e martë, 12 qershor 2007

Causes of Diabetic Neuropathies

Diabetic neuropathies are a family of nerve disorders caused by diabetes. People with diabetes can, over time, have damage to nerves throughout the body. Neuropathies lead to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. Problems may also occur in every organ system, including the digestive tract, heart, and sex organs. People with diabetes can develop nerve problems at any time, but the longer a person has diabetes, the greater the risk.
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An estimated 50 percent of those with diabetes have some form of neuropathy, but not all with neuropathy have symptoms. The highest rates of neuropathy are among people who have had the disease for at least 25 years.
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Diabetic neuropathy also appears to be more common in people who have had problems controlling their blood glucose levels, in those with high levels of blood fat and blood pressure, in overweight people, and in people over the age of 40. The most common type is peripheral neuropathy, also called distal symmetric neuropathy, which affects the arms and legs.
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Causes
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The causes are probably different for different varieties of diabetic neuropathy. Researchers are studying the effect of glucose on nerves to find out exactly how prolonged exposure to high glucose causes neuropathy. Nerve damage is likely due to a combination of factors:

  • metabolic factors, such as high blood glucose, long duration of diabetes, possibly low levels of insulin, and abnormal blood fat levels
  • neurovascular factors, leading to damage to the blood vessels that carry oxygen and nutrients to the nerves
  • autoimmune factors that cause inflammation in nerves
  • mechanical injury to nerves, such as carpal tunnel syndrome
  • inherited traits that increase susceptibility to nerve disease
  • lifestyle factors such as smoking or alcohol use
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Symptoms of Diabetic Neuropathies

Symptoms
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Symptoms depend on the type of neuropathy and which nerves are affected. Some people have no symptoms at all. For others, numbness, tingling, or pain in the feet is often the first sign. A person can experience both pain and numbness. Often, symptoms are minor at first, and since most nerve damage occurs over several years, mild cases may go unnoticed for a long time. Symptoms may involve the sensory or motor nervous system, as well as the involuntary (autonomic) nervous system. In some people, mainly those with focal neuropathy, the onset of pain may be sudden and severe.
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Symptoms may include

  • ..numbness, tingling, or pain in the toes, feet, legs, hands, arms, and fingers
  • wasting of the muscles of the feet or hands
  • indigestion, nausea, or vomiting
  • diarrhea or constipation
  • dizziness or faintness due to a drop in postural blood pressure
  • problems with urination
  • erectile dysfunction (impotence) or vaginal dryness
  • weakness
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In addition, the following symptoms are not due to neuropathy but nevertheless often accompany it:

  • weight loss
  • depression
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Types of Diabetic Neuropathies

Types of Diabetic Neuropathy

Diabetic neuropathies can be classified as peripheral, autonomic, proximal, and focal. Each affects different parts of the body in different ways.

  • Peripheral neuropathy causes either pain or loss of feeling in the toes, feet, legs, hands, and arms.
  • Autonomic neuropathy causes changes in digestion, bowel and bladder function, sexual response, and perspiration. It can also affect the nerves that serve the heart and control blood pressure. Autonomic neuropathy can also cause hypoglycemia (low blood sugar) unawareness, a condition in which people no longer experience the warning signs of hypoglycemia.
  • Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads to weakness in the legs
  • Focal neuropathy results in the sudden weakness of one nerve, or a group of nerves, causing muscle weakness or pain. Any nerve in the body may be affected.

Neuropathy Affects Nerves Throughout the Body

Peripheral Neuropathy

  1. toes
  2. feet
  3. legs
  4. hands
  5. arms
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Autonomic Neuropathy

  1. heart and blood vessels
  2. digestive system
  3. urinary tract
  4. sex organs
  5. sweat glands
  6. eyes
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Proximal Neuropathy

  1. thighs
  2. hips
  3. buttocks
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Focal Neuropathy

  1. eyes
  2. facial muscles
  3. ears
  4. pelvis and lower back
  5. thighs
  6. abdomen

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Peripheral Neuropathy

Peripheral Neuropathy
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Peripheral neuropathy affects the nerves in your arms, hands, legs, and feet.

