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Mold can cause allergic reactions pulse pressure 15 buy cheap microzide on-line, trigger asthma attacks prehypertension 21 years old buy microzide 25 mg line, or cause other health problems in some people blood pressure medication regimen buy microzide 25mg. Stop indoor mold growth by fixing leaks hypertension 160100 buy on line microzide, drying damp or wet areas and controlling humidity. Control Moisture Sources fi In bathrooms without windows, check that bathroom fans or exhaust vents are working. If more than 10 square feet of mold growth is present also: fi Cover the floor in the work area with plastic sheeting. Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Review Article Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management Luca Busettoa Dror Dickerb Carmil Azranc Rachel L. Batterhamd, e, f Nathalie Farpour-Lambertg Martin Friedh Joran Hjelmesfithi Johann Kinzlj Deborah R. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. Luca Busetto Clinica Medica 3 Azienda Ospedaliera di Padova Via Giustiniani 2, 35128 Padova, Italy luca. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations. Karger GmbH, Freiburg Introduction Bariatric surgery produces sustained long-term weight loss and reduces co-morbidity burden and mortality in patients with severe obesity [1]. Therefore, the total number of bariatric procedures performed world-wide has increased steadily in recent years [3]. On the other hand, bariatric patients may face new specific multifaceted clinical problems after surgery. Eating habits need to adapt to the new gastro-intestinal physiology, and nutritional deficits may arise according to the type of bariatric procedure. Management of obesityassociated disease needs to be modulated according to weight loss taking into account the possibility of changes in drug pharmacokinetics. Specific problems may arise in women during pregnancy, and the patients may experience some psychological difficulties in adapting to the profound changes in eating behaviour and body image. Multidisciplinary long-term follow-up is recommended after bariatric surgery, and the provision of an adequate follow-up programme is mandatory for bariatric centres [2]. However, giving the accumulating numbers of bariatric patients, follow-up should be at least in part transferred to primary care over time. Moreover, post-bariatric patients may confront obesity specialists, dieticians and nurses not specifically trained in bariatric medicine with thus far unknown problems in their professional activity. Referral to the bariatric centre is often necessary and should be possible, but there is a growing need for dissemination of firstlevel knowledge in managing bariatric patients. The aim of this document is therefore to provide a brief but comprehensive review of the major clinical points in bariatric medicine and some practical recommendations for post-bariatric surgery medical management. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations. In this document, we tried therefore to convey the basic skills to those health care professionals that need to provide adequate first-level medical care to post-bariatric patients. Firstlevel information about nutritional management, micronutrients supplementation, management of co-morbidities, pharmacotherapy after bariatric surgery, pregnancy after bariatric surgery, psychological aspects as well as weight regain prevention and management are derived from current evidences and existing guidelines. A short list of clinical practical recommendations is derived from the full paper and included in each session. The anatomical and functional modifications of the gastro-intestinal tract produced by bariatric surgery always require the adaptation of patients’ eating behaviour to the new gastro-intestinal physiology, and procedure-specific nutritional problems and symptoms may occur. The nutritional management of the post-bariatric patients requires therefore specific nutritional skills and the intervention of experienced nutritionists and dieticians. Detailed guidelines for post-operative bariatric nutritional management have been published [4, 5] and recently updated [6]. In this section, first-level information about early, late and life-long nutritional management, protein intake and supplementation as well as specific nutritional problems is included. A short list of graded clinical practical recommendations on nutritional management is reported in table 2. Early, Late and Life-Long Nutritional Management Most bariatric procedures include the reduction of the volume of the stomach and/or the creation of a small gastric pouch. Therefore, the ingestion of solid foods in the first days after surgery is impossible and a gradual change of food consistency in the first post-operative weeks is preferred in order to avoid or minimise regurgitation and vomiting, which can threaten the integrity and safety of the recent surgical procedure, and result in severe vitamin B1 (thiamine) deficiency [5]. List