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The plas tic was always positioned on the patient table at a distance of 5 cm from the image intensifier entrance surface medicine used to induce labor purchase naltrexone 50mg. The radiation detector was positioned between the acrylic plastic and the table medicine 7 year program purchase genuine naltrexone on-line, utilizing spacers to symptoms 9f diabetes cheap naltrexone 50 mg with amex prop the plastic above the tabletop treatment shingles buy generic naltrexone line. The radiation exposure rate measurements were made in both the fluoroscopic mode and the cine mode with the image intensifier FoV clos est to the 18 cm diameter. They also were dependent upon whether pulsed fluoroscopy or continuous fluo roscopy mode was used. During the catheter placement in diagnostic cardiac cath procedures, approxi mately 5 to 15 min of fluoroscopy time is required. The position and the FoV do change during a clinical cardiac cath examination; nevertheless, a significant por tion of the total fluoroscopy time is directed at nearly the same region of a patients chest. Based upon the phantom measurements for medium to large patient sizes and a 10-minute fluoroscopy time, the anticipated patient skin entrance dose can be anticipated to be around 40 to 100 cGray for the fluoroscopy portion of the pro cedure. Of course, the usage of pulsed fluoroscopy would reduce this radiation dose by about 20% to 50%. During cine imaging (digital or film) higher values of tube current (mA) and shorter pulse durations are utilized in order to limit motion blur of the beating heart. Moreover, many systems utilize less x-ray beam filtration during cine imaging as compared to fluoroscopy. During the cine imaging portion of diagnostic cardiac cath examinations in adults, 30 fps of cine imaging is done for 5 to 7 sec per run. Hence, one can anticipate that the entire cine portion of the examination will require about 1 min of cine imaging. Based upon the phan tom measurements and medium to large patient sizes, the patient entrance radiation dose from the cine imaging can be expected to be 50 to 200 cGray per examina tion. Hence, the total radiation dose from both fluoroscopy and cine imaging for 48 49 diagnostic cardiac studies can be expected to be around 100 to 300 cGray with large variations due to equipment design, patient size, FoV selected, and geometrical positioning of the patient. Interventional cardiac procedures would deliver an even higher entrance radiation dose to the patient (Strauss 1995; Li et al. Scattered Radiation Levels There have been a number of published studies over the years about the scat tered radiation doses in cardiac cath labs (Vano et al. In this report, only key issues are superficially reviewed; the reader is referred to the listed references for more details. The most important item is that these scattered radiation levels can be high and that appropriate radiation protection practices should be employed to protect the clinical staff working in and around these procedures rooms. The radiation levels during cine imaging are about 10 times larger than during fluoroscopy imaging; however, cine imaging duration is about 1 min and fluo roscopy duration is about 10 min. Hence, the high cine radiation levels are offset by the shorter cine duration; and therefore, the amount of scattered radiation expo sure from cine and from fluoroscopy are nearly equal. Nevertheless, scattered radiation levels inside the procedures room can be expected to range from 20 to 450 mR per hour of actual x-ray usage. Since the scattered radiation exposure from the fluoroscopy portion of a diagnostic cardiac cath examination is nearly equal to scattered radiation from the cine imaging por tion, one can double the typical fluoroscopy time to obtain an estimate of the total x-ray usage time; the total time would typically be about 20 min. Thus, the scat tered radiation levels to the clinical staff would be about 10 to 150 mR per diag nostic proceduredependent upon the location inside the procedure room and the angulation of the x-ray equipment. The scattered radiation levels are highest closer to the patient and the levels decrease significantly with distance away from the patient. Unfortunately, the physicians placing the catheters are usually close to the patient. Moving 50 cm towards the feet end of the patient (caudal) also significantly reduces the scattered radiation levels by nearly a factor 50 of 4 during cardiac cath procedures (Vano et al. Radiation Safety Procedures A number of radiation safety measures can be employed to reduce the radia tion exposure of the clinical staff to scattered radiation during cardiac cath exam inations. First, if pulsed fluoroscopy and last frame fluoroscopy image hold are available, these features should be utilized. Next, the largest image intensifier FoV consistent with clinical goals should be used, i. The image intensifier should be placed close to the patient; this geometry reduces the patient and scattered radiation levels. For lateral projections, the clinical staff will be exposed to less scattered radiation if they stand on the image intensifier side (x-ray beam exit side) of the patient. Hence, it is impor tant to replace the image intensifier approximately every 5 to 7 