Guillain Barre' Syndrome
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Guillain Barre' Syndrome
(Acute Idiopathic Polyneuritis)





Pregnancy and Asthma

Asthma is one of the most common medical problems that can seriously complicate pregnancy. Approximately 3-5 percent of all pregnant women have asthma and 20 percent have some type of allergic disorder. Except in most severe cases, asthma is no bar to normal delivery and cesarean section is no more common than in the nonasthmatic population.

How asthma affects the mother and fetus during pregnancy?

Uncontrolled asthma can have an adverse effect both on the mother and fetus. When asthma is severe less oxygen will reach the lungs. Even from this deficient supply mother sacrifices some share of oxygen for the fetus. On the one hand supply of oxygen is reduced while on another hand it is shared between the mother and fetus. The mother tries to save the fetus at the cost of her suffering and suffers from complications of deficient oxygen.

These complications include hyperemesis gravidorum, vaginal hemorrhage, toxemia, and complicated labor. Despite suffering when the mother can not maintain fetal oxygen supply adequately fetus also suffers. Fetal complications include premature birth, low birth weight, neonatal hypoxia, and fetal death. Sometimes when asthma is severe enough it may even cause the death of the mother. Death is usually from mucous impaction causing asphyxiation or from tension pneumothorax.

In view of these potential problems, asthmatic mothers should realize that they are breathing for two persons. Therefore for the sake of two lives, asthma must remain under control during pregnancy.

Who will get severe asthma during pregnancy?

Generally, it appears that in an equal number of patients asthma improves, worsens, or stays the same during pregnancy. However, the course of asthma is often consistent in an individual woman's successive pregnancies.

Women with more severe asthma prior to pregnancy are more likely to experience severe asthma during pregnancy The peak incidence of flares during pregnancy appears to be between the 24th and 30th week of gestation, particularly in women whose asthma worsens with pregnancy.

Fewer symptoms are experienced by all pregnant asthmatic women during weeks 37-40.

Patients with mild to moderate asthma are likely to improve throughout the pregnancy, particularly during the last trimester but in one-third, that improvement may be followed by postpartum deterioration.

These changes are attributable to the effects of pregnancy rather than the natural course of asthma because most women revert to their pre-pregnancy status within one to three months of the postpartum period.

Which asthma therapy is safe in pregnancy?

On one hand, uncontrolled asthma is dangerous and on the other hand, some asthma medicines are not safe for fetuses. Therefore therapy of asthma during pregnancy requires more care and attention. Following may be helpful in this regard,

What an asthmatic woman do when she detects pregnancy?

Self-management

There is a strong genetic predisposition therefore asthmatic mothers should adopt measures of primary prevention.

Management of acute asthma during pregnancy

Approximately 10-15 percent of pregnant asthmatic women require hospitalization for treatment of status asthmaticus. The condition has been associated with maternal and fetal deaths as well as intrauterine growth retardation. Fetal jeopardy exists when maternal arterial pO2 drops below 60mm Hg.

Acupuncture has proven to be effective in addressing some of the negative side effects of pregnancy such as back pain, fatigue, and even asthma. Book an appointment with AB Acupuncture to experience these positive results for yourself.

Labor and Delivery

The majority of well-managed asthma patients do not show any symptoms of asthma during labor and they may require at the most inhaled beta 2-agonists. Steroids-dependent asthmatic patients may need an extra dose of steroids for the stress of labor. A current protocol is as follows,

Breast Feeding

Medications used in asthma rarely cause problems for infants and therefore breastfeeding should be continued. Infants of the mother receiving theophylline receive less than 1 percent of the drug but in some, it may cause irritability and insomnia. Inhaled beta 2-agonist are safe and appear in a negligible amounts in breast milk. Less than 20 percent of daily physiological requirements would be received by an infant of a mother receiving 50 mg Prednisolone daily.

To ensure the lowest drug concentration in the milk, nursing mothers can take any necessary medication 15 minutes after nursing.






Ginger: A Traveler's Aid

While studying herbal medicine, I noticed an interesting trend that's worth passing along: if a particular herb had a large role in the cuisine of any ancient culture, look further. It usually means that the herb has valid medicinal properties the ancient people figured out centuries before modern medicine ever invented the concept of the research study.

