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Several more recently discovered antibodies, such as CRMP-5 and anti-Ma1 and -Ma2, have been detected in cases of brainstem encephalomyelitis; the latter cross-react with testicular antigens (Dalmau et al; Voltz et al) While rare, the clinical syndromes associated with the anti-Ma antibody and testicular tumors have been diverse: limbic, brainstem, or hypothalamic in ammation and an ataxicopsoclonic syndrome that is more typical of anti-Ri antibody (see above) The more recently discovered antibody CRMP-5 (colapsinresponsive mediator protein) is reported to be second in frequency to anti-Hu Lung carcinoma has been the most common source in the series of Yu and colleagues, with thymoma, renal cell, and other

Notice the capacitors in this circuit The operation of any voltage multiplier is dependent on the ability of these capacitors to hold a charge, even when a load is connected to the output of the supply Thus, the capacitors must have large values If the intent is to get a high dc voltage from the supply, massive capacitors will be necessary Also, notice the resistors in series with the diodes These have low values, similar to those needed when diodes are connected in parallel When the supply is switched on, the capacitors draw a huge initial charging current Without the resistors, it would be necessary to use diodes with astronomical Io ratings Otherwise the surge current would burn them out

In addition to subacute degeneration of spinal cord tracts that may be associated with paraneoplastic cerebellar degeneration (see

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In addition to 1 week of restricted activities and supportive care, the patients should wear compressive chin/neck strap dressings for 2 to 3 weeks postoperatively to promote healing and recontouring in the submental region Pain is minimal and there are no dietary restrictions Sleeping with the head of the bed elevated will promote lymphatic drainage and help with postoperative edema Most patients return to work after 1 week

neoplasms accounting for a few of the cases The clinical features have been as diverse as for anti-Hu, including seizures, dementia, confusion, depression, as well as a variety of peripheral and cranial neuropathies and, surprisingly, the Lambert-Eaton syndrome Optic Neuropathy An optic neuropathy is the most speci c associated syndrome with the CRMP antibody, as described by Cross and colleagues There is subacute visual loss, disc swelling, and a cellular reaction in the vitreous Most patients have features of another paraneoplastic syndrome Others have remarked on the occurrence of chorea as a presenting symptom and basal ganglionic changes in MRI It is dif cult for us to make sense of the clinical features aside from the optic neuropathy (really an optic neuritis), but they suggest a type of perivenous in ammatory encephalitis and neuritis comparable to the anti-Hu syndromes Presumably this antibody accounts for some of the odd subacutely progressive syndromes previously thought to be antibody-negative; testing for this antibody might be included when an odd paraneoplastic syndrome is suspected The heterogeneity of antibody response to these expressed proteins may account for different clinical manifestations of the immune process, but there is no certain evidence yet of their pathogenetic role Stiff-Man Syndrome Occasionally this disorder (page 1279) occurs as a paraneoplastic syndrome Lesser degrees of unexplained mild rigidity are seen from time to time, due perhaps to loss of spinal cord interneurons In what might be called stiff-woman syndrome, Folli and associates have described three patients with breast cancer who developed a state of generalized motor hyperexcitability and rigidity These patients generally have no antibodies to glutamic acid decarboxylase, as in the sporadic cases of stiffman syndrome ; probably there are antibodies to other synaptic proteins Retinopathy In recent years, there have been several reports of retinopathy as a paraneoplastic syndrome that is distinct from the above-described optic neuropathy Small-cell carcinoma of the lung has been the most common underlying malignancy In about half of the reported cases, retinal symptoms preceded the discovery of the tumor by several months The lesion is in the photoreceptor cells, and antiretinal antibodies (directed against a calcium-binding protein, recoverin) have been identi ed in the serum Photosensitivity, ring scotomas, and attenuation of the retinal arterioles are the main clinical features; Jacobson and coworkers have suggested that they constitute a diagnostic triad The Lambert-Eaton syndrome is the most common paraneoplastic syndrome; it is associated with antibodies directed against calcium channels, as mentioned earlier This disorder is discussed on page 1259 Basal ganglia syndromes, chorea in particular, are associated with the anti-Hu and CRMP-5 antibodies as already noted A myoclonus syndrome without ataxia or opsoclonus is reported from time to time in the literature and probably is a derivative of one of the better characterized antibody diseases Another peculiar syndrome associated with prostate cancer, which we have encountered only once, was described by Baloh and colleagues prior to the discovery of most of the currently known paraneoplastic antibodies These patients display brainstem signs, particularly loss of horizontal gaze, and facial and pharyngeal spasms or abdominal myoclonus Whether this process will be subsumed under one or another of the known antibody syndromes is.

390 Power supplies This circuit subjects the diodes to a PIV of 28 times the rms ac input voltage Therefore, they should be rated for PIV of at least 42 times the rms ac input voltage In this circuit, each capacitor charges to the peak ac input voltage when there is no load (the output current is zero) As the load draws current, the capacitors will have trouble staying charged to the peak ac input voltage This isn t much of a problem as long as the load is light, that is, if the current is low But,for heavy loads, the output voltage will drop, and it will not be smooth dc The major difference between the voltage doubler and the supplies discussed previously, besides the increased output voltage, is the fact that the dc output is filtered The capacitors serve two purposes: to boost the voltage and to filter the output Additional filtering might be wanted to smooth out the dc still more, but the circuit of Fig 21-7 is a complete, if crude, power supply all by itself

not known, but it is notable because prostate cancer otherwise rarely gives rise to paraneoplastic disease Isolated case reports relating neuromyelitis optica and optic neuritis to neoplasm cannot presently be evaluated

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