text:
List of Big Brother 3 houseguests (U.S.)
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The third edition of the American reality series Big Brother featured twelve houseguests competing for the grand prize.
Contents
[hide]
1 Amy
2 Chiara
3 Danielle
4 Eric
5 Gerry
6 Jason
7 Josh
8 Lisa
9 Lori
10 Marcellas
11 Roddy
12 Tonya
13 References
Amy[edit]
Amy Crews Ouellette was a real estate appraiser from Memphis, TN.[1] Amy was often seen as snobby and conceited by her fellow HouseGuests, and fellow HouseGuest Roddy went as far as stating that Amy "puts herself ahead of other people", and believed she felt as though she was "more important than the others in the house". In the first few weeks, Amy and Marcellas had a close bond and friendship in the game, though it was ultimately strained after the two were nominated together. She had a strong dislike of Chiara in the game, and often referred to her as "Chi-Whore-A" behind her back. The first night, Amy became a member of the six person alliance that consisted of herself, Gerry, Eric, Chiara, Lisa and Josh, but quickly cut ties with them by the end of the first week. Amy was nominated during the first week as a replacement nominee for Marcellas, who was saved with the Power of Veto. She survived the eviction in a five to four vote. Amy was nominated for a second time in the third week, this time alongside good friend Marcellas. Being on the block together ultimately led to the two friends having a falling out, and Amy's eviction on Day 27. Following her eviction, Amy was sequestered along with Lori, Tonya and the next evictee Eric. Amy and Eric won the chance to re-enter the game on Day 41, with the current HouseGuests deciding who would return. They voted for Amy to return in a five to two vote. Following her return to the game, Amy won the endurance Head of Household competition, her first win of the season. She nominated Chiara and Roddy for eviction, with the former being evicted that week. Following this win, Amy was nominated four consecutive times afterwards. She won the eighth Power of Veto competition, but could not use it on herself as it was the Silver Power of Veto. She was evicted for a second time on Day 76, with Jason casting the sole vote to evict her. She came in fourth place, and voted for Lisa to win.
Since her appearance on Big Brother 3, Amy has returned to the series numerous times. Amy appeared in a segment during Big Brother: All Stars, in which she talked about Marcellas's gameplay thus far. She made a third appearance during a food competition in Big Brother 10, which featured a representative for each previous season. Amy has since been married, and now goes by the name Amy Crews Ouellette. She is the author of the poetry book Conglomeration, and is currently working on her first novel.
Chiara[edit]
Chiara Jude Berti was a 25-year-old marketing representative from New York City.[2] While in the house, Chiara had a flirtatious and somewhat romantic relationship with Roddy. She and Roddy were a part of the 'Couples Alliance', along with Lisa and Eric. Chiara was very open about her sex life, and often teased HouseGuest Jason about being a virgin. She did not get along well with Amy, and didn't have a good relationship with Josh while in the house. Chiara won the fourth Power of Veto competition, and chose not to use it. She was the fifth Head of Household, and nominated Josh and Roddy for eviction, with the former being evicted. Chiara annoyed her fellow HouseGuests after her HoH win, which ultimately led to her nomination and subsequent eviction the following week on Day 48. She came in eighth place, and voted for Lisa to win. Since Big Brother 3, Chiara has gotten married and had two children.
Danielle[edit]
Main article: Danielle Reyes
Danielle Reyes (born January 22, 1972), 45, was a media buyer from Fairfield, California.[3] Danielle became a teenage mother while in high school, and later had another child. While in the house, Danielle had friendships with the majority of the cast. She became known for her Diary Room entries, in which she often made fun of her fellow HouseGuests. She also gained notability for the "countdown", in which she would countdown the number of HouseGuests remaining until the Final Two. She had a secret alliance with Jason that was formed during the first week, in which the two would strategize while playing chess or cards. The secret alliance managed to get to the Final Three together uncaught, until Jason's eviction on Day 78. Danielle won the second Power of Veto of the season, and chose to leave Marcellas's nominations intact that week. She went on to win the tenth Head of Household of the season, and nominated Amy and Lisa for eviction, resulting in Amy's eviction. She managed to escape being nominated throughout the entire game, and was only technically nominated on Day 78, when Lisa won the Final Head of Household competition and immediately had to choose to evict either Jason or Danielle; she chose to evict Jason. On Day 82, Danielle became Runner-up of Big Brother 3 in a nine to one vote, only receiving the vote of alliance member Jason. The jury vote was a source of controversy for fans of the series, who blamed Danielle's Diary Room entries for her loss.[4] Following this season, Big Brother 4 saw the evicted HouseGuests being sequestered until after the series finale, and they were not shown Diary Room sessions or private conversations. Danielle is seen as one of the great players to ever play the game by fans of the series.[5]
Following her appearance on this season, Danielle returned in 2006 for Big Brother: All Stars, where she ultimately came in sixth place.
Eric[edit]
Eric Ouellette was a firefighter from Milford, Connecticut.[6] While in the house, Eric had a romantic relationship with Lisa, and the two were members of the 'Couples Alliance' with Chiara and Roddy. He won the third Power of Veto competition of the season, and chose not to save either Amy or Marcellas. The following week, Eric was nominated for eviction alongside Lisa. When the Veto was not used, Eric was evicted in a tie-breaker vote, with Head of Household Gerry casting the final vote to evict him. On Day 41, Eric was given the chance to return to the house, but ultimately did not get to re-enter the game. He came in tenth place, and voted for Lisa to win.