I think ginger falls into that category. A favorite flavoring in Asian cuisine, ginger has a solid history of over 2500 years in Chinese medicine. Used particularly for gastrointestinal problems, it was believed to help improve digestion, calm nausea, and aid in the expulsion of gas from the intestines (the perfect food additive, no?). In western cultures, ginger tea continues to be a common folk remedy for upset stomachs and for morning sickness.

Fortunately for those of us skeptics not a hundred percent sure that two millennia of medicinal use is proof enough of an herb's benefit, modern science has studied ginger fairly thoroughly in at least one area-that of its use in the prevention of motion sickness.

Several recent studies have put ginger to the test in controlling nausea some people experience when riding in a moving or spinning vehicle. One particular study published in Lancet in 1982 gave subjects either ginger or Dramamine prior to giving them a "ride" on a spinning, tilting chair. Those who took ginger experienced far less nausea than those that took Dramamine.

Another study out of Denmark tested ginger versus placebo in subjects who then took to the open sea on a ship. Again, ginger showed effectiveness in controlling nausea commonly associated with seasickness.

I personally prefer ginger because it lacks the side effects of most modern medicines used for motion sickness-namely, fatigue, dry mouth, dizziness, and rapid heartbeat. Whenever I've used Dramamine, for example, I have a difficult time staying awake to enjoy the scenery I went to look at in the first place.

Capsules of ginger usually contain approximately 500 milligrams of dried ginger rhizome and the recommended dose is two capsules up to three times daily. Doses of up to 4 grams per day are considered acceptable. Try some the next time you travel!

A word about ginger and morning sickness: several sources, including the German Commission E Monograph, caution against the use of ginger for the treatment of nausea in pregnancy. None of the sources gave what I thought was a valid reason for the recommendation. My guess is that nobody has tortured enough pregnant lab rats to make any particular recommendation one way or the other about ginger's safety in pregnancy. My personal advice would be to avoid the high-dose capsules containing ginger and to stick to a warm cup of ginger tea instead.

It’s clear to see that there’s a lot we can learn from eastern medicine. If you want to experience more of the benefits of alternative medicine, book an appointment with AB Acupuncture today.






All About Acupuncture

Why are so many Americans looking for oriental medicines for their unresolved health problems? The answer to that question may be found in the nature of the medicine itself.

Your doctor of oriental medicine does not simply look for disease in your body, instead, she or he looks for a global imbalance involving your entire body, mind, and spirit. The condition you're seeking help for can only exist within that imbalance. When balance is restored the condition can no longer exist.

Consequently, the intent of your doctor is to encourage your body's innate healing response -- to promote help, rather than suppress symptoms or pathogens. In this way, the disease is resolved normally. Perhaps more than any other feature, it is this force on your overall health that makes oriental medicine attractive.

Oriental medicine is a refined medical system that has been used for more than three thousand years to diagnose and treat illness, prevent disease and improve well-being. It is effective for physical, psychological, and emotional problems. Acupuncture is one of oriental medicine's most important treatment modalities. While science has recently determined that human beings are complex bioelectric systems, this understanding has been the foundation of acupuncture practice for thousands of years.

Energy circulates throughout the body along defined pathways. Points on the skin along these pathways are energetically connected to specific organs, body structures, and functional systems. If this energy circulation is disrupted, optimal function is effective, resulting in pain or illness. Acupuncture points are stimulated to balance the circulation of energy, which in turn influence the health of the entire being.

Acupuncture needles are quite thin -- about the size of a hair. They are solid and nothing is injected through them. Over the centuries, needle insertion techniques have been refined, enabling the skilled physician to place a needle with little or no sensation. During treatment, various sensations, such as warmth or pleasure may be felt, but these sensations should not be painful.

In some cases, it is not necessary to use needles at all. For example, when treating young children, infants, or sensitive adults, there are other effective techniques. If you have a real fear of needles, discuss it with your doctor.

Treatment with acupuncture is the most commonly used technique in oriental medicine. An equally important, but lesser-known modality is Chinese herbal medicine. This highly evolved science differs from western herbology. Chinese herbs are almost always prescribed in combination, giving the formula a synergistic effect far greater than the sum of its parts. And most formulas are hundreds of years old, with proven clinical effectiveness.

While some disorders are effectively treated with acupuncture, others may respond better to herbal medicine. Often a combination of the two will be appropriate.