years when the aperture is within 1 to 2 f-stops of being fully open (or sooner if necessary) to maintain the reasonable radiation levels to the patient. The proper usage of x ray beam collimation improves image quality, reduces the amount of patient tissue exposed to radiation, and reduces the amount of scattered radiation levels. The radiation levels also increase directly with cine frame rate; hence, the lowest cine frame rate consistent with clinical goals should be employed. Radiation barriers should also be employed to reduce the scattered radiation levels. Most cardiac cath labs have mobile overhead face shields and mobile floor shields; these shields have 0. Sometime the tables themselves have leaded rubber drapes at the sides that reduce the scattered radiation from under the patient table. The clinical staff who are located inside the procedure room during cardiac studies must wear protective aprons. The best aprons wrap around the person in order to provide protection from 360 degrees. When the apparel overlaps in front of the individual, a double thickness of shielding mate rial is provided. Modern x-ray tubes, which have heavy 51 copper filtration to reduce patient radiation doses, also produce less scatter, but the scatter that is present is more penetrating; hence, proper protective shielding is important. Radiation badge monitors must be provided for wearing at the collar outside the apron. Review of these badge readings is essential to assess the radiation doses to the staff. Users should also be provided with an additional radiation badge monitor to be worn under the apron. This second monitor, in conjunction with the collar moni tor, allows more accurate estimates of the equivalent whole body radiation dose to the operator from stray radiation (Rosenstein and Webster 1994). Personnel in the immediate vicinity of the patient during procedures should also be provided thy roid shields (Miller and Castronovo 1985). While protective gloves for the operator have been recommended in the past (Miller and Castronovo 1985), this protective device must be carefully evaluated (Wagner and Mulhern 1996). Moreover, overconfidence may lead to placing the gloved hands directly in the x-ray beam which will increase the radi ation dose to the patient and operator, in addition to increasing the scatter radia tion levels in the room (Wagner and Mulhern 1996). The procedure room itself should be adequately shielded with lead attenuation material in the walls and leaded viewing windows. The appropriate thickness of lead will depend upon the workload for the room, the room size, the type of occupancy in adjacent areas and the design/operation of the x-ray equipment. Studies have shown that the fluoroscopic portion of cardiac studies is typically performed around 80 kVp and the cine imaging portion of the studies is centered around 110 kVp. Although these factors must be care fully analyzed by a qualified expert (usually a medical physicist), it is certain that cardiac cath rooms require some radiation attenuation material. Biological Risks Associated with Radiation Exposure Both the patient and the clinical staff are exposed to radiation during cardiac studies. However, the patient radiation dose is considerably higher since he/she is in the direct x-ray beam whereas the staff is exposed to the scattered radiation, which is less in magnitude. Nevertheless, the staff is exposed to the cumulative 52 radiation dose from many different cardiac procedures, which are conducted over many years. Hence, both types of radiation exposure must be assessed for biolog ical risks (Stern et al. Cancer Risks the patient skin entrance exposure can be readily determined or measured with various types of radiation measurement equipment attached directly to the x-ray equipment. To assess the potential cancer risks, the radiation doses to various organs in the patients body must be obtained. This handbook outlines procedures for esti mating patient organ doses based upon the skin entrance radiation levels. The data were obtained from Monte Carlo calculations of a standard size and composition mathematical model of a person.
In this view treatment jalapeno skin burn naltrexone 50mg low price, the perceptual organiza interactive) processing streams in the human brain medicinenetcom symptoms buy cheap naltrexone 50mg on line. However symptoms queasy stomach purchase naltrexone 50mg with amex, the role for the auditory system to treatment for strep throat purchase naltrexone on line amex resolve and likely has an of the planum temporale in sound processing is con equally complex neural basis. Multimodal respon region for perceptual organization (binding) of multimodal (vision, sivity is shown in purple. The two main types of phonemes are consonants (such as d ) and vowels (such as i). Individual phonemes are stored in echoic memory while an entire word is being spoken, for example, dig. In order to decode the spo ken word dig, you might imagine that the neural rep resentations for d , i , and g are decoded individually and sequentially, and combined to map onto a sound representation of the word dig. The result is that the word dig is activated in the semantic/conceptual knowledge system. Unfortunately, this description makes perfect sense but it is not how the speech