Gerry[edit]
Gerald "Gerry" Lancaster was a teacher from Shadow Hills, California.[7] While in the house, Gerry had a close friendship with the majority of the HouseGuests, though he was a victim of numerous personal attacks from HouseGuest Josh during the first two weeks. Gerry won the first Power of Veto of the season, and later chose to remove Marcellas from the block as he believed he had been nominated due to racism and homophobia. The decision upset numerous HouseGuests, leading to Josh's attacks. Gerry won the fourth Head of Household competition of the season, and nominated Eric and Lisa for eviction; Eric was evicted that week with Gerry casting the tie-breaker vote. He also won the sixth Power of Veto competition, and chose to leave Chiara and Roddy on the block. The following week, Gerry was nominated for eviction by Head of Household Jason, and was ultimately evicted on Day 55 in a four to zero vote. He came in seventh place, and voted for Lisa to win.
Jason[edit]
Main article: Jason Guy (Big Brother contestant)
Jason Martin Guy (born June 22, 1977), 36, was a videographer from Mobile, Alabama.[8] He is a born-again Christian, and his religion played an important role in his life both inside and out of the Big Brother house. He had a close friendship with Chiara in the house, and had a secret alliance with Danielle, with the two helping each other get to the Final Three together. Jason was the seventh Head of Household of the season, and later won the Power of Veto that same week. He won the ninth Head of Household competition, making him the second person to win two Head of Household competitions this season. Both Jason and ally Danielle managed to avoid being nominated until the Final Three, when they both failed to win the Final Head of Household competition. Lisa won the Final HoH, and chose to evict Jason from the house on Day 78. He came in third place, and was the sole vote for Danielle to win.
Josh[edit]
Josh Feinberg was a waiter from Long Island, New York.[9] While in the house, his bossy and constant scheming caused him to be disliked by the majority of the HouseGuests, though he had somewhat of a friendship with Roddy and Eric. He was nominated the second week by Marcellas, but he survived the eviction. He was nominated for a second time by Chiara, and was evicted on Day 41. He came in ninth place, and voted for Lisa to win. Following his appearance on the show, Josh posed for Playgirl magazine.
Lisa[edit]
Main article: Lisa Donahue
Lisa Donahue (born February 4, 1976), 38, was a bartender from Los Angeles.[10] While in the house, Lisa had a romantic relationship with Eric, and the two were members of the 'Couples Alliance' with Chiara and Roddy. She avoided confrontation while in the game, though did have a verbal argument with HouseGuest Josh shortly before his eviction. Lisa was the first Head of Household of the season, after winning the "Wheel of First Impressions" competition. She nominated Lori and Marcellas for eviction, and later nominated Amy as a replacement nominee for Marcellas. Lisa was nominated in the fourth week alongside romantic partner Eric, though she survived the eviction after Gerry broke a tie in her favor. She won the fifth Power of Veto competition, and chose to leave ally Chiara's nominations the same. Lisa was nominated for a second time in the Final Four, but was not evicted as Danielle and Jason believed they could beat her in the Final Head of Household competition. Lisa won Round 1 of the Final HoH competition, and on Day 78 became the Final HoH of the season. She cast the sole vote to evict Jason. On Day 82, Lisa was crowned the Winner of Big Brother 3 in a nine to one jury vote, earning the $500,000 grand prize. Following her appearance on the season, Lisa was a candidate for Big Brother: All Stars in 2006, but ultimately was not chosen to compete during the season.
Lori[edit]
Lori Olson was a bank representative from Superior, Wisconsin.[11] She was nominated in the first week by Head of Household Lisa, who nominated Lori as a pawn to get Marcellas evicted. When Gerry used the Power of Veto to remove Marcellas from the block, Amy was named the replacement nominee. Lori had an explosive argument with Danielle when she became offended that the other HouseGuests were gossiping about Gerry's hygiene when he wasn't around. She came in twelfth place, and voted for Lisa to win.
Marcellas[edit]
Main article: Marcellas Reynolds
Marcellas Reynolds was a fashion designer from Chicago, Illinois.[12] While in the house, he had a close relationship with Amy, though it was later strained after they were nominated together. He strongly disliked Josh while in the house, and often said negative things about Tonya. Marcellas was nominated the first week, but was later saved by the Power of Veto after Gerry chose to use it on him. He won the second Head of Household competition of the season, nominating Josh and Tonya for eviction. Tonya was evicted that week. The following week, Marcellas was nominated for a second time, but survived the eviction on Day 27. He won the eighth Head of Household competition of the season, and nominated Amy and Roddy, leading to Roddy's eviction. This win made Marcellas the first HouseGuest to win two HOH competitions this season. The following week, Marcellas was nominated for eviction by Jason. Marcellas went on to win the first Golden Power of Veto in Big Brother history that week, and later made the shocking decision to not use the Veto. Marcellas stated that he believed he would not be evicted, and didn't want Jason to have to choose to nominate either Danielle or Lisa in his place. The decision ultimately proved to be a bad one, as Marcellas was evicted in a tie-breaker vote that night. The move is often regarded as one of the worst moves in Big Brother history by fans of the show. He came in fifth place, and voted for Lisa to win.
Following his appearance on the season, Marcellas co-hosted House Calls: The Big Brother Talk Show, an Internet talk show that was available at CBS.com. Marcellas returned on Big Brother: All Stars in 2006, where he came in ninth place.
