Saturday, April 28, 2012

Fainting (Syncope) The article

I. Fainting also known as Syncope of "black out" is defined as a condition of sudden loss of consciousness followed by the return to full wakefulness in a short duration as a result of  abnormally low blood pressure. In most cases, it is caused by hypotension, with blood pressure that's lower than 90/60 mmHg.(1). Even though Low blood pressure has mainly been regarded as good health for people who exercise, but recent studies have indicated an association with depression in elderly people. there are epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.(2). In some case, severely low blood pressure can seriously impair adequate blood flow to vital organs and a life-threatening condition called shock.

II. Symptoms
In the study of Medical Centre/University of Amsterdam, the research team of Wieling W found that Prior to loss of consciousness the affected individual tends to exhibit unclear thinking[1], followed by fixation of the eyes[2] in the midline and a 'frozen' appearance[3]. Narrowing of the field of vision with loss of colour vision[4] ('greying' out) and finally a complete loss of vision[5] (hence 'blacking' out) occurs. Hearing loss[6] may occur following loss of vision. This process may take as little as approximately 7 s in cases of sudden complete circulatory arrest[7] (e.g. abrupt asystole), but in other circumstances it may take longer depending on the rate and depth of cerebral hypoperfusion[8]. Complete loss of consciousness occurs with the 'turning up' of the eyeballs. Profound cerebral hypoperfusion may be accompanied by myoclonic jerks[9].(3)

III. Causes and risk factors
Causes of fainting may be a result of your heart rate and blood vessels can't react fast enough when your body's need for oxygen changes
1. History of any cardiovascular disease and and cardiac arrhythmias
 In  a study of consecutive patients evaluated for syncope from 1996 through 1998 at an academic medical center, we documented causes, clinical characteristics, and recurrence of syncope while driving. Of 3877 patients identified, 381 (9.8%) had syncope while driving (driving group). Compared with the 3496 patients (90.2%) who did not have syncope while driving, the driving group was younger (P=0.01) and had higher percentages of male patients (P<0.001) and patients with a history of any cardiovascular disease (P=0.01) and stroke (P=0.02). Syncope while driving was commonly caused by neurally mediated syncope (37.3%) and cardiac arrhythmias (11.8%). Long-term survival in the driving group was comparable to that of an age- and sex-matched cohort from the Minnesota population (P=0.15). Among the driving group, syncope recurred in 72 patients, 35 of whom (48.6%) had recurrence >6 months after the initial evaluation. Recurrences during driving happened in 10 patients in the driving group, 7 of which (70%) were >12 months after the initial evaluation.(4)

2. Low blood pressure 
researchers suggested that Syncope due to orthostatic hypotension (OH) refers to loss of consciousness caused by hypotension induced by the upright position; it is an important risk factor for fall-related physical injuries, especially in the elderly adults(5). Other report indicated that eventhough Low blood pressure has mainly been regarded as good health for people who exercise, but recent studies have indicated an association with depression in elderly people. there are epidemiological evidence for an association of low blood pressure with anxiety and depression, which is not caused by cardiovascular disease.

3.  Parkinson's disease and neurological comorbidity in olders
Low blood pressure is considered as a major cause of fainting of patient older than 65 years as a result of  Parkinson's disease and neurological comorbidity. (5)

4.  Medication
there is a report that in patients with AD treated with donepezil, a noninvasive evaluation identified a probable cause of syncope in over two-thirds of patients. Cardiovascular abnormalities were predominant. Noninvasive evaluation is recommended before discontinuing treatment with cholinesterase inhibitors in patients with AD and unexplained syncope.(6)

5. Hemodynamic ischemia 
There a report that a patient with convulsive syncope whose convulsive movements seemed to be associated with transient hemodynamic ischemia in the basal ganglia. In Single-photon emission computed tomography (SPECT, a significant decrease in blood flow was revealed in the anterior part of the left basal ganglia, bilateral frontal areas, and right cerebellar hemisphere. An alteration in the functional balance between the basal ganglia and the cerebral cortices may play a role in the generation of convulsive movements in patients with convulsive syncope.(7)

6. Vertebrobasilar disease
Vertebrobasilar disease is a broad classification describing the condition where there is an insufficient delivery of blood flow via the vertebral and/or basilar arteries to the brain.(8)

7. Vasovagal (situational) syncope
A vasovagal episode or vasovagal response or vasovagal attack (also called neurocardiogenic syncope) is a malaise mediated by the vagus nerve. When it leads to syncope or "fainting", it is called a vasovagal syncope, which is the most common type of fainting(9)

8. Deglutition syncope 
Deglutition suncope is defined as a  loss of consciousness on swallowing. There are report that a 49-year-old woman was referred to the ENT department with a 1.5-year history of dysphagia accompanied by globus sensation and regurgitation as well as recurrent syncopal attacks associated with swallowing solid foods(10) and a case of swallow syncope associated with cold beverage ingestion(11) and a woman who faints when she eats and drinks(12) may be as a result of an ambulatory electrocardiogram revealed atrial and ventricular asystoles immediately after swallowing (13)

9. Cardiac syncope
Structural cardiac abnormalities may cause syncope include cardiac obstructions, pulmonary hypertension, and myocardiopathy. Children with congenital heart disease who experienced syncope should always be referred to a specialist. Primary arrhythmias which are easily diagnosed on ECG are complete atrio-ventricular block and Wolff-Parkinson-White syndrome. "Channelopathies" such as the long OT syndrome and catecholaminergic ventricular tachycardia are increasingly recognized in children, carry a high risk of sudden death and deserve a complete work up, including familial screening and lifelong treatment with beta-blockers(14)

10. History of diaphoresis In the investigation of   whether the pattern of presyncopal prodromal symptoms can predict the recurrence probability of vasovagal syncope, fifty-four patients (68.4%) reported at least one of the four main prodromal symptoms. Median syncopal +/- presyncopal spells were 4 episodes. Forty-two patients (53.2%) experienced recurrence of syncope or presyncope during the follow-up period. In recurrent symptomatic patients, diaphoresis had been more significantly reported in their past medical history (p = 0.018) and they had more syncopal spells before TTT (p = 0.001). Age, gender and type of TTT response did not have any effect on the recurrence of VVS.(15)

11.  Prolonged exercise
Some researchers suggested that the magnitude of exercise-induced hypotension (post-exercise hypotension; PEH), and the hypotensive response to postural change (initial orthostatic hypotension; IOH) are predictors of syncope post-exercise, but research team from the University of Otago, found that endurance athletes who present with greater hypotension are not necessarily at a greater risk of syncope than those who present with lesser reductions in BP.(16)

12.  Chiari type I malformation (CMI)
Chiari type I malformation (CMI) is a congenital hindbrain anomaly characterized by downward displacement of the cerebellar tonsils through the foramen magnum. Chiari type I malformation often presents with a complex clinical picture and can be sporadic or linked to a variety of genetic conditions. (17)

13. Low blood sugar
In the study of Syncope and Hypoglycemia posted in International Journal of Clinical Medicine, 2011, 2, 129-132 doi:10.4236/ijcm.2011.22023 Published Online May 201, showed that hypoglycemic syncope should be sus-pected in older diabetic patients with preserved postural tone, usually but not always using insulin therapy, who show a slow recovery from transient loss of consciousness with persisting neurological impairment and low blood glucose levels.(18)

14. Dehydration 
Dehydration  is defined as a condition of  the excessive loss of body fluid. of which can lead to symptoms of decreased blood pressure (hypotension), and dizziness or fainting(19)

15. Family history
In the study conducted by Johns Hopkins Bloomberg School of Public Health, researchers showed that family history of fainting is not a risk factor for adult-onset NMH in fatigued veterans. Our findings may differ from other studies of familial aggregation in NMH because of study methods or because NMH-fatiguers may differ from NMH-fainters.(20)

16. Pregnancy
A 23-year-old woman at 34 weeks' gestation developed recurrent syncope due to profound sinus arrest captured on electrocardiography. Syncopal events occurred in the same sitting position. An echocardiogram revealed severe collapse of the inferior vena cava each time the patient changed her posture from a supine to a sitting position, which was related to the syncope.(21)

17. Etc.

IV. Diagnosis
In the Part 1 of two-part unit outlines. Dr. Meyer A. indicated that the various possible causes of transient loss of consciousness (blackouts), the importance of accurate diagnosis and the impact of misdiagnosis. It also discusses the establishment of specialist clinics in order to help with diagnosis and management.
(22) Other researchers suggested that Syncope is much more common than epilepsy and may present with symptoms akin to the latter. This fact is not well appreciated and often leads to misdiagnosis.(23)
A. Misdiagnosis
1. Seizure
Neurocardiogenic syncope (NCS) can be mistaken as a seizure. Scientists at the Capital Health Authority found that NCS is commonly misdiagnosed as epilepsy. Some patients had an incorrect diagnosis for > 10 years. Patients with this misdiagnosis are often excessively investigated, inappropriately treated, and have unnecessary restrictions placed on driving and employment(24)

2. Cardiac arrest
In the report of presents two patients, both known to have cardiac disease, with implanted cardiac devices, who presented with loss of consciousness, who were initially investigated for epilepsy, but were subsequently shown to have had a cardiac arrhythmia, diagnosed following device interrogation.(25)

3. Status cataplecticus 
A 76-year-old patient, since the age of 45, presented with frequent attacks often triggered by emotional stimuli and characterised by forward head drop and a fall to the ground without loss of consciousness. Status cataplecticus misdiagnosed as recurrent syncope(26)

4. Etc.

B. Diagnosis
1. According to the University of Wisconsin School of Medicine suggestion in Diagnosing syncope. Part 1, Dr. Linzer M,  and the team indicated that Despite the absence of a diagnostic gold standard and the paucity of data from randomized trials, several points emerge. First, history, physical examination, and electrocardiography are the core of the syncope workup (combined diagnostic yield, 50%). Second, neurologic testing is rarely helpful unless additional neurologic signs or symptoms are present (diagnostic yield of electroencephalography, computed tomography, and Doppler ultrasonography, 2% to 6%). Third, patients in whom heart disease is known or suspected or those with exertional syncope are at higher risk for adverse outcomes and should have cardiac testing, including echocardiography, stress testing. Holter monitoring, or intracardiac electrophysiologic studies, alone or in combination (diagnostic yields, 5% to 35%). Fourth, syncope in the elderly often results from polypharmacy and abnormal physiologic responses to daily events. Fifth, long-term loop electrocardiography (diagnostic yield, 25% to 35%) and tilt testing (diagnostic yield < or = 60%) are most useful in patients with recurrent syncope in whom heart disease is not suspected. Sixth, psychiatric evaluation can detect mental disorders associated with syncope in up to 25% of cases. Seventh, hospitalization may be indicated for patients at high risk for cardiac syncope (those with an abnormal electrocardiogram, organic heart disease, chest pain, history of arrhythmia, age > 70 years) or with acute neurologic signs and suggested that Many tests for syncope have a low diagnostic yield. A careful history, physical examination, and electrocardiography will provide a diagnosis or determine whether diagnostic testing is necessary in most patients.(27)

2. According to the University of Wisconsin School of Medicine suggestion in Diagnosing syncope. Part 2. Dr. Linzer M,  and the team indicated that after a thorough history, physical examination, and electrocardiography, the cause of syncope remains undiagnosed in 50% of patients. In such patients, information may be derived from the results of carefully selected diagnostic tests, especially 1) electrophysiologic studies in patients with organic heart disease, 2) Holter monitoring or telemetry in patients known to have or suspected of having heart disease, 3) loop monitoring in patients with frequent events and normal hearts, 4) psychiatric evaluation in patients with frequent events and no injury, and 5) tilt-table testing in patients who have infrequent events or in whom vasovagal syncope is suspected. Hospitalization is indicated for high-risk patients, especially those with known heart disease and elderly patients.(28)
V. Preventions
A. Do and do not list
1. Avoid fatigue
  It may be the result of the physiological mechanisms that regulate blood pressure and actually trigger neurally mediated hypotension, because of miscommunication between the heart and the brain which causes blood pressure to lower when it should rise.(29)

2. Anxiety, fear, pain, intense emotional stress, hunger, or use of alcohol or drug
Sometime, you may suffer a simple fainting spell as a result of anxiety, fear, pain, intense emotional stress, hunger, or use of alcohol or drugs. Most people who suffer from simple fainting have no underlying heart or neurological (nerve or brain) problem.(30)

3. Avoid changing positions quickly and standing for long periods of time, always getting up from a sitting or lying-down position slowly by preventing postural hypotension cause of fainting

4. Drink plenty of fluids
At least 8-10 glasses per day is necessary to enhance the blood volume.

5. Aerobic exercise
Aerobic exercise can also help prevent fainting, and strengthening the leg muscles can improve the circulation and helps avoid pooling of blood in the lower part of the body.