system actually works. In fact, there is little agreement in the field of speech perception regarding the basic building blocks of speech: is an individual phoneme the small est unit of analysis for speech systems Regions in blue show a specific response but it must also decode who information in order to to language-specific phonological structure. Regions in lilac respond know who is speaking and when in order to under to stimuli with the phonetic cues and features of speech, whereas those in purple respond to intelligible speech. Regions in pink stand the temporal order of speech phonemes, syl respond to verbal short-term memory and articulatory representa lables, words, and sentences. This information must be decoded accurately regardless of the differences in human speech: whether we hear a high-pitched voice of a child or a low-pitched voice of information. In a recent review article, Scott (2005) a man, whether we are speaking very loudly or whis provides a summary of findings to date and pro pering, or whether we are speaking quickly or slowly. However, the functional mapping of cor not rely solely on the physical aspects of speech since tical auditory processing streams remains an ongoing they vary so widely both within and across speakers. Despite the intricacies of speech perceptual processes, they occur with little attention or apparent effort on our part. While scientists have long function, it may well be the case that the auditory studied language in the brain and investigations of system in humans differs sharply from those in non the physical properties of sound date back to the early human primates. Lets begin our discussion of how 19th century, the specific study of how acoustic signals we decode human speech with a brief discussion of map onto meaning is relatively new. The spectrograph was also by analyzing and recoding speech into simpler sig developed by scientists at Bell Labs and was based on nals that contained far less information than natural some of the principles Dudley developed during the human speech. The spectrograph analyzed the signal that was, nonetheless, quite understandable, sound signals and produced a picture called a spectro providing evidence that the speech signal contained gram (Figure 7. Darker shadings indicate higher amplitude, mostly contained in the formants within each speech sound. In a spectrogram, frequency of the speech signal is presented on the y-axis and time on the x-axis. The shading of the speech signal represents a third dimen sion, intensity (or energy). Intensity is presented in two ways: across time (x-axis) and within frequency (y-axis). In this way, the amount of intensity or energy can be represented both as a function of time during a sentence and as a function of frequency band within a spoken syllable or word. No shading (white areas) in regions of the spectrogram along the x-axis indicates silence at those points in time. Similarly, darker ning with the sound d will map onto a single phoneme /d/, the shading along the y-axis indicates more energy at that physical instantiations of the initial /d/ are quite different. You will note that each speech sound Carroll, 1999, originally from Liberman, 1970. The formants or cally quite different depending on the phonemes that harmonics differ by individual, based on the size of the occurred just before and after them. The spectrograph radically changed how ance implied that there were no simple sound tem speech perception was investigated and provided a plates in the brain that mapped in a one-for-one basis method for scientists to evaluate substructural elements to phoneme identities. Despite these complexities regarding how speech There were two important outcomes of early inves is decoded, spectrograms enabled speech scientists to tigations of speech using spectrograms: first, spec describe pictorially important features in phonemes, trograms of sentences showed that gaps or silences such as where in the speech articulation system they within sentences did not map onto word boundaries, are produced (place of articulation) and the duration but occurred within words in many cases; and second, of the onset of vocal cord vibration (voice onset time). First, gaps or silences in the speech stream do not pro An important outcome of early speech science was vide the speech decoding system with information the realization that the physical features in individual 4. An alternative view is that speech and language processes exploit brain systems in use in general cognition, i. These two opposing viewpoints are still the topic for distinctive features in classes of speech sounds. However, it is likely that the neural systems for decod ing speech have a combination of domain-specific and speech sounds or phonemes did not provide invariant domain-general processing. Recall that the work of Fourier and Ohm provided a basis for deconstruct ing complex sounds into simpler sinusoidal parts. What are the basic elements or units for decoding That is, if speech perception did not entail an analysis speech The early of the sum of the physical parts, and it clearly could findings of a lack of invariance in phonemes provide not because the physical parts vary widely for a sin evidence against the phoneme as the best unit of anal gle phoneme, then how