Roddy[edit]
Roddy Mancuso was a writer from Morristown, New Jersey.[13] He had a flirtatious and somewhat romantic relationship with Chiara in the house, and the two were in the 'Couples Alliance' with Eric and Lisa. Roddy was the third Head of Household of the season, nominating Amy and Marcellas for eviction. He was ultimately evicted on Day 62, in a unanimous three to zero vote. He came in sixth place, and voted for Lisa to win.
Tonya[edit]
Tonya Paoni was a retail sales specialist from Las Vegas, Nevada.[14] She was nominated for eviction in the second week by Head of Household Marcellas. Tonya was evicted on Day 20 in a five to three vote. Tonya has since changed her name to Tonya Casper and was later sent to jail on a million dollars bond for reckless homicide.[15]
References[edit]
Jump up ^ "Amy". CBS. Retrieved February 28, 2009.
Jump up ^ "Chiara". CBS. Retrieved February 28, 2009.
Jump up ^ "Danielle". CBS. Retrieved February 28, 2009.
Jump up ^ http://www.csnetserver.com/lisadonahue/index.htm
Jump up ^ http://www.ew.com/ew/article/0,,20400144_355372,00.html
Jump up ^ "Eric". CBS. Retrieved February 28, 2009.
Jump up ^ "Gerry". CBS. Retrieved February 28, 2009.
Jump up ^ "Jason". CBS. Retrieved February 28, 2009.
Jump up ^ "Josh". CBS. Retrieved February 28, 2009.
Jump up ^ "Lisa". CBS. Retrieved February 28, 2009.
Jump up ^ "Lori". CBS. Retrieved February 28, 2009.
Jump up ^ "Marcellas". CBS. Retrieved February 28, 2009.
Jump up ^ "Roddy". CBS. Retrieved February 28, 2009.
Jump up ^ "Tonya". CBS. Retrieved February 28, 2009.
Jump up ^ http://www.tmz.com/2010/06/16/big-brother-3-star-arrested-for-double-homicide-tonya-paoni-casper/
[show]
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[show]
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text:
Nigerian English
From Wikipedia, the free encyclopedia
Jump to: navigation, search
For the pidgin, see Nigerian Pidgin.
This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (July 2010) (Learn how and when to remove this template message)
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An example of an educated woman speaking with a Nigerian accent
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Nigerian English, also known as Nigerian Standard English, is a dialect of English spoken in Nigeria.[1] It is based on British English, but in recent years, because of influence from the United States of America, some words of American English origin have made it into Nigerian English.[which?] Additionally, some new words and collocations have emerged from the language, which come from the need to express concepts specific to the culture of the nation (e.g. senior wife).[2]
Nigerian Pidgin, a pidgin derived from English, is mostly used in informal conversations, but the Nigerian Standard English is used in politics, formal education, the media, and other official uses.
See also[edit]
Nigeria portal
Language portal
References[edit]
Jump up ^ "Nigerian English". Encarta. Microsoft. Archived from the original on 9 September 2010. Retrieved 17 July 2012.
Jump up ^ Adegbija, Efurosebina. (1989) "Lexico-semantic variation in Nigerian English", World Englishes, 8(2), 165–177.
Further reading[edit]
Kortmann, Bernd (2004). A Handbook of Varieties of English: Morphology and syntax. 2. Walter de Gruyter. p. 813. ISBN 3110175320.
Cheshire, Jenny (1991). English around the world - Sociolinguistic perspectives. Cambridge University Press. p. 514. ISBN 0521330807.
Faraclas, Nicholas G. (1996). Nigerian Pidgin. Routledge. p. 2. ISBN 0415022916.
Ngefac, Aloysius (2008). Social differentiation in Cameroon English. Peter Lang. p. 19. ISBN 9781433103902.
Ihemere, Kelechukwu U. (2007). A Tri-Generational Study of Language Choice & Shift in Port Harcourt. p. xvi. ISBN 1581129580.
[show]
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Calzone
From Wikipedia, the free encyclopedia
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Not to be confused with canzone.
This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (January 2016) (Learn how and when to remove this template message)
Calzone
A fried calzone from Apulia in southern Italy
Type
Turnover
Place of origin
Italy
Region or state
Apulia, Abruzzo, Campania, Calabria, Sicily, Sardegna, Basilicata
Main ingredients
ricotta, mozzarella, salami/ham, parmesan/pecorino
Variations
tomato, provolone, anchovies, olives, onions, chards, minced meat, fish, cabbage
Cookbook: Calzone Media: Calzone
Part of a series on
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Calzone topped with tomato sauce, cheese, pine nuts and pesto, as served in Theix, France
A calzone (US: /kælˈzoʊneɪ, -ni, -ˈzoʊn/, UK: /kælˈtsoʊni, -neɪ/; Italian: [kalˈtsoːne], "stocking" or "trouser")[1] is an Italian oven-baked folded pizza[2] that originated in Naples.[3] A typical calzone is made from salted bread dough, baked in an oven and is stuffed with salami, ham or vegetables, mozzarella, ricotta and Parmesan or pecorino cheese, as well as an egg.[3] Different regional variations on a calzone can often include other ingredients that are normally associated with pizza toppings.
Contents
1 Regional variations
1.1 In Italy
1.2 In the United States
2 Cultural notes
3 See also
4 References
5 Bibliography
Regional variations[edit]
In Italy[edit]
Sandwich-sized calzones are often sold at Italian lunch counters or by street vendors, because they are easy to eat while standing up or walking.[4] Fried versions of the calzone are typically filled with tomato and mozzarella: these are made in Apulia and are called panzerotti.[5]
The Sicilian cuddiruni or cudduruni pizza is distantly related to the calzone. This is a dish stuffed with onions (or sometimes other vegetables, such as potatoes or broccoli), anchovies, olives, cheese and mortadella; the rolled pizza dough is folded in two over the stuffing and the edges are sealed before the dish is fried.
