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Fast activity can also fade during repeated spasms or in partial seizures that occur with spasms (72). In some studies (98), late-onset spasms may be cryptogenic or associated with cortical dysplasia, hypoxicischemic encephalopathy, or genetic anomalies, and were refractory to medications (16). Late-onset spasms may be intermixed with atonic, tonic, partial, myoclonic, or generalized tonicclonic seizures or atypical absences. Watanabe has suggested that a subset of the cryptogenic group may be truly an "idiopathic" form of West syndrome (51). These patients have normal development, and the spasms usually remit after a short period. This group may represent from approximately half to 80% of the cryptogenic cases (24,75). Tonic seizures usually coexist with and are more marked during this stage of the syndrome. A firm diagnosis is necessary before initiation of therapy because many common medications (specifically corticotropin and vigabatrin) carry a higher risk of morbidity or mortality than most commonly used anticonvulsants. As with all forms of epilepsy, the evaluation begins with the history and physical/neurologic examination. The skin should be examined for evidence of neurocutaneous disorders and the fundi for a cherry-red macula suggestive of a storage or mitochondrial disorder or for chorioretinitis indicating possible transplacental infection. Nearly half of all of the etiologic diagnoses are established or suspected by the historical and physical data. In the remaining 30% of cases, an etiology will be established for no more than one third, leaving about 10% of cases in which a diagnosis is determined by results of lumbar puncture or metabolic or genetic testing. Delayed myelination in 27% of patients did not appear to be associated with any specific etiology (Table 17. Metabolic Studies Metabolic studies are indicated to identify more than 50 disorders associated with infantile seizures (105107). A trial of folinic acid is warranted (108), as is a 100-mg intravenous pyridoxine bolus to rule out pyridoxine-dependent seizures. Complete blood count, electrolytes (looking for an anion gap), and glucose determinations are appropriate. Nevertheless, such screening is not routine in all countries, and measurement of urine amino acid levels will detect phenylketonuria and maple-syrup urine disease, as well as other, rarer, metabolic diseases. Zellweger syndrome and neonatal adrenoleukodystrophy are other rare causes of hypsarrhythmia that can be diagnosed with the serum very-longchain fatty acid test (Table 17. In the 45 years since that report, efficacy has been repeatedly confirmed, but agreement is still lacking on the most appropriate dose and duration of treatment. Dosing is complicated by the existence of natural and synthetic forms of corticotropin. Studies of the synthetic product generally used much lower doses than studies of the natural product. If spasms are controlled and hypsarrhythmia disappears, I taper the dose over 1 to 4 months, while failed responders are rapidly tapered and the drug discontinued from a riskbenefit perspective. Most children develop a Cushing syndrome with obesity, plethora, hypertension, and intense irritability. Corticotropin and, as of 2009, vigabatrin are approved by the Food and Drug Administration for use in the United States. In addition, some patients respond to valproic acid, lamotrigine, high-dose pyridoxine, topiramate, and zonisamide, while most conventional antiepileptic drugs are ineffective. Sepsis, tuberculosis, meningoencephalitis, and protracted cytomegalovirus infection are major infections that have been reported. Corticotropin exacerbates the seizures in a few infants, and treatment for more than a few weeks leads to steroid insufficiency if the drug is stopped abruptly (114). Parents must be fully informed of the associated morbidity and mortality risks (reported at approximately 2% to 5%) before the therapy begins, and these must be balanced against the virtual certainty of mental retardation if the spasms are not rapidly controlled. Careful follow-up with regular measurements of blood pressure, electrolytes, and urinalysis is mandatory. The current risk-to-benefit assessment favors corticotropin, but if another, less hazardous medication proves to be as effective, it would be the drug of choice. Following response to steroids or corticotrophin, the relapse rate is high and variably reported between 33% and 56% (34).
