Friday, November 17, 2006

Prophylaxis of coronary artery disease

Week 8

Patient’s need for education

This week, I am lucky enough to get a chance to go to the Cath lab to observe the procedure. I am so amazed by the procedure, amazed how quickly a narrowing coronary artery can be fixed during the procedure. I really appreciate the opportunity I got.

One patient went to see his doctor for other reasons other than coronary artery disease. Just before he left the doctor’s office, he asked: “What is about the chest pain I am having now?” made him to be referred to a cardiologist. After few noninvasive diagnostic tests, he was diagnosed as coronary artery disease and scheduled for coronary angiogram and possible intervention. Under X-ray during agiogram, we saw a significant narrowing of his mid LAD, and the cardiologist decided to put a stent in it to treat the lesion. The procedure was successful and the patient can go home the same day.

There are still 3 places of his coronary artery a narrowed but insignificant and there is no need to put a stent in. It can be managed with medication. But the patient really needs to be taught to manage his blood cholesterol and change lifestyle which can reduce the factor of myocardial infarct. He also needs to be on Aspirin for at least a year to Prophylaxis of transient ischemic attacks and MI.

I would basically use the hand out the cath lab have abut the procedure and the hand out in PCU about CAD to do my patient teaching. I would also give him the information about internet and community services for him to get information in the future. The important thing need to be stressed is the cholesterol management and the life style changing. It can enhance pt’s well being and protect future damage of the coronary arteries. Stent fixed the existing problem, the potential problem need the pt. To be motivated to act and prevent.

5 stressors in my life

Weekly Journal Assignment

Week 7

5 stressors in my life and the intervention that would enhance my ability to cope with these stressors

1) School ---
As a nursing school, middle aged and English as second language student, school is a stressor of my life now. Sometimes I felt like I am reaching the point I want to quit or never going to school again. Yes, the intensive training of nursing can really stress students well. But I think to be able to see the future is a positive reinforcement of the students’ life. And also, it is the student’s decision to go to school. We have to remember it and respect it. For me, I just see the intensive training period is temporary, it is time limit. Once you graduate, life will be different. So laundry can wait, house doesn’t need to be super clean and food can be simple. It is all temporary, it will be over soon. For study, I put my mind on reading, trying to understand all the objects. Of curse, my back ground knowledge helps me too. So even with the second language, I cannot complain much.I think a positive attitude; an active learning plan can enhance my ability to cope with the stress.

2) Work ---
Work is wonderful! It gives us opportunity to be socialized, it gives us a source to live, and it gives us a reason to live too. But when you are stressed for school, plus there is not every day’s work is wonderful and peaceful, work can be stressful. When there is a work scheduled, I think it is a better idea to make the entire study and work plan together in detail so that when there is a work day, concentrate on work and forget about school. When there is the time to study, do not let anything else to interrupt you. So straight schedule and study plan is helping me to cope with this. And if you feel like it is too much to deal with, cut off some work hours. Take some student loans, live a simpler life. These all can help.

3) Children ---
Children occupy my mind all the time, even sometimes I cannot do anything. It really bothers me when they are not listening; they are not doing what they suppose to do. I used to be bothered a lot, but my brother’s talking put my on ease. He said: “everyone has their own orbit. Children have their own fates; you don’t have to be a slave of your children.” Since then, I am just talking to them and let them know what I am thinking and what I want them to do. If they listen or not, it is their choice. They are old enough to make decisions not matter good or bad; sometimes they have to learn the hard way.

4) Parents ---
As middle aged person, parents are getting old and need us to care of. One phone call from my parents can make me worry all day long. And when I am worried I cannot concentrate on my study. This can be stressful. My way to cope this stress is to ask my friends and brother close to my parents to call them and help them. And then write a dairy to talk to myself that they are already being taken cared of by my friends and nothing I can do here, so just do not worry. Writing to myself if another way I cope with stress and it works well for me so far.

5) Grades ---
I am a perfectionist. I always want to be the best of my life. This really is a big stressor for me. It pushes me keep going and sounds like there is no stopping. As a student now, I always want to get good grades; I mean “A”s. But with the 15 credits courses I am taking, it is hard to get all “A”s. It bothered me when I got my first “B”, I felt so sorry that I was so close to an “A”. So grades are a stressor for me and I am trying to let myself notice that “B” is a respectful grade too. I think I need to compare with people “C”s and be happy. Do not put on oneself too high expectation is a way to cope this stressor I think. I am doing better with it now. I think it enhanced my ability to cope with the unexpected grades.