was it performed One theory ysis for speech perception, although phonemes are was that the neural systems for speech decoding were clearly critical elements in speech perception. Speech specialized and not part of the general auditory sys contains multiple cues, however, and so it is perhaps tem. A strong view of this theory that speech was spe not surprising that a simple one-to-one mapping of cial held that the special systems for speech decoding phonemes to words does not provide a full descrip occurred as early as the ear (Liberman et al. Recall that the leagues to develop the motor theory of speech perception auditory system is not a uni-directional system, but (for a review, see Liberman and Mattingly, 1985). This has complex feedback systems that extend all the way theory suggested that speech perception was tightly to the cochlea as well as parallel interactive systems coupled to speech production, specifically the motor across cortical regions within auditory cortex, across articulation processes or gestures used in producing the hemispheres, and extending to other sensory and speech. The syllable as a basic neural representations of these gestures were accessed unit of speech makes some intuitive sense because of in speech perception. Other theories for speech per the lack of invariance issue as well as the importance ception have been developed since the motor theory, of decoding syllabic stress when mapping sound and this work is ongoing in speech science, with the onto meaning. For example, the words melody and underlying notion that the speech system must have a melodic are very similar in terms of the sequence of the way to maintain a perceptual constancy across a wide phonemes. However, the syllabic stress differences in variety of physical features in phonemes and words. Early neuroimaging studies by Binder and colleagues (for a review, see Binder, 1997) investigated stimulus based differences in auditory cortex by comparing brain 4. A general finding was more widespread lapping cues, perhaps a better way to understand activation in superior temporal gyrus and the superior how speech is encoded is to investigate what is the temporal sulcus for words as compared to the tones or minimal information required to comprehend speech Although these results could be interpreted as this approach was taken by Shannon and colleagues representing speech-specific processing in those audi (Shannon et al. Therefore, different brain activation pat quency information but differing levels of temporal terns might reflect speech versus non-speech functional information. Listeners were able to decode continu areas, but might also reflect areas that differ in terms of ous speech with remarkable accuracy, indicating that decoding complex features in sounds. Shannons the presentation of many classes of sounds, including work provided evidence that the temporal envelope noise bursts, tones, words, pseudowords (pronounce of speech might carry more relevant information for able non-words, such as hig, and reversed speech its decoding than the fine-grained features found in (Binder et al. Nevertheless, the major findings were that Heschls gryus and there have been many studies of how speech and the planum temporale were activated similarly for other classes of sounds are decoded in the brain and all sound stimuli. This result supports the notion that we highlight some of these here for you in the follow sound is processed in a hierarchical fashion, with ing section. Speech sounds activated a larger region of audi acquired, there are complex interactions between tory cortex than the non-speech sounds, extending into heard language and spoken language which guide the posterior superior temporal gyrus and the superior the development of language. Interestingly, the activation did not proposed a model for language processing in the late differ for words, pseudowords, and reversed speech. Because there were no differences would serve to constrain the output when producing between the words, pseudowords, and reserved speech words. This model remains in use today, and while we conditions, Binder and colleagues concluded that these know more about dynamic brain processes now than regions likely do not reflect semantic processing of the during Wernickes time, the model has provided an word meaning, but reflect phonological processing of important theoretical framework for studying human the speech sounds.
Excitability is enhanced when monthly seizure exacerbations are correlated with the men female rats in low-estrogen states are given estrogen (diestrus) strual cycle treatment diabetes buy online naltrexone. Estrogen and progesterone are relatively low at but not when estrogen is given during a high-estrogen state day 1 symptoms dust mites best 50 mg naltrexone, and estrogen increases slightly throughout the follicular (diestrus) (110) medications during breastfeeding buy 50 mg naltrexone free shipping. Progesterone secretion then increases throughout the latory cycles due to medicine checker order naltrexone visa hypothalamicpituitarygonadal axis dys luteal phase as estrogen levels remain at levels much lower regulation and consequent low progesterone luteal phases, than the peak level. At day 26, just to the high levels of circulating neurosteroids during