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This chapter provides an overview of a conceptual approach to providing care for the patient with medication-resistant epilepsy (MRE), with consideration of the care sequence and components. This discussion of the gestalt is not intended to provide one established algorithm, as one treatment pathway cannot serve the needs of the diverse MRE patient population. Nevertheless, the considerations described below comprise a generally accepted care process aimed to improve the MRE clinical outcome. Detailed discussions of the care elements are provided in other chapters.
The vagus nerve performs many different functions in the human body. Understanding these functions helps inform the potential side effects of vagus nerve stimulation (VNS). The nerve consists of 80% afferent fibres [1,2]. These include visceral sensory and taste fibres which travel primarily to the nucleus of the tractus solitarius, as well as cutaneous sensation fibres from the external auditory meatus which project to the spinal nucleus of the trigeminal nerve. The efferent component includes branchial motor fibres from the nucleus ambiguus, parasympathetic fibres primarily from the dorsal nucleus of the vagus and parasympathetic fibres from the nucleus ambiguus to the heart. The motor fibres innervate skeletal muscles in the head and neck involved in speech production and swallowing, while the parasympathetic fibres innervate most of the viscera serving to control heart rate, respiration, gastrointestinal motility and many other autonomic functions. The majority of fibres in the vagus nerve consist of unmyelinated C fibres, but commensurate with its wide variety of functions, it also contains larger and faster-conducting A- and B-type fibres. The brainstem nuclei that receive vagal inputs integrate homeostatic information, provide commensurate adjustments to autonomic functions and also send this information to other brainstem nuclei projecting widely throughout the brain.
Fifty million people worldwide have epilepsy and yet up to 35% of patients experience seizures that are resistant to anti-epileptic drugs. Patients with medication-resistant epilepsy have increased risks of premature death, psychosocial dysfunction and a reduced quality of life. This key resource delivers guidance for all clinicians involved in caring for patients with medication-resistant epilepsy in order to reduce these risks. Covering the epidemiology, biology, causes and potential treatments for medication-resistant epilepsy, this definitive and focused text reviews the clinical care needs of patients. Guidance is practical and includes treatment for specialized groups including pediatric patients and those with psychiatric comorbidities. Several promising non-pharmacologic interventions available for patients, such as surgery, neuromodulation diet therapy and botanical treatment are explored in detail. Leading international figures from a range of disciplines bring their expertise together holistically in this essential manual.
Human variability in temperament allows a unique natural experiment where reactivity, self-regulation, and experience combine in complex ways to produce an individual personality. Personality disorders may result from changes in the way past memories filter new information in situations of emotional involvement with others. According to this view, disorders are specific to their initiating circumstances rather than a general difficulty that might extend to classes of information processing remote from triggers for the disorder. A different view suggests a more general deficit in attentional control mechanisms that might extend to a wide range of situations far from those related to the core abnormality. This paper outlines methods for examining these views and presents data from the study of borderline personality disorder, arguing in favor of high negative emotionality being combined with a deficit in an executive attentional control network. Because this attentional network has already been well described in terms of anatomy, the cognitive operations involved, development, chemical modulators, and effects of lesions and candidate genes, these findings may have implications for understanding the disorder and its treatment. We consider these implications in terms of a general approach to the study of personality development and its disorders.
The use of neuropsychological tests in non-English-speaking
populations and among those with less education has been
limited because most tests have been standardized for English-speaking
populations with relatively high levels of education. In
effort to establish norms, a battery of neuropsychological
tests was administered, in either English or Spanish, to
995 normal elders with a wide range of educational attainment,
residing in the community of Washington Heights–Inwood
in northern Manhattan. Results indicate that age, education,
and language all influence test performance and should
be considered when evaluating neuropsychological measures.
(JINS, 1998, 4, 311–318.)
Cervical cancer and pre-cancer form a disease continuum ranging from cervical intraepithelial neoplasia (CIN) through microinvasion to invasive carcinoma; about 70% of the tumours are squamous and 30% are adeno- and adenosquamous carcinomas (Buckley & Fox, 1989). Most tumours are thought to develop from an area of intraepithelial neoplasia within the transformation zone (Coppelston & Reid, 1967). Cervical cancer is estimated to be the second most common female cancer with approximately 500 000 new cases per annum worldwide (Parkin, Laara & Muir, 1980). Sexually transmitted infections are recognized as one of the major risk factors and the active agents are thought to be specific types of human papillomavirus (HPV) (Munoz et al., 1992).
Papillomaviruses are small DNA viruses associated with benign and malignant proliferative lesions of cutaneous epithelium. Over 60 different types of papillomavirus have been described and they can be segregated into groups distinguished by DNA sequence homology and the specific lesions with which they are associated (de Villiers, 1989). HPV 6 and 11 are found most commonly in cervical condyloma, benign lesions that tend to regress spontaneously, and low-grade CIN. HPV 16 and 18 are the types most commonly associated with high-grade CIN lesions and invasive carcinoma of the cervix. The viruses will replicate only in specific differentiation stages of epithelia, which limits the use of in vitro culture methods for producing HPV. To circumvent this, molecular biological techniques have been utilized extensively to characterize HPV.
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