In the United States[edit]
In the United States, calzones are typically made from pizza dough and stuffed with meats, cheeses and vegetables. Traditional calzone dough consists of flour, yeast, olive oil, water and salt. Calzones are similar to stromboli; traditionally, though, the two are different dishes.
As a rule, calzones are usually stuffed with cheeses such as ricotta, mozzarella, Parmesan, provolone or a different local cheese. The dough is folded into a half-moon shape, then either sealed with an egg mixture or shaped into a sphere. It is then either baked or fried. After being cooked, calzones might be served with marinara sauce, or alternatively topped with a combination of garlic, olive oil, and parsley: this depends on the region.
Scacciata is a similar dish to a calzone; however, this dish is normally filled with either broccoli, spinach, potatoes or onions, and sometimes sausage.
Cultural notes[edit]
In Italy, calzones are popularly believed to be the most efficient type of pizza for home delivery.[6] This popular credence has some scientific ground as the folded nature of the calzone results in a lower surface-to-volume ratio than a traditional pizza resulting in better heat retention during the journey from the pizzeria to the buyer's home. This results in a calzone being delivered warmer than pizza all things equal. Nowadays pizza delivery motorbikes have electrically heated bags to keep pizzas warm during the journey, but the preference towards calzone when ordering for home delivery remains; probably more as a tradition than for the heat retention advantages offered by the calzone.
See also[edit]
Food portal
List of Italian dishes
Panzerotti
Pepperoni roll
Pizza puff
References[edit]
Jump up ^ "dictionary.com". Dictionary.reference.com. Retrieved 2012-11-07.
Jump up ^ "calzone | Jamie Oliver | Food | Recipes (UK)". Jamie Oliver. Retrieved 2012-11-07.
^ Jump up to: a b Gosetti (1967), p.785
Jump up ^ MacKenzie, Shea (1995). The Pizza Gourmet. Garden City Park, N.Y.: Avery Pub. Group. pp. Preface iv. ISBN 089529656X.
Jump up ^ Annamaria Settanni McDonald. "Puglia panzarotti". Justapinch.com. Retrieved 2012-11-07.
Jump up ^ Gosetti (1967), p.787
Bibliography[edit]
Wikimedia Commons has media related to Calzone.
Look up calzone in Wiktionary, the free dictionary.
Gosetti Della Salda, Anna (1967). Le ricette regionali italiane (in Italian). Milano: Solares.
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Jeff Beal
From Wikipedia, the free encyclopedia
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Not to be confused with Jeffrey Beall, a librarian.
This biography of a living person needs additional citations for verification. Please help by adding reliable sources. Contentious material about living persons that is unsourced or poorly sourced must be removed immediately, especially if potentially libelous or harmful. (March 2013) (Learn how and when to remove this template message)
Jeff Beal (born June 20, 1963) is an American composer of music for film, television, recordings, and the concert hall. Highly regarded as a jazz instrumentalist and versatile composer, Beal's music often incorporates a synthesis of improvisatory and composed elements.
Contents
[hide]
1 Early life
2 Jazz career
3 Film and television composing
4 Later life
5 Selected film credits
6 Selected television credits
6.1 Discography
7 References
8 External links
Early life[edit]
Beal was born in Hayward, California,[1] and began trumpet studies in the third grade after attending a school music assembly at Castro Valley's Marshall Elementary School with his father. Upon hearing the trumpet played, he chose it as his instrument. Beal's grandmother, Irene Beal, was an accomplished pianist, professional silent-movie accompanist, and fan of trumpeter Miles Davis. She gave Jeff a recording of Miles' collaboration with Gil Evans, Sketches of Spain. Beal wrote his first long-form composition for the Oakland Youth Symphony Orchestra while a student at Castro Valley High School. OYSO conductor Kent Nagano had Jeff combine his love of jazz improvisation with an orchestral accompaniment. This merging of improvisation with classical composition has remained a hallmark of Beal's music. Beal went on to study composition and trumpet at the Eastman School of Music in Rochester, New York,[2] and graduated in 1985 with a Bachelor of Music degree. [3]
Jazz career[edit]
Beal married fellow Eastman graduate, soprano Joan (Sapiro) Beal,[2] and the pair moved from Rochester to New York City. It was there Beal composed and recorded his debut album, Liberation, for Island Records. Beal's jazz band went on to perform at The Blue Note and the Montreaux Jazz Festival. At the request of Chick Corea, Beal composed and recorded a concerto for the virtuosic jazz bassist, John Patitucci, for Corea's Stretch Records label. Beal's signature work, Alternate Route, was composed for improvised trumpet and orchestra. Written fifteen years after his first long form composition, this piece was again premiered by Kent Nagano and the Berkeley Symphony Orchestra, with Beal as trumpet soloist. He has also composed improvisatory concerti for Dave Samuels, Larry Coombs, and Turtle Island String Quartet.[4]
Film and television composing[edit]
In the mid-1990s, Beal relocated to Los Angeles. His first critical notice came in 2001, for his minimalist Americana score to Ed Harris' directorial debut, Pollock. He has since been nominated for seventeen Emmy Awards, and has won four, one in 2007 for dramatic underscore to the TNT miniseries Nightmares & Dreamscapes Battleground episode, one in 2003 for his main theme to the USA Network detective series Monk, and the other for a documentary aired during the 2002 Winter Olympics entitled Peggy & Dorothy. Other Emmy nominations include HBO's evocative Depression era series, Carnivàle and epic drama Rome, as well as four nominations and one win for Netflix's House of Cards.[5]
Beal is noted for composing most of his music at his home, without assistants or orchestrators, playing most of the instruments himself. For the music from House of Cards, he added strings through recording a 17-piece string ensemble, which he invited to record in the living room of his home.[2]
Later life[edit]
Beal has disclosed that in 2007 he was diagnosed as suffering from multiple sclerosis. Beal attributes the stabilization of the disease symptoms in part to his busy schedule and the concentration required to compose, as well as treating his MS as a vascular disease with lifestyle intervention and venoplasty treatment. [2]
Selected film credits[edit]
Pollock
The Situation
Where God Left His Shoes
Emmanuel's Gift
Realms of the Unreal
The Deal
He Was a Quiet Man
Appaloosa
Ring of Steel
Spirit of the Marathon
Jesse Stone
The Passion of Ayn Rand
Spirit of the Marathon II
Blackfish
An Inconvenient Sequel: Truth to Power
Selected television credits[edit]
GCB
Carnivàle
Rome
Ugly Betty
Nightmares & Dreamscapes
Back When We Were Grownups
Door to Door
The Wool Cap
Monk
In Plain Sight
House of Cards
Medium
Discography[edit]
Year
Album
U.S.