the luteal prior to the onset of menstrual bleeding, estrogen and proges phase and the natural reduction or withdrawal of proges terone levels drop precipitously; progesterone levels remain terone that occurs around the time of menstruation. However, catamenial epilepsy has been noted to be results in an anovulatory cycle. Due to the poor corpus luteum more common in focal epilepsy compared to generalized development, progesterone production is decreased during the epilepsy (111,112). For example, epilepsy, primary ovarian defects, or defects in luteal cell Duncan et al. They are, though, an uncommon cause of rence of 75% of seizures within the 10-day frame from 4 days infertility (105). Only Chapter 44: Hormones, Catamenial Epilepsy, Sexual Function, and Reproductive Health in Epilepsy 545 12. However, in another seminal study by Herzog in the role of hormones as a contributor to seizure occurrence which the pattern of seizure exacerbation throughout the and cyclic seizure patterns. However, supporting a role of hormonal influ had a catamenial relationship (114). The seizure patterns dis ences on seizure exacerbation, they found that women with covered in this study are described in the following section more frequent seizures in general showed more relevant and have served as a frame of reference for all further clinical changes in their sex hormone profile and lower progesterone work in this area. Another recent report supports the differentiation of seizure patterns between ovulatory and anovulatory cycles in a large cohort of women with partial Seizure Patterns epilepsy (118). These clusters are known as perimenstrual, peri Besides the direct effect hormones have on the cortex con ovulatory, and luteal. This suggests that tuate during a menstrual cycle, which can partly explain the a reliable criterion for catamenial epilepsy is a twofold increase cyclic nature. The decrease in circulating estrogen and proges in seizure frequency during the perimenstrual, periovulatory, terone premenstrually may induce hepatic isoenzymes utilized and luteal phases as described in detail next. They found that phenytoin levels on observed, is characterized as maximal seizure frequency dur day 28 of the menstrual cycle in women with catamenial ing the ovulatory phase (days 10 to 13) compared to the mid seizures were significantly lower than levels in women without follicular and midluteal phases. Phenobarbital concentrations, In the luteal (C3) pattern, maximal seizure frequency however, did not change significantly. In another recent report, the relationship between hor coincide with the known physiology of ovarian hormones as mone levels and seizure frequency was disputed altogether and described in above sections. Patients with C3 pattern showed lower progesterone levels in Water Balance in Menstrual Cycles and Its the midluteal phase compared to patients with noncatamenial Importance in Catamenial Epilepsy pattern, to those with C1 pattern, or to controls. Patients with C1 pattern had lower progesterone levels than controls in the In 1911, drainage of subarachnoid fluid was noted to have perimenstrual phase. This study reports progesterone levels as some success in treating epilepsy (123). However, water in 14 epileptic patients, including seven women with clinicians must take care in understanding the medications perimenstrual seizures, and 10 healthy controls, or between pharmacokinetics, as only a medication with a linear dose epileptic women with and without catamenial tendencies. Its Most of the following interventions have been described as mechanism of action toward reducing seizure frequency is cur treatments aimed at the premenstrual seizure exacerbation rently unknown. The standard kept in mind that only women with regular menstrual periods dose is 150 mg intramuscularly every 12 weeks. Usually this is around day 18 to 21 depending the effectiveness of this medication for catamenial epilepsy on the individual seizure pattern, since the luteal phase is stems from the fact that you are halting normal menstruation. In 1986, Herzog (132) was first to daily for 5 to 7 days prior to the onset of menses was effica describe natural progesterone and its use in seizure treatment. Doses were adjusted to of the medication, the two patients body weight, sodium obtain serum levels ranging from 5 to 25 ng/mL about 2 to metabolism, and total body water were not statistically differ 6 hours after dosing. The results showed that com range of 8 to 30 mg/kg/day (not to exceed 1 g/day) divided up pared to each patients baseline, monthly seizure frequency to four doses daily. Common and usually dose-related adverse decreased by 68% during the 3-month treatment. Seventy-five effects include paresthesias, drowsiness, nausea, malaise, percent of women had fewer seizures. The study group was 25 women with tem of menstrual bleeding is a reasonable, albeit unproven, treat poral lobe epilepsy matching the definition for catamenial ment regimen. The women were all started at 200 mg three times Benzodiazepines daily during their exacerbation phase. Their main results show that over a 3-month period, 72% of women use is for abortive therapy due to the development of habitua reported a decrease in seizure frequency and that the average tion and tolerance with chronic, long-term