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By U. Snorre. Saint Rose College.

Crohns disease) generic 50 mg viagra overnight delivery diabetes and erectile dysfunction relationship, of treatment include hypokalaemia effective 100 mg viagra erectile dysfunction in young males, gout and the un- pancreatic failure and following gastrectomy or small masking of iron deciency generic 75mg viagra with visa erectile dysfunction zyprexa. Vitamin causes failure of intrinsic factor production order viagra 100mg can erectile dysfunction cause prostate cancer, vitamin B12 B12 is involved in nucleic acid synthesis (see Fig. Clinical features In addition to symptoms of anaemia, patients with vita- Age min B deciency may have neurological complications More common in the elderly. The Schilling Aetiology/pathophysiology test is used to identify the cause of the deciency (see The gastric parietal cells normally produce intrinsic fac- Table 12. Patients may also complain of a sore mouth and tongue (glossi- Clinical features tis). Patients may also have neurological complications of vitamin B Investigations 12 deciency (see page 471). In many cases the cause is not obvious and further investigations may have to be Investigations undertaken including barium follow through or upper Full blood count will demonstrate a macrocytic anaemia gastrointestinal endoscopy and biopsy. The Schilling test is used to differentiate the causes of vitamin B12 deciency Management (see Table 12. Prior to treatment with oral folic acid Management supplements, concurrent vitamin B12 deciency must be Parenteral vitamin B12 replacement is required for life. Prophylaxis is advised in preg- reticulocytosis can be demonstrated 23 days after com- nancy, haemolytic anaemias, premature babies, dialysis mencing therapy. Causes of The causes of haemolytic anaemia are shown in Table folic acid deciency: r 12. Low intake is most common in elderly, people living in poor social conditions and chronic alcoholics. Folic acid is found in fresh vegetables and meat, but may Pathophysiology be destoyed by overcooking. Shortening of the life span of red cells does not always r Malapsorption occurs due to small bowel disease (es- cause anaemia. If the increased loss can be compen- pecially if affecting the jejunum) such as coeliac dis- sated for by an up-regulation of the bone marrow (which ease. In addition to ditions, myeloproliferative disorders, other rapidly bone marrow up-regulation, reticulocytes (red cell pre- growing tumours and severe inammatory disease. Inherited haemolytic anaemia Complications Achronically high serum bilirubin predisposes to the Hereditary spherocytosis formation of pigment gallstones. Chronic haemolysis predisposes to folate deciency and thus levels should Denition be monitored and replacement given as required. Par- An autosomal dominant condition in which the red cells vovirus infections that cause a temporary bone marrow are spherical. Hereditary elliptocytosis is an autosomal failure may result in an aplastic crisis. Investigations r Haemolysis is suggested by a rise in bilirubin, high Incidence urinary urobilinogen (due to bilirubin breakdown Commonest inherited haemolytic anaemia; 1 in 5000. In intravascular haemolysis, red cell fragments are Aetiology/pathophysiology seen in the blood lm, whereas spherocytes may be There is a high new mutation rate with 25% of patients present in extravascular haemolysis. The underlying cause is cell life span can be demonstrated using labelled red aweakness in the link between the cytoskeleton and cells. These cells are more rigid than normal and As HbF synthesis is normal, it presents at 6 months. Sex Clinical features M = F Spherocytosis may present as neonatal jaundice or anaemia with chronic malaise and splenomegaly. Nor- Geography mal infections cause a relative increase in haemolysis and Occurs most frequently in Africa, Middle East, India and may result in jaundice. Aetiology Investigations Apoint mutation on chromosome 11 results in a sub- Anaemia is usually mild. A blood lm will demonstrate stitution valine for glutamine at the sixth codon on the the spherocytes, but this cell morphology is not diagnos- globin chain to form haemoglobin (Hb)S. Thediagnosiscanbeconrmedbydemonstratingthe dehydration, hypoxia and cold may precipitate a sickle osmotic fragility of the red blood cells. Patients are given Pathophysiology pneumococcal vaccinations and prophylactic antibiotics HbS molecules, when