Ekaterina A Stepanova, M.D., Ph.D.
- Assistant Professor of Psychiatry and Behavioral Sciences
https://www.hopkinsmedicine.org/profiles/results/directory/profile/10001197/ekaterina-stepanova
While we were testing him herbal salvation 30caps npxl fast delivery, hiseyessuddenlyrolledupin his head and he started to collapse banjara herbals generic 30 caps npxl visa. He was "coning"; this is the rather mild term used for a terrifying event in which herbs de provence substitute buy discount npxl 30 caps line, with excessive pressure in the head herbals scappoose oregon generic 30caps npxl fast delivery, the cerebellar tonsils and brain stem get pushed through the foramen magnum at the base of the skull. Coning can be fatalwithinseconds,andwith the speed of reflex I grabbed our patient and held him upside down; his cerebellar tonsils and brain stem went backintotheskull,andIfeltI had snatched him from the veryjawsofdeath. When she heard that I had a motorbike andlivedinTopangaCanyon, she expressed a special last wish:shewantedtocomefor a ride with me on my motorbike, up and down the loops of Topanga Canyon Road. I came to the hospital one Sunday with three weight-lifting buddies, and we managed to abduct the patient and lash her securely tomeonthebackofthebike. Butmycolleagues- andthepatient-spokeupfor me, and I was strongly cautioned but not dismissed. In general, I was something of an embarrassment to the neurology department but also something of an ornament-the only resident who had published papers- and I think this might have saved my neck on several occasions. My motive, I think, was not an uncommonone;Iwasnotthe ninety-eight-pound weakling of bodybuilding advertisements, but I was timid, diffident, insecure, submissive. I became strong -very strong-with all my weight lifting but found that this did nothing for my character, which remained exactly the same. Ihadpushed my quadriceps, in squatting, far beyond their natural limits, and this predisposed them to injury, and it was surely not unrelated to my mad squatting that I ruptured one quadriceps tendon in 1974 and the other in 1984. While I was in hospital in 1984, feeling sorry for myself, with a long cast on my leg, I had a visit from DaveSheppard,mightyDave, from Muscle Beach days. He hobbledintomyroomslowly and painfully; he had very severe arthritis in both hips and was awaiting total hip replacements. I too was training hardatthetime,gettingready for what I hoped might be a record-breaking squat, and our workout times would sometimescoincide. Hehadasoftbrowndeerskin jacket-he had shot the deer, he said, in his native Minnesota-and I gave him the spare crash helmet I always kept on the bike. I thoughtwemadeagoodpair, and I had a little tickle of excitement at his sitting on the saddle behind me and holdingmefirmlyaroundthe waist;itwashisfirsttimeon amotorcycle,hesaid. We would go on weekend motorbike rides together, camping out, swimming in ponds and lakes, and sometimes wrestlingtogether. Erotic with the urgent opposition of our bodies, though there was no explicit sexualelement,norwouldan observer have thought we were anything more than a couple of young men wrestlingtogether. Bothofus wereproudofourwashboard abdominalsandwoulddosets ofsit-ups,ahundredormore at a time. Mel would sit astride me, punching me playfullyinthestomachwith each sit-up, and I would do thesamewithhim. We couldworkourabdominalsor wrestleandgetpleasurefrom it, at one and the same time. Ourbucolicandinasense innocent honeymoon, with delight in the present and little thought of the future, lasted a year, but as the summer of 1962 approached, wehadtomakeplans. He didnotlikeacceptinggiftsor moneyfrommeandsecureda job for himself in a carpet factoryashortwalkfromour apartment. Mel and I had separate beds, and the rest of the apartment was filled with books and the ever-accumulating journals andpapersIhadbeenwriting for years; Mel had very few possessionsofhisown. Once a week we would go to a movie, and a couple of times a week Mel would take off on his own for a motorcycleride. Mel liked being massaged and would lie naked facedown on his bed and ask me to massage his back. He enjoyed this, relaxing and surrendering to my hands, andIenjoyedittoo;indeed,it would bring me to the brink of orgasm. I felt him suddenly stiffen when this happened,andwithoutaword hegotupandhadashower. He would not speak to me for the rest of the evening; it was evident that I had gone toofar.