Friday, November 03, 2006

Different way to study

Week 6

The care I provided to my patients this week is ordinary works: give IV, SQ and oral medications, assessments, educations etc. There is not something really can make me think that any interventions could be different. But I do have some thought about the way we study since our instructor mentioned about the two exams this term.
The formal way to study would be follow the objectives, do the required readings, attend classes and labs, attend clinical experiences. In fact, with the short amount time and the intensive training, the required reading sometimes can be difficult to be done. So there are module groups, people getting together and divided all the objectives and type them done and share with others. I think that is a great idea to do so and I totally support it!
But sometimes only studying the modules done by other students could narrow our sight of the course. It could be confusing sometimes because you are not the one actually did the module. And with the time limit, we cannot write done all the modules by ourselves.
There are alternated ways to study. One is useful for me. I do not write done any answers of the objectives, but I read the book against them. The difference is I read more then the objective asked for so that I can have a better understanding of the topics. I think I did even more than the required readings. And I don’t try to memorize everything, but really try to understand them. I guess my point here is trying to learn the topics lively.
I am a slow reader, especially English is my second language; I have to use my dictionary a lot when I am reading. But just read through against the module’s objectives but write done them spend less time. I write done some simple notes on my module and sometimes just the page of the book just incase I need to go back to read. I am not an “A” student, but I am getting fair grades. It works for me. I am sure there are other alternatives to learn too, one just needs to find a one to work for them.
For me, the goal of learning is to put the knowledge to practice. So when we think about this, we could feel a little ease when we are leaning. Not just for examination, not just for a good grades.

Sunday, October 29, 2006

The clinical path and the disease process

Week 5
The clinical path and the disease process

This week, we only have one day clinical. It is nice that our instructor let us to come to the clinical site without prep. It reduced our paper work but challenged our time management skill and the ability to face the real patient care situation. We also discussed the clinical path and the disease process which made us realized the difference with theory and facts.

In theory, diseases have certain path to go, either better or worse, it is kink of black and white compared with the reality life with disease process. That is where the clinical path came from. It is other people’s experiences, other practitioner’s conclusion. Patients who have the same disease and treatment would most likely to go that way. But there always are some exceptions.

We discussed my patient this week which is a relatively young guy who went through a coronary bypass surgery. He was in post op day two, and already ambulating. His chest tubing drainage was only 40ml at my shift, which met the protocol to disconnect. He is pretty much following the clinical path. But on the other patient my classmate care of was a different story. He is much older in his 80s. I think he was post op of CABG week two and still there with lots of complications. As the ordinary clinical path, open heart patients should be discharged in a week. But this one was staying for another week at least. That is an example of exception.

Medicine is called “practice” because there are not always black and white answers. Same disease, same procedure with different patient can have different outcomes. It based on the individual’s health status, life style, and genetic variation and … as a student, it is very important for us to know there are differences, so we can be really careful with assessments, treatments and assistance. I appreciate our instructor leaded us for the discussion. Thanks.

Thursday, October 19, 2006

Patient’s fall

Thursday, October 19, 2006

Weekly journal assignment

Week 4

Patient’s fall

This week, my assigned patient went to home when I arrived at the clinical day. The RN assigned me another one which is in the same bed. Without preparation, I started to take care of the patient. It went well. It also gives me some confidence for clinical patient care as real (without prep). This patient’s diagnose is not really clear yet. I have some thought about it.

The admission reason was “post fall”. Patient felled when he was walking his dog. He has an ICD in place, ER admitted him to PCU for evaluation of the ICD, and to find the reason of this fall.

Patient has history of CAD, A-fib, multiple stroke, hypertension, hyperlipidemia, diabetes and so on.

The reason for fall is “syncope” as the doctor’s H&P stated. But patient does not remember the event, did not feel dizziness and so force. There is no newly developed weakness, language difficulties and thought process disorders after the fall. Based on this, they basically ruled out stroke, and focused on “syncope”.

The cause for syncope has multiple reasons: it could be sudden onset arrhythmia, acute hypotension, hypertension crisis, hypoglycemia; they all can lead to temporary cerebral dysfunction and result to syncope and fall.

With a history of a-Fib and CAD, it is almost guaranteed that life threatening arrhythmia could happen. But with an ICD in place, the possibility became too little to be worried of, unless the ICD does not function well. Then, check the ICD is necessary.

The result is the ICD functioning perfectly. So this can rule out of cardiac syncope. And the blood sugar showed on the high side in ER.