deoxygenated tend to aggregate post splenectomy. The red blood cells become inex- ible and sickle shaped and become trapped in the mi- Haemoglobinopathies crocirculation, especially within bones, resulting in mi- Haemoglobinopathies are abnormalities in the nor- crovessel occlusion. Normal haemoglobin is made up of four polypeptide chains Clinical features each containing a haem group. HbA is the main adult Sickle cell trait (the carrier state) is asymptomatic, but form comprising two chains and two chains. Sickle cell also have a minor haemoglobin HbA2,which makes up anaemia is a clinical spectrum ranging from asymp- around 2% of the circulating haemoglobin and con- tomatic to severe haemolytic anaemia and recurrent sists of two chains and two chains. Painful vascular occlusive crises typically haemoglobins result from: produce symptoms of bone pain and pleuritic chest pain r Abnormal globin chain production such as thalas- with a low-grade fever. Other patterns of crisis: r Acute sequestration (pooling of blood in liver and Sickle cell anaemia spleen) requires transfusion for apparent hypo- Denition volaemia. Autosomal recessive condition in which there is abnor- r Pulmonary infarction may occur in association with mal structure of the globin chain. Transfusionsmayalso streptococcal infections and osteomyelitis often due be indicated in patients with regular severe crises and to salmonella. Prognosis Retinal detachment and proliferative retinopathy may Thereismarkedvariationintheseverityofthecondition, result in blindness. See also complications of haemolytic some patients have a relatively normal life span with few anaemia (page 473). Blood lm shows a -Thalassaemia high reticulocyte count and sickle shaped red blood cells. Denition r Sickle screening tests use a reducing solution, which Inherited haemoglobinopathy with defective synthesis causes HbS to precipitate. Aetiology r X-ray of the tubular bones may show destruction and -Thalassaemia is caused by gene deletions. There are medullary sclerosis together with periosteal bone for- four copies of the gene, two on each chromosome 16. Management Clinical features Treatment is largely symptomatic with prophylactic an- r Deletion of all four copies of the gene (/) prevents tibiotics,folicacidandpneumococcalvaccination. This disorder agement of a painful crisis includes oxygenation, ade- is also termed haemoglobin Barts (4)hydrops syn- quate hydration and analgesia. Acute se- r Deletion of three genes (/-) causes HbH disease (a questration requires blood transfusion, as patients be- moderate anaemia with splenomegaly and the pro- comeshocked. Normal Investigations Full blood count shows microcytosis with or without Sickle Trait anaemia. These mutations may result in no chain production Investigations (0)orveryreducedproduction (+). The reticulocyte count is noproductionof globinandhavetheclinicalpicture raised and there are nucleated red cells. Management Excess chains precipitate in the red blood cells r Thalassaemiaminordoesnotrequiretreatment;how- or combine with resulting in increased HbA2, and ever, iron supplements should be avoided unless resulting in increased levels of fetal haemoglobin co-existent iron deciency has been demonstrated. The partners of women with thalassaemia minor r If there are defects in both and genes, patients shouldbescreenedtoallowappropriategeneticcoun- have thalassaemia intermedia (homozygous) or tha- selling. Homozygous combined, and are in- r Thalassaemia major and symptomatic thalassaemia compatible with life. This Clinical features aims to suppress ineffective erythropoesis and pre- r Thalassaemia minor/trait is asymptomatic with a vent bony deformity, while allowing normal growth mild hypochromic microcytic anaemia. Iron overload is prevented by the r Thalassaemia intermedia causes symptomatic mod- use of the chelating agent desferrioxamine, which is erate anaemia with splenomegaly. Splenectomy should be considered in patients ure to thrive and recurrent infections. Bone the production of fetal haemoglobin ceases and the marrow transplantation has been used successfully patient becomes symptomatic with a severe anae- in young patients with severe -thalassaemia major. Extramedullary haemopoesis causes hepato- Other treatments under investigation include gene splenomegaly, maxillary overgrowth and trabecula- therapy and drugs to maintain the production of fetal tion on bone X-rays. Random X inacti- vation (Lyonisation) means that some