This type of neuropathy damages nerves in the arms and legs. The feet and legs are likely to be affected before the hands and arms. Many people with diabetes have signs of neuropathy upon examination but have no symptoms at all. Symptoms of peripheral neuropathy may include:

  1. numbness or insensitivity to pain or temperature
  2. a tingling, burning, or prickling sensation
  3. sharp pains or cramps
  4. extreme sensitivity to touch, even a light touch
  5. loss of balance and coordination
  6. These symptoms are often worse at night.
  7. Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle, leading to changes in gait (walking).
  8. Foot deformities, such as hammertoes and the collapse of the midfoot, may occur.
  9. Blisters and sores may appear on numb areas of the foot because pressure or injury goes unnoticed.
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If foot injuries are not treated promptly, the infection may spread to the bone, and the foot may then have to be amputated. Some experts estimate that half of all such amputations are preventable if minor problems are caught and treated in time.



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Autonomic Neuropathy (affecting many organs and systems)

Autonomic neuropathy affects the nerves in your lungs, heart, stomach, intestines, bladder, and sex organs.
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Autonomic neuropathy affects the nerves that control the heart, regulate blood pressure, and control blood glucose levels. It also affects other internal organs, causing problems with:
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  • digestion, respiratory function,
  • urination,
  • sexual response,
  • vision, and
  • the system that restores blood glucose levels to normal after a hypoglycemic episode may be affected, resulting in loss of the warning signs of hypoglycemia such as sweating and palpitations.
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Unawareness of Hypoglycemia
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Normally, symptoms such as shakiness occur as blood glucose levels drop below 70 mg/dL. In people with autonomic neuropathy, symptoms may not occur, making hypoglycemia difficult to recognize.
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However, other problems can also cause hypoglycemia unawareness so this does not always indicate nerve damage.
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Heart and Circulatory System
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The heart and circulatory system are part of the cardiovascular system, which controls blood circulation. Damage to nerves in the cardiovascular system interferes with the body's ability to adjust blood pressure and heart rate. As a result, blood pressure may drop sharply after sitting or standing, causing a person to feel light-headed—or even to faint. Damage to the nerves that control heart rate can mean that it stays high, instead of rising and falling in response to normal body functions and exercise.
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Digestive System
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Nerve damage to the digestive system most commonly causes constipation. Damage can also cause the stomach to empty too slowly, a condition called gastroparesis. Severe gastroparesis can lead to persistent nausea and vomiting, bloating, and loss of appetite. Gastroparesis can make blood glucose levels fluctuate widely as well, due to abnormal food digestion.
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Nerve damage to the esophagus may make swallowing difficult, while nerve damage to the bowels can cause constipation alternating with frequent, uncontrolled diarrhea, especially at night. Problems with the digestive system may lead to weight loss.
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Urinary Tract and Sex Organs
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Autonomic neuropathy most often affects the organs that control urination and sexual function. Nerve damage can prevent the bladder from emptying completely, allowing bacteria to grow in the bladder and kidneys and causing urinary tract infections. When the nerves of the bladder are damaged, urinary incontinence may result because a person may not be able to sense when the bladder is full or control the muscles that release urine.
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Neuropathy can also gradually decrease sexual response in men and women, although the sex drive is unchanged. A man may be unable to have erections or may reach sexual climax without ejaculating normally. A woman may have difficulty with lubrication, arousal, or orgasm.
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Sweat Glands
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Autonomic neuropathy can affect the nerves that control sweating. When nerve damage prevents the sweat glands from working properly, the body cannot regulate its temperature properly. Nerve damage can also cause profuse sweating at night or while eating.
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Eyes
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Finally, autonomic neuropathy can affect the pupils of the eyes, making them less responsive to changes in light. As a result, a person may not be able to see well when the light is turned on in a dark room or may have trouble driving at night.
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Proximal Nuropathy (Lumbosacral Plexus Neuropathy...)

Proximal Neuropathy
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Proximal neuropathy, sometimes called lumbosacral plexus neuropathy, femoral neuropathy, or diabetic amyotrophy, starts with pain in either the thighs, hips, buttocks, or legs, usually on one side of the body. This type of neuropathy is more common in those with type 2 diabetes and in older people. It causes weakness in the legs, manifested by an inability to go from a sitting to a standing position without help. Treatment for weakness or pain is usually needed. The length of the recovery period varies, depending on the type of nerve damage.
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Focal Neuropathy (affecting specific nerves)

Focal Neuropathy
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Occasionally, diabetic neuropathy appears suddenly and affects specific nerves, most often in the head, torso, or leg. Focal neuropathy may cause:

  1. inability to focus the eye
  2. double vision
  3. aching behind one eye
  4. paralysis on one side of the face (Bell's palsy)
  5. severe pain in the lower back or pelvis
  6. pain in the front of a thigh
  7. pain in the chest, stomach, or flank
  8. pain on the outside of the shin or inside the foot
  9. chest or abdominal pain that is sometimes mistaken for heart disease, heart attack, or appendicitis

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Focal neuropathy is painful and unpredictable and occurs most often in older people. However, it tends to improve by itself over weeks or months and does not cause long-term damage.

