bluuebunny/crossref_metadata_2025 huggingface dataset:
Different Things Delight Different People
Authors: de Melo-Martín Inmaculada
Published: November 2017

This chapter deals with another problematic assumption that grounds mainstream defenses of reprogenetic technologies: the value-neutrality of science and technology. The thesis that science and technology are value-neutral or value-free is presented and called into question. The value-neutrality thesis presents an implausible view of scientific and technological practices; it limits the ethical evaluation of reprogenetic technologies to an assessment of risk and potential benefits and thus leads to a neglect of other relevant normative concerns; and it renders democratic participation in scientific and technological policy making unnecessary.
Sexual Health and Intimacy in the Military
Authors: Parkinson Glenn W. , Chin Martin S.
Published: November 2017

Sexual health and intimacy are universal aspects of the human experience that are deeply influenced by culture and community. Unique attributes of the military culture can impact the thoughts and feelings of service members and veterans. These thoughts and feelings may include those about sexuality or self-concept as sexual beings. It is critical to have an understanding of these issues, both policy-driven and cultural, when assessing or treating military service members. This chapter explores some historical, cultural, and policy issues that make military community and culture unique. Special consideration is given to lesbian, gay, bisexual, and transgender (LGBT) issues in this context. The background provided can serve as a context for clinicians trying to understand how military culture influences sexual health and intimacy.
Psychosocial Issues Related to Genitourinary Injury
Authors: Waddingham Suzanne M.
Published: November 2017

Given the incidence of genitourinary trauma in service members surviving severe injury in Operation Iraqi Freedom/Operation Enduring Freedom, all health care and mental health providers attending this population need to have an awareness of the extent of injury, the physical and psychosocial impacts, and the resulting approaches to care. It is also important that clinicians are comfortable with assessment for issues relating to sexual health and intimacy, capable adequately addressing these issues, familiar with military culture as a component to these issues, and familiar with treatment, intervention, and resources available to this population for these very specific and critical needs.
Side Effects of Medications and Mitigation Strategies
Authors: Burger John
Published: November 2017

Sexual dysfunction is a common side effect of many common medications, including the first-line agents for treating post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), and attention-deficit hyperactivity disorder (ADHD). Selective serotonin and norepinephrine reuptake inhibitors have been especially well studied. This chapter reviews the different classes of medications used to treat PTSD, TBI, and ADHD that can cause sexual side effects as well as several strategies important in understanding the source of sexual symptoms. Specific mitigation strategies are then reviewed, including changing the dose, switching within a class, switching to a different class, adding an augmenting agent, watching and waiting, and taking drug holidays. Key research supporting each strategy is presented and discussed with consideration for the typical responses of both men and women. Strength of research is also weighed. Finally, some considerations for future treatment strategies are considered.
Understanding Failed Relationships as a Factor Related to Suicide and Suicidal Behavior among Military Personnel
Authors: Garrick Jacqueline
Published: November 2017

Suicide among service members is associated with several demographic and social risk factors, especially precipitating intimate partner relationship issues, but the cause and nature of these failed relationships in the military have not been well explored. Service members have histories leading up to a suicide analogous to those among civilians. However, separations from families, deployments, combat or other trauma, command climate, and medical and psychological injuries are also stressors and may be linked to additional risks related to substance abuse, sexual dysfunction, domestic violence, lifestyle disagreements, or secretive thoughts and behaviors, which distance couples and add to disintegration of the supportive dyad the relationship could provide. Loss of vital social supports impacts resilience and facilitates a mindset enabling suicidal or other harmful thoughts and actions. Therefore, prevention programs that build, maintain, and sustain resilience are critical, as is availability of mental health clinicians trained to address relationship issues.
Intimacy after Intimate Partner Violence
Authors: Gerlock April , Tinney Glenna
Published: November 2017

Military service provides many opportunities but also may result in experiences that are highly stressful to Service members or military veterans and their families. This chapter explores the intersection of the common conditions of post-traumatic stress disorder, traumatic brain injury, substance misuse, and intimate partner violence (IPV). It discusses how these conditions impact intimacy and health and also compound elements of risk and danger within the couple relationship. Included are narratives from veterans and their wives or partners about how these conditions affect things such as taking medications and keeping medical appointments to feeling safe with each other. The importance of conducting screening and assessment for IPV perpetration and victimization and how IPV impacts these co-occurring conditions and vice versa, are also addressed. IPV impacts intimacy from the most basic aspect of feeling safe with each other, to talking about highly distressing traumatic experiences, to sharing physical closeness.
Intimacy after Sexual Violence
Authors: Tinney Glenna , Gerlock April
Published: November 2017