heterozygous fe- Glucose-6-phosphate dehydrogenase males may also have symptoms. Clinical features With such a wide variety of genes and enzymatic activity, Aetiology aspectrum of clinical conditions occur. Investigations Pathophysiology During an attack the blood lm may show irregularly IgMorIgG antibodies are produced, which bind to red contracted cells, bite cells (indented membrane), blister cells. Autoimmune haemolytic anaemia Denition Clinical features Acquired disorders resulting in haemolysis due to red The clinical features, specic investigations and manage- cell autoantibodies. Splenectomy may be indicated if lymphatic leukaemia, haemolysis is severe and carcinoma and drugs such refractory. Cold haemagglutinin May be primary or secondary IgM antibodies agglutinate best Treat any underlying cause and disease to Mycoplasma at 4C, often against minor avoid extremes of temperature. Denition A pancytopenia due to a loss of haematopoetic precur- Investigations sors from the bone marrow. Full blood count and blood lm will demonstrate a pan- cytopenia with absence of reticulocytes. A bone marrow Aetiology/pathophysiology aspirate and trephine shows a hypocellular marrow with Aplastic anaemia can be either congenital or much more no increased reticulin (brosis). This agents, supportive care (blood and platelet transfusions) is an autosomal recessive aplastic anaemia with limb and some form of denitive therapy. Otherdrugsmaycauseaplasticanaemia Immunosuppressive therapy is used as rst line treat- through dose dependent (e. Prognosis Clinical features The course is dependent on the severity of the dis- Patients present with the features of pancytopenia: ease and the age of the patient. In the United Kingdom, travellers to these ar- 3year survival but there is a signicant risk of developing eas who do not take adequate precautions are at greatest paroxysmal nocturnal haemoglobinuria, myelodysplas- risk. Transmission occurs predominantly by the bite of the female Anophe- Denition les mosquito although transmission may occur by blood Malaria is an infection caused by one of the four species transfusion or transplacentally. Incidence Worldwide there are 300500 million cases of malaria Pathophysiology peryear with a mortality rate of up to 1%. In the United Parasites consume red cell proteins, glucose and Kingdom there are 15002000 cases per year, most of haemoglobin. They affect the red cell membrane making which are caused by Plasmodium falciparum. The inci- the cell less deformable and ultimately causing cell ly- dence in the United Kingdom is rising. Falciparum induces cell surface adhesion molecules on red cells causing adhesion to small vessels and un- Geography infected red cells. This leads to occlusion within the Endemic malaria is found in parts of Asia, Africa, Cen- microcirculation and organ dysfunction.

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In addition cheap viagra 100mg with visa erectile dysfunction occurs at what age, compliance to the intervention could only be assessed in three studies [8 order viagra 75 mg without a prescription cialis causes erectile dysfunction, 10 order viagra 100 mg on-line erectile dysfunction medication prices, 20] where both a rigid carbohydrate prescription and adequate reported dietary data of partici- pants were available viagra 75 mg for sale erectile dysfunction opiates. Future research should more adequately consider the potential consequences of interventions that aim to reduce HbA1c in this population. Therefore, outcomes of this review should form the minimum set of outcomes that are reported in future type 1 diabetes research. None of the studies in this review measured all six outcomes and only four studies [8, 10, 22, 24] reported complete measurements for both HbA1c and insulin dose. Another important consideration for future studies is whether to substitute carbohydrate with fat or protein. This review is unable to draw any conclusion for potential differences in effect and more primary studies are necessary. Conclusion Type 1 diabetes is a chronic disease with severe complications for its mismanagement. To strengthen patient-centered care and improve individual capacity for problem solving and self-management, health professionals should be equipped with the appropriate evidence base to present multiple management strategies to their patients. Dietary strategies can serve as effective adjuncts to pharmaceutical therapy in the treatment of various metabolic