The perivascular spaces contain lymphocytes and macrophages laden with neutral fats herbs used for pain order 30 caps npxl with amex. Later the damaged myelin disappears and astrocytes proliferate to form a glial scar herbals that clean arteries buy generic npxl 30caps on-line. At this stage axonal destruction is observed within the plaque lotus herbals 4 layer facial buy npxl 30 caps online, although recent evidence demonstrates that axonal degeneration starts early and is a universal and persistent feature of the disease (Dutta & Trapp 2007) himalaya herbals review order 30caps npxl with visa. Axons may be damaged by Other Disorders of the Nervous System 849 circumstances (available at Attention has also been directed to the possibility that psychological factors may be associated with relapses of the disease. The historical development of psychiatric interest in the disorder is traced by Surridge (1969). Early investigators regarded intellectual deficits as the main disturbance, and towards the end of the nineteenth century there were numerous reports of acute psychoses occurring in the disease. In a consecutive series of 100 outpatients, they found that emotional changes were strikingly common, usually taking the form of increased cheerfulness and optimism. A sense of physical well-being was frequent among the patients despite their severely disabled state. In contrast to these affective changes, intellectual disorders were minimal or negligible. Meanwhile, Ombredane (1929) re-emphasised the occurrence of intellectual deficits. Disturbances of affect were common in the intellectually deteriorated cases, but consisted chiefly of rapid unstable variations in mood rather than constant shifts towards euphoria or depression. Runge (1928) maintained that depression occurred in the early stage but gave way to euphoria as the disease progressed further. More recent investigators have sought to resolve the dilemma by careful surveys of the psychiatric changes in large series of patients. Intellectual deterioration was present in 61%, varying in degree from mild memory loss to profound global dementia. Abnormalities of mood were found in 53% compared with 13% of controls; 27% were depressed, 26% euphoric and 10% showed exaggeration of emotional expression. Euphoria was almost exclusively seen in patients who were intellectually impaired, and a significant correlation emerged between increasing euphoria and increasing intellectual deterioration. Euphoria was also associated with denial of disability which was observed in 11% of the patients. This was predominantly a change towards irritability, whereas the muscular dystrophy controls often showed increased patience and tolerance. These findings effectively set the stage for subsequent studies, which have increasingly used neuropsychological assessments and objective rating procedures for charting the changes observed. Control comparisons have amply confirmed the vulnerability of patients to a range of cognitive and emotional complications, as outlined below. However, considerable difficulties are encountered in reaching firm conclusions about the prevalence of psychiatric disorder in the disease in view of its widely varying manifestations. It can be uncertain how far psychiatric manifestations are attributable to brain pathology rather than representing psychological reactions to the threats and limitations imposed by the physical symptoms. Evidence can sometimes be found for a causal role of brain pathology even where seemingly non-organic symptoms such as depression are concerned, but other influences are also clearly at work. For example, Ron and Logsdail (1989) found that psychiatric morbidity in their sample was strongly related to the degree of social stress perceived by the patient. This suggests an interactional model whereby the vulnerability created by the presence of brain damage enhances the effects of environmental and personal factors in producing psychiatric disorder (Ron & Feinstein 1992). In seeking to define the organic contribution, recent studies have been greatly helped by the availability of sensitive brain-imaging techniques. Much is likely to depend on the stage of the disease at which assessments are made, but even so it is apparent that patients differ markedly in their liability to become impaired. This is perhaps not surprising since the accent of the disease can fall on very different parts of the neuraxis. The severity of impairments also varies widely, from those only detectable on careful testing to pictures of global dementia.