6. Sleep with the foot of your bed raised
The position will promote blood flow to the brain and allow the blood trapped in the legs to return to the heart.

7. Avoid Wearing elastic stockings 
As this may cause blood to be trapped in the leg of which reduce blood flow to the brain

8. Medication, such as diuretic, Vasodilators (hydralazine, nitrates, angiotensin-converting enzyme inhibitors may cause the drop of blood pressure excessively

9. Tight clothing around the neck can reduce blood flow to the brain

10. Avoid caffeine
Too much caffeine may cause an arrhythmia(31), a fast or irregular heartbeat of that can lead chest pain, fainting, dizziness, shortness of breath, etc.

11. Etc.
B. Diet against syncope 
1. Salmon
a. Cardiovascular disease
It contains high levels of Omega-3 Fatty Acids that helps to reduce the levels of bad cholesterol, thus reducing the risk of hardening of arteries and veins and damaging the functions of amino acids in repairing the cardiovascular tissues according to the study of "Fish oil for the treatment of cardiovascular disease" by Weitz D, Weintraub H, Fisher E, Schwartzbard AZ, posted in PubMed(32)

b. Antioxidants
In the research of the antioxidant effect of vitamin E after ingestion of salmon found that that megadoses of vitamin E, far from having pro-oxidative activity, actually increase the anti-oxidative capacity of the liver, especially after ingestion of salmon oil, according to "Effects of megadoses of dietary vitamin E on the antioxidant status of rats fed lard or salmon oil" by Flader D, Brandsch C, Hirche F, Eder K.(33) 

c. Omega 3 fatty acids
Omega 3 fatty acids is necessary to maintain the ratio of good and bad cholesterol, thus reducing the risk of cholesterol inflammation according to the study of "In vitro fatty acid enrichment of macrophages alters inflammatory response and net cholesterol accumulation" by Wang S, Wu D, Lamon-Fava S, Matthan NR, Honda KL, Lichtenstein AH., posted in PubMed (IV) and forming of free radical in the heart cells, leading to heart diseases. It also reduces the risk of plaque forming in the arterial wall, thus also decreasing the risk of stoke, according to the study of "N-3 vs. saturated fatty acids: effects on the arterial wall" by Sudheendran S, Chang CC, Deckelbaum RJ., posted in PubMed (34).

2. Flaxseed
a. Cardiovascular health
In the research of
Flaxseed and its effect on cardiovascular risk found that flaxseed can modestly reduce serum total and low-density lipoprotein cholesterol concentrations, reduce postprandial glucose absorption, decrease some markers of inflammation, and raise serum levels of the omega-3 fatty acids, ALA and eicosapentaenoic acid. Data on the antiplatelet, antioxidant, and hypotensive effects of flaxseed, however, are inconclusive. More research is needed to define the role of this functional food in reducing cardiovascular risk, according to "Flaxseed and cardiovascular risk' by Bloedon LT, Szapary PO.(35)

Hypercholesterolemic atherosclerosis
In the evaluation of
Flaxseed (Type I flaxseed) and CDC-flaxseed (Type II flaxseed) and theirs effect onhypercholesterolemic atherosclerosis found that Type II flaxseed reduced the development of atherosclerosis by 69%, according to "Reduction of hypercholesterolemic atherosclerosis by CDC-flaxseed with very low alpha-linolenic acid" by Prasad K, Mantha SV, Muir AD, Westcott ND.(36) 

c. Omega 3 fatty acids
Besides well known for its benefits for the maintenance of a healthy cardio-vascular system, according to the study of "Omega-3 Fatty acids for cardiovascular disease prevention" by Defilippis AP, Blaha MJ, Jacobson TA, posted in PubMed(37) and proper ratio of Omega 3 and 6 fatty acid and prevent blood clotting, it also extends the portion of your cycle in which you are fertile, by promoting natural ovulation, according tothe study of "Postpartum ovarian activity in multiparous Holstein cows treated with bovine somatotropin and fed n-3 fatty acids in early lactation" by Carriquiry M, Dahlen CR, Weber WJ, Lamb GC, Crooker BA., posted in pubMed (38)

3.  Garlic (39)
a, Garlic for VARICOSE VEINS. Garlic helps to keep your blood from clumping or becoming too sticky, helping your blood move through your blood vessels and reduces the risk of blood clots. One clove a day should do the trick. You can also take garlic capsules. CAUTION: Medication and Garlic could lead to uncontrolled bleeding and spell HEMORRHAGIC STROKES if it occurs in your brain. To avoid this, take caution against taking standardized garlic extract. Experts suggest eating no more than one clove of garlic a day.

b. Garlic For BLOOD FORTIFIER. Raw garlic is said to do a super job of blood fortifying. It also helps REJUVENATE the body. Eat raw garlic and garlic supplements daily.

c. Garlic For CHOLESTEROL: Eating 4 cloves of garlic a day can cut total CHOLESTEROL by 70%(Fresh or Supplement). The member of the allium family fights poor circulation.The sulfur compound in garlic keep your platelets from clumping together.

4. Black Beans
a. Nervous system
Protein is essential for the brain in transmitting information between themselves and cells in the other parts of the body, thus reducing the blood sugar levels from rising too rapidly after a meal, reducing the risk of nervous symptoms cause of anxiety, stress and depression, etc., according to the study of "The planar polarity protein Scribble1 is essential for neuronal plasticity and brain function" by Moreau MM, Piguel N, Papouin T, Koehl M, Durand CM, Rubio ME, Loll F, Richard EM, Mazzocco C, Racca C, Oliet SH, Abrous DN, Montcouquiol M, Sans N (40)

b. Antioxidant
Black bean contains flavoinoid, the powerful antioxidant (it contains more antioxidant than any bean in the same family with difference skin colors). It not only enhances the immune system in regulating cells in DNA replication and division, but also improves the immune system in fighting against the forming of free radical and protects our body from infection and inflammation. In a study of "Evaluation of Crocus sativus L. stigma phenolic and flavonoid compounds and its antioxidant activity" by Karimi E, Oskoueian E, Hendra R, Jaafar HZ., posted in Pubmed (41), researchers found that In summary, saffron stigmas showed antioxidant activity and methanol appeared to be the best solvent to extract the active components, among which the presence of gallic acid and pyrogallol might contribute towards the stigma's antioxidant properties.

c. Low-density lipoprotein
in the evaluation of fermentation on the contents of total phenolics and amino nitrogen pf balck bean and their lowering cholesterol effect found that the A. awamori-fermented black soybean prepared at 30 °C for 3 days exhibited the highest inhibitory effect on LDL oxidation. The bioactive principles related to the inhibitory effect on LDL oxidation in black soybeans, regardless of fermentation, could be most efficiently extracted with water rather than 80% methanol or 80% ethanol, according to "Fermentation with Aspergillus awamori enhanced contents of amino nitrogen and total phenolics as well as the low-density lipoprotein oxidation inhibitory activity of black soybeans" by Chen YF, Lee SL, Chou CC.(42) 

5.  Broccoli
a. Potential heart health benefits
In the investigation of cruciferous vegetables which include broccoli, cabbage and cauliflower and theirs bioactive components in functional foods effect for the improvement of health found that the molecular basis of the biological activities of the chemicals present in broccoli potentially responsible for health promotion, from chemoprevention to cardio protection, are outlined based on in vitro and in vivo studies with a note on the structure activity relationship of sulforaphane and a few other isothiocyanates, according to "Potential health benefits of broccoli- a chemico-biological overview" by Vasanthi HR, Mukherjee S, Das DK.(43) 

b. Free radicals 
Broccoli helps to fight against the forming of free radical by detoxificating and cleansing the toxins accumulated in the body, according to "Effect of broccoli (Brassica oleracea) and its phytochemical sulforaphane in balanced diets on the detoxification enzymes levels of tilapia (Oreochromis niloticus) exposed to a carcinogenic and mutagenic pollutant" by Villa-Cruz V, Davila J, Viana MT, Vazquez-Duhalt R.(44)  

6. Blueberries
a. Antioxidant Capacity
In the investigation of
Blueberry and blackberry wines commercially available in Illinois and theirs potential health benefits, found that fruit wines made from blueberries and blackberries may have potential health applications and therefore could contribute to the economy of the wine industry. Practical Application: The majority of wines are produced from grapes, but wine can also be produced from other fruits including blueberries and blackberries, which contain phenolic compounds that may contribute to human health, according to "Comparison of Chemical Composition and Antioxidant Capacity of Commercially Available Blueberry and Blackberry Wines in Illinois" by Johnson MH, Gonzalez de Mejia E.(45)

b. Cardiovascular health
In the
rmination of polyphenols, especially anthocyanins, micronutrients, and fiber in berries, including to chokeberries, cranberries, blueberries, and strawberries found that purified anthocyanin extracts have demonstrated significant improvements in LDL oxidation, lipid peroxidation, total plasma antioxidant capacity, dyslipidemia, and glucose metabolism. Benefits were seen in healthy subjects and in those with existing metabolic risk factors. Underlying mechanisms for these beneficial effects are believed to include upregulation of endothelial nitric oxide synthase, decreased activities of carbohydrate digestive enzymes, decreased oxidative stress, and inhibition of inflammatory gene expression and foam cell formation. Though limited, these data support the recommendation of berries as an essential fruit group in a heart-healthy diet, according to " Berries: emerging impact on cardiovascular health" by Basu A, Rhone M, Lyons TJ.(46) 

