phys TII
seizure treatments might not work if:
-inappropriate treatment -inappropriate dose -poor compliance/lack of education - drug interactions (CYP450/p-gp) -seizure refractoriness
primary hyperlipidemia is caused by:
-inc sensitivity to dietary cholesterol -lack of defective LDL receptors -cellular defects -altered synthesis of apoproteins
protease inhibitors _____ insulin resistance/TC/TG and cause _______
-increase -lipodystrophy
METS complications
-T2D -heart/blood vessel disease -nonalcoholic fatty liver disease -kidney disease -accelerated cognitive aging -recurrent preeclampsia -cancer (breast, colon, gallbladder, kidney)
borderline high cholesterol
-TC 200-239 -LDL 130-139 -HDL 40-49
Normal lipid levels
-TC <200 -LDL <130 -HDL >/50 women; >/ 40 med
High cholesterol
-TC >/240 -LDL >/160 -HDL <40
meds that can cause seizures
-clozapine -bupropion -carbamazepine
stage 2 of atherosclerosis: cytokines and growth factors cause smooth muscle cells to proliferate. The smooth muscle cells then move into the subendothelial space where they produce _________ and take up LDLs, adding to the population of foam cells forming a _______________
-collagen -fatty streak
Decreasing HTN in the renin-ang-aldosterone system by:
-inhibiting angiotensinogen to ANGI by blocking renin -inhibiting ACE = ANGI to ANGII conversion -Blocking ANGII directly ---> dec vasoconstriction and Na/H2O retention
Diabetes can lead to :
-endothelial dysfunction -vascular resistance -HTN -vessel wall inflammation
BP =
CO X PVR
inc TNF, IL-6, CRP, fibrinogen, and AT2 causes
RAAS activation
• LDL is calculated • LDL = ___________ • Calculator does not work if TGs are > _____ mg/dL --> Underestimates LDL
TC-HDL-(TG/5) 400
type of fat found in the blood composed of glycerol and 3 fatty acid chains
Triglyceride
delivers triglycerides to cells in the body
VLDL
Organ that gets damaged when: -atherosclerosis causes impaired blood flow/inc oxygen demand -enlarged left ventricle d/t PVR -failure d/t weak muscle and loss of elasticity -leading to MI and heart failure
heart
Peripheral artery disease (PAD) occurs when:
plaque builds up in the walls of the arteries leading to dec/blocked blood flow to the kidneys, arms, stomach, and legs
failure of mechanisms responsible for seizure termination or from the initiation of mechanisms which lead to abnormally prolonged seizures. -seizure last >5 minutes (continuous) and duration of seizure beyond risk of long-term consequences (30 min)
status epilepticus
chylomicrons and VLDL are mostly made of
triglycerides
motor cortex
twitching/jerking in the arm, should face, legs
Atherosclerosis can cause:
-MI -ischemic stroke -heart failure -vascular insufficiency -aneurysm
these vasodilators cause a dec in peripheral resistance
-NO -prostacyclins -kinins -ANP
Neuronal regulation of the autonomic nervous system:
- Baroreceptors • Major negative-feedback mechanism to control sympathetic activity • Sense pressure changes in the arterial wall - Chemoreceptors - External stimuli
drugs that can induce HTN include
-NSAIDS -amphetamines - estrogen (OC) -glucocorticoids
calcium channel targets for treatment
-T type -> dec thalamocortical reverbs -L type -> dec cortical excitation -N type -> dec NT release
S/Sx of hyperglycemia can include:
-acanthosis nigricans -hirsutism -peripheral neuropathy -retinopathy
METS risk factors
- >/60 - hispanic females or non-hispanic white males - obese - genetics -meds that cause change BP, cholesterol, glucose or inc weight
Endothelial dysfunction occurs when...
