodding, stretching neck and shrugging. And the symptoms are aggravated by explosive voluntary movement of limbs and trunk, such as throwing action and upper limb turning.
Vocal cord spasm is another feature of this disease. 30% ~ 40% of children have repetitive, explosive and meaningless monotonous abnormal laryngeal sounds due to laryngeal muscle spasm, such as barking, growling, hey hey, tongue licking and laryngeal sounds, as well as clicking, creaking and creaking. Some children unconsciously and rigidly swear, speak vulgar and obscene language (swearing), imitate others' language and actions (imitating language and actions), and often repeat words or phrases (repeating language).
3. About 85% children have mild and moderate behavioral disorders, and mild children are uneasy, irritable and irritable. About half of the children are accompanied by attention deficit hyperactivity disorder (ADHD), lack of concentration, poor learning, hyperactivity, restlessness and fidgeting. Some patients have compulsive behaviors such as washing hands repeatedly and checking locks, and also have self-mutilation behaviors such as biting nails, pulling out hair, picking nostrils, biting lips or tongue, which may cause sensory spasms, such as nervousness, itching, cold and heat, blasphemy, excessive provocation and violence.
4. Children's intelligence is generally unaffected, and sometimes their learning ability declines, making it difficult to read and write compositions, and even failing to complete their normal studies. Learning is related to ADHD. Patients have a certain degree of control and can suppress involuntary convulsions for several minutes or longer. Examination usually can't find other abnormal signs, and the course of disease can alleviate the recurrence.
Complications of Tourette's syndrome 13 The common accompanying symptoms of Tourette's syndrome are: emotional disorder, obsessive-compulsive disorder, attention deficit, hyperactivity, learning difficulties, disciplinary behaviors, obscene and aggressive behaviors, and social adaptation difficulties. Some patients have behavioral disorders and weirdness, such as compulsive behavior or thinking, showing uncontrollable self-injury behaviors such as touching objects or others, hand circling, tongue biting, finger biting, disfigurement, hitting a wall, swinging arms and so on.
14 laboratory examination 1. Routine examination of blood and cerebrospinal fluid is normal.
2. The blood biochemical examination is generally normal, and sometimes it is found that the 5HT level is reduced.
15 auxiliary examination 1.50% ~ 60% patients may have mild EEG abnormalities, but there is no specificity, mainly slow wave or spike wave increase, and the abnormal rate of dynamic EEG (AEEG) can reach 50%.
2. How normal the electrocardiogram is.
3. How normal is the brain CT? MRI examination of the head showed that the volume of bilateral basal nuclei was asymmetric, and the average volume of bilateral caudate nucleus and lenticular nucleus was smaller than that of normal control group. In Tourette's syndrome patients with attention deficit, the left globus pallidus is significantly smaller than the right globus pallidus.
4. SPECT examination of the head showed that the blood perfusion in temporal lobe, frontal lobe and basal ganglia decreased. Grunwald et al. found that the local blood perfusion of the focus decreased during the seizure, but increased during the seizure, which is similar to the characteristics of SPECT images of epileptic patients, and whether it has the same pathological basis with epilepsy needs further study.
The diagnosis of 16 Tourette's syndrome is a complex neuropsychiatric disorder, and the diagnosis is mainly based on the medical history and clinical symptoms.
16. 1 International Classification of Diseases (ICD 10) standard diagnosis points are as follows:
The incidence of (1) is mostly before 2 1 year, and the most common is 2~ 15.
(2) There are many kinds of motor convulsions and one or more kinds of vocal convulsions in the course of the disease, but they do not necessarily exist at the same time.
(3) The twitch is sudden, rapid, short-lived, repetitive, involuntary, aimless and repeated, which affects many groups of muscles.
(4) The twitch can be controlled by the will for a short time (a few minutes to several hours), which intensifies under pressure and disappears during sleep.