8. Etc.

C. Nutritional supplement against syncope
1. Omega-3 fatty acids
a. Vascular smooth muscle tone
In the investigation of the comparative effects of omega-3, omega-6 and omega-9 fatty acids on vascular smooth muscle tone, showed that Docosahexaenoic acid (1-255 microM) and eicosapentaenoic acid (31-255 microM) inhibited phenylephrine-induced contractions, (8-63%) and (20-65%), respectively, which were not altered by indomethacin, NDGA, or by removal of the endothelium. Linoleic acid (18:2n6) and arachidonic acid (20:4n6) also induced significant relaxation. Therefore, fatty acid-induced relaxation of the rat aorta is specific to polyunsaturated fatty acids, 20:5n3, 22:6n3, 18:2n6 and 20:4n6, according to "Effects of omega-3, omega-6 and omega-9 fatty acids on vascular smooth muscle tone" by Engler MB.(47)

b. Systolic blood pressure, triglycerides and LDL cholesterol
In the ccomparison of the cardiovascular risk-reduction potential of three major polyunsaturated fatty acids in a double-blind study. showed that for the diet supplemented with EPA plus DHA compared with the linoleic acid diet systolic blood pressure fell 5.1 mm Hg (p = 0.01); plasma triglyceride and VLDL cholesterol fell by 39% (p = 0.001) and 49% (p = 0.01), respectively; and LDL cholesterol rose by 9% (p = 0.01). There were no significant changes with the diet supplemented with alpha-linolenic acid. The net effect on cardiovascular risk therefore is complex and the systolic blood pressure reduction was substantial, according to "n-3 fatty acids of marine origin lower systolic blood pressure and triglycerides but raise LDL cholesterol compared with n-3 and n-6 fatty acids from plants" by Kestin M, Clifton P, Belling GB, Nestel PJ.(48)

c. Cardiovascular effects
In the comparison of the effects of alpha-linolenic acid (ALA, C18:3n-3) to those of eicosapentaenoic acid (EPA, C20:5n-3) plus docosahexaenoic acid (DHA, C22:6n-3) on cardiovascular risk markers in healthy elderly subjects, found that Both n-3 fatty acid diets did not change concentrations of total-cholesterol, LDL-cholesterol, HDL-cholesterol, triacylglycerol and apoA-1 when compared with the oleic acid-rich diet. However, after the EPA/DHA-rich diet, LDL-cholesterol increased by 0.39 mmol/l (P = 0.0323, 95% CI (0.030, 0.780 mmol/l)) when compared with the ALA-rich diet. Intake of EPA/DHA also increased apoB concentrations by 14 mg/dl (P = 0.0031, 95% CI (4, 23 mg/dl)) and 12 mg/dl (P = 0.005, 95% CI (3, 21 mg/dl)) versus the oleic acid and ALA-rich diet, respectively. Except for an EPA/DHA-induced increase in tissue factor pathway inhibitor (TFPI) of 14.6% (P = 0.0184 versus ALA diet, 95% CI (1.5, 18.3%)), changes in markers of hemostasis and endothelial integrity did not reach statistical significance following consumption of the two n-3 fatty acid diets, according to "Effects of alpha-linolenic acid versus those of EPA/DHA on cardiovascular risk markers in healthy elderly subjects" by Goyens PL, Mensink RP.(49)

d. Cognitive effects
In the assessment of the cognitive effects of fish oil supplementation at college age, hypothesizing benefits on affect, executive control, inhibition, and verbal learning and memory. College-aged participants, indicated that the benefits of n-3 PUFA on RAVLT performance derived more from depreciated placebo performance than improved performance due to fish oil. The placebo gain on TMT performance likely derived from a learning effect. Together, these results present limited cognitive benefits of n-3 PUFA at college age; however, the treatment may have been subtherapeutic, with a larger sample needed to generalize these results, according to "Omega-3 polyunsaturated fatty acids and cognition in a college-aged population" by Karr JE, Grindstaff TR, Alexander JE.(50)

2. Antioxidant for heart health
2.1. Antioxidants and ischemia(51)
a. Nitric oxide (NO)

Nitric oxide (NO), one of the antioxidant and peroxynitrite can inhibit pathways of oxygen radical generation, and, in turn, oxidants can inhibit NO synthesis from NOS.

b. glutathione and vitamin E
Reduced form of glutathione may act as a first line of defense against oxidative stress during ischemia–reperfusion while vitamin E may act later on during severe oxidative stress by rendering resistance to the heart against the ischemic–reperfusion injury

c. 2-dithiole-3-thione (D3T)
Researcher found that in rat cardiac H9c2 cells, D3T and time-dependent induction of a number of cellular antioxidants and phase 2 enzymes, including catalase, reduced glutathione (GSH), GSH peroxidase, glutathione reductase (GR), GSH S-transferase (GST), and NADH:quinone oxidoreduc- tase-1 (NQO1) help to protect against H9c2 cell injury caused by various oxidants and simulated ischemia-reperfusion. D3T pretreatment also resulted in decreased intracellular accumulation of reactive oxygen in H9c2 cells after exposure to the oxidants as well as simulated ischemia-reperfusion.

d. Selenium
Deficeiency of of a co-enzyme selenium, which is required in maintaining the glutathione redox cycle, also promote more susceptible to oxidative injure.

e. Etc.
2.2. Antioxidants and Atherosclerosis(52)
a. Bioflavonoids or vitamin P
Discovered by Szent-Gyorgyi and his colleagues back in the 1930`s. In Laboratory tests, B
bioflavonoids help to reduce the fragility and “permeability” in capillaries and prevent the clotting up of arterial as a result of oxidation.

b. Vitamins C and E, beta-carotene
Recent research findings have suggested that antioxidants such as vitamin C, E and beta carotene play an important role in the prevention of atherosclerosis. Data from animal studies showed they are able to prevent oxidative modification of low density lipoproteins (LDL).

c. Alpha-tocopherol
Alpha-tocopherol, a antioxidant found abundant in vitamin E, helps to decrease lipid peroxidation and platelet aggregation, adhesion and inflammatory. Epidemiological studies suggest that low levels of antioxidants are associated with increased risk for cardiovascular disease.

d. Vitamin C and E
Studies showed in take of 500mg of vitamin C and 400 IU of vitamin E helps to retard the progression of coronary atherosclersis.

e. Chlorophyl
Antioxidant chorophyll in the green algae shows to inhibit the chemical cadmium of smoking, by preventing from oxidation that cause building up of plaque along the walls of arteries.

f. Etc.

3. Coenzyme Q10
 Lower CoQ10 is a risk factor to coronary artery disease and chronic heart failure (CHF) and mortality due to CHF suggest that low CoQ10 is another factor explaining the risk to cardiovascular disorder in depression.(53)

4. Acetyl-L-carnitine
a. Acetyl-L-carnitine prevented the marked cognitive decline otherwise observed in normal mice maintained on this challenge diet(54)

b. Many clinical trials have suggested Acetyl-L-carnitine (ALC) and propionyl-L-carnitine (PLC) as potential strategies in the management of peripheral arterial disease, heart and cerebral ischemia, and congestive heart failure(55)

5. Alpha-lipoic acid
Alpha-lipoic acid (LA) is highly effective in preventing the endotoxin-induced oxidative stress in the heart and in improving the glutathione redox system.(56)

6.  Allyl sulfides
a. Antioxidant against oxidation
According to the study of " Antioxidant Health Effects of Aged Garlic Extract" by Carmia Borek, posted in (Journal of Nutrition. 2001;131:1010S-1015S.)© 2001 The American Society for Nutritional Sciences, researcher found that AGE contains a wide range of antioxidants that can act in synergistic or additive fashion and protect cells against oxidative damage, thus helping to lower the risk of heart disease, stroke, cancer and Alzheimer’s disease and protect against toxic, tissue-damaging effects of ROS-producing radiation, including UV light, drugs used in therapy and chemicals in the environment and industry.(57)

b. Cholesterol, heart disease and stroke
In an article of "GARLICTHE BOUNTIFUL BULB" by Carmia Borek, Ph.D. posted in Life extension magazine, the author indicated that in the past 15 years, garlic supplementation studies have concentrated on the bulb's effects in reducing blood cholesterol and triglycerides (the form in which fat is transported in the blood). All studies did not agree with one another, given differences in the kind of garlic preparation, quality of standardization, doses and periods of treatment. But most findings showed that garlic slightly lowered blood cholesterol, LDL cholesterol and triglycerides with a consistent lowering of blood lipids seen in studies that used aged garlic extract as the supplement. For example, while a University of Oxford study showed that garlic powder, given to patients at 900 mg a day for six months, had no protective effects and did not lower cholesterol levels, a study at East Carolina University found that aged garlic extract given at 2.4-4.8 gm a day, for six months, lowered cholesterol by 5-7%, and reduced LDL, triglycerides and blood pressure in men with high cholesterol.(58)

c.  Blood circulation
In an article of "Onions, Garlic, and Scallions... Oh My!" By Dr. Leo Galland, M.D., and Jonathan Galland", posted in the Chritian Broacasting Network, the authors wrote that scientists believe the components in onions, garlic, and scallions called allyl sulfides and bioflavonoids are key to their powerful health benefits. For cardiovascular health, clinical experiments have shown regular consumption of garlic may help improve circulation and help decrease calcium deposits and the size of arterial plaque in coronary arteries. As for detoxification, one study found that eating fresh garlic and onions each day can help remove toxins from the body.(59)

7. Etc.
VI. Treatments
A. In conventional medicine perspective
1. Prehospital Care(60)
Acute care to someone faint must be taken to increase blood flow to the brain, such as with the legs raise, loosen all tight clothing, crossing the legs or squeezing the thighs together, etc. and call 911. The patient may require the below from the medical team.
a. Intravenous access
b. Oxygen administration
c. Advanced airway techniques
d. Glucose administration
e. Pharmacologic circulatory support
f. Pharmacologic or mechanical restraints
g. Defibrillation or temporary pacing
h. Etc

2. Medication
2.1. Beta blockers
a. Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists are the most commonly used type of medication to prevent syncope, as a result of blunting of elevated catecholamine levels that precede vasovagal syncope. Dr. John R. Kapoor, MD, PhD at the Stanford University said "Notwithstanding the widespread use of beta-blockers in the past, some studies on chronic beta-blocker use have been less than encouraging and may suggest some benefit in older but not in younger patients, as mentioned in the recent article by Tan and Parry"(61). In other study group consisted of 62 patients (29 females, mean age 32.8+/-12.3 years and 33 males, mean age 35.9+/-18.2 years) with at least two syncopal episodes during the six months preceding positive tilt testing, propranolol administered intravenously prevents syncope during tilt testing in a significant proportion of patients. Both complete or partial efficacy of intravenous propranolol predict long-term efficacy of chronic beta blocker therapy in patients with vaso-vagal syncope.(62)

b. Side effects
Major cardiac effects caused by beta blockade include the precipitation or worsening of congestive heart failure, and significant negative chronotropy(62a) and severe and therapy-resistant rhinitis, sinusitis, and nasal polyp(62b)
and (62c)
* Nausea
* Diarrhea
* Bronchospasm
* Dyspnea
* Cold extremities
* Dizziness
* Hair loss
* Abnormal vision
* Insomnia
* Nightmares
* Sexual dysfunction
* Erectile dysfunction
* Etc.