diseases. This systematic review presents all available evidence for low-carbohydrate diets in the management of type 1 diabetes mellitus. The existing body of evidence is limited and more pri- mary studies evaluating the short and long-term effects of low-carbohydrate diets on type 1 diabetes management outcomes are necessary to support its use in practice. Reported dietary intake data of participants in intervention and comparator Groups of included studies. Summary of risk of bias assessments for included randomised controlled trials using the Cochrane Collaborations Risk of Bias for randomised controlled trials assess- ment tool. Summary of quality assessments using the National Institute of Healths quality assessment tool for pre-post intervention studies with no control group. Risk of bias assessment for case-series using Joanna Briggs critical appraisal tool for case-series. Risk of bias assessment for Bernstein (1980) (26) using Joanna Briggs critical appraisal tool for case-reports. Bero (Chair of Medicines Use and Health Outcomes, University of Syd- ney) for assisting in the selection of risk of bias / critical appraisal tools and offering ongoing support for this part of the review process. Thank you to Monica Cooper (Academic Liaison Librarian, University of Sydney) for assisting with the online database searches. Conflicts of interest Jessica Turton completed an internship (2016) at a private practice that supports the use of low-carbohydrate diets. Kieron Rooney has given talks for "Low Carb Down Under" on the biochemistry of low carbohydrate diets and has been a collaborator on primary research investigating the effect of lower carbohydrate diets for weight loss. Australian Diabetes Soci- ety Position Statement: Individualization of HbA1c Targets for Adults with Diabetes Mellitus [Internet]. The diabetes control and complications trial/epidemiology of diabetes inter- ventions and complications study at 30 years: overview. Dietary carbohy- drate restriction as the first approach in diabetes management: Critical review and evidence base. Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison. Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: A clinical audit. Bernsteins diabetes solution: the complete guide to achieving normal blood sugars. A randomised trial of the feasibility of a low carbohydrate diet vs standard carbohydrate counting in adults with type 1 diabetes taking body weight into account. Australian Government Department of Health and Ageing, National Health and Medical Research Council, New Zealand Ministry of Health. Nutrient reference values for Australia and New Zealand: including recommended dietary intakes [Internet]. National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults. Data collection forms for intervention reviews Cochrane Training: The Cochrane Collaboration,; 2014 [cited 2017 Jun 03]. The Cochrane Collabora- tions tool for assessing risk of bias in randomised trials. Quality Assessment Tool for Before-After (Pre-Post) Studies With No Con- trol Group: Department of Health and Human Services; 2014 [updated March 2014; cited 2017 Jun 03]. Joanna Briggs Institute Reviewers Manual: 2016 edition Australia: The Joanna Briggs Institute; 2016 [cited 2017 April]. Metabolic effects of high- carbohydrate, high-fiber diets for insulin-dependent diabetic individuals. Diet liberalization and metabolic control in type I diabetic outpatients treated by continuous subcutaneous insulin infusion. Quantitative assessment of dietary intake in adults with Type 1 diabetes following flexible insulin therapy education with an active promotion of dietary free- dom. The effects of a low-carbohydrate regimen on glycemic control and serum lipids in diabetes mellitus. Clinical experience of a carbohy- drate-restricted diet: effect on diabetes mellitus. Virtually continuous euglycemia for 5 yr in a labile juvenile-onset diabetic patient under noninvasive closed-loop control. Similarity of the impact of type 1 and type 2 diabetes on cardiovascular mortality in middle-aged subjects. Poor glycemic control predicts coronary heart disease events in patients with type 1 diabetes without nephropathy. Hyperandrogenism, Insulin Resistance and Hyperinsulinemia as Cardiovas- cular Risk Factors in Diabetes Mellitus. Metabolic Syndrome as a Risk Factor for Cardiovascular Disease, Mortality, and Progression of Diabetic Nephropathy in Type 1 Diabetes. Iatrogenic hyperinsulinemia in type 1 diabetes: Its effect