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Monitoring for Adverse Effects Because in patients with aplastic anemia from other causes, symptoms often precede laboratory confirmation (70), the best protection for patients is probably education about early symptoms, especially unusual fatigue, pallor, dyspnea, easy bruising, and bleeding. Patients for whom risk-to-benefit ratio supports use because there is class I evidence of benefit. Patients for whom the current risk-to-benefit assessment does not support the use of felbamate. Practice advisory: the use of felbamate in the treatment of patients with intractable epilepsy. It is important to tell patients that periodic blood testing may not detect adverse events early enough to prevent serious illness or death. Nevertheless, the manufacturer recommends periodic blood counts and liver function tests, but the frequency is not mandated (33). A reasonable schedule is monthly testing for the first 6 months and every 2 months for the next 6 months. The lessening of risk after 1 year of therapy requires less frequent testing, perhaps every 3 months during the second year, then only if symptoms develop thereafter. Animal studies and experience with LennoxGastaut syndrome suggest a broad spectrum of activity against generalized seizures as well. Nevertheless, it is not easy to use because of the many pharmacokinetic interactions. These risks are almost certainly less than the risks of continued poor seizure control. Comparative anticonvulsant activity and neurotoxicity of felbamate and four prototype antiepileptic drugs in mice and rats. Efficacy of felbamate in childhood epileptic encephalopathy (LennoxGastaut syndrome). Felbamate in the treatment of LennoxGastaut syndrome: results of a 12-month open-label study following a randomized clinical trial. Pilot study of felbamate in adult medically refractory primary generalized seizure patients. Efficacy and safety of felbamate in children under 4 years of age: a retrospective chart review. Evaluation of the potential interaction between felbamate and erythromycin in patients with epilepsy. Felbamate serum concentrations: effect of valproate, carbamazepine, phenytoin, and phenobarbital. Effects of felbamate on the pharmacokinetics of the monohydroxy and dihydroxy metabolites of oxcarbazepine. Evaluation of case reports of aplastic anemia among patients treated with felbamate. Quantification in patient urine samples of felbamate and three metabolites: acid carbamate and two mercapturic acids. Investigating the role of 2phenylpropenal in felbamate-induced idiosynncratic drug reactions. Felbamate-induced apoptosis of hematopoietic cells is mediated by redox-sensitive and redox-independent pathways. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. An epidemiological study of aplastic anemia: relationship of drug exposures to clinical features and outcome. A self-complementary, self-assembling microsphere system: application for intravenous delivery of the antiepileptic and neuroprotectant compound felbamate. The new antiepileptic drugs lamotrigine and felbamate are effective in phenytoin-resistant kindled rats. Levetiracetam and felbamate interact both pharmacodynamically and pharmacokinetically: an isobolographic analysis in the mouse maximal electroshock model. Subtype-selective antagonism of N-methyl-D-aspartate receptors by felbamate: insights into the mechanism of action. Posthypoxia treatment with felbamate is neuroprotective in a rat model of hypoxia-ischemia. Anticonvulsant and antiepileptogenic effects of fluorofelbamate in experimental status epilepticus.
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Pertinent laboratory data included HbAlC, plasma glucose, creatinine, liver function tests, lipid levels and microalbuminuria. Patients were instructed to continue with their regular lifestyle, to keep a food diary and to record event markers into the monitor. After 72 hours, the monitor was removed and the data were downloaded using Minimed Solutions Software version 2. Blood glucose concentration >140 mg/dL for at least 30 minutes indicated hyperglycemia. Hyperglycemic prevalence was calculated as the percentage of a specified time period spent during hyperglycemia. Changes in blood glucose > 100mg/dL within a 60-min period were defined as rapid glucose excursions. Of the 84 patients, 18 were on oral medications alone, 51 were on insulin alone, while 15 were on both. The analysis of the glycemic levels were divided into 3 time periods: 6 am 6 pm (daytime), 6 pm midnight (evening), and midnight 6 am (early morning). Zero order correlations Overall, a greater percentage of time was spent in hyperglycemia during the day (57. Also no significant findings were seen in the evening hours (6 pm to midnight) when examining the same variables for either age or treatment type for any glycemic state. Increasing values of HbA1C were associated with a significantly greater percentage of time in the hyperglycemic state, as expected, but only during the early morning hours. On the other hand, subjects older than 65 years exhibited a significantly greater percentage of time in the hyperglycemic state for the daytime interval and a lower percentage of time in the hyperglycemic state for the early morning interval. That is subjects younger than 65 spent a greater percentage of time in hyperglycemia during the early morning