2.2. Serotonin re-uptake inhibitor (SSRI)
a Antidepressants are commonly used in the treatment of depression, anxiety disorders, and some personality disorders. In the study to assess whether the well-tolerated serotonin re-uptake inhibitor paroxetine hydrochloride could prevent vasovagal syncope in young patients resistant to or intolerant of previous traditional therapies, Paroxetine significantly improved symptoms of young patients with recurrent vasovagal syncope unresponsive to or intolerant of traditional medications and was well tolerated by patients.(63). Other report indicated that the serotonin reuptake inhibitor sertraline hydrochloride can be effective in preventing recurrent neurocardiogenic syncope in selected patients unresponsive to or intolerant of other therapeutic modalities.(64)

b. Side effects (65)
Almost all SSRIs are known to cause one or more of these symptoms, including Sexual Dysfunction(66) and withdrawal syndrome(67), Suicide risk(68) and
* Nausea/vomiting
* Drowsiness or somnolence
* Headache (very common as a short-term side effect)
* Bruxism
* Extremely vivid or strange dreams
* Dizziness
* Fatigue
* Mydriasis (pupil dilation)
* Urinary retention
* Changes in appetite
* Insomnia
* Etc.
In rare case, SSRI antidepressants may cause cardiac effects, according to American Family Physician, 8/1/97 by Grace Brooke Huffman, but SSRIs are safe and do not have a high rate of cardiovascular adverse events. However, further study is needed to determine whether tricyclic antidepressants and SSRIs are equally efficacious in patients with cardiovascular disease.(69)

3. Surgical
Pacemaker implantation may be necessary for some patient because of either severity or do not respond to the medication to has been successful in decreasing the number of fainting episodes. Pacemaker implantation is a procedure to put a small battery-operated device into the chest to help the heart beating regularlyas it send out the regular electrical pulses. There is a report  on a patient with recurrent sleep syncope (with physical injury) in whom an asystolic pause was documented during one of her "sleep syncope" spells. Implantation of a dual chamber pacemaker (5-year follow-up) "cured" her of further syncope(70)

B. In herbal medicine perspective
1. Bilberry
a.  Antioxidants
Edible berries of bilberry contains high amounts of antioxidant of natural anthocyanin may be used to trigger genetic signaling in promoting human health and disease prevention, according to the study of "Berry anthocyanins as novel antioxidants in human health and disease prevention" by Zafra-Stone S, Yasmin T, Bagchi M, Chatterjee A, Vinson JA, Bagchi D., posted in PubMed(71)

b. Anti-angiogenic, antioxidant, and anti-carcinogenic properties
Anthocyanins, a natural compounds of pigmentation in bilberry is also considered as natural antioxidants have exerted the property of Anti-angiogenisis and genomic DNA repairment and protection in reducing the risk of cancers, according to the study of "Anti-angiogenic, antioxidant, and anti-carcinogenic properties of a novel anthocyanin-rich berry extract formula" by Bagchi D, Sen CK, Bagchi M, Atalay M., posted in PubMed(72)

c. Cardiotoxicity
Bilberry extract significantly inhibited DOX-provoked reduced glutathione depletion and accumulation of oxidized glutathione, malondialdehyde and protein carbonyls in cardiac tissues, according to the study of "Protective effect of bilberry (Vaccinium myrtillus) against doxorubicin-induced oxidative cardiotoxicity in rats" by Ashour OM, Elberry AA, Alahdal A, Al Mohamadi AM, Nagy AA, Abdel-Naim AB, Abdel-Sattar EA, Mohamadin AM., posted in PubMed(73)

d. Cholesterol
Oxidative modifications of low density lipoproteins (LDL) can be result of thickening of artery wall as a result of the accumulation of fatty, affecting arterial blood vessels. Vaccinium myrtillus contains high amount of antioxidants which help to block the oxidation of low density lipoproteins (LDL), according to the study of "Antioxidant action of Vaccinium myrtillus extract on human low density lipoproteins in vitro: initial observations" by Laplaud PM, Lelubre A, Chapman MJ., posted in PubMed(74)

2. Ginkbo Biloba
a. Cardiovascular tissues
Ginkgo biloba extract (EGb) has shown the protection of the cardiovascular tissues against HgCl(2)-induced oxidative damage, according to the study of "Protective effects of Ginkgo biloba extract against mercury(II)-induced cardiovascular oxidative damage in rats" by Tunali-Akbay T, Sener G, Salvarli H, Sehirli O, Yarat A., posted in PubMed(75)

b. Hyperlipidemia
Ginkgo biloba leaves (EGB) has demonstrated the activities of limitation of the absorption of cholesterol, inactivation of HMGCoA and favorable regulation of profiles of essential polyunsaturated fatty acid (EFA), according to the study of "Application of GC/MS-based metabonomic profiling in studying the lipid-regulating effects of Ginkgo biloba extract on diet-induced hyperlipidemia in rats" by Zhang Q, Wang GJ, A JY, Wu D, Zhu LL, Ma B, Du Y., posted in PubMed(76)

3. Peppermint
a. Cholesterol effects
In the investigation the choleretic effect and molecular mechanisms of action of peppermint oil (PO), the main component of Danshu capsules (Sichuan Jishengtang Pharmaceutical Co., Ltd., Pengzhou, Sichuan Province, China), found that PO might play a role in upregulating CYP7A1 and FXR mRNA levels, suggesting that the molecular mechanisms are related to gene expression involved in bile acid synthesis, according to "Preliminary experimental research on the mechanism of liver bile secretion stimulated by peppermint oil" by Zong L, Qu Y, Luo DX, Zhu ZY, Zhang S, Su Z, Shan JC, Gao XP, Lu LG.(77)

b. Cardiovascular effects
In the assessment of Cardiovascular effects of intravenous (i. v.) treatment with the essential oil of Mentha x villosa (EOMV) in pentobarbitone-anaesthetised rats, found that The present study shows for the first time that i. v. treatment with EOMV in pentobarbitone-anaesthetised rats induces hypotensive and bradycardic effects, which appear mostly attributed to the actions of the major constituent of EOMV, PO. These cardiovascular effects appear to be independent since EOMV-induced bradycardia appears dependent upon the presence of an intact and functional sympathetic nerve drive to the heart, while EOMV-induced hypotension appears independent of the presence of an operational sympathetic nervous system. This suggests that hypotensive activity of EOMV may result from its vasodilatory effects directly upon vascular smooth muscle, according to "Cardiovascular effects of the essential oil of Mentha x villosa and its main constituent, piperitenone oxide, in normotensive anaesthetised rats: role of the autonomic nervous system" by
Lahlou S, Carneiro-Leão RF, Leal-Cardoso JH, Toscano CF.(78)

c. Antimicrobial and antioxidant activities
In the observation of the antimicrobial activity and free radical scavenging capacity (RSC) of essential oils from Mentha aquatica L., Mentha longifolia L., and Mentha piperita L., found that The M. piperita essential oil also exhibited the highest OH radical scavenging activity, reducing OH radical generation in the Fenton reaction by 24 % (pure oil). According to GC-MS and TLC (dot-blot techniques), the most powerful scavenging compounds were monoterpene ketones (menthone and isomenthone) in the essential oils of M. longifolia and M. piperita and 1,8-cineole in the oil of M. aquatica, according to "Antimicrobial and antioxidant activities of three Mentha species essential oils" by Mimica-Dukić N, Bozin B, Soković M, Mihajlović B, Matavulj M.(79)

4. Rosemary
Rosemary contains high amount of carnosic acid, a natural benzenediol diterpene which has found to reduce the risk of free radical cause of cancers, according to "Inhibitory effects of rosemary extracts, carnosic acid and rosmarinic acid on the growth of various human cancer cell lines" by Yesil-Celiktas O, Sevimli C, Bedir E, Vardar-Sukan F.(80)

5. Lavender
a. Antioxidants
In the observation of total phenolics and total flavonoids for the extracts of three medicinal plants including oregano (Origanum vulgare L.), lavender (Lavandula angustifolia) and lemon balm (Melissa officinalis) found that Origanum vulgare and Melissa officinalis extracts present the most effective antioxidant capacity in scavenging DPPH radicals, while Lavandula angustifolia is less active. High performance liquid chromatography-mass spectrometry analysis was used to identify the components of extracts. Major phenolic acids identified in the analysed species were ferulic, rosmarinic, p-coumaric and caffeic, while predominant flavonoids were quercetin, apigenin kaempherol, which were present as glucosides, according to "Antioxidant capacity and total phenolic contents of oregano (Origanum vulgare), lavender (Lavandula angustifolia) and lemon balm (Melissa officinalis) from Romania"by Spiridon I, Colceru S, Anghel N, Teaca CA, Bodirlau R, Armatu A. (81)

b. Antidepressant-like effect
In the classification of the antidepressant effects of essential oils of Anthemis nobilis (chamomile), Salvia sclarea (clary sage; clary), Rosmarinus officinalis (rosemary), and Lavandula angustifolia (lavender)found that clary oil could be developed as a therapeutic agent for patients with depression and that the antidepressant-like effect of clary oil is closely associated with modulation of the DAnergic pathway, according to "Antidepressant-like effect of Salvia sclarea is explained by modulation of dopamine activities in rats" by Seol GH, Shim HS, Kim PJ, Moon HK, Lee KH, Shim I, Suh SH, Min SS.(82)

c. Cognition and mood
In the evaluation of Aromas of rosemary and lavender essential oils and theirs effect on cognition and mood found that rosemary produced a significant enhancement of performance for overall quality of memory and secondary memory factors, but also produced an impairment of speed of memory compared to controls. With regard to mood, comparisons of the change in ratings from baseline to post-test revealed that following the completion of the cognitive assessment battery, both the control and lavender groups were significantly less alert than the rosemary condition; however, the control group was significantly less content than both rosemary and lavender conditions. These findings indicate that the olfactory properties of these essential oils can produce objective effects on cognitive performance, as well as subjective effects on mood, according to "Aromas of rosemary and lavender essential oils differentially affect cognition and mood in healthy adults" by Moss M, Cook J, Wesnes K, Duckett P.(83)

d.  'Subsyndromal' anxiety disorder
In the investigation of orally administered Lavandula oil preparation and its effect on'subsyndromal' anxiety disorder, found that Lavandula oil preparation had a significant beneficial influence on quality and duration of sleep and improved general mental and physical health without causing any unwanted sedative or other drug specific effects. Lavandula oil preparation silexan is both efficacious and safe for the relief of anxiety disorder not otherwise specified. It has a clinically meaningful anxiolytic effect and alleviates anxiety related disturbed sleep, according to "Silexan, an orally administered Lavandula oil preparation, is effective in the treatment of 'subsyndromal' anxiety disorder: a randomized, double-blind, placebo controlled trial"by Kasper S, Gastpar M, Müller WE, Volz HP,
Möller HJ, Dienel A, Schläfke S.(84)

6. Etc.

C. In  Chinese medicine perspective
Depending to differentiation, some traditional Chinese TCM practitioners classify fainting (Syncope) as a result of (85)
C.1. Deficiency of the Heart yang and Kidney yang
1. Symptoms
a. Shortness of breath
b. Dizziness, occasional fainting,
c. Fatigue and weakness,
d. Tinnitus
e. Pain in the loins,
f. Aversion to cold,
g. Cold limbs,
h. Restlessness and insomnia
i. Pale thick or dark red tongue,
j. Thready,
l. Slow and uneven pulse
m. Etc.

