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Directly comparing pre and post-redesign estimates on similar data points skin care professionals purchase eurax in united states online, without taking into account the impact of the surveys redesign, can lead to an erroneous conclusion. Missing values have been excluded from analysis and only valid percents are included in this document. Students responding "not applicable" were excluded from several analyses, which are specifically noted throughout this document. This will often explain differences observed between this document and the full data report. A note about the use of sex and gender in this report: Survey responses are reported by sex based on the responses to questions 47a, 47b, and 47c. Proportion of college students who reported being diagnosed or treated by a professional for any of the following health problems within the last 12 months: Allergies: 19. Disease and Injury Prevention College students reported receiving the following vaccinations (shots): 68. College students reported the following behaviors within the last 12 months: N/A, did not do this Never* Rarely or Mostly or activity within the sometimes* always* Percent (%) last 12 months Wear a seatbelt when you rode in a car 0. Academic Impacts Within the last 12 months, students reported the following factors affecting their individual academic performance, defined as: received a lower grade on an exam, or an important project; received a lower grade in the course; received an incomplete or dropped the course; or experienced a significant disruption in thesis, dissertation, research, or practicum work; (listed alphabetically): Alcohol use: 3. Violence, Abusive Relationships and Personal Safety Within the last 12 months, college students reported experiencing: Percent (%) Male Female Total A physical fight 6. Tobacco, Alcohol and Marijuana Use Reported use versus perceived use reported use for all students within the past 30 days compared with how often students perceived the typical student on campus used substances within the same time period. The last line of each table combines all categories of any use in the last 30 days. Cigarette Actual Use Perceived Use Percent (%) Male Female Total Male Female Total Never used 73. College students who drank alcohol reported experiencing the following in the last 12 months when drinking alcohol:* Percent (%) Male Female Total Did something you later regretted 31. Sexual Behavior College students reported having the following number of sexual partners (oral sex, vaginal or anal intercourse) within the last 12 months: Percent (%) Male Female Total None 34. College students reported having oral, vaginal or anal sex in the last 30 days: Oral sex within the past 30 days Percent (%) Male Female Total No, have never done this sexual activity 30. Contraceptive use reported by students or their partner the last time they had vaginal intercourse: Percent (%) Male Female Total Yes, used a method of contraception 50. Nutrition and Exercise College students reported usually eating the following number of servings of fruits and vegetables per day: Percent (%) Male Female Total 0 servings per day 10. From the American College of Sports Medicine and the American Heart Association (2007): Moderate-intensity cardio or aerobic exercise for at least 30 minutes on 5 or more days per week, or vigorous-intensity cardio or aerobic exercise for at least 20 minutes on 3 or more days per week. Students meeting the Recommendations for moderate-intensity exercise, vigorous-intensity exercise, or a combination of the two (2 moderate-intensity exercise periods = 1 vigorous-intensity exercise period). Mental Health Students reported experiencing the following within the last 12 months: Felt things were hopeless Felt overwhelmed by all you had to do Percent (%) Male Female Total Percent (%) Male Female Total No, never 35. Sleep Past 7 days, getting enough sleep to feel rested in the morning: Percent (%) Male Female Total 0 days 10. For the purpose of forming the Reference Group, only institutions located in the United States that surveyed all students or used a random sampling technique are included in the analysis, yielding a final data set consisting of 88,178 students at 140 schools. Note that schools surveying in the 30 days following their Spring Break are omitted from this report. These patients may have a primary complaint of dizziness, of ear pain, of ear or head fullness, sinus pressure, and even fluctuating hearing loss. Fortunately, treatment regimens long established for the treatment of classic migraine headaches are generally effective against these atypical symptoms of migraine. In general, there is a decrease in headache intensity and an increase in the incidence of atypical symptoms of migraine (vertigo, ear pain, bowel symptoms, etc) as patients mature. This is usually a reflection of a lack of understanding of the nature of migraine and its treatment, or lack of commitment to effective treatments. Most individuals exposed to loud noise, bright light, or excessive motion can adapt to these strong stimuli within minutes, but in the brain of a migraineur, the strength of the stimulus continues to grow until a migraine crisis occurs. This lack of ability to adapt to strong sensory stimulation helps us understand why so many patients have migraine headache or other migraine symptoms that can be provoked by bright light, excessive noise, strong smells, excessive motion, and painful stimuli. Abnormal activity may occur in, on, and around the brain during a migraine attack. Hyperactivity deep in the brainstem and other brain centers that control pain and other sensations in the head has been found on brain imaging studies in patients having migraine attacks. This means a person having a migraine who senses pain, motion, or sound will tend to have an exaggerated, distorted experience of the pain, motion, or sound that may be so intense that it is difficult to tolerate. The patient may become so sensitive that he has no choice but to withdrawal to a quiet, dark place and sleep until the episode has passed. Patients also have altered electrical activity at the surface of the brain during a migraine episode. This most commonly occurs over the vision areas of the brain and may result in unusual visual phenomena such as the appearance of spark-like bursts, wavy lines, blind spots, or even complete visual loss in rare cases. Abnormal cortical brain activity over other regions of the cortex can result in temporary confusion, inability to speak, numbness, or even paralysis of any part of the body. These symptoms which occur at the surface of the brain typically are brief, lasting no longer than 20 minutes. Painful throbbing headache may be associated with sensitization of the blood vessels around the brain by abnormal chemicals which themselves irritate and cause the blood vessels to hurt. A migraine trigger is any environmental, dietary, or physiologic factor that can provoke migraine activity in the brain. The most common of these are neck injury and spasm, temporomandibular joint pain, and sinus pain. Comprehensive lists of foods which may contribute to triggering migraine can easily be found on the Web. In general, these foods fall into two main categories: 1) byproducts of food aging and 2) foods with chemicals similar to neurotransmitters our brains use. Byproducts of food aging are found in fermented products like red wine, aged cheeses, and yeast in fresh bread and yogurt. Food triggers are not the result of allergy, but are direct chemical sensitivities. Added to this confusion is the reality that many real food triggers may not cause migraine alone, but only in combination with other partial triggers, which together may provoke an attack of migraine headache or symptoms. For example, some migraineurs can eat chocolate or red wine alone with no problem, but will suffer a migraine attack if chocolate and red wine are taken together. We generally recommend an initial dietary trial which avoids only the most common migraine triggers. If good results are not achieved within a few weeks, a comprehensive diet which eliminates all potential migraine triggers is recommended. After an improvement in symptoms is achieved, suspect foods can be added to the diet one at a time to see whether they are an important trigger for that patient. Patients commonly report increased symptoms when they are stressed, fatigued, and suffer lack of sleep. Many other physiologic stresses can also trigger migraine, such as hunger, exercise, and pain. It is not uncommon for someone with new-onset headaches to find their eyeglass prescription has changed. You will be asked to consider an eye examination if other obvious triggers are not identified. Other common physiologic triggers include pain from temporomandibular joint dysfunction, neck problems, and sinusitis. Treatment of these underlying problems can result in dramatic reduction in typical and atypical migraine symptoms. It is typical for patients to get themselves into a vicious cycle, resulting in decreased functioning at work and at home with the expected emotional consequences before treatment is sought. The best treatment results will be obtained by those patients who work to understand what migraine is and how migraine is affecting their lives. The mainstay of treatment for migraine headache and atypical migraine symptoms is trigger identification and avoidance. This requires education about migraine triggers and the use of a migraine diary in which the patient is asked to record their symptoms and the probable trigger for that particular episode. In general, an attempt to improve lifestyle by reducing stress, improving sleep habits, and adding regular exercise are beneficial.