Sexual violence is a significant problem in the military and civilian communities. Sexual assault is the ultimate violation and causes grievous injuries affecting all aspects of self. The impact of the trauma can linger for many years or, for some, a lifetime, and it can have a devastating effect on a person’s ability to feel safe and engage in intimate relationships, whether sexual or nonsexual. This chapter explores the psychological injuries that occur following the trauma of sexual violence and how that trauma affects a person’s ability to be intimate in relationships. It provides information on the scope of sexual violence, adverse childhood experiences and the military and veteran populations, complex trauma, and the intersection of sexual violence and co-occurring conditions. The chapter also addresses the healing and recovery process and discusses implications for practice related to a trauma-informed approach, risk and danger, screening, assessment, and intervention.
Toxic Exposures from Service in the US Military
Authors: Nevin Remington L. , Ritchie Elspeth Cameron
Published: November 2017

Exposure of military personnel to known and plausible reproductive toxicants may pose a risk of reproductive harm. Such exposures also may contribute to sexual dysfunction, either by direct organic effects or because of reasonable concerns among the exposed over risking conception and consequent reproductive harm through sexual intercourse. Intimacy among military personnel returning from deployment may be prominently impaired by these concerns, which may persist despite efforts at good health risk communication. This chapter reviews common military toxic exposures with known or perceived reproductive toxicity or effects on sexual health. Recommendations are made for assessing such exposures when evaluating military personnel or veterans suffering impaired intimacy or sexual functioning. This chapter concludes with a recommendation that military specific exposure guidelines consider not only the existing evidence base regarding sexual and reproductive toxicity but also the valid concerns of military personnel about such effects and the possibility of their later confirmation.
The Way Ahead
Authors: Tuffaha Sami , Brandacher Gerald , Redett Richard
Published: November 2017

Male genitourinary trauma with penile loss or deformity can have devastating physical and psychosocial consequences for patients and their loved ones. The return of many servicemen from the recent conflicts in Iraq and Afghanistan with these types of injuries has brought this problem into focus. Traditional penile reconstructive techniques are often inadequate in addressing these injuries; penile transplantation may provide better outcomes. To date, however, only two penis transplants have been performed, with mixed results. To maximize the likelihood of success, a number of considerations must be addressed; these include optimizing the technical surgical approach and minimizing the risks associated with immunosuppression and rejection. The psychological implications of the procedure also must be taken into account, and a multidisciplinary team approach is of utmost importance.
The Plastic Age
Authors: Moore Charles , Mosko Sarah S.
Published: November 2017

We describe the environmental and physiologic consequences of our toxic love affair with synthetic polymers in the Anthropocene epoch’s plastic age. It took only three generations for man-made polymers to attain ubiquity. The masses of synthetic polymers invading billions of lives and every part of the globe have created wealth and convenience, but their use also has generated surprising and unwanted outcomes such as intractable pollution problems and adverse health effects for humans and animals. Plastic often is perceived as an inert and physiologically harmless, because most polymers have little taste or smell, but numerous chemicals attach to and leach from polymeric materials. Many are bioactive and have been implicated as etiologic agents in diverse pathologies. The ocean is downhill from nearly everywhere on earth and receives plastic waste from far inland as well as from coastal areas. Ocean currents gather the floating fraction in enormous eddies known as gyres.
Microwave/Radiofrequency Radiation and Human Health
Authors: Davis Devra , Sears Margaret E. , Miller Anthony B. , Bray Riina
Published: November 2017

Radiation from wireless transmitting devices can cause or worsen acute and chronic health conditions. Outdated exposure limits for cell phones and other wireless devices emitting microwave radiation, a form of radiofrequency radiation, are based solely on avoiding an increase in temperature and do not accommodate increasing evidence of nonthermal effects on reproductive, neurologic, developmental and cardiac health, and cancer. In 2016, the U.S. National Toxicology Program reported significantly greater risks of brain (i.e. gliomas) and heart tumors in the largest rodent study ever conducted. Case-control studies found that regular and heavy cell phone users incurred increased risks of these tumors. Increasing trends of aggressive gliomas among young people have been reported. Chapter 10 provides an overview of microwave chemistry and in vitro, in vivo, epidemiologic, and clinical study findings. Guidance from international authorities addresses history taking, clinical management of relevant exposures, and promotion of safer technologic approaches and policies.
Food Additives
Authors: Maffini Maricel V. , Vogel Sarah
Published: November 2017

The American diet is dramatically different today than in 1958, when Congress passed the Food Additives Amendment. Innovations in processing, preserving, and packaging have made food more affordable and convenient but added thousands of new chemicals to our diet. More than 10,000 additives are allowed in food, but most have not been tested, and their long-term, chronic effects have rarely been studied. The regulatory system has fallen short of being fully implemented and has been weakened by decades of limited resources. A legal loophole allows new chemicals in food without notice to or review by the Food and Drug Administration, and the outdated safety assessment process fails to adequately address public health concerns. The result is that consumers bear the burden of deciding what is safe to eat, with limited information to do so. Without robust review of the safety of chemicals in food, there is little insight into the extent to which they may be contributing to chronic diseases.
Sustainable Chemistry
Authors: Warner Genoa R. , Collins Terrence J.
Published: November 2017