interval 18 Hypoglycemia Causes and Occurrences and a lower percentage of time in hyperglycemia during the daytime interval. The difference between the age groups for the percent time hyperglycemic during the day was significant, p = 0. In addition, Figure 2 displays the percentage of time in the hyperglycemic state as a function of age for the early morning period (A) and for the daytime (B). The distinctive positive and negative effects of increasing age has a beneficial effect (lower percentage time in hyperglycemia) during early morning and a detrimental effect (higher percentage time in hyperglycemia) during the day. Although these effects were not significant, the results are of interest due to the fact that clinical evidence of hyperglycemic patterns can help physicians better control glycemic excursions. Multiple Linear Regressions Relationship between Age Group and % Time Hyperglycemic Relationship Between Age and Diabetic Treatment Type on the Frequency of Hyperglycemic Episodes Monitored by Continuous Glucose Monitoring 19. Percentage of time spent in hyperglycemia as a function of age during the time interval from 12 am to 6 am (A) and from 6 am to 6 pm (B) 20 Hypoglycemia Causes and Occurrences Multiple linear regressions (Table 4) examine the effects of diabetes treatment type on the percentage of time that subjects were in the hyperglycemic state. To further clarify the analyses only those receiving either insulin or oral medication were examined. The results indicated that during the early morning period, those taking oral medication exclusively exhibited a lower percentage of time in the hyperglycemic state (p = < 0. Multiple Linear Regressions Relationship between Medication Type (Oral, Insulin) and % Time Hyperglycemic. Percent of time spent in hyperglycemia from 12 am to 6 am as a function of age and type of medication. Relationship Between Age and Diabetic Treatment Type on the Frequency of Hyperglycemic Episodes Monitored by Continuous Glucose Monitoring 21 Finally to test the hypothesis that age and type of treatment may have interacting effects with respect to percentage time in the hyperglycemic state a third multiple regression was constructed (Table 5). The Interaction was not significant for either the early morning interval or for the daytime interval. Apparently, age and type of treatment have relatively independent influences on the percentage of time in the hyperglycemic state. Multiple Linear Regressions Relationship Between the Interaction of Age X Medication Type (Oral, Insulin) and % Time Hyperglycemic 4. Conclusion Results from this study demonstrate that both increasing age and the exclusive use of oral anti-hyperglycemic medications are associated with a lower percent of time spent in hyperglycemia during the early morning. On the other hand, as age increases, the opposite effect is exhibited during the daytime interval, namely a higher percent of time in the hyperglycemic state. In search for an explanation for these findings there is evidence from the animal literature that in older rats, glucose utilization by the brain, using autoradiography, tended to increase more slowly in the morning and decrease faster in the afternoon and evening (Wise et al.
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Isolated postoperative auras are often ignored and classified among the "seizure-free" outcomes. In a few studies, isolated postoperative auras occurred in 20% (20,21) to 35% (22) of patients after surgery for temporal lobe epilepsy and in 22% of a series after focal resective surgery unselected for location (23). Residual auras seem particularly common after temporal lobe surgery and may relate to incomplete removal of the mesial temporal structures comprising the amygdala, hippocampus, and parahippocampal gyrus. The persistence of epigastric auras after functional hemispherectomy, in which the insula is the only cortical structure still functionally connected on the side of surgery, suggests that continuing seizure activity in that structure may be another mechanism. Postoperative auras commonly recurred within the first 6 months of operation and tended to persist (22). Although isolated postoperative auras are widely regarded as of little significance, they may accompany an increased risk of recurrence of complex partial seizure (22) and reduced quality of life on self-assessment (23). A small number of patients may lose their aura after temporal lobectomy even as they continue to have postoperative complex partial seizures; others may experience a different aura. These alterations occurred in 55% of patients who had residual postoperative seizures (20). Stimulation of various mesial limbic structures elicited auras with features that were intimately related to ongoing psychopathologic processes (25). Emotional responses and hallucinations produced by electrical stimulation were reported to depend on the background affective apply to patients with aura. Epilepsy and Other Chronic Convulsive Diseases: Their Causes, Symptoms & Treatment. Similarly, patients who experienced anxiety or fear during temporal lobe electrical stimulation scored higher on the "psychasthenia" scale of the Minnesota Multiphasic Personality Inventory, whereas those experiencing dreamlike or memorylike hallucinations scored higher on the "schizophrenia" scale (8). Thus, the memory flashback that may be