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The poll was not able to obtain a representative sample of the transgender population acne keloidalis nuchae home treatment generic 20gm eurax visa. Two women holding hands are read as lesbian, two men as gay, and a man and a woman as straight. The majority of research lumps data on bisexuals under gay or lesbian, which makes it difficult to draw any conclusions about bisexuals and skews the data about lesbians and gay men. Only a handful of studies separate out bisexuals and/or report on their bisexual-specific findings. A good set of guidelines is to allow participants to self-report their own gender and sexual orientation labels and to describe the gender(s) and sexual identity(ies) of their sexual partner(s). Not Just a Phase While bisexuality has often been considered merely a phase en route to a stable gay or lesbian 11 orientation, it is also a stable sexual orientation in itself. A longitudinal study of sexual minority women (lesbian, bisexual, or unlabeled) found that over 10 years, more women adopted bisexual/unlabeled identities than relinquished them [emphasis in original]. Of those who began the study identifying as bisexual, 92% identified as bisexual or unlabeled 10 years later, and 61% those who began as unlabeled identified as bisexual or unlabeled 10 years later. While no similar long-term study has been done with bisexual men, at least one study suggests that bisexuality can be a stable 12 sexual orientation for men as well. Female Bisexuality From Adolescence to Adulthood: Results From a 10-Year Longitudinal Study. While I thought occasionally about women, I largely discounted these feelings as random daydreams. I had heard that bisexuality was a farce so many times from gay friends, that people who were bisexual were just afraid to come all the way out of the closet, that I never thought of coming out as bisexual when I was younger. I was attracted to men, I didnt have any shame about this, and I wanted to be recognized. Despite San Franciscos reputation as a gay mecca, it is where I first came to recognize my opposite-sex attractions. Being single at college parties, I often found myself in situations where women were hitting on me. The idea that my same-sex attractions represented an inflexible and absolute sexuality had become entrenched in my thinking, and I wasnt prepared to question this. Despite this lack of mental readiness, my desire and curiosity were far greater, and I eventually began sleeping with women. I kept my opposite-sex attractions subordinated, leaving them out of discussions with friends back home and rationalizing them away as mistakes to myself. As questions and underhanded comments started coming in, I found myself constantly being put on trial. In the process of trying to answer these questions for myself and others, I realized how long I had been cheating myself and sublimating my desires to others ideas about sexuality. Aggressive queries about when I was going to focus on guys full-time again became a standard part of trips home. Women I was with, no longer with the safety of presuming me straight, would question my real orientation and complain that my sexuality made them anxious that I would one day vanish into a relationship with a man. Men I was with wouldnt acknowledge my sexuality, referring to me as gay despite my protest. I found myself in relationships waiting for accusations and dismissive comments, ready from the start to move along to someone new. I am happy with my sexuality, and very grateful that I was finally able to fully realize my desires. I only wish I didnt have to sacrifice feeling safe, feeling part of a community, and feeling like I have anyone to confide in but myself. Predictors of movement toward homosexuality: A longitudinal study of bisexual men. Many famous peoplesuch as Marlene Dietrich, June Jordan, Freddie Mercury, Eleanor Roosevelt, and Walt Whitmanhave been labeled as lesbian or gay for their same-sex relationships, yet their long-term relationships with different-sex partners are ignored or their importance minimized. This disrespects the truth of their lives for the sake of a binary conception of sexual orientation. It also makes it more difficult for bisexuals just coming out to find role models. In just one example, it was a bi woman, Brenda Howard, who organized the one-month anniversary rally in honor of the Stonewall uprising (which in turn was led by transsexuals and drag queens). Then a year later, she organized a march and celebration that turned into New Yorks annual pride parade and inspired countless other pride celebrations around the world. Yet it wasnt that long ago that bisexuals and transgender people had to fight for inclusion in the name of San Francisco Pride, one 13 of the last major U. Bisexual Exclusion Often, the word bisexual shows up in an organizations name or mission statement, but the group doesnt offer programming that addresses the specific needs of bisexuals (see the chapter on organizations and programs serving bisexuals). Even when an organization is inclusive, the press and public officials often fall back on the safety of saying just gay and lesbian. In a 2010 court case, three San Francisco softball players filed a lawsuit alleging they were disqualified from the 2008 Gay Softball World Series for being bisexual (see sidebar). For example, Colorados Amendment 2 would have repealed any regulations that protected people based on their homosexual, lesbian, or bisexual orientation. Bisexual Invisibility: Impacts and Recommendations 5 San Francisco Human Rights Commission positive atmosphere at Hastings for lesbian, gay, bisexual, transgendered, intersex, asexual, two-spirit, and queer students and their allies. District Court for the western district of Washington on behalf of three bisexual softball players from San Francisco. Their team, D2, had been playing together in the San Francisco Gay Softball League for years. In 2008, they had practiced more than ever in the hopes of winning the World Series, and they made it all the way to the championship game. During the championship, D2 learned that another team challenged their eligibility to play based on a tournament rule that each team could have no more than two straight players. The players were forced to answer whether they were predominantly attracted to men or predominantly attracted to women, without the option of answering that they were attracted to both. The committee recommended disciplinary measures against Apilado, Charles, and Russ, their team, and the San Francisco Gay Softball League, including forcing their team, D2, to retroactively forfeit their second-place World Series win. It damages our community to 6 Bisexual Invisibility: Impacts and Recommendations San Francisco Human Rights Commission conduct witch hunts and to exclude people from playing in a sports league for not being gay enough. This had me angry, had me in tears, contemplating whether I even want to be part of the league anymore after being in it since 1999. We believe that team sports can offer opportunities for personal enrichment, and a sense of community that is not available otherwise. It is not unlike other groups whom [sic] choose to organize around a commonality such as the Black American Softball Assoc. Our group recognizes that in the arena of team sports, homophobia is still all too common. Almost daily it seems, one hears or reads of another gay bashing, often resulting in fatal outcomes. These tragedies serve as a reminder of our mission to provide a safe place for Gay/Lesbian [sic] players to enjoy competition while not compromising their true identity. The bi community served as a kind of refuge for people who felt excluded from the established lesbian and gay communities. This was especially important when both groups lobbied gay and lesbian groups for more inclusion of their issues. For example, the Human Rights Commission first formed a Gay Advisory Committee in 1979, in response to a call for the city to create a Lesbian/Gay Commission in the wake of Harvey Milks assassination. Both recognized that together they could push for broader recognition of their communities concerns and needs. By February 1994, the Commission had voted to change the name to the Lesbian Gay Bisexual Transgender Advisory Committee, and in May 1994, held a public hearing on discrimination against transgender people. The recommendations that came out of that hearing paved the way for the Board of Supervisors to pass groundbreaking legislation adding gender identity as a protected category in San Francisco. Other Forms of Biphobia15 Bisexual invisibility is one of many manifestations of biphobia.