on atherogenic risk markers. Insulin therapy and colorectal cancer risk among type 2 diabetes mel- litus patients. Extending an evidence hierarchy to include topics other than treatment: revising the Australian levels of evidence. The incidence of type 1 diabetes is mortality, time spent by family members accompanying increasing in both rich and poor countries. In addition, close to improper utilization of insulin by target cells and 113,100 people died from diabetes related causes, tissues. With a prevalence of Diabetes mellitus and lesser forms of glucose 200,000 type 1 diabetics in India, Shobhana et al. In England and Wales, the estimated is expected to increase to about 438 million, by 2030. Unfortunately, there is a dearth of similar projected to increase to 472 million, or 8. Piero et al: Asian Journal of Biomedical and Pharmaceutical Sciences; 4(40) 2014,1-7. Insulin is a pancreatic hormone amounts of urine produced by diabetics attracted flies responsible for blood glucose level regulation. The traditional way of diagnosing diabetes hormone binds to its receptor sites on peripheral side of mellitus in ancient Chinese was by observing whether the cell membranes. Insulin ages, the European doctors tested for diabetes by stimulates catabolism on glucose into pyruvate through tasting the urine themselves, a scene occasionally glycolysis. These metabolic events Diabetes mellitus has been known since antiquity, its are antagonistic to metabolic events triggered by the treatments were known since the Middle Ages, and the hormone glucagon. When glucose levels are at or below elucidation of its pathogenesis occurred mainly in the threshold, glucose stays in the blood instead of entering 20th century. The discovery of the The body attempts to arrest hyperglycemia, by drawing role of the pancreas in diabetes was made by Joseph water out of the cells and into the bloodstream. This is why that upon complete removal of the pancreas from dogs, diabetics present with constant thirst, drinking large the dogs exhibited all the signs and symptoms of amounts of water, and polyuria as the cells try to get rid diabetes and died shortly afterwards. This subsequently leads to Edward Albert Sharpey-Schafer of Edinburgh in glucosuria (Piero, 2006). Scotland suggested that diabetics lacked a single As hyperglycemia prolongs, the body cells are devoid of chemical which was normally produced by the glucose due to the lack of insulin. Name of this chemical was later proposed to seek alternative mobilizable energy sources. The fats are not fuel sources for the red blood Best repeated the work of Von Mering and Minkowski cells, kidney cortex and the brain. The red blood cells but went a step further and managed to show that they lack mitochondria in which beta-oxidation pathway could reverse the induced diabetes in dogs by giving rests. The fatty acids cannot pass the blood-brain them an extract from the pancreatic islets of barrier. This was a step forward in acetyl-CoA arising from catabolism of fatty acids is elucidation of the endocrine role of pancreas in diverted to ketogenesis to generate ketone bodies, metabolism and existence of insulin (Banting et al. These ketone bodies are also passed in from bovine pancreases at the University of Toronto in the urine, thereby leading to ketonuria, which Canada, thereby leading to the availability of an characterizes diabetes mellitus. Build up of ketone effective treatment of diabetes mellitus, with the first bodies in the blood produces ketosis. A combination of diabetes was made by Sir Harold Percival (Harry) ketosis and acidosis lead to a condition called Himsworth in 1935 (Himsworth, 1936). If left untreated, ketoacidosis leads to Following these discoveries, other landmark discoveries coma and death (Belinda, 2004). Insulin output under Insulin exhibits a multitude of effects in many tissues, basal condition approximates 0. The effects of insulin on carbohydrate clearing the postprandial glucose load (Ginsberg et al. The insulin production is directly across muscle and adipocyte cell membranes, proportional to the amount of sugar (carbohydrate) regulation of hepatic glycogen synthesis, and inhibition consumed. The more sugar one consumes, the more of glycogenolysis and gluconeogenesis (Piero, 2006). Incorporation of fatty acids from over-production of insulin will eventually exhaust that circulating triglyceride into adipose triglyceride and capacity and the cells will cease to operate (Robert, lipid synthesis are stimulated by insulin; lipolysis is 2002). Insulin deficiency plays a central role in all Insulin initiates its physiological effects by binding to a forms of diabetes because it is the major hormone that high affinity specific receptor located on the plasma enables cells (primarily muscle and fat cells) to uptake membrane. Insulin makes it possible binding capacity and the biological activity of insulin for most body tissues to remove glucose from the blood are maximal at a plasma insulin concentration of 20 to for use as fuel, for conversion to other needed 30 U/ml. Furthermore, insulin is also process, and reaction of the disulfide bonds is not the major regulatory signal for glycogenesis in the involved. As a Stimulation of intracellular Potassium transport is one consequence of the widespread prevalence of diabetes of the well-known effects of insulin (Steiner, 1977). Magnesium is to identify and develop more effective remedies to involved in the activation of many intracellular improve the quality of life of those affected by the enzymes.

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Neurological examination is hypertension and must be used cautiously in those usually within normal limits viagra 100 mg for sale causes of erectile dysfunction in 20 year olds, and between episodes with vascular risk factors viagra 25mg without prescription erectile dysfunction caused by lipitor. Hemiplegic and ophthalmoplegic migraine Prophylaxis Rarely focal neurological features may persist for sev- Precipitating causes should beidentied and avoided quality viagra 75 mg erectile dysfunction causes heart. Preventative treatment for migraine should be considered for patients who suffer: Investigation cheap viagra 50 mg line erectile dysfunction under 40. Neurology 173 Cluster headache raised intracranial pressure (false-localising sign). They may occur several times mone and corticosteroids), systemic lupus erythema- a day, often waking the patient from sleep. In injection) is the treatment of choice for cluster more chronic cases, medical therapy with acetazol- headaches simple analgesics are rarely effective in amide, other diuretics or corticosteroids may be tried this condition. High-ow oxygen and corticosteroids but surgical intervention (lumboperitoneal shunt or have also been reported to be efcacious in some optic nerve sheath decompression) is often required patients. Prophylaxis with verapamil or lithium may torelievesymptomsand/orprotectvisionprolonged be tried (methysergide is reserved for refractory cases raised intracranial pressure predisposes to optic and,aswithmigraineprophylaxis,mustbeusedunder atrophy. Meningeal irritation Irritation of the meninges (meningism) occurring in meningitis or following subarachnoid haemorrhage characteristically produces a triad of symptoms: Secondary causes. Raised intracranial pressure In meningitis the headache evolves over minutes to hourswhereasinsubarachnoidhaemorrhageitisabrupt Usually secondary to an intracranial tumour, haema- in onset and may be followed by loss of consciousness. It improves Post-concussion 12h after rising and is exacerbated by coughing, sneezing, straining and bending down. Visual func- Similar to tension headache but usually associated tion may be preserved despite papilloedema, but with dizziness (not vertigo) and impaired concentra- other neurological symptoms and signs related to the tion, post-concussion headache persists for months primary lesion are usually evident. The pain often and there may be a history of inadequate recovery responds to simple analgesics. Occasionally, bilateral Trigeminal neuralgia predominantly affects those over sixth cranial nerve palsies are present and reect 50 years of age. It reects compression of the sensory 174 Neurology root of the trigeminal nerve (e. Eachyearasmallnumberofindividualswith Theagonisingsharppainisconnedtothedistribution this condition (12 per 100,000) die prematurely as a of the trigeminal nerve on one side, commonly the consequence of status epilepticus (see below), acci- maxillaryormandibulardivisions. It tends to get worse with age, and even- tually a continuous background pain may develop if Classication left untreated. Physical examination is usually normal but may reveal neurological signs inthe presence of an Partial seizures underlying mass lesion. These have a single focus of activity, which may be Simpleanalgesicsaregenerallyineffective. Usually scar tissue