Your doctor may use other techniques as well. Moxabustion is an effective form of heat therapy. A variety of manual therapy techniques, such as massage and manipulation are often utilized. And dietary modifications are often an integral part of oriental healing regimens.

Although the roots of oriental medicine are thousands of years old, it is a living, evolving system of health care. Many doctors of oriental medicines employ complementary medicines, such as homeopathy, modern nutritional supplements, contemporary therapeutic exercises, or any number of appropriate techniques to ensure your continued health. A DOM may also utilize a number of diagnostic tests or procedures developed by conventional medical science.

When you visit your doctor of oriental medicine, she or he may suggest appropriate changes in your diet or lifestyle, since these contribute to well-being. The role you play in your healing is often an active one.

This implies a partnership between patient and physician and brings up important considerations. Individual styles and treatment modalities vary widely from doctor to doctor. When choosing a doctor, look for someone you feel comfortable with, who inspires confidence, and who respects you and your needs.

The effectiveness of acupuncture is well documented and is endorsed as a system of primary health care by the World Health Organization. People from all walks of life -- athletes, taxi drivers, diplomats, moms, dads, children, grandparents -- all professionals, all ages benefit greatly: throughout its long history, oriental medicine has established itself as a comprehensive system of health care that works. If you’d like to experience the incredible benefits of this treatment for yourself, visit AB Acupuncture.

Below is a small sample of conditions for which oriental medicine is appropriate:

While regulation of oriental medicine varies from state to state, New Mexico's residents enjoy an outstanding combination of benefits and protection by law. The acupuncture and oriental medicine practice act provide both a broad scope of practice and stringent guidelines for licensing. Upon completion of a four-year educational program, candidates for licensing must demonstrate competence by passing written and practical state board examinations.

Only a doctor of oriental medicine is qualified and licensed to practice acupuncture.

In order to assure your complete confidence, and comply with FDA regulations, DOMs use pre-sterilized, disposable needles. Many health insurance policies, HMOs, worker’s compensations, and auto-accident insurance cover oriental medicine. Your DOMs office can assist you in determining your coverage.






Complications Caused By Gerd

Failure To Thrive

Newborns and young infants are expected to grow at a steady and predictable rate, much more rapidly than they will as they get older. Within the acceptable limits of weight gain, there are those that fall in the high end and those that fall in the low end.

Sometimes; however, babies will not gain weight at an acceptable or safe rate and fall below even the low end of the scale. These babies are labeled as failure to thrive.

Failure to thrive is a general term, and can have many different causes. Causes of failure to thrive tend to be classified as organic (an underlying health issue), or inorganic (external reasons, for example the caregiver). Failure to thrive caused by GERD is classed as organic and is in no way the fault of the caregiver.

GERD can cause failure to thrive a few ways. Even with the most enthusiastic eaters, frequent or constant vomiting of entire feeds will make weight gain, or even maintaining current weight, difficult or impossible.

Adults may have an easier time managing their GERD, and there are long-term solutions available, such as the minimally invasive anti-reflux procedure available at IES Medical Group. For babies, however, there are many specific complications that can make daily life with GERD more difficult.

Even if vomiting isn't present, some babies will begin to associate food with pain and unpleasantness from their reflux and they will begin to develop aversions to eating. They will actually refuse their meals making it difficult to obtain weight gains.

Although there are some things that can help with feeding a stubborn eater, these tricks will work with some children, others actually require tube feeding to gain weight and survive.

Sometimes journaling your child's food intake can help you keep better track of their caloric intake and can help with failure to thrive.

Food and Oral Aversions

As touched on above, associations made by the baby between food and pain can cause some to become difficult to feed, or even stop eating altogether.

As a parent, this can be one of the more frustrating complications since some children are so fearful of food that nothing short of tube feeding can provide the nourishment required. The drawbacks of short term tube feeding— those inserted through the nose—can unfortunately be food and oral aversions.

Inserting feeding tubes can reinforce a baby's bad feelings about anything going into their mouth, as they can have a difficult time separating the two areas of the face.

Gagging and Choking

Babies and children with GERD seem to have a stronger gag reflex than other children and may gag and choke on their food frequently. They may also gag and choke throughout the day for no apparent reason, this is likely from refluxed material coming part of the way up, perhaps into the throat enough to cause a gag, or into the airways enough to temporarily block airflow.