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However skin care during pregnancy home remedies order eurax 20gm without prescription, many probiotics containing food products fail to maintain the recommended probiotic concentrations due to instability of probiotics in food matrices (Sadeghar et al. Taking into account table olives, the daily rec ommendation for a healthy adult is around 25 g of olives per day, or about seven olives carrying about 1091010 viable cells of probiotic strains (Lavermicocca et al. As already emphasized, lactic acid fermentation is the predominant biologi cal preservation method contributing to unique flavor development, and con sidered as the major contributor to the beneficial characteristics observed in fermented foods including olive fermentation (Soomro et al. As a result of an increased number of investigations in the probiotic field, this concept has been expanded to include bacteria from traditionally fermented foods; they constitute the untapped source for a wide variety of beneficial probiotic microorganisms (Zeng et al. There has been a recent increase of interest in probiotics due to consumer demand for better therapies and problems, such as drug resistance and oppor tunistic infections due to inadvertent use of antimicrobial therapy (Peres et al. Health conditions that can benefit from probiotics therapy include diarrhea, gas troenteritis, irritable bowel syndrome, inflammatory bowel disease, colitis, and alcoholic liver disease; probiotic consumption will also reduce the risk of colon and liver cancer (Juan et al. Probiotics increase intestinal mucin production, which prevents the attachment of enteropathogens by steric hindrance or through competi tive inhibition for attachment sites on mucins, as well as augmenting pro duction of antimicrobial peptides, and decreasing epithelial permeability to intraluminal pathogens and toxins (Quigley, 2010). Assays on antagonistic activity performed with some potential probiotic lactobacilli strains isolated from olive fermentation against 10 target gastrointestinal pathogens reduced their incidence; this suggests that they can act either directly when included in the olives, or after accommodation in the intestine of the host, after ingestion (Peres et al. In competitive exclusion assays, the relative percentages of adhesion and invasion of S. Previ ous research done in Portuguese table olives indicated that several of the bacte ria present during the fermentation process have the ability to inhibit the growth of Helicobacter pylori, a common human pathogen that is resistant to a growing number of antibiotics. This shows a potential for such probiotics to be used as an antibiotic alternative (unpublished results). Cholesterol, a fatty substance known as a lipid vital for the normal func tioning of the body, is a precursor to certain hormones and vitamins and a component of cells; it is mainly produced by the liver but can also be found Role of Natural Fermented Olives in Health and Disease Chapter 22| 525 in some foods (Nes, 2011). Hypercholesterolemia is considered a major risk factor for the development of coronary heart disease, with cellular cholesterol homeostasis being very important for the prevention of cardiovascular diseases (Reyes-Nava and Rivera-Espinoza, 2014). The main cause of the reduced flow in the heart is an accumulation of plaques in arteries, mainly in the intimae of arteries, causing atherosclerosis (Clark and Weiser, 2013). Regular consumption of probiotics could result in lower blood pressure, particularly, in people with hypocholesterolemic high blood pressure; consequently, scientific evidence indicated that there is potential for the derivation of health benefits providing a prophylactic effect in heart disease, through consumption of food containing probiotics (Parvez et al. This mechanism could be used in the control of cholesterol levels in the blood by conversion of deconjugated bile acids into secondary bile acids by probiotics (Kumar et al. The ability of probiotic strains to hydro lyze bile salts has often been included among the criteria for probiotic strain selection. Carcinogens can be ingested or generated by metabolic activity of micro organisms that live in the gastrointestinal system (Shinde, 2012). It has been hypothesized that probiotic cultures may decrease the exposure to chemical car cinogens by detoxifying ingested carcinogens, modulation of the environment of the intestine, and thereby decreasing populations or metabolic activities of bacteria that may generate carcinogenic compounds, reducing the production of carcinogenic metabolic products, production of anticarcinogenic compounds, or stimulation of the immune system (Shinde, 2012; Lee et al. Cases of microbial foodborne infections associated with carcinogen production have been reported in association with fermented olives, as well as risk involving microbial food intoxications due to mycotoxins from raw materials, production of bacterial toxins or possible mycotoxin production by fungi, toxins by Esch erichia coli O157:H7, and other toxic fermentation products including biogenic amines. Mycotoxins occur in several fermented food products associated with specific species or subgenera of Aspergillus (Palencia et al. The presence of mycotoxins has been recently reported in table olives (El Adlouni et al. Aflatoxins have been recently considered as an important safety problem (Jarvis, 2002). They are hepatocar cinogenic and recent studies also suggest that the B aflatoxins may cause neural disturbances (Wild and Gong, 2010). The elucidation of metabolic pathways responsible for the production of aflatoxins by A. Studies have identified aflatoxins as the toxicological agent that initi ated mycotoxicology as a serious and complex problem of food safety (Hussein and Brasel, 2001). These results support the suggestion that specific Lactobacillus strains from fermented olives can reduce the bioavailability of dietary carcinogens (unpublished data). Escherichia coli O157:H7 toxins have been referred to as a problem occur ring during olive technology (Argyri et al. Results indicate that, under the tested conditions, the pathogen was not able to produce Shiga toxins at detectable levels. The high survival rate of the enteropathogen in colon conditions suggests that toxin production would take place there but this phenomenon can be controlled by probiotics (Arroyo-Lopez et al. Biogenic amines have been also detected in fermented olives and their occurrence is attributed to spoilage microorganisms possessing decarboxylase enzymes, which convert amino acids to amines. Putrescine seems to be pro duced during the active fermentation phase of olive fermentation, maintaining low levels in the final products. The effects of temperature and the debitter ing process on cadaverine and tyramine formation related to fermented olive zapatera spoilage have been reported (Arena et al. Limits of toxicity of biogenic amines in a given product have not been estab lished yet, because their effects do not depend on their presence alone (type of amine and levels present), but they are also influenced by other compounds (Linares et al. Despite functional properties of phenolic compounds from table olives, as well as their promising performance as carriers of probiotic strains, stud ies focusing on the combined effect of phenolic compounds with such wild probiotic bacteria have been reported (Dutra et al. Studies to elucidate the relationship between probiotic strains originating in fer mented table olives and the foodborne pathogen Escherichia coli, when in the Role of Natural Fermented Olives in Health and Disease Chapter 22| 527 presence of oleuropein and hydroxytyrosol at the recommended daily dose for table olives, were performed (Peres et al. Results showed that pheno lic compounds can modify the intestinal microbiota positively and prevent the in vitro colonization of E. The potential synergism between phenolic compounds and probiotic bacteria may be taken advantage of to selectively stimulate prolif eration or activity of probiotics aimed at pathogen control. Many of the health benefits are attributed to monosaturated fatty acids (mainly oleic acid), and phenolic compounds (mainly oleuropein and hydroxytyro sol) (Garrido-Fernandez et al. Southern European populations that consume a traditional Mediterranean Diet, where olive products are the primary source of fat, have lower rates of cancer than in North America, Northern Europe, and Australia (Trichopoulou et al. In general, cancer is caused by mutation or activation of abnormal genes that control cell growth and division. One of the mechanisms linking olive intake to cancer protection may involve genes. Most of the abnormal cells do not result in cancer as normal cells usually out-compete abnormal ones. Research on whole olives and cancer has often focused on breast cancer and stomach (gastric) cancer. In the case of breast cancer, special attention has been paid to the triterpene phytonutrients in olives, including erythrodiol, uvaol, and oleanolic acids that have been shown to help interrupt the life cycle of breast cancer cells. Interruption of cell cycles has also been shown in the case of gastric cancer, but with this second type of cancer, the exact olive phytonutrients involved are less clear (Allouche, 2011). Research on the antioxidants of olive oil has also focused on their capacity to inhibit proliferation and promote apoptosis in several tumor cell lines (Visioli et al. Olives contains oleocan thal, an in vitro cyclooxygenase inhibitor with potential antiinflammatory and analgesic properties similar to the nonsterol antiinflammatory drug ibu profen. Oleocanthal may also offer special protection against Alzheimers disease (Pitt et al. Fermentation can positively affect the nutritional quality of food by induc ing important physicochemical changes that improve the nutrient density and increase its amount and bioavailability. The acidic nature of the fermentation products enhances the activity of microbial enzymes. Enzyme involvement of cellulose, hemicellulose, and related polymers in the cell walls of plant tissues during fermentation release the nutrients locked into plant structures and cells and improve nutritionally the fermented product (Potter and Hotchkiss, 2006). In addition, fermentation reduces the levels of some antinutritional compounds present in vegetables, such as oxalate, protease and amylase inhibitors, lectins, tannins, and phytic acid (Swain et al. The reduction of antinutrients leads to an increased bioavail ability of minerals, such as iron, proteins, and simple sugars. Increased utiliza tion of iron from fermented foods is due to breakaway of inorganic iron from complex substances under the influence of vitamin C (Akande et al. They provide small amounts of B group vitamins as well as liposoluble vitamins, such as provitamin A and vitamin E, considered to have great antioxidant effects (Peres et al. Plants, yeasts, and some bacterial species from fermented food contain the folate biosynthesis pathway and produce natural folates, but mammals lack the ability to synthesize folate and they are therefore depen dent on sufficient intake from the diet (Kariluoto et al.

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The heterosexual market brings an important change in the nature of dichotomous thinking acne information 20 gm eurax, as suddenly, opposites are supposed to attract. Opposition gains the twist of complementarity, and where before male and female might have been in conflict, now they are collaborators. And with this comes the introduction to gender of the conscious element of desire. They appear in poses in which he looks straight ahead, confident and direct; she looks down or off into the distance, often dreamily. Standing or sitting, she is lower than him, maybe leaning on him, maybe tucked under 5 For press coverage, see Joyner (2010). And from the time they are very young, most kids have learned to desire that perfectly matched partner of the other sex. A girl begins to see herself leaning against his shoulder, him having to lean down to kiss her, or to whisper in her ear. She learns to be scared so she can have him protect her; she learns to cry so he can dry her tears. This concentration of desire, or cathexis (Connell 1987), is an extraordinarily powerful force in the maintenance of the heterosexual gender order. It leads one not simply to desire those in the other sex class, but to form oneself in a particular mold as an object of desire by those others. Or at least these are the dominant socially endorsed images of self, images that sometimes rest uncomfortably with such developments as the explosion of girls and women in competitive sports requiring strength and often height or weight. Even the athletic young woman, however, is instructed to work on making her body desirable to men, as is attested by advertising and features in such publications as Sports Illustrated for Women. Diets, hairstyling, shaving legs or heads, appetite suppressants, steroids, tattoos, body piercing, makeup: all these and more are in the service of the 10 desired self. Consumption of all kinds is driven by desire, and this desire is overwhelmingly gendered. We think of emotion and desire as natural, but in fact both are highly structured and learned. It is generally said that the taboo against men crying or showing fear requires men to learn to control their emotions. This is certainly true, and many boys and men can attest to how difficult such control can sometimes be. Following the tragic events of September 11, 2001, many Americans watched obviously brave and tough men from the New York City police and fire departments weeping unashamedly for their friends and colleagues and for the many others who died in the World Trade Center. News media began to speculate that we were moving into a new era in which men no longer need to control their tears. More likely is that there will be more acceptance of mens tears in some contexts but there will still be gendered constraints on crying and other expressions of emotional vulnerability. We also tend to have very short memories about things related to gender, emotion and intimacy. Indeed, even men are beginning to devote more effort to their bodies; there is an increase in plastic surgery among men as well as considerable attention to diet and exercise as urged by the recent spate of mens magazines. This is not to say that bodywork is no longer gendered: women and men continue to be steered in different directions in their body projects, and most women still invest far more time and money in those projects than their male peers. It is appropriate for women to shed public tears, for instance, upon the death of an acquaintance, and it is appropriate for women to show fear in the face of physical threat. In fact, it is appropriate for women to show these emotions in imagined situations, as they read novels or watch movies. There are situations in which girls and women push themselves to shed a tear for something that has not touched them as much as it should, and perhaps sometimes to convince themselves that it has touched them after all. Learning to be immune to fear in these situations, and learning to not be immune, are gendered alternatives. And the choice between these alternatives is further supported by the structuring of desire. People do not simply learn to have the appropriate emotional responses; they learn to want those responses, and to be the kind of people who have those responses. Girls and boys envision themselves in situations, and mold themselves to those situations. A sad or a scary scene sends the girl into her boyfriends protective arms, hiding her head in his jacket. The movie provides the pretext for the girl and the boy to play out their gender roles, and to activate the complex links among romance, heterosexuality, gender, and the theme of fear and protection. As we age, we continue to learn new ways of being men and women: whats expected from the teenage girl is rather different from expectations for a woman in her mid-forties and those expectations differ from those for a woman approaching eighty. Those not caught up in heterosexual alliances are not thereby rendered exempt from gender expectations. Personals looking for lesbian partners, for example, often specify that respondents should be feminine in appearance: no butch need apply (Livia 2002). As weve seen above, learning to be male or female involves learning to look and act in particular ways, learning to participate in particular ways in relationships and communities, and learning to see the world from a particular perspective. However, habits, preferences, and beliefs develop in response to experience, and to the extent that the social order structures our experience, there are likely to be patterns to who develops what. This does not mean that women or men are homogeneous groups: some men may cry readily, some women may never shed tears. How we develop, however, is never a matter of the straightforward unfolding of individual dispositions but always reflects exposure to norms, expectations, and opportunities that depend on gender and other social categories. Gender interacts with other hierarchies based in such socially constructed categories as class, age, ethnicity, and race: we find, for example, sexualized racism and racialized sexism. The rewrites would, of course, bring out interesting and important differences between how gender and other categories are structured. Importantly, there is not really an analogue of the heterosexual market and the broader heterosexual imperative, or of the strong gender polarization and notions of gender complementarity it supports. Gender norms try to inculcate the desire for a partner of the other sex, whereas, while there are cases in which race and class do structure aspects of family life, race and class norms do not operate in this way. Indeed, there are strong pressures towards finding a partner of the other sex who is of the same race or class; this is one way that gender and race or class interact. And gender and age are categories that systematically structure family life, whereas racial or class diversity within families is relatively rare. As Rudman and Glick (2008, 4) argue, gender relations involve pervasive intimate heterosexual interdependence, often with genuine feelings of love and affection between the sexes, feelings that help explain some of the ambivalence characteristic of ideas about gender. Yet although gender differs crucially from other principles of social division and inequality, the important point remains that social hierarchies interact and inflect one another, making talk about any of them in isolation potentially misleading. This focus on the individual obscures the fact that we cannot accomplish gender on our own. Although gender includes individuals sense of their own gender identity, it is not primarily an individual matter, but a practice connecting the individual to the social order. As we have noted, children learn gender initially by having other people do gender for them, and eventually take over the responsibility for their own performances and for supporting the performances of others. This support involves some direct coercion, but mostly gender is so built into our ways of doing things that simple actions and interactions usually call forth gendered responses in others with eventually little or no conscious attention to this gendering.