But patient felled. And don’t remember the event. That is the key I think. I would like to order an EEG to see if there were any epilepsy event (with multiple stroke, there is very possible to have secondary epilepsy); I also would like to at least have a brain CT to see if there were any new changes if I were his doctor. Some mini stroke could make patient “pass out” without leaving marked signs and symptoms.

I am wondering why the doctor did not order these tests yet. Well, patient is in the hospital only one day, probably the doctor is going to order those tests later. This just are some my thoughts. I sure appreciate the opportunity I got to learn and think.

Thanks for being so patient to read my thought.

Saturday, September 16, 2006

The troublesome of the “kick back” money

9/16/2006 3:57:04 PM























The e-mail from a friend Zhourong yesterday terrified me. It is about the hospital I used to work in, my friends, the people I knew for a long time, it is about my friend Xiaorui. For money, the "kick back" money, some of them are in jail now. I am not sure if this is the good or bad thing. I surely feel sorry for the people I knew.

I understand that the financial situation in China is not that great, people everywhere in China are trying to get more money for their families, no matter it is legal or illegal. If one could find a way to make more money, one would not give it up. That is the true situation in China. That is the thought of many people in China. The main reason is they don’t pay people enough.

As human beings, we do need money. It helps us to live better, to help our children to get better education, to help us to take better care of our parents. But people who love money get it the correct way as the old Chinese saying said so. The question is 'what is the correct way"?

As a socialism country, China started to make every job equally paid since 1949. The simple physical labors and the complicated knowledge labors get equally paid because the amount of time they works regardless of their education leveland their contribution for the society. The idea is fine, but once higher education is not free anymore, it has to be changed. People pay more money to get higher education; they sure want to get better paid once they start to work. In recent 20 years, people do get more paid by their knowledge, but probably not enough or at least people think it is not enough for their education and contribution. That is how the money like "kick back" money developed.

This kind of “kick back money” becomes a rich soil of Fu Bai(deprave). Only one who has the power can get this kind of money. So some people get rich and others are still the same as before. Look on this way; the "kick back money" need to be aborted. But does the person who gets it really need to be destroyed?

Again, things exist have its reasons. It is not the people’s fault; it is the society, the cultural atmospheres. It is time for the society to carefully exam the system.

One of my friends who work in a private hospital now once told me that in the past, he got the same amount of money as he gets now, but he felt unease. Now he is getting the same amount paid but feels very peaceful and happy! The private hospital pays him well but the public one he used to work. So the real solution for end up all the "kick back money" is to pay people well enough so that people would not take the risks to get it. It would be not worth for people to get it.

Unfortionally, people are getting in jail for the "kick back money" now.

As an experienced cardiologist, Xiao Rui was doing great in the medical field. She is the one opened the cath lab in the city's hospital, started the invasive cardiology there. She became a chief cardiologist and the medical director of the cardiac unit. She is the one trying very hard to get the job done and make sure her knowledge to be on top of the field. Yes, it is true that she is very Shi Gu (She is rather a smooth character), very Shi Li (snobbish) sometimes, but she is very smart as well. There is a Chinese proverb saying that the smart people get in trouble with their smartness. That is why she finally gets in to trouble.

When she was just a young girl in medical school, she was not acting like other young girls. She was so mature than others. That was why even few of boys in the program fall in love with her but no one got any chance to express their feelings to her. They all knew that they would be refused. She is not the one who takes her future to any uncertainties. But she was very smart that she studied hard in school and worked hard in clinical experiences in hospital. When she was doing the clinical rotations, there was a teacher of the medical school asked her to meet his son who was an army officer, she refused. Her father was an army officer when she grown up, she knew how difficult being an army officer's wife. Her mother was the one who had to take care all of them. And the army officer later on becoming my other classmate's husband.

After graduation, me, Xiao Rui and my other friend were arranged to work in the city's hospital, the best arrangement of all ours classmates. People were surprised that she got in the hospital, but that is her, quite but wisely dealing with every difficulties.

Practicing internal medicine, she was a good physician. Later on, she was sent to study cardiology. Her path in the medical field was smooth; one part was because her hard work, and the other part was her wisdom of being in a society like China. She finally got married with a guy who is one year younger than her whose father was a mayor of the city. That made her life even better. Having a life like her should be happy and peaceful if the “kick back” money was not attracted to her.