Unsustainable chemical products and processes cause damage to the earth that will become irreparable without ethical principles that prioritize the good of future generations. A serious challenge is posed by anthropogenic endocrine disruptors, synthetic chemicals that can alter development and impair health at current exposure levels. These low-dose adverse effects caused by everyday chemicals represent one of the great challenges of green science. Solutions require interdisciplinary collaboration among the fields of sustainable chemistry, environmental health sciences, and integrative environmental medicine. Their joint mission is to advance assessment, design, stewardship, and regulation of chemical products and processes and to promote environmental and health performances that are valued as much as the historically dominant economic and technical performances. The Chemistry and Sustainability Bookcase and the framework for strategic sustainable development are organizational tools for tackling these challenges. Solutions already built by interdisciplinary partnerships offer examples of practical transgenerational justice.
A 35-Year-Old Man with Progressive Left-Hand Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Multifocal motor neuropathy (MMN) may be mistaken for common entrapment neuropathies, although absence of significant sensory findings is a helpful clue to the diagnosis. Multifocal motor neuropathy may also mimic motor neuron disease. Electrophysiological evidence of conduction block at a nerve site not typically prone to compression is consistent with MMN. A positive anti-GM1 antibody also supports the diagnosis. First-line treatment of MMN is intravenous immunoglobulin (IVIG), and the majority of patients have rapid improvement of their weakness. The clinical features, differential diagnosis, investigations, and treatment options are described in this chapter.
A 45-Year-Old Male with Toxin Exposure
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

A patient presents with a sensorimotor neuropathy and believes he has been poisoned. The approach to the differential diagnosis of arsenic toxicity is presented. Comparisons with mimics of this entity are made, and clinical clues to its early detection are provided. There are typical skin and nail changes with can occur with arsenic poisoning. Arsenic poisoning can appear similar to Guillain-Barre syndrome with gastrointestinal symptoms and later an ascending paralysis. Urine arsenic levels are more reliable than blood levels. Hair and nail samples are very useful in confirming the diagnosis. Electrodiagnostic testing confirmed an axonal polyneuropathy. Treatment of arsenic poisoning is discussed. The recent lead contamination in Flint Michigan points out that heavy metal poisoning still occurs despite public health awareness.
A 63-Year-Old Male with Severe Flaccid Weakness Post Motor Vehicle Accident
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Neuromuscular disorders are important causes of newly acquired weakness in the intensive care unit. Although evaluation usually begins with physical examination findings, these can be compromised in the intensive care unit environment. Therefore, electrodiagnostic study becomes even more important as a tool in localizing weakness to nerve, muscle or neuromuscular junction. Critical illness neuropathy and myopathy occurs in the setting of sepsis and multiple organ failure where sepsis is accompanied by the systemic inflammatory response syndrome. Additional, intensive care unit-specific risk factors exist, predominantly relating to administration of high-dose steroids, nondepolarizing neuromuscular blocking agents, and sedating agents such as propofol. There is no specific treatment except for optimizing medical management of the underlying disorder, including prevention and management of sepsis, systemic inflammatory response syndrome, and organ damage, as well as avoidance of exacerbating medications.
A 55-Year-Old Female with Slowly Progressive Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Chronic inflammatory demyelinating polyneuropathy (CIPD) typically presents with both proximal and distal weakness, areflexia, and distal sensory findings. Two-thirds of patients have a progressive course over many months to years, however one-third of patients have a relapsing course with partial or complete recovery. It is important to be aware of several systemic disorders which may be associated with CIDP. Immunoglobulin M antibody–producing neuropathies have a monoclonal protein that is usually detected with serum protein electrophoresis, which may mimic CIDP. This chapter emphasizes the importance of differential diagnosis and workup. Treatment options are also described.
A 59-Year-Old Man with Progressive Difficulties with Balance and Weight Loss
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Paraneoplastic peripheral neuropathies are rare but important to consider in the evaluation of subacute peripheral neuropathy. The clinical and electrophysiological pattern as well as antibody evaluation is essential order to identify a specific paraneoplastic neuropathy. A positive paraneoplastic antibody in the cerebral spinal fluid is not required to make the diagnosis, but is helpful to consider if the serum antibodies are negative. This chapter emphasizes the importance of differential diagnosis and work up. Treatment options are described. Immunotherapy is also an important consideration.
A 56-Year-Old Woman with Small-Fiber Neuropathy and Progressive Leg Pain and Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

