Doctors assign the term erectile dysfunction to medical conditions of different patients: those who are not able to maintain an erection without aid kamagra australia like his physical form and other aspects, but age related decrease of sexual intercourse doesn't happen overnight.

Nerves and neuropathy

Nerves and Neuropathy Janice Wiesman M.D. Adjunct Assistant Professor of Neurology Boston University School of Medicine

What is a nerve? • A nerve is a cable-like bundle of axons that runs between the spinal cord and the periphery • Axons transmit information by an electrical current that runs along the axon like a wire in your home • The axons are each surrounded by a fatty coating, called myelin, that acts like insulation on a wire

What is an axon? • An axon is the arm-like extension of a nerve cell (neurons) • There are motor, sensory and autonomic neurons which send out axons • The neurons are located in or near the End that
contacts the
muscle or skin

Motor Axons (to muscle) • Motor axons run from the motor neuron cell body in the spinal cord via nerves to contact a muscle cell • When the motor neuron fires an electrical impulse, the impulse races down the axon and the end of the axon releases a chemical, called a neurotransmitter, that causes the muscle cell to contract. Sensory Axons (from skin) • Sensory axons bring information from the skin and organs up to the spinal cord so we can feel, hear, taste, smell and see • The sensory neuron sits just outside the spinal cord and sends one long axon out to the skin and sends one short axon into the spinal cord • The cells bodies that make these axons sit in the spinal cord and in brainstem and send out axons that contact – Salivary glands in the mouth – Tear glands in the eye – Muscle in the walls of blood vessels – Muscle in the walls of the stomach and What is Neuropathy? • Neuropathy is a general term meaning damage to a nerve • One nerve = mononeuropathy – Example carpal tunnel syndrome • Many nerves = polyneuropathy – Also called peripheral neuropathy Nerve Damage in amyloidosis • Seen in most types – Primary (AL) – Inherited • TTR – also called Familial Amyloid Polyneuropathy • Gelsolin • ILE122 (though not common) – Not typically seen • AA amyloid • Focal amyloid Nerve Damage in Amyloidosis • Can be one nerve – Carpal tunnel syndrome • Can be multiple (but not all) nerves • Can be generalized disorder of nerves – Amyloid polyneuropathy = peripheral Amyloid Polyneuropathy • Axonal, length-dependent, symmetrical, dying- – Axon itself is damaged • Compression • Metabolic component – Longest nerves affected first – why? – Symmetrical – The nerve degenerates from the end, upward – Thin axons affected first (pain and autonomic) – Thick axons affected later (to muscle) Symptoms of Polyneuropathy • Same in amyloid as in neuropathy due to diabetes, kidney failure or alcohol use • Start in feet, slowly climbs up the legs. When the symptoms are at knee level may have symptoms in the hands Symptoms of Polyneuropathy • Tingling, numbness, burning, feeling cold, feeling like walking on cotton/something in your shoe • Often feel worse at night – Off your feet – Not distracted Symptoms of Polyneuropathy • Why does it feel numb and painful at the – Different axons mediate different sensations – Thin axons mediate pain sensation • When damaged, they fire – brain "feels" it as pain – Thick axons mediate touch and pressure • When damaged, do not transmit information to the brain – so brain does not "feel" touch Diagnosis of Amyloid • History • Examination • Nerve Conduction Studies • Electromyography (EMG) • Blood work • Nerve biopsy (not common) • No other cause Polyneuropathy related to the organ damage caused by amyloidosis • Kidney dysfunction • Malnutrition Polyneuropathy related to other medical problems – Good sugar control is key • Regular alcohol consumption – Don't hit your nerves when they are down – Ask your doctor Polyneuropathy related to treatment of amyloidosis • Not an issue with inherited forms • Primary amyloidosis – Chemotherapy • Revlimid (derived from thalidomide) • Velcade • Platinum medications • Typically improves after treatment stopped – 6-12 months typical • NOT – dexamethasone or Melphalan If I am treated will my nerves • Maybe • Nerves regrow best in people who are young and otherwise healthy • Nerves grow back slowly Treatment of Polyneuropathy • First ask – Do I Need To Be Treated? – Is underlying disease being treated? – No treatment to make nerves grow back – Treatment is symptomatic • Crazy-making: Yes or No?? Symptomatic Treatment of • Without Medication – Foot rub or warm water foot massage before – Acupuncture (but check with your doctor regarding risk of infection!!!) Symptomatic Treatment • Topical Medication – Lidoderm patch – topical anesthetic – Solarcaine – topical anesthetic – Capsacin • causes release of Substance P (causes pain) • initially increases pain • must be used 2-3 times/day Symptomatic Treatment • Anti-seizure medications – Lyrica (pre-gabalin) – Neurontin (gabapentin) – others • Antidepressants – Cymbalta (duloxetine) – "tricyclic antidepressants" like Elavil – not typically used in • Anti-inflammatory – Aspirin-like drugs – Tylenol – Extended release pills or patch Treatments for severe pain – Extended release pill or patch • Nerve stimulation (TENS) • Spinal cord stimulation – Very invasive, risk of infection Symptoms of Autonomic • Dry eyes and mouth – Nerves to the glands are damaged • Trouble accommodating to bright light – Autonomic nerves control how constriction of the pupil in the eye • Lightheadedness when standing – Blood vessels do not constrict when you stand up – Heart rate does not increase when you stand up • Diarrhea • Constipation • Erectile dysfunction • Talk to your doctor about symptomatic treatment for