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People with diabetes also tend to develop nerve compressions, also called entrapment syndromes. One of the most common is carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness or pain. Other nerves susceptible to entrapment may cause pain on the outside of the shin or the inside of the foot.




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Prevention

Preventing Diabetic Neuropathy
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The best way to prevent neuropathy is to keep your blood glucose levels as close to the normal range as possible. Maintaining safe blood glucose levels protects nerves throughout your body.
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For additional information on preventing diabetes complications, including neuropathy, see the Prevent Diabetes Problems series, available from the National Diabetes Information Clearinghouse at 1–800–860–8747. ..


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Diagnosing Neropathy

Diagnosis

Neuropathy is diagnosed on the basis of symptoms and a physical exam. During the exam, the doctor may check blood pressure and heart rate, muscle strength, reflexes, and sensitivity to position, vibration, temperature, or a light touch.

The doctor may also do other tests to help determine the type and extent of nerve damage:

  • A comprehensive foot exam assesses skin, circulation, and sensation. The test can be done during a routine office visit. To assess protective sensation or feeling in the foot, a nylon monofilament (similar to a bristle on a hairbrush) attached to a wand is used to touch the foot. Those who cannot sense pressure from the monofilament have lost protective sensation and are at risk for developing foot sores that may not heal properly. Other tests include checking reflexes and assessing vibration perception, which is more sensitive than touch pressure.
  • Nerve conduction studies check the transmission of electrical current through a nerve. With this test, an image of the nerve conducting an electrical signal is projected onto a screen. Nerve impulses that seem slower or weaker than usual indicate possible damage. This test allows the doctor to assess the condition of all the nerves in the arms and legs.
  • Electromyography (EMG) shows how well muscles respond to electrical signals transmitted by nearby nerves. The electrical activity of the muscle is displayed on a screen. A response that is slower or weaker than usual suggests damage to the nerve or muscle. This test is often done at the same time as nerve conduction studies.
  • Quantitative sensory testing (QST) uses the response to stimuli, such as pressure, vibration, and temperature, to check for neuropathy. QST is increasingly used to recognize sensation loss and excessive irritability of nerves.
  • A check of heart rate variability shows how the heart responds to deep breathing and to changes in blood pressure and posture.
  • Ultrasound uses sound waves to produce an image of internal organs. An ultrasound of the bladder and other parts of the urinary tract, for example, can show how these organs preserve a normal structure and whether the bladder empties completely after urination.
  • Nerve or skin biopsy involves removing a sample of nerve or skin tissue for examination by microscope. This test is most often used in research settings.

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Treatment For Neuropathy and Pain

Treatment

The first step is to bring blood glucose levels within the normal range to prevent further nerve damage. Blood glucose monitoring, meal planning, exercise, and oral drugs or insulin injections are needed to control blood glucose levels. Although symptoms may get worse when blood glucose is first brought under control, over time, maintaining lower blood glucose levels helps lessen neuropathic symptoms. Importantly, good blood glucose control may also help prevent or delay the onset of further problems.

Additional treatment depends on the type of nerve problem and symptom, as described in the following sections.


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86,000 Amputations Per Year Due to Diabetes

Foot Care
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People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers.

  1. More than half of all lower limb amputations in the United States occur in people with diabetes—86,000 amputations per year. Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care. Here are the steps to follow:
  2. Clean your feet daily, using warm—not hot—water and a mild soap. Avoid soaking your feet. Dry them with a soft towel; dry carefully between your toes.
    Inspect your feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror (laying a mirror on the floor works well) or get help from someone else if you cannot see the bottoms of your feet. Notify your health care provider of any problems.
  3. Moisturize your feet with lotion, but avoid getting it between your toes.
  4. Each week or when needed, cut your toenails to the shape of your toes and file the edges straight across with an emery board.
  5. Always wear shoes or slippers to protect your feet from injuries. Prevent skin irritation by wearing thick, soft, seamless socks.
  6. Wear shoes that fit well and allow your toes to move. Break in new shoes gradually by wearing them for only an hour at a time at first.
  7. Before putting your shoes on, look them over carefully and feel the insides with your hand to make sure they have no tears, sharp edges, or objects in them that might injure your feet.
  8. If you need help taking care of your feet, make an appointment to see a foot doctor, also called a podiatrist.

