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O. Felipe, M.S., Ph.D.

Vice Chair, University of Oklahoma College of Medicine

Such measurements must be recorded during a seizure to be of great value to the therapist. Brain waves measured during an attack exhibit low frequency rectangular waves with an average frequency of four per second and a magnitude of approximately 100 microvolts. Often seizures may be so organized that entire scenes with both visual and auditory stimuli may be experienced. Of course, the nature of the overt symptoms depends upon the areas of the brain involved in the seizure, which will vary from person to person and even with different attacks. Tactile disturbances in attacks may disrupt limb position sense; some may even claim limbs enlarge and change shape. Often the patient cannot recall the seizure once it has passed and brain functioning has returned to normal. Psychiatric manifestations may consist of recurrent episodes of abnormal ideas, with or without some sensory involvement. Delusions of depersonalization in which one feels separated from the environment or body are common. Treatment of psychomotor epilepsy involves the use of antiepileptic drugs, most commonly phenytoin (Dilantin). Dosage should be in sufficient quantities to control seizures and reduction may be feasible if on a nutrient supplement regime. Responsiveness to antiepileptic agents may be used as a diagnostic tool if a battery of clinical tests have revealed no clues as to the basis of the nervous disturbance. Unlike drugs, nutritional therapy of epilepsy will affect and control all types of seizures, so one does not need to design nutrients for each type of seizure. You should know that lead-intoxicated children convulse, and other metals such as cobalt and aluminum produce seizures when applied to the brain of animals. Some natural dietary trace elements combat this effect and rid the body of convulsants such as lead and aluminum. Adelle Davis taught, "give them all liberal doses of magnesium and their seizures will go away. If any single trace element corrects the biochemical imbalance of epilepsy, it is manganese. Although often ignored by nutrition-conscious individuals, manganese is an essential trace metal frequently deficient in our diet. A component of at least six known enzymes, manganese is required for efficient sugar metabolism and for the production of cartilage, a vital structural component of our bodies. Unfortunately, most diets, even the best planned, tend to be deficient in this important trace metal. Our manganese-deficient farmlands often produce fruits and vegetables lacking adequate levels of the element. And, many of our frequently-eaten foods fail to concentrate manganese even under the best conditions; for example, meat, even liver, provides little manganese. Foods rich in manganese include nuts, whole grains, spices, legumes, and tea leaves. Tropical fruits such as banana, papaya, and mango are particularly good sources; these fruits, growing in a sun-rich climate, have a high capacity of photosynthesis, and photosynthesis is a manganese-dependent process. We recommend, and successfully use, 50 to 100 mgm of manganese per day taken orally at bedtime. Many children and teenagers have the mauve factor (kryptopyrrole) in their urine which robs them of zinc and B-6. We start with 50 mgm taken orally each morning and double the dose until dreams or a total of 1000 mgm is reached. B-6 doses in excess of 1000 mgm may produce numbness of the fingers or toes, an indication for shifting to pyridoxal phosphate at 1/5 to 1/10 the oral dose. If any single amino acid is needed to control epileptic seizures it is taurine, the simplest of the amino acids.

