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pre-existent subarachnoid hemorrhage To distinguish between these two types of bloody tap, two or three serial samples of uid should be taken at the time of the LP With a traumatic tap, there is usually a decreasing number of RBC in the second and third tubes Also with a traumatic tap, the CSF pressure is usually normal, and if a large amount of blood is mixed with the uid, it will clot or form brinous webs These are not seen with pre-existent hemorrhage because the blood has been greatly diluted with CSF and de brinated With subarachnoid hemorrhage, the RBC begin to hemolyze within a few hours, imparting a pink-red discoloration (erythrochromia) to the supernatant uid; allowed to stand for a day or more, the uid becomes yellow-brown (xanthocromia) Prompt centrifugation of bloody uid from a traumatic tap will yield a colorless supernatant; only with large amounts of blood (RBC over 100,000/mm3) will the supernatant uid be faintly xanthochromic due to contamination with serum bilirubin and lipochromes The uid from a traumatic tap should contain one or two white blood cells (WBCs) per 1000 RBC assuming that the hematocrit is normal, but in reality this ratio varies widely With subarachnoid hemorrhage, the proportion of WBC rises as RBC hemolyze, sometimes reaching a level of several hundred per cubic millimeter; but the vagaries of this reaction are such that it, too, cannot be relied upon to distinguish traumatic from pre-existent bleeding The same can be said for crenation of RBC, which occurs in both types of bleeding The reason that red corpuscles undergo rapid hemolysis in the CSF is not clear It is surely not due to osmotic differences, insofar as the osmolarity of plasma and CSF is essentially the same Fishman suggests that the low protein content of CSF disequilibrates the red cell membrane in some way The explanation for the rapid phagocytosis of RBC in the CSF, which begins within 48 h, is also obscure The pigments that discolor the CSF following subarachnoid hemorrhage are oxyhemoglobin, bilirubin, and methemoglobin; in pure form, these pigments are colored red (orange to orange-yellow with dilution), canary yellow, and brown, respectively Mixtures of these pigments produce combinations of these colors Oxyhemoglobin appears rst, within several hours of the hemorrhage, becomes maximal in about 36 h, and diminishes over a 7- to 9-day period Bilirubin begins to appear in 2 to 3 days and increases in amount as the oxyhemoglobin decreases Following a single brisk bleed, bilirubin persists in the CSF for 2 to 3 weeks, the duration varying with the number of RBC that were present originally Methemoglobin appears when blood is loculated or encysted and isolated from the ow of CSF Spectrophotometric techniques can be used to distinguish the various hemoglobin breakdown products and thus determine the approximate time of bleeding Not all xanthochromia of the CSF is due to hemolysis of RBC With severe jaundice, bilirubin of both the direct- and indirectreacting types will diffuse into the CSF The quantity of bilirubin is from one-tenth to one-hundredth that in the serum Elevation of CSF protein from whatever cause results in a faint opacity and xanthochromia, more or less in proportion to the albumin-bound fraction of bilirubin Only at levels of more than 150 mg/100 mL does the coloration due to protein become visible to the naked eye Hypercarotenemia and hemoglobinemia (through hemoglobin breakdown products, particularly oxyhemoglobin) also impart a yellow tint to the CSF, as do blood clots in the subdural or epidural space of the cranium or spinal column Myoglobin does not enter.

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Oracle Data Guard provides protection from data corruption by keeping an identical copy of the primary database on the standby site The database on the standby site can be utilized to repair the corruption encountered on the primary database, and vice versa Moreover, the Data Guard redo apply process performs data block integrity checks while applying the redo, and ensures that the corruption on the primary database does not get propagated to the standby Data Guard also helps recover from logical corruption initiated by the user or the application on the primary database by delaying the application of redo to the standby site With the delay in place, if you notice the corruption before it is propagated to the standby, you can stop the apply process and recover the data from the intact copy on the standby You can also use the database Flashback features on the primary or the standby to recover from logical corruption To enable corruption protection with Data Guard, the best practice is to set the database parameter DB_ULTRA_SAFE to DATA_AND_INDEX on the primary and the standby database As stated earlier, setting DB_ULTRA_ SAFE to DATA_AND_INDEX will incur a slight performance overhead on the system, but the benefits of protecting the critical data from corruptions will surely outweigh the impact If performance impact on the primary database becomes an issue, at a minimum, you should enable this parameter on the standby database

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Touch, pressure Spindle afferents Pain and temperature, soma touch (Sharp, lancinating, prickly pain) Slow pain and temperature (Dull, burning, poorly localized pain)

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(C bers) form a discrete bundle, the tract of Lissauer (Fig 8-1A) That Lissauer s tract is predominantly a pain pathway is shown (in animals) by the ipsilateral segmental analgesia that results from its transection, but it contains deep sensory or propriospinal bers as well Although it is customary to speak of a lateral and medial division of the posterior root (the former contains small pain bers and the latter, large myelinated bers), the separation into discrete functional bundles is not complete, and in humans the two groups of bers cannot be differentially interrupted by selective rhizotomy

(See Fig 9-1, page 129) Each sensory unit (the sensory nerve cell in the dorsal root ganglion, its central and peripheral extensions, and cutaneous and visceral endings) has a unique topography that is maintained throughout the sensory system from the periphery to the sensory cortex The discrete segmental distribution of the sensory units permits the construction of sensory maps, so useful to clinicians (see Fig 9-1) This aspect of sensory anatomy is elaborated in the next chapter, which includes maps of the sensory dermatomes and cutaneous nerves However, as a means of quick orientation to the topography of peripheral pain pathways, it is useful to remember that the facial structures and anterior cranium lie in the elds of the trigeminal nerves; the back of the head, second cervical; the neck, third cervical; the epaulet area, fourth cervical; the deltoid area, fth cervical; the radial forearm and thumb, sixth cervical; the index and middle ngers, seventh cervical; the little nger and ulnar border of hand and forearm, eighth cervical rst thoracic; the nipple, fth thoracic; the umbilicus, tenth thoracic; the groin, rst lumbar; the medial side of the knee, third lumbar; the great toe, fth lumbar; the little toe, rst sacral; the back of the thigh, second sacral; and the genitoanal zones, third, fourth, and fth sacrals The distribution of pain bers from deep structures, though not fully corresponding to those from the skin, also follows a segmental pattern The rst to fourth thoracic nerve roots are the important sensory pathways for the heart and lungs; the sixth to eighth thoracic, for the upper abdominal organs; and the lower thoracic and upper lumbar, for the lower abdominal viscera

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