- cells are subject to shear stress from blood flow and endogenous of exogenous substances (inc cholesterol/glucose, smoking, hypertension, and inflammatory mediators) -reduced vasodilators (NO) -oxidative stress (ROS)
Inc in visceral adiposity can cause:
- inc leptin/FFA -dec adiponectin -inc TNF, IL-6, CRP, fibrinogen, PA-1, and ATII
METS occurs when 3 or more of these factors are present:
- low HDL - fasting glucose >/100mg/dL -obese (waist >40in=M, >35in=F) -TG >/150 mg/dL -inc BP (SBP >/130, DBP>/85)
Normal BP is < ____/____ mmHg Elevated has an SBP of ____-____ and DBP of <____ mmHg
-120/80 -120-129 -80
Hypertension is broken down into 2 stages. stage 1: SBP is b/w ___-___ *OR* DBP is ___-___ mmHg stage 2: SBP >/___ *OR* DBP >/ ___ mmHg
-130-139 -80-89 ->/140 ->/90
I seizure free for __ to __ years and depending on the seizure type, a patient may consider stopping treatment. __ years for absence __ years for partial, tonic-clonic
-2 to 4 -2 -4
Orthostatic hypotension can occur when systolic drops >____mmHg or diastolic drops > ___mmHg within 1 minute of standing
-20 -10
Resistant hypertension is classified as the BP being above goal when the pt is on ___ meds or BP goal is achieved with >/ ___ meds
-3 -4
Humoral mechanisms that contribute to primary HTN include:
-ADH -estrogen -insulin resistance -renin-ANG-aldosterone system
increased peripheral resistance is caused by these vasoconstrictors
-ANGII -catecholamines -thromboxane -endothelin -vasopressin/ADH
Hyperlipidemia can lead to
-ASCVD -microvascular disease -pancreatitis (inc TG)
Oral contraceptives can cause and increase is _____, ___, ____ but when only taking estrogen OC they have been shown to decrease _____
-BG, TG, weight -LDL
Niacin is known to increase _______/_____ and decrease ____, ____
-BG/HDL -LDL, TG
The endothelium is a smooth delicate lining of blood vessels that has many functions including:
-Controls vascular function through relaxation and contraction • Transfers molecules via semi permeable membrane • Modulates flow and resistance • Regulates immune and inflammatory reactions
antihypertensives that decrease PVR
-Diuretics • α1-blockers • Central α2-agonist •Direct vasodilators • Direct renin inhibitors • Calcium channel blockers (DHP-CCB) • Angiotensin converting enzyme inhibitors (ACEI) • Angiotensin II receptor blockers (ARBs)
______ carries cholesterol to cells and deposits it in artery walls. _______ carries cholesterol from cells and plaques back to the liver
-LDL -HDL
seizure risk factors
-abnormal EEG -seizure occurs during sleep -positive family history (sibling) -prior acute seizure -down syndrome/cerebral palsy - no clear association of seizure type - no association with seizure length - no association with age of onset
Seizure treatment is appropriate:
-after 2 or more seizures -after 1 seizure if: - idiopathic and abnormal EEG - symptomatic and abnormal EEG - prior neurologic abnormality - positive family history
ASCVD findings:
-angina -numbness -temp vision loss -xanthomas -slurred speech -drooping face muscles -lipid panel
5 target organs that can get damaged with HTN
-arteries -heart -brain -eyes -kidneys
inc PA1 leads to
-atherosclerosis -HTN
seizure etiological considerations
-cerebrovascular abnormality -tumor -head trauma -infection -hypoxia -fever >104 -drug intoxication -alcohol withdrawal -stress
Antagonizing the beta-1 pre/post synaptic neurons _______ HR and contractility ---> decreasing ____
-decreases -CO
Vascular endothelial mechanisms for elevated BP:
-deficiency in synthesis of vasodilators (prostacyclin/bradykinin) & excess vasoconstrictors (ANGII & endothelin I)
Antihypertensives that decrease CO
-diuretics -beta blockers -central alpha2-agonists -nondihydropyridine (non-DHP) ca2+ channel blockers
Other names for METS
-dysmetabolic syndrome -hypertriglyceridemic waist -insulin resistance syndrome -obesity syndrome -syndrome X