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Discussion will focus on what is needed to bring these approaches into broad regulatory use skin care wiki buy cheap eurax 20 gm on-line. Abstract # #2551 3:00 New Approaches Using Mode of Action to Predict Acute and Systemic Toxicity. Primary Endorser: Cardiovascular Toxicology Specialty Section Other Endorser(s): Drug Discovery Toxicology Specialty Section; Regulatory and Safety Evaluation Specialty Section Echocardiography provides a noninvasive means to assess cardiac structure and function and is widely used clinically to assess left ventricular function, hypertrophy, valvular disease, and myocardial infarction. Increasingly, echocardiography has become a sought-after tool in nonclinical research to make informed decisions on intended pharmacology and/or off-target actions of test articles under development. The session will start with an outline of the use of small (rodents) and large (dogs, monkeys) animal echocardiography, including a description of common endpoints assessed. In addition, the first presenter will address the utility of echocardiography in healthy animals and animal models of cardiac disease as part of nonclinical safety assessment. The second presenta tion will address a range of anatomic, behavioral, and hemodynamic factors that affect quantitative analyses, including common design elements used to maximize data quality and effect size detection thresholds, and potential pitfalls to avoid. The target audience is toxicologists who may have limited exposure to the utility of echocardiography in nonclinical animal studies and are looking to expand their knowledge in the area. Based on the fact that cardiovascular liabilities continue to be a leading cause of drug attrition in late-stage clinical trials and post-market approval, it is expected that additional measures to assess cardiac function will be of great interest to the toxicology and drug development communities. Abstract # #2555 3:00 the Utility of Echocardiography in Cardiac Safety Assessment. Walisser #2558 3:55 Echocardiography in Nonclinical Safety Assessment: A Regulatory Perspective. Data will be presented from assays that assess genotoxicity, hepa totoxicity, and cardiotoxicity, along with an overview ofin vitrotoxicology panels. Attendees will gain insight into Eurofinss approach for screening drug candidates, which assesses drug safety profiles earlier in the discovery process, ultimately improving the likelihood of advancing safer molecules into clinical development. Many of these diseases are inherited or start in utero from naturally occurring mutations, so the key target population for therapy is young infants. How do we accelerate entry into these trials, before significant or irretrievable loss of abilities has occurred Presented by: Ellegaard Gottingen Minipigs A/S and Marshall BioResources In this session the reasons for selecting Gottingen Minipigs for preclinical studies will be reviewed. Primary Endorser: Postdoctoral Assembly Other Endorser(s): Ethical, Legal, Forensics, and Societal Issues Specialty Section; Graduate Student Leadership Committee For research to broadly and positively impact public health, it must be efficiently communicated to , and understood by, the general public. The majority of univer sity-level scientific training focuses on performing cutting-edge research and sharing those findings with other scientists within ones own field. In a time where information is readily accessible, ensuring effective and accurate scientific messaging through community outreach is necessary for maximizing societal impact and understanding. This is true during one-on-one conversations with nonscientists, and through interactions utilizing social and mass media. Deficiencies in the capacity to share science-related topics with nonscientists result in misinterpretation of conclusions and decreased community engagement in science. This session is designed to bring in scientific outreach experts to share tips and strategies for researchers to successfully communicate science with the general public. Speakers will focus on (1) individual interactions, (2) controlling your message, (3) the use of innovative social media platforms, and (4) effective utilization of mass media. These interactive presentations will include real-world examples of successful scientific communication as well as illustrations of common errors scientists are prone to committing. These discussions will be highly applicable to all attendees, including graduate students, postdoctoral trainees, and senior toxicologists. This session will allow both trainees and seasoned toxicologists to learn and implement this increasingly useful and necessary skill set. Abstract # #2559 4:45 Tips for Improving Scientific Communication with a General Audience. This is the eighth year of the Tox ShowDown, the toxicological quiz game par excellence. Topics run the gamut, including the role of toxicology in history, current events, arts, culture, and society, not to mention science. The event features a cash bar and is a great opportunity to see how many questions you can answer correctly while enjoying a good laugh. Primary Endorser: In Vitro and Alternative Methods Specialty Section Other Endorser(s): Computational Toxicology Specialty Section; Risk Assessment Specialty Section Acute systemic toxicity testing is required by regulatory agencies worldwide, provides the basis for hazard labeling and risk management of industrial chemicals, agrochemical formulations, and pharmaceuticals, and represents the highest cumulative animal use across chemical sectors. Despite the multitude of in vitro and in silico methods, a lack of regulatory acceptance of defined approaches prevents the widespread adoption of these approaches by industry. This session will demonstrate how engaging regulators and stakeholders up-front facilitates effective integration of alternatives, ensuring a path to success in reducing the use of animals in acute testing. Efforts in the United States to identify, develop, validate, and implement alternatives to the traditional acute systemic toxicity tests associated with oral and inhalation exposures will be highlighted. Overall this session will review the current status of developing alternative approaches to acute systemic toxicity testing to meet agency needs, challenges in integrating new methods, and approaches to facilitate the adoption of these alternative methods in the near term and achieve the goal of significantly reducing animal use in acute toxicity testing by 2020. Abstract # #2560 8:00 Establishing Effective Alternatives for Acute Oral and Inhalation Systemic Toxicity Testing. Karmaus #2564 9:35 In Silico and In Vitro Approaches to Assess Inhalation Toxicity Testing. Primary Endorser: Carcinogenesis Specialty Section Other Endorser(s): Regulatory and Safety Evaluation Specialty Section Health authorities responsible for regulating pharmaceuticals and pesticides request studies to determine carcinogenic potential. For drugs these studies are requested to be conducted when human treatment is necessary for longer than six months; for crop protection chemicals they are required for most exposure scenarios. The value of the rodent bioassays continues to be questioned because of their lack of relevance to humans. In-between compounds remain for which the outcome is equivocal and where experimental studies may add value to identify real hazards. This symposium is intended to provide transparency into the progress being made to establish internationally harmonized approaches to enable more flexible carcinogenicity assessment strategies focused on mechanisms while reducing reliance on the two-year rodent bioassay. Case examples for pharmaceutical and pesticide development will be provided that demonstrate how successful implementation would look. The oppor tunities that emerging new technologies and rich scientific information sources can play to impact the future evolution of this flexible framework will be described. Abstract # #2566 8:00 Progress toward Charting the Course for Improving Carcinogenicity Assessments of Human Pharmaceuticals and Pesticides. How can toxicologists leverage knowledge about epitranscriptomics to develop new biomarkers for toxicity or targets for therapeutic intervention Goodrich #2577 10:13 Epitranscriptomic Marks Translationally Regulate Stress Response Programs to Protect against Environmental Insults. Primary Endorser: Ocular Toxicology Specialty Section Other Endorser(s): Regulatory and Safety Evaluation Specialty Section Unexpected ocular findings in general toxicology studies represent a unique challenge in pharmaceutical drug development. Eye lesions are uniquely monitorable in this