of graded clinical practical recommendations for post-bariatric nutritional management Recommendations Level of Grade of evidence recommendation* Bariatric patients should receive periodic counselling by a registered 1 A dietician about long-term dietary modifications. The focus of dietary counselling should be the adaptation of patients eating behaviour to the surgical procedure and the general qualitative aspects of a healthy nutrient-dense diet. Regular physical activity should be encouraged after bariatric surgery, 1 A starting since after the recovery from surgery. Patients should be advised to incorporate moderate aerobic physical activity to include a minimum of 150 min/week and goal of 300 min/week, including strength training 2–3 times per week. Nutritional counselling should address the problem of protein intake, 4 D particularly in the first months after surgery. Nutritional manipulation should be the first line treatment for the 1 A control of dumping syndrome. Medical therapy with octreotide should be considered in patients who fail to be controlled with dietary modifications. Patients should be trained to chew adequately and receive clear instruction about post-operative meal initiation and progression by an experienced bariatric dietician before discharge [6]. There are protocols for meal progression specific to most of the bariatric procedures [4], but bariatric centres may design their own protocols taking into account personal and regional variations in food preferences. After the end of the post-operative diet and thereafter, patients should receive periodic counselling by a registered dietician about long-term dietary modifications in order to maximize the results of the bariatric procedure and reduce the risk of late weight regain. Patients who received regular dietary counselling for the first 4 months after surgery achieved a slightly greater weight loss than patients who received standard post-operative care not involving counselling in a randomised trial, although the difference did not reach statistical significance [7]. Patients in the dietary counselling arm did report significant changes in several eating behaviours believed to be important for successful long-term weight maintenance [7]. The focus of dietary counselling should be the adaptation of patients’ eating behaviour to the surgical procedure and the general qualitative aspects of a healthy nutrientdense diet. In particular, patients with gastric restriction should be counselled to eat three small meals during the day and chew small bites of food thoroughly before swallowing, without drinking beverages at the same time (more than 30 min apart) [4–6]. A positive relationship between physical activity levels and the amount of weight loss after bariatric surgery has been observed in several studies [8], and regular physical activity is considered a critical factor for weight maintenance. Protein Intake and Protein Supplementation Sufficient protein intake is considered protective against the loss of lean body mass in any situation when a rapid weight loss occurs. A preference toward low-protein foods is common after all procedures having a restrictive component, particularly in the first months after surgery which is based on gastric intolerance to protein-rich foods [4]. Usually, most food intolerances tend to diminish over time, and protein intake tends to increase, but protein intake may be lower than recommended in the first year after surgery, when most part of weight loss occurs. Therefore, dietary counselling should address the problem of protein intake, particularly in the first months after surgery. The use of liquid protein supplements (30 g/day) can facilitate adequate protein intake in the first period after surgery. Bariatric procedures involving a certain degree of malabsorption can cause protein malnutrition. The incidence of protein malnutrition depends on the degree of the malabsorption as well as on the dietary habits and the protein requirements of the patients. An incidence of protein malnutrition ranging from 3 to 18% has been reported after biliopancreatic diversion [4]. The occurrence of any pathologic (infections) or physiologic (pregnancy) state characterised by an increase of protein requirements may precipitate protein malnutrition in individual patients. Prevention of protein malnutrition involves regular assessment of protein intake, encouraging the ingestion of protein-rich foods (>60 g/day) divided into several meals and the use of modular protein supplements [4]. Parenteral nutrition is mandatory in case of severe non-responsive protein malnutrition, and surgical revision with lengthening of the common channel to decrease malabsorption should be considered if a patient remains dependent on parenteral nutrition or has recurrent episodes of protein depletion [12]. Specific Nutritional Problems Food Intolerance, Vomiting and Regurgitation: Food intolerances are common after any bariatric procedure involving a functional or anatomical reduction of the gastric volume.