use. In the study group, have long been used as a practical and safe intermittent treat five women reported no change in seizure frequency. Clobazam, at 20 to 30 mg/day, cyclically taken 2 to two women stopped the study due to side effects. In a 3-year 4 days premenstrually has been shown to reduce catamenial follow-up of the remaining 23 women, the mean reduction in seizures as well as decrease the tolerance associated with con focal and generalized seizures was 54% and 58%, respec tinual use. States, but this data does support the use of intermittent ben From these studies, it is clear that natural progesterone zodiazepines in the treatment of catamenial epilepsy. As of this writing, natural progesterone is not and free testosterone levels are indicated in this situation and approved for use in the treatment of seizures; however, it is usually are low. It is clear through the evidence stated earlier in the chapter that epilepsy and the medications used for treatment have a the Amygdala and Sexual Drive: Insights significant effect on the normal hormone balance in human from Epilepsy Surgery physiology. It is not a stretch to expect that sexual function of men and women with epilepsy could be affected. While this Amygdalar size has been associated with sexual functioning in subject is usually avoided by the clinician and the patient persons with epilepsy (147). Epilepsy appears to were compared in patients with and without a reported produce a higher incidence of sexual dysfunction compared to increase in sexual drive after temporal lobectomy and in neu other neurologic diseases. Studies reviewing ment in sexual functioning after surgery had significantly this topic have shown sexual dysfunction in 30% to 66% of larger contralateral amygdala volumes than patients with no men with epilepsy (136139) and 14% to 50% of women change or a decrease in sexual drive after surgery and control with epilepsy (135,136,140). This study suggests that the amygdala is an influenc this section will cover in more detail the prevalence, com ing factor in sexual functioning for persons with temporal mon manifestations, localization, and etiology of sexual dys lobe epilepsy. First, sexual dysfunction in the normal population these findings may be related to previously reported will be reviewed. Change in sexuality was more likely to General Population occur in women and in patients with right-sided resections. Men and woman have different types of sexual dysfunction, this association between change in sexuality after surgery and which are likely secondary to adaptive issues determined by lateralization supports the findings of Herzog et al. In general, as in most mammalian who reported that women with temporal lobe epilepsy of species, the female is the more heavily invested in the offspring; right-sided origin had lower bioactive testosterone levels and thus, they are usually more discriminatory and less promiscu more sexual dysfunction than women with left-sided temporal ous than males. It is possible, therefore, that the most often presents with issues in restraint and disinhibition, lateralization as well as the presence of epileptic discharges is while men have more issues with sexual stimulation (141). Sexual Dysfunction in Females Sexual Dysfunction in Both Men the International Consensus Development Conference on and Women with Epilepsy Female Sexual Dysfunction has divided the disorders of women into four categories: (i) sexual desire disorders, (ii) sexual Early clinical research supports the existence in both women arousal disorders, (iii) orgasmic disorders, and (iv) sexual pain and men with epilepsy of a physiologic impairment of sexual disorders (142). These categories are further divided into sub arousal that could lead to inadequate arousal and orgasm, types for different durations and etiologies and may have over which, for men, differs from the sexual dysfunction in the gen lap. The increase in genital blood flow in response to visual erotic stimulation was significantly diminished in persons with epilepsy compared with controls. The authors Sexual Dysfunction in Males hypothesized that dysfunction of specific regions in the limbic and frontal cortical areas by epileptic activity could be the the most prominent types of dysfunction seen in males are cause of sexual dysfunction. Hyposexuality Living with the stigma of epilepsy also may be detrimental also occurs in males as related to an endocrinopathy. None of the women with epilepsy had levels of Therefore, the cause of dysfunction is probably multifactorial, free or total testosterone or testosterone-binding globulin out with a psychological component, in the epileptic population side the normal range. Arousal is also affected when patients begin to associate moral and less open to sexual experiences, but in general, intercourse with seizures due to prior incidences with seizures those with regular partners appeared to desire and enjoy inter and sexual activity. It has been shown that acceptance of the course as much as the controls and the untreated women. In pituitarygonadal axis (154), sexuality in epilepsy may be another study of patient-reported sexual functioning and sex adversely affected by alterations in the levels of pituitary ual arousability in 116 women with epilepsy, anorgasmia was gonadotropins, prolactin, and the sex steroid hormones reported by one third of 17 women with primary generalized (155157). Compared associated with sexual dysfunction, and adequate amounts of with historical controls, the women in this study did not have estrogen and progesterone are required for sexual behavior in reduced sexual experience but reported less sexual arousabil females (158). The authors concluded that in addition to what appears to be physiologic impairment of sex ual functioning, that is, inadequate orgasms or anorgasmia, Sexual Dysfunction in Women psychosocial factors are likely to contribute to self-reported with Epilepsy sexual dysfunction in women with epilepsy.