Primary HTN risk factors
-family history -age (m>/55, F>/65) -african american -metabolic syndrome (diabetes/obesity) -salt intake >2.4g/day -low K/Ca in diet -alcohol >1 drink/day in women, >2 drink/day in men
what to rule out in childhood epilepsy (3)
-fever -infection -trauma
proposed mechanisms of primary HTN (6):
-genetics -environment/lifestyle -humoral mech -neuronal regulation -peripheral autoregulatory components -vascular endothelial mecansisms
Epilepsy etiologies
-genetics: usually young age -structural: neuronal imaging abnormalities (cortical dysplasia, posttraumatic epilepsy) - infectious: parasite, meningitis, encephalitis - metabolic: abnormal glycogen metabolism *(lafora disease)* - immune: anti-NMDA receptor encephalitis -unknown
PAI-1 causes __________ and TNFa/IL-6 cause ________ leading to increased visceral adiposity
-hypercoagulability -inflammation
Present illnesses that are signs/symptoms of METS
-hyperglycemia -HTN -dyslipidemia
free fatty acids cause:
-insulin resistance -atherogenic dyslipidemia
_________ in atherosclerosis causes reduced arterial flow resulting in insufficient oxygen to meet needs. ________ is the area of ischemic necrosis resulting from occlusion of arterial supply
-ischemia -infarction
neurologic changes include:
-longer seizures ---> more ischemia -inc glutamate exposure --> neuronal damage -repeated GTC or status epilepticus -->cognitive decline
Labs to diagnose METS
-metabolic panel -lipid panel -thyroid levels (inc TSH) -uric acid level -sleep study (sleep apnea) **chest pain, dyspnea, claudication may warrant additional tests: - electrocardiography -ultrasonography
seizures can occur d/t:
-neuronal hyperexcitability - alterations in ion channels (K/Na/Ca/Cl) - defects in ion transport (ATPase) across membrane -abnormal synaptic vesicle protein 2-A. ~normally responsible for fusion of vesicles to membrane, but gets upregulated in some epilepsies. -biochemical modification of receptors -modulation of second messaging systems and gene expression -changes in extracellular ion concentration -alteration in neurotransmitter uptake and metabolism in glial cells -modifications in the ratio and function of inhibitory circuits -NT imbalance: enhanced excitatory NT (glutamate/aspartate)
inc in leptin/FFA and dec in adiponectin leads to inc muscle insulin resistance and dec glucose uptake as well as hepatic steatosis, which causes many diseases like:
-non-alcoholic fatty liver -hepatitis -fibrosis -cirrhosis -carcinoma/cancer
secondary hyperlipidemia is caused by:
-obesity -high-calorie intake -diabetes mellitus
PAD findings
-pain/cramps/numbness in legs -pain with activity -skin thinning, ulcerations -weak pulse -cool temp -loss of hair -ankle-brachial index -6-min walk test -MRI/CT
PAD can lead to
-poor blood flow in extremities -infection/gangrene -loss of limb
HDLs are mainly composed of _____ while LDLs are mostly _______
-protein -cholesterol
stage 4 of atherosclerosis: the fibrous plaques with defective/broken caps can _______ triggering thrombosis and blocking blood flow. - in the heart, this causes __________ ________ - in the brain, this causes ________
-rupture -myocardial infarction -stroke
Can consider stopping seizure treatment if:
-seizure free 2-4 years -normal neurological exam/ normal IQ -normal EEG w/ treatment -epilepsy of single seizure type (control w/in 1 year) -no juvenile or myoclonic epilepsy
Secondary HTN can be caused by
-sleep apnea -primary aldosteronism -renal parenchymal -renal artery stenosis -meds -pheochromocytoma -cushing's -thyroid/parathyroid disease -aortic coarctation -intracranial tumor
temporarily inc BP but not found to cause HTN
-stress -pain -cold -tobacco -caffeine
Cerebrovascular disease can cause
-stroke -transient ischemic attack (TIA)
blood vessels are composed of 3 layers....