She is a knowledgeable hard worker, responsible cardiologist; she should not be the one in prison. There are lots of people who Shou Hui (take bribes) muck more than her, but for some reason they are still enjoying life outside of the jail. That is the sad part of the event. I feel sorry for her and others like her. But I am not saying what she got is not her self’s responsibilities, she is responsible for what she has done. Staying in jail for a while will give her a chance to think through what life really mean. It is good for her I think. But others who were doing worse should be in prison too.

A friend told me to help her to get a better lawyer. It is possible that a good lawyer could make her sentences lighter. But there is nothing I can do in America. I am sure my friends in China may think about it too, plus her social influence in town, I am sure people would help her. But she needs to think through her troublesome and live a simpler life in the future.

We cannot let any injustice go just because there were much more badly crimes even our loved ones were in trouble. I am thinking this way in English. I wish someday I could think this way in Chinese too.

Thursday, August 24, 2006

Some pictures of my trip in China

This one is the picture of all the pediatricians!















Here is one from other high school which has been 28 years!















This one is from a high school classmates reunion. We have not seen each other for 29 years!!














This is the picture of some people from the picture of 25 years ago got together this time. They are all experts in medical field now. Can you recognize anyone of them?

Monday, August 21, 2006

The picture from 25 years ago


Here is the picture from 25 years ago while we were graduating from medical school. Time is flying. Now all of us are over 45 years old. They are experienced cardiologist, gynecologist, pediatrician, cardiac surgeon, orthopedic surgeon, internist, and so on. They are all very successful! Could you imagine that when you look on the picture?

Friday, August 11, 2006

My trip in China (3)

July 7, 2006, 11:17 PM

I don’t know why, I feel like I am not the person as before. My husband was correct that I do not fit in this society anymore.

I wrote a story named “He and Her”? That is a story about my best friend with a old classmate in high school. After 20 years later, he came to her and asked her to run away with him from her family.

I was with the “Her” yesterday, we talked about it. Surprisingly, “He” did not really talk about “love” to her, he just asked her to run away with him. That is ALL! Of course she refused him. Couple years later, for her son’s future, she called him and ask him if he can help to arrange a medical college for her son in his city. He refused right away.

Yes, he has the right to say so and to do whatever he wants. But in this culture, his action is not acceptable, it is ridiculous for people. So as me. But it gave me some idea about Chinese men at the present time. I feel sorry that I have got the idea like this, but I cannot help. I just wrote a short article about “Chinese men’s play mind” in Chinese and I am going to put it on my blog.

Chinese men have the mind that love to play with women. They want more women in their life but they all want their wife be good. My friend told me that every Chinese men except who could not meet one’s basic need wants to get more than one woman. I think she is right. It does not mean they will go get it but they would think about it. For lots of reasons, some would not get more than one, but they are sure wish to. I feel sorry for Chinese wives, but there is another talking from my friend: “Women have lots of chances to go beyond of the wall”.

That is true, there have to be some wild flowers for man who wants or already do to take. So women go beyond the wall should be common as the nature. It is really sad of the situation for everyone. I wish people in China could realize it soon.

Anyway, I am lucky having a American husband and live in America. I have got enough of the garbage in China.

My trip in China (2)

Wednesday, July 5, 2006

Last night, I met some classmates in elementary school and middle school. I met a girl who used to be my best friend in high school. She went to countryside for re-education. Since then, she become over talkative and always feels good. But without much inside, there is no good for her and the listener at all. I feel sorry for her but as long as she is happy talking and acting, I think that is all the matters. She is a business lady now.

The other two gentlemen were my middle school classmates and they both mature and happy, and I can tell they are happy inside. They helped me when I needed, I appreciate it and happy to see them.

There is one classmate from elementary school whose name is Lang Chao is one I have not seen since graduated from elementary school. It is over 30 years and I can hardly recognize him. But with few minutes, the young boy’s look came out. We talked and laughed. They are nice friends.

Life is short and making a living is not easy everywhere in the world. But as long as one feels happy of one self’s life, that is a wonderful life. So I think they are fine, but it is sure not my life style anymore.

My Dad took me to my brother’s house and my sister in law’s, they both have a place at their work. It is fine but the houses really need some work. I think once my parents started to remold the house there, it would look great!

My trip in China (1)

Wed, 5 Jul 2006 20:12:58

Almost couple of weeks past, I am here in my hometown where I have not been here for 8 years. Everyone here is very warm and friendly. I feel very welcomed to back to home. But the drinking culture and the food culture are shocking me. I am wondering if it is me becoming a stranger or I was a stranger with this before.

