Thursday, May 04, 2006

( Summarize) The Ketogenic Diet Treatment in Pediatric Epilepsy

( Summarize) The Ketogenic Diet Treatment in Pediatric Epilepsy

Dreamer
August 8th, 2004

Introduction:

The Ketogenic Diet is a high fat, low carbohydrate and low protein diet. As a way to treat epilepsy, it started in 1921 when Wilder designed the diet. Later on many clinical researches and animal studies have been done and still doing. It shows the Ketogenic diet is effective in epilepsy. But the mechanism is unknown. This becomes a hot study point for refractory epilepsy.

Animal studies have proved that the Ketogenic diet can increase the threshold of the seizures. The diet only uses for the refractory epilepsy as a adjuvant treatment. Before initiate the diet, fasting 36--48 hours, and then give 4:1 Ketogenic diet. Stay in it at least 6 weeks so that the body can remain ketosis. Adjust calories and water intake as individual needs to keep the patient’s weight does not change too much.

Ketogenic diet is more efficiency t in children than adults. Because the brain’s ability of using ketone body as energy source decreases with aging. And adults are difficult to remain ketosis. Also long time high fat diet can course adults serious cardiovascular and cerebrovascular diseases.

The side effects of ketogenic diet includes: constipation, abdominal distention, anorexia, hyperlipidemia, kendiny stone, vitamin deficiency, hypoproteinemia and sometimes can course dehydration, hypoglycemia and osteoporosis. Using ketogenic diet with some antiepileptic medication can make side effects more severe. So when using ketogenic with antiepileptic medication, caution needs to be taken.

Below is a summarize of the recent years publications about ketogenic diet study.

Background:

The ketogenic diet was designed in the 1920s to mimic the body's response to starvation. Starvation induces a ketotic state, shifting the body's metabolism from carbohydrate to fat utilization for fuel (1). The ketogenic diet can treat two disorders: Epilepsy and some inborn errors of metabolism (2). This article will only summarize the use of ketogenic diet in epilepsy.

Ketogenic diet can decrease seizures of patient with epilepsy. In its heyday, the diet was predominantly used to treat patients with intractable childhood epilepsy. The efficacy and tolerability of modern antiepileptic drugs (AEDs) led to decreased use of the ketogenic diet.(1)


Recently, however, there has been a rebirth of popular interest in the ketogenic diet following the television news documentary Dateline, a movie made for television First, Do No Harm, and a published report on the diet's efficacy in 58 patients. Its mechanism is not well described, but it appears to be useful when traditional AEDs have failed or there are unacceptable side effects from AED therapy.(1)

Ketosis, or the physiologic state in which there are elevated levels of ketones in the blood, usually occurs in people in the fasting state. A state similar to fasting can be induced by a very high fat diet. Hence the ketogenic diet.(3)The ketogenic diet has its origin in the observation that fasting reduces seizures. This observation is old since Hippocrates used fasting to treat seizures, and the Bible mentions fasting as a treatment for seizures (2)(4). However, the first scientific assessment using dietary manipulation was reported by Guelpa in 1911. In 1921, Geyelin confirmed that seizures ceased on absolute fasting (6). In 1921, Wilder proposed a high fat, low carbohydrate diet as a means of mimicking fasting, and attributed the anticonvulsant properties to the production of ketones (2)(6). There were not much AEDs available before 1938, the ketogenic diet was used in a group of children and adults which more representative of the current general population of people with epilepsy. (6)

After 1938, phenobarbital and phenytoin became available, interest in the diet declined (2).

However, interest has increased recently because 20-30% of epileptic children have seizures that are resistant to antiepileptic drugs (2). And the diet lack of unpleasant side-effects associated with AED's (4). In the last 10--30 years patient series reported on the diet have generally included people with multiple seizure types refractory to multiple ant epileptic drugs (AEDs) (6).

The diet has been described as difficult to tolerate, being unpalatable leading to poor compliance. However, there remains a group of children who have seizures that are difficult to control or who have significant side effects with AEDs. So the diet has been remained interested (6).

The basis of the ketogenic diet is the brain’s ability to utilize ketones as an energy source. Ketones include b-hydroxybutyrate, acetoacetate, and acetone, which are products of fat breakdown. Under normal conditions, the brain derives most of its energy from glucose. Under fasting conditions, hormonal changes cause fat cells to release fats, which are then broken down in the liver. The liver packages the energy contained in fat into ketones. The liver releases ketones into the blood, which then transports them to the brain (2).

While on the ketogenic diet, the patient will be in ketosis and will have elevated levels of ketones in his/her blood. Ketone levels can be measured in the blood, but blood levels generally are not measured daily. Instead, they are monitored using a urine dipstick since they also spillover into urine when present at high levels in the blood. Normally, urine has no ketones (2).

Descriptions of the Ketogenic Diet:

When the body is deprived of glucose, ketone bodies, acetoacetic acid (AcAc) and b-hydroxybutyrate (BHB), are formed from the breakdown of fat and cross the blood-brain barrier where they can be used by the brain for energy.(1) The ketogenic diet's aim is to simulate the body's response to starvation by inducing production of these ketone bodies.This diet is high in fat and low in carbohydrates and protein, with each component of the diet being meticulously weighed in a specific ratio and proportion. Foods in this diet are considered either "ketogenic" (fat) or "antiketogenic" (carbohydrates and protein) (1).

Accuracy and compliance with the diet are critical. It takes dedicated individuals to make the diet a successful seizure treatment. When patients are ill and either cannot ingest their diet properly or need to take additional medications (which generally contain carbohydrates), disruption of ketosis becomes more likely. It is therefore important for health care practitioners, patients, and family members to easily recognize the carbohydrate content of frequently used medications and other ingested products.
Pharmacists are the ideal source to supply this information and are essential to make the diet work with the least amount of effort (1).

The modern form of the ketogenic diet was described by Wilder in 1921. Wilder initially described a diet high in fat content (i.e., long-chain saturated fats) with a low percentage of both proteins and carbohydrates. This diet is referred to as the "classic" (4:1 or 3:1) diet comprising four or three parts fat:one part nonfat (protein or carbohydrate) kilocalories. Wilder believed this would mimic the fasting state while providing the body with enough calories to maintain proper growth and function (1).

Because the classic 4:1 diet was considered unpalatable and, hence, associated with poor compliance, Huttenlocher developed a medium-chain trigylceride (MCT) diet. The MCT diet is easier to prepare, is more ketogenic because the fats used (decanoic and octanoic acids) yield more ketones per calorie, allowing more carbohydrate and protein utility, and thus causes less elevation of serum cholesterol (1).However, recent experience suggests that the classic ketogenic diet may be better tolerated than the MCT diet (3).

In addition to the classic 4:1 and MCT diet, a third diet -- the modified MCT diet -- was developed by the John Radcliffe Hospital in Oxford that incorporates both long- and medium-chain fatty acids (1).

Efficacy:

Most epilepsy in Children can be controlled with 1 medication. Those whose seizures cannot be controlled with the first medication, properly used, have a <20% chance of their seizures being controlled with second medication. Children who have seizures that are difficult to control with two medications have only 25% to 40% chance of their seizures being controlled with other medications. It is latter population of children who have failed >3 medications that some have termed “intractable”, or that we call “difficult to control”(13).

The diet has been shown to significantly reduce the frequency of seizures in some children with difficult to control epilepsy. Not all children show an improvement in seizure control with the diet. If it is successful in controlling seizures, the doctor may decide to reduce or gradually withdraw medication (5).

Ketogenic diets have been used to treat seizures that are both idiopathic and sympto-matic. Patients with the following seizure types have been evaluated for efficacy of the diet: myoclonic, focal motor, atypical absence, generalized tonic, and tonic-clonic. All three of the diet formulations are equally efficacious. Overall efficacy ranges from 33-67%. Most of the studies that have been published use seizure frequency, intensity, and compliance as end points of the study (1).

It appears that children younger than 10 years old respond the best to the diet from a physiologic perspective. These children tend to be more prone to ketosis than older children or adults. The brain's ability to extract ketone bodies and utilize them as an energy source decreases with age. This is because the relative fractional extrac-tion of ketone bodies decreases with age.[23-25] Younger children are also more dependent on someone else preparing their diet than are older children or adults. Surprisingly, a majority of the children do not mind the taste of the high-fat diet, especially if they are involved in the selection of foods and their parents explain the importance of the special diet to them (1).

One study observed 150 children whose seizure were intractable. They averaged 410 seizures per month and has failed an average of 6 medications before the time of starting on the diet.One year after starting the ketogenic diet, 7%of these children had become seizure-free and an additional 20% children had a >90%decrease in seizures. Three to 6 years later, 27% of the 150 had a >90% decrease in their seizures, and most had discontinued the diet. Half of those(13%) were seizure-free. This 27% with marked improvement in seizure control is the same percentage as we had found after 1 year on the diet, although they are not necessarily the same children. Three to 6 years after starting the diet, a higher percentage(13%) have become free of seizures(13).


Preliminary results from a multicenter study seem to indicate that it can be useful in controlling seizures of a percentage of children who had not been controlled with anticonvulsant medications. Approximately 33% of these children gain full control, and another 33% are able to get improved control and decrease their medications. Seizure type does not predict which child may benefit from the diet(14).

There are reports on efficacy of the diet. They provided additional retrospective evidence of the efficacy of the diet in 17 children under 2 years of age. Two patients quickly withdrew; of the 15 who remained on the diet, 40% became almost seizure-free and 53% experienced more than a 50% reduction in seizure frequency. The durability of this outcome is not clear, but these investigators continue to demonstrate the lack of difficulty in using the diet in very young children(11).

In another study, they reported 4 patients with "epileptic spasms," an entity clinically similar to infantile spasms but occurring in older children. One of these patients achieved partial control (> 50% reduction) of spasms using the ketogenic diet. This would not be surprising, given the diet's recently reported efficacy in infantile spasms(11).