(5) The convulsion symptoms appear many times a day, almost every day, or the course of intermittent seizures exceeds 1 year, and the symptoms are relieved within 2 months in the same year.
(6) Exclude extrapyramidal diseases such as rheumatic chorea, Huntington's chorea, hepatolenticular degeneration, myoclonia, and hand and foot peristalsis.
16.2 the revised classification scheme and diagnostic criteria of mental illness in China (CCMD2R) 1994 was adopted at Quanzhou meeting, with the following contents:
Before (1)2 1 years old, most of them were 2 ~ 15 years old.
(2) The main manifestations are multiple convulsions and one or more involuntary vocalizations, which occur at some time in the course of the disease, but not necessarily at the same time.
(3) Tic symptoms recur many times a day, almost every day, but the intensity of symptoms changes within weeks or months, which can be restrained by the will for several minutes to several hours. The course of the disease lasts at least 65,438+0 years, and the symptoms are relieved within 2 months in the same year.
(4) Involuntary convulsion and phonation cannot be explained by other diseases.
17 differential diagnosis attention and childhood diseases that may cause dyskinesia and convulsions. ① Habitual spasm: It is found in boys aged 5 ~ 10, who have bad habits, mental factors or imitate others' behavior, hyperactivity is limited for a short time, and can disappear on their own, without speech disorder and mental retardation; ② Mild chorea: If there is no evidence of rheumatic fever, arthritis and heart involvement in recent years, it is difficult to distinguish. Chorea minor generally has no voice spasm, and it is a self-limited disease, which often disappears in 3 ~ 6 months, and anti-rheumatic treatment is effective. ③Wilson's disease: according to liver involvement, corneal KF ring, abnormal serum copper and ceruloplasmin, etc. ④ Shaking head syndrome: children with progressive hydrocephalus have rapid rhythmic shaking head.
Tourette syndrome needs to be differentiated from Huntington's disease, hand and foot peristalsis, myoclonia and other diseases.
Treatment of Tourette's syndrome 18 Generally, patients with mild symptoms do not need treatment, and those who have been diagnosed should be treated with drugs at an early stage. The principle of treatment is: low dose can be used at the initial stage of treatment, and the dose can be gradually increased to reduce side effects, especially when nerve blockers or cola are often used. The treatment should have a certain course of treatment and appropriate dosage, and it is not advisable to change the medicine too early. When the symptoms are only partially improved by using a single drug, or Tourette's syndrome is accompanied by complex accompanying symptoms, the combination of drugs can be considered. But taking more drugs is not the best way, so be careful. As for maintenance treatment, because drug treatment is symptomatic, maintenance treatment should be carried out for a certain period of time. The duration of maintenance treatment depends on the specific situation of each patient. Mild patients need 6 ~ 12 months, and severe patients need 1 ~ 2 years or more. The maintenance treatment dose is generally 65438+ 0/2 ~ 2/3 of the treatment dose.
18. 1 drug therapy (1) Haloperidol: It is a selective central dopamine receptor blocker. 196 1 year, Seignot reported that haloperidol was successful in treating Tourette's syndrome. Later, many reports confirmed that this medicine was effective. Now it has been widely used in Tourette's syndrome and is the first choice drug. The curative effect can reach 60% ~ 90%, which is mainly effective for exercise and vocal cord twitch, and can make many patients with Tourette's syndrome return to normal, but it has no obvious effect on some accompanying symptoms of Tourette's syndrome. At the beginning, haloperidol was taken orally 0.25 ~ 0.5 mg /d, 2 ~ 3 times /d, or 0.5 mg /d before going to bed, and the dose gradually increased, generally increasing/kloc-0 times every 3 ~ 5 days, and the effective dose often reached 5 ~ 30 mg/d. Generally, the dosage is 2 ~ 1 0 mg/d. Usually, the dosage is children1.5 ~14 mg/d [0.25 ~ 0.5 mg/(kg d)] and adults16 mg/d [0.5 mg/]. After the symptoms are controlled, the dose should be gradually reduced to below 10mg per day.
