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Manford E, Garg A, Manford M. Drop attacks: a practical guide. Pract Neurol 2024; 24:106-113. [PMID: 37891001 DOI: 10.1136/pn-2023-003791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/29/2023]
Abstract
'Drop attacks' encompass both falls and transient loss of consciousness, but the term is not clearly defined. We offer our definition and explore the differential diagnoses. The most common causes are cardiovascular. We discuss clinical and electrographic criteria that suggest underlying arrhythmia or other serious cardiac disorders that require further investigation, and the potential diagnoses that may underlie these 'worrying syncopes'. Vestibular dysfunction also commonly causes collapses, sometimes without typical vertigo. These two common conditions may coexist especially in the elderly. Falls in elderly people often require assessment through a lens of frailty and multifactorial risk factors, rather than seeking a unitary diagnosis. Some drop attacks may be due to longstanding epilepsy and we discuss how to approach these cases. Functional neurological disorder is a common cause in younger people, for which there may also be clinical clues. We review the rarer causes of collapse that may be described as drop attacks, including cataplexy and hydrocephalic attacks.
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Affiliation(s)
- Evelyn Manford
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anupam Garg
- Cardiology, Royal United Hospital NHS Trust, Bath, UK
| | - Mark Manford
- Neurology, Royal United Hospital Bath NHS Trust, Bath, UK
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Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
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Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
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Affiliation(s)
- Mark Manford
- Neurology, Cambridge University, Cambridge CB2 1TN, UK
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Abstract
Traumatic brain injury (TBI) is one of the commonest presentations to emergency departments and is associated with seizures carrying different significance at different stages following injury. We describe the epidemiology of early and late seizures following TBI, the significance of intracranial haemorrhage of different types in the risk of later epilepsy and the gaps in current understanding of risk factors contributing to the risk of post-traumatic epilepsy (PTE). The delay from injury to epilepsy presents an opportunity to understand the mechanisms underlying changes in the brain and how they may reveal potential targets for anti-epileptogenic therapy. We review existing treatments, both medical and surgical and conclude that current research is not tailored to differentiate between PTE and other forms of focal epilepsy. Finally, we review the increasing understanding of the frequency and significance of dissociative seizures following mild TBI.
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Affiliation(s)
| | - Mark Manford
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK.
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Affiliation(s)
- Mark Manford
- Neurology, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Manford M. Reflections in the rear-view mirror. Two decades of epilepsy 6. ACNR 2020. [DOI: 10.47795/bcdw9725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
For the first series of ACNR in 2001, I wrote a series of articles covering key areas in the management of epilepsy: diagnosis; first line treatment; refractory epilepsy; status epilepticus; women and epilepsy; social effects of epilepsy. Now, 20 years on, it is interesting to review progress.
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Illingworth JL, Watson P, Xu S, Manford M, Ring H. A method for identifying associations between seizures and possible trigger events in adults with intellectual disability. Epilepsia 2015; 56:1812-8. [PMID: 26385590 DOI: 10.1111/epi.13137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Precipitants of seizures are often reported by patients and carers, but the accuracy of these claims remains unknown. Focusing on epilepsy in people with intellectual disability (ID), the aims of this work were to (1) identify a set of methods for assessing the validity of reported seizure triggers in individual patients; and (2) undertake an initial assessment of the ease of implementation and acceptability of the method by applying it to a series of cases. METHODS Data collection materials (developed with carer involvement) consisted primarily of carer diaries of seizure and trigger occurrences. Statistical analysis of diary data was using the self-controlled case series method. Unlike previously used methods, the analysis method included a means of choosing the time window, following trigger exposure, during which changes in seizure likelihood are to be assessed. RESULTS The method developed was trialed in five adults with ID and epilepsy, who had a range of ID severities and living circumstances. Examples of the application of the method in two of the five cases are presented for illustrative purposes. The method was acceptable to participants and most aspects successfully implemented. SIGNIFICANCE This method may be useful for clinicians and researchers wishing to investigate possible triggers in individual patients with epilepsy and ID. It also supports the identification of a statistically defined time window following exposure to a precipitant, during which the risk of developing a seizure is increased. The identification of such a window has value not just in contributing to clinical management, but also in guiding future work into the mechanisms of seizure precipitation.