The ketogenic diet for intractable epi lepsy: novel susceptibility loci in idiopathic lepsy in adults: preliminary results treatment xdr tb buy cheap naltrexone on line. The ketogenic methylation profles of coding and non-coding diet as a treatment paradigm for diverse neuro genes defne hippocampal sclerosis in human tem logical disorders symptoms jaw pain cheap 50mg naltrexone with mastercard. The infuence of concur Antiepileptic efects of silk-polymer based ade rent anticonvulsants on the efcacy of the keto nosine release in kindled rats medications by mail order naltrexone master card. Adenosine and the concept of retal ine use is associated with decreased efcacy of the iatory metabolites medications similar to xanax generic 50 mg naltrexone overnight delivery. Tuning and pal glucocorticoid receptor gene expression in fne-tuning of synapses with adenosine. Ketone bodies (or the state of ketosis) have been The mechanistic link of ketosis and neuroprotec shown to be neuroprotective following oxidative tion also remains unclear and exploratory. The stress and metabolic challenges, such as those asso mechanisms appear to be related to the change in ciated with stroke, ischemia, injury, Alzheimers the regulation of the cells stress responses (Milder disease, Parkinsons disease, glucose transporter et al. They are thought to be more ef and apoptotic and infammatory mediators, and cient energy substrates to glucose for utilization increased protective pathways (Veech, 2004; Julio by brain (Cahill and Veech, 2003; Kashiwaya et al. One application for the use of ketone bodies nisms that elucidate the neuroprotective efects as an alternative substrate is for those with aging of ketosis in the brain. Studies measuring Our view is that the neuroprotection associated the ratio of 13C-amino acid / C-13 lactate in brain with diet-induced ketosis is mainly through sta showed the fraction of amino acid carbon derived bilization of glucose metabolism and downstream from glucose decreased with ketosis, refecting metabolic pathways such as the citric acid cycle and the utilization of ketones as carbon precursors cytosolic-mitochondrial redox shuttle systems. The neu Vannucci and Simpson, 2003) and moderate to roprotective role of ketone bodies may be through high blood levels of ketosis (26 mM) (Leino et al. More recently, we glucose and the degradation of muscle-derived have established in our rat model of ketosis that amino acids for substrates. Diet-induced approaches avoid the con the neurovascular unit is a major determinate of straints (sodium or fuid overloads, pH imbal the pathophysiologic outcome. We have previ recovery of neurologic function afer resuscita ously reported that 3 weeks of diet-induced stable tion following cardiac arrest is limited by the ketosis is necessary to induce metabolic adapta ability of the central nervous system to recover tions in brain of rats resulting in neuroprotection from an ischemic event due to metabolic stress (Puchowicz et al. This lactic acidosis and downstream metabolic blocks regime can be inferred to as a preconditioning in energetics. Afer 24 hours of reperfusion there state where blood concentrations of ketone bod is an apparent defect in glucose metabolism, ies remain stable over time. Mitochondria are among the most susceptible Anaplerosis, a process that balances cataplero organelles to oxidative stress. Brain mitochon sis, ordinarily maintains/supplies intermediates drial function is known to decrease 2 days follow to the citric acid cycle, which becomes vital dur ing ischemia reperfusion (Xu et al. The ketosis is neuroprotective under conditions when possibility of increased pyruvate carboxylation glucose utilization is limited (Xu et al. One explanation may be the lack of bidity and mortality following ischemic or hypoxic glucose carbon entry (fux) into the citric acid events, such as those related to stroke or other cycle. Stroke is a leading resulting in a dysregulation or leakiness of the disease/disability in the United States, as there are citric acid cycle (cataplerosis). Results: Afer fed with 3 weeks of ketogenic diet, plasma ketone bodies (mM) were increased 5-fold (3. All brain cells are suscep injury, ofen results in energy imbalances related to tible to infarction following ischemia-reperfusion dysregulation of glucose (oxidative) metabolism. Another example of a condi could be that ketones are efective against pathol tion that results in moderate to severe ischemia/ ogy associated with altered glucose metabolism reperfusion injury is cardiac arrest and resuscita (Cahill and Veech, 2003; Prins and