recalled in an aura is not a generic item but an experience specific to the patient. It is important to differentiate auras from prodromes and from nonspecific premonitions before generalized seizures. Auras may vary in the same patient or occur in combination but should show a certain stereotypy and consistency. It may be particularly difficult to classify a first seizure based on the report of a preceding sensation. One study (28) noted poor interobserver agreement about the nature of such preceding sensations. At 1-year follow-up, seizures had recurred in 22 of the 67 patients with preceding sensations, but only 11 of these had clinical indications that the recurrences were of focal onset. Thus, self-report of a preceding sensation in an isolated first convulsion may not be a reliable indicator of focal epilepsy. Sometimes, though rarely, patients have pseudoseizures starting with an epileptic aura (29). Whether the pseudoseizure that follows the aura represents a learned response or occurs from other psychogenic mechanisms cannot be determined. Subsequent studies with long-term intracranial electrodes for the recording of spontaneous seizures and extraoperative electrical brain stimulation have extended early observations (3034). Although an aura may help to localize the epileptogenic zone, an important point must be kept in mind. The initial sensation of an aura is related to the first functional brain area activated by the seizure that has access to consciousness, but this may not be the site of seizure origin. A seizure starting in the posterior parietal region may be initially asymptomatic until ictal activity spreads to adjacent functional areas. Spread to the postcentral gyrus may elicit a somatosensory sensation as the first warning; propagation to parieto-occipital association cortex may give rise to initial visual illusions or hallucinations. Furthermore, it remains unclear whether experience of an aura is contingent on direct ictal involvement of the cortical areas subserving those functions or whether an aura sensation may also be evoked by excitation at a distance, provided a pathway of projection or facilitation exists between the site of excitation and an eloquent cortical structure. A sensory Jacksonian march cannot be explained by other than ictal spread along the somatosensory cortex. The indistinguishable auras found in patients with hippocampal sclerosis and temporal neocortical pathology underlie the distributed network that functionally links the limbic and neocortical structures in the temporal lobe.
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Radiofrequency electromagnetic radiation from cell phone causes defective testicular function in male Wistar rats. As cell phone usage has become more widespread, concerns have increased regarding the harmful effects of radiofrequency electromagnetic radiation from these devices. The current study was undertaken to investigate the effects of the emitted radiation by cell phones on testicular histomorphometry and biochemical analyses. Adult male Wistar rats weighing 180-200 g were randomly allotted to control, group A (switched off mode exposure), group B (1-hr exposure), group C (2-hr exposure) and group D (3-hr exposure). The animals were exposed to radiofrequency electromagnetic radiation of cell phone for a period of 28 days. Histomorphometry, biochemical and histological investigations 563 were carried out. There was an uneven distribution of germinal epithelial cells in groups B, C and D. However, there was degeneration of the epithelia cells in group D when compared to the control and group B rats. The study demonstrates that chronic exposure to radiofrequency electromagnetic radiation of cell phone leads to defective testicular function that is associated with increased oxidative stress and decreased gonadotropic hormonal profile. Radiofrequency radiations induced genotoxic and carcinogenic effects on chickpea (Cicer arietinum L. Maximum nuclear membrane damages and ghost cells were again recorded in 48 h exposure of cell phone and laptop. Conclusion It is concluded that radiofrequency radiations are genotoxic as they induced chromosomal aberrations in chickpea mitotic cells and the presence of ghost cells is clear indication of their carcinogenic potential. It must be placed on desk top rather lap to minimize their exposure to human body. This, however, did not affect notably the overall dynamics and efficiency of granulopoiesis. Since magnetoreception is still not fully understood, studying magnetic alignment provides evidence for magnetoreception and broadens current knowledge of magnetic sense in animals. Furthermore, magnetic alignment widens the roles of magnetic sensitivity in animals and may contribute to shed new light on magnetoreception. In this context, spontaneous alignment in two species of lacertid lizards (Podarcis muralis and Podarcis lilfordi) during basking periods was monitored. Both species exhibited a highly significant bimodal orientation along the north-northeast and south-southwest magnetic axis. On the contrary, lizard orientations were significantly correlated with geomagnetic field values at the time of each observation. We suggest that this behaviour might provide lizards with a constant directional reference while they are sun basking. This directional reference might improve their mental map of space to