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ory, a global dementia with deteriorated executive function, or a confusional-psychotic state also occur in the advanced stages of the disease The cognitive impairment is more in keeping with what has been ascribed to subcortical dementia (page 372) Symptoms of bladder dysfunction including hesitancy, urgency, frequency, and incontinence occur commonly with spinal cord involvement Urinary retention, due to affection of sacral segments, is less frequent (Fig 26-5) In males, these symptoms are often associated with impotence, a symptom that the patient may not report unless speci cally questioned in this regard Abrupt attacks of neurologic de cit, lasting a few seconds or minutes and sometimes recurring many times daily, are a relatively infrequent but well-recognized feature of MS (see Osterman and Westerbey) Usually the attacks occur during the relapsing and remitting phase of the illness, rarely as an initial manifestation These clinical phenomena are referable to any part of the CNS but tend to be stereotyped in an individual patient The most common phenomena are dysarthria and ataxia, paroxysmal pain and dysesthesia in a limb, ashing lights, paroxysmal itching, or tonic seizures, taking the form of exion (dystonic) spasm of the hand, wrist, and elbow with extension of the lower limb The paroxysmal symptoms, particularly the tonic spasms, may be triggered by sensory stimuli or can be elicited by hyperventilation On a few occasions we have seen dystonic hand and arm spasms as the rst symptoms; an acute plaque was detected in the opposite internal capsule In advanced cases, the spasms may involve all four limbs and even a degree of opisthotonos The cause of paroxysmal phenomena is uncertain They have been attributed by Halliday and McDonald to ephaptic transmission ( cross-talk ) between adjacent demyelinated axons within a lesion Carbamazepine is usually effective in controlling such attacks These transitory symptoms appear suddenly, may recur frequently for several days or weeks, sometimes longer, and then remit completely, ie, they exhibit the temporal pro le of a relapse or an exacerbation It is sometimes dif cult to determine whether they represent an exacerbation or a new lesion Years ago, Thygessen pointed out, in an analysis of 105 exacerbations in 60 patients, that there were new symptoms in only 19 percent; in the remainder there was only a recurrence of old symptoms Another problem is that the original lesion may have been asymptomatic This is most obviously re ected in the many patients who are found to have impaired visual evoked responses but have never had symptomatic visual changes Thus, new symptoms and signs may be manifestations of previously formed but asymptomatic plaques However, the observations of Prineas and Connell indicate that symptoms and signs may progress without the appearance of new plaques These and other factors need to be taken into consideration in evaluating the clinical course of the illness and the effects of a therapeutic program (see Poser) Unusually severe fatigue is another peculiar symptom of MS; it is often transient and more likely to occur when there is fever or other evidence of disease activity, but it can be a persistent complaint and a source of considerable distress Depression may play a role in these recalcitrant cases, although the response to pharmacologic agents suggests that these two aspects of the disease are dissociable Thus, antidepressants often do not improve fatigue, while drugs that alleviate fatigue, such as moda nil and amantadine, do not function as antidepressants A number of other interesting manifestations of MS have come to our attention over the years and have given rise to dif culties in diagnosis The occurrence of typical tic douloureux in.

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naked, 89 risk management for, 108 110 Short risk reversals, 134, 138 142 Short selling, 2 3, 77 Short straddles, 180 183, 185 189 Short strangles, 183 189 Shorting options (see Selling options) Short-side volatility, 44 Short-term covering long exposure strategy, 248 Soft stops, 80 implied volatility, 83 price, 81 Software, option analysis (see Option analysis software) Soybean futures, 39 40, 67 S&P 500 index, 214, 215, 218, 270, 272 273 Spreads, 113 189 back, 155 160 bear puts, 126 127, 131 134 bull calls, 126 131 covered calls, 115 122, 126 covered puts, 122 126 credit, 114, 161 166 debit, 114 diagonal, 115 horizontal, 115 intermarket, 115 long straddles, 167 175, 177 180

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