For additional information on foot care, contact the National Diabetes Information Clearinghouse at 1–800–860–8747. Materials are also available at ndep.nih.gov/resources/health.htm.

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Treating Pain from Neuropathy

Pain Relief
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To relieve pain, burning, tingling, or numbness, the doctor may suggest aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. (People with renal disease should use NSAIDs only under a doctor's supervision.) A topical cream called capsaicin is another option. Tricyclic antidepressant medications such as amitriptyline, imipramine, and nortriptyline, or anticonvulsant medications such as carbamazepine or gabapentin may relieve pain in some people. Codeine may be prescribed for a short time to relieve severe pain. Also, mexiletine, used to regulate heartbeat, has been effective in treating pain in several clinical trials.
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Other pain treatments include transcutaneous electronic nerve stimulation (TENS), which uses small amounts of electricity to block pain signals, as well as hypnosis, relaxation training, biofeedback, and acupuncture. Walking regularly or using elastic stockings may also help leg pain.


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Eat Small, frequent meals, and avoid high fat and High Fiber Meals

Gastrointestinal Problems

To relieve mild symptoms of gastroparesis—indigestion, belching, nausea, or vomiting—doctors suggest eating small, frequent meals, while avoiding fats, and eating less fiber. When symptoms are severe, the doctor may prescribe erythromycin to speed digestion, metoclopramide to speed digestion and help relieve nausea, or other drugs to help regulate digestion or reduce stomach acid secretion.

Gastroparesis and Diabetes

What is gastroparesis?
Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. It often occurs in people with type 1 diabetes or type 2 diabetes.

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.














The digestive system

Signs and Symptoms
Signs and symptoms of gastroparesis are

  1. heartburn
  2. nausea
  3. vomiting of undigested food
  4. an early feeling of fullness when eating
  5. weight loss
  6. abdominal bloating
  7. erratic blood glucose levels
  8. lack of appetite
  9. gastroesophageal reflux
  10. spasms of the stomach wall

These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis
If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

Major Causes of Gastroparesis
Gastroparesis is most often caused by

  1. diabetes
  2. postviral syndromes
  3. anorexia nervosa
  4. surgery on the stomach or vagus nerve
  5. medications, particularly anticholinergics and narcotics (drugs that slow contractions in the intestine)
  6. gastroesophageal reflux disease (rarely)
  7. smooth muscle disorders such as amyloidosis and scleroderma
  8. nervous system diseases, including abdominal migraine and Parkinson's disease
  9. metabolic disorders, including hypothyroidism

Diagnosis
The diagnosis of gastroparesis is confirmed through one or more of the following tests.

  1. Barium x ray. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x ray shows food in the stomach, gastroparesis is likely. If the x ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
  2. Barium beefsteak meal. You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help detect emptying problems that do not show up on the liquid barium x ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.
  3. Radioisotope gastric-emptying scan. You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
  4. Gastric manometry. This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
  5. Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.



To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.


Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.



Treatment
The primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

It is important to note that in most cases treatment does not cure gastroparesis—it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.

Insulin for blood glucose control

If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To control blood glucose, you may need to

  1. take insulin more often
  2. take your insulin after you eat instead of before
  3. check your blood glucose levels frequently after you eat and administer insulin whenever necessary
    Your doctor will give you specific instructions based on your particular needs.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

  1. Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement.
  2. Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
  3. Domperidone. The Food and Drug Administration is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. It is a promotility agent like metoclopramide. Domperidone also helps with nausea.
  4. Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.

Meal and Food Changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis is corrected. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem—the stomach—and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

Parenteral Nutrition

Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.

This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult spell of gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

New Treatments

A gastric neurostimulator has been developed to assist people with gastroparesis. The battery-operated device is surgically implanted and emits mild electrical pulses that help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications.

The use of botulinum toxin has been shown to improve stomach emptying and the symptoms of gastroparesis by decreasing the prolonged contractions of the muscle between the stomach and the small intestine (pyloric sphincter). The toxin is injected into the pyloric sphincter.

Hope Through Research
NIDDK's Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal motility disorders, including gastroparesis. Among other areas, researchers are studying whether experimental medications can relieve or reduce symptoms of gastroparesis, such as bloating, abdominal pain, nausea, and vomiting, or shorten the time needed by the stomach to empty its contents following a standard meal.