2. Herbal treatment 
Modified prescriptions of Decoction for Protecting Primordial qi and Decoction of Ephedra, Aconite and Asarum. Prepared aconite root (Fu Zi) 6-20g, Red ginseng (Hong Seng) 10-30g, astragalus root (Huang Qi) 30g, Siberian solomonseal rhizome (Huang Jin) 30g, Cinnamon twig(Gui Zhi) 10g, Ephedra (Ma Huang) 6-12g, Asarum herb (Xi Xin) 3g, Prepared liquorice (Zhi Gan Cao) 6-30g

C.2. Deficiency of both qi and yin
1. Symptoms
a. Shortness of breath
b. Vague pain in the precordial region,
c. Dizziness
d. Blurred vision
c. Palpitation
f. Insomnia
g. Amnesia (memory loss
h. Dry mouth
i. Pale or dark red tongue with thin and white fur,
j. Slow or thready pulse
k. Etc.

2. Herbal treatment
Prescription/Formula: Modified Decoction of Prepared Licorice Prepared licorice root (Zhi Gan Cao) 30g, Dangshen (Dang Shen) 30g, Astragalus root (Huang Qi) 30g, Siberian solomonseal rhizome (Huang Jin) 30g, Dried rehmannia root Sheng Di Huang) 20g, Ophiopogon root (Mai Dong) 15g, Sesame kernel (Ma Ren)12g, Cinnamon twig (Gui Zhi) 10g, Chinese-date (Da Zao)10 pieces, Schisandra fruit (Wu Wei Zi) 10g

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Friday, April 27, 2012


Meningitis is defined as a condition of inflammation of the protective membranes,  covering the brain and spinal cord (meninges). Meningitis, a life threaten disease, can kill and immediate action can and does save lives.(1) Although bacterial meningitis has become an uncommon disease in the developed world. Unfortunately, because of limited economic resources and poor living conditions, many developing countries are still affected by the devastating consequences of this life-threatening systemic infection(2)

Signs and Symptoms
In the research posted in European Journal of Pediatrics, scientists showed that
1.  The most common symptoms according to age were as follows: 1–5 months: irritability (85%), 6–11 months and 12 months or more: vomiting (82%) and neck rigidity (78%).
2. Meningitis should be suspected in irritable or lethargic febrile children despite absence of neck rigidity. Fever and vomiting were the most frequent reasons for consulting a physician (60% and 31%, respectively). Despite the frequency and alarming character of irritability, impaired consciousness and neck rigidity, their presence led infrequently to a consultation (6%, 22% and 3%, respectively).(8)

2. In other study to identify 433 patients with viral meningitis and 101 TBM patients and compared their clinical and laboratory features. Multivariable analysis showed a statistically significant association between TBM and the following variables: duration of symptoms before admission of ≥5 days, presence of neurological impairment (altered consciousness, seizures, mild focal signs, multiple cranial nerve palsies, dense hemiplegia or paraparesis), cerebrospinal fluid/blood glucose ratio < 0.5 and cerebrospinal fluid protein level > 100 mg/dl(10)

3. Confusion
Confusion is also associated with symptoms of meningitis. in study of a seventy-five-year-old patient was hospitalized because of relapsing feverish confusion episodes with meningitis. During the year before his admission he had experienced four spontaneously regressive episodes of feverish confusion(9)

4. Other symptoms include sleepiness, discomfort looking into bright lights and In some cases, rash may be presented as a result of meningococcal bacteria.

5. Etc.

Causes and risk factors
A. Causes
1. Bacterial
Bacterial causes of meningitis can be classified according to age group
a. In Infants and children In the report of "Acute bacterial meningitis in infants and children" conducted by Johns Hopkins University School of Medicine, scientists showed that bacterial meningitis continues to be an important cause of mortality and morbidity in neonates and children throughout the world. The introduction of the protein conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has changed the epidemiology of bacterial meningitis(12). Another study of "Meningitis in children in Fiji" showed that Over a 3-year period, all eligible children with suspected meningitis admitted to CWMH had blood drawn for culture. Of these children, those for whom is was possible were tested for a four-fold rise in antibody titers to Haemophilus influenzae type b (Hib) and pneumococcal surface adhesin A (PsaA). Cerebrospinal fluid (CSF) was taken for bacteriological culture and antigen testing. CSF was also tested by PCR for Streptococcus species, Neisseria meningitidis, Hib, Mycobacterium tuberculosis, and enterovirus.(13)
Some researchers suggested bacterial meningitis in young children can impair vestibular function completely, leading to delayed posturomotor development if meningitis occurs before independent walking, even in absence of neurologic impairment(11) 

b. In adult
 In adults, according to Community-Acquired Bacterial Meningitis in Adults, bacterial meningitis has an annual incidence of 4 to 6 cases per 100,000 adults (defined as patients older than 16 years of age), and Streptococcus pneumoniae and Neisseria meningitidis are responsible for 80 percent of all cases.(14). In a report conducted by National Institute of Infectious and Tropical Diseases, S. suis was commonly diagnosed as a cause of bacterial meningitis in adults in northern Viet Nam. In countries where there is intense and widespread exposure of humans to pigs, S. suis can be an important human pathogen.(15)

2. Viral
Certain virus can cause meningitis. Enteroviruses is defined as condition in which a virus that enters the body through the gastrointestinal tract and thrives there, often moving on to attack the nervous system.  are the most common cause at all ages, including 29 Coxsackieviruses (23 Coxsackie A viruses and 6 Coxsackie B viruses), 28 echoviruses, and 4 other enteroviruses.(16)
a. Varicella zoster virus 
Varicella zoster virus is defined as a condition of infection and results from exposure of a person susceptible to the virus. The virus remains latent in cranial nerve ganglia and reactivates and can cause a wide range of neurologic disease if a infected patient is association with a decline in cell-mediated immunity in the elderly and immuno-compromised. there are report of a 46-year-old female who initially presented with worsening headache, nuchal rigidity, fever, and a skin rash, who was subsequently found to have varicella zoster meningitis.(3)

b. Immunodeficiency virus and tuberculosis
In the study of 642 individuals conducted by University of KwaZulu-Natal, 14 episodes of meningitis in 10 patients were identified. For 8 patients, this episode of meningitis was the AIDS defining illness, with cryptococcus (9/14 episodes) and tuberculosis (3/14 episodes) as the commonest aetiological agents. The combination of headache and neck stiffness (78.6%) was the most frequent clinical presentation. Relapsing cryptococcal meningitis occurred in 3/7 patients. Mortality was 70% (7/10), with 4 deaths directly due to meningitis(4)

3. Aseptic meningitis
Aseptic meningitis is defined as a condition of all cases of meningitis in which no bacterial infection can be found. In the study of DIFFICULT AND RECURRENT MENINGITIS by L Ginsberg showed that examination yields a typical ‘‘aseptic meningitis’’ picture (elevated white cell count, predominantly lymphocytic, no organisms on Gram stain, normal or elevated protein concentration, normal or reduced glucose concentration) because of the breadth of the differential diagnosis, both infective and non-infective (table 1). In these circumstances, it is particularly important to exclude or diagnose tuberculosis, cryptococcosis, and other fungal infections, partially treated pyogenic meningitis, neurosyphilis, and Lyme disease, because of the need for urgent treatment and the consequences of failure to treat.(17)

4. Parasitic
It is a very common in underdeveloped countries as result of  parasites found in contaminated water, food, and soil, including Angiostrongylus cantonensis, Gnathostoma spinigerum, Schistosoma etc.

5. Non-infectious
5. 1. Medication
Meningitis is either caused by infection of bacteria or viral, but certain medication, including nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, intravenous immunoglobulins, and OKT3 antibodies (monoclonal antibodies against the T3 receptor) are the most frequent cause of Drug-induced aseptic meningitis (DIAM), as resolution occurs several days after drug discontinuation and the clinical and cerebrospinal fluid profile (neutrophilic pleocytosis) do not allow DIAM to be distinguished from infectious meningitis(7)

a. Infliximab
There are report of  a 51-year-old female, was being treated for Crohn's disease. After an infliximab infusion, she had headache, fever, arthralgia, myalgia, and meningismus. Infliximab commonly causes headache and is very immunogenic, we infer that infliximab-induced meningitis is immune-mediated and underrecognized. Potential risk factors and means for minimizing its occurrence are offered(4)

b. Spinal analgesia and anaesthesia
Even though spinal analgesia and anaesthesia (SA) is a rare predisposing condition to bacterial meningitis but, due to the seriousness of the infection, it should be considered in the differential diagnosis for any patient who develops fever or headache in this setting(5). Also there are report of two cases of meningitis which developed after combined spinal-extradural procedures for obstetric analgesia. The first case was thought to be caused by aseptic or chemical meningitis and the second was a case of bacterial meningitis in a patient who also received an extradural blood patch.(6)

5.2. Inflammatory conditions
a. Systemic lupus erythematosus
is defined as a condition of autoimmune diseases, as the immune system attacks the body's cells and tissue,of that lead to inflammation and tissue damage. There is report that Aseptic meningitis appears to be an early manifestation of SLE and may herald more serious brain damage. No new cases of aseptic meningitis occurred in this series after initiation of therapy for SLE. In contrast, bacterial meningitis did occur as a late complication of the disease(18)

b. Vasculitis
Vasculitis is defined as a inflammatory condition of the blood vessels as a result of group of diseases. In a study of a 53-year-old man with pneumococcal meningitis who developed numerous ischemic lesions in the brainstem and basal ganglia caused by parainfectious vasculitis, researchers suggested that parainfectious vasculitis may respond to late corticosteroid treatment. MMP-9 level in CSF may be a marker of vasculitic complication in bacterial meningitis.(19)

c. Migraine
Dr. Bruce H. Dobkin at the Daniel Freeman Hospital Medical Center Stroke/Neurological Rehabilitation Unit, wrote" Schraeder and Burns (ARCHIVES 1980;37:377-379) suggested that the rare CSF lymphocytosis found in patients with hemiplegic migraine results from a secondary meningeal reaction. Another report concluded that the complicated migraines of seven patients resulted from an inflammatory disturbance.....(20)

d. Etc.