accomplish efficient escape behaviour. This study is the first to provide spontaneous magnetic alignment behaviour in free-living reptiles. In the 21st century, corporations have worked their way into government and, as they become increasingly more powerful, arguments about their involvement with public health have become increasingly black and white. With corporations at the center of public health and environmental issues, everything chemical or technological is good, everything natural is bad; scientists who are funded by corporations are right and those who are independent are invariably wrong. There is diminishing common ground between the two opposed sides in these arguments. Corporate Ties that Bind is a collection of essays written by influential academic scholars, activists, and epidemiologists from around the world that scrutinize the corporate reasoning, false science and trickery involving those, like in-house epidemiologists, who mediate the scientific message of organizations who attack and censure independent voices. This book addresses how the growth of corporatism is destroying liberal democracy and personal choice. A Battleground-From Phenoxyacetic Acids, Chlorphenyls and Dioxins to Mobile Phones-Cancer Risks, Greenwashing and Vested Interests Chapter 10: Christian Blom. Abstract the purpose of this study was to clarify ownership and usage of mobile phones among young patients with brain tumors in Japan. The subjects of this study were patients with brain tumors diagnosed between 2006 and 2010 who were between the ages of 6 and 18 years.
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Incisural sclerosis and temporal lobe seizures produced by hippocampal herniation at birth. Stroke in the developing brain and intractable epilepsy: effect of timing on hippocampal sclerosis. Herpes simplex virus type 1 inoculation enhances hippocampal excitability and seizure susceptibility in mice. Hippocampal lesions produced by prolonged seizures in paralyzed artificially ventilated baboons. Hippocampal sclerosis in children with lesional epilepsy is influenced by age at seizure onset. The clinical-pathogenic mechanisms of hippocampal neuron loss and surgical outcomes in temporal lobe epilepsy. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data from five studies. Prolonged febrile seizures are associated with hippocampal vasogenic edema and developmental changes. Quantitative magnetic resonance characterization of mesial temporal sclerosis in childhood. Clinical spectrum of paediatric patients with mesial temporal lobe epilepsy: hippocampal sclerosis and post-surgical outcome. Neuronal loss induced in limbic pathways by kindling: evidence for induction of hippocampal sclerosis by repeated brief seizures. Childhood generalized and mesial temporal epilepsies demonstrate different amounts and patterns of hippocampal neuron loss and mossy fibre synaptic reorganization. Abnormalities in hippocampi remote from the seizure focus: a T2 relaxometry study. Resistance of the immature hippocampus to seizure-induced synaptic reorganization. Mesial atrophy and outcome after amygdalohippocampectomy or temporal lobe removal. Relationship of hippocampal sclerosis to duration and age of onset of epilepsy, and childhood febrile seizures in temporal lobectomy patients. Atrophy of mesial structures in patients with temporal lobe epilepsy: cause or consequence of repeated seizures? Clinical features and surgical outcome of medial temporal lobe epilepsy with a history of complex febrile convulsions. Magnetic resonance image-based hippocampal volumetry: correlation with outcome after temporal lobectomy. Temporal lobe epilepsy due to hippocampal sclerosis in pediatric candidates for epilepsy surgery. A retrospective analysis of hippocampal pathology in human temporal lobe epilepsy: evidence for distinctive patient subcategories. Interictal epileptiform discharges in temporal lobe epilepsy due to hippocampal sclerosis versus medial temporal lobe tumors. Psychiatric outcome of surgery for temporal lobe epilepsy and presurgical considerations. A multicenter study on the prevalence of psychiatric disorders among new referrals for epilepsy in Japan. Psychopathology in children with epilepsy before and after temporal lobe resection. Hippocampal sclerosis and other hippocampal abnormalities in the early identification of candidates for epilepsy surgery. Visual confrontation naming outcome after standard left anterior temporal lobectomy with sparing versus 72. During the first stage, stem cells proliferate and differentiate into young neurons or glial cells deep in the forebrain, with the ventricular and subventricular zones lining the cerebral cavity. During the second stage, neurons migrate away from their place of origin toward the pial surface and settle within the cortical plate. When neurons reach their destination, they order themselves into specific "architectonic" patterns and this third phase involves final organization within the typical six layers of cortex, associated with synaptogenesis and apoptosis. Until the advent of high-resolution neuroimaging and the recent increase in the treatment of neocortical epilepsy by surgery, these disorders were much less commonly known. Microcephaly Syndromes Microcephaly, as a primary abnormality, is best defined as a head circumference of three standard deviations or more below the mean.