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Caution: With regular drinking of aloe vera juice hypertension migraine purchase microzide 25 mg mastercard, diabetics may improve the ability of their pancreas to blood pressure spikes purchase microzide cheap online produce more of its own insulin prehypertension american heart association order microzide 25mg free shipping. Therefore hypertension medication drugs discount 25 mg microzide amex, diabetics should consult their physician to monitor their need for extra insulin, since too much insulin is dangerous. Small enema treatments (in comparison to colonics or colemas) involve the introduction of liquids into the rectum (usually, that is as far as they reach) for the purpose of cleansing and nourishment. It alleviates constipation, distension, chronic fever, the common cold, headaches, sexual disorders, kidney stones, pain in the heart area, vomiting, low backache, stiffness and pain in the neck and shoulders, nervous disorders, hyperacidity, and tiredness. Moreover, disorders such as arthritis, rheumatism, sciatica, and gout may greatly benefit from an enema. The Kidney Cleanse If the presence of gallstones in the liver, or any other situation, has led to the development of sand, grease, or stones in the kidneys or urinary bladder, you may also need to cleanse your kidneys. The kidneys are extremely delicate, blood-filtering organs that congest easily because of dehydration, poor diet, weak digestion, stress, and an irregular lifestyle. Most kidney grease/crystals/stones, however, are too small to be detected through modern diagnostic technology, including ultrasounds or x-rays. To prevent kidney problems and kidney-related diseases, it is best to eliminate kidney stones before they can cause a crisis. You can easily detect the presence of sand or stones in the kidneys by pulling the skin under your eyes sideways toward the cheekbones. Any irregular bumps, protrusions, red or white pimples, or discoloration of the skin indicates the presence of kidney sand or kidney stones. The following herbs, when taken daily for a period of twenty to thirty days, can help to dissolve and eliminate all types of kidney stones, including uric acid, oxalic acid, phosphate, and amino acid stones. If you have a history of kidney stones, you may need to repeat this cleanse a few times, at intervals of six weeks. Before bedtime, soak 3 tablespoons of the mixture in 2 cups of water, cover it, and leave it covered overnight. If you forget to soak the herbs in the evening, boil the mixture in the morning, and let it simmer for 5 to 10 minutes before straining. If you experience discomfort or stiffness in the area of the lower back, this is because mineral crystals from kidney stones are passing through the ureter ducts of the urinary system. Normally, though, the release is gradual and does not significantly change the color or texture of the urine. Important: Support the kidneys during the cleanse by drinking extra amounts of water, a minimum of six and a maximum of eight glasses per day, unless the color of the urine is dark yellow (in which case you will need to drink more than that amount). During the cleanse, try to avoid consuming animal products, including meat, dairy foods (except butter), fish, eggs, tea, coffee, alcohol, carbonated beverages, chocolate, and any other foods or drinks that contain preservatives, artificial sweeteners, coloring agents, and the like. In addition to drinking this kidney tea each day, if convenient, you may also chew on a small piece of rind from an organic lemon on the left side of your mouth and a small piece of carrot on the right side of your mouth 30 to 40 times each. If you are doing liver flushes, make certain that you do a kidney cleanse after every three or four liver flushes. In addition, those suffering from large kidney stones may benefit from drinking the juice of one to two lemons (diluted with water) per day for about ten to fourteen days. Drink Ionized Water Frequently the sipping of hot ionized water has a profound cleansing effect on all the tissues of the body. It helps reduce overall toxicity, improves circulatory functions, and balances bile. When you take frequent sips of this water throughout the day, it begins to systematically cleanse the tissues of the body and help rid them of certain positively charged ions (those associated with harmful acids and toxins). As the negative oxygen ions enter the body with the ingested water, they are attracted to the positively charged toxic material. This neutralizes waste and toxins, turning them into fluid matter that the body can remove easily. For the first couple of days or even weeks of cleansing your body tissues in this way, your tongue may take on a white or yellow coating, an indication that the body is clearing out a lot of toxic waste. If you have excessive body weight, this cleansing method can help you shed many pounds of body waste in a short period of time, without the side effects that normally accompany sudden weight loss. Take one or two sips every half hour all day long, and drink it as hot as you would sip tea. You may use this method anytime you do not feel well, have the need for decongesting, wish to keep the blood thin, or simply want to feel more energetic and clear. Some people drink ionized water for a certain duration, such as three to four weeks; others do it ongoing. The oxygen ions are generated through the bubbling effect of boiling water, similar to water falling on the ground in a waterfall or breaking against the seashore. In