For treatment of seizures. Many studies report that the ketogenic diet effectively treats a variety of seizures in children and adults. The seizure types that can be helped by the diet include absence, myoclonic, generalized tonic, generalized clonic, generalized tonic-clonic, simple partial, complex partial, and partial seizures with secondary generalization. It may be most effective against myoclonic, astatic or drop seizures, and atypical absence seizures. It can be effective in children with multiple seizure types including Lennox Gastaut syndrome(2)(11). Another benefit of the ketogenic diet for some children is that it may reduce or end the need for medication and thus avoid the side effects that result from medication(12).

About 1/3 of children have a >90% reduction in seizures with 5% becoming seizure free at 6-12 months. Another 1/3 have a 50-90% reduction in seizure frequency at 6-12 months with the remainder having no significant improvement. Other potential benefits of the diet include a reduction in the number of antiepileptic drugs, increased alertness, and improved behavior even if seizure control is not improved(2)(11).

For treatment of inborn errors of metabolism. The ketogenic diet is the treatment of choice for some inborn errors of metabolism and is a treatment option for others. It is the treatment of choice for children with glucose transporter protein syndrome since they cannot get glucose to their brains. Children with diseases characterized by an inability to metabolize pyruvate such as pyruvate dehydrogenase complex deficiency are candidates for the diet. It may also be helpful in infantile phosphofructokinase deficiency(2).

A recent review of the results from numerous studies of the ketogenic diet found that over half of children with seizures that don't respond to medications who follow the ketogenic diet have a 50% or greater decrease in seizures. Some children have an even greater reduction(11)(12).

The other benefits of the ketogenic diet are mainly avoiding the side effects of
anticonvulsants such as sedation or impaired thinking, as well as the cost savings. Like
anticonvulsants, the diet is not a cure, but merely another treatment mode for hard to control seizures(14).

Mechanism:

It is not clear how the diet work and it is possible that there are two separate mechanisms. When the fats are broken down they produce ketone bodies which are passed throughout the body and then are excreted in the urine. These can be tested very simply by dipping a special stick into the urine (or on to a nappy) to ensure that the child has become ketotic. It is thought that in some children these ketone bodies are actually working like antiepileptic (anti-fit) medicines. In these children the level of ketones is crucial and must be maintained to ensure good seizure control.
In other children, who take longer to respond to the diet, they appear to receive something that is deficient from their diet. Seizure control is often not obtained for about one month but then the effects are not so dependent on the ketone levels. It is impossible to predict into which group your child will fall. Not all children respond to the diet(15).

Numerous theories have been proposed on how the ketogenic diet works in both human and animal studies. Several authors believe that the anticonvulsant effects of the ketogenic diet are related to the ketosis and production of AcAc and/or BHB. The protection against seizures by elevated blood levels of BHB and AcAc in animals also has been studied.
The mechanisms of the ketogenic diets, however, are still unknown. It does appear that BHB and AcAc are involved in the efficacy of the ketogenic diet, but elevation of these substances may not be the only mechanism of action of the diet. More animal and human research is needed to completely determine the true mechanism or mechanisms of the ketogenic diet(1).

The effectiveness of the Ketogenic Diet is a combination effect of the following processes, all of which tend to remove extra-cellular fluid. Acidosis--mild degree of compensated acidosis. Ketosis--accumulation of mildly anesthetic acetone bodies in tissue. Dehydration--slight lowering of water content of the body(4).

The ketogenic diet a "therapy in search of an explanation", Carl E. Stafstrom, M.D., Ph.D., associate professor at Tufts University School of Medicine and the New England Medical Center in Boston described research in animal models to investigate the mechanisms of action through which the ketogenic diet confers its apparent beneficial effect. Dr. Stafstrom indicated that we have learned the following from animal models:
1) the ketogenic diet appears to afford protection against acute seizures in some models, 2) the mechanism of anticonvulsant action may be related to the ketosis itself, rather than to the associated acidosis or other metabolic effects, and 3) several features of experimental responses parallel those observed clinically. For example, the diet seems to be more effective in younger animals just as it seems to be more effective in children than in adults. Also, although the onset of action is gradual, the reversal of the effect occurs rapidly. We see this clinically when it may take several days after beginning the diet for the effect to build up, but, if ketosis is interrupted by the consumption of carbohydrates, the anticonvulsant effect can reverse within hours. This is why it is so important to maintain the diet strictly, and why it is so easy to undo its effects: weeks of hard work can be undone if the child eats a couple of cookies or candies because they contain enough glucose to switch the body over to using glucose for fuel rather than the ketone bodies. (Remember that the body only uses the ketones when sugar is unavailable; as soon as the slightest amount of sugar is made available the body immediately converts it to glucose to use for fuel)(3).

Dr. Stafstrom described several experiments in which rats given ketogenic diets were compared with rats on normal diets as various parameters of cognition and behavior were tested. In general, the rats on the ketogenic diet did better in several tests, such as the "water maze", which measures the ability to learn and remember the location of food on a platform in a pool of water through which the rat has to swim to reach the food. "I am not willing to say that the ketogenic diet makes rats smarter, but at least it's clear that it doesn't make them any dumber", said Dr. Stafstrom, and this observed effect correlates with observations in children with severe epilepsy on the ketogenic diet who experience improvements in mood, behavior, and cognition. Unfortunately, this improvement carries with it an increase in activity, possibly hyperactivity, in terms of awareness and exploration of the surroundings; this may correlate with observations of increased irritability in some children on the diet(3).

Elevated levels of ketone bodies have been strongly associated with seizure control and seizure freedom, and all practicing neurologists employ them as biochemical markers of treatment. However, the ketosis produced by the ketogenic diet may not be the main factor in controlling epileptic seizures in children [Schwartzkroin 1999]. Nevertheless, the clinical goal has historically been to achieve high urine ketone levels, and the importance of this time-honored practice can only be appreciated through an understanding of intermediary metabolism(16).

When the glycolytic pathway is deprived of glucose, as during starvation or the ketogenic diet, free fatty acids are mobilized as substrates for mitochondrial oxidation. In addition, certain amino acids may be converted to ketoacids that can provide other substrates (e.g., alanine to pyruvate) for Krebs cycle activity. The hepatic microsomal system can also convert fatty acids to dicarboxylic acids (via omega oxidation). These dicarboxylic acids require carnitineesterification for urinary secretion [Sankar & Sotero de Menezes, 1999](16).

Free fatty acids are not readily available to the neuron itself. However, fatty acids can undergo aseries of conversions and translocations to produce acetate substrates for ketone body production. These ketone bodies are carried across the blood-brain barrier (by a fasting-inducible transporter called the monocarboxylic acid transporter) and into the neuron where they are available as an energy substrate for cerebral metabolism(16).

Thus, one major physiologic role for ketone bodies is to provide an alternative energy substrate for brain and muscle under conditions of fasting or a high-fat diet. In a classic study of fasting obese volunteers, for example, glucose utilization accounted for only 29% of the brain’s oxygen consumption while ketones extraction accounted for 52% [Cahill 1966]. Playing another major physiological role, ketone bodies act as the principle source of energy during early postnatal development. Furhter, they are the substrates for the carbon skeleton of lipids that comprise the cell membranes of growing brains and organs. Thus, ketones are involved in both the energy supply and lipid biosynthesis of the embryonic central nervous system (CNS)(16).

But do ketone bodies exert a direct antiepileptic effect? Can they modulate neuronal excitability? Several clinical studies have now shown that diet-induced ketosis (especially at very high concentrations) seems to correlates with the level of seizure control. (The most recent studies will be discussed later.) Also, abrupt loss of seizure control has long been known to occur within hours after ketosis is broken [Huttenlocher, 1976](16).

Thus the compelling question remains: are ketones directly responsible for anticonvulsant activity? Or are they just an epiphenomenon of some other diet-induced physiological change? These questions have been explored in varied experimental settings(16).

One recent animal study, for example, showed that ketone bodies do not directly alter the excitatory or inhibitory hippocampal synaptic transmission. [Thio 2000] Neither beta-hydroxybutyrate nor acetoacetate affected whole cell currents evoked by glutamate, kainite, or gamma aminobutyric acid (GABA) in cultured hippocampal neurons. The ketone bodies also failed to prevent spontaneous epileptiform activity in the hippocampal-enterorhinal cortex slide seizure model(16).

Results from our laboratory in cultured mouse neocortical neurons were similar, with no effects of the ketone bodies on the classic neuronal targets of anticonvulsants. Investigators should also be aware that beta-hydroxybutyrate is a stereoisomer, with the D-isomer being the biologically relevant species. The non-physiologic L-isomer possesses anticonvulsant activity both in vivo and in vitro, and is due to the presence of a contaminant, diphenylamine(16).

Similarities in the chemical structures of beta-hydroxybutyrate and GABA have led to speculation about GABAergic inhibition induced by the ketogenic diet. Results from studies are conflicting, with one showing no changes in whole brain GABA [Al-Mudallal 1996] and another demonstrating that ketonescan increase GABA in synaptosomes. [Erecinska 1996](16).

Finally, magnetic resonance spectrophotometric techniques have shown elevated levels of cerebral ketones in patients who are successfully controlled by the ketogenic diet [Pan et al., 1999](16).

Overall, the experimental evidence supporting a direct link between ketone and seizures is far from convincing. Indeed, as with the underlying causes of the seizures themselves, the ameliorating actions of the ketogenic diet may be multiple, with a host of diet-influenced metabolic changes acting in concert to decrease membrane excitability(16).

But even as research continues, the clinical connection between peripheral ketone levels and seizure control still impels clinicians to confront more practical questions. For example, what assay method should be employed to monitor diet efficacy? Urine dipsticks are commonly used for this purpose but these measure acetoacetate, the less prominent ketone body. Which ketone body actually correlates best with seizure control is unknown. If beta-hydroxybutyrate ketone is actually the preferred marker, a new reflectance meter (Keto-Site™, GDS Diagnostics) will assay the D-isomer from a small drop of blood. But then, what is the “therapeutic concentration”for either of these ketones? And what does the peripheral level predict about the brain level?(16)

Clearly, many questions remain about the physiological relevance and the practical utility of monitoring ketone bodies in the ketogenic diet(16).