5.3. Immunodeficiency virus and tuberculosis
In the study of 642 individuals conducted by University of KwaZulu-Natal, 14 episodes of meningitis in 10 patients were identified. For 8 patients, this episode of meningitis was the AIDS defining illness, with cryptococcus (9/14 episodes) and tuberculosis (3/14 episodes) as the commonest aetiological agents. The combination of headache and neck stiffness (78.6%) was the most frequent clinical presentation. Relapsing cryptococcal meningitis occurred in 3/7 patients. Mortality was 70% (7/10), with 4 deaths directly due to meningitis(4)

5.4. Etc.

B. Risk factors
Some people are more susceptible to meningitis than others

1. People with weakened immune systems
In a study conducted by Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Dr. Koppe U and the research team indicated "The innate immune system is critical for the control of colonization and for defence during invasive disease. Initially, pneumococci are recognized by different sensors of the innate immune system called pattern recognition receptors (PRRs), which control most subsequent host defence pathways. These PRRs include the transmembrane Toll-like receptors (TLRs) as well as the cytosolic NOD-like receptors (NLRs) and DNA sensors". Streptococcus pneumoniae is both a frequent colonizer of the upper respiratory tract and a leading cause of life-threatening infections such as pneumonia, meningitis and sepsis.(21)

2. Pregnant women
In the examine listeriosis cases reported through the U.S. Listeria Initiative during 2004-2007. Cases were classified as pregnancy-associated if illness occurred in a pregnant woman or an infant aged <28 days. Of 758 reported Listeria cases, 128 (16.9%) were pregnancy-associated. Maternal infection resulted in four neonatal deaths and 26 (20.3%) fetal losses. Invasive illnesses in newborns (n=85) were meningitis (32.9%) and sepsis (36.5%)(21). There is a case report of TBM in a previously healthy woman whose signs and symptoms developed immediately after delivery and were initially attributed to postpartum depression and a puerperal-acquired bacterial infection.  Although tuberculous meningitis (TBM) rarely complicates pregnancy and seldom occurs in puerperal women,(22)

3. Chronic Diseases 
a. AIDS 
People with AIDS are more susceptible to develop Meningitis. In a retrospective review of confirmed HIV-TB coinfected patients previously enrolled as part of the SAPiT study in Durban, South Africa. Patients with suspected meningitis were included in this case series. From 642 individuals, 14 episodes of meningitis in 10 patients were identified. For 8 patients, this episode of meningitis was the AIDS defining illness, with cryptococcus (9/14 episodes) and tuberculosis (3/14 episodes) as the commonest aetiological agents.(23)

b.  Diabetes
In a study conducted by , Far Eastern Memorial Hospital, Dr. Ho MP and the research team showed that advanced age, newly recognized DM, K. pneumoniae bacteremia, and DIC may be the cause of a fatal Klebsiella pneumoniae meningitis and concomitant disseminated intravascular coagulation (DIC) in a 72-year-old woman(24)

c. Rheumatoid arthritis
People with Rheumatoid arthritis may have an increased risk of Meningitis. Even though most common complications of RA occur in the severe and chronic stages of the disease, but Meningoencephalitis is a rare but aggressive complication of rheumatoid arthritis (RA).(25)

d. Others chronic diseases such as heart diseases, liver disease may also  risk factors of meningitis

4. Removal of your spleen puts you at risk for meningitis, as spleen is essential part of the immune system

5. In the study to overview outcome of meningococcal meningitis in Slovakia, researcher(s) indicated that risk factors such as underlying disease, cancer, diabetes, alcoholism, surgery (brain surgery), age (children under 5, teens and young adults ages 16 to 25 (especially college freshman living in dorms), and adults over 55), previous infections, trauma, sepsis were recorded and mortality, survival with sequellae, therapy failure were compared between meningococcal and non-meningococcal cases of bacterial meningitis(26)

f. Etc.

Complications and diseases associated
A. Complications
1. In the study to raise awareness of meningitis and its symptoms and describes some of the practical support that can be offered to sufferers, their families and friends. Doctors at the University of Hertfordshire. indicated that he prognosis and possible complications are described. These include potential problems such as sensorineural deafness, raised intracranial pressure, the need for skin grafting and the amputation of limbs and/or digits.(1)

2. Spectrum of complications 
Systematically central nervous system and systemic complications during the acute phase of adult bacterial meningitis
a. Central nervous system complications
Include brain swelling, hydrocephalus, brain abscess, subdural empyema, or subdural effusion (using computed tomography) and cerebrovascular involvement (using cerebral angiography),
b. Systemic complications
Include septic shock, disseminated intravascular coagulation, adult respiratory distress syndrome, or septic or reactive arthritis(30). Cerebrovascular complications are the most frequent intracranial complications in bacterial meningitis of the adult (37.1%) and are major determinants in the prognosis of this disease(31)

3. Others spectrum of complications

In the analysing 87 consecutive cases between 1984 and 2002. Meningitis-associated intracranial complications developed in 74.7% and systemic complications in 37.9% of cases. Diffuse brain oedema (28.7%) and hydrocephalus (16.1%) developed more frequently than previously reported. The incidences of arterial (21.8%) and venous (9.2%) cerebrovascular complications were also very high. Furthermore, 9.2% of cases developed spontaneous intracranial haemorrhages (two patients with subarachnoid and two with subarachnoid and intracerebral bleedings, all in association with vasculitis; one subject with intracerebral haemorrhage due to sinus thrombosis; and three cases with intracerebral bleedings of unknown aetiology). Other new findings were the incidence of acute spinal cord dysfunction due to myelitis (2.3%) and that of hearing loss (19.5% of all patients and 25.8% of survivors). The in-hospital mortality was 24.1%. Only 48.3% of the patients had a good outcome at discharge (32)

4. Etc.

B. Diseases associated
1. Hodgkin's disease
In a report of  a seventy-five-year-old patient was hospitalized because of relapsing feverish confusion episodes with meningitis. and exploration of these episodes disclosed a paraneoplastic limbic encephalitis due to an underlying Hodgkin's disease. The treatment of Hodgkin's disease led to perfect recovery of cognitive function.(9)

Patient with AIDS are susceptible to
a. Cryptococcal
b. Tuberculous
c. Syphilitic
d. Listeria species
e. Lymphomatous
f. Aseptic
as a result of infections and very low CD4+ lymphocyte counts.(27)

3. Kikuchi's Disease
Kikuchi's disease is an idiopathic illness, typically causing cervical lymphadenopath. Dr. Dr. Mahdad Noursadeghi, Dept. of Infection & Tropical Medicine, Northwick Park Hospital in the study of "Kikuchi's Disease: A Rare Cause of Meningitis?" said that many patients with Kikuchi's disease who present with fever and meningitis will be assessed by infectious disease physicians who will not be aware of the association of Kikuchi's disease with meningitis.(28)

4. Other diseases
In the data collected from medical records of all adult patients with bacterial meningitis admitted to Chang Gung Memorial Hospital-Kaohsiung from January 1986 to December 2000, three of the 14 patients with ALD had liver cirrhosis (2 with Child's class B and 1 with Child's class C). The causative pathogens of these 14 cases were Klebsiella pneumoniae in 11, Staphylococcus aureus in 2 and Enterococcus in 1. Diabetes mellitus (DM) was the most common underlying disease and was present in 64% of patients (9/14). All patients with DM had K. pneumoniae as the causative pathogen. Bacteremia and thrombocytopenia were found in 64% (9/14) and 50% (7/14) of the patients, respectively. Focal suppurations including brain abscess, intracranial subdural empyema, and cervical epidural abscess were found in 4 patients. The overall mortality rate was 14% (2/14). ALD accounted for 11.5% (14/122) of the underlying conditions of all adult cases of community-acquired spontaneous bacterial meningitis treated during the study period.(29)

1. Spinal tap
After assessing the symptoms and taking the physical exam, the diagnosis is to obtain a sample of spinal fluid to identify type of bacteria responsible by performing a  lumbar puncture with local anesthetic and a needle inserted into an area in the lower back where fluid in the spinal canal, but the risk of lumbar puncture can lead to brain herniationis  if there is an elevation of a mass in the brain (tumor or abscess) or the intracranial pressure (ICP)(33).

2.  The Xpert EV test
Approved by the Food and Drug Administration (FDA) in 2007, when used in combination with other laboratory tests, will help physicians distinguish between viral meningitis and the less-common, but more severe, version of meningitis caused by detecting the RNA of the enterovirus that causes meningitis, but results from the Xpert EV test are available in two and one-half hours(34)

3. Meningococcal rash pressure test
Patient with rash and a cold or flu with fever, headache, aches and pains in joints and muscles and suspected to have menigitis, meningococcal rash pressure test may be the best choice. By using medical instruments to apply pressure to the skin around, bacterial meningitis will not whiten under pressure. As Meningococcus bacteria cause several different infections besides meningitis. They can cause different forms of blood poisoning: septicemia, which is severe; and meningococcemia, a milder form; also pneumonia, arthritis, and infections of the heart, eye, or other parts of the body(35)

4. Blood Culture Tests
Blood Culture Tests is to  is a microbiological culture of blood to detect for the presence of  of meningococcal bacteria.

5. Etc.

A. Do's and Do not's list
1.  Behavioral
Neisseria meningitidis bacteria are spread through the exchange of respiratory and throat secretions like spit (e.g., living in close quarters, kissing). Fortunately, these bacteria are not as contagious as what causes the common cold or the flu. Also, the bacteria are not spread by casual contact or by simply breathing the air where a person with meningococcal disease has been(36). Especially when you are pregnant to avoid listeriosis

2. Eat your vegetable and fruits
Vegetable and fruit contain high amount of antioxidant, not only enhances the immune system but also fight against foreign virus and bacteria infection and inflammatory causes of meningitis(37)

3. Avoid excessive drinking
Excessive drinking can increase the risk of liver diseases that can lead to weaken immune function causes of meningitis

4. Moderate exercise
Moderate exercise can enhance the circulatory system and increase the function of immune system in fighting against bacterial and viral invasion.

5. Smoking
The odds ratio of purulent meningitis for children receiving passive smoking was 3.0, and the 95% confident limit was greater than 1 (P < 0.05). There was significant dose-effect relationship between the daily dosage of cigarette smoked by family members and the odds ratio of purulent meningitis (P < 0.005)(38)

6. Etc.

B. Diet against meningitis
1. Flaxseed oil is extracted from the seeds of the flax plant (Linum usitatissimum) contained both omega-3 and omega-6 fatty acids. Flaxseed oil generally contains 50% of the omega-3 fatty acid - alpha-linolenic acid and 25 % of the omega-6 fatty acid linolenic acid, 15 % of mainly monounsaturated oleic acid and trace amounts of palmitoleic acid and eicosenoic acid.
In the investigation of Omega 3 fatty acids and theirs effect on inflammation, a physiological response to tissue trauma or infection found that dietary n-3-PUFA, EPA, to inhibit this process not only revealed an unsuspected level of regulation in the migration of inflammatory leukocytes, it also contributes to our understanding of the interactions of this bioactive lipid with the inflammatory system. Moreover, it indicates the potential for novel therapeutics that target the inflammatory system with greater affinity and/or specificity than supplementing the diet with n-3-PUFAs, according to "Omega-3 Fatty acids and inflammation: novel interactions reveal a new step in neutrophil recruitment" by Tull SP, Yates CM, Maskrey BH, O'Donnell VB, Madden J, Grimble RF, Calder PC, Nash GB, Rainger GE.(46)

2. Green Tea
a. Antimicrobial activities
 In the investigation of Antimicrobial activities of green of the study of "Antimicrobial activities of tea catechins and theaflavins and tea extracts against Bacillus cereus" by Friedman M, Henika PR, Levin CE, Mandrell RE, Kozukue N., researchers found that flavonoids in green tea has exerted its ability in protective effects against Bacillus cereus.(47)

b. Immune system
a. In the investigation of the immunomodulatory effects of decaffeinated green tea extract in rain bow of the study of "Immunomodulatory effects of decaffeinated green tea (Camellia sinensis) on the immune system of rainbow trout (Oncorhynchus mykiss)" by Sheikhzadeh N, Nofouzi K, Delazar A, Oushani AK., researchers found that showed that decaffeinated green tea in lower doses of administration could be optimum to enhance the immunity of rainbow trout(48)

3. Garlic
Garlic is the natural superfood healer for its natural antibiotic with antiviral, antifungal, anticoagulant and antiseptic properties. Garlic cooked is fine but it loses many of its health-giving powers. Raw garlic does most of its antibiotic and preventive medicines. Here are some of effective use of garlics for PROVEN DISEASE CURED.