The 12 tools for assessing evidence presented in this chapter provide a basis to make decisions about patient care when reading published reports. These strict requirements for evidence are essential if true evidence-based decisions are to be incorporated into the daily practice of periodontics. Furthermore, the design of studies to solve periodontal questions must have a foundation based on these 12 tools, if they are to provide credible solutions. At present, much of what is accepted in periodontal therapy is scientifically flawed, and the future of periodontology must have a foundation of reliable scientific procedures; only then can evidence-based decisions become clear and reliable. Temporality is the only criterion that needs to be satisfied for claiming causality; the cause needs to precede the effect. In periodontal research, many studies relating plaque or specific infections to periodontal diseases suffer from unclear temporality. Do individuals with periodontitis have more plaque because they have more root surface areas to clean, or do they have poorer oral hygiene Similarly, studies on the potential association between so-called chronic periodontitis and systemic diseases may not have adequately addressed the issue of temporality. Is chronic periodontitis preceding the systemic disease, or are chronic periodontitis and systemic disease comorbid conditions caused by a common causal factor, such as smoking Unequivocal establishment of temporality is an essential element of causality and can be difficult to establish for chronic diseases, including the epidemiology of periodontal diseases. NoBettingontheHorseaftertheRaceIsOver Predictions are difficult, especially about the future. Results of a large collaborative study demonstrating that aspirin use after myocardial infarct increased mortality risk in patients born under Gemini or Libra provided a comical example of an important scientific concept; the unreliability of datagenerated ideas. An essence of science is that hypotheses or ideas predict observations, not that hypotheses or ideas can be fitted to observed data. This essential characteristic of scientific enterprise-prediction- is often lost in medical and dental research when poorly defined prestudy hypotheses result in convoluted data-generated ideas or hypotheses that fit the observed data. It has been reported that even for well-organized studies with carefully written protocols, investigators often do not remember which hypotheses were defined in advance, which hypotheses were data derived, which hypotheses were "a priori" considered plausible, and which were unlikely. A common posttrial modification of a hypothesis is to evaluate proper or improper subgroups of the original study sample. Improper subgroups are based on patient characteristics that may have been influenced by the exposure. For example, one may evaluate tumor size only in those patients who survived or pocket depths only in those teeth that were not lostduring the maintenance. Results of improper-subgroup analyses are almost always meaningless when establishing causality. A review of trials in the area of cardiovascular diseasesuggested that even the results of proper- subgroup analyses turn out to be misleading in a majority of cases. After or during the conduct of a study, the exposure definition can be changed, or the number of exposures under study can be modified. In another example of "betting on the horse after the race was over," a negative finding for cigarette smoking (the primary exposure) as a cause for pancreatic cancer led reportedly to the data-generated hypothesis that coffee drinking increased pancreatic cancer risk. In the initial investigation of the " clot buster" drug streptokinase, the primary endpoint was a measure of how well the heart pumped blood. When treatment had no effect on this endpoint, the endpoint definition was changed to reperfusion of the blocked artery. The typical periodontal trial has six endpoints and does not specify which endpoint is primary,59 and it is not always clear what is a good or a bad outcome. Opportunistic data torturing refers to exploring data without the goal of "proving" a particular point of view. Opportunistic data torturing is an essential aspect of scientific activity and hypothesis generation. Procrustean data torturing refers to exploring data with the goal of proving a particular point of view.

These sites are important because several conditions may occur as a result of changes in pressure within each system. The most common conditions include: Hemorrhoids, Esophageal Varices, and Caput Medusae. Hemorrhoids that are above the pectinate line do not cause pain due to visceral innervation. Hemorrhoids that are below the pectinate line have somatic innervation, and are therefore painful. Venous drainage is from the superior rectal vein to the inferior mesenteric vein, and into the portal system. The menisci can be torn when doing low-impact activities such as walking, and can be torn when doing high-impact activities such as weight lifting and playing sports. Common causes of injury are impact to the knee and a "twisting" motion of the knee when it is firmly planted. Attached proximally to the medial condyle of the femur below the adductor tubercle and medial surface of its body. The posterior fibers are short and incline backwards upon descent, and are inserted into the tibia above the semi-membranous muscle groove. Injuries are common in skiing and in football when valgus stress is applied (this is "abduction stress" aka stress to the lateral aspect of the knee). Injury to the anterior cruciate ligament is the most common knee injury, and is especially seen in athletes. It connects the posterior intercondylar area of the tibia to the medial condyle of the femur. A common mechanism of injury during sporting events is a fall on a hyperflexed knee with the foot pointed downwards. Memorization of the embryologic derivatives is important, as it is likely to show up on the exam, as is the majority of the information from this chapter. This occurs in the testes and epididymis in a step-by- step fashion, taking approximately 65 days. The starting point for spermatogenesis is the seminiferous tubules of the testes, where the stem cells that are adjacent to the inner tubule wall divide in a centripetal direction (moving towards the lumen). The following table and illustration demonstrate the most important points from fertilization to implantation. The cells of the endoderm being as squamous cells, but finally change into columnar cells. Some mesodermal tissues contain the ability to differentiate into a diverse range of tissues, such as the bone marrow. The umbilical vein is responsible for supplying the fetus with oxygenated blood, while the arteries are responsible for carrying deoxygenated blood from the fetus.