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Very divergent rates are offered for the proportion of patients whose ventricular enlargement is due to hydrocephalus as opposed to atrophy (Guyot & Michael 2000) herbals aarogya buy npxl 30caps mastercard. This latter figure is perhaps more consistent with the finding that surgery for post-traumatic ventriculomegaly may not improve outcome (Fu et al herbals in the philippines generic npxl 30 caps with mastercard. It must also be remembered 178 Chapter 4 that a good proportion of hydrocephalus remits spontaneously (Front et al himalaya herbals nourishing skin cream npxl 30caps mastercard. Therefore most would not proceed to surgery unless there was good clinical evidence everyuth herbals skin care products order npxl 30 caps fast delivery. The clinical syndrome of a post-traumatic progressive dementia, with or without deteriorating incontinence and gait ataxia, that responds to shunting is very rare but needs occasionally to be considered, particularly if there are risk factors for hydrocephalus. Brain imaging not only excludes a subdural haemorrhage but also allows the present state of the ventricles to be compared with previous findings, or act as a baseline to determine any future change in ventricular size. However, a moderate progressive increase in size of the ventricles, months and even years after injury, does not necessarily indicate the presence of hydrocephalus as a secondary complication. On the time-dependent plot of standardised brain volume the greatest reduction was seen between the groups measured at a mean of 13 and 42 days after injury, respectively. Further increases in ventricular volume were not observed in the groups with post-injury intervals greater than 136 days. Reductions in brain volume were seen across the later groups, but beyond 310 days after injury the reductions were hardly greater than those predicted by reductions in brain volume seen with normal ageing (0. Despite the limitations of this study it does match clinical experience; the vast majority of cerebral atrophy is to be found within the first 6 months after injury. The rate of reduction in brain volume over time was three to four times faster than seen in four controls with repeat scans. Neither of these studies reported whether the patients were abusing alcohol or drugs, which could have been a confounder. Nineteen patients undergoing rehabilitation between 3 months and 3 years after injury were subjected to all three investigations. Changes over time are corrected for differences in age, sex and head size using data from a normative database. Note that this is not a longitudinal study but consists of multiple cohorts each at different times after injury. Similar findings have been reported more recently, with hypoperfusion in the frontal lobes being associated with personality change (Kinuya et al. Some of the patients in this study had suffered minimal injuries and the significance of the hypometabolism in such cases should perhaps be viewed with caution. For example, reductions in cerebral metabolic rate in thalamus and brainstem in the days after injury are greater in those who remain in coma (Hattori et al. Those with executive and memory difficulties were more likely to demonstrate hypometabolism in lateral and medial prefrontal areas, whereas medial prefrontal and cingulate areas were affected in those with behavioural disorder. Patients with more severe injury also show changes in the pattern of cerebral metabolic response to task demand. For example, on a memory retrieval task they showed more widespread activation with less asymmetry of cerebral activation and less activation of dorsomedial thalamus, known to be involved in normal memory retrieval (Levine et al. Whether or not patients show greater or lesser activation than controls may depend on the task. Smaller increases in regional cerebral blood flow in the frontal lobe were seen during free recall on a verbal memory task, whereas during the recognition phase of the same task there was greater activation than seen in controls (Ricker et al. Although the injured patients performed almost as well as controls, they showed a different pattern of cerebral activation. With the more demanding task (2-back), comparing it with the 1-back task, the brain-injured patients showed more extensive activation of frontal and parietal areas. The value of functional imaging in the assessment of individual cases is yet to be established, although the findings can be of interest. Six months later the right frontal and temporal damage was still evident on structural scans; metabolism had improved in both frontal lobes but the right was still impaired. For example, a low N-acetylaspartate to creatinine ratio is thought to be a marker of neuronal/ axonal loss or damage.