4. Blueberry
In the investigation of Blueberry and blackberry wines commercially available in Illinois and theirs potential health benefits, found that fruit wines made from blueberries and blackberries may have potential health applications and therefore could contribute to the economy of the wine industry. Practical Application: The majority of wines are produced from grapes, but wine can also be produced from other fruits including blueberries and blackberries, which contain phenolic compounds that may contribute to human health, according to "Comparison of Chemical Composition and Antioxidant Capacity of Commercially Available Blueberry and Blackberry Wines in Illinois" by Johnson MH, Gonzalez de Mejia E.(49)

5. Shiitake mushroom
a. Immune system
Shiitake mushroom enhances the immune system in fighting against infection and disease. influenza, viruses and irregular cells growth due to it anti-tumor polysaccharide lentinan, according to "Immunoregulatory effects of the antitumor polysaccharide lentinan on Th1/Th2 balance in patients with digestive cancers" by Yoshino S, Tabata T, Hazama S, Iizuka N, Yamamoto K, Hirayama M, Tangoku A, Oka M.(50)

b. Free radicals
Shiitake mushroom contains high levels of antioxidants such as L-ergothioneine, that helps to
reduce the risk of oxidative cause of mutation in cell division and alternation, according to"Ergothioneine; antioxidant potential, physiological function and role in disease" by Cheah IK, Halliwell B.(51)

6. Etc.

C. Nutritional supplement against meningitis
 1. Vitamin A, C, E. D.
a. a. Vitamin A
Vitamin A occurs in the form retinol and is best known for its function in maintaining the health of cell membrane, hair, skin, bone, teeth and eyes. It also plays an important role as an antioxidant as it scavenges free radicals in the lining of the mouth and lungs; prevents its depletion in fighting the increased free radicals activity by radiation; boosts immune system in controlling of free radicals; prevents oxidation of LDL and enhances the productions of insulin pancreas.

b. Vitamin C
Vitamin C beside plays an important role in formation and maintenance of body tissues, it as an antioxidant and water soluble vitamin, vitamin C can be easily carry in blood, operate in much of the part of body. By restoring vitamin E, it helps to fight against forming of free radicals. By enhancing the immune system, it promotes against the microbial and viral and irregular cell growth causes of infection and inflammation.
Vitamin C also is a scavenger in inhibiting pollution cause of oxidation.

c. Vitamin E
Vitamin E is used to refer to a group of fat-soluble compounds that include both tocopherols and tocotrienols discovered by researchers Herbert Evans and Katherine Bishop. It beside is important in protecting muscle weakness, repair damage tissues, lower blood pressure and inducing blood clotting in healing wound, etc, it also is one of powerful antioxidant, by moving into the fatty medium to prevent lipid peroxidation, resulting in lessening the risk of chain reactions by curtailing them before they can starts.

d. Vitamin D
Reseacher found that vitamin D, a group of fat-soluble secosteroids is also a membrane antioxidant, with the ability to inhibit iron-dependent lipid peroxidation in liposomes compared to cholesterol.(39)

2. Antioxidants
a. Catechin
a.1. Anti-inflammatory effect
In the preparation of the gel of Chinese medicine catechu, and to observe the release mechanism in vitro and anti-inflammatory activity in rats, found that the optimum condition of extraction from catechu was as follows, the concentration of ethanol, ratio of raw material to solvent, ultrasonic time, and extraction temperature were 50% , 1: 12, 35 min and 60 degrees C, respectively. The formulation of catechu gel was carbomer-9 400.5 g, glycerol 5.0 g, the extracts of catechu 50.0 mL, and triethanomine 0.5 mL The gel was semitransparent and stable. The drugs released quickly. The catechu gel reduced the paw edema considerably in dose-dependent manner compared to carrageenan-induced rat, according to "[Preparation and pharmacodynamics studies on anti-inflammatory effect of catechu gel].[Article in Chinese]" by Zheng X, Zheng C.(41)

a.2. Anti-influenza virus activity
In the study of Polyphenolic compounds present in green tea, particularly catechins, and its effect on strong anti-influenza activity, found that therapeutic administration of green tea by-products via feed or water supplement resulted in a dose-dependent significant antiviral effect in chickens, with a dose of 10 g/kg of feed being the most effective (P < 0.001), according to "Anti-influenza virus activity of green tea by-products in vitro and efficacy against influenza virus infection in chickens" by Lee HJ, Lee YN, Youn HN, Lee DH, Kwak JH, Seong BL, Lee JB, Park SY, Choi IS, Song CS.(42)

b. Quercetin
b.1. Anti-Inflammatory effects
According to the study of `Antioxidant and Anti-Inflammatory Activities of Quercetin 7-O-β-D-Glucopyranoside from the Leaves of Brasenia schreberi.`by Legault J, Perron T, Mshvildadze V, Girard-Lalancette K, Perron S, Laprise C, Sirois P, Pichette A. (Source from Laboratory for Analysis and Separation of Plant Species (LASEVE), Université du Québec à Chicoutimi , Chicoutimi, Québec, Canada.), posted in PubMed, researchers found that some flavonoids have been reported to possess beneficial effects in cardiovascular and chronic inflammatory diseases associated with overproduction of nitric oxide. Quercetin-7-O-β-D-glucopyranoside possesses anti-inflammatory activity, inhibiting expression of inducible nitric oxide synthase and release of nitric oxide by lipopolysaccharide-stimulated RAW 264.7 macrophages in a dose-dependent manner. Quercetin-7-O-β-D-glucopyranoside also inhibited overexpression of cyclooxygenase-2 and granulocyte macrophage-colony-stimulating factor.

b.2.  Antimicrobial and cytotoxic activities
According to the study of `Antimicrobial and cytotoxic activities of leaves, twigs and stem bark of Scutia buxifolia Reissek.`by Boligon AA, Janovik V, Frohlich JK, Spader TB, Forbrig Froeder AL, Alves SH, Athayde ML. (Source from a Phytochemical Research Laboratory, Department of Industrial Pharmacy , Federal University of Santa Maria , Build 26, room 1115 , Santa Maria , CEP 97105-900 , Brazil.), posted in PubMed, researchers found that quercitrin, isoquercitrin and rutin were identified by HPLC and may be partially responsible for the antimicrobial activities observed. This study reports for the first time the antimicrobial and cytotoxic activities of S. buxifolia leaves, twigs and stem bark.

c. Lycopene
c.1. Anti Inflammation
According to the study of `Inhibitory mechanism of lycopene on cytokine expression in experimental pancreatitis.`by Kim H. (Source from Department of Food and Nutrition, Brain Korea 21 Project, College of Human Ecology, Yonsei University, Seoul, South Korea., posted in PubMed, researchers found that in pancreatic acinar cells, which is mediated by the activation of NADPH oxidase. Lycopene functions as a very potent antioxidant to suppress the induction of inflammatory cytokines, in pancreatic acinar cells stimulated with cerulein. In this review, the possible beneficial effect of lycopene on experimental pancreatitis shall be discussed based on its antioxidant activity.

c.2. Antioxidants
In the study of `Comparison of lycopene and tomato effects on biomarkers of oxidative stress in vitamin E deficient rats` by Delphine Gitenay, Bernard Lyan, Mathieu Rambeau, Andrzej Mazur and Edmond Rock. (Source from European Journal of Nutrition Volume 46, Number 8, 468-475, DOI: 10.1007/s00394-007-0687-2), posted in, researchers found that Our study showed for the first time that tomatoes, containing or not containing lycopene, have a higher potential than lycopene to attenuate and or to reverse oxidative stress-related parameters in a mild oxidative stress context.

d. Theaflavin
d.1. Antioxidant effects
In the investigation of four main TF derivatives (theaflavin (TF(1)), theaflavin-3-gallate (TF(2)A), theaflavin-3'-gallate (TF(2)B), and theaflavin-3,3'-digallate (TF(3))) in scavenging reactive oxygen species (ROS) in vitro, their properties of inhibiting superoxide, singlet oxygen, hydrogen peroxide, and the hydroxyl radical, and their effects on hydroxyl radical-induced DNA oxidative damage, found that compared with (-)-epigallocatechin gallate (EGCG), TF derivatives were good antioxidants for scavenging ROS and preventing the hydroxyl radical-induced DNA damage in vitro. TF(3) was the most positive in scavenging hydrogen peroxide and hydroxyl radical, and TF(1) suppressed superoxide. Positive antioxidant capacities of TF(2)B on singlet oxygen, hydrogen peroxide, hydroxyl radical, and the hydroxyl radical-induced DNA damage in vitro were found, according to "Evaluation of the antioxidant effects of four main theaflavin derivatives through chemiluminescence and DNA damage analyses" by Wu YY, Li W, Xu Y, Jin EH, Tu YY.(43)

d.2. Antibacterial effects
in the evaluation of the antibacterial effects of various concentrations of theaflavin as well as combinations of theaflavin and epicatechin, using the disk diffusion assay, found that strong antibacterial activity of theaflavin against eight clinical isolates of S. maltophilia and A. baumannii. Significant synergy (P≤0.05) was also observed between theaflavin and epicatechin against all isolates, according to "Antibacterial effects of theaflavin and synergy with epicatechin against clinical isolates of Acinetobacter baumannii and Stenotrophomonas maltophilia" by Betts JW, Kelly SM, Haswell SJ.(44)

3. Minerals(40)
a. Manganese
Manganese is an essential trace nutrient in all forms of life. It is well known for its role in helping the body to maintain healthy skin and bone structure, but also acts as cofactors for a number of enzymes in higher organisms, where they are essential in detoxification of superoxide (O2−, with one unpaired electron) free radicals. Although superoxide is biologically quite toxic and is deployed by the immune system to kill invading microorganisms by utilizing the enzyme NADPH oxidase. Any Mutations in the gene coding for the NADPH oxidase cause an immunodeficiency syndrome.

b. Zinc
Zinc is an essential mineral that is naturally present in some foods. The ability of zinc in inhibiting oxidative processes has been recognized for many years. Chronic effects, zinc enhances the introduction of metallothioneins, which help to capture the superoxide and hydroxyl radicals due to cysteine residues, resulting in lessening the risk of oxidative stress. Over acute effects, zinc may reduce the postischemic injury to a variety of tissues and organs by involving the antagonism of copper reactivity as a result from its antioxidant functions.

c. Copper
Copper, an essential trace element is essential for the absorption and utilization of iron and distributed widely in the body and occurs in liver. Antimicrobial and viral Copper enhances the immune function in fighting against foreign invasion, such as bacteria and virus, thus reducing the risk of infection and inflammation by utilizing the absorption of oxygen and production of energy within cells.