setting, often using the same techniques that are applied in clinical studies. This allows for detailed assessment of the dose response and onset of lesions as well as their functional impact. However, understanding the specialized grading scales and imaging modalities is key to interpreting these data. Additionally, many tissues of the eye, particularly the retina, are terminally differentiated and unable to regenerate following toxic insult. This makes the detection, characterization, and mechanistic understanding of ocular lesions caused by novel therapeutics of vital importance for an assessment of human risk prior to clinical trials. The objective of this session will be to focus on adverse ocular findings on general toxicology studies for non-ophthalmology products. The first presentation will focus on the common ocular assessments used on these studies and frequently observed ocular lesions. This will be followed by three case studies in which unexpected ocular findings were observed on general toxicology studies, with a focus on the sponsors investigative and regulatory strategy to address these findings. Abstract # #2578 8:00 A Sharp Stick in the Eye: Understanding and Managing Ocular Findings in General Toxicology Studies. Primary Endorser: Drug Discovery Toxicology Specialty Section Other Endorser(s): Neurotoxicology Specialty Section Seizure liability remains a significant cause of attrition in drug discovery and development, leading to loss of competitiveness, delays, and increased costs. Current detection methods usually rely on observations made in the nonclinical rodent and nonrodent studies required to support clinical trials.

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Vestibular Evoked Measures integrity of inner ear reflex pathways in response to loud acoustic acne 1800s order line eurax. Rotary Chair Measures presence of bilateral inner ear dysfunction; however, side of lesion. Video Head Impulse Measures the vestibular ocular reflex by detecting retinal slippage. Information regarding side of lesion is obtained References and Resources Center for Disease Control: and Prevention. Dizziness and imbalance in the elderly: age-related decline in the vestibular system. Interprofessional care improves the outcomes of older adults with complex health problems. If you have any questions about what prostate cancer treatment services are covered by your health insurance, please contact your health care provider or health insurance provider. This education material was made possible by a Grant from the California Please feel free to read only those parts of the booklet you need now. YouDepartment of Justice, Antitrust Law Section, from litigation settlement funds to dont need to read everything right now. When you have prostate cancer surgery or radiation therapy the muscles that help you control your urine flow may be weakened. This is a very common side effect or unwanted change of prostate cancer treatment. The good news is that there is a simple exercise, called a Kegel (Key-gul) exercise, you can do to help strengthen your muscles. This exercise will help you have more control over your urine flow after your prostate cancer treatment. Words that appear in bold (dark text) can be found in the Key Words section at the end of this booklet. Your pelvic floor muscles are a network of muscles that support your bladder and help you control your urine flow. These muscles help you open and close your urethra, the tube that drains urine from your bladder. Kegel exercises are easy exercises you can do before and after your prostate cancer treatment to help strengthen your pelvic floor muscles. Kegel exercises are one of the most effective ways of controlling incontinence without medication or surgery. The prostate is a gland, about the size of a walnut, located under the bladder surrounding the upper part of the urethra. The urethra is a tube that carries urine through the penis to the outside of the body. Building up the strength in your pelvic floor muscles can help you gain better control of your bladder and urine flow. Remember, that just as it takes time to build your biceps and strengthen any other muscle in your body, it takes time to strengthen muscles in your pelvic floor. In order to help strengthen you pelvic floor muscles, it is important that you take time to make sure you are exercising the right muscles. Try to stop and start your urine stream while you stand at your toilet to urinate (pee). Imagine that someone walks in to your bathroom while you are urinating (peeing) and you need to stop your urine flow. These are the muscles you want to strengthen before and after your prostate cancer treatment. Now that you have located your pelvic floor muscles, you can exercise them even when you do not have to urinate (pee) by following these simple steps: 1. Tighten and hold your pelvic floor muscles for five seconds (count 1 one thousand, 2 one thousand, 3 one thousand, 4 one thousand, 5 one thousand). Squeeze your muscles together tightly and imagine that you are trying to lift this muscle up. When you first start doing your Kegel exercises, you may not be able to repeat the exercise 10 to 20 times. It is much better for you to do fewer Kegel exercises that make your pelvic floor muscles stronger, than to do more exercises that do not work the muscle in the right way. As you get better at doing your Kegel exercises, slowly increase the number of times you repeat the exercise until you reach 20. The great thing about Kegel exercises is that you can do them anytime you want to do them. You can do your Kegel exercises before you get up in the morning, at lunchtime, at suppertime, and at bedtime. Some men put notes on their refrigerator or on their bathroom mirror to remind them to do their Kegel exercises. It can take six weeks or longer to strengthen your pelvic floor muscles so it is best to start doing your Kegel exercises before you have prostate cancer treatment. This will help you become better at doing the Kegel exercises and strengthen your pelvic floor muscles before your treatment starts. Doctors Name Doctors office phone number Doctors pager 9 Can I do Kegel Exercises If I Have A Catheter A catheter is a thin rubber tube placed in your body to drain urine from your bladder out through your penis. Start doing your Kegel exercises according to the instructions above as soon as the catheter is taken out of your penis. After your catheter is removed you may experience some urine leakage (incontinence) when you stand up, cough, sneeze, laugh, or lift something. If you have urine leakage when you stand up, cough, sneeze, laugh, or lift something, try doing a Kegel exercise. Most men gain control of their urine leakage (incontinence) within nine to 12 months after their surgery. If you do your Kegel exercises on a daily basis, you can expect to see some results. You may have a great improvement or you may help keep your urine leakage from getting worse. You will need to continue doing your Kegel exercises each day so that your pelvic floor muscles stay strong. If you have any questions or concerns about urine leakage (incontinence), how to do a Kegel exercise, or if you would like to know about other things that may help with urine leakage, please talk to your doctor or your healthcare team. It is important for you to think about and plan how you will take care of yourself before and after your prostate cancer treatment. This knowledge will help you take better care of yourself and feel more in control so that you can get the most from your treatment. Catheter: a thin rubber tube placed in your body to drain urine from your bladder out through your penis. Kegel (Key-gul) exercise: exercises strengthen the pelvic floor muscles, which support the bladder and bowel. Stools are stored in the rectum until they are passed out of the body through the anus. Side effect: unwanted changes in your body caused by your prostate cancer treatment. Sphincter muscles: muscles which help open and close your urethra, the tube that carries urine and semen through the penis to the outside of the body. Though for attraction may or may not manifest itself in there are several reasons for these disparities, a terms of sexual interaction. The scale ranges from 0 to 6, with "0" representing people who exclusively desire sexual experiences with the opposite-sex and "6" representing those who exclusively desire sexual experiences with the same sex. Those whose sexual desires range from 1 to 5 are considered to have varying levels of desire or experiences with both sexes, including "incidental" or "occasional" desire for sexual activity with the same sex. The scale does not reference whether they "identifed" as heterosexual, bisexual, or homosexual.