UK
RIAA Certification
BPI
1987 Liberation — — — —
1988 Perpetual Motion — — — —
1991 Objects in the Mirror — — — —
— Three Graces — — — —
— Contemplations — — — —
— The Gathering with Joan Beal — — — —
— Alternate Route — — — —
— Red Shift — — — —
— Pollock Original Soundtrack to film by Ed Harris — — — —
— Monk — — — —
— Tibet: Cry of the Snow Lion — — — —
— Carnivàle — — — —
— Rome — — — —
— Jesse Stone — — — —
References[edit]
Jump up ^ http://www.jeffbeal.com/Pages/PressPages/JeffBealBio.html
^ Jump up to: a b c d Tim Grieving, A wrong note sets the right mood in "House of Cards". NPR Music, February 26, 2015. Retrieved 2016-11-19.
Jump up ^ http://www.esm.rochester.edu/news/2011/05/alumnus-and-emmy-winning-composer-jeff-beal-is-eastman-school-of-musics-commencement-speaker/
Jump up ^ https://itunes.apple.com/us/artist/jeff-beal/id6804481
Jump up ^ http://www.imdb.com/name/nm0063618/awards?ref_=nm_awd
External links[edit]
Official website
Jeff Beal on IMDb

Authority control
WorldCat Identities
VIAF: 49410695
LCCN: no90005215
ISNI: 0000 0001 1443 5791
GND: 135080142
SUDOC: 078156475
BNF: cb13928634f (data)
MusicBrainz: 742dd300-528c-4e27-9e16-587d4c1d5ef6
BNE: XX1501729
IATH: w65f3d8j
Retrieved from "https://en.wikipedia.org/w/index.php?title=Jeff_Beal&oldid=796172622"
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Chronic inflammatory demyelinating polyneuropathy
From Wikipedia, the free encyclopedia
Jump to navigation Jump to search
Chronic inflammatory demyelinating polyneuropathy
Specialty
Neurology
Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated inflammatory disorder of the peripheral nervous system. The disorder is sometimes called chronic relapsing polyneuropathy (CRP) or chronic inflammatory demyelinating polyradiculoneuropathy (because it involves the nerve roots).[1] CIDP is closely related to Guillain–Barré syndrome and it is considered the chronic counterpart of that acute disease.[2] Its symptoms are also similar to progressive inflammatory neuropathy. An asymmetrical variant of CIDP is known as Lewis-Sumner Syndrome.[3]
Contents
[hide]
1 Signs and Symptoms
2 Cause
3 Diagnosis
3.1 Differential diagnosis
4 Treatment
5 Prognosis
6 Epidemiology
7 See also
8 References
9 External links
Signs and Symptoms[edit]
Diagnosis is typically made on the basis of presenting symptoms in tandem with electrodiagnostic testing or a nerve biopsy. Doctors may use a lumbar puncture to verify the presence of increased cerebrospinal fluid protein. Symptoms such as diminished or absent deep-tendon reflexes and sensory ataxia are common. Other symptoms include proximal and distal muscle weakness in the limbs.
Cause[edit]
Structure of a typical neuron
Neuron
Dendrite
Soma
Axon
Nucleus
Node of
Ranvier
Axon terminal
Schwann cell
Myelin sheath
Chronic inflammatory demyelinating polyneuropathy (or Polyradiculoneuropathy) is considered an autoimmune disorder destroying myelin, the protective covering of the nerves. Typical early symptoms are extremities "tingling" (sort of electrified vibration or paresthesia) / numbness, frequent (night) leg cramps, loss of reflexes (in knees), muscle fasciculations, "vibration" feeling, loss of balance, general muscle cramping and nerve pain. (See references at CIDPlog and 2017 Nature Reviews Neurology 10(8) · July 2014 Norman Lavrov CIDP is extremely rare but under-recognized and under-treated due to its heterogeneous presentation (both clinical and electrophysiological) and the limitations of clinical, serologic, and electrophysiologic diagnostic criteria. Despite these limitations, early diagnosis and treatment is favoured in preventing irreversible axonal loss and improving functional recovery.[4]
There is a lack of awareness and treatment of CIDP. Although there are stringent research criteria for selecting patients for clinical trials, there are no generally agreed-upon clinical diagnostic criteria for CIDP due to its different presentations in symptoms and objective data. Application of the present research criteria to routine clinical practice often misses the diagnosis in a majority of patients, and patients are often left untreated despite progression of their disease.[5]
CIDP has been associated with diabetes mellitus, HIV infection, and paraproteinemias.