-tunica externa -tunica media -tunica intima
Hyperlipidemia findings:
-typically asymptomatic -xanthomas -lipid panel testing
90-95% of hypertension is primary where the cause is __________. Secondary hypertension is less common and the cause is ______
-unknown -known
seizure treatment goals
1. prevent occurrence of seizures 2. prevent/reduce drug side effects/interactions 3. prevent development of neurologic changes 4. improve patient's quality of life
recommended amount of cardio per week to prevent atherosclerosis
150 minutes
Hypertensive crisis can occur if the pt's BP is >___/___
180/120 mmHg
it is recommended that patients __ to ___ be screened every __ years for lipids
40 to 75 5
apolipoproteins that are a major component of HDL are _____. apolipoproteins that are a major component of LDL and are associated with heart disease are ____
A-1 B-100
Thiazolidinesdiones
Decrease BG, insulin resistance,increase in TC, LDL and weight
________ is a graphical representation of cortical electrical activity. -It provides high temporal resolution, poor spatial resolution of cortical disorder. - most important neuropsychological assessment tool for diagnosis and treatment
EEG
as the triglycerides on VLDL are broken down by the cells, the particle becomes denser due to the change in the lipid to protein ratio resulting in VLDL being converted into..
IDL
cluster of metabolic disorders increasing a patient's changes for future CVD, diabetes, fatty liver, cancer, etc. more than one factor presenting alone
Metabolic syndrome
fat-derived hormone that regulates metabolic processes such as: -improved insulin sensitivity -improved vascular function
adiponectin
ratio that is a predictive marker of vascular disease
apoB-100/apoa-1
proteins bound to lipids that transport lipids throughout the body, provide stability to triglycerides and cholesterol
apolipoproteins
_____________ system delivers oxygen and nutrients to tissues and the ___________ system *returns* blood to the heart
arterial venous
What organ is damaged when: -damage/inflammation to endothelium -wall thickening leading to arteriosclerosis
arteries
HTN is called the silent killer because the patient is often ..
asymptomatic
_________________ is an arterial disorder that causes platelet aggregation and plaque buildup
atherosclerosis
muscles in the body relax during this seizure
atonic
periods of shaking or jerking parts of the body
clonic
antagonizing B2 pre/pos synaptic neurons causes constriction of the:
blood vessels and bronchioles
Organ that gets damaged when: -stroke/TIA d/t atherosclerosis or thromboembolism -ruptured blood vessels/aneurysms leading to hemorrhage -vascular dementia & cognitive impairment from narrowing blockage or arteries leading to hypoperfusion
brain
Reduce neuronal excitability by binding to sodium channels in inactive state and slow channel recovery from inactivation, preventing hyperexcitable neurons from rapidly/repetitive firing
carbamazepine and phenytoin
waxy, fat-like substance in all cells
cholesterol
transport lipid from intestinal tract to cells in the body
chylomicron
HTN meds agonize a-2 presynaptic neurons causing:
dec NE release into synapse = dec PVR
hepatic steatosis also increases insulin resistance and glucose output leading to
diabetes
____ ____ _____ is measured after contraction, when the cardiac chambers are filling with blood
diastolic blood pressure
Inc in CRP can lead to
endothelial dysfunction
>/2 unprovoked seizures occurring more than 24 hours apart OR 1 unprovoked seizure and a probability of further similar seizures after 2 unprovoked seizures occurring over the next 10 years
epilepsy
stage 3 of atherosclerosis: A plaque is formed and matures into a ______ _______ as the extracellular lipid core protrudes, blocking blood flow.