I love the food. I love the feeling of being with friends. But sometimes when they are using the drinking skills to fool me, I don't think I can deal with it. I feel like a fool for being an honest person, but I am me anyway. Who cares? I am happy.

I have learned that all the friends here are doing well. They became a powerful team with these years. And they are all looked young and beautiful. Most importantly, they sound happy.

The only thing which is confusing is that the government is trying to change the hospital running system in town. The three big main hospitals are involved and no one is happy. People are angry with the change and the government gave up on two and now it is the time to work on my hospital. There were about 200 people sitting in front of the city hall last week trying to force the government gave up this one too. So far I heard that they are going to delay the revolution.

The working environments are still the same as I left. The crowding, the smelling and the dirtiness 鈥?I feel sorry for my ex-colleagues for them having to work in such condition. I feel sorry for people have to live in such condition. And such condition all caused by the crowd population. The baby boom happened in 1960s. So much of complaining I am making. They are happy anyway.

Monday, May 08, 2006

The man's first 4 babies were born!!!

Look! The man's first babies were born today at 6:30 AM!!

 


 


 


 


 

Sunday, May 07, 2006

Typing practice

In my new two bedroom apartment, there was a big living room connected with a small dinning room, a kitchen, a bathroom and two balconies one is connected with main bedroom, the other one is connected with kitchen.

I live in the bedroom with a balcony. The other bedroom, I set up as a reading room which have all my books and a bed that I can lay on it when I am reading. I love to read. After work, I stayed in my reading room a lot. Also, when there is a company to come, reading room can be a guest bedroom.

There were simple maple wood furniture , a TV set and a VCR borrowed from my sister’s in the living room. The coffee table which had never been used for coffee but for everything else. It was a glass toped table. It was clean and clear. It was surprisingly different because undernease of the glass top, there was an artificial keyboard. It was a peace of white paper were drawn a computer keyboard. It was attached to the glass top so people could see the keyboard. On the glass top, on the letter “F” and “J”, there were two peace of clear tape so I could feel these two letters and practicing typing on it.

In Haikou city, I worked as a administration doctor in a private boarding school. I got paid well enough which almost were 4 times than I got in the mainland hospital. I also got a free apartment to live. But I didn’t feel my life there were stable. I always had the feeling that some day I will have to leave. So I didn’t spend too much money for furniture and only got few I needed for basic living. I didn’t have a computer. That was in 1998 in Haikou, China.

Working as school doctor was not terriblely busy.

The desire of learning to use a computer and the need for typing all the documents I had to write is the powerful motivation for me to learn and practice typing skill which was not common as my generation in China. It was not something I had to do when I worked there. Everything was in paper and in hand writing. People actually evaluate your hand writing, but your typing speed. There was a professional type writer in every organization or company. There was not the really needs for a doctor to learn to type. It was the self motivation, the eager to learn the new technology, the … that is how I practiced my typing skill and where I started to learn the use of the computer.

I did practice typing on the coffee table everyday. I borrowed a book from my sister which taught me how to use my fingers. I sat there and followed the instructions to practice for at least 20 minutes a day. At the beginning, it was hard. I had to look on which finger suppose to go where to make it right. And again, there was no screen for me to see if I did correct or not.

I did fine. After a few weeks practice, when I went to my sister’s house to use the real computer keyboard to type, I felt much better. I still needed to look on the keyboard, but much quicker though. I kept practice on the coffee table during the week where I had no computer to use at work. I practiced on the computer during the weekend when I stayed in my sister’s.

I will never forget the coffee table in Haikou Jingshan School. I will never forget my sister's where I actually learned how to use computer and the internet.

I think I was the first one in Jingshan school learned how to use the internet. That was because my sister, her house had the internet at that moment. She taught me how to use it and let me go to her house every weekend to practice and search for information. I am lucky having such a wonderful sister and the opportunity to get involved with this modern technology.

I remembered once my friend Yvonne and Deanna went to my apartment, they were surprised with my strange coffee table. They got the idea right away but still were so different with the world they came from. They are Americans.

Saturday, May 06, 2006

To The officer of the US embassy

To The officer of the US embassy

Monday, May 16, 2005

Dear Sir,

My name is Dreamer. I immigrated to the US in 1999. I am a permanent resident here in the US. I am writing a letter to you regarding my parents’ application for a visitor visa to the US.

At March 22. 2005, my parents went to the US embassy in their home country to apply a visitor visa to the United State to visit my new family and I. They want to make one trip to North America to visit both my sister in Canada and I in the United States. Unfortunately, they did not get the visa to the US, So that they cannot come here to visit.