Diagnosis[edit]
There are several types of immune-mediated neuropathies recognised.[6][7] These include
Chronic inflammatory demyelinating polyneuropathy (CIDP) with subtypes:
Classical CIDP
CIDP with diabetes
CIDP/monoclonal gammopathy of undetermined significance
Sensory CIDP
Multifocal motor neuropathy
Multifocal acquired demyelinating sensory and motor neuropathy (Lewis-Sumner syndrome)
Multifocal acquired sensory and motor neuropathy
Distal acquired demyelinating sensory neuropathy
Guillain-Barre syndrome with subtypes:
Acute inflammatory demyelinating polyradiculoneuropathy
Acute motor axonal neuropathy
Acute motor and sensory axonal neuropathy
Acute pandysautonomia
Miller Fisher syndrome
IgM monoclonal gammopathies with subtypes:
Waldenstrom's macroglobulinemia
Mixed cryoglobulinemia, gait ataxia, late-onset polyneuropathy syndrome
Myelin-associated glycoprotein-associated gammopathy, polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes syndrome (POEMS)
For this reason a diagnosis of chronic inflammatory demyelinating polyneuropathy needs further investigations.
The diagnosis is usually provisionally made through a clinical neurological examination. Patients usually present with a history of weakness, numbness, tingling, pain and difficulty in walking. They may additionally present with fainting spells while standing up or burning pain in extremities. Some patients may have sudden onset of back pain or neck pain radiating down the extremities, usually diagnosed as radicular pain. These symptoms are usually progressive and may be intermittent.
Autonomic system dysfunction can occur; in such a case, the patient would complain of orthostatic dizziness, problems breathing, eye, bowel, bladder and cardiac problems. The patient may also present with a single cranial nerve or peripheral nerve dysfunction.
On examination the patients may have weakness, and loss of deep tendon reflexes (rarely increased or normal). There may be atrophy (shrinkage) of muscles, fasciculations (twitching) and loss of sensation. Patients may have multi-focal motor neuropathy, as they have no sensory loss.
Most experts consider the necessary duration of symptoms to be greater than 8 weeks for the diagnosis of CIDP to be made.
Typical diagnostic tests include:
Electrodiagnostics – electromyography (EMG) and nerve conduction study (NCS). In usual CIDP, the nerve conduction studies show demyelination. These findings include:
a reduction in nerve conduction velocities;
the presence of conduction block or abnormal temporal dispersion in at least one motor nerve;
prolonged distal latencies in at least two nerves;
absent F waves or prolonged minimum F wave latencies in at least two motor nerves. (In some case EMG/NCV can be normal).
Serum test to exclude other autoimmune diseases.
Lumbar puncture and serum test for anti-ganglioside antibodies. These antibodies are present in the branch of CIDP diseases comprised by anti-GM1, anti-GD1a, and anti-GQ1b.
Sural nerve biopsy; biopsy is considered for those patients in whom the diagnosis is not completely clear, when other causes of neuropathy (e.g., hereditary, vasculitic) cannot be excluded, or when profound axonal involvement is observed on EMG.
Ultrasound of the peripheral nerves may show swelling of the affected nerves[8][9][10]
MRI can also be used in the diagnosic workup[11][12]
In some cases electrophysiological studies fail to show any evidence of demyelination. Though conventional electrophysiological diagnostic criteria are not met, the patient may still respond to immunomodulatory treatments. In such cases, presence of clinical characteristics suggestive of CIDP are critical, justifying full investigations, including sural nerve biopsy.[13]
Differential diagnosis[edit]
Bickerstaff brainstem encephalitis
Fisher syndrome
Guillain–Barré syndrome
Treatment[edit]
First-line treatment for CIDP is currently intravenous immunoglobulin (IVIG) and other treatments include corticosteroids (e.g. prednisone), and plasmapheresis (plasma exchange) which may be prescribed alone or in combination with an immunosuppressant drug.[14] Recent controlled studies show subcutaneous immunoglobin (SCIG) appears to be as effective for CIDP treatment as IVIG in most patients, and with fewer systemic side effects.[15]
IVIG and plasmapheresis have proven benefit in randomized, double-blind, placebo-controlled trials. Despite less definitive published evidence of efficacy, corticosteroids are considered standard therapies because of their long history of use and cost effectiveness. IVIG is probably the first-line CIDP treatment, but is extremely expensive. For example, in the U.S., a single 65 g dose of Gamunex brand in 2010 might be billed at the rate of $8,000 just for the immunoglobulin—not including other charges such as nurse administration. Gamunex brand IVIG is the only U.S. FDA approved treatment for CIDP, as in 2008 Talecris, the maker of Gamunex, received orphan drug status for this drug for the treatment of CIDP.
Immunosuppressive drugs are often of the cytotoxic (chemotherapy) class, including rituximab (Rituxan) which targets B cells, and cyclophosphamide, a drug which reduces the function of the immune system. Ciclosporin has also been used in CIDP but with less frequency as it is a newer approach.[16] Ciclosporin is thought to bind to immunocompetent lymphocytes, especially T-lymphocytes.