Eileen P.G. Vining, MD summarized the mechanism of ketogenic diet studies on American Epilepsy Society 56th Annual Meeting (11):

Pan and colleagues[13] from Albert Einstein College of Medicine, Bronx, New York, and Yale University School of Medicine, New Haven, Connecticut, have addressed monitoring the diet from another important point of view. They have asked how the brain uses ketones, recognizing that a simple measurement of plasma ketones may not reflect the critical biological parameter. They used in vivo MR spectroscopy to evaluate how beta-hydroxybutyrate (BHB) is used in the brains of healthy adults who become ketotic. They found that the rise in plasma BHB is rapid and accompanied by a near simultaneous rise in brain BHB. Perhaps their most interesting finding is that the BHB consumption appears to be preferred by the neuronal compartment, bypassing the astrocytic compartment that had been suggested by others(11).

Five poster presentations discussed various aspects of basic science relating to the ketogenic diet. Sullivan and associates[14] from University of California at Irvine examined synaptosomal mitochondria from the cortex of mice fed either normally or with the ketogenic diet for 10 days, with BHB levels reaching twice the normal level in the ketogenic-diet-fed rats. They found increased mitochondrial uncoupling activity and reduced reactive oxygen species (ROS) production in the animals on the diet, suggesting a possible neuroprotective as well as anticonvulsant effect(11).

Bough and coworkers[15] from University of Washington, Seattle, University of California at Irvine, and University of California at Davis, reported on in vivo recordings from Kcna1-null mice with recurrent seizures, a possible model of developmental epilepsy. The ketogenic diet did not further augment the inhibition shown by Kcna1 -/- mice to paired-pulse stimulation within the dentate gyrus, resulting in an elevated threshold to electrographic seizures at 5-6 weeks of age(11).

Two other presentations dealt with seizure susceptibility using 2 different models. In a multicenter Korean study, Dong-Wook Kim and colleagues[16] examined flurothyl-induced seizure susceptibility in 3- to 12-week old rats that were treated with a ketogenic diet. Levels of ketosis were lower and seizure latencies were shorter in older animals, suggesting that the diet was more efficacious in younger animals. The efficacy of the diet is generally assumed to be better in younger patients, but substantive evidence to confirm this is not available. In a second, multicenter Korean study, Jae-Moon Kim and colleagues[17] examined the effect of the diet on continuing seizures in rats with PTZ-induced seizures. The diet was effective in reducing the length of seizures, again more so in the younger animals(11).

Finally, Eagles' group[18] at Georgetown University, Washington, DC, presented information about the effects of gamma-butyrolactone (GBL) -- which induces absence seizures -- and the ketogenic diet on the behaviors of male and female rats. Absence seizures were induced in rats, and several functions (posture, gait, and performance on a roto-rod) were scored. Ketogenic animals, particularly females, did less well behaviorally than standard-fed animals. In general, sex differences on the ketogenic diet have not been observed clinically. This preliminary finding in animals is obviously of interest as we explore the neuroendocrine effects of the diet(11).

Indication and Contraindication:

Most experts say the diet is worth trying when two or more medications have failed to control seizures, or when medications cause side effects that are having a harmful effect on a child's life. It also helps to have a child who is willing to try foods that he might otherwise not be enthusiastic about, and is tolerant and not fussy about eating. The diet seems to work for more than one kind of seizure, and for children who have a lot of seizures or few seizures. But most doctors say it shouldn't be used instead of medications if the drugs are working and the child is not having bad side effects(5)(18).

Epilepsy patients must meet certain criteria to start ketogenic diet at Johns Hopkins Hospital(17):
--They previously must have tried two anti-convulsant medications.
--They must undergo an evaluation by their own neurologist and EBMP's ketogenic team to determine their seizure type.
--They or their families must demonstrate an ability to understand the ketogenic diet and the importance of adhering to its specific requirements.
--Patients and families must be highly motivated in following the diet(17).

The ketogenic diet has two primary indications. Some children with epilepsy that standard antiepileptic drugs cannot control are candidates for the ketogenic diet. And Several specific inborn errors of metabolism can upset mitochondrial function and lead to dysfunctional glycolysis. Children with these special conditions may be strong candidates for the ketogenic diet(2)(16).

It appears that the best candidates for the ketogenic diet are those who have refractory epilepsy or unacceptable side effects to standard AEDs. In addition, patients placed on the diet must have a strong support system at home to implement the diet because of its strict guidelines. Patients and family members must be willing to work closely with a dietitian to help make meal planning more realistic(1).

John M. Freeman et el wrote the indication about the diet at the book The epilepsy diet treatment(7):
A) Children with difficult to control seizures occurring searal times each week and had failed at least two AEDs.
B) Seizure type: myoclonic, absence, and atonic (drop) seizures which are particularly
difficult to control with standard medication. The diet also helps some patients with genalized tonic-clonic seizure and even the multifocal seizures of the Lennox-Gastaut syndrom. The ketogenic diet may be tried on children with any type of seizures.
C) Age: The ketogenic diet is most often prescribed for children over one year of age. Children under the age of one year have trouble becoming ketotic and maintaining ketosis. They are also prone to hypoglycemia. The ketogenic diet may be recommended for older children provided that they and their families are highly motivated. It has been said that adults have difficulty maintaining ketosis, but to our knowledge this has not been studied in depth.(7).

There are some contraindications: Medical contraindications to the ketogenic diet include metabolic disorders with a defect in fat metabolism, ketone metabolism, or mitochondrial disorders. These include β-oxidation defects, primary and secondary carnitine deficiency, carnitine cycle defects, electron transport chain defects, ketogenic defects, ketolytic defects, pyrvuate carboxylate deficiency, and pyruvate dehydrogenase phosphatase deficiency. Though the diet can exacerbate ketotic hypoglycemia, this condition is not an absolute contraindication(2).

Most inborn errors of metabolism involving mitochondrial transport of fatty acid oxidation are absolute contraindications for the ketogenic diet. These include, for example, deficiencies in carnitine (primary or secondary), carnitine palmitoyltransferase I or II, and translocase. The most common fatty acid disorder to be vigilant for is the medium-chain acyl dehydrogenase deficiency (MCAD). Other such deficiencies include those of long-chain acyl dehydrogenase, short-chain acetyl CoA dehydrogenase, long-chain 3-hydroxyacyl-CoA, and medium-chain 3-hydroxyacyl-CoA(16).

Clues to an inborn error of metabolism include developmental delay, hypotonia, exercise intolerance, and easy fatigability. In children with these presenting symptoms, several tests can determine if the child is suitable for the ketogenic diet. The recommended biochemical screening tests (in addition to the routine laboratory studies such as liver function tests, complete blood count, etc.) are for urine organic acids, serum amino acids, and serum lactate and pyruvate. As implied in Figure 1, findings of highly elevated dicarboxylic acids in the urine signal a problem with the normal pathway of intermediary metabolism (either mitochondrial cytopathy or a fatty acid oxidation defect) and this warrants further investigation(16).

Some antiepileptic drugs can potentially exacerbate some of the adverse effects of the ketogenic diet, and these drugs require careful use when combined with the diet. These antiepileptic drugs include acetazolamide, topiramate, and zonisamide, which all can cause acidosis and kidney stones. Another antiepileptic drug requiring careful monitoring in children on the diet is valproate.

Finally, some children and adolescents are not candidates for the diet because they can get their own food and cannot understand the restrictions of the diet. These children and adolescents will not maintain the diet without constant supervision, which usually is not practical(2).

Adverse Effects(Side effects):

Similar to other antiepileptic drugs, the ketogenic diet has a variety of side effects that range from minor to severe. Common ones include nausea, vomiting, constipation, and loss of appetite. Less common ones include poor growth, kidney stones, and abnormal heart rhythms. It may impair white blood cell and platelet function. White blood cells help our bodies to fight infections, and platelets help our blood to clot. In rare cases, it can cause death(2).During the fasting period, it may be have Nausea , Severe acidosis and Vomiting. During the diet period: One can have Vomiting , Hunger , Decreased ketosis , Constipation , Illness (4). The ketogenic diet may cause Dehydration, High cholesterol level and Behavior changes(12)(18).These may lessen with time and they can sometimes be avoided by careful monitoring. The most common side effects when starting the diet are nausea and constipation. If the diet is kept to carefully, the child will not usually become overweight or have an increased risk of heart disease(5). Possible long-term effects of high fats(cholesterol,
triglycerides), Growth retardation due to protein deficiency, Vitamin and mineral deficiencies, Impaired immune defenses (possibly related to neutrophils), Metabolic acidosis and Liver failure, etc(16).

1) Digestive system side effects: Typical early problems included GI intolerance (11). These are including nausea, vomiting, and abdominal cramping. These adverse effects are seen in approximately 50% of patients on the MCT diet because of its hyperosmolar concen-tration, and are somewhat less common with the classic diet. Excessive ketonemia also may produce GI side effects and should be ruled out. On a daily basis, urinary ketones should be monitored. Pharmacists are excellent resources for explaining how to monitor urinary ketones. A small amount of orange juice may be given for excessive nausea to lessen the degree of ketosis.[20] Medium-chain triglyceride oil is hyperosmolar, which can cause a large influx of fluid into the large intestines. When GI side effects are present with the MCT diet, they can be eliminated by decreasing the amount of MCT oil in the diet and gradually titrating it back up slowly. It may also be helpful to have the patient sip the MCT drink throughout a meal to decrease abdominal pain. A few severely retarded children treated with the classic diet have developed dehydration and severe metabolic acidosis during illnesses, requiring hospitalization. When these children required intravenous rehydration, electrolyte solutions without glucose or lactate were given(1).