Apnea

Apnea refers to a period of more than ten to twenty seconds of interrupted breathing. Children with GERD are susceptible to apnea episodes because refluxed material can block the airways, preventing air flow.

Aspiration and Aspiration Pneumonia

Aspiration is when food or refluxed material is allowed to enter the lungs. The damage done to the lungs (if any) is determined by the characteristics and amount of aspirated material. The more acidic it is, the more severe the injury to the lungs. Aspiration itself won't cause pneumonia, if the lungs become infected from the aspirated material, pneumonia can occur.

Asthma

It's suggested that more than 75% of people (of all ages) with asthma also have reflux or GERD and those who have asthma are twice as likely to have GERD as those who don't. Read more about the asthma / reflux connection>.

Chronic Cough, Hoarseness, and Laryngitis

Just as acid refluxed from the stomach can damage the esophagus and lungs, it can damage the throat and vocal cords.

In some cases this can be the only symptom of GERD, making it more difficult to diagnose.

Dysphagia and Structures

Dysphagia means difficulty swallowing. The main cause of dysphagia from reflux is severe scarring in the esophagus (strictures) from constant acid exposure. The scar tissue is thicker than the normal lining of the esophagus causing strictures that can basically clog the esophagus and prevent food and even liquids from passing through. Although rarely does it get this severe in infants it is possible if left untreated.

Esophagitis

Inflammation of the esophagus caused by frequent contact with stomach acid.

Anemia

Anemia is caused by blood loss and is defined as a drop in hemoglobin count (distributes oxygen to the body's cells and carries carbon dioxide back to the lungs). Reflux can cause anemia by eating away the esophagus until it begins to bleed.

Like the strictures, it would be rare for it to get this extreme in infants, but again, if left untreated, it's possible.

Eroded Dental Enamel

Stomach acid entering the mouth can erode teeth, just as it does the esophagus, throat, vocal cords, etc.

Barrett’s Esophagus

This occurs when cells in the esophagus change in an attempt at protecting themselves against constant acid exposure. The stomach is protected from the acid it produces by special cells called columnar epithelium cells.

The esophagus has more delicate cells called squamous epithelium which are not designed to protect against acid.

When it becomes chronically burned and damaged from acid exposure, these delicate squamous epithelium cells attempt to protect themselves against further damage by replacing the squamous epithelium cells with a special type of cell similar to the columnar epithelium cells found in the stomach.

It is unknown why, but these changes are precancerous. This is not likely to occur in infants, it takes long term acid exposure for this to occur.

Cancer

Years of untreated GERD can eventually result in esophageal cancer. It is said that the survival rate is low because symptoms usually only appear after it has progressed to other areas of the body.






Heartburn Symptoms Need Attention

Most people think of heartburn as a normal part of life – uncomfortable, but normal. Everyone they know gets heartburn at one time or another. They know the television ads by heart – the ones that show people thumping or rubbing their chests to indicate they have heartburn. Typically, people take an antacid and suffer until the burning sensation passes.

Heartburn symptoms are indeed common, but that is no reason to treat them too lightly. Heartburn symptoms do not happen by accident. They are a warning issued by your digestive system.

Heartburn symptoms must be considered in the context of their closely-related concerns: acid indigestion, acid reflux, acid regurgitation, non-cardiac chest pain, and sour stomach. Heartburn symptoms should also be considered in relation to GERD symptoms.

Heartburn symptoms closely resemble the symptoms of all the above, especially symptoms of acid.

Frequently-described Heartburn Symptoms

Heartburn symptoms are most frequently described as a burning sensation. Some may say they feel heat or warmth in the upper abdomen. Others describe heartburn symptoms as pain in the lower chest.

Heartburn symptoms are most frequently described as a burning sensation. Some may say they feel heat or warmth in the upper abdomen. Others describe heartburn symptoms as pain in the lower chest.

Heartburn symptoms occur behind the sternum – the central breastbone. The location, near the heart, is the reason for the name “heartburn,” but the heart is not involved. Some have described their heartburn symptoms as a feeling that the heart is on fire.

In addition to the burning pain, heartburn symptoms can include trouble swallowing, nausea, gas, and bloating.

Heartburn symptoms last as long as 2 hours for some. Some people have difficulty sleeping due to heartburn symptoms.