the thermos, the water will stay ionized for up to 12 hours or for as long as it remains hot. The total amount of water you need to boil to give you enough hot, ionized water for one day would be about 20 to 24 ounces. It doesn‘t hydrate the cells like normal water does; the body uses it to only cleanse the tissues. These essential materials, however, can easily become depleted when you do not get enough of them from the food you eat. Centuries of constant use of the same agricultural fields have led to foods that are highly nutrient-deficient. When minerals and trace elements run low in the body, important functions can no longer be sustained, or they become subdued. Disease is generally accompanied by a lack of one or more of these important substances. Because of the unnatural situation of mineral depletion in our soil today and, therefore, in our bodies, it may be useful to supplement with minerals. The crucial question is whether the minerals sold in nutrition stores or pharmacies are capable of replenishing the mineral supply to the cells of the body. When a plant grows in a healthy soil environment, it absorbs existing colloidal minerals and changes them into ionic, eater-soluble form. The ionic minerals are an angstrom in size, whereas the colloidal minerals, also known as inorganic, metallic minerals, are about 10,000 times larger (micron-size). In contrast, colloidal particles packed into complex compounds, and delivered in pill form, stand less than a 1 percent chance of absorption. Common colloidal particles, such as the compounds calcium carbonate and zinc picolinate, tend to get caught in the bloodstream and are subsequently deposited in various parts of the body. In the form of deposits, they can cause major mechanical, structural, and functional damage. Many health problems today, including osteoporosis, heart disease, cancer, arthritis, brain disorders, kidney stones, gallstones, and so on, are the direct result of ingesting such metallic minerals. Fortunately, there is a very efficient way to obtain minerals in the size of, and with the characteristics of, plant minerals. When vaporized in a vacuum chamber (without oxygen), minerals are prevented from oxidizing and forming into complex states. Once vaporized, the minerals can be combined with purified water and be made readily available to the cells of the body. The company, Eniva, makes these minerals available via 27 distributorship (see Product Information at the end of the book). More companies now offer similar ionic minerals; you can easily locate them on the Internet. Drinking Enough Water To produce the right amount of bile each day (1–1fi quarts), which the body requires for proper digestion of food, the liver needs plenty of water. In addition, the body uses up a lot of water to maintain normal blood volume, hydrate the cells and connective tissues, cleanse out toxins, and carry out literally thousands of other functions. Since the body cannot store water the way it stores fat, it is dependent on regular, sufficient water intake. To maintain proper bile production and bile consistency, as well as balanced blood values, you need to drink about six to eight glasses of water each day. The most important time to drink water is right after getting up: First, drink one glass of warm water to make it easier for the kidneys to dilute and excrete urine formed during the night.

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Is port site resection necessary in the surgical management of gallbladder cancer heart attack 720p movie buy microzide uk. Impact of chemotherapy and external-beam radiation therapy on outcomes among patients with resected gallbladder cancer: A multi-institutional analysis blood pressure chart to keep track order line microzide. There should be a patient/physician discussion regarding appropriate follow-up schedules/imaging hypertension guideline update jnc 8 buy discount microzide 25mg. A suspicious mass on imaging in the proper clinical setting should be treated as malignant blood pressure 58 over 38 generic 25mg microzide visa. Lymph node metastases beyond the porta hepatis and distant metastatic disease contraindicate resection. Intrahepatic cholangiocarcinoma: Rising frequency, improved survival and determinants of outcome after resection. Intrahepatic cholangiocarcinoma: an international multi-institutional analysis of prognostic factors and lymph node assessment. Adjuvant therapy in the treatment of biliary tract cancer: a systemic review and meta-analysis. Cholangiocarcinoma: Current opinion on clinical practice diagnostic and therapeutic algorithms: A review of the literature and a long-standing experience of a referral center. This generally requires a pancreaticoduodenectomy for distal bile duct tumors and a major hepatic resection for hilar tumors. These are relatively morbid procedures and should only be carried out in very healthy patients without signifcant comorbidity. Hilar Cholangiocarcinoma • Detailed descriptions of imaging assessment of resectability are beyond the scope of this outline. The basic principle is that the tumor will need to be resected along with the involved biliary tree and the involved hemi-liver with a reasonable chance of a margin-negative resection. The contralateral liver requires intact arterial and portal infow as well as biliary drainage. The Blumgart preoperative staging system for hilar cholangiocarcinoma: analysis of resectability and outcomes in 380 patients. Role of preoperative biliary drainage of live remnant prior to extended liver resection