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Prevalence: 1:20 skin care zamrudpur order eurax 20gm on-line,000 Behavioral symptoms/clinical presentation: Early development is normal. Microcephaly is also typically noted (called stage 1), but children will initially continue to acquire developmental milestones. Subsequently, seizure disorder and deterioration of visual, motor, and cogni tive functioning occurs over a period of months (stage 3). Other symptoms that may present include choreathetosis, dystonias, truncal ataxia, and myoclonic jerks. This is followed by further loss of visual, motor, and cognitive functioning (stage 4). Mortality generally occurs by age 11 years, but survival to 16 years old has been reported. Neuropathology: Thalamic T2 hypointensity are first abnormalities typically appreciated, but only after the first 6 months of age (no abnormalities present early). White matter lesions, particularly involving the periventricular white matter surrounding the lateral ventricle are next appreciated. After age 2 years old, the macula is often discolored a brownish color along with degeneration of the retina and optic nerve. Other changes early in course of disease is neuropsychological deficits, behavioral/personality changes, and motor deficits presenting as truncal ataxia and other Parkinsonian symptoms. Seizures are typically primary or secondary general ized seizures along with complex partial seizures. Children may appear increasingly clumsy and uncoordinated with shortened and shuffling gait as Parkinsonism worsens. Progression of cognitive deterioration occurs over years and progresses to blindness, global dementia, and 846 M. Neuropsychological deficits include attention, memory, and speech deficits (dysarthria). Motor impairments lead individuals to become wheel chair bound, typically in adolescence or early adulthood. Neuropathology: No structural abnormalities observed early (until after age 10 years old). Cerebral and/or cerebellar atrophy that progresses is observed after age 10 years old (typically in early adolescence). Incidence: 1/1,000,000 Behavioral symptoms/clinical presentation: Two subtypes described. While visual problems may be present, patients have not pro gressed to blindness. Atrophy of brain stem, cere bellum, and subcortical gray matter (thalamus and striatum) is also observed. The Aminoacidopathies A group of 48 inherited aminoacidopathies in which disruption of various aminoacids occur. Children with severe form with 28 Cognitive Decline in Childhood or Young Adulthood 847 autosomal mothers are born with mental retardation. Alternatively, some children with milder forms may not exhibit symptoms until early school age or even early adoles cence or not at all. Behavioral symptoms/clinical presentation: Affected children will present with lighter colored skin, eyes, and hair than siblings/parents. In untreated children, development is typically normal initially, but after several months, progressive decline in motor skills and deterioration in global cognitive function occurs. Infants may exhibit weight loss, frequent vomiting (emesis), diarrhea, and be sensitive to bright light. In older chil dren, symptoms can progress with repetitive behaviors (rocking, head banging) and self-injurious behaviors. Progression of untreated disease leads to severe cognitive impairment (mental retardation) with seizures. Neuropsychological deficits are associated with childhood treatment indicators. Neuropathology: Cerebral and/or cerebellar atrophy can be found, but more often among patients with longer disease course. Recovery is classically described as complete after several months, with no residual deficits after 1 year. However, about a third of patients can exhibit permanent neurological and/or neuropsychological deficits. In North America, incidence increases during February/March and are less frequent in July/August. Symptoms typically present within days or weeks following exposure to virus/bacteria, and often when other symptoms of infection have resolved or are resolving. Scott Behavioral symptoms/clinical presentation: Symptoms present acutely, and include confusion, somnolence, seizures, fever, and/or stiffness of the neck. A form affecting only the cerebellum has been reported [particularly with Varicella (Chicken Pox)], presenting with predominate ataxia. The syndrome can rapidly progress over hours to days with headache, confusion, and neck stiffness being more common. Neuropsychological deficits are associated with the extent of underlying neuro pathology present, which can none to significant. Less profound neuropsychological impairments can include deficits in attention/concentration, memory, language, visuoperception, executive, and/or motor skills. Learning and memory scores may fall below normal, but recognition memory is usually better and normal or nearly normal. Rassmussens Encephaolpathy Rassmussens syndrome is an autoimmune disorder which causes severe deficits that start unilaterally, but spread bilaterally if not arrested. Prevalence: Very rare (less than 1:100,000) Onset: the onset of the disease is typically in middle childhood (mean onset peaks at age 6 years old), but can be quite variable (Bien et al. The onset is marked by unilateral seizures, hemipareisis, and lateralized cognitive and motor symptoms. Progression is insidious and often includes increased seizure frequency, hemiple gia, and marked cognitive and less frequently sensory deficits over an 8 to 12-month time period. Behavioral symptoms/clinical presentation: As noted, the initial symptoms are often seizures of unknown etiology and hemiparesis. These symptoms are progressive 28 Cognitive Decline in Childhood or Young Adulthood 849 and lead to increased seizure frequency, duration and severity as well as associated hemiplegia. The prodromal phase is associated with the initial onset of mild infrequent seizures and, often gradually, hemiparesis that develops often in less than a year (median duration was 7. The second phase, termed acute phase, results in more frequent and severe seizures, evolving from frequent simple seizures to more complex partial seizures. This stage is also marked by greater hemiparesis or frank hemiplegia, cognitive deterioration (see below) and occasional hemianopsia. The third stage, or residual stage, is characterized by a decrease in seizure frequency, relatively stable neurological deficits, and additional cognitive decline. In this last stage, some patients may recover from hemiplegia, and exhibit a spastic hemiparesis. Diagnosis is made using criteria of unilateral seizures, unilateral focal physical of cognitive symptoms and unilateral hyperintensities in the cortex and underlying white matter and caudate. Treatment with antiepileptic drugs is typically unsuccessful both in mono-therapy and poly-therapy. Clinical monitoring of the disease course may be achieved by assessing extent of hemiparesis. Hemispherectomy has demonstrated the only effective treatment in controlling seizures, but is not without its residual consequences of spastic hemiplegia and homonymous hemianopsia. Neuropsychological deficits are typically striking unilateral deficits in the cogni tive domains in the effected hemisphere.