2) Carnitine deficiency: Recently, carnitine deficiency has been reported in a small number of children receiving the ketogenic diet (1) (11). Although the clinical relevance of measuring free carnitine remains in question, the investigators conducted a retrospective chart review and found that 61% of 20 children on the diet developed a carnitine deficiency. However, only 1 child developed symptomatic carnitine insufficiency (acyl/free ration > 0.4) with increased seizures and lack of energy. Two of the 20 children experienced improved energy and alertness after carnitine supplementation, although free carnitine levels had improved in all of them. Children who received the diet orally appeared to have more abnormalities than those who were fed enterally, perhaps because the formula was fortified. Others who have looked at total carnitine levels find that they stabilize or return to baseline over time and that most children on the diet do not need supplementation(11). Baseline and periodic serum carnitine levels should be evaluated in patients receiving valproate, phenobarbital, phenytoin, or carbamazepine (which may also cause carnitine deficiency) who also are being treated with the ketogenic diet.[26-28] At this time, the significance of this interaction is unknown, and some clinicians contend that the only way to truly monitor carnitine stores is by muscle biopsy(1).

3) Hyperlipidemia: Hyperlipidemia with significant elevations in serum cholesterol, triglycerides, and total lipids may occur. A serum lipid panel should be obtained prior to diet initiation and periodically throughout the treatment(1). A preliminary report suggested that there realy is substantial hyperlipdemia, and if and when the it occurs, adjistment of the diet ratio will bring the lipid levels toward normal. We have not had to stop the diet whom it has been successful in controlling seizures(13).

JAMA. published the study Effect of a High-Fat Ketogenic Diet on Plasma Levels of Lipids, Lipoproteins, and Apolipoproteins in Children at 2003;290:912-920. by
Peter O. Kwiterovich, Jr, MD; Eileen P. G. Vining, MD; Paula Pyzik, BA; Richard Skolasky, Jr, MA; John M. Freeman, MD (8).

A) Their study showed after 6 months of receiving the ketogenic diet, is the marked increase in the apoB-containing lipoproteins, VLDL and LDL cholesterol. But these group was also receiving a number of medications of seizure control. It is possible that these seizure medications may have produced higher baseline VLDL cholesterol and triglyceride levels in theis population, but the mean LDL cholesterol level was similar to that found in reference healthy populations(8).

B) The ketogenic diet also had marked effect on the HDL cholesterol level in this population. At baseline, the distribution of the HDL level was similar to that expected for a pediatric population. After 6 months of ketogenic diet, only about half of the study group had an HDL level in the acceptable range(8).

C) The ratio of total to HDL cholesterol, LDL to HDL, and apoB to apoA-I have been used to assess the relative proportions of the apoB-containing and apoA-I-containing lipoprotein. Higher ratios indicate an increase in the risk of developing coronary artery disease in adults, and of parental history of myocardial infarction. Each of these ratios increased significantly after the ketogenic diet primarily because of the marked increase in the apoB-containing lipoproteins, a conclusion further supported by the significant increase in the non-HDL cholesterol, another indicator of the concentrations of the apoB-containing lipoproteins(8).

Even if the ketogenic diet in this group is inflammatory and atherogenic, this will most likely not preclude its use in intractable seizures in children. Such treatment is highly effective and its use and its anti-epileptic action may persist long after the diet is discontinued. Mosst patients have stopped the ketogenic diet after 2 years and the temporary use in childhood is unlikely to be associated with a long-term increase in risk for coronary artery disease in adulthood. Conversily, prolonged use of a hypercholesterolemic diet throughout childhood and adolescence is likely to be atherogenic(8).

In brief, a high-fat ketogenic diet produced significant increases in the atherogenic apoB-containing lipoproteins and a decrease in the antiatherogenic HDL cholesterol. Further studies are necessary to determine if such a diet adversely effects endothelial vascular function and promotes inflammation and formation of atherosclerotic lesions(8).

4) Affective of growth: Generally, growth has not been affected(1). 41% of parents who responded believed that their children did not grow as well on the diet. Most equated growth with lack of weight gain. Carefull serial measurements indicate that height, in general, increases at a low but normal rate(13). And most children who experienced growth failure showed normalization of growth when the diet was discontinued(11).
Some studies have also begun to examine bone density in children on the ketogenic diet. Using a cross-sectional (rather than longitudinal) design they showed that males on the ketogenic diet for 12-24 months experienced a significantly worse osteopenia than females. This is part of an ongoing prospective study that may clarify observations made in 1979, when Hahn and colleagues reported that children on the diet had a significant reduction in serum 25OHD as well as loss of bone mass, which can be partially reversed by vitamin D treatment. This work will be important to providing optimal care for children who are on the diet for an extended period of time(11).

5) Micronutrient deficiencies: The ketogenic diet is deficient in some micronutrients and may be deficient in carnitine. It is deficient in vitamin B, vitamin C, vitamin D, calcium, magnesium, and iron. Children on the diet receive supplements of these vitamins and minerals. Carnitine supplementation may be helpful for some children but generally is not required(2).

6) Other side effects: Including kidney stones, cardiomyopathy, Steatorrhea, Optic neuropathy, Neutrophil impairment, infections, hepatitis, lipoid pneumonia, and acute pancreatitis. Those all needs to be monitored(1)(2)(11)(13).

Food-Drug Interactions:

When ketogenic diet used with AEDs, needs to pay attention about the food-drug interactions.

A) Acetazolamide should be used with caution in patients receiving the ketogenic diet because severe metabolic acidosis may occur, especially in younger children. If the patient is to remain on acetazolamide, it should be temporarily discontinued prior to diet initiation. The drug may then be restarted cautiously after metabolic adaptation has occurred(1).
B) Phenobarbital serum levels may increase significantly in patients receiving the diet and may cause profound sedation. This is related to the acidotic state induced by the ketogenic diet and the low pKa of phenobarbital, resulting in phenobarbital accumulation in the central nervous system.[28] When the diet is initiated, phenobarbital should be tapered, or the dosage decreased with serum levels monitored(1).
C) Valproate can interfere with ketone production, causing carnitine deficiency and a Reye's-like syndrome.[33] This syndrome can cause lethargy, nausea, vomiting, hepatic failure, and encephalo-pathy. Carnitine levels should be monitored at baseline and periodically if patients are receiving concomitant antiepileptic drugs, especially valproate, or show clinical evidence of carnitine deficiency. L-Carnitine replacement may be warranted in patients with low carnitine levels, although the significance of carnitine depletion is unknown(1).
D) Topiramate (TPM) is widely used as ass-on therapy for epilepsy. TPM inhibits carbonic anhydrase, which may result in metabolic acidosis from decreased serum bicarbonate. The ketogenic diet predisposes patients to metabolic acidosis, especially during induction. In children with refractory epilepsy, co treatment with TPM and ketogenic diet may be considered, but special attention should be paid to the combines risk for metabolic acidosis and nephrolithiasis. Bicarbonate levels should be monitored carefully and bicarbonate supplements given when symptomatic(9).
E) Ketogenic diets require patients to take vitamin supplemention. Patients and their families need to know which vitamin supplements they can take safely (e.g., no carbohydrate content or the amount of carbohydrate to be calculated into their daily needs). Because this information is not easy to obtain and generally requires contact with the drug manufacturer, pharmacists are instrumental in retrieving this information(1).

Ketogenic Diet Protocol:

There are different protocol of ketogenic diet. The ratio, which refers to the grams of fat to the grams of protein plus carbohydrate, gives the strength of the diet. Thus, a 3:1 ketogenic diet means that the diet contains 3 grams of fat for every gram of protein plus carbohydrate. Since each gram of fat provides 9 calories and each gram of protein and carbohydrate provides 4 calories, 87% of the total calories in a 3:1 ketogenic diet come from fat. In comparison, fat provides 25-40% of the total calories in the typical diet consumed by American children while protein provides 10-20% and carbohydrates provide 40-60%. The ketogenic diet ratio usually ranges from 3:1 to 4.5:1. For the diet to be successful, you and your child must adhere to this ratio strictly, since any deviation may lead to your child coming out of ketosis. If your child is not consistently in ketosis, the diet will likely fail to control the seizures. Thus, the fat, protein, and carbohydrate content of everything your child eats, including medications, must be taken into account. In short, the diet will not work if you child cheats on the diet(2).

In the present time, most medical center use the classical ketogenic diet. They all follow the diet protocol shows below(2)(3)(7)(10)(11)(16):

1) GENERAL RULES FOR THE KETOGENIC DIET

A) Calorie intake should be approximately 75% of the recommended calorie level for a child's age and ideal weight. Level may be higher for an especially active child.
B) Ideal weight should be based on recognized standards.
C) Most children are on a 4:1 ketogenic ratio. Children under 15 months or obese children may be started on a 3:1 or 3.5:1 ratio of FAT:PROTEIN plus CARBOHYDRATES.
D) Liquid intake should be restricted to less than 1X maintenance (approximately 75%). As a rule of thumb, a child should not drink more cc's per day than the number of calories in the diet.
E) Diet must meet protein RDA as calculated by dietitian.
F) Diet must be supplemented daily with calcium, a sugar-free, lactose- free MVI and fluoride if indicated.

2) CALCULATING THE DIET (3)(4)(7)(10):

A) AGE AND WEIGHT AGE____________ WEIGHT_________

B) CALORIES/KG
Use chart for reference in determining the number of calories/kg:
Under 1 yr. 80 Kcal/kg
1-3 yrs. 75 Kcal/kg
4-6 yrs. 68 Kcal/kg
7-10 yrs. 60 Kcal/kg
11 and up 40-50 Kcal/kg or less

C) TOTAL CALORIES
Determine the total number of calories in the diert by multiplying the weight by the calories/kg required.
WEIGHT_________ X CALORIES/KG________ = ____________ total calories

D) DIETARY UNIT COMPOSITION
Dietary units are the building blocks of the ketogenic diet. A 4:1 diet has dietary units made up of 4 grams of fat to each 1 gram of protein plus carbohydrate. Because fat has 9 calories/gram, a dietary unit at a 4:1 ratio has 36 plus 4 = 40 calories. The caloric value and breakdown of dietary units vary with the ketogenic ratio.