There are no symptoms, physical findings, or tests that reliably distinguish bacterial from viral sinusitis. Patients generally can be assumed to have bacterial sinusitis if symptoms do not resolve, or if they worsen, over the course of 7-10 days. Any patient with high fever or severe or unusual symptoms should be evaluated urgently for other causes of illness. The value of antibiotics in chronic sinusitis is unclear; consider especially if a trial of antibiotics has not been undertaken. If symptoms persist or worsen, refer patients to an otolaryngologist for further evaluation and treatment. It is a complex disease with protean variations that can mimic many common infections or illnesses. Many clinicians strongly recommend performed within the measurement year routine syphilis testing every 3-6 months for (Group 2 measure) patients at risk of syphilis. There has been a resurgence of syphilis in metropolitan areas of the United States and western Europe. The natural history of untreated syphilis infection is divided into stages based on length of infection. Section 6: Comorbidities, Coinfections, and Complications Primary Syphilis Primary syphilis usually manifests after an incubation period of 1-3 weeks from exposure and is characterized by a painless self-limiting ulcer (chancre) at the site of sexual contact. Some patients have no primary lesion, or have a primary lesion that is not visible. Secondary Syphilis Secondary syphilis usually develops 2-8 weeks after initial infection and is caused by ongoing replication of the spirochete, with disseminated infection that may involve multiple systems. Rash is the most common presenting symptom; skin lesions may be macular, maculopapular, papular, or pustular, or they may appear as condyloma lata (which may look like the condyloma of papillomavirus). The rash often appears on the trunk and extremities and may involve the palms and soles of feet. In the absence of treatment, the manifestations of secondary syphilis last days to weeks, then usually resolve to the latent stages. Latent Syphilis Section 6: Comorbidities, Coinfections, and Complications Latent syphilis follows resolution of secondary syphilis. Latent syphilis is further classified as "early latent" if the infection is known to be <1 year in duration, "late latent" if the infection is known to be >1 year in duration, or "latent syphilis of unknown duration" if the duration of infection is not known. Late or Tertiary Syphilis Late or tertiary syphilis is caused by chronic infection with progressive disease in any system causing serious illness and death in untreated patients. The most common manifestations include neurosyphilis, cardiovascular syphilis, and gummatous syphilis. It is associated with neurologic symptoms, including cranial nerve abnormalities (particularly extraocular or facial muscle palsies, tinnitus, and hearing loss) or symptoms of meningitis. S: Subjective Symptoms depend on the site of initial infection, the stage of disease, and whether neurosyphilis is present. Titers may be used to follow response to treatment; a fourfold change in titer is considered a significant change. Another possible cause of a false-negative nontreponemal result is the prozone phenomenon, seen when A: Assessment Because syphilis has a wide range of manifestations, the differential diagnosis is broad. It is important to consider syphilis as a possible cause of many presenting illnesses. If serologic test results are negative and suspicion of syphilis is high, perform other diagnostic tests. This is very sensitive but not very specific; a negative result indicates that neurosyphilis is highly unlikely. If the leukocyte count is not lower at 6 months, consider retreatment (consult with a specialist). Note that a Jarisch-Herxheimer reaction may occur after initial syphilis treatment, especially in primary, secondary, or even latent syphilis.