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Affiliation(s)
- Josephine L Illingworth
- Department of Psychiatry, University of Cambridge, Douglas House, Cambridge, United Kingdom.,NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, Cambridge, United Kingdom
| | - Peter Watson
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge, United Kingdom
| | - Stanley Xu
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, U.S.A.,School of Public Health, University of Colorado, Aurora, Colorado, U.S.A
| | - Mark Manford
- Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.,Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Howard Ring
- Department of Psychiatry, University of Cambridge, Douglas House, Cambridge, United Kingdom.,NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England, Cambridge, United Kingdom.,Cambridgeshire & Peterborough NHS Foundation Trust, Cambridge, United Kingdom
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Okpala O, Von Essen A, Cummins G, Manford M. Teaching NeuroImages: internal carotid artery dissection presenting as Villaret syndrome. Neurology 2014; 82:e110-1. [PMID: 24688102 DOI: 10.1212/wnl.0000000000000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ogechukwu Okpala
- From the Department of Neurology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge Biomedical Campus, UK
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Manford M. Undergraduate neurology in the 21st Century and the bedside tradition. Pract Neurol 2014; 14:72-3. [DOI: 10.1136/practneurol-2013-000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Spyropoulos A, Manford M, Horvath R, Alston CL, Yu-Wai-Man P, He L, Taylor RW, Chinnery PF. Near-identical segregation of mtDNA heteroplasmy in blood, muscle, urinary epithelium, and hair follicles in twins with optic atrophy, ptosis, and intractable epilepsy. JAMA Neurol 2014; 70:1552-5. [PMID: 24126373 DOI: 10.1001/jamaneurol.2013.4111] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Mitochondrial DNA (mtDNA) disorders have emerged as major causes of inherited neurologic disease. Despite being well recognized for more than 2 decades, the clinical presentation continues to broaden. The phenotypic heterogeneity is partly owing to different percentage levels of mutant mtDNA heteroplasmy in different tissues, but the factors influencing this are poorly understood. OBSERVATIONS This case report describes monozygotic male twins with ptosis, optic atrophy, and recent-onset intractable myoclonic epilepsy. The assessment of respiratory chain enzyme activities in the muscle from 1 twin revealed a severe and isolated defect involving mitochondrial complex I. Mitochondrial DNA sequencing revealed a pathogenic m.14487T>C MTND6 mutation, which was present at very high levels of heteroplasmy in muscle (84%) and lower levels in blood (15%), urinary epithelium (75%), and buccal mucosa (58%). Of particular interest, his identical twin was found to harbor very similar levels of the m.14487T>C mutation in his blood, urine, buccal mucosa, and hair follicle DNA samples, while the presence of low levels in the mother's tissues confirmed maternal transmission. CONCLUSIONS AND RELEVANCE It was shown that m14487T>C can also cause the unusual combination of optic atrophy, ptosis, and encephalomyopathy leading to intractable seizures. Near-identical heteroplasmy levels in different tissues in both siblings support a nuclear genetic mechanism controlling the tissue segregation of mtDNA mutations.
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Affiliation(s)
- Achilles Spyropoulos
- Wellcome Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, England
| | - Mark Manford
- Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, England
| | - Rita Horvath
- Wellcome Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, England
| | - Charlotte L Alston
- Wellcome Centre for Mitochondrial Research, Institute of Ageing and Health, Newcastle University, Newcastle Upon Tyne, England
| | - Patrick Yu-Wai-Man
- Wellcome Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, England
| | - Langping He
- Wellcome Centre for Mitochondrial Research, Institute of Ageing and Health, Newcastle University, Newcastle Upon Tyne, England
| | - Robert W Taylor
- Wellcome Centre for Mitochondrial Research, Institute of Ageing and Health, Newcastle University, Newcastle Upon Tyne, England
| | - Patrick F Chinnery
- Wellcome Centre for Mitochondrial Research, Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, England
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Manford M. Using Option Grids: a referee's commentary. Pract Neurol 2014; 14:4-5. [PMID: 24453268 DOI: 10.1136/practneurol-2013-000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Agarwal S, Manford M. Acute Korsakoff's Psychosis and Disinhibition Syndrome Triggered by a Cortical Posterior Cerebral Artery Infarction (P07.182). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p07.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Fuller G, Manford M. Disorders of the motor neurone. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00055-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Multiple sclerosis II. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00044-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Fuller G, Manford M. Parkinson's disease and other akinetic rigid syndromes II. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Fuller G, Manford M. Transient ischaemic attacks and prevention of strokes. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Fuller G, Manford M. Cranial nerves 1, 3–6. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00012-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Fuller G, Manford M. Nerve conduction studies and electromyography. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fuller G, Manford M. The autonomic nervous system. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00058-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Common peripheral nerve lesions. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00054-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Fuller G, Manford M. Other movement disorders. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00047-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Fuller G, Manford M. Peripheral neuropathies I. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00052-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Fuller G, Manford M. Sleep and sleep disorders. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Gait, coordination and abnormal movements. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Disorders of the neuromuscular junction. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Fuller G, Manford M. Organization of the nervous system. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00004-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Numbness and sensory disturbance. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Fuller G, Manford M. Confusion and delirium. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Fuller G, Manford M. The eyes and visual system. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Intracranial pressure. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Neurology and psychiatry. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Multiple sclerosis I. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00043-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Pathological processes in neurology. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Infections of the nervous system II. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00051-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Fuller G, Manford M. Disturbances of vision. Neurology 2010. [DOI: 10.1016/b978-0-7020-3224-0.00029-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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