The sudden onset of leg weakness and pain may be mistaken for an acute lumbosacral radiculopathy due to a herniated disc. However, in diabetics it is also essential to consider the entity of Bruns-Farland syndrome, or diabetic lumbosacral plexopathy (DLSP). DLSP is uncommon compared with lumbosacral radiculopathy, so delays in diagnosis are the rule rather than the exception. In this chapter we present the clinical characteristics of DLSP and the key features that can help with making a prompt diagnosis. The use of nerve conduction studies and EMG for confirmation of DLSP is reviewed. Treatment options and controversies are discussed.
An 18-Year-Old Male with Slowly Progressive Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Slow progression of proximal weakness in an adult may suggest Becker muscular dystrophy, but limb-girdle muscular dystrophy needs to be considered. This chapter discusses a diagnostic approach that includes the utility of ever-evolving genetic tests. Electromyography is helpful in cases of suspected muscular dystrophy without a family history, if creatine kinase levels are low, or in evaluation of possible female carriers for BMD who are symptomatic. Management considerations are also outlined. A muscular dystrophy clinic with a multidisciplinary approach is helpful for coordination of care. A consult from a clinical geneticist is often very helpful.
A 30-Year-Old Male with Severe Cramps
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Muscle cramps are a common complaint. When not associated with weakness, the course is usually benign but can still be frustrating to patients. Diffuse cramping may be indicative of a neuromuscular disorder. Cramps can be associated with a metabolic or endocrine disorder or medications. Normal nerve conduction studies and electromyography are reassuring for a benign cause of cramps. In motor neuron disease cramps are common. There are rare spontaneous activity syndromes associated with cramping. Stiff person syndrome is rare and usually has severe axial rigidity. It can be treated with immune modulating medications. McArdles disease has a prominent symptom of diffuse muscle cramping associated with activity. Unfortunately not always will a specific cause for cramps be discovered. Various treatment modalities are presented.
A 46-Year-Old Man with Double Vision and Proximal Leg Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

Lambert-Eaton myasthenic syndrome (LEMS) can be a difficult condition to diagnose. In this chapter, the clinical picture and characteristics are discussed. The pathophysiology is also reviewed. Features to distinguish LEMS from more common neuromuscular junction conditions such as myasthenia gravis are reviewed. We review features that distinguish between idiopathic and paraneoplastic forms, and we discuss the importance of tumor surveillance. Antibody testing and the correct electrodiagnostic strategy are presented. Treatment of LEMS is outlined.

Lambert-Eaton syndrome (LES) is a difficult condition to diagnose. The unique clinical picture and its characteristics are discussed. This is especially true in the patient without a diagnois of cancer. Antibody testing and the correct electrodiagnostic strategy are presented. Treatment of LES is outlined.
A 2-Month-Old Boy with Acute Diffuse Weakness
Authors: Cohen Jeffrey A. , Mowchun Justin J. , Lawson Victoria H. , Robbins Nathaniel M.
Published: November 2017