By observing and recording their behavior while they interacted with this system 3-1 herbals letter draft buy generic npxl 30caps on line, we were able to elucidate more clearly the role and process of mimicry in dolphin vocal learning guaranteed herbals cheap npxl 30 caps. Although this system was not designed to elicit vocal mimicry herbals2go purchase npxl 30 caps mastercard, the whistles could be easily perceived and reproduced by the dolphins wonder herbals npxl 30 caps otc, which facilitated their ability to process, produce, and remember the signals. The computer-generated whistles were designed to be similar to the frequency and temporal parameters of natural dolphin whistles but different from the actual frequency modulation (the actual whistle contours) of the whistles in the repertoires of the dolphins in the study. This precaution was deemed necessary because vocal mimicry has been operationally defined as copying an otherwise improbable act or utterance (Thorpe 1963; Richards, Wolz, and Herman 1984) rather than a mere elicitation of species-specific whistles (Andrew 1962). Mimicry and Productive Use of Whistles Our analysis of audio and video recordings of experimental sessions revealed that the dolphins had begun to spontaneously mimic and produce facsimiles of the computer-generated model sounds, which provided strong evidence for vocal learning in this species. The term "mimicry" was designated to represent facsimiles of the model sounds emitted by dolphins immediately after the model sound, and the term "production" was used to indicate when facsimiles were emitted by dolphins in other contexts and at times not immediately after the model sound. After only 19 exposures to the "ball" whistle, an interesting pattern of vocal mimicry was recorded. In three successive trials, one young male dolphin reproduced different aspects of the model sound; he first mimicked the end of the ball whistle, then the beginning of the whistle, and finally the entire harmonic structure of the whistle. From the onset of mimicry, the dolphins showed a tendency to mimic and reproduce the absolute frequency and temporal parameters of the model sounds and to compress or expand the temporal parameters of their whistled versions. Similar patterns were observed in the initial mimicry of other model sounds, and far fewer acoustic exposures were required prior to the onset of initial mimicry in these cases. For example, the "rub" whistle was mimicked after nine exposures and the "ring" whistle after two exposures. In addition, the dolphins began to spontaneously produce facsimiles of the model sounds before they used the corresponding key. The first instance of productive use occurred in the same session in which vocal mimicry began. This session was marked by a multiplicity of contexts in which the facsimiles were emitted. The dolphin remained at the keyboard and interacted with the ball it Page 555 obtained. The dolphin produced two instances of the ball whistle while it pushed the ball about in the vicinity of the keyboard. The dolphin then reapproached the keyboard, produced the ball whistle, immediately used the ball key on the keyboard, and swam away with the ball that it subsequently received. During the first year of this study, the amount of vocal mimicry in relation to production followed a consistent relation across keyboard sessions (simple regression, R2 = 0. Across all sessions, vocal mimicry (N = 165) was about 19 percent higher than production (N = 139). In contrast, during the second year, the occurrence of vocal mimicry in relation to production showed no consistent relation across sessions (simple regression, R2 = 0. However, in this later stage of the research program, vocal production (N = 210) was slightly higher than vocal mimicry (N = 19). This was a significant increase in the ratio of productions to vocal mimicry (c2 test, p = 0. New Combination Whistles Analysis of keyboard sessions during the second year of the study revealed that the dolphins had spontaneously begun to produce a new sound that appeared to be a combination of the ball- and ring-model sounds combined into one continuous whistle. Thus, the emergence of this apparent combination could not have been acquired through vocal mimicry. Producing the new combination persisted during the second year, and a total of 28 such whistle types were recorded, primarily in the context of a new pattern of interaction with balls and rings that also emerged during the same time period. The new behavior involved the dolphins holding both objects in their mouths or interacting with a ball and ring simultaneously in various manners. Contextually Appropriate Use of Whistles Analysis of behavioral narratives recorded during keyboard sessions during the second year enabled us to determine the contextual use of the whistle production and mimicry. As noted above, the dolphins were producing whistles much more often than they were mimicking during the second year. Our analysis revealed that they were also using whistle facsimiles in behaviorally appropriate contexts: 1. In a total of 92 ball productions, 74 (80 percent) were emitted in contexts of ball play Of 64 ring productions, 47 (73 percent) were emitted during ring play Page 556 3. Of 5 rub productions, all (100 percent) were produced during contexts of physical rubbing between the dolphin and investigators Of 28 instances of productions of the novel ring-ball combination whistle, 23 (82 percent) were emitted during simultaneous ring and ball play the results of this study provide compelling evidence for vocal learning by this species and for the ability of dolphins to spontaneously acquire new vocal signals, to learn associations between new acoustic signals and specific objects or actions, and to use these signals in new, appropriate behavioral contexts in the absence of explicit training.
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