About half of the patients can't tolerate its adverse reactions, such as bad mood, lethargy, extrapyramidal symptoms, cognitive impairment affecting learning and heart block. Bradycardia and akathisia are the main adverse reactions of haloperidol therapy. Benzene should be used at the same time to reduce extrapyramidal reactions. Some patients will have oculomotor nerve crisis, that is, binocular tension upward, which can be relieved by intramuscular injection of scopolamine (heroin). The minimum effective concentration of haloperidol is 2.0ng/ml, and adverse reactions may occur when the blood concentration exceeds 6.0ng/ml.
(2) Pimozide: The curative effect is similar to haloperidol, but it has no sedative effect and is easily accepted by patients. Now it has been widely used as a second-line drug. The drug has a long action time, with a single oral time of 24 hours, and can be taken 1 time a day. The initial dose is 0.5 ~ 1 mg/d, preferably taken in the morning; After that, it can be increased slightly every week until the convulsion symptoms are controlled. The average dose of children is 2 ~ 6 mg/d, the maximum dose is 0.2 mg/(kg d), the adult dose is 4 ~ 12 mg/d, and the maintenance dose is 3 ~ 6 mg. Pimiqing-induced cardiac block is more common than haloperidol, which can cause T wave inversion, U wave appearance, QT interval prolongation, bradycardia and so on. Therefore, ECG should be checked every 1 ~ 2 months before and during treatment. Once T wave inversion and U wave appear, the drug should be stopped. When QT interval prolongation is not obvious, you can continue to take medicine, but you can't add it any more. Long-term use can cause anxiety.
(3) Tiapride: The curative effect of this product is not as good as haloperidol, with the advantage of light adverse reactions. Those who are intolerant of haloperidol can switch to this medicine. Studies by Eggers and others show that Tiapride has definite curative effect on Tourette's syndrome. The initial dose is 50 ~ 100 mg/d, taken orally for 2 ~ 3 times, and then gradually increased according to the condition. The usual dose is 200 ~ 300 mg/d, and children generally do not exceed 600 mg/d. The curative effect of most cases appears after 1 ~ 2 weeks. Adverse reactions include drowsiness, dizziness and weakness, and nausea and vomiting may occur in large doses.
(4) Sulpiride: This product also has a good effect on controlling convulsion symptoms. The dosage of anticonvulsant is 200 ~ 400 mg/d, and the main adverse reactions are drowsiness, depression, anxiety, mild tremor and decrease of * * *.
(5) penfluridol: It is reported that patients who have no response to haloperidol and pimozide (pimiqing) have less adverse reactions, especially drowsiness, when using penfluridol (Shapim et al., 1983).
(6)α2 adrenergic receptor blocker clonidine hydrochloride: The pharmacological action of this product in treating Tourette's syndrome may be to inhibit the release of adrenaline from locus coeruleus synapses, thus relieving TIC symptoms. Clonidine is a safe and effective anticonvulsant with an effective rate of 22% ~ 70%. It takes 3 weeks or longer than haloperidol to take effect. In addition, clonidine is the first choice for the treatment of attention deficit hyperactivity disorder.
Clonidine is available in tablets and skin patches. The initial oral dose is 0.025~0.075mg/d/d, which is taken orally for 2 ~ 3 times and slowly added. Generally, the total daily dose should not exceed 0.5mg, or the dose should be calculated as 3 μ g (kg d). For some children who don't want to take medicine, you can use patches. Patches (each containing 2mg) can be attached behind the ears, with a dose of 0.5 ~ 1 patch each time and a weekly replacement of 1 patch. The adverse reactions of clonidine include drowsiness, dry mouth, headache, dizziness, irritability, increased heart rate and decreased blood pressure. During the treatment, blood pressure and pulse should be monitored, and ECG should be checked regularly. If there are adverse reactions, the dosage should be adjusted to slow down the administration speed. Don't stop taking drugs during treatment, otherwise there may be acute withdrawal reaction.