An infant presenting with acute weakness is an alarming problem that requires urgent diagnosis and action. Acute inflammatory demyelinating polyradiculoneuropathy is always a consideration, but botulism is important to remember. We discuss the key clinical signs that distinguish botulism from other causes of acute weakness, including pupillary and gastrointestinal dysfunction. We review the various forms of botulism and the known epidemiology. Botulism-related neuromuscular junction pathophysiology is reviewed. We discuss treatment and stress that supportive modalities and BIG-IV should be instituted early. We discuss prognosis and reinforce that despite the condition's seriousness, prognosis is good with prompt recognition and treatment.
Treatment of Acute Right-Sided Weakness
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Intravenous tissue plasminogen activator (IV tPA) is the mainstay of stroke therapy and is US Food and Drug Administration-approved for the treatment of acute ischemic stroke. Its benefit on functional outcome has been established in multiple randomized trials when administered within 3 hours. Select patients may be treated off-label up to 4.5 hours from symptom onset. Eligibility criteria need to be reviewed carefully to optimize benefit and to minimize complications, namely reperfusion hemorrhage.
Large Vessel Occlusion
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Select patients who are not eligible for IV tPA, or who do not recanalize with IV thrombolysis alone, may be treated with acute endovascular therapies within a 6-hour window. Mechanical thrombectomy, with or without intra-arterial tPA, has recently been shown to be effective in treating acute ischemic stroke caused by large vessel occlusion. Intra-arterial therapy using approved stent retrievers has become the standard of care for acute large vessel occlusion.
Progressive Quadriplegia
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Spinal cord ischemia most often presents as an anterior spinal artery syndrome and involves watershed regions of the spinal cord. The clinical presentation and etiologies can be heterogeneous, but cord infarcts are typically the result of aortic surgeries, systemic hypotension, vertebral artery and aortic dissections, embolus, or vascular malformations. Given that it is a rare entity, involving symptoms that can progress over minutes to hours, a diagnosis is often delayed until after conventional windows for revascularization, including thrombolysis, have passed. Magnetic resonance imaging (MRI) is usually required to confirm the diagnosis.
To Treat or Not to Treat (Blood Pressure)
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Blood pressure is commonly elevated after a stroke. There are theoretical risks of allowing very high blood pressures, but clinical data suggest early lowering of blood pressure may worsen outcomes.
Detected Bruit
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Carotid stenosis is a risk factor for stroke. Revascularization of high-grade asymptomatic carotid stenosis in select patients can lower the risk of incident stroke. Endarterectomy and stenting are both associated with periprocedural risk. Risks and benefits need to be evaluated carefully before proceeding with any intervention. Certain patient demographic and clinical characteristics, such as female gender, may reduce the benefits of surgery and influence treatment decisions.
A New Arrhythmia
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Atrial fibrillation is a potent risk factor for stroke. Anticoagulation significantly lowers recurrent stroke risk in patients with atrial fibrillation. The novel oral anticoagulants offer options in addition to warfarin, and they are associated with lower risk of bleeding complications.
A Horner’s Syndrome Following Trauma
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Carotid dissection should be considered as a stroke etiology, especially in young patients with a history of trauma. Carotid dissection can be recognized by exam findings and radiographic studies. Treatment can include aspirin or anticoagulation.
Cancer and Coagulopathy
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Advanced cancer is well known to cause a procoagulant state. The formation of sterile platelet thrombin vegetations on cardiac valves (i.e., nonbacterial thromboembolic disease) and arterial thrombosis are common etiologies of stroke in these patients. Despite preventative therapy with antiplatelet agents or low-molecular-weight heparins, stroke in cancer often portends a poor prognosis.
Fevers in a Patient with Valve Replacement
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Infective endocarditis can cause neurological complications, including stroke, hemorrhage, and mycotic aneurysms. Patients with endocarditis and neurological complications need vascular imaging to evaluate for aneurysm formation. Patients with acute ischemic stroke from septic emboli may not respond to conventional intravenous thrombolysis and have higher rates of hemorrhagic complications.
Seeing Jellyfish
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Migraine may mimic stroke, but acute migraine can also be a (rare) cause of stroke, particularly in the posterior circulation. This risk is particularly high in patients who experience migraine aura, or in those who are smokers or who take oral contraceptives. Because this is a diagnosis of exclusion, other etiologies of stroke need to be investigated. Although there are no high-level clinical trial data, it is advised to control vascular risk factors and avoid medications that can potentially induce vasoconstriction in patients with migraine-related stroke.
Puff of Smoke
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Moyamoya is a rare cause of stroke caused by progressive distal carotid occlusion. Children and adults may be affected, but it is more common in Asian populations, particularly in patients presenting with intracranial hemorrhage. Angiographic findings of distal internal carotid artery stenosis with lenticulostriate or choroidal neocollaterals are important in the diagnosis of moyamoya disease. A similar pathophysiological state to moyamoya disease is associated with several clinical conditions, some of which are acquired and some of which have a genetic etiology. Treatment is with surgical revascularization, which can reduce both ischemic and hemorrhagic complications.
A Protean Presentation
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Primary angiitis of the central nervous system is a rare but often dramatic cause of ischemic and hemorrhagic stroke. Its varied clinical course, in combination with high false-negative rates of cerebral angiography and brain biopsy, makes it a difficult disease to definitively diagnosis. Consider a diagnosis of vasculitis in patients with atypical-appearing or multifocal vascular lesions, particularly if they involve both ischemic and hemorrhagic components. Central nervous system angiitis can result in a high degree of mortality and morbidity despite immunosuppressant therapy.
Hemorrhage in a Patient with Dementia
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Cerebral amyloid angiopathy (CAA) is more prevalent with advancing age. Recurrent lobar hemorrhage, microhemorrhages, and white matter disease may be seen. A presumptive diagnosis is made by clinical factors and imaging, and definitive diagnosis is by pathology. There is no specific medical therapy to prevent hemorrhages in CAA; however, blood pressure should be well controlled and anticoagulation avoided. There is no evidence that most patients with acute, superficial intracerebral hemorrhage respond to surgical evacuation using currently available invasive techniques; however, a subset of patients with good premorbid baseline may be considered for surgery if the hemorrhage is considered life-threatening.
An Unusual Hemorrhage
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

A young patient without hypertension should have an evaluation for underlying cause of intracerebral hemorrhage. Arteriovenous malformations may cause intracerebral hemorrhage. Treatment can be challenging, and multimodal treatment is often required. The options include surgery, endovascular embolization, and radiotherapy.
Forget About It
Authors: Chong Ji Y. , Lerario Michael P.
Published: November 2017

Cognitive impairment is common following stroke. The clinical course and presentation are variable in vascular dementia, but the diagnosis can often be tied to recent vascular events or to progressive white matter lesions on MRI. Because there is considerable overlap between patients with vascular and Alzheimer’s type dementia, both acetylcholinesterase inhibitors and memantine have been tried off-label to treat the cognitive symptoms of vascular dementia with mixed results.
Auditory Responses
Authors: Hari Riitta , Puce Aina
Published: November 2017