Non-cytotoxic immunosuppressive treatments usually include the anti-rejection transplant drugs azathioprine (Imuran/Azoran) and mycophenolate mofetil (Cellcept). In the U.S., these drugs are used as "off-label" treatments for CIDP, meaning that their use here is accepted by the FDA, but that CIDP treatment is not explicitly indicated or approved in the drug literature. Before azathioprine is used, the patient should first have a blood test that ensures that azathioprine can safely be used.
Anti-thymocyte globulin (ATG), an immunosuppressive agent that selectively destroys T lymphocytes is being studied for use in CIDP. Anti-thymocyte globulin is the gamma globulin fraction of antiserum from animals that have been immunized against human thymocytes. It is a polyclonal antibody.
Although chemotherapeutic and immunosuppressive agents have shown to be effective in treating CIDP, significant evidence is lacking, mostly due to the heterogeneous nature of the disease in the patient population in addition to the lack of controlled trials.
A review of several treatments found that azathioprine, interferon alpha and methotrexate were not effective.[17] Cyclophosphamide and rituximab seem to have some response. Mycophenolate mofetil may be of use in milder cases. Immunoglobulin and steroids are the first line choices for treatment.
In severe cases of CIDP, when second-line immunomodulatory drugs are not efficient, autologous hematopoietic stem cell transplantation (HSCT) is sometimes performed. The treatment may induce long-term remission even in severe treatment-refractory cases of CIDP. To improve outcome, it has been suggested that HSCT should be initiated before irreversible axonal damage has occurred. However, a precise estimation of the clinical efficacy of HSCT for CIDP is not available, as randomized controlled trials have not been performed.[18]
Physical therapy and occupational therapy may improve muscle strength, activities of daily living, mobility, and minimize the shrinkage of muscles and tendons and distortions of the joints.
Prognosis[edit]
As in multiple sclerosis, another demyelinating condition, it is not possible to predict with certainty how CIDP will affect patients over time. The pattern of relapses and remissions varies greatly with each patient. A period of relapse can be very disturbing, but many patients make significant recoveries.
If diagnosed early, initiation of early treatment to prevent loss of nerve axons is recommended. However, many individuals are left with residual numbness, weakness, tremors, fatigue and other symptoms which can lead to long-term morbidity and diminished quality of life.[1]
It is important to build a good relationship with doctors, both primary care and specialist. Because of the rarity of the illness, many doctors will not have encountered it before. Each case of CIDP is different, and relapses, if they occur, may bring new symptoms and problems. Because of the variability in severity and progression of the disease, doctors will not be able to give a definite prognosis. A period of experimentation with different treatment regimens is likely to be necessary in order to discover the most appropriate treatment regimen for a given patient.[citation needed]
Epidemiology[edit]
In 1982 Lewis et al. reported a group of patients with a chronic asymmetrical sensorimotor neuropathy mostly affecting the arms with multifocal involvement of peripheral nerves.[19] Also in 1982 Dyck et al reported a response to prednisolone to a condition they referred to as chronic inflammatory demyelinating polyradiculoneuropathy.[20] Parry and Clarke in 1988 described a neuropathy which was later found to be associated with IgM autoantibodies directed against GM1 gangliosides.[21][22] This latter condition was later termed multifocal motor neuropathy[23] This distinction is important because multifocal motor neuropathy responds to intravenous globulin alone while chronic inflammatory demyelinating polyneuropathy responds to intravenous globulin, steroids and plasma exchanges.[24] It has been suggested that multifocal motor neuropathy is distinct from chronic inflammatory demyelinating polyneuropathy and that Lewis-Sumner syndrome is a distinct variant type of chronic inflammatory demyelinating polyneuropathy.[25]
The Lewis-Sumner form of this condition is considered a rare disease with only 50 cases reported up to 2004.[26] A total of 90 cases had been reported by 2009[27]
See also[edit]
Autoimmune diseases
Neurology
References[edit]
^ Jump up to: a b Kissel JT (2003). "The treatment of chronic inflammatory demyelinating polyradiculoneuropathy". Semin Neurol. 23 (2): 169–80. doi:10.1055/s-2003-41130. PMID 12894382.
Jump up ^ "GBS (Guillain-Barré Syndrome) - CIDP Neuropathy". cidpneuropathysupport.com. Retrieved 2017-12-14.
Jump up ^ http://www.cidpusa.org/LEWIS%20SUMMER.dwt
Jump up ^ Toothaker TB, Brannagan TH (2007). "Chronic inflammatory demyelinating polyneuropathies: current treatment strategies". Curr Neurol Neurosci Rep. 7 (1): 63–70. doi:10.1007/s11910-007-0023-5. PMID 17217856.
Jump up ^ Latov N (2002). "Diagnosis of CIDP". Neurology. 59 (12 Suppl 6): S2–6. doi:10.1212/wnl.59.12_suppl_6.s2. PMID 12499464.
