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Pain and dysesthesias may be prominent in patients with either severe or slight degrees of motor, re ex, and sensory loss The term hyperesthetic is used commonly to designate the exquisitely painful form of neuropathy but is not well chosen; as pointed out on page 118, one is usually able, by using nely graded stimuli, to demonstrate an elevated threshold to painful, thermal, and tactile stimuli in the hyperesthetic zone Once the stimulus is perceived, however, it has a painful and diffuse, unpleasant quality (hyperpathia) Tactile evocation of pain or burning is an example of allodynia In most patients with nutritional polyneuropathy, only the limbs are involved and the abdominal, thoracic, and bulbar muscles are usually spared; however, we have encountered two cases in which there was sensory loss in the pattern of an escutcheon over the anterior thorax and abdomen.

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Another key consideration when installing APEX is the network topology and physical separation of the HTTP server, database, and TNS (Transparent Network Substrate) Listener. It is a security architecture best practice to install the HTTP server on a physical machine that s different from the database, because this topology provides several essential security benefits. The database and TNS Listener should reside completely within the corporate network with no network access exposed to the public Internet. It s not uncommon to place the database behind an additional firewall so that it is not publicly accessible on the corporate intranet. The most common and desirable location for the HTTP server is on a separate server in your networks demilitarized

Another distinctive problem arises in distinguishing generalized GBS with ophthalmoparesis or the Fisher variant from basilar artery thrombosis The presence of reactive pupils, are exia, and F-wave abnormalities in GBS, and of lively re exes and Babinski signs in the case of brainstem infarction, dependably separates the disorders Ptosis and oculomotor weakness, features of GBS in some severe generalized cases and in Fisher syndrome, may cause confusion with acute myasthenia gravis, but in the latter disease there are no sensory symptoms and the tendon re exes are unimpaired The mandibular muscles remain relatively strong in GBS, whereas the exercised jaw hangs open in myasthenia Botulism may also simulate GBS, but pupillary re exes are lost early in botulism (pupillary paralysis occurs mainly in advanced cases of GBS), and there is usually a bradycardia, which is unusual for GBS.

In the most advanced instances of neuropathy, hoarseness and weakness of the voice and dysphagia due to affection of the vagus nerves may be added to the clinical picture Some idea of the incidence of the motor, re ex, and sensory abnormalities and the combinations in which they occur can be obtained from Table 41-1, which is based on Victor s examination of 189 nutritionally depleted alcoholic patients Noteworthy is the fact that only 66 (35 percent) of the 189 patients showed the clinical picture of polyneuropathy in its entirety ie, a symmetrical impairment or loss of tendon re exes, sensation, and motor power affecting legs more than the arms and the distal more than the proximal segments of the limbs In the remaining patients, the motor-re ex-sensory signs occurred in various combinations, as indicated in Table 41-1.

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Tick paralysis, a disease of children in the United States but affecting both children and adults in Australia, may be nearly impossible to distinguish from GBS unless one nds the tick (page 1034) In addition to an ascending paralysis, both also sometimes cause ataxia and may paralyze eye movements, but sensory loss is not usually a feature of tick paralysis and the CSF protein remains normal Ingestion of shell sh or reef sh contaminated with saxitoxin, ciguatoxin, or tetrodotoxin (ciguatera, neurotoxic shell sh poisoning) is another cause of acute facial-brachial paresthesias, weakness, tachypnea, and iridoplegia lasting a few days symptoms that resemble the cranial nerve variants of GBS A number of neuromuscular disorders in critically ill patients with systemic medical conditions may be dif cult to distinguish from GBS.

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