related to previous trauma, a cerebrovas- carbamazepine provides good symptom control, cular accident or tumour. Glossopharyngeal neuralgia Generalised seizures A rare disorder precipitated by swallowing, which Generalised seizures are typied by widespread activ- produces pain in the pharynx or deep inside the ear. The pain may be difcult to treat, but Aetiology sometimes responds to tricyclic antidepressants, carbamazepine or topically applied capsaicin. There may be a family history suggesting genetic susceptibility, particularly with petit mal seizures. Seizures may be secondary to Atypical facial pain cerebral disorders, metabolic dysfunction and drug This describes episodic aching in the jaw and cheek ingestion (Table 15. In some women seizures mayincrease Epilepsy in frequency around the time of menstruation. Epilepsy results from intermittent paroxysmal electri- Differential diagnosis cal discharges of cerebral neurons causing stereotyp- icalattacksofalteredconsciousness,motororsensory. Ideally, all patients basilar ischaemia with a rst unexplained seizure should be rapidly. Alzheimers disease, Huntingtons disease) All/most ages Metabolic disturbance (e. This is followed by loss of This usually presents between 4 and 10 years and is consciousness and the tonic phase (characterised by more common in girls. It is characterised by brief generalised muscle spasms), which usually lasts up to (1015s) moments of absence without warning (e. The clonic phase, charac- the child stops talking and stares blankly) followed by terised by sharp repetitive muscular jerks in all limbs, immediate recovery. Tongue biting, salivation and involuntary berty, although 510% of children will develop adult micturition may occur. Febrile convulsions These are seizures occurring in the context of fever, Temporal lobe epilepsy usually in young children under 5. The majority are Patients typically experience an aura which may one-off events although up to 5% go on to develop includeasenseoffearordeja-vu, hallucinations epilepsy. They are usually generalised and brief but (visual, olfactory or gustatory) or a rising sensation occasionally longer lasting or focal in nature. Confusion and anxiety may de- velop and some patients exhibit automatism (organ- Infantile spasms ised stereotyped movements, e. Aetiology includes perinatal asphyxia, Epileptic activity originates in one part of the motor metabolic disorders, encephalitis and cerebral cortex. Temporary paresis of the originally Juvenile myoclonic epilepsy affected limb may persist after the attack (Todds This form of primary generalised epilepsy with typical paralysis). Sensory epilepsy is a parallel condition onset in teenagers is characterised by relatively originating in the sensory cortex. Biochemical evidence of excess alcohol, hypogly- Status epilepticus caemia, hyponatraemia or hypocalcaemia should be sought. Intravenous lorazepam (4mg) (clonazepam and di- azepam are alternatives) dose may be repeated Management after 10min if seizures recur/continue. Intravenous phenytoin (15mg/kg, maximum rate Asingletrarelyrequirestreatmentbutanunderlying of 50mg/min), fosphenytoin (prodrug of pheny- cause should be sought. However, it may be prudent 100mg/min) should be used when there is estab- to treatafterarstseizurewhenneuroimagingreveals lished status. Absence: ethosuximide or sodium valproate are This should be considered in patients with intractable the drugs of choice for classical absence seizures; epilepsy if a focus for seizure onset can be identied clonazepam and lamotrigine are alternatives. Myoclonic: sodium valproate is the drug of choice for most cases; clonazepam, levetiracetam and topiramate may be tried as second-line agents. Seizure control with minimal must be continued especially if there is a history of adverse effects can be achieved using a single anti- recent seizure activity. The addition of a 3 years) history of seizures, a trial off therapy before second drug produces satisfactory control in a fur- pregnancy should be considered. Women with epilepsy who wish to become preg- Refractory epilepsy (inadequate control on mul- nant should receive pre-pregnancy counselling about tiple agents) may reect: the risk of congenital abnormality and the individual Neurology 177 pros and cons of continuing treatment. Wherever type of epilepsy; durationof remission;potentialdele- possible, the lowest dosage of a single agent should terious effects of seizure recurrence (driving and