Points to Remember

  1. Gastroparesis may occur in people with type 1 diabetes or type 2 diabetes.
  2. Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of the food moving through the digestive tract normally, it is retained in the stomach.
  3. The vagus nerve becomes damaged after years of poor blood glucose control, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
  4. Symptoms of gastroparesis include early fullness, nausea, vomiting, and weight loss.
  5. Gastroparesis is diagnosed through tests such as x rays, manometry, and scanning.
  6. Treatments include changes in when and what you eat, changes in insulin type and timing of injections, oral medications, a jejunostomy, parenteral nutrition, gastric neurostimulators, or botulinum toxin.




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The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, this does not mean or imply that the product is unsatisfactory.


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National Digestive Diseases Information Clearinghouse
2 Information Way
Bethesda, MD 20892–3570
Email: nddic@info.niddk.nih.gov

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.


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NIH Publication No. 04–4348

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      Dizziness and Weakness From Blood Pressure and Circulation

      Dizziness and Weakness

      Sitting or standing slowly may help prevent the light-headedness, dizziness, or fainting associated with blood pressure and circulation problems. Raising the head of the bed or wearing elastic stockings may also help. Some people may benefit from increased salt in the diet and treatment with salt-retaining hormones. Others may benefit from high blood pressure medications. Physical therapy can help when muscle weakness or loss of coordination is a problem.


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      Urinary and Sexual Problems

      Urinary and Sexual Problems
      ...

      • To clear up a urinary tract infection, the doctor will probably prescribe an antibiotic. Drinking plenty of fluids will help prevent another infection. People who have incontinence should try to urinate at regular intervals (every 3 hours, for example) since they may not be able to tell when their bladder is full.
      • To treat erectile dysfunction in men, the doctor will first do tests to rule out a hormonal cause. Several methods are available to treat erectile dysfunction caused by neuropathy, including taking oral drugs, using a mechanical vacuum device, or injecting a drug called a vasodilator into the penis before sex. The vacuum and vasodilator raise blood flow to the penis, making it easier to have and maintain an erection. Another option is to surgically implant an inflatable or semirigid device in the penis. A constriction ring or penile sling may be helpful.
      • Vaginal lubricants may be useful for women when neuropathy causes vaginal dryness. To treat problems with arousal and orgasm, the doctor may refer the woman to a gynecologist.
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      Quick Review of Diabetic Neuropathies

      Points to Remember
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      1. Diabetic neuropathies are nerve disorders caused by many of the abnormalities common to diabetes, such as high blood glucose.
      2. Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, and sex organs.
      3. Treatment first involves bringing blood glucose levels within the normal range. Good blood glucose control may help prevent or delay the onset of further problems.
      4. Foot care is another important part of treatment. People with neuropathy need to inspect their feet daily for any injuries. Untreated injuries increase the risk of infected foot sores and amputation.
      5. Treatment also includes pain relief and other medications as needed, depending on the type of nerve damage.
      6. Smoking significantly increases the risk of foot problems and amputation. If you smoke, ask your health care provider for help in quitting.



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      There Is Hope!

      Hope Through Research
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      The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the National Institute of Neurological Disorders and Stroke (NINDS) conduct and support research to help people with diabetes, including studies related to diabetic neuropathy. A complete listing of clinical research studies can be found at ClinicalTrials.gov.
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      For More Information:

      For more information, contact the following organizations:


      • American Diabetes Association
        National Service Center
        1701 North Beauregard Street
        Alexandria, VA 22311
        Phone: 1–800–232–3472 or 1–800–DIABETES (1–800–342–2383)
        Fax: 703–549–6995
        Email: customerservice@diabetes.org
        Internet: www.diabetes.org
      • American Foundation for Urologic Disease
        1128 North Charles Street
        Baltimore, MD 21201
        Phone: 1–800–242–2383 or 410–468–1800
        Email: admin@afud.org
        Internet: www.afud.org
      • American Podiatric Medical Association
        9312 Old Georgetown Road
        Bethesda, MD 20814–1698
        Phone: 1–800–FOOT–CARE(1–800–366–8227) or 301–571–9200
        Fax: 301–530–2752
        Email: askapma@apma.org
        Internet: www.apma.org
      • Centers for Disease Control and Prevention
        National Center for Chronic Disease
        Prevention and Health Promotion
        Division of Diabetes Translation
        Mail Stop K-104770 Buford Highway, NE.
        Atlanta, GA 30341–3717
        Phone: 1–800–CDC–DIAB(1–800–232–3422)
        Fax: 301–562–1050Email: diabetes@cdc.govInternet: www.cdc.gov/diabetes
      • Juvenile Diabetes Research Foundation Internationa
        l120 Wall Street, 19th floor
        New York, NY 10005
        Phone: 1–800–533–2873 or 212–785–9500
        Fax: 212–785–9595
        Email: info@jdrf.org
        Internet: www.jdrf.org
      • Lower Extremity Amputation Prevention Program
        HRSA/BPH/DPSP
        4350 East-West Highway, 9th floor
        Bethesda, MD 20814
        Phone: 1–888–275–4772
        Internet: www.bphc.hrsa.gov/leap
      • National Diabetes Education Program
        1 Diabetes Way
        Bethesda, MD 20892–3600
        Phone: 1–800–438–5383
        Internet: ndep.nih.gov
      • National Digestive Diseases Information Clearinghouse
        2 Information Way
        Bethesda, MD 20892–3570
        Phone: 1–800–891–5389
        Fax: 703–738–4929
        Email: nddic@info.niddk.nih.govInternet: digestive.niddk.nih.gov/about/index.htm
      • National Heart, Lung, and Blood Institute Information CenterP.O. Box 30105Bethesda, MD 20824–0105Phone: 301–592–8573Fax: 301–592–8563Email: NHLBIinfo@rover.nhlbi.nih.govInternet: www.nhlbi.nih.gov/health/infoctr
      • National Institute of Neurological Disorders and Stroke
        P.O. Box 5801
        Bethesda, MD 20824
        Phone: 1–800–352–9424
        Internet: www.ninds.nih.gov
      • National Kidney and Urologic Diseases Information Clearinghouse
        3 Information Way
        Bethesda, MD 20892–3580
        Phone: 1–800–891–5390
        Fax: 703–738–4929
        Email: nkudic@info.niddk.nih.gov
        Internet: kidney.niddk.nih.gov
      • Pedorthic Footwear Association
        7150 Columbia Gateway Drive, Suite G
        Columbia, MD 21046–1151
        Phone: 1–800–673–8447 or 410–381–7278
        Fax: 410–381–1167
        Internet: www.pedorthics.org

      • National Diabetes Information Clearinghouse
        1 Information Way Bethesda,
        MD 20892–3560
        Email: ndic@info.niddk.nih.gov
      • The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

        This publication was reviewed by Peter J. Dyck, M.D., Peripheral Neuropathy Research Center, Mayo Clinic Rochester, Rochester, MN; Eva L. Feldman, M.D., Ph.D., Department of Neurology, University of Michigan, Ann Arbor, MI; and Aaron I. Vinik, M.D., The Diabetes Research Institute, Eastern Virginia Medical School, Norfolk, VA.


        This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.
        NIH Publication No. 02–3185May 2002
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      Introduction - The Brain

      Introduction ... The Brain
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      The brain is the most complex part of the human body. This three-pound organ is the seat of intelligence, interpreter of the senses, initiator of body movement, and controller of behavior. Lying in its bony shell and washed by protective fluid, the brain is the source of all the qualities that define our humanity. The brain is the crown jewel of the human body.
      ...
      For centuries, scientists and philosophers have been fascinated by the brain, but until recently they viewed the brain as nearly incomprehensible. Now, however, the brain is beginning to relinquish its secrets. Scientists have learned more about the brain in the last 10 years than in all previous centuries because of the accelerating pace of research in neurological and behavioral science and the development of new research techniques. As a result, Congress named the 1990s the Decade of the Brain. At the forefront of research on the brain and other elements of the nervous system is the National Institute of Neurological Disorders and Stroke (NINDS), which conducts and supports scientific studies in the United States and around the world.
      This fact sheet is a basic introduction to the human brain. It may help you understand how the healthy brain works, how to keep it healthy, and what happens when the brain is diseased or dysfunctional.
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      This fact sheet is a basic introduction to the human brain. It may help you understand how the healthy brain works, how to keep it healthy, and what happens when the brain is diseased or dysfunctional.



      The brain is like a committee of experts. All the parts of the brain work together, but each part has its own special properties. The brain can be divided into three basic units:



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      The forebrain is the largest and most highly developed part of the human brain: it consists primarily of the cerebrum and the structures hidden beneath it (see The Inner Brain).


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      The uppermost part of the brainstem is the midbrain, which controls some reflex actions and is part of the circuit involved in the control of eye movements and other voluntary movements.