$70 for one month A word about foot care • Foot care is important • If you can't feel your feet you can't feel cuts or sores that can become infected. • Foot care tips – Look between and under your toes every day – Wear soft, well fitting shoes – Do not walk barefoot, particularly outside – Keep feet soft and well moisturized – Have nails filed rather than cut • A podiatrist or specialized pedicurist can help • Don't cut your own nails • We want you have all 10 toes, all of the time! A word about muscle disease • Steroids, such as prednisone and dexamethasone can cause wasting and weakness of muscles. • This typically affects muscles that are closest to • Trouble walking up stairs or getting out of a chair • Muscle mass and strength typically return to normal after treatment ends. Carpal tunnel syndrome (CTS) • Common in primary and TTR Amyloidosis • The median nerve runs down from the neck into the hand • At the wrist, the nerve runs under a band of connective tissue that encircles the wrist • Amyloid deposits in the connective tissue and compresses the nerve Carpal Tunnel Syndrome • There are 3 main nerves that go into the hand • The Median nerve runs under the transverse carpal ligament and can be compressed in amyloidosis because amyloid deposits in the ligament and thickens it. • The Radial and Ulnar nerves run over the ligament and are not compressed. Carpal Tunnel Syndrome Carpal Tunnel Syndrome • Tingling, pain ,numbness in the thumb, forefinger and middle finger • Weakness of the thumb and of grip • Trouble opening jars and buttoning • Worse at night, with driving, typing • Ergonomic adjustment • Wrist brace • Local injection of steroid • Surgery – Always make sure the surgeon sends a sample of the connective tissue band to pathology!! What you can do for healthy 1. CUT DOWN ON ALCOHOL – IT IS DIRECTLY TOXIC TO NERVES 2. STOP SMOKING – WITH EVERY PUFF YOU CAUSE CONSTRICTION OF THE BLOOD VESSELS THAT NOURISH NERVES 3. EAT A LOT OF FRUITS AND VEGETABLES, ESPECIALLY DARK GREEN LEAFY VEGETABLES WHICH CONTAIN B VITAMINS (but not if you are taking coumadin) 4. MUSCLES DEPEND ON THEIR NERVE SUPPLY TO STAY HEALTHY – USE THEM BOTH • Healthy Nerves pamphlet on ASG website • Boston University Amyloid Treatment and Research Website – Podcasts – Healthy Nerves pamphlet



Material Safety Data Sheet Hazard Alert Code Section 1 - CHEMICAL PRODUCT AND COMPANY IDENTIFICATION PRODUCT NAME STATEMENT OF HAZARDOUS NATURE CONSIDERED A HAZARDOUS SUBSTANCE ACCORDING TO OSHA 29 CFR 1910.1200. Company: Santa Cruz Biotechnology, Inc. Address:2145 Delaware Ave Santa Cruz, CA 95060

LOS ATRIBuTOS DE LOS ACTOS ADMINISTRATIVOS uNILATERALES, SON APLICABLES A LOS CONTRATOS ADMINISTRATIVOS* stRictly unilateRal administRative acts' attRibutes, aRe fully applicable to administRative contRacs Ciro Nolberto Güechá Medina** Universidad Santo Tomás ResumenLa administración pública consigue la realización de sus fines a través de los actos administrativos, los cuales en