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a spastic or ataxic paraparesis The tendon re exes are retained and later become hyperactive with extensor plantar re exes; disappearance of the abdominal re exes and varying degrees of deep and super cial sensory loss may be associated It is a useful adage that the patient with MS presents with symptoms in one leg but with signs in both; the patient will complain of weakness, incoordination, or numbness and tingling in one lower limb and prove to have bilateral Babinski signs and other evidence of bilateral corticospinal and posterior column disease Flexion of the neck may induce a tingling, electric-like feeling down the shoulders and back and, less commonly, down the anterior thighs This phenomenon is known as a Lhermitte sign, although it is more a symptom than a sign and was originally described by Babinski in a case of cervical cord trauma Lhermitte s contribution was to draw attention to the frequent occurrence of this phenomenon in MS It is attributable to an increased sensitivity of demyelinated axons to the stretch or pressure on the spinal cord induced by neck exion There are, in addition, several syndromes that are typical of multiple sclerosis and may be the initial manifestations These common modes of onset are: (1) optic neuritis, (2) transverse myelitis, (3) cerebellar ataxia, and (4) various brainstem syndromes (vertigo, facial pain or numbness, dysarthria, diplopia) These are often features of the established disease as well When they represent the initial phases of the illness, they may pose diagnostic questions, since they also certainly occur with numerous diseases other than MS Optic Neuritis (See also page 213) In about 25 percent of all MS patients (and in a larger proportion of children), the initial manifestation is an episode of optic neuritis It will be recalled that the optic nerve is in fact a tract of the brain, and involvement of the optic nerves is therefore consistent with the rule that lesions of MS are con ned to the CNS Characteristically, over a period of several days, there is partial or total loss of vision in one eye Many patients, for a day or two before the visual loss, experience pain within the orbit, worsened by eye movement or palpation of the globe Rarely, the visual loss is steadily progressive for several weeks, mimicking a compressive lesion or intrinsic tumor of the optic nerve (Ormerod and McDonald) Usually a scotoma involving the macular area and blind spot (cecocentral) can be demonstrated, but a wide variety of other eld defects may occur, rarely even hemianopic involvement (sometimes homonymous) In some patients, both optic nerves are involved, either simultaneously or, more commonly, within a few days or weeks of one another, and at least 1 in 8 patients will have repeated attacks Serial examinations may disclose evidence of swelling or edema of the optic nerve head (papillitis) in about half the patients The occurrence of papillitis depends on the proximity of the demyelinating lesion to the nerve head As emphasized in Chap 13, papillitis can be distinguished from the papilledema of increased intracranial pressure by the severe and acute visual loss that accompanies only the former More often, the optic nerve head appears normal or nearly so; this represents a retrobulbar neuritis Subtle manifestations of optic nerve affection such as an afferent pupillary defect (page 206), atrophy of retinal nerve bers or sheathing of retinal veins (page 213) and abnormalities of the visual evoked response (page 30) should be sought in patients who have no visual complaints but are suspected of having MS In cases of substantial visual loss there is a diminished pupillary response to light (afferent pupillary paralysis) and instability of the direct pupillary response,.

Navigation in the BEx Web Analyzer is a bit different from navigation in its counterpart frontend, the BEx Analyzer In the BEx Analyzer, the functionality of adding a characteristic or other component to the format is to use the context menu or dropdown and either insert the characteristic by drilling down or across with the options offered in the menu This is a bit easier than using the drag and drop functionality in the BEx Analyzer In contrast, with the BEx Web Analyzer, we can use either the ability to drag and drop characteristics into the query format or using the context menu and the functionality from the navigational pane to pick the item from the dropdown list of options Both are very easy and quick to use in the Web toolsets These are user-friendly options that allow you to navigate by using your cursor, from just about anywhere on the screen, and position the characteristic where you want it In the BEx Analyzer, several navigational steps might be necessary before you get the characteristic in exactly the correct position With the ability to drag and drop, you can format the report in one movement and more intuitively Most of the navigation and manipulation within the BEx Web Analyzer is accomplished using the toolbar functionality found in the standard Web template As you will see, this is a combination of multiple standard templates grouped together to support user-friendly activities

Runaway markets, selling options in, 96 97 Russell 2000 index, 214, 218, 272 273 S Scholes, Myron, 259 SEC (Securities and Exchange Commission), 2 Sector risk, 271 Securities and Exchange Commission (SEC), 2 Sell-buy-sell strategy, 143 146, 247 Selling options, 17, 87 111 call options, 99 102 derivatives options, 104 108 elevated implied volatility, 90 94 with limited time to expiration, 94 96 and liquidity, 97 98 motivation for, 87 89 put options, 102 104 in runaway markets, 96 97 short option risk management, 108 110 strategies for, 89 90 Short options: chasing call positions, 97 covered, 89 letting the market come to you, 98

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The conventional view of MS as a disease that strikes young people at a time when they are enjoying perfect health is not always accurate In some patients, the history discloses that fatigue, lack of energy, weight loss, and vague muscle and joint pains had been present for several weeks or months before the onset of neurologic symptoms Nor is it generally appreciated that the neurologic disorder may have an acute, almost apoplectic onset In fact, McAlpine and coworkers (1972), who analyzed the mode of onset in 219 patients, found that in about 20 percent the neurologic symptoms were fully developed in a matter of minutes, and, in a similar number, in a matter of hours In about 30 percent the symptoms evolved more slowly, over a period of a day or several days, and in another 20 percent more slowly still, over several weeks to months In the remaining 10 percent the symptoms had an insidious onset and slow, steady, or intermittent progression over months and years The classic relapsing-remitting pattern of disease is more likely to appear in patients who are less than 40 years of age The in ammatory process of MS affects no organ system other than the CNS Early Symptoms and Signs Weakness or numbness, sometimes both, in one or more limbs is the initial symptom in about half the patients Symptoms of tingling of the extremities and tight bandlike sensations around the trunk or limbs are commonly associated and are probably the result of involvement of the posterior columns of the spinal cord The symptoms generally appear over a period of hours or days, at times being so tri ing that they are ignored, and less often, coming on so acutely and prominently as to bring the partient urgently to the doctor The resulting clinical syndromes vary from a mere dragging or poor control of one or both legs to.

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