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      The hindbrain includes the upper part of the spinal cord, the brain stem, and a wrinkled ball of tissue called the cerebellum The hindbrain controls the body’s vital functions such as respiration and heart rate. The cerebellum coordinates movement and is involved in learned rote movements. When you play the piano or hit a tennis ball you are activating the cerebellum.

      When people see pictures of the brain it is usually the cerebrum that they notice. The cerebrum sits at the topmost part of the brain and is the source of intellectual activities. It holds your memories, allows you to plan, enables you to imagine and think. It allows you to recognize friends, read books, and play games.

      The cerebrum is split into two halves (hemispheres) by a deep fissure. Despite the split, the two cerebral hemispheres communicate with each other through a thick tract of nerve fibers that lies at the base of this fissure. Although the two hemispheres seem to be mirror images of each other, they are different. For instance, the ability to form words seems to lie primarily in the left hemisphere, while the right hemisphere seems to control many abstract reasoning skills.

      For some as-yet-unknown reason, nearly all of the signals from the brain to the body and vice-versa cross over on their way to and from the brain. This means that the right cerebral hemisphere primarily controls the left side of the body and the left hemisphere primarily controls the right side. When one side of the brain is damaged, the opposite side of the body is affected. For example, a stroke in the right hemisphere of the brain can leave the left arm and leg paralyzed.

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      The Geography of Thought

      Each cerebral hemisphere can be divided into sections, or lobes, each of which specializes in different functions. To understand each lobe and its specialty we will take a tour of the cerebral hemispheres, starting with the two frontal lobes which lie directly behind the forehead. When you plan a schedule, imagine the future, or use reasoned arguments, these two lobes do much of the work. One of the ways the frontal lobes seem to do these things is by acting as short-term storage sites, allowing one idea to be kept in mind while other ideas are considered. In the rearmost portion of each frontal lobe is a motor area (4), which helps control voluntary movement. A nearby place on the left frontal lobe called Broca’s area (5), allows thoughts to be transformed into words.

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      When you enjoy a good meal—the taste, aroma, and texture of the food—two sections behind the frontal lobes called the parietal lobes (6), are at work. The forward parts of these lobes, just behind the motor areas, are the primary sensory areas (7). These areas receive information about temperature, taste, touch, and movement from the rest of the body. Reading and arithmetic are also functions in the repertoire of each parietal lobe.

      ...As you look at the words and pictures on this page, two areas at the back of the brain are at work. These lobes, called the occipital lobes (8), process images from the eyes and link that information with images stored in memory. Damage to the occipital lobes can cause blindness. The last lobes on our tour of the cerebral hemispheres are the temporal lobes (9), which lie in front of the visual areas and nest under the parietal and frontal lobes. Whether you appreciate symphonies or rock music, your brain responds through the activity of these lobes. At the top of each temporal lobe is an area responsible for receiving information from the ears. The underside of each temporal lobe plays a crucial role in forming and retrieving memories, including those associated with music. Other parts of this lobe seem to integrate memories and sensations of taste, sound, sight, and touch.
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      The Cerebral Cortex

      Coating the surface of the cerebrum and the cerebellum is a vital layer of tissue the thickness of a stack of two or three dimes. It is called the cortex, from the Latin word for bark. Most of the actual information processing in the brain takes place in the cerebral cortex. When people talk about "gray matter" in the brain they are talking about this thin rind. The cortex is gray because nerves in this area lack the insulation that makes most other parts of the brain appear to be white. The folds in the brain add to its surface area and therefore increase the amount of gray matter and the quantity of information that can be processed.

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      The Inner Brain

      Deep within the brain, hidden from view, lie structures that are the gatekeepers between the spinal cord and the cerebral hemispheres. These structures not only determine our emotional state, they also modify our perceptions and responses depending on that state, and allow us to initiate movements that you make without thinking about them. Like the lobes in the cerebral hemispheres, the structures described below come in pairs: each is duplicated in the opposite half of the brain.
      The hypothalamus
      (10) about the size of a pearl, directs a multitude of important functions. It wakes you up in the morning, and gets the adrenaline flowing during a test or job interview. The hypothalamus is also an important emotional center, controlling the molecules that make you feel exhilarated, angry, or unhappy. Near the hypothalamus lies the thalamus (11), a major clearinghouse for information going to and from the spinal cord and the cerebrum.