for hilar cholangiocarcinoma. The data from key PubMed articles and Liver/European Organization for Research and Treatment of Cancer 2 articles from additional sources deemed as relevant to these Guidelines and the consensus statement from the 2009 Asian Oncology Summit. Surgical resection is the only curative option, and younger patients when the subgroup of patients with early-stage patients who receive surgery have better survival outcomes than disease was considered. Though it may be used at centers of expertise as a cirrhosis and liver nodules between 1 and 2 cm detected during problem-solving tool for characterization of indeterminate nodules, it is surveillance, thereby reducing the need for a biopsy. However, there are a few scenarios in which biopsy immunohistochemical tests can be performed on the paraffin waxmay be considered. Third, biopsy may be indicated in patients with conditions number of factors including sampling error, particularly when lesions associated with formation of nonmalignant nodules that may be are less than 1 cm. The guidelines emphasize that a growing mass with a telangiectasia, or nodular regenerative hyperplasia. Advantages of the Child-Pugh score include ease of patients with cirrhosis who are not on a liver transplantation waiting performance (ie, can be done at the bedside) and the inclusion of 123 list. Therefore, another alternative to the Childintervention, and they may be used to guide treatment decision-making. The Child-Pugh score provides an estimate of liver function, treatment response and outcome. Further, limited resection may be feasible in following liver resection have been reported to exceed 70%. A multivariate analysis characteristics of the liver and the tumor(s), is essential. Although no limitation on the size of met standard criteria for resection but did not undergo resection (n = the tumor is specified for liver resection, the risk of vascular invasion 144); 3) did not meet standard criteria for resection but underwent and dissemination increases with size. The study investigators suggest that criteria total liver volume can be calculated. In multivariate analysis, Child-Pugh class, tumor associated with a significantly improved survival and higher rate of size, and tumor number were independent predictors of survival. In a retrospective comparative study, Peng et al reported that from the portal vein, blood flow to liver tumors is mainly from the hepatic artery. In addition, Tumors should be in a location accessible for laparoscopic, more individualized patient selection that is specific to the particular percutaneous, or open approaches. Lesions in certain portions of the arterially directed therapy being considered is necessary to avoid liver may not be accessible for ablation. General patient selection criteria tumors located on the liver capsule may cause tumor rupture with track for arterially directed therapies include unresectable or inoperable seeding. The angiographic endpoint of embolization may be chosen by the treating physician. Treatment duration was shorter for those receiving the While more mature results from ongoing studies are needed to sorafenib/erlotinib combination (86 vs. Adverse events were universal among patients randomized to receive regorafenib (n = 374), with the most frequent grade 3 or 4 Version 1. Other Agents and Emerging Therapies Additionally, trials are ongoing to evaluate experimental systemic Other therapeutic agents have been assessed in patients with therapies for emerging molecular targets in hepatobiliary cancers. However, sorafenib has and is the preferred treatment for patients with the following disease produced a small but statistically significant survival benefit in large, characteristics: adequate liver function (Child-Pugh class A and randomized clinical trials. Based on the results of these trials, sorafenib selected Child-Pugh class B patients without portal hypertension), is recommended as a category 1 option (for selected patients with solitary mass without major vascular invasion, and adequate liver Child-Pugh class A liver function) and as a category 2A option (for remnant. Hepatic resection is controversial characterized as: unresectable (liver-confined) and extensive/not in patients with limited multifocal disease as well as those with major suitable for liver transplantation; local disease only in patients who are vascular invasion. Liver resection in patients with major vascular not operable due to performance status or comorbidity; or metastatic invasion should only be performed in highly selected situations by disease. Additionally, transplantation can be administered to patients with unresectable disease, metastatic disease, considered for patients who have undergone successful downstaging or extensive tumor burden. The panel recommends ongoing surveillance — specifically, multiphasic Risk Factors high-quality cross-sectional imaging of the chest, abdomen, and pelvis Cholelithiasis with the presence of chronic inflammation is the most every 3 to 6 months for 2 years, then every 6 to 12 months. Other risk factors include anomalous pancreaticobiliary duct junctions, gallbladder polyps (solitary and symptomatic polyps greater than 1 cm), Biliary Tract Cancers chronic typhoid infection, primary sclerosing cholangitis, and inflammatory bowel disease. Prophylactic cholecystectomy may be beneficial for patients who A vast majority of gallbladder cancers are adenocarcinomas. Patients with a mortality rates in the United States are highest among American Indian 392 history