This chapter briefly describes the various types of evoked and event-related responses that can be recorded in response to auditory stimulation, such as clicks and tones, and speech. Transient auditory-evoked responses are generally grouped into three major categories according to their latencies: (a) brainstem auditory evoked potentials occur within the first 10 ms, typically with 5–7 deflections, (b) middle-latency auditory-evoked potentials occur within 12 to 50 ms, and (c) long-latency auditory-evoked potentials range from about 50 to 250 ms with generators in the supratemporal auditory cortex. Steady-state auditory responses can be elicited by periodic stimuli, They can be used in frequency-tagging experiments, for example in following inputs from the left and right ear to the auditory cortices of both hemispheres.
Dietary Therapy in Adults
Authors: Johnson Emily L. , Cervenka Mackenzie C.
Published: November 2017

First described over a century ago, dietary treatments for adults with epilepsy were rarely used until the last two decades. Studies show that ketogenic diets are feasible and effective in adults as well as children, and there is growing use in adults with medically refractory epilepsy. Children on ketogenic diets are also transitioning to adulthood and require ongoing neurology care. The classic ketogenic diet and the modified Atkins diet are most commonly used in adults. Results are encouraging, with response rates potentially rivaling those of new antiepileptic drugs. Dietary therapies offer adults with epilepsy an alternative that may reduce antiepileptic drug burden. While lipid elevations and gastrointestinal side effects are common, many patients find intentional weight loss and improved cognition as additional secondary benefits. The ketogenic diet is also a promising therapy for refractory status epilepticus in adults. This chapter examines the use of dietary therapies in adult epilepsy.
How Do You Implement the Diet?
Authors: Bergqvist A. G. Christina
Published: November 2017

There is great variability in how the ketogenic diet (KD) is implemented. Most of the differences are preference based. A consensus statement attempted to unify professional practices. The KD can be safely used in all ages, modified for specific dietary needs, and administered as food, formula, or intravenous alimentation. Effectiveness, compliance, and minimal side effects are achieved using a team-based, family-centered support structure. The KD is commonly initiated in an in-patient setting with a gradual advancement of the fat. Some centers still begin the KD with a brief fast. Out-patient initiation with slower advancement to a full diet can be challenging but safely executed. Time to determine response and duration of treatment in responders varies. Side effects are better understood and best managed proactively by monitoring, but cannot always be prevented and must be weighed with the benefit of continuing the therapy.
Overview
Authors: Rho Jong M.
Published: November 2017

After nearly a century of clinical use, the ketogenic diet is firmly established as an efficacious treatment for medically intractable epilepsy. Intriguingly, there is growing experimental evidence that the ketogenic diet and its metabolites also render neuroprotective and potentially disease-modifying effects. Hence, dietary and metabolic therapies have been attempted in a variety of neurological disorders other than epilepsy, including brain cancer, cognitive disorders, autism, neurotrauma, pain, and multiple sclerosis. This section, “Ketogenic Diet: Emerging Clinical Applications and Future Potential,” explores the current preclinical and clinical evidence for metabolism-based treatments designed to counter the myriad disease processes seen in many neurological conditions. Specific attention has been given to the effects of the ketogenic diet in malignant brain cancer, autism spectrum disorder, Alzheimer’s disease, traumatic brain and spinal cord injury, pain, and multiple sclerosis.
Amino Acids in the Treatment of Neurological Disorders
Authors: Hartman Adam L.
Published: November 2017

Studies of metabolism- and diet-based therapies in epilepsy and neuroprotection have focused primarily on the quality and quantity of fat supplementation or carbohydrate restriction. However, protein is another key dietary component that has not been as thoroughly studied. A number of amino acids have been shown to stop, terminate, or prevent seizures. In addition, some have been shown to exert neuroprotective effects in other neurological disorders. Amino acids (and their metabolites) may exert their effects by acting at membrane or cytoplasmic receptors, serving as substrates for membrane transporters and as modulators of signaling pathway activity. This chapter highlights examples of each of these mechanisms of action in select nervous system disorders.
Ketogenic Diets as Highly Effective Treatments for Diabetes Mellitus and Obesity
Authors: Westman Eric C. , Maguire Emily , Yancy William S.
Published: November 2017

Obesity and type 2 diabetes mellitus (T2DM) have reached epidemic proportions worldwide. While characterized by chronic hyperglycemia, the underlying cause of T2DM is insulin resistance—most often related to an increase in abdominal adiposity caused by obesity. The goal of treatment of T2DM is to put the disease into remission by targeting the underlying insulin resistance. The observation that dietary carbohydrate is the major factor to cause glycosuria and hyperglycemia, has been known since the early days of modern medicine. As a result, low-carbohydrate, ketogenic diets were employed to treat obesity and diabetes in the nineteenth and early twentieth centuries. This chapter reviews the rationale and recent clinical research supporting the use of a low-carbohydrate, ketogenic diet in individuals with obesity and diabetes. For individuals affected by obesity-related T2DM, clinical studies have shown that carbohydrate restriction and weight loss can improve hyperglycemia, obesity, and T2DM.
Keto-Adaptation in Health and Fitness
Authors: Hyde Parker , Miller Vincent J. , Volek Jeff S.
Published: November 2017