Why Heartburn Symptoms Need Attention

Heartburn symptoms, whether mild or serious, occasional or frequent, need attention. Let’s look at some of the reasons, beginning with one of the most serious.

1. Heartburn symptoms can feel much like heart attack symptoms. If you have heart disease or are at risk for heart disease, seek medical attention immediately, even though you believe it may be heartburn. It is not worth risking serious or fatal results.

2. Heartburn symptoms, if frequent, can lead to serious medical concerns such as cancer of the esophagus. The acid that washes back into the esophagus can damage the sensitive linings of the esophagus, and lead to GERD. As it worsens, cancer can develop. Consulting your doctor immediately can help him perform a proper diagnosis and recommend you the right procedure, such as an EsophyX TIF procedure.

3. Heartburn symptoms are not isolated pain. They occur because something is not right in your digestive system. Heartburn symptoms are warnings. Just as you should not ignore warning lights on your car’s dashboard, you should not ignore the warning provided by heartburn symptoms.

Cause of Heartburn Symptoms

Heartburn symptoms are caused by a malfunction of the sphincter muscle at the bottom of the esophagus. This ring of muscle, the lower esophageal sphincter, is known in shorthand as the LES.

The first job of the LES is to open so that swallowed food can enter the stomach. Its second job is to close quickly to keep stomach food and juices from washing back into the esophagus.

When the LES is weakened, pressured, or relaxes inappropriately it malfunctions. Stomach juices, and even bits of food, reflux (washback) into the esophagus. Since the linings of the esophagus are not meant to handle the strong stomach acids, the nerves react with a sensation of burning.

Listen to Heartburn Symptoms

Since heartburn symptoms are the result of a malfunctioning LES, it makes sense to learn why the muscle is malfunctioning.

  1. Does it need more oxygen?
  2. Does it need more potassium or other electrolytes?
  3. Is it dehydrated?
  4. Would exercise strengthen it?

When another muscle malfunctions, we treat the muscle to strengthen it. Ask your physician how to strengthen your lower esophageal sphincter (LES).






Guillain-Barré (Ghee-yaw Bah-ray) Syndrome, also called acute inflammatory demyelinating polyneuropathy and Landry's ascending paralysis, is a disorder of the peripheral nerves, those outside the brain and spinal cord (peripheral nerves and spinal roots are the major sites of demyelination in GBS patients). It is typically characterized by the rapid onset of muscle weakness and often, paralysis of the legs, arms and breathing muscles. The cause of Guillain-Barre' syndrome is not known; and why the disorder only occurs in certain patients is still not known. Research to date indicates that the nerves of the GBS patient are attacked by the body's own defense system against disease-antibodies and white blood cells. As a result of this autoimmune attack, the nerve insulation (myelin) and sometimes even the covered conducting part of the nerve (axon) is damaged.

The rapid onset of (ascending) weakness, frequently accompanied by abnormal sensations and pain that affect both sides of the body similarly, is a common presenting picture, and quite often, the patient's symptoms and physical exam are sufficient to indicate the diagnosis. A lumbar puncture may be performed to find elevated protein levels in the cerebro-spinal fluid to confirm the diagnosis. The severity of Guillain-Barre' syndrome can vary greatly. In its milder form, it may cause a waddling or ducklike gait, and perhaps some tingling and upper limb weakness that may briefly, for days or weeks, impair a patients lifestyle. Some primary care physicians have described patients who complained of mild brief tingling and/or limb weakness accompanying or following a viral illness, such as a sore throat or diarrhea. Such a set of symptoms may represent a very mild form of GBS. In contrast to such mild forms, at the other extreme a GBS patient may become almost totally paralyzed and fraught with complications.

Although the exact percentages vary from study to study for long-term prognosis, up to 85 percent of GBS patients reach nearly complete recovery, although they may suffer chronic problems, such as muscular pain and weakness. Perhaps 5 to 15 percent of GBS patients will have severe long-term disabilities. Less than 5 percent die. GBS can develop in any person at any age, regardless of gender or ethnic background. Most GBS patients' health will improve significantly over time. Among GBS survivors, those patients who experienced their worst symptoms within the first seven days of the illness tend to have a worse outcome. It is important to emphasize that, as in many aspects of medicine the prognosis or expectation for degree of recovery for any particular patient cannot be predicted.