(7) Clomipramine: This product can increase the 5HT level in the brain and is effective for obsessive-compulsive symptoms related to Tourette's syndrome. The initial dose was 3mg/kg for children and 25mg/d for adults, and then it was added slowly according to the condition. The maximum dose for adults was 250 mg/d. The adverse reactions included dry mouth, sedation, tremor, constipation, dysuria and sexual dysfunction.
(8) Fluoxetine is a new generation of antidepressant, with an initial dose of 20mg/d, and then gradually increased to 60 ~ 80 mg/d, and children are sensitive to the activation of this drug, with an initial dose of 10 ~ 20 mg/d, once every other day. Compared with clomipramine, fluoxetine has fewer adverse reactions. Fluoxetine can cause indigestion, nausea, rash or hypomania. Studies show that it is safe for children to take a small amount of fluoxetine.
(9) Olanzapine: It is an atypical psychodepressant with various receptor activities, including antagonism of DA2, 5HT2A and 2C. Budman et al.' s research shows that this drug can obviously relieve TIC symptoms, but it is ineffective for accompanying symptoms. The final dose was 2.5mg/d, with an average of10.9 mg/d. The common adverse reactions were drowsiness, weight gain, appetite increase, dry mouth and transient asymptomatic hypoglycemia. The author thinks that olanzapine can be used as a routine psychodepressant in the treatment of exercise TIC and Tourette's syndrome.
(10) Drugs for controlling attention deficit hyperactivity: Clonidine is the first choice. Cohen( 1992) reported that clonidine was effective in treating Tourette's syndrome with attention deficit hyperactivity disorder.
(1 1) inosine: Some people think that inosine therapy may be effective. It is considered that inosine is an intermediate product of purine metabolism, which can quickly enter the central nervous system through the blood-cerebrospinal fluid barrier, has sedative and anticonvulsant effects, and can increase the release of dopamine. It is considered that inosine can not rule out the action on axonal endings of dopaminergic nerves as a dopamine receptor antagonist similar to haloperidol. Zhao Chunyu and others in China reported that the combination therapy of inosine and haloperidol was better, and it could reduce the dosage of haloperidol and reduce adverse reactions.
(12) others: methylphenidate (ritalin) is controversial in the treatment of attention deficit hyperactivity disorder, because central stimulants will aggravate the TIC symptoms of patients. In addition, trifluoperazine, flunarizine (flunarizine hydrochloride), naltrexone (naltrexone), diazepam (diazepam), vitamin E, vitamin B6 and other drugs can be used to treat Tourette syndrome.
Combination drugs are mostly used in the following situations: first, haloperidol alone can not control the symptoms of patients or the adverse reactions are too great to continue treatment; Second, after taking clonidine, the symptoms of exercise and vocalization still exist. Haloperidol and clonidine are commonly used together. The advantage is that both of them are very small doses, which can achieve satisfactory results and have few adverse reactions. Haloperidol and tiapride can also be used together.
18.2 The adverse effects of psychotherapy on personality are very common, so patients will be highly affected by psychopathology, and some of them still can't adapt to society after convulsion control. Therefore, while emphasizing the etiology and symptomatic treatment, we should attach importance to mental and psychological treatment.
(1) Supportive psychotherapy: For patients with Tourette's syndrome, the purpose of psychotherapy is not to directly eliminate TIC symptoms, but mainly to support and help patients to eliminate psychological troubles, reduce anxiety and depression, and adapt to the real environment. At the same time of drug treatment, we should pay attention to the study and living environment of patients, solve the stress in the environment in time, and give psychotherapy and psychological education.