When dietary carbohydrate is restricted and protein consumed in moderation, the evolutionarily-conserved ketogenic metabolic machinery awakens. After just a few days circulating ketones increase by an order of magnitude, and over several weeks there is a profound shift away from glucose as the primary energy substrate to the preferred use of fatty acids and ketones. This metabolic process is known as keto-adaptation. The deemphasis on insulin-dependent glucose uptake into cells and concomitant increase in fat oxidation has important implications in management of insulin resistance and its secondary manifestations, which are all functionally carbohydrate-intolerant conditions. The health implications of keto-adaptation are profound. In a definitive break from traditional groupthink, athletes are now experimenting with diets low in carbohydrate in an effort to improve their health, body composition, performance, and recovery. This chapter explores the rationale for the construct of keto-adaptation as a tool for achieving general well-being and improved performance.
Advancing the Awareness and Application of Ketogenic Therapies Globally
Authors: Zupec-Kania Beth , Abrahams Jim , Williams Emma , Masino Susan A.
Published: November 2017

The Charlie Foundation was founded in 1994 out of Jim and Nancy Abrahams’s desire to spare children from the unnecessary suffering their son Charlie endured before achieving seizure freedom with the ketogenic diet. The Abrahams shared their story widely. Emma Williams, whose son Matthew similarly suffered unnecessarily and became seizure-free on the ketogenic diet, founded Matthew’s Friends in 2004 with a similar mission. Nevetheless the diet remained underutilized until several key breakthroughs in 2008. Use of ketogenic diet therapy has spread rapidly worldwide, and with increased use came a broader understanding of benefits for other disorders; less restrictive versions were developed to meet the needs of older children and adults. In 2012 the Charlie Foundation also began recommending that all people with epilepsy eliminate sugar, reduce refined carbohydrates, and choose a predominantly whole foods diet. Both foundations have expanded efforts to additional conditions that can benefit from ketogenic therapies.
Introduction
Authors: Baloh Robert W.
Published: November 2017

The inner ear contains three major sensory receptors: the crista of the semicircular canals for sensing angular acceleration, the macule of the utricle and saccule for sensing linear acceleration, and the organ of Corti of the cochlea for sensing sound. Vertigo is an illusion of movement—usually spinning or turning but occasionally linear movement or tilt. Abnormalities of the inner ear or its connections in the brain cause an illusion of movement—vertigo. Benign paroxysmal positional vertigo (BPPV) is by far the most common cause of vertigo. Sudden violent spells of spinning are triggered by a change in position, such as turning over in bed, getting in and out of bed, and extending the head back to look up. This book tells the story of how the cause of BPPV was discovered and how a simple bedside cure was developed.
Breuer, the Renaissance Man
Authors: Baloh Robert W.
Published: November 2017

Josef Breuer was educated at home by his father and was able to read by age 4. In 1850, at age 8, Breuer entered the Akademisches Gymnasium, a secondary school in Vienna that placed particular emphasis on the natural sciences. Breuer began his medical training at the University of Vienna in the winter term of 1859–1860. Breuer planned to become a professor at the university, but multiple factors interfered with these plans. He made a clean cut with the university system by resigning his lectureship in 1885. Despite this, Breuer maintained close contacts with many members of the medical faculty at the university who became his friends and patients in his private practice. Election to the Academy of Sciences in 1884, a rare accomplishment for a practicing physician, undoubtedly lessened the disappointment of not receiving a professorship at the medical school.
Bárány’s Formative Years and the Conflict in Politzer’s Clinic
Authors: Baloh Robert W.
Published: November 2017

When Robert Bárány published his book on the physiology and pathology of the vestibular system in 1907, he did not mention his collaboration with Gustav Alexander or any of Alexander’s work. After writing the book in a few weeks apparently because of concerns that others might publish findings first, Bárány had Adam Politzer write the introduction but he did not show it to Alexander until after he had sent it to the publisher. Alexander reacted angrily, claiming that Bárány left out many important references in his book and had failed to give credit to Alexander for his contributions to the overall work. Gossip began to circulate within the Otology Clinic and the University Hospital suggesting that Bárány’s ideas were not original and that he had plagiarized others in his writings. Bárány’s aloof personality and his propensity for generating enemies with his caustic comments no doubt contributed to his problems.
Hallpike’s Formative Years
Authors: Baloh Robert W.
Published: November 2017