I totally understand why you did not issue a visa to my parents. Here are the reasons why I understand the situation.

Each year, there are thousands and thousands of visitors come to the US from all over the world. Most of them went back to their home country after visit. But some of them over stayed, some of them even stayed here forever becoming permanent residents. Some of them even stayed and relayed on the society to provide food and shelters. Some of them were terrorism and made troubles for the nation. It is very reasonable and also a good idea to carefully exam all the applicants who want to come to the US to visit. It is good for everyone’s security and happiness that people live in the US.

I have heard lots of cases that people came to the US and illegally stayed. I also heard lots of cases that people came to the US to visit and stayed for some other reasons. I knew a person who came to the US for visit 8 years ago, but has never gone back to his home country. He changed his status as a student after he arrived in the US and stayed for few years as a student and now he has gotten his green card for permanent stay. I also heard another person who came to visit and over stayed for two years for learning English. She went back to her motherland after overstayed for two years, but she also lost her privilege to visit the US again.

It is very important to check everything out to make sure the applicant will go back to their home country after the limiting visit time. As the US embassy website stated: All the applicants must be able to demonstrate his or her intention to enter the United States for a temporary period, solely for the purpose of tourism and/or short-term business. The applicant must also provide evidence of financial ability to cover his or her travel expenses to and stay in the United States, and sufficiently strong social, economic, and other ties in the applicant's home country to compel the applicant's return after a temporary and lawful visit.

The points here are to make sure they will not illegally overstay, they will not add any burdens for the US society, they will not do anything harmful to the US society.

I really understand and support all the requirements for getting a visa to visit the US. I appreciate all you have done and are still doing for protecting out nation, our society, the citizens and the residents. I appreciate that you left your families, friends and homeland, stayed overseas to serve the nation and the people. I totally support what you have done as an officer in American Embassy.

But in my parents’ case, I think they are qualified for getting a visitor’s visa to the US by the policy. I sincerely ask you to reconsider their applications.

The first, they are in their 70s, and they are not terrorists. The documents they provided to you by their home country’s government showed they have never done anything illegal in their home country all of their life. They are good citizens there.

The second, they have sufficiently strong economic tie in their home country. They have provided the documentations to prove the good retirements they have in their home country. They also provided the evidence of the two houses they own there and a big amount of saving money they have in their home country’s bank.

The third, they have sufficiently strong social tie with their home country. They provided the evidences that they have another two children who still live in their home country with them, and the numerous friends and family members and relatives they have in their home country. Also they don’t speak any English. They do not have any interests to stay in the US.

The forth, they will not be any kind of burden for the US. They provided the sponsor form my husband and I filled to support them when they were here in the US. We will pay all the expenses while their stay in the US. We provided our tax return, our employment letters, our mortgage and saving accounts information to indicate that we are financially qualified to support them.

They also provided their visitor visa to Canada which is an evidence that their plan to visit their two daughters in North America are true visit, they are not intended to stay.

I wish you would agree with me that at least it is worth for you to reconsider my parents’ application for their visitor visa. It is also my wish for you to reconsider this case as an American tax payer. Here is my reason for wishing them to come to visit:

1) It is my parents’ wish. They want to come to visit when they are physically able to do so. It is their plan to visit my family in the US and my sister’s family in Canada in 2005.

2) They have never been to the US. I want to show them the different world, different life. I want to take them to the beautiful US national parks, nice US big cities, and introduce the ways people live in the US.

3) My husband and I were married 5 years ago. At that time, my parents did not come for ours wedding. I want them to come to our new family to see ours life here. I also want them to meet my mother in law and other relatives in the US, to meet my
stepson and stepdaughter.

4) My parents are in their 70s. Now they have good health. I want them to come to visit while they are in good shape. I don’t want to wait till they are too old to travel. When they are older, they are most likely to stay at home in their home country with my sister and brother, enjoy their life with old friends.

5) They are always worried about me because I am far away from them. I want them to come to see my life in the US so that they would not worry any more.

6) We love them. They have worked hard all their life to raise my sisters, my brother and I. They supported us gotten good educations. Now it is time for me to do something for them. I want them to come to visit the US and have a wonderful time here with my American family and I.

My husband and I, my son, stepson, stepdaughter and my mother in law, my sister in law, the whole family is all sincerely inviting my parents to come to visit. We (my husband and I) will pay all their expenses while they are in the US. The whole family is sincerely asking you to reconsider my parents’ application for a visitor visa.

Thanks.

Sincerely,

Dreamer

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