Not infrequently, after apparent recovery from Guillain-Barre' syndrome, patients may experience the recurrence of abnormal sensations, typically in the lower and/or upper limbs. They may consist of numbness, decreased sensations, tingling, burning, a sense of worms crawling under the skin, pain, muscle spasms or cramps in the form of severe Charlie Horses, and a variety of other disconcerting symptoms that the patient may even have difficulty describing.

A particularly frustrating consequence of this disorder is long-term recurrences of fatigue and/or exhaustion as well as abnormal sensations including pain and muscle aches. These problems can occur following the exertion of normal walking or working and can be alleviated by reduction of activity and rest. Many patients learn by trial and error how much activity they can tolerate.

Studies now suggest that the degree of damage or number of diminished axons, the conducting part of nerve cells or, if you will, the wire, rather than damage of its surrounding covering or insulation, the myelin sheath, may explain chronic or long-term damage and paralysis. Such studies are shedding light on some of the long-term effects of GBS. Several years after the recovery phase of the illness, some GBS patients experience symptoms identical to Post-Polio Sequela (Post-Polio Syndrome), a condition affecting many "recovered" Polio survivors.

Sometimes motor axon damage is not severe and the cells can recover much of their function. Other axons may sustain more complete and irreversible damage. Even if this is the case, however, function can often be restored by "sprouting". Motor axons have the ability to send out new branches that can innervate neighboring muscle fibers whose own axons have been destroyed. Nerve cells normally innervate between 200 and 500 individual muscle fibers. If a percentage of motor axons are destroyed, and sprouting takes place, the remaining axons may be innervating as much as four times the normal amount of muscle fiber. Some individuals may have gained a degree of recovery by building up the strength of their remaining musculature by exercise and intense use, similar to athletic training. These individuals, however, used this strength in their daily activity and thus the muscles have been performing continually at a level that is no longer tolerated.

Recurrent abnormal sensations may reflect the presence of residual nerve damage that had occurred during the initial stages of the syndrome's development. Frustration arises because the sensations are truly felt by the patient and can be quite severe or annoying but have no physical correlate outside the body and may be difficult to control. Furthermore, they can be difficult to demonstrate, measure, or otherwise document. One example is the sense of vibration while lying perfectly still in bed. Another example is the feeling of pain without an underlying injury. The pain may be severe enough so that routine analgesic medications don't give relief, and more potent analgesics such as narcotic pain relievers may be considered. The treating physician may be hard pressed to justify use of such drugs for a problem he can't prove exists. Such drugs, however, are relatively safe and there is no occurrence of addiction in these patients when given opioids to control chronic pain.

Persisting abnormal sensations, if sufficiently bothersome, may sometimes respond to a variety of treatment modalities. These can include simple and relatively safe approaches such as over-the-counter analgesics (for pain), including aspirin and acetaminophen. Some people find that the local applications of heat, especially moist heat, or cold may be beneficial. Should these initial measures give inadequate relief, alternative approaches, such as prescription medications, may be entertained, especially to treat persisting pain. For patients with persisting muscle group weakness, various methods (orthotic devices) can be used to circumvent the disability. For example, a dropped foot can be treated with a molded ankle foot orthosis (MAFO), a lightweight plastic device that fits behind the leg and under the foot.

Each case of Guillain-Barre' syndrome is different. It is important to realize that the complications and therefore treatments of Guillain-Barre' syndrome are not predictable. For the most part, treatments are highly individualized.




Articles

Residual Effects Following Guillain-Barre'

Disability After “Recovery” From GBS

What's In a Name? Important Differences
Between GBS, CIDP and Related Disorders

The Vexed Question of Residuals in GBS


Web Sites

Guillain-Barre' Syndrome Articles
https://www.angelfire.com/home/gbs/

GBS/CIDP Foundation International
http://www.gbs-cidp.org/

Guillain Barre' Syndrome Discussion Boards
http://www.gbs-cidp.org/forums/

Harvest Center's Post-Polio Library
http://www.poliosurvivorsnetwork.org.uk/archive/lincolnshire/library/cs_h.html#Harvest

Health, Wellness and Aging with a Disability
http://www.jik.com/hwawd.html

DISCLAIMER
GBS - Guillain-Barre' Syndrome     

Last Update: 11/01/2013