Jump up ^ Finsterer J (2005) Treatment of immune-mediated, dysimmune neuropathies. Acta Neurol Scand 112(2):115-125
Jump up ^ Ensrud ER, Krivickas LS (2001) Acquired inflammatory demyelinating neuropathies. Phys Med Rehabil Clin N Am 12(2):321-334
Jump up ^ Herraets IJT, Goedee HS, Telleman JA, van Asseldonk JH, Visser LH, van der Pol WL, van den Berg LH (2017) High-resolution ultrasound in patients with Wartenberg's migrant sensory neuritis, a case-control study. Clin Neurophysiol 129(1):232-237. doi: 10.1016/j.clinph.2017.10.040
Jump up ^ Goedee HS, van der Pol WL, van Asseldonk JH, Franssen H, Notermans NC, Vrancken AJ, van Es MA, Nikolakopoulos S, Visser LH, van den Berg LH (2017) Diagnostic value of sonography in treatment-naive chronic inflammatory neuropathies. Neurology 88(2):143-151. doi: 10.1212/WNL.0000000000003483
Jump up ^ Décard BF, Pham M, Grimm A (2017) Ultrasound and MRI of nerves for monitoring disease activity and treatment effects in chronic dysimmune neuropathies - Current concepts and future directions. Clin Neurophysiol 129(1):155-167. doi: 10.1016/j.clinph.2017.10.028
Jump up ^ Shibuya K1, Sugiyama A, Ito S, Misawa S, Sekiguchi Y, Mitsuma S, Iwai Y, Watanabe K, Shimada H, Kawaguchi H, Suhara T, Yokota H, Matsumoto H, Kuwabara S (2015) Reconstruction magnetic resonance neurography in chronic inflammatory demyelinating polyneuropathy. Ann Neurol 77(2):333-337. doi: 10.1002/ana.24314
Jump up ^ Rajabally YA, Knopp MJ, Martin-Lamb D, Morlese J (2014) Diagnostic value of MR imaging in the Lewis-Sumner syndrome: a case series. J Neurol Sci 342(1-2):182-185. doi: 10.1016/j.jns.2014.04.033
Jump up ^ Azulay JP (2006). "[The diagnosis of chronic axonal polyneuropathy: the poorly understood chronic polyradiculoneuritides]". Rev. Neurol. (Paris) (in French). 162 (12): 1292–5. PMID 17151528.
Jump up ^ Hughes RA (2002). "Systematic reviews of treatment for inflammatory demyelinating neuropathy". Journal of Anatomy. 200 (4): 331–9. doi:10.1046/j.1469-7580.2002.00041.x. PMC 1570692  . PMID 12090400.
Jump up ^ Hadden, Robert D. M.; Marreno, Fabrizio (2016-12-28). "Switch from intravenous to subcutaneous immunoglobulin in CIDP and MMN: improved tolerability and patient satisfaction". Therapeutic Advances in Neurological Disorders. 8 (1): 14–19. doi:10.1177/1756285614563056. ISSN 1756-2856. PMC 4286942  . PMID 25584070.
Jump up ^ Odaka M, Tatsumoto M, Susuki K, Hirata K, Yuki N (2005). "Intractable chronic inflammatory demyelinating polyneuropathy treated successfully with ciclosporin". J. Neurol. Neurosurg. Psychiatry. 76 (8): 1115–20. doi:10.1136/jnnp.2003.035428. PMC 1739743  . PMID 16024890.
Jump up ^ Rajabally YA (2017) Unconventional treatments for chronic inflammatory demyelinating polyneuropathy. Neurodegener Dis Manag 7(5):331-342. doi: 10.2217/nmt-2017-0017
Jump up ^ Burman, Joachim; Tolf, Andreas; Hägglund, Hans; Askmark, Håkan (2018-02-01). "Autologous haematopoietic stem cell transplantation for neurological diseases". J Neurol Neurosurg Psychiatry. 89 (2): 147–155. doi:10.1136/jnnp-2017-316271. ISSN 0022-3050. PMID 28866625.
Jump up ^ Lewis RA, Sumner AJ, Brown MJ, Asbury AK (1982) Multifocal demyelinating neuropathy with persistent conduction block. Neurology 32: 958–964
Jump up ^ Dyck PJ, O'Brien PC, Oviatt KF, Dinapoli RP, Daube JR, Bartleson JD, et al. Prednisone improves chronic inflammatory demyelinating polyradiculoneuropathy more than no treatment. Ann Neurol 11: 136–141
Jump up ^ Parry GJ, Clarke S. Multifocal acquired demyelinating neuropathy masquerading as motor neuron disease. Muscle Nerve 11: 103–107
Jump up ^ Pestronk A, Cornblath DR, Ilyas AA, Baba H, Quarles RH, Griffin JW, et al. A treatable multifocal motor neuropathy with antibodies to GM1 ganglioside. Ann Neurol 24: 73–78
Jump up ^ Nobile-Orazio E. Multifocal motor neuropathy. J Neuroimmunol 115: 4–18
Jump up ^ Van Doorn PA, Garssen MP (2002) Treatment of immune neuropathies. Curr Opin Neurol 15: 623–631
Jump up ^ Lewis RA (2007) Neuropathies associated with conduction block. Curr Opin Neurol 20(5):525-530
Jump up ^ Viala K, Renié L, Maisonobe T, Béhin A, Neil J, Léger JM, Bouche P (2004) Follow-up study and response to treatment in 23 patients with Lewis-Sumner syndrome. Brain 127(Pt 9):2010-2017
Jump up ^ Rajabally YA, Chavada G (2009) Lewis-Sumner syndrome of pure upper-limb onset: diagnostic, prognostic, and therapeutic features. Muscle Nerve 39(2):206-220. doi: 10.1002/mus.21199
External links[edit]
Classification
D
ICD-10: G61.8
ICD-9-CM: 357.81
OMIM: 139393
MeSH: D020277
DiseasesDB: 30084
External resources
eMedicine: neuro/467

CIDP at NINDS
My CIDP Record 2013 through 2018 - CIDP Experience Log CIDPlog - My CIDP Record 2013 through 2018 - CIDP Experience Log

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