Ratio Fat Calories Calories脂肪热量 Totalcarb&protein Diet. unit
2:1 2g x 9 Kcal/g =18 1g x 4 Kcal/g = 4 18 + 4 = 22
3:1 3g x 9 Kcal/g = 27 1g x 4 Kcal/g = 4 27 + 4 = 31
4:1 4g x 9 Kcal = 36 1g x 4 Kcal/g = 4 36 + 4 = 40
5:1 5g x 9 Kcal = 45 1g x 4 Kcal/g = 4 45 + 4 = 49



E) DIETARY UNIT QUANTITY
Divide the total calories allotted (from #3 above), by the number of calories in each dietary step.
total calories___________ divided by _________ calories in dietary unit =___________ dietary units/day

F) FAT ALLOWANCE
Multiply the number of dietary units X units of fat in the prescribed ketogenic ratio to determine grams of fat/day.
____________dietary units X __________ units of fat = _________fat grams/day

G) PROTEIN + CARBOHYDRATE ALLOWANCE
Dietary Units __________ X units of protein + carbohydrate (usually 1)________ = _____________ combined daily protein + carbohydrate allowance.

F) PROTEIN ALLOWANCE:
calculated by dietician; RDA requirement

I) CARBOHYDRATE ALLOWANCE
Carbohydrates are the diet's filler, and are always determined last.
Total carbohydrate + protein allowance__________ - protein allowance _______ = ____________ carbohydrate allowance in grams.

J) MEAL ORDER
Divide the daily fat, protein, and carbohydrate allotments into 3 or 4 equal meals. It is essential that the proper ratio of fat to protein + carbohydrate be maintained at each meal.

K) LIQUIDS
Calculate: standard weight X 60--70 ml = liquids allowance/day (ml)

L) DIETARY SUPPLEMENTS
Every child should take a daily dose of 600 mg of oral calcium in a sugar-free form such as Long's oyster shell calcium (500 mg) and a sugarless MVI with Fe, such as Sugar-free Bugs Bunny Complete with Iron. Sodium fluoride drops if child's water source does not contain fluoride are also necessary.

3) Ideal schedule(3)(4)(9)(10):


DAY 0 (AT HOME)
-Low carbohydrates or sweets
-Child fasts after dinner, except for water

DAY 1 (Admission to Hospital)
-Continue fast, child NEEDS fluids to prevent dehydration!
-PO liquids at 60--70 ml/kg; Water or diet, caffeine-free soda
-Family meets with dietition (order Nutrition consult)
-Baseline LABWORK: serum antiepileptic medication levels (AED), lipoprotein profile, Chem 23 (if not done within last week at clinic)
-Baseline EEG (usually done within last few weeks)
-(IF CHILD IS ON PHENOBARBITAL, THIS WILL NEED TO BE REDUCED, AS LEVELS MAY RISE DURING THE FAST) Other seizue medications are usually decreased as well
-IV start, may heparin lock
-parent to keep seizure diary
-strict Intake/Output (parents to keep diary of intake). Strict I/O EVERY DAY OF HOSPITALIZATION
-check urine for ketones q void -check blood for glucose level (glucoscan) q 4-6 hrs, as ordered
-weight (after void, in early am) and vital signs (q 4 hours); head circumference
-teach family how to check urine for ketones and blood for glucose
-NOTE: CHILD CANNOT TAKE ANY MEDICATIONS, TOOTHPASTE, MOUTHWASH WITH SUGAR OR CARBOHYDRATE IN THEM.

DAY 2
-Child begins to register elevated urine ketones (usually need 4+/large for best results)
-Dietitian calculates meal plans
-Parents begin learning how to plan and prepare diet
-Draw serum AED levels and lytes
-weight and vital signs
-if child needs IV fluids, use a saline solution, NOT a dextrose IV fluid
NURSING CONTINUES TO MONITOR CHILD'S BLOOD FOR GLUCOSE, URINE FOR KETONES

DAY 3
-Child, in ketosis, starts food with 1/3 strength meals
-parents continue with diet education
-AED levels
-weight in am and vital signs q 4 hours
NURSING CONTINUES TO MONITOR CHILD AND TEACH FAMILY HOW TO TEST URINE, BLOOD

DAY 4
-Child progresses to 2/3 strength meals
-education continues
-AED levels
-weight and vital signs
- CONTINUE MONITORING AND EDUCATION

DAY 5
-Child starts full diet, and if child is stable and parents understand diet, child is discharged from hospital
-AED levels
-weight and vital signs

At 1 month (3):

- Neurologist, nurse, dietitian Adjust diet if needed
- Blood chemistry tests, CBC, platelets
- Lipoprotein electrophoresis
- AED level(s) if needed

3, 6, 12 months(3):
- Neurologist, nurse, dietitian
- Blood chemistry tests, CBC, platelets
- Lipoprotein electrophoresis
- AED level(s) if needed

Maintain for 2 years and use abother 1 year to wean out(4):
- 4:1 Ratio--2 years
- 3:1 Ratio--6 months
- 2:1 Ratio--3 months
- Regular Diet

4) HYPOGLYCEMIA CHECKLIST(10):
-Often blood sugar falls to 40 without signs, while at other times child becomes listless or vomits
-If glucose falls to 30 or 40, and child appears well, recheck glucose in 2 hours. If child is stable, no intervention.
-If glucose drops below 30mg %, watch child very closely, give 30 cc of orange juice
-If symptoms of hypoglycemia develop: nausea, weakness, increase in sweating, dizziness, palor or very lethargic/sleepy, give 15-30 cc orange juice and a cup of ice chips. Another 15 cc of juice may be given. Too much juice will prevent ketosis.
-If child has seizures or major changes in LOC, or glucose drops below 25%, obtain order to administer 5% dextrose solution IV

Questions that need to think about:

The ketogenic diet is highly effective in some children, but efficacy rates have varied depending on the study. Results from large prospective multicenter trials using either the classic Hopkins diet or the modified medium chain triglyceride (MCT) oil-diet are listed in Table 1. In general, more recent studies have reported lower rates of seizure control, probably due to better tracking of drop-outs (i.e., intention-to-treat analysis) and longer follow-up periods. Overall, about one-third of children come close to seizure freedom on the ketogenic diet, one third have reductions in seizure frequency, and one third do not respond. In recent prospective, multicenter studies, only 10% actually become seizure-free [Vining 1998; Freeman 1998](16).


Even many studies showed the efficacy of the diet, There are many questions remaining about the practical application of the ketogenic diet.

1) When to initiate? (ie, after how many antiepileptic drug (AED) failures?) How long can it be maintained, or should it be maintained? What are the side effects, and how can we monitor and reduce them? What are the psychosocial effects of the diet on the child and on his or her siblings and family structure?(3)

2) Determining which seizure types respond best to the diet, for example, has been a subject of debate for decades. The early controversy centered on cryptogenic versus idiopathic efficacy [Keith 1963, Livingston 1972]. And more recently, despite some reports of efficacy in both partial and generalized seizures [Schwartz 1989, Freeman 1998] many patient type- for example, those with partial seizures arising from temporal lobe pathology-still appear relatively resistant to the diet’s effects. In fact, patients with partial seizures have been excluded from most studies assessing the clinical efficacy of the ketogenic diet(16).

3) Other remaining points of controversy include the benefits of the classic diet versus the modified MCT oil diet, the potential of vagal nerve stimulation as a therapeutic alternative in these drug refractory patients, the long-term developmental effects of restricted protein and calories, and the effect of age on efficacy. On this last point, note that the diet has historically been considered more effective in infants and children because ketone extraction from periphery to brain is more efficient in the developing brain. The clinical data with the ketogenic diet in the adults is sparse, with approximately half the patients responding with greater than 50 % seizure reduction [Sirven et al., 1999].

4) The potential adverse effects of the ketogenic diet are well known. In recent years, the clinical literature has focused on nephrolithiasis, growth retardation, and the potential for cardiac disease. Some of the acute toxic effects can be serious and careful monitoring is required(16).

5) Because many children with intractable epilepsy are on valproic acid, the special issue of potential exacerbation of drug side effects by the diet becomes another key issue. In particular, because carnitine deficiency is well documented with valproic acid use, supplementation is recommended in documented cases of deficiency (e.g., plasma free carnitine < 20 _mol/L after the first week of life or an esterifed to free ratio of > 0.4)(16).

6) Studies are continuing on the mechanism of the diet. Whether caloric restriction or ketosis is at the heart of the efficacy of the diet. We know that caloric restriction reduces synaptic excitability, increases fast inhibition in the dentate gyrus, and raises the electroconvulsive threshold. However, ketosis may be more important in maximal dentate afterdischarge. Participants queried whether we could possibly use blood glucose levels as a surrogate for BHB, and specifically whether lower blood glucose levels may be directly related to seizure control. One of the suggestions that also evolved from this discussion was whether a protocol should be devised that would look at calorie restriction vs nonrestriction in an otherwise classical ketogenic diet. Certainly in diabetic patients who are both ketotic and hyperglycemic, there is no protection against seizures. It might also be possible to retrospectively look at glucose levels in children who have been on the diet and establish whether there is a relationship to seizure control(11).