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Continuous sodium valproate or phenobarbitone in the prevention of simple febrile convulsions. A meta-analytic review of the preventive treatment of recurrences of febrile seizures. Reversible cerebral atrophy: radiologic correlate of valproate-induced parkinson-dementia syndrome. Weight gain patterns in patients with epilepsy: comparison of antiepileptic drugs. Metabolic changes during treatment with valproate in humans: implications for weight gain. Severe hepatotoxicity during valproate therapy: an update and report of eight new fatalities. Hematologic manifestations and impaired liver synthetic function during valproate monotherapy. Valproate-mediated disturbances of hemostasis: relationship to dose and plasma concentration. Absence of bleeding complications in patients undergoing cortical surgery while receiving valproate treatment. Preoperative valproate administration does not increase blood loss during temporal lobectomy. Chronic valproic acid therapy and incidence of increases in venous plasma ammonia. Polycystic ovary syndrome associated with treatment with the anticonvulsant sodium valproate. On the association between valproate and polycystic ovary syndrome: a response and an alternative view. The risk of spina bifida aperta after first-trimester exposure to valproate in a prenatal cohort. Side effects of sodium valproate in monotherapy controlled by plasma levels: a study in 88 pediatric patients. Plasma concentrations of valproate during maintenance therapy in epileptic children. Safety of rapid intravenous infusion of valproate loading doses in epilepsy patients. Intensive follow-up monitoring in patients with once daily evening administration of sodium valproate. Lack of significant correlation between circadian profiles of valproic acid serum levels and epileptiform electroencephalographic activity. The landmark work of Merritt and Putnam in 1937 and 1938 (2,3) demonstrated that the antiepileptic potential of drugs could be tested in animals, the anticonvulsant effect and sedative effects could be separated, and anticonvulsant activity could be achieved without sedation. In a subsequent series of articles, Merritt and Putnam demonstrated that phenytoin was effective in humans; the first clinical trial of phenytoin in epilepsy (4) documented freedom from seizures in 50% of 142 patients with refractory disease. This trial showed, for the first time, that a drug effective against seizures in experimental animals could be successfully used in humans. A follow-up study described effectiveness in complex partial seizures, with or without secondarily generalized tonicclonic seizures, but not in absence seizures (5). As a result, parenteral phenytoin sodium must be formulated as an aqueous vehicle containing 40% propylene glycol and 10% ethanol in water for injection, adjusted to a pH of 12 with sodium hydroxide (7,8,11). Phenytoin affects ion conductance, sodiumpotassium adenosine triphosphatase activity, various enzyme systems, synaptic transmission, posttetanic potentiation, neurotransmitter release, and cyclic nucleotide metabolism (12). Phenytoin blocks membrane channels through which sodium moves from the outside to the inside of the neuron during depolarization, suppressing the sustained repetitive firing that results from presynaptic stimulation (1214). Fosphenytoin Fosphenytoin, a phenytoin prodrug, is the disodium phosphate ester of 3-hydroxymethyl-5,5-diphenylhydantoin (molecular weight 406. Thus, fosphenytoin is freely soluble in aqueous solutions and can be formulated without organic solvents (15). Unfortunately, parenteral phenytoin sodium is associated with cardiovascular complications and phlebitis (9,10). First synthesized in 1973, fosphenytoin was developed as a water-soluble phenytoin prodrug that might reduce the risks of the cardiovascular complications and phlebitis from parenteral phenytoin administration (11). Fosphenytoin itself has no known anticonvulsant activity and derives its utility from its rapid and total conversion to phenytoin (15,16).