em- beused. Screeningforneuraltubedefectsis especially ployment) and side effects of treatment. For mothers taking carbamazepine, phenobarbi- Stroke tone or phenytoin (enzyme inducing agents), vitamin Stroke is characterised by rapidly developing K should be prescribed before delivery and for the symptoms and/or signs of loss of central nervous newborn. Stroke has an annual increase metabolism of oestrogens and progestagens, incidence of 12 per 1000 population, is the third making oral contraception unreliable. Currently, for an isolated Approximately 85% of cases are ischaemic (thrombo- seizure, a 6-month off driving period is stipulated sis or embolism) in origin, 10% are caused by providing the individual has undergone assessment intracerebral haemorrhage and 5% by subarachnoid by an appropriate specialist and no relevant abnor- haemorrhage. A 12- Thrombosis is due to one or more of the following: month off driving period applies if there is deemed. More stringent regula- tions apply to licences for heavy goods or passenger- Emboli may arise from vascular or cardiac sources, carrying vehicles (www. Epilepsy and employment Degenerative arterial disease is the most common cause of stroke. Potentially salvagable sur- should be guarded and children should not be left in rounding areas of brain which lie within the so-called the bath unattended. Prognosis in epilepsy Both cytotoxic(accumulation of water in damaged The long-term prognosis of epilepsy is good, with neurones and glial cells) and vasogenic (extracellular most patients attaining a 5-year remission and many uid accumulation secondary to disruption of the stopping treatment in due course. The decision to bloodbrain barrier) oedema may complicate discontinue anticonvulsant therapy is determined by: infarction. Look for an unequal smile or grimace has their mouth or eye drooped or is there obvious facial asymmetry? Arm weakness Lift the patients arms together and ask them to hold the position for 5s after you have let go. Visual field defect Y (+1) N (0) *Total Score(2 to +5) Provisional diagnosis Stroke Non-stroke (specify) *Stroke is unlikely but not completely excluded if total scores are 0. Thrombolysis with recombinant 180 Neurology tissue plasminogen activator (alteplase) should be. The efcacy of thrombolysis is highly time dependent and the decision to thrombo- lyse should be taken by a specialist stroke physician/ neurologist. Venous infarction For patients with haemorrhagic stroke, any pre- Thrombosis of the intracranial venous sinuses disposing coagulopathy (including warfarin therapy) produces clinical syndromes which are distinct from should be immediately corrected. Superior sagittal sinus intervention is only rarely indicated in acute stroke, thrombosis may present with headache, papilloe- e. Antithrombotic therapy: long-term aspirin (or clo- focal features such as syncope, confusion or dizziness pidogrel) is indicated in most patients for secondary are not diagnostic. Anticoagulants should be considered for those with atrial brillation or other cardiac Aetiology sources of emboli. Hypertension: in the longer term, good blood pres- The most common cause is thromboembolism from sure control is crucial to reducing the risk of further atherosclerotic neck vessels. Deepvenousthrombosisandpulmonaryembolism: Symptoms and signs depend on the arterial territory use graduated compression stockings and consider involved: low molecular weight heparin prophylaxis. Urinary infections/septicaemia: especially in those Involvement of the dominant hemisphere may requiring catheterisation. For patients with a score of < 4, aspirin should be commenced of subsequent stroke, and within 1 week in other immediately and the patient referred for specialist cases. Focal neuro- cardioembolism there are no conclusive data to sup- logical signs may point to the site of the lesion or may port the routine use of oral anticoagulants. It may Surgical treatment result from: The decision to perform carotid endarterectomy. Nimodipine (to reduce vasospasm) This occurs most frequently in the elderly, especially. Symptoms may develop over a period of weeks to Aneurysmal subarachnoid haemorrhage carries a months. Headache, confusion and progressive very high mortality (up to 3040% of patients within loss of conscious level occur with uctuation of the rst few days). Focal neurology and/or signs of raised bleeding, with the second bleed often more severe intracranial pressure may be evident.