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of testing have their main use in the study of amyotrophic lateral sclerosis (ALS) and related disorders As described in Chap 2, by applying repetitive electrical stimuli to a peripheral nerve, the sensory evoked responses can be recorded from sites along the nerve and plexus as well as in central pathways (the thalamus and somatosensory cortex) These evoked potential tests nd their main use in the diagnosis of multiple sclerosis and in disorders of the sensory nerve roots as discussed in Chaps 2 and 36 Other special nerve conduction techniques are available in many laboratories For details of their performance and interpretation the reader is referred to specialized texts on the subject Discussion of magnetic stimulation, collision techniques, quantitative EMG, etc, can be found in several monographs, such as the ones by Kimura, by Aminoff, and by Brown and Bolton

Repetitive Motor Nerve Stimulation (Jolly Test)

6:

premium in which to liquidate the spread and place the order with your brokerage house Volatility stops Monitoring implied volatility is critical in long neutral delta trading Check the current volatility of the underlying asset regularly, and average the implied volatility of the options on both sides of the market to monitor for changes in the implied volatility for the option Your risk tolerance to decreasing volatility is a personal preference, but we typically recommend no more than 20 percent of the current underlying volatility So, for example, if current volatility is 40 percent on the underlying asset, then we would be looking at no more than an 8-point drop in implied volatility as a trigger for at least minimal rechecking of the probability calculation We also recommend placing a hard stop for the spread based on the theoretical value of the option spread at that price, depending on the risk tolerance of the investor Avoid a volatility trap This risk control is a pre-trade risk management technique Before considering a neutral delta strategy ahead of a market event, news, or report, take the time to investigate the history of implied volatility on the underlying and the options prior to making your trade If you see a signi cant increase in volatility in the days or weeks leading up to the event you are expecting, then others may have already priced any changes into the options market ahead of time It is not uncommon for expected earnings, dividends, or fundamental news for a market to be priced into the options well ahead of the event If you are looking at a long straddle as a potential portfolio hedge

This test of the function of the neuromuscular junction is based on Jolly s observation in 1895 that in myasthenia gravis the strength of muscular contractions progressively declines in response to a train of stimuli By adjusting the amplitude of a stimulus over a nerve to supramaximal range, a maximal CMAP may be obtained for each stimulus With repeated stimuli, each response will have the same waveform and amplitude until fatigue supervenes In a healthy individual, the response follows each stimulus even with rates of stimulation up to 25 per second for periods of 60 s or more before a decrement of the CMAP appears In certain disorders, notably myasthenia gravis, a train of 4 to 10 stimuli at rates of 2 to 5 per second (optimally 2 to 3 per second), the amplitude of the motor potentials decreases and then, after four or ve further stimuli, may increase slightly (Fig 45-4A) A progressive reduction in amplitude is most likely to be found in proximal muscles, but these are not easily stimulated for which reason the locations most commonly used for clinical testing are the accessory nerve in the posterior triangle of the neck (trapezius), the ulnar nerve (hypothenar muscle), the median nerve at the wrist (thenar muscle), and the facial nerve and orbicularis oculi muscle A decrement of 10 percent or more denotes a failure of a proportion of the neuromuscular

junctions that are being stimulated The sensitivity of the procedure is improved by rst exercising the tested muscle for 30 to 60 s The induced failure of neuromuscular transmission in myasthenia is similar to the one produced by curare and other nondepolarizing neuromuscular blocking agents, and both cases can be partially corrected with anticholinesterase drugs such as neostigmine and edrophonium Similar but lesser decremental responses may occur in poliomyelitis, ALS, and certain other diseases of the motor unit or motor nerve, particularly those resulting in the growth of reinnervating nerve twigs The myasthenic syndrome of Lambert-Eaton, often associated with oat-cell carcinoma of the lung, is characterized by a presynaptic blockage of acetylcholine release and produces the opposite defect of neuromuscular transmission to the one recorded in myasthenia gravis During tetanic stimulation (20- to 50-per-second repetitive stimulation of nerve), the muscle action potentials, which are small or practically absent with the rst stimulus, increase in voltage with each successive response until a more nearly normal amplitude is attained (see Fig 45-4B) Exercising the muscle for 10 s before stimulation will cause a similar posttetanic facilitation (200-fold increases are not uncommon) A less important decremental response to slow stimulation may occur, but it is dif cult to discern because of the greatly diminished amplitude of the initial responses Neostigmine has little effect on this phenomenon, but it may be reversed by guanidine and 3,4-diaminopyridine, which stimulate the presynaptic release of ACh The effects of botulinum toxin and of aminoglycoside antibiotics are similar, ie, being active at the presynaptic membrane, they produce an incremental response at high rates of stimulation The single- ber EMG, discussed in a later section, is an even more sensitive method of detecting failure of the neuromuscular junction

Needle Examination of Muscle (Electromyography)