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As a general matter, transgender servicemembers are just as medically fit for service and deployable as non-transgender servicemembers. Even prior to the 2016 transgender policy change, military surgeons were called upon to perform surgeries, such as those for blast victims, whose core procedures are the same as or similar to surgeries needed for transgender health. There is no evidence that being transgender alone affects military performance or readiness and there is no medical justification for the categorical exclusion of transgender individuals from the Armed Forces. I served as Deputy Surgeon General for Mobilization, Readiness and Army Reserve Affairs in the Office of the Surgeon General of the United States Army from July 2014 to May 1, 2017. When I graduated with my nursing degrees at the end of the Vietnam War, the Army was drawing down, so I went into civilian practice. While I was teaching at the University of Delaware, my father, who had joined the Air Force Reserve after serving as a pilot, encouraged me to pursue my dream of serving as an Army nurse by joining the United States Army Reserve (U. When I was promoted to Brigadier General in 2005, I became the first nurse and first woman to command a medical brigade as a general officer. When I was promoted to Major General, I became only the third nurse from the Army Reserve ever to achieve that rank. From July of 2008 through October 2011, I served as Assistant for Mobilization and Reserve Affairs in the Office of the Secretary of Defense for Health Affairs. In July of 2014, I was appointed Deputy Surgeon General for Mobilization and Reserve Affairs. When I received this appointment, I became the first nurse in the more than 106-year history of the Army Reserve and the first woman to serve in this position. In August of 2014, I was also appointed by the Secretary of the Army to the Army this Reserve Forces Policy Committee, where I most recently served as Deputy Chair. In my more than three-and-a-half decades of service, I received many decorations, including the Distinguished Service Medal, Defense Superior Service Medal, the Legion of Merit Medal, the Meritorious Service Medal, the Army Commendation Medal, and the Army Achievement Medal. I also hold the Expert Field Medical Badge and was awarded the 9A proficiency designation in medical surgical nursing by the Surgeon General, U. My civilian professional experience includes academic appointments at Central Missouri State University, University of Kansas, University of North Carolina at Charlotte, and Georgia State University. I am also a Fellow of the American Academy of Nursing, where I have served as Co-Chair of the Military/Veterans Expert Panel. In August of 2017, I joined the University of North Carolina School of Nursing as the Executive Dean and Associate Dean for Academic Affairs. Throughout my academic and research careers, my practice and research focus has My research led to the development of a subspecialty in been in psychosocial oncology. On July 28, 2015, Secretary of Defense Ashton Carter directed Brad Carson, Acting Undersecretary of Defense for Personnel and Readiness, to convene a working group (the "Working Group") to study the policy and readiness implications allowing transgender persons to serve openly in the Armed Forces. The Working Group was asked to determine whether there were any objective, evidence-based impediments to permitting transgender people to serve openly and, if not, to develop an implementation plan for changing the policy to permit open service with the goal of maximizing military readiness. When Secretary Carter directed the formation of the Working Group, I was serving as Deputy Surgeon General for Mobilization, Readiness, and Army Reserve Affairs. At the Working Group, I was able to provide the benefit of my medical expertise, my academic research, and my knowledge of the workings of the Military Health System and the Defense Health Agency. I participated in the meetings of the Working Group from its initial meeting in the summer of 2015 though the final meeting in late spring of 2016. The Working Group addressed many topics, one of which was determining how the medical needs of transgender service members could be met by the military. With respect to that topic, our process involved three steps: (1) Understanding the medical needs of transgender service members; (2) identifying how those needs could be met within the Military Health System; and (3) developing policies and protocols to ensure transgender service members could serve openly and have their medical needs met. The first step for the members of the Working Group was to establish a baseline level of knowledge among all Working Group members about the medical needs of transgender service members. We educated ourselves by meeting with experts from the civilian sector so we could begin to understand what being transgender means. We wanted to learn about the full range of medical treatment that might be required for a transgender service member. We sought to understand how an individual might go through a transition process and what the medical components of that process might be.