7) Levy R & Cooper P reviewed the Cochran Epileopsy Group trials, their conclusions are: “There is no reliable evidence from randomized trails to support the use of ketogenic diets for people with epilepsy. There are large observational studies, some prospective, suggesting an effect on seizures. These effects need validating in randomized control trails. For those with a difficult epilepsy on multiple ant epileptic drugs, we consider the ketogenic diet a possible option.”(6)

References:

(1) Jacquelyn L. Bainbridge, Pharm. D., Barry E. Gidal, Pharm. D., Melody Ryan, Pharm.D. The Ketogenic Diet Pharmacotherapy 19(6):782-786, 1999. 1999Pharmacohterapy Publications
http://www.medscape.com/viewarticle/417997?src=search

(2) Liu Lin Thio. MD. PhD Ketogenic Diet Pediatric Epilepsy Center 2002
http://www.neuro.wustl.edu/epilepsy/pediatric/articleKetogenicDiet.html

(3)Gregory Homes, MD Special Meeting: Controversies In Epilepsy The Ketogenic Diet
http://w3.ouhsc.edu/neuro/division/cope/ketogen.htm

(4) Katherine Chauncey, Ph.D., R.D. The Ketogenic Diet In The Treatment of Pediatric Epilepsy
http://www.ttuhsc.edu/SOM/FamMed/Ketogenic.html

(5)The National Society for Epilepsy
http://www.epilepsynse.org.uk/pages/info/leaflets/keto.cfm

(6) Levy R, Cooper P Ketogenic Diet For Epilepsy (Cochrane Review). The Cochrane Library, Issue 2, 2004. Chichester, UK: John Willey & Sons, Ltd.

(7) John M. Freeman, MD; Millicent T. Kelly, RD, LD.; Jennifer B. Freeman The epilepsy Diet Treatment An Introduction to The Ketogenic Diet 2en Edition, Demos Vermande publiccation

(8) Peter O. Kwiterovich, Jr., MD; Eileen P.G. Vining, MD; Paula Pyzik, BA; Richard Skolasky, Jr, MA; John M. Freeman, MD. Effect of a High-Fat Ketogenic Diet on Plasma Levels of Lipids, Lipoproteins, and Apolipoproteins In Children JAMA, August 20, 2003 ---Vol 290, No. 7 Page 912-920
http://jama.ama-assn.org/cgi/content/abstract/290/7/912?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ketogenic+diet&searchid=1091994361646_1711&stored_search=&FIRSTINDEX=0&journalcode=jama

(9) Masanori Takeoka; James J. Riviello, Jr; Heidi Pfeifer, and Elizabeth A. Thiele Concomitant Treatment with Topiramate and Ketogenic Diet In Pediatric Epilepsy Epilepsia 43(9):1072-1075, 2002 Blackwell Publishing, Inc. International League Against Epilepsy

(10) Packard Children's Hospital Stanford University Medical Center Ketogenic Diet at Packard Children's Hospital @ Stanford
http://www.stanford.edu/group/ketodiet/download.html

(11)Eileen P.G. Vining, MD The Ketogenic Diet Medscape
http://www.medscape.com/viewarticle/450346?src=search

(12) Dana L. Rowett Ketogenic Diet for Epilepsy WebMD Health


(13) Cheryl Hemingway, MB ChB; John M. Freeman, MD; Diana J. Pillas, BA; and Paula L. Pyzik, BA Pediatrics Vol. 108 No. 4 October 2001 Page 898-905The Ketogenic Diet: A 3- to 6- year follow-up of 150 Childresn enrolled prospectively

(14) Len Leshin, MD Ketogenic Diet for Epilepsy
http://www.quackwatch.org/04ConsumerEducation/QA/keto.html

(15)R Schwartz MD The Ketogenic Diet STURGE WEBER Foundation UK
http://www.sturgeweber.org.uk/ketogenicdiet.htm

(16) Jong M. Rho, MD The Ketogenic Diet In Pediatric Epilepsy Ketogenic Diet Overciew
http://www.charliefoundation.org/noframes/diet/overview.php

(17) The Ketogenic Diet
http://www.epipro.com/k_diet.html

(18) Landover, MD Ketogenic diet The Epilepsy Foundation
http://www.epilepsyfoundation.org/answerplace/Medical/treatment/diet/index.cfm

Sunday, April 30, 2006

A man wants to be a Mommy!

There is a man who really wants to be a mommy. Here he is.

 


This is the man who wants to be a Mommy of a bunch of quails. Look how sincere he is!

 


Those are the eggs he got in to the incubator.

 


This are the Partridge’s egg. The man want to be their mommy too!

 


Working hard!

 


The quail egg.

Saturday, April 29, 2006

Working as a CCT in the US

As an immigrant from China, and now an allied health professional working in the United States as an Electrocardiogram (ECG) technician, I feel that I have a unique perspective on our wonderful profession. I have witnessed that a good majority of ECG technicians in the USA are trained by coworkers. I feel that this allows a great opportunity for those individuals who are passionate about our field to learn as they work, but for whatever reason cannot attend a formal educational program. On the job training program cannot only be beneficial for employees, but also be beneficial for employers, allowing for individuals to learn “on-the-job” and gives the employers the ability to “mold” new employees into successful members of their “team” and “culture”.

As a on the job trained employee, who again also happens to be an immigrant where English is my second language, I am thankful for all the opportunities which I have received. No matter how rich and diverse my background was when arriving in my new home, I had to start over again in many aspects of my life. For me, I appreciate the on the job training opportunities that have allowed me to stay in a career which started while living in China. The fact that I qualified to sit for a certificate level examination through CCI made it even better. People can get credentialed as a Certified Cardiographic Technician (CCT) through the examination process, and there are multiple pathways to qualify, including by way of on the job training.

While co-worker training taught me how to be efficient at “the basic work” of an ECG lab, work such as getting an ECG tracing, finishing the paper work, performing the stress test, and hooking up a Holter monitor / event monitors…there are other tasks and skills which I feel you must teach yourself. Included in some of these “self taught” traits are inter-personal skills. It is very important that you learn how to treat people around you, not only your co-workers, but the patient who you are employed to serve. In my opinion, patients are the ones who make our life meaningful. The saying is true world-wide, “treat people as you want to be treated”. Treat your patients as your family members. Be respectful, gentle, and professional. There is a common saying in China that translates into “Customers are the God.” I would suppose this saying would be closest to the American saying “the customer is always right”…but with slightly different context. The meaning of this saying as interpreted by a healthcare professional should be that we need to treat our patients as high dignitaries. We are here to serve them, to take care of them. We are here to serve them in the most professional and courteous manner we can. The same level of courtesy, appreciation and professionalism should be shown to your coworkers. We all work together as a team, and together we help each other to provide the best service to our patients.

Working in a hospital keeps us very busy and there are times when we hardly see certain members of our “team”. That makes communication more important. It is our job to create a nice working environment. We are here to take care of patients and as a team we are here to help each other so that the job is done well. Our primary goal is to do the best work we can do as an individual; but a close second is helping others perform to their best. Being positive with your coworkers will only help everyone do their best in serving patients.

The benefits from a positive and understanding work-place are countless. As an ECG technician, we are not required to read ECGs, but we do need to know what we are doing and what the ECG means. Knowledge levels which go above and beyond that of “minimum” or “fundamental” can only make us better at assisting patients in understanding procedures and help to make them more comfortable. Included in the quest for knowledge, I feel that ECG technicians can always use help in understanding how to make the tracing better. As a “new resident” in the USA, I utilized Dubin’s “Rapid Interpretation of ECGs” and found it a very excellent reference.

I have also found it helpful to listen to what the doctors or nurses say to the patients when we are doing stress tests. By being attentive I feel more comfortable in understanding more patient situations and the purpose of the tests we perform. I have been a CCT since the fall of 2002, and I love the knowledge I have gained to become a CCT and allied health professional.

I believe that getting credentialed by CCI was a positive move in my career as a healthcare professional. However, I am not ready to stop the progression of my learning. I am looking forward to working in and learning more about the opportunities in the Invasive Cardiovascular field.

I recently took and passed the Cardiovascular Science Examination through CCI. I found the computer based testing format to be wonderful. Studying for this exam was made easier by following the instructions and studying the books which were referenced with the examination content outline. I found that in addition to the knowledge I had gained through my schooling in China and my work experience here in Eugene, Oregon, that I did not require much studying time, half hour a day was enough for preparing the test. When I felt I was almost ready, CCI had a self assessment exam which I ordered and then tested my knowledge in the particular subject areas.

My job doesn’t require me to be certified to be an ECG technician. I did it for myself, as a professional achievement. I have received many personal rewards from becoming credentialed. Besides the growth of confidence in myself, I have also gained the desire to study more, learn more and “do” more. I believe that as I learn more, I can serve my patients better. I also believe that knowledge is something that will never be wasted. For my experience working in the USA as a CCT, knowledge of the technology basics is the only the beginning, by adding positive interpersonal communication with patients and coworkers you can become the best at whatever health care profession you work in.



This article was published on The Pulse at fall 2004

Tuesday, April 25, 2006

Ducklings have moved to the new house!

Last weekend my husband and I worked hard and finished the duck house. And put it by the side of the fish pound. We put a lock on it so that we can lock them during the night to prevent Rocco’s attack. Now, the grown up ducks can happily moving to their new house!

The floor of the duck house are laminate which is same as ours living room. And the material of the house came from a gift from work, so we only spend $10 for the hardware. But it sure cost us two weekend work to get it done. I think we treat the ducks nice enough.

The only worrying is the floor is too slippery for the ducks, but we put woodchips on it, they will get use to it. Living in a beautiful house like that, they need to pay some time to get used to it. Hahahaha!!

 


This is the new house.

 


The close look of the floor.

 


The lock.

 


The guard.

 


First time get out of the house. They were scared.

 


Wha!! That feels good!

 


Finnaly, they are happy again.

 


Here is the whole picture of the duck house.

Saturday, April 15, 2006

Letter to Star

April 15, 2006, 2:38 PM

Dear Star,

I am so happy getting your letter. Here everything is just fine. Ben, Sean and I are in school and Bob is working. And we all are in good health. Thanks for caring!