      An arching tract of nerve cells leads from the hypothalamus and the thalamus to the hippocampus (12). This tiny nub acts as a memory indexer—sending memories out to the appropriate part of the cerebral hemisphere for long-term storage and retrieving them when necessary. The basal ganglia (not shown) are clusters of nerve cells surrounding the thalamus. They are responsible for initiating and integrating movements. Parkinson’s disease, which results in tremors, rigidity, and a stiff, shuffling walk, is a disease of nerve cells that lead into the basal ganglia.

      Making Connections

      The brain and the rest of the nervous system are composed of many different types of cells, but the primary functional unit is a cell called the neuron. All sensations, movements, thoughts, memories, and feelings are the result of signals that pass through neurons. Neurons consist of three parts.

      The cell body (13) contains the nucleus, where most of the molecules that the neuron needs to survive and function are manufactured. Dendrites (14) extend out from the cell body like the branches of a tree and receive messages from other nerve cells. Signals then pass from the dendrites through the cell body and may travel away from the cell body down an axon (15) to another neuron, a muscle cell, or cells in some other organ. The neuron is usually surrounded by many support cells. Some types of cells wrap around the axon to form an insulating sheath (16). This sheath can include a fatty molecule called myelin, which provides insulation for the axon and helps nerve signals travel faster and farther. Axons may be very short, such as those that carry signals from one cell in the cortex to another cell less than a hair’s width away. Or axons may be very long, such as those that carry messages from the brain all the way down the spinal cord.

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      Scientists have learned a great deal about neurons by studying the synapse—the place where a signal passes from the neuron to another cell. When the signal reaches the end of the axon it stimulates tiny sacs (17). These sacs release chemicals known as neurotransmitters (18) into the synapse (19). The neurotransmitters cross the synapse and attach to receptors (20) on the neighboring cell. These receptors can change the properties of the receiving cell. If the receiving cell is also a neuron, the signal can continue the transmission to the next cell.

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      Some Key Neurotransmitters at Work:

      • Acetylcholine is called an excitatory neurotransmitter because it generally makes cells more excitable. It governs muscle contractions and causes glands to secrete hormones. Alzheimer’s disease, which initially affects memory formation, is associated with a shortage of acetylcholine.
      • GABA (gamma-aminobutyric acid) is called an inhibitory neurotransmitter because it tends to make cells less excitable. It helps control muscle activity and is an important part of the visual system. Drugs that increase GABA levels in the brain are used to treat epileptic seizures and tremors in patients with Huntington’s disease.
      • Serotonin is an inhibitory neurotransmitter that constricts blood vessels and brings on sleep. It is also involved in temperature regulation.
      • Dopamine is an inhibitory neurotransmitter involved in mood and the control of complex movements. The loss of dopamine activity in some portions of the brain leads to the muscular rigidity of Parkinson’s disease. Many medications used to treat behavioral disorders work by modifying the action of dopamine in the brain.

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        Neurological Disorders

        When the brain is healthy it functions quickly and automatically. But when problems occur, the results can be devastating. Some 50 million people in this country—one in five—suffer from damage to the nervous system. The NINDS supports research on more than 600 neurological diseases. Some of the major types of disorders include:

        1. neurogenetic diseases (such as Huntington’s disease and muscular dystrophy),
        2. developmental disorders (such as cerebral palsy),
        3. degenerative diseases of adult life (such as Parkinson’s disease and Alzheimer’s disease),
        4. metabolic diseases (such as Gaucher’s disease),
        5. cerebrovascular diseases (such as stroke and vascular dementia),
        6. trauma (such as spinal cord and head injury),
        7. convulsive disorders (such as epilepsy),
        8. infectious diseases (such as AIDS dementia), and
        9. brain tumors.

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        The National Institute of Neurological Disorders and Stroke

        Since its creation by Congress in 1950, the NINDS has grown to become the leading supporter of neurological research in the United States. Most research funded by the NINDS is conducted by scientists in public and private institutions such as universities, medical schools, and hospitals. Government scientists also conduct a wide array of neurological research in the more than 20 laboratories and branches of the NINDS itself. This research ranges from studies on the structure and function of single brain cells to tests of new diagnostic tools and treatments for those with neurological disorders...

        For information on other neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute's Brain Resources and Information Network (BRAIN) at:

        BRAINP.O. Box 5801Bethesda, MD 20824

        (800) 352-9424

        http://www.ninds.nih.gov/Top..

        Prepared by:

        Office of Communications and Public Liaison

        National Institute of Neurological Disorders and Stroke

        National Institutes of Health

        Bethesda, MD 20892..

        NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient's medical history.

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        All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.

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        NIH Publication No.01-3440a

        Last updated December 08, 2005 ..




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