(2) Behavioral therapy usually includes the following methods:
① Negative exercise method: based on the theory that repetitive actions can cause cumulative inhibition. It can make the patient consciously repeat a twitch within a specified time (15 ~ 30 min). As time goes on, the patient gradually feels tired, the twitching frequency decreases and the symptoms are alleviated.
② Self-monitoring method: that is, patients are encouraged to reduce or control twitch through self-monitoring. Ask patients to record in detail their involuntary movements within a specified time every day, such as whether the number and frequency of convulsions are related to the environment. Through recording for a period of time, the patient's convulsion consciousness can be enhanced and overcome. This law applies to adults or older children.
③ Relaxation training: Let patients learn to relax and adjust breathing and relax tense muscles, which can reduce twitch and improve anxiety.
④ Behavior reverse training: Behavior reverse training is to control twitch by exerting an antagonistic reaction that is opposite or inconsistent with twitch. Antagonistic reaction can prevent exercise twitch by tightening the muscles corresponding to twitch. Using a closed mouth and slow deep breathing through the nasal cavity can inhibit the twitching of vocal cords. Breathing slowly and deeply through your mouth can inhibit nasal convulsions.
18.3 surgical treatment of refractory Tourette's syndrome, surgical treatment can be used, and stereotactic destruction of the unfixed zone, ventrolateral thalamic nucleus or thalamic intermediate plate is often used, which has a significant long-term effect on reducing the severity of refractory Tourette's syndrome.
The prognosis of 19 Tourette's syndrome is chronic, fluctuating, good and bad, with periodic remission and recurrence, which requires long-term medication. The prognosis is good, and most patients have symptoms relieved after puberty. Recently, it was found that the disease can also be relieved naturally (7% ~ 19%). Most of the tic symptoms of this disease have a good prognosis. Follow-up studies show that 50% of patients fully recover, about 40% of patients are partially improved, and only about 5% of patients continue to adulthood, and rarely progress to schizophrenia. Male patients have a better prognosis than female patients. Patients with conduct disorder are prone to criminal offences, and their prognosis may be poor. This disease does not affect the patient's life span.
Body surface area calculator body mass index calculation and evaluation of female safety period calculator expected date calculator normal weight gain during pregnancy medication safety classification (FDA) five elements and eight characters adult blood pressure evaluation body temperature level evaluation diabetes diet suggestion clinical biochemical common units conversion basal metabolic rate calculation sodium supplement calculator iron supplement calculator prescription common Latin abbreviations quick check pharmacokinetics common symbols quick check effective plasma osmotic pressure calculator alcohol intake calculator.
Encyclopedia of medicine, count now!
Prevention of Tourette's syndrome has a genetic background, and preventive measures include avoiding consanguineous marriage, genetic counseling, genetic testing for carriers, prenatal diagnosis and selective abortion to prevent children from being born.
2 1 Related drugs: dopamine, haloperidol, norepinephrine, epinephrine, clonidine, diphenhydramine, scopolamine, pimozide, tiapride, sulpiride, penfluridol, clomipramine, fluoxetine, olanzapine, inosine, methylphenidate, trifluoperazine, flunarizine and cinnarizine.
22 related examination of vitamin e
To treat Tourette's syndrome, the lumbosacral part is 2/5 of the acupuncture point of cervical vertebra. Indications: Cervical vertebra points are used for stiff neck and cervical spondylosis. * * * Methods: Needle burying method, seed pressing method and pricking blood method are generally adopted. ...
Endocrine therapy diseases: ear point endocrine therapy for dysmenorrhea, irregular menstruation, menopausal syndrome, acne, vivax malaria. * * * Method: generally use filiform needle, buried needle and pressing. ...
The ghost heart tomb is under the corpse star. It is more reasonable to test the names of two stars, Daling and Jishi. Is it old or old? ...
The great mausoleum is under the corpse star. It is more reasonable to test the names of two stars, Daling and Jishi. Is it old or old? ...
Sanyang