I love your dreaming about future. I can understand why you want to have pets. They are cute and lovely. I can understand why your Mom does not like pets now. They are messy and require lot of energy to taking care of. I did not have any when I were in China. I did not like them either at that time. But now I have lots of pets without choice. (I have a husband who love pets.) But with the time goes by, I start fall in love with them. We now have two dogs, two cats, two ducks and lots of fish. We also have lots of birds around the house. We feet them. There is a hummingbird which fall in love with my Chinese flag! He flies to outside of my kitchen’s window everyday and look on the Chinese flag I put there. I think he must be a Chinese hummingbird.

I am sending a picture of a hummingbird to you. I hope you like it.

 


 


 



I love your idea of becoming a reporter. That is a great profession! And I will welcome you to come to the US as a reporter! What kind of reporter do you want to be?

I am sure your dream will come true. You will have chance to visit Hong Kong, Australia and lots more of other places. You can dress what ever you want to. It is a free country in the US. So study hard and make your dream come true.

I fully support you!
Thanks for the greetings from your Dad and Mom. I am looking forward to get your letter again.

Love Dreamer

As a translator by friend's request

Beautiful Life

Thanks God, he let us living and studying in his creation.

Love

When I first met Yvonne in Haikou Jingshan School in China in 1996, we did not have much contact with work. Since we lived in the same compound, we got chance to know each other.

She was the one always dressed clean and neat. Even the wild wind from the south China Sea could not mess up her hair. It made me jealous because my hair had been messed up so badly. The sunlight in Hainan is so hot and bright; she was always interested in everything and looked happier. It transmitted to me some energy to work harder. She put the straw mat which we used to put on bed on her wall and decorated them special and beautiful. It made me want to hang one on my wall!

Sometimes during lunch or dinner, she would hold a plate went to the dinning hall, looking on the strange and unfamiliar food, she shrugged and went back her home with the empty plate. I did not know what she used to fill her stomach instead, but when she went out of her home again, she was still the energetic Yvonne!

I have relatives in America. When they came back to China to visit, there was a big inconvenience for them which was the squatting down toilet. I was guessing she probably had this problem too. And used to worry about her. One time on the school party, she read her dairy to everyone which included the experience she had with the typical Chinese toilet. Her sense of humor made everyone laugh and also got our respect: What made her so much in love with life?

I remember Yvonne once found a lost baby duckling. She took her home and fed her. Since then, the baby duckling was like Yvonne’s child, following her everywhere and everyday! Every morning, it was the duckling’s “good morning” waking her up and in the evening, the duckling would sleep close to her bed. One day, the duckling disappeared, we all were sad, but Yvonne said that the duckling had found her home.

Yvonne liked shopping and made friends with a lady who sold fruit. Even after she came back to America, she still asked friend to say “hello” to the fruit lady. Yvonne also liked to ride bicycles with friends in the countryside; all her friends still remember the wonderful time they spent together. They all have the same impression: Yvonne has the passion of love for life!

Yes, Love. She loves everything around her, she loves everyone around her. Love the world! Love the life! Only there is love in one’s heart, one could be able to love life like Yvonne!

There always is a beautiful picture in my mind: Clean, neat and beautiful Yvonne was walking on the dusty road followed by a yellow baby duckling. The sun was bright, the wind was gentle, and on the side of the road, the blossom of the lotus flower was fresh and charming.



Faith


In July 2000, it was my first time went to Yvoone’s house in Olympia and met her husband Norval. That was my first time came to the US to study. After contacted with her, they came to pick me up for a weekend.

We sat on the balcony, drinking and talking.

Norval asked me: “Have you ever thought about sitting here in my house and drink tea with us?” I really haven’t. I remember when Yvonne left China, in the airport, she wrote her home address and telephone number on a piece of paper and handed it to me: “Please come to my house. You are always welcomed there.” I was touched, but in my mind, I know I would have no chance to use it. I would not have any chance to go to America. So I lost the piece paper.
I answered honestly: “No. I have not thought about it.”

Noval told me: “You need to have faith for life. Many times we don’t know what will happen in the future. But we should never give up on faith.”

Faith! How nice he was teaching me!

In his little farm, there were lots of pears on the tree. And some of them had fallen on the ground. He said, this year the pears were not as good as last year, but I believe it will be better next year.

One day he told me, he has planed his fruit tree for three years and that was the first time to get fruit. There were only 5 fruits on the tree but he believed next year it will be better.
…………..
Faith! If you have faith in your heart, life will be better!

There is always another picture in front of me: Sitting on the balcony, with a glass in hand, Norval is smiling. And on the side of the balcony, there is a big strong pine tree standing there. Near the house there are the beautiful sunset glow , and at the end of the forest , there was the clear blue sky, far more, the shinning water in a lake were dancing and singing.

There is Love, there is happy life. There is faith, there is a better life.

By Dezhang Young Rose at Yvonne & Norval’s 50 years anniversary



Translated by Dreamer

Friday, April 14, 2006

Duckling are playing

So tired from working today, there is no intend to do anything else. Thought watching ducking to play in Pond would be a nice stress reducer. Here they are!

 



Where are their head?

 



Ah! They were playing hide and found. Look how dirty they made their faces are!

 



See, feeling uncomfortable, isn't it? You have to clean youself up. Sorry.

 



"What a nice life we have!"

 



"We are lucky having Buddha blessing us. Weng Ma Ni Ba Mi Hong!"

 



"Parents are building us a beautiful house. It is not ready yet. But we love it!"

 



"This is Dad teaching us what life in real world is and telling us how much he loves us. We are so lucky, aren't we?"

Saturday, April 08, 2006

This is the first time my ducklings get in the pond.

They are scared at the first, but few minutes later, they are happy there! Now everyday they are expecting the time to swim in the pond. But the mess they made really scared the fish I think.

 


 


 


 


 


 

Friday, April 07, 2006

Yvonne, a special friend of Chinese

Thursday, March 30, 2006

Yvonne, a special friend of Chinese

For Yvonne and Norval’s 50 years anniversary

Dreamer

I first met Yvonne in spring of 1996 in a boarding school in China.
At that time, Haikou Jingshan School was not like it is now. It was only a group of villas in the Bai Shui Tang area. At that time the School only had about 40 staff members, and Yvonne was one of the founders..

I was the only doctor there building the school clinic. Yvonne was the first American I actually got to know. In 1996, Haikou was not an open city, and foreigners were really rare. Her special beauty, warm heart, sincere friendship and understanding mind really brought a new culture and fresh air to the school and she became a friend of many teachers there.

I personally became her friend from the day I was asked to help the communication between her and the school’s chef since I spoke a little English. My English was very poor, but I could use my dictionary to simply communicate with her. After the first talk, I asked Yvonne to help me to practice and teach me English.

In China, when people build a school, the school needs to be running at the same time. At the beginning of the spring in 1996, there were already 200 students in the school (from kindergarten to high school), and the daily teaching and living was already started. As the school doctor, I was responsible for all the students and staff’s health 24 hours a day, 7 days a week. I lived next to my office so that people could find me whenever they needed me.

When Yvonne and I started the English teaching and learning, it was already Autumn of 1996. The student house and the clinic were moved to the new building in the other end of the Bai Shui Tang, but Yvonne, teachers and the kitchen were still in the villa area which was 20 minutes away from the actual school campus. Because the villas were temporarily borrowed from a company, the owner felt there was no need to make the road nicer and even put some lights on the side of the road. So the 20 minutes walking was a challenge for most of the teachers, especially when it was dark.

The only free time I had was in the evening between 8:00 to 9:00 when students were in the classroom. So I could go to Yvonne’s house to learn English from her. We did this for a month, quite frequently, we were interrupted by the phone calls from the campus requiring me to come back to my office. Yvonne decided to come to my office to continue our teaching and learning, I felt bad that she had to walk through the difficult road in the dark to teach me! Because of her kindness, my English was getting better and better, and soon we overcame the difficulties of communication and also became close friends.

Every day after school when students were playing, there was a special picture of Haikou Jingshan school: An elegant beautiful American lady with gloves and cleaning basket in hands was picking up garbage on the road from villa area to campus. That was Yvonne. She was trying her best to make the environment better. At that time, school construction was still going, that road was out of campus, and the school did not pay any attention to clean it. Garbage was all over the road. Yvonne’s action embarrassed every Chinese who was working there. A couple of weeks later, the school started to organize students to do a weekly cleaning of the road. And Yvonne won a great respect from our Chinese people.

Yvonne taught elementary to high school during her first year working in Haikou Jingshan School. Many students’ English names came from her; this included my son. At that time, my son was in fifth grade. Yvonne taught one class a week, just for the one class and my son got his English name: Ben. Now, he is 20 and attending college in the United States, he is still using this name.

Yvonne brought new culture and new vision to Haikou Jingshan School. There were always lots of students and teachers around her. Many of them do not speak English, but still love to be with her because her sense of humor, her friendship, her understanding and her kindness. Sufang Liang, Dianne Feng were her buddies in teaching. The school chief, Cheng Li, Aiping Zhang, Liming Yang, Honghai Li, Yang Young and I were her friends. Many of us do not understand English and Yvonne does not speak Chinese. This friendship built from body language, facial expression and caring for each other, it is special, precious and lasting. It gave us so much pleasure in the stressful life in Hainan. This friendship kept Yvonne in China for years. She still cannot stop herself from going back to “home” to visit.

Yvonne’s experience in China not only brought her so many ordinary Chinese friends, but also won great deal of respect from the leaders of the school. Mr. Wu Wei Xong, the former chairman of the board of the school and the mayor of Haikou now is one of her good friend, and his only daughter is one of Yvonne’s Chinese daughters.