Charles Skinner Hallpike was born in 1900 in Muree, a small hill station and health resort in the northernmost part of India (now a part of Pakistan). He was baptized at the Church of St. James in Delhi. This was one of the three places of worship—a Hindu temple, a mosque, and a Christian church—built by Hallpike’s great-grandfather, James Skinner. Hallpike began his medical training at Guy’s Hospital in 1919. After graduating from medical school, he was appointed House Surgeon to T. B. Layton in the Ear, Nose and Throat Department at Guy’s Hospital. He took his Membership of the Royal College of Physicians of London and followed with his Fellowship of the Royal College of Surgeons. Hallpike had a reputation of being rather unapproachable, but he was comfortable with his clinical peers and had a protective attitude to the people who worked for him.
Hallpike’s Caloric Test
Authors: Baloh Robert W.
Published: November 2017

Charles Hallpike decided that greater precision could be obtained with the caloric test by measurement of one or more attributes of the responses to some suitably graded stimulus. He chose to measure the duration of induced nystagmus. Hallpike chose water at 30°C and 44°C (7°C below and above body temperature, respectively) and allowed it to flow for 40 seconds. These temperatures were generally well tolerated, and the comparatively large quantity of water and rapid flow minimized errors due to misdirecting the stream within the ear canal. A simple chart was used to summarize the results of the bithermal caloric test. The chart consisted of two continuous lines, each representing a total of a 3-minute period, subdivided into 10-second intervals. Hallpike conducted a series of experiments on the phenomenon of directional preponderance with caloric testing and emphasized the importance of vestibular tonus originating from the inner ear receptors.
Schuknecht’s Crusade Against Myths in Otology
Authors: Baloh Robert W.
Published: November 2017

Like Joseph Toynbee, Harold Schuknecht believed that the only way to develop rational treatments for inner ear diseases was to understand the pathology of these diseases. Schuknecht used his human temporal bone studies to “refute the conceptual validity of several popular otologic therapies.” Probably the most controversial of these was the treatment of Ménière’s disease with endolymphatic shunt surgery. Schuknecht argued the concept that the endolymph sac can be drained to relieve endolymphatic hydrops is a pedantic notion at best. He studied numerous human temporal bone specimens of patients who had had shunts placed in the endolymphatic sac, and in every case the shunt devices were ensheathed in fibrous tissue. He debunked many other controversial treatments in otolaryngology. He argued that most cases of sudden deafness and acute vertigo (vestibular neuritis) were due to viral infections of the inner ear and eighth nerve, and that vascular treatments were inappropriate.
Evolution of Treatment Maneuvers for Benign Paroxysmal Positional Vertigo
Authors: Baloh Robert W.
Published: November 2017

Near the turn of the 21st century, as more physicians began performing the Epley and Semont maneuvers for treatment of benign paroxysmal positional vertigo (BPPV), it became apparent that the procedures could be done at the time of initial examination without the need for sedation or vibration. Furthermore, modified versions of the maneuvers evolved that were more effective and easier to perform. There are clear similarities in these modified repositioning maneuvers. BPPV nearly always results from otoconial debris within the posterior semicircular canal because this is the canal in which it is most easily trapped. Although less common, there are horizontal and anterior semicircular canal variants of BPPV, and otolithic debris can become attached to the cupula, producing a true cupulolithiasis. The nystagmus is in the plane of the affected canal; the nystagmus is transient when the debris is freely floating and persistent when debris is attached to the cupula.
Becoming a Little Forgetful
Authors: Fox Susan H. , Picillo Marina
Published: November 2017

Many patients with Parkinson’s disease will experience some degree of cognitive impairment during the course of their disease. Cortical involvement in the underlying synuclein pathology is variable in its severity and extent. The most severe end of the spectrum is seen in dementia with Lewy bodies, in which cognitive impairment is prominent from the beginning. In most patients, however, mild memory difficulty and executive dysfunction are present to some degree but do not impair function until the later stages of the disease; after 20 years, dementia is almost universal and can be as disabling as the motor features of the disease.
Beyond Tremor, Slowness, and Stiffness
Authors: de Bie Robertus M. A.
Published: November 2017

Parkinson’s disease may be accompanied by a variety of nonmotor symptoms, such as autonomic, cognitive, psychiatric, sensory, and sleep disorders. These may even precede the motor symptoms, and in a considerable proportion of patients nonmotor symptoms are the major determinant of disability, especially in the more advanced stages of the disease. The patient in this chapter is experiencing two nonmotor symptoms—pain and insomnia. If present, it should be determined whether nonmotor symptoms fluctuate, because many are worse in the “off” period. The most common cause for insomnia is untreated or undertreated nocturnal parkinsonism, which is very responsive to levodopa therapy. If a medical condition requiring further evaluation is excluded and a temporal relationship between pain and the medication schedule is recognized, the emphasis should be on adjusting dopaminergic medication accordingly.