Hovda, 2009; tion, as the brain is exposed to ischemic-hypoxia Sato et al. Ketones may also play a role as million cardiac arrests occur per year; about half signaling molecules that directly or indirectly act of the population (aged or adult) having frst-time through the regulation of cell salvation pathways, cardiac arrests will not survive the frst few days. As a neuroprotec associated with neuropathologies and degenera tive agent Epo has many functions: antagonizing tive disorders. Since the aged population has an glutamate cytotoxic action, enhancing antioxidant increased risk for ischemic events, such as those enzyme expression, reducing free radical produc associated with transient global or focal stroke, the tion rate, and afecting neurotransmitter release development of treatment strategies that incorpo (Bartesaghi et al. Although apoptosis is not teasome function, as a result of very low ratios of reversible, early intervention with neuroprotective alpha ketoglutarate / fumarate (Serra Perez et al. Comparison of why the aged are at greater risk for morbidity and regional cerebral blood fow and glucose metabo mortality following an oxidative insult (Ndubuizu lism in the normal brain: efect of aging. The mechanism of the keto Over the past decade our research has consistently genic diet in epilepsy. Bull Johns Hopkins Hos 48, shown that ketosis is neuroprotective against isch 373 389. Trans Am Clin Climatol Assoc and improved survival and recovery afer cardiac 114, 149 161. Expression of hypoxia-inducible 223 Chapter 24: Ketogenic Diet, Aging, and Neurodegeneration 223 factor-1alpha in the brain of rats during chronic Cerami, A. Activation in blood-brain transfer of ketone bodies during of hypoxia-inducible factor-1 in the rat cerebral starvation. American Heart Association/American College of Maintenance of homeostasis in the aging hypo Cardiology Foundation/Heart Rhythm Society sci thalamus: the central and peripheral roles of suc entifc statement on noninvasive risk stratifcation cinate. Apaf den cardiac death: a scientifc statement from the 1, Bcl-xL, cytochrome c, and caspase-9 form the American Heart Association Council on Clinical critical elements for cerebral vascular protection Cardiology Committee on Electrocardiography by erythropoietin. J Cereb Blood Flow Metab 23, and Arrhythmias and Council on Epidemiology 320 330. Intermediary metabolite Ketotic hypoglycemia and the ketogenic diet ther precursor dimethyl 2 ketoglutarate stabilizes apy. Mechanism of anti-convulsant actin of ketogenic Protection of hypoglycemia-induced neuronal diet. Succinate: a meta ervation of energy levels and decreased produc bolic signal in infammation. D-beta threshold and brain contetents of adenosine nucle hydroxybutyrate protects neurons in models of otides. Cerebral metabolic adaptation poietin that are tissue protective but not erythro and ketone metabolism afer brain injury. Am J Physiol Endocrinol neuroprotective properties of calorie restriction, Metab 292, E1607E1615. Pyruvate dehydrogenase insulin sensitivity and the metabolic disturbances complex activity controls metabolic and malig of diabetes mellitus. Modulation of oxida treatments: cardiopulmonary bypass, hyperten tive stress and mitochondrial function by the keto sive hemodilution, and mild hypothermia. Insulin, ketone bodies, and 225 Chapter 24: Ketogenic Diet, Aging, and Neurodegeneration 225 mitochondrial energy transduction. Am J Physiol Endocrinol Metab 285, the anti-epileptic efcacy of the ketogenic diet. The pathological conditions: ketosis, ketogenic diet, evolution of focal ischemic damage: a metabolic redox states, insulin resistance, and mitochondrial analysis. Regulation of metabolism by the mitochondrial permeability transition hypoxia-inducible factor 1. Cold Spring Harb pore provides a key to the diagnosis and treat Symp Quant Biol 76, 347353. Increased sensitivity to transient global hydroxybutyrate, an endogenous histone deacety ischemia in aging rat brain. Mitochondrial dysfunction in aging rat of vascular endothelial growth factor in mes brain following transient global ischemia. Hypoxia-inducible factor 1 contributes to ruption of blood-brain barrier and angiogenesis N-acetylcysteines protection in stroke. In each that the metabolic status of the mother impacts case investigators assessed the efectiveness of the the phenotype and metabolic disease susceptibil diet, or ketones themselves, on limiting the states ity of the ofspring (Rando and Simmons, 2015). The ketone body The global epidemic of metabolic syndrome has acetone has anticonvulsant efects, and it could play increased the concern over the efects of parental a role in seizure control. With both Ruskin and Masino, 2012; Stafstrom and Rho, 2012; extremes (starvation and obesity) prevalent across Danial et al. The neuroprotective protein, or fat) and the present energy needs of the efects of the diet are compelling, and in recent organism. From an evolutionary perspective there years the potential therapeutic uses of the diet in is nothing more important than the consistent humans (Kossof et al. The use of fatty adrenal gland, and peripheral sensory receptors acids by systemic tissues reduces the need for and converge on the central nervous system.
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