June first is Children’s day. Children all over the China celebrate the day every year. On the first of June in 1996 at Haikou Jingshan School there was a big celebration. Yvonne, as a special English teacher, of curse had to be pushed? to the front for school’s benefits by the principal. A Haikou Jingshan School’s edition of the sound of music was performed by Yvonne, Andy (the other American English teacher) and 5 students in Haikou theatre. When we were watching the performance, we could not believe the singer, dancer on the stage was Yvonne. She was so professional, so unforgettable! She was not Yvonne, she was Maria! That performance won a good name for the school and Yvonne herself got more respects from Chinese: for her capabilities, for her hard work and her love of Haikou Jingshan! I used to keep a copy of the performance of the celebration but when I moved to the US, I let a friend borrowed it. I can not find it anymore.

Yvonne’s friendship is so precious to us. Living in Haikou, for some reasons, life was stressful. Sometimes people got depressed by certain situations. Yvonne always could use her special view to help friends overcome the difficulties. I was one of them who used to get her help. Her home was the most happy place friends liked to be. We felt safe, warm and happy there. When we watch TV, there was popcorn, when we were there, there was dinner and beer waiting. Sometimes during holidays, we played music, singing and dancing there till midnight. Those unforgettable memories are so charming and romantic. I miss that…

I often think, as an American who has a happy warm family, a nice and convenient life in the US, how come Yvonne was so much in love with China? So much in love with Haikou Jingshan School? Probably, because of her beautiful mind, loving heart as a Christian, she loves to help people. Probably, it is this love that has made her gone back to serve Haikou Jingshan so many years and come back to China for many times. As one member of Haikou Jingshan School, I want to say: “Thank you, Yvonne!”

Saturday, March 11, 2006

People need to be encouraged

Thursday, March 09, 2006

People need to be encouraged, so do I.

I am surprised how much joy I had when my instructor told me that I will be an exceptional nurse and all the instructors were impressed what I have done as a student. My heart was signing, my mind was dancing. I had to tell myself that was just a comparison with other students who didn’t know anything about medicine before so that I would not be so happy and forgot who am I.

Indeed, as a former medical doctor who was doing well in nursing school had nothing to be proud of: I already learned lots of things long time ago; and already practiced medicine before. Learning to become a nurse is not completely new for me. I should do well here. There is no excuse for me to not being a good student. So all the instructors should not give me the best commands. But I appreciate it though.

Even though, I am well educated in healthcare system, I am very well aware that I should not consider myself as a very beginner in nursing school, but I am still happy with what I got from instructors, nurses, coworkers and classmates. I am still happy with the nice commands I got from them. I still appreciate all the encouragement they gave to me. I think that is what I should give back to them in return: everyone needs encouragements.

I remembered that I wrote a little article about organization. I did that when I was up set with an instructor’s way manage the team’s time and affected all the team’s performance.
I didn’t let anyone read it except my husband. I did put it on my Chinese blog even it was an English article. That is the point: I had to express my anger without hurt any one. I knew there would be no one in school and work that would be interested in Chinese blog since they don’t know Chinese at all. But now, when I am experience my feelings of being encouraged, I still feel not good for doing so. I should change my word to encouragment from complaining.

It is true that no one is perfect, but only we ca learn is to be better. Treat people like what you like to be treated. Do what you want other people to do. Try your best to help others. That is what I will try to do. I put it here just as a reminder for myself.

Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong! Weng Ma Ni Ba Mi Hong!

Buddha blesses everyone. Buddha helps me to become a better person!

Thanks.

Tuesday, February 21, 2006

Essay for scholarship

Additional essay for scholarship:

(1) Describe your academic, career, and life goals. How will your academic program at Lane help you meet your goals?

My academic and career goal in America is to continue getting good grades in school and to become a nurse manager or a nursing instructor in the future; Using my cultural and language background to serve the nursing profession in the US.

I was born in China, and lived there for 38 years. I worked as a pediatrician there for 18 years. I understand Chinese culture and healthcare system well. I have been here in the US for 6 years now. I want to learn more about the American healthcare system and more about American culture. I am also fluent in both English and Chinese and willing to use my language skills to serve patients.

My personal goal is to start an English Language Nursing School in China to help the global shortage of the nursing professionals.

Studying in LCC nursing program definitely helps me to meet my goals. The LCC nursing program will help me to get my RN license. After graduating from LCC, I will continue working on my bachelor’s and master’s degrees so that I can teach in a nursing educational program. Also, I will strengthen my leadership skills in order to become a nurse manager in the clinical setting.

(2) How have you demonstrated leadership? (e.g., family, community, church, class projects, paid or volunteer employment).

When I was in Medical School in China, I was a leader of my class that contained 45 students. I was in charge of all the class activities for instance art performance, sports, and academic posters. It was a challenge to find enough time, but I enjoyed it. So I served as a president of the class for 3 years.

When I worked in Nanyang city’s hospital, I was a research leader in the pediatrics department. During the 15 years I worked there, I designed 11 research projects. I was a manager of a boarding school clinic during 1996-1999. I actually established the clinic and ran it for 3 years. I always got a bonus since there were no disease outbreaks, a low injury rate, and low cost and satisfied students.

I still like to do research. I have done some research of Ketogenic Diet in the treatment of pediatric epilepsy and wrote a report in both Chinese and English. I also organized a little group of Chinese to help each other. We meet few times a year to exchange information and help the people who need it. I will keep doing that for the rest of my life.

(3) What significant life challenges have you faced, and how did you handle them?
As a new immigrant, the most significant challenge in my life was trying to find a job in a country where the language is completely different from my native one. That is why I am still trying my best to help other new immigrants to find a job here in the US.

When I first came to the US, I spoke very little English. I even didn’t know how to shop in a grocery store, how to order food in restaurant, and how to use public transportation. I needed to find a job to feed myself.

To find a job, the first thing is to have a nice resume. With the help of my dictionary and the sample resume in the computer program, I composed one. Second, I needed to find the job opening in the paper. It took me a whole day to read the few pages of the paper and find some jobs I thought I could apply for. Because of the language barrier, I had to go to place by place to apply in person that was easier for me to communicate with them.

As an experienced medical doctor, I thought I could do lots of things in medical field. But after I failed many times on the job-hunting, I realized that without good English language skill and proper credentials in the US, there is almost no job that I could get.

Then I decided to go to college to study English and at the same time worked as a volunteer in the American Red Cross, while still trying to find a paid job for living. As my language improved, I found my first job as a support staff in a community service helping people with disabilities. It was completely different from the job I was doing in China, but it sure helped me to stand on my feet. I appreciate the opportunity and did my best on the job.

With the improving of my English skills, I have tried to go back to medical field. I worked as a phlebotomist, a medical assistant, and an ECG technician. And now I am in nursing school. I believe that if I work and study hard, in a dynamic country like the United States, I will have much more opportunities in the medical field and provide my best services to patients in the society.

Saturday, February 04, 2006

Saturday, January 21, 2006

Swimming in the winter.

I got couple pictures from a friend in China who swimming in the cold winter water every year. I really admire him. Here are the pictures taken couple days ago when he was swimming in the Winters river in China.



Thursday, January 19, 2006

Should I be Happy?

Should I be Happy?
Wednesday, January 18, 2006
It is a shame when people want to do something good for the human world; there always is someone there to destroy the hopefulness. I guess it is nature as a human being who wants to live better, wants to get promotion, and wants to be Important. And for this very purpose, to find any possible way to get what they want should not be criticized. That is why for being selfish in this point is becoming another part of human’s nature.
I wonder when people will eliminate the weakness of human nature. That way the world would be so much cleaner and happier.
At this moment, I am not happy. One and half years ago, I wrote a summarized article about The Ketogenic Diet Treatment in Pediatric Epilepsy in Chinese. The purpose of the article was to introduce the treatment to my colleagues in China.
I am a new Immigrant and work in the hospital In Eugene Oregon. The treatment caught my attention because one day at work during break, I was browsing around on the Intranet trying to learn more about American medical system. I was reading the pediatric policies and noted there is a protocol for Ketogenic diet. Working as a pediatrician In China for 18 years, I was believed not the ones who were behind the time of the knowledge. But I have never heard about such treatment. It got my curiosity. I decided to learn more about it.
Internet is my best resources of learning. I got online and read more about it. I liked it. It is a great altered way to treat epilepsy. I thought I was behind the time for this treatment because I left clinical site 3 years before I came to the US and now I am living in the US for 6 years and far away from pediatric practice. So I searched Chinese articles about the treatment and also talked to friend there about the treatment. Surprisingly, I only found few articles about the treatment in Chinese which came from Singapore, Taiwan and Hong Kong. The articles mainly reported information about the treatment in North America, Australia and England. No research done in China. And my MD friends in China know nothing about the treatment.
I decided to do some research and write a summarize of the treatment and send to Chinese medical journal to introduce the altered pediatric epilepsy treatment to my colleagues in China.
Writing a summarize article with all the references in English is not easy for a person like me using English as Second language. I spend over three months, read about 30 articles, research papers and a book of the treatment. Finally, I wrote an over 9000 words summarize both in Chinese and English. I sent the Chinese version to a medical journal in China and they said it is too long to use at the time. And I tend to forget about it since I was busy for work and school.
Last night, I was visiting a Chinese website and happily talking to the people there. I suddenly wanted to put my article there for people whoever was interested to read it. I only put an aberration there and thinking that I should check to see if anyone staled my work in China. So I check it online and unfortunately, I found a web posting just like what I wrote. The only different is the article was shorted and the author is someone I don’t know. My article really got stolen! That is a hospital website.
I was angry, up set and also confused. I don’t know what to do. I trust them too much to send them my article by printing, emailing, attachment and discs. I gave them anyway they wanted to. And than, there is an e-mail, telling me that they don’t have enough space for my article and then, there is one hospital practicing the treatment and there is someone published it online with their name…
At least there is some hospital trying this treatment, there is someone published the treatment online. I guess, the original point of writing this article is done. I probably should be happy with it. Should I?

Wednesday, January 18, 2006

Welcome to my blog!!

Hello!

This is my first English blog. I will put all my thoughts and dreams here. I will share everything here to friends and ...