fibrous cap
first stage of atherosclerosis: monocytes bind to the endothelium and cross into the subendothelial space where they become macrophages and take up oxidized LDL, becoming _________ _________
foam cells
Seizures that begin in one part of the brain then to the next area and produce a series of shaking to other body parts are called ____ ____.
focal seizures
seizures that involve both sides of the brain
generalized seizures
Kidneys can be damaged from HTN when: 1. damage to renal arteries results in less filtering and more fluid accumulation. 2. _________________ resulting from scarring of the damaged glomeruli
glomerulosclerosis
occipital lobe
hallucination
high elevations in BP without acute or progressive target-organ injury is
hypertensive *urgency*
seizures rarely cause long term brain damage without neurologic insult. Changes of this might increase with ________ in the first 24-48 hours
hypoxia
favorable prognosis in children with:
idiopathic first seizure and normal EEG
Enhance GABA transmission by:
inc GABAa receptor activity, GABA synthesis, and serotonin release. Decreased GABA reuptake
3 things that cause an inc in cardiac output: *** decrease in these causes dec in CO
inc blood volume, heart rate, myocardial contractility
When the SBP >/160 and DBP </90 mmHg it is considered ___ ___ ____. This is most common in elderly d/t compliance of the arterial wall
isolated systolic hypertension
peripheral autoregulatory components that contribute to primary HTN
kidneys regulation of extracellular fluid volume by maintaining Na/H2O balance
risk factors for atherosclerosis:
modifiable: -hyperlipdemia -smoking -obesity -hypertension -diabetes mellitus non-modifiable: -inc age -family history of CVD -men/post-menopausal women Mod/non-mod: -inc inflammatory markers (c-reactive protein) -inc homocysteine
Risk factors for PAD
modifiable: -hyperlipidemia w/ atherosclerosis -smoking -hypertension -diabetes -obese -sedentary -high sat fat diet non-modifiable: -inc age -fam history of ASCVD -male -black
childhood absence epilepsy
mutation in T-type Ca2+ channels and GABA receptor subunits
dravet syndrome
mutations in Na channel, type I alpha subunit
Generalized seizure where there is short jerking in parts of the body
myoclonic
parietal lobe
numbness or tingling
lipid molecule with hydrophilic lipid tail
phospholipid
enzymes that catalyze biochemical reactions and are vital to metabolism
protein
difference b/w systolic and diastolic BP
pulse pressure
HTN can cause damage to blood vessels in the eye leading to microaneurysms, hemorrhaging, swelling of the optic nerve and vision loss. The outcome diseases is:
retinopathy
temporal lobe (auditory cortex)
ringing or buzzing sounds
discrete clinical event that results in abnormal discharge of a set of neurons in the brain
seizure
_____ ______ _____ is the peak value during cardiac contraction. This is a stronger predictor of CV disease in adults >/50 y/o
systolic blood pressure
muscles in the body become stiff during this type of seizure
tonic
antagonizing the alpha-1 post synapse causes ________ which is a target for the treatment of HTN
vasodilation
_______________ ____________ is a venous disorder in which the activation of clotting cascade causes clots
venous thromboembolism
Risk factors for Hyperlipidemia
• Modifiable • Cigarette smoking •Overweight/obesity • Hypertension • Diabetes • Hypothyroidism • Diet • Medications • Non-modifiable • Family history • Increasing age • Gender (male and post-menopausal females)
Nutrition/medications that increase risk of hyperlipidemia
• Nutrition •Elevated LDL: saturated or trans fat • Elevated TG: very low-fat diet, high intake of carbohydrates, excessive alcohol• Medications • Elevated LDL: diuretics, cyclosporine, glucocorticoids, amiodarone • Elevated TG: estrogen, glucocorticoids, bile acid sequestrants, beta blockers (except carvedilol), thiazide diuretics, antipsychotics