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chosen were those who had failed to derive bene t from medications The bene t with bilateral stimulation of the globus pallidus was somewhat less Several groups have pointed out that cognitive function is not improved and may even decline The ideal patient for deep-brain stimulation is currently considered to be an individual who, to maintain mobility, requires a dose of L-dopa that produces unacceptable dyskinesias and who is constantly cycling between on and off periods Dystonia, when present as part of the native disease or as a result of medication, may also bene t by this treatment However, some patients appear to do very well with the introduction of brain stimulation early in the course of illness Presumably, the high-frequency electrical impulses cause a disruption of local neuronal activity that is the functional equivalent to an ablative lesion, but the effects may be more complex by way of stimulating neurotransmitter release The observed improvement in the L-dopa-induced dyskinesias has recently led to the earlier more liberal use of subthalamic stimulators But as with ablative surgery, the durability of the bene t is uncertain Readjustment of the frequency of the stimulus and breakage of the wire are minor problems Hemorrhage into the basal ganglia and local infection near the stimulator has occurred in a small number of patients so treated The cerebral implantation of embryonic adrenal medullary tissue from 8- to 10-week-old human fetuses has provided a modest but undeniable improvement in motor function (Spencer et al, Freed et al), and some patients also appear to have bene ted from the striatal implantation of human fetal and porcine nigral cells and autologous adrenal cells The study by Freed and colleagues found a small improvement on a global scale that measures functional, psychologic, and neurologic aspects only in younger patients These procedures are hampered by many dif culties, mainly in obtaining tissue and the failure of grafts to survive but also the problem of uncontrollable dyskinesias in some patients Much of the enthusiasm for these procedures has temporarily subsided Investigation into their possible usefulness continues Other Ancillary Treatments Finally, in the management of the patient with Parkinson disease, one must not neglect the maintenance of optimum general health and neuromuscular ef ciency by a planned program of exercise, activity, and rest; expert physical therapy and exercises such as those performed in yoga may be of help in achieving these ends Sleep may be aided by the sopori c antidepressants Postural imbalance and falls can be greatly mitigated by the use of a cane or walking frame A number of excellent exercise programs have been devised speci cally for patients with Parkinson disease, and measures such as massage and yoga have their advocates Our position has been that any activity that keeps the patient active and committed is of great value Speech exercises help the motivated patient Hypotensive episodes respond to 05 mg of udrocortisone (Florinef) each morning Focal dystonias of the foot are partially treatable with local injections of botulinum toxin In addition, the patient often needs a great deal of emotional support in dealing with the stress of the illness, in comprehending its nature, and in carrying on courageously in spite of it.

HyperText Markup Language (HTML) is the language of web pages The HTML language is used to create web page code, which is converted by your browser into the web pages that you see when you browse the Internet HTML supports text, hyperlinks, graphics, and streaming media, such as video clips or sound files that play when you view the web page HTML has evolved into HTML 4 and continues to evolve, Languages such as XHTML, and XML while separate can trace their ancestry back to HTML, To learn more about these, go to http://wwwxhtmlorg/ HTML pages can be created using graphics applications that can translate pages into HTML format You can also create HTML pages using Notepad or another text editor to manually enter the HTML code Follow the steps in Exercise 11-7 to create and view a small HTML web page

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Closely related to Parkinson disease but with a different pathologic basis is a state designated by Adams and colleagues as striatonigral

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to an application server that is networked to the Database Machine An internal Ethernet switch is provided in the Database Machine, but that switch is intended for administration purposes For higher-speed communications and support of other devices, gateway products and media servers can be connected to the Database Machine via InfiniBand, provided there is no change made to the Oracle InfiniBand software on the Database Machine For example, Oracle Exalogic hardware running WebLogic can be connected to the Exadata Database Machine using InfiniBand and provide load balancing and failover integration from the middle tier through a GridLink for Exadata feature in the software Media servers are commonly used as intermediate servers in performing tape backups For example, Sun Fire X4275s or similar servers might serve as Oracle Secure Backup Media Servers Two or more servers are typically configured for high availability and performance and connect the Database Machine into a wider InfiniBand QDR network Where performance requirements are lower, media servers might be connected directly into Ethernet ports The TCP/IP protocol is used over the network connections by Oracle Secure Backup The media servers are also connected to a Fibre Channel SAN that is then attached to a large-scale tape backup device One RMAN channel is set up per tape drive Figure 4-2 illustrates how a typical configuration might look where media servers are provided to connect the Database Machine to a tape

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