of chronic cholecystitis or pancreaticobiliary maljunction have a and Alaska Native men and women. An analysis of 10,705 patients diagnosed with gallbladder incidental finding at cholecystectomy for presumed benign gallbladder cancer between 1989 and 1996 in the National Cancer Data Base disease or, more frequently, on pathologic review following demonstrated that this revised staging system provided an improved cholecystectomy for symptomatic cholelithiasis. It is important to jaundice, the resectability rate was low (7%), with even fewer having note, however, that these retrospective analyses did not control well for negative surgical margins (5%). Consultation with a pathologist with common bile duct excision significantly increased overall perioperative expertise in the hepatobiliary region should be considered, and careful morbidity (53%) and were not independently associated with long-term review of the pathology report for T stage, cystic duct margin status, survival. Nevertheless, in all patients with a patients with primary gallbladder cancer, staging laparoscopy should be Version 1. A biopsy is not necessary and a diagnostic laparoscopy is the preferred primary treatment for patients with incidental finding of recommended prior to definitive resection. However, caution should be exercised in margins are negative since these tumors have not penetrated the patients with biliary obstruction as drainage is not always feasible and muscle layer and long-term survival approaches 100% with simple can be dangerous. In patients for whom there is evidence of Surveillance locoregionally advanced disease (ie, nodal disease or evidence of other There are no data to support surveillance following resection of high-risk disease), neoadjuvant chemotherapy should be considered. It is recommended that follow-up of patients undergoing an extended cholecystectomy for gallbladder cancer should include consideration of Fluoropyrimidine chemoradiation and fluoropyrimidine or gemcitabine imaging studies every 6 months for 2 years, then annually up to 5 chemotherapy are options for adjuvant treatment. Re-evaluation according to the initial workup should Management of Unresectable or Metastatic Disease be considered in the event of disease relapse or progression. More than 90% of cholangiocarcinomas are beyond the porta hepatis, and extensive involvement of the porta adenocarcinomas and are broadly divided into 3 histologic types based hepatis causing jaundice or vascular encasement). Primary options for on their growth patterns: mass-forming, periductal-infiltrating, and intraductal-growing. In the biliary tree and are typically classified as either intrahepatic or Version 1. These cancers may have previously been diagnosed as cholangiocarcinomas including the hilar cholangiocarcinomas and the cancers of unknown primary, in which incidence has decreased from distal bile duct tumors. These the right and left hepatic ducts to the common bile duct, including the risk factors, like those for gallbladder cancer, are associated with the intrapancreatic portion (Figure 1) — and are further classified into hilar presence of chronic inflammation.

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With psychic symptoms (including dysphasia arteria dawson purchase microzide paypal, hallucinatory hypertension dizziness buy generic microzide canada, and affective changes) 4 arteria iliaca interna cheap microzide 25 mg on line. Does the plaintiff have a neurologic disease that places them at risk for seizuresfi There is a familial incidence of certain types of seizures including absence or petit mal and psychomotor epilepsy blood pressure chart hong kong order microzide 25 mg without prescription. Asymmetry in the size of hands, feet and face may also show the existence of long-standing lesions in the contralateral (opposite side) hemisphere. Many conditions of birth trauma lead to what is loosely termed as "cerebral palsy" and are often associated with seizures. If the witness indicates the possibility of a factitious disorder, see the section on factitious disorders for further questions. Infections such as viral encephalitis, and bacterial and fungal infections in the brain can lead to the development of seizures. Questions Primary, metastatic, and slow growing tumors may cause the onset of seizures. Symptoms may include nausea or vomiting, malaise or weakness; autonomic hyperactivity (such as tachycardia and sweating); anxiety or irritability; orthostatic hypotension; coarse tremor of the hands, tongue and eyelids; insomnia; and grand mal seizures. Other side-effects may include nausea, diarrhea, polyuria (the passage of an excessive quantity of urine), polydipsia (excessive thirst), and weight gain. Toxic effects may include gross tremor, increased deep tendon reflexes, persistent headaches, vomiting, mental confusion progressing to stupor, seizures,or cardiac arrhythmias. Seizures usually occur the morning after a weekend or even a single-day of drinking rather than during inebriation. Seizures usually occur singly or as a brief cluster; status epilepticus is infrequent. Focal features are present in 25% and do not consistently correlate with evidence of previous head injury or other structural cerebral pathology. Plaintiff complaints may include vertigo (illusion of movement), weakness, loss of consciousness, manipulated seizures, headaches, visual impairment, and loss of skin sensation. There is a gradual onset of the spell, enough time to sit down, take medicine, or see the floor coming up. Seizures are