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Diagnostic work-up of cardiovascular autonomic failure (adapted from Fanciulli ). CNS = central nervous system; CRMP-5 = collapsin response mediator protein 5; DAT = dopamine active transporter; HbA1c = haemoglobin A1c; HIV = human immunodeficiency virus; I-MIBG = I-metaiodobenzylguanidine; MRI = magnetic resonance imaging; PCA-2 = Purkinje cell cytoplasmic autoantibody type 2; SPECT = single-photon emission computed tomography; SS-A = Sjogren’s syndrome-associated antigen A; SS-B = Sjogren’s syndrome-associated antigen B.

Figure 17
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Diagnostic work-up of cardiovascular autonomic failure (adapted from Fanciulli ). CNS = central nervous system; CRMP-5 = collapsin response mediator protein 5; DAT = dopamine active transporter; HbA1c = haemoglobin A1c; HIV = human immunodeficiency virus; I-MIBG = I-metaiodobenzylguanidine; MRI = magnetic resonance imaging; PCA-2 = Purkinje cell cytoplasmic autoantibody type 2; SPECT = single-photon emission computed tomography; SS-A = Sjogren’s syndrome-associated antigen A; SS-B = Sjogren’s syndrome-associated antigen B.

The results of interictal EEGs are normal in syncope. 410 , 430 An interictal normal EEG cannot rule out epilepsy and the EEG in epilepsy must always be interpreted in a clinical context. An EEG is not recommended when syncope is the most likely cause of TLOC, but it is when epilepsy is the likely cause or when clinical data are equivocal. The EEG is also useful to establish PPS, if recorded during a provoked attack.

Computed tomography and MRI in uncomplicated syncope should be avoided. If neurological examination points out Parkinsonism, ataxia, or cognitive impairment, MRI is recommended. In cases of contraindication for MRI, computed tomography is recommended to exclude brain lesions.

No studies suggest that carotid Doppler ultrasonography is valuable in patients with typical syncope.

An acute or subacute onset of multidomain autonomic failure suggests a paraneoplastic or autoimmune cause. Screening for specific paraneoplastic antibodies is recommended: the most common paraneoplastic antibodies are anti-Hu, while others are anti-Purkinje cell cytoplasmic autoantibody type 2 and anti-collapsin response mediator protein 5. 431 Seropositivity for any of the above-mentioned antibodies may therefore prompt further investigation for occult malignancy (e.g. whole-body fluorodeoxyglucose−positron emission tomography). 432

Seropositivity for antiganglionic acetylcholine receptor antibodies is the serological hallmark of autoimmune autonomic ganglionopathy. 433 , 434

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/ Roulette is a particularly silly form of gambling.
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Game companies now lean heavily on loot boxes to monetize their products. Legislators around the world are threatening to impose regulations on the boxes, claiming that they're gambling. Industry groups, however, insist that the boxes are not .

I play games that are funded with loot boxes. My favorite game of all time, Dota 2 , is funded almost exclusively through loot boxes. Regulations that tightly restrict or absolutely prohibit loot boxes will definitely hurt the gaming industry and will hurt, perhaps even fatally, games I love. There will definitely be economic harm, and games companies will have to figure something out to fill the monetary gap. It's no surprise that game companies are defending the practice.

But here's the thing: loot boxes are gambling. The essential features of the transaction match those of gambling, the reward pathways and addiction mechanisms are those of gambling, and playing dumb about it, as the industry is currently doing, is a bad look.

The loot box mechanism is straightforward: you buy a box for a fixed price, and you receive a random reward. Some rewards are commonplace and low value; others are rare and high value. So far, so gambling: these essential features are found in roulette, slot machines, betting on horses, raffles, and lotteries.

The excitement loot boxes offer their buyers is comparable, too: the moment of uncertainty, the high of getting a big win, the low of missing out. This is the same high as the one gamblers enjoy. Regulators in swim trunks Blue Lygia amp; Nanny Quality Free Shipping Low Price Classic kCIQOt
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have agreed that this basic structure makes loot boxes a kind of gambling.

Game companies defend loot boxes by saying they're not the same as gambling because you can't lose with them: you always win something , even if it's not very valuable. This is a weak defense. For one thing, that consolation prize may, in fact, be worthless.

The six cosmetics on the left enforce the no-duplicate policy. The ones on the right, however, marked "rare," "very rare," and "ultra rare," are only awarded at random. Want another go on the slot machine? That'll be 15 bucks.
The ultra-rare item still attracts a price premium, though well below the expected cost given the number of treasures that need to be opened to receive it.

Consider Dota 2 's loot boxes. They offer a number of standard, low-value prizes, along with a small chance of getting a "rare," "very rare," or "ultra rare" high-value prize. The loot boxes are designed so that if you buy as many boxes as there are standard prizes, you'll always get one of each standard prize. But if you keep on buying more copies of the same loot box in order to spin the dice yet again and have another chance at one of those rare prizes, you will, through necessity, receive duplicates of the standard items. These duplicates are, functionally, worthless: Dota 2 's items are cosmetics for the game's heroes, and the heroes simply can't equip more than one copy of any given item. The first copy has value; the subsequent ones don't, as you have no way of using them.

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