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The challenge skin care for pregnancy purchase 20gm eurax overnight delivery, therefore, is to utilize technological resection and an unlikely chance of achieving seizure freedom. Under the strictest definition, multifocal refers to the goal of treatment in patients with multifocal epilepsy three or more foci. Especially in children, one ictal-onset zones, interictal discharge foci, or sites of resection. However, that depends upon how one is defining development, education, and quality of life (16). A patient with independent electro any decision one makes about multifocal resections should be graphic ictal onsets within three or more locations has multi made together with members of a comprehensive team and focal epilepsy. This is in contrast to the presence of three or the family, weighing all the possible risks and potential bene more distinct interictal epileptiform discharge populations, fits as they pertain to the individual patient. The concept that successful epilepsy mately a discussion outside of the scope of this chapter. In many cases, the term epilepsy does not provide a clear understanding of the indi multifocal epilepsy is utilized to describe a difficult epilepsy cations and outcome of this approach. In fact, very few 957 958 Part V: Epilepsy Surgery investigators have directly studied this group of patients as possible explanation for this better-than-predicted outcome an independent entity. With some exception, it is difficult multiple seizure foci are involved, and are confined to a to discern how many patients within individual series actu single hemisphere of the brain, surgery can also be very effec ally underwent resections for multifocal epilepsy. An Italian group of investigators recently regions of that network become more active and can generate reported that 20 of 113 (18%) children they studied had spikes and eventually can become independent foci to actually multilobar resections (31). In other resection, and complete lesionectomy were all associated multifocal patients, independent onset zones may start truly with a significantly lower risk of seizure recurrence. Can a strategic surgical intervention target went a second operation because of persistent seizures (31). The hypothesis Our center reported 13 patients who underwent surgical that this question is based on is that multifocal epilepsy is the treatment of multifocal epilepsy involving eloquent cortex observed phenotype of a primary seizure focus driving a com (32). Independent seizure foci were literature indicates that this theme has been repeatedly defined by subdural electrode recordings, when separate observed over the history of epilepsy surgery. This as well as electrophysiologic studies, the challenge remains group concluded that further studies are necessary to assess how to enhance the detection of a primary focus when it is not prospectively the indications for multilobar surgery and apparent. They demon criteria for epilepsy surgery, we developed a novel strategy with strated that certain patients with temporal lobe epilepsy with the goal of improving outcomes in this worst prognostic group, bilateral independent seizures could be cured with a focal based on a rational treatment philosophy (33). These patients tistage surgery, in which more than two operative stages were would have been rejected as surgical candidates by standard performed during the same hospital admission, with subdural selection criteria at that time. They concluded that having electrodes, to treat a select group of patients, including those fewer than 80% of seizures originate in one temporal lobe with multifocal seizure foci. The rationale was to identify should not be an absolute contraindication for temporal which seizure foci were primarily epileptogenic, and therefore lobectomy in bitemporal patients in whom most evidence needed to be resected, in a multifocal setting. They posited three theories free outcomes in 60% of all patients, with acceptable risk (33). The surprising focal brain lesions could be the underlying etiology in certain result that two thirds of these patients were free of seizures at cases of infantile spasm (45). One potential surgery candidates based on the conventional work Chapter 85: Multifocal Resections or Focal Resections in Multifocal Epilepsy 959 up at that time (45). Clearly, functional brain imaging was focus could be identified and resected in these patients. Similarly, multifocal epileptiform activity likelihood that these events were partial in nature, perhaps a observed in patients with hypothalamic hamartoma, respon bilateral electrode survey could identify a discrete focus that sive to focal therapy directed at the lesion, supports the could be targeted. The multidisciplinary epilepsy team felt that hypothesis that patients with a more generalized epileptic phe the alternative path, a continued course of severe epilepsy notype may be harboring a focal, intrinsically epileptogenic despite multiple medications, entailed significant risk as well. They argue that selected children and adolescents tion or success from surgery (54). The significant majority of these patients a primary epileptogenic zone for strategic resection. However, this too, is kindling or secondary epileptogenesis, masking this epilepto often not feasible in many cases, due to several factors, which genic lesion (49,50). Indeed, it is often dif the observed phenotype when an occult ictal focus is driving a ficult to define the epileptogenic zone with precision when complex epileptic network (14,15). In fact, we were surprised by many of the unexpected good We have proposed multistage epilepsy surgery as one possi outcomes, which challenged our group to pursue this thera ble approach for rationally trying to distinguish which foci peutic strategy even further. This philosophy is not unique to need to be resected in the patient with presumed multifocal our group. Removal of a radiation-induced frontal lobe tional phase on monitoring, in order to determine the impor cavernous malformation resulted in amelioration of his dis tance of additional distal and/or adjacent seizure foci. The hypothesis we began with was that, despite the mul hospital length-of-stay, and the theoretical risk associated with tifocal findings on imaging and electrophysiology, an ictal an additional operation. Second, the alternative strategy may 960 Part V: Epilepsy Surgery be better: resecting the presumed primary focus only and see ing how the patient does. Our experience indicates that families seem more willing to undergo an additional surgical stage acutely rather than return to the operating room at a later date. Finally, we do not know definitively whether what is recorded between the second and third surgical stages is actually clinically significant. Perhaps seizures recorded after the initial resection would simply dissi pate over time, obviating the need for further resection. While we have been encouraged by the utility and safety of the multistage approach, it, nevertheless, clearly reflects the philosophy and referral bias of our institution. The limi tations of this strategy point to the need for better noninva sive modalities for defining those specific situations that demand multifocal resection. Occasionally, festation of disturbed circuitry resulting from interaction secondary generalization was seen. Other seizures were char between the early lesion and the developing brain (50). But, acterized by right arm clonic activity, right head deviation, and lacking this experience, how can one transform an occult pri tongue thrusting lasting less than 1 minute. Bilateral rhythmic synchronous the following case illustrates how a resective surgical strategy delta bursts lasting over 20 seconds were also seen. Ictal events was utilized successfully for a case of apparent multifocal were characterized by staring, bilateral arm jerking, gaze devia epilepsy in a young girl who, as a result of the nonlocalizing tion to the right, left facial pulling, and behavioral arrest that work up, was not felt to be a surgical candidate. Because the were associated with diffuse polyspike and wave activity extensive preoperative evaluation did not precisely localize a followed by attenuation. She developed relatively In brief, she was experiencing multiple daily seizures which well until age 2, when she experienced an episode of noncon were not responsive to several antiepilpetic medications. Her vulsive status, resulting in the loss of language that had devel case was discussed in detail at the Multidisciplinary oped up to that point, and developmental regression in general. Her data were suggestive of She also began experiencing secondarily generalized seizures. Weighing the risks and benefits in detail have daily seizures, about four events per day on average. The Chapter 85: Multifocal Resections or Focal Resections in Multifocal Epilepsy 961 goal was to identify one or maybe two seizure foci which these two active areas (frontal and temporal) were resected, could then be approached for resection. The understanding and new electrodes were placed to determine if adjacent or was that bilateral epileptiform activity was likely to be distal areas would continue to be active. The the following week, monitoring showed residual seizures orig parents agreed to proceed with this plan, and the patient inating posterior and superior to the frontal resection cavity, underwent bilateral subdural strip electrode placement at age 4. The frontal region Interictally, during the 5 days of intracranial monitoring, was resected further based on the ictal map and the electrodes very frequent spikes were seen in multiple bilateral strips. Twenty-one typical seizures were recorded: these showed dif Postoperatively, she was seizure-free for 3 months, during fuse attenuation with high frequency, low amplitude beta which time her parents noted developmental gains.