not abortable, while spells are abortable or delayable by some tactic. Seizures are generally accompanied by tonic-clonic activity but spells often consist of pure syncope (without tonic-clonic convulsive activity). Seizures often result in a fall while spells only occur in the standing position, or on standing up from a lying position. If the plaintiff was conscious or can recall events s/he has probably not had a true seizure. If there was purposeful, well-organized, or premeditated behavior during the spell, the plaintiff probably did not have a true seizure. Seizures are almost always accompanied by postictal confusion, lethargy, or headache. The patient may be having spells if they continue unabated despite adequate anticonvulsant medication. There are enough exceptions to the above tips to make each one only a guideline, not a firm rule. The simultaneous occurrence of two or more of these, however, markedly raises the improbability of a seizure disorder. Tension headaches are the most common type and migraine is the second most common primary headache disorder. The headache phase consists of 4 to 72 hours of unilateral throbbing head pain of moderate to severe intensity that is worsened by routine physical exertion and associated with nausea, photophobia, and phonophobia. It derives its name from the cluster of headaches during a period of time, separated by headache-free periods. Episodic tension-type headache consists of recurrent attacks of tight, pressing (band-like), bilateral, mild to moderate head pain that lasts from minutes to days. This includes cluster headache, hemicrania continua, chronic paroxysmal hemicrania, and chronic tension-type headache. Secondary Headache Disorders Headache may be the initial complaint in a host of central nervous system and systemic abnormalities. Prominent abnormalities that may result in chronic headache include the following: (1) Giant cell arteritis this is an inflammatory vasculitis involving branches of the temporal arteries. Substance-induced headaches, exposure and withdrawal Metabolic disturbance Hypoxia, altitude sickness, sleep apnea (reduced oxygen) Hypercapnia (excess of carbon dioxide in the blood) Hypoglycemia (reduced blood sugar) Dialysis Head and Face Pain Associated with Disorders of Cranial Nerves Neuralgias Trigeminal neuralgia Glossopharyngeal neuralgia Occipital neuralgia Herpes zoster Head and Face Pain Associated with Disorders of Other Cranial Structures Glaucoma Sinusitis Temporomandibular joint disease Dental pain Neck abnormalities (reference 23, pp. General Defense counsel should ask the following questions for the diagnosis given by the Questions witness. Sixty percent of all patients who suffer from migraine headaches have a familial history of headaches. If the witness indicates the possibility of a life stressor, see the section on Other Life Stressors for additional questions. Aneurysms along the posterior communicating arteries or the internal carotid artery may cause a frontal headache. The result is an impaired blood flow, hypervolemia (greater than normal volume of blood), increased cardiac output, and hyperviscosity (abnormally high resistence to flow). These increases are responsible for most of the symptoms of the disease, such as headaches. The meningitides are named by either the causative agent (viral meningitis, tuberculous meningitis, pneumococcal meningitis) or by symptom characteristics (acute, chronic). These congenital defects are usually located within the largest part of the brain. They range in size from barely detectable lesions up to huge networks occupying an entire lobe or hemisphere of the brain. Symptoms include sudden head pains and migraine headaches on the side of the malformations. Hypoglycemic plaintiffs often have headaches three to four hours after a meal due to the dilation of the scalp blood vessels. Migraine headaches may be caused by foods that contain phenylethylamine, tyramine (cheese, fermented dairy products, and chocolate), and monosodium glutamate (Chinese restaurant syndrome). Vascular headaches may be caused by chemicals, drugs, and foods that have a vasodilator effect, such as: (reference 4, p. Painful ophthalmoplegia is characterized by a boring, headache-like pain behind the eyes usually due to a chronic inflammatory lesion. Poor posture results in tension in the muscles of the head and neck and are known as postural headaches. A strain in (continued) the cervical region of the neck may cause or contribute to headaches. The muscle strain can persist for weeks to months, especially when ongoing legal action is based on the presence of disability. Fatigue can cause an acute tension-type headache that responds to analgesic and rest. Excessive exertion can cause an acute tension-type headache that responds to analgesic and rest. A positive relationship has been found between the onset of migraine headaches and the change in the endocrine balance that accompanies pregnancy. Pheochromocytoma is a tumor of the sympathetic nervous system which specifically causes headaches, lightheadedness, nausea, sweating, trembling, and elevated blood pressure during anxiety attacks. An unruptured brain abscess may cause headaches in a manner similar to a brain tumor. Questions Infectious disease, or any fever producing illness, may cause headaches due to an (continued) increased cerebral blood flow. Syphilis is a chronic disease usually contracted from another person through sexual contact. Pain and progressive dementia with agitation, expansiveness, or depression are common symptoms.