4. Etc.

A. In conventional Medicine
A.1. Vaccines
Vaccine is defined as is a biological preparation to enhance immune function against a particular disease.
1. Monovalent meningococcal C conjugate vaccine (MCV-C)
 One dose of serogroup C meningococcal conjugate vaccine (MCV-C) at 12 months of age is the most common immunization schedule in Canada, but immunity may wane over time.(52)

2. Tetravalent meningococcal polysaccharide vaccine (MPV-ACWY)
Serum bactericidal activity and antibodies against serogroups A and C were determined before and after they received MCV-C, and 4 weeks after they received MPV-ACWY. Near-total splenectomy provides a favourable immunological basis for natural and vaccine-induced protection against meningococcal serogroup A and C infections. Sequential meningococcal vaccination is immunogenic in patients splenectomized for hereditary spherocytosis.(53)

3. Meningococcal conjugate vaccine(MCV-4) 
A newly licensed vaccine (pneumococcal conjugate vaccine) that appears to be effective in infants for the prevention of pneumococcal infections and is routinely recommended for all children greater than 2 years of age.(54)

4. The pneumococcal polysaccharide vaccine
College freshman, especially those who live in dormitories are at higher risk for meningococcal disease and should be educated about the availability of a safe and effective vaccine which can decrease their risk. Although large epidemics of meningococcal meningitis do not occur in the United States, some countries experience large, periodic epidemics. Overseas travelers should check to see if meningococcal vaccine is recommended for their destination. Travelers should receive the vaccine at least 1 week before departure, if possible. Information on areas for which meningococcal vaccine is recommended can be obtained by calling the Centers for Disease Control and Prevention at (404)-332-4565. There are vaccines to prevent meningitis due to S. pneumoniae (also called pneumococcal meningitis) which can also prevent other forms of infection due to S. pneumoniae . The pneumococcal polysaccharide vaccine is recommended for all persons over 65 years of age and younger persons at least 2 years old with certain chronic medical problems(54)

5. Etc.

A. 2. Medication
1. Antibiotics
a. Bacterial meningitis can be treated with a number of effective antibiotics, depending to  the bacteria causing the infection, In the study of moxifloxacin and ampicillin + gentamicin in the treatment of Listeria monocytogenes meningitis in a rabbit meningitis model, scientists at Ege University showed that moxifloxacin (M), ampicillin + gentamicin (A), ampicillin + gentamicin 2 (A2) and control (C). Group M received 20 mg/kg moxifloxacin at the end of the incubation time and 5 h later by intravenous (i.v.) route. Group A received ampicillin (30 mg/kg/h) and gentamicin (2.5 mg/kg/h) by i.v. route with continuous infusion for 8 h in 36 mL of 0.9% NaCl, group A2 received the same dosage of gentamicin and ampicillin in two different 36 mL 0.9% NaCl solutions and group C did not receive any treatment. Cerebrospinal fluid (CSF) samples (0.1-0.25 mL) were obtained 16 and 24 h after induction of meningitis. When the three treatment groups were compared, bacterial counts were found to be similar (P > 0.05)(55)

b. Side effects are not limit to diarrhea and gastrointestinal discomfort. In some cases, antibiotics can cause
b.1. Vomiting Severe watery diarrhea and
b.2. Abdominal cramps
b.3. Allergic reaction, such as shortness of breath, hives, swelling, etc.
b.4. Skin  Rash
b.5. Etc.

2.  Corticosteroids
a. Dexamethasone treatment may be associated with a lower mortality in adults and fewer neurological and auditory sequelae in adults and children from high-income countries, in particular in adults suffering from pneumococcal meningitis. In contrast, studies conducted in developing countries have yielded less favourable results.(56). Others suggested that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of HIV infection.(57)

b.  Side effects are not limit to
b.1. stomach irritation
b.2. rapid heartbeat (tachycardia)
b.3. nausea
b.4. insomnia
b.5. Etc.
Other severe side effects include hyperglycemia, insulin resistance, diabetes mellitus,osteoporosis, cataract, anxiety, depression, colitis, hypertension, ictus, erectile dysfunction, hypogonadism, hypothyroidism, amenorrhoea, and retinopathy.(58)

A.2. Viral Meningitis 
1. According to the statistic
Enteroviruses account for more than 85% of all cases of viral meningitis,  Arboviruses account for about 5% of cases in North America, Herpes family viruses (Herpes simplex virus (HSV)-1, HSV-2, varicella-zoster virus (VZV), Ebstein-Barr virus (EBV), cytomegalovirus (CMV), and human herpesvirus-6 collectively)  cause approximately 4% of cases of viral meningitis(58)

2.  There is no treatment for viral meningitis, as the immune system, however, will produce antibodies to destroy the virus. Care must be taken during the Leighton for the body to run its course.

A.3. Aseptic meningitis
Clinicians must consider partially-treated bacterial meningitis as a possible etiology for the aseptic nature of their patient's disease; for example, patients with bacterial otitis and sinusitis who have been taking antibiotics may present with meningitis and CSF findings identical to those of viral meningitis.(58)

A.4. Parasitic meningitis
Parasitic meningitis usually is treat with a benzimidazole derivative or corticosteroid
1. Benzimidazole derivative
a. Albendazole 
Researchers at the Chung Shan Medical University, in the study of the efficacy of Albendazole  in parasitic meningitis, showed that examination of brain tissue revealed a similar pattern of decrease (48.6% by day 7, and 53.9% by day 14). Albendazole may thus be an effective compound for the treatment of angiostrongyliasis through its larvicidal activity and facilitation of an improved inflammatory response via the reduction of MMP-9 activity(59)

b. Albendazole-GM6001 co therapy
The combination treatment reduced MMP-9 activity by 89.2% in cerebrospinal fluid. The numbers of inflammatory cells increased significantly upon establishment of infection, but subsided upon co-treatment. Significantly fewer larvae were recovered from treated mice than from untreated, infected mice. The present results strongly suggest that co-therapy with albendazole and GM6001 may be an useful approach for the treatment of human angiostrongyliasis.(60)

c. Etc.

2. Corticosteroid
Dr. Sawanyawisuth K, at the Khon Kaen University, in the study of Drug target in eosinophilic meningitis caused by Angiostrongylus cantonensis showed that eosinophilic meningitis caused by Angiostrongylus cantonensis is an emerging infectious disease. It is the most common form of human angiostrongyliasis. The diagnosis is made by clinical criteria including the presence of cerebrospinal fluid eosinophils and a history of exposure to A. cantonensis larvae, e.g., from raw freshwater snails or contaminated vegetables. Among various treatment options, corticosteroid is the only effective treatment.(61)

3. Others suggested treatment options consist of symptomatic interventions, steroid therapy, antihelminthic therapy, or a combination of these strategies(62). Others showed that interleukin-12 and mebendazole lower levels of worm recovery and dramatic lessening of the eosinophilic meningitis. A reverse transcriptase PCR assay of mRNA expression in the brain also revealed that the use of IL-12 had shifted the immune response of the mouse from Th2 type to Th1 type.(63)

4. Etc.

A.5. Non medication causes of meningitis
There is report of 39-year-old woman with systemic lupus who presented with recurrent aseptic meningitis secondary to treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), clinical manifestation resolved rapidly with ibuprofen discontinuation, and corticosteroids therapy was unnecessary. Aseptic meningitis related to NSAIDs reported in lupus patients should be considered because of their specific modality of care and their favourable outcome.(64).

B. Treatment in herbal medicine(71)
The aim of  herbal remedies are to aid the recovery process during recover phase from meningitis by strengthening the body immune system.
1. Garlic
a. Antifungal antitumor cytotoxicity and blood coagulability effects
In the identification of organosulfur compounds and theirs effects on cardiovascular diseases found that in vitro antifungal antitumor cytotoxicity and blood coagulability effects of steroid saponins from garlic and related Allium species are provided. Animal studies on the cholesterol-lowering effects of the saponin fractions from garlic are also summarized, according to "Saponins in garlic as modifiers of the risk of cardiovascular disease" by .Matsuura H(67)

b. Antioxidant effects
In the study of the Extracts of aged fresh garlic that are aged over a prolonged period and its antioxidant effects found that the ability of AGE to protect against oxidant-induced disease, acute damage from aging, radiation and chemical exposure, and long-term toxic damage. Although additional observations are warranted in humans, compelling evidence supports the beneficial health effects attributed to AGE, i.e., reducing the risk of cardiovascular disease, stroke, cancer and aging, including the oxidant-mediated brain cell damage that is implicated in Alzheimer's disease, according to "Antioxidant health effects of aged garlic extract" by
Borek C.(68)

2. Ginseng
a. Antioxidant activity
In the evaluation of the extraction conditions of polysaccharides from the rhizomes of Panax japonicus C.A. Meyer and its antioxidant effect found that antioxidant activity exhibited Panax japonicus polysaccharides (PJP) had a good potential for antioxidant, according to "Optimization of polysaccharides from Panax japonicus C.A. Meyer by RSM and its anti-oxidant activity" by Wang R, Chen P, Jia F, Tang J, Ma F.(69)

b.  Immunological activities
In the study of Water-soluble ginseng oligosaccharides (designated as WGOS) with a degree of polymerization ranging from 2 to 10 were obtained from warm-water extract of Panax ginseng roots, found that WGOS were potent B and T-cell stimulators and WGOS-1 has the highest immunostimulating effect on lymphocyte proliferation among those purified fractions. It is hoped that the WGOS will be developed into functional food or medicine, according to "Structural characterization and immunological activities of the water-soluble oligosaccharides isolated from the Panax ginseng roots" by Wan D, Jiao L, Yang H, Liu S.(70)

3. Astralgus 
 a. Immune system
Astragalus polysaccharides (APS) isolated from astragalus enhances the immune system by enhancing and regulating the function of T cells, by suppressing the CD4(+)CD25(+)Treg activity, at least in part, via binding TLR4 on Tregs and trigger a shift of Th2 to Th1, according to the study of "Astragalus polysaccharides attenuate postburn sepsis via inhibiting negative immunoregulation of CD4+ CD25(high) T cells" by Liu QY, Yao YM, Yu Y, Dong N, Sheng ZY., posted in PubMed(65)
C. Treatment in Traditional Chinese medicine

b. Anti-inflammation
Astragalus has exerted an anti-inflammatory effect as a result of inactivation the p38 and Erk1/2 and inhibition NFkappaB-mediated transcription, according to the study of "Astragali Radix elicits anti-inflammation via activation of MKP-1, concomitant with attenuation of p38 and Erk" by Ryu M, Kim EH, Chun M, Kang S, Shim B, Yu YB, Jeong G, Lee JS., posted in PubMed(66)

C. In Chinese medicine(72)
C.1. Meningitis is defined as a condition caused by
1. Heat excess in the Liver channel stirring up internal movement of Wind. Liver-Yang rising
a. Symptoms
a.1.  High fever;
a.3. Persistent fever
a.4. Restlessness
a.5. Loss of consciousness
a.6. Restless legs
a.7. Dry tongue with red-tipped spots;
a.8. Rapid-Wiry pulse
a.9. Etc.

b. Formula Ling Jiao Gou Teng Tang(72)
* Ling Yang Jiao (Cornu Antelopis, Antelope Horn) - 4.5g.  -soothes liver, eliminates wind, clear heat  *Gou Teng (Ramulus cum Uncis Uncariae, Gambir Vine Stem, Gambir) - 9g.  -restores relationship between fire and wood (pericardium and liver)
*Sang Ye (Folium Mori Albae, White Mulberry Leaf) - 6g.  -expel wind, clear lung and liver heat
*Ju Hua (Flos Chrysanthemi Morifolii, Chrysanthemum Flower) - 9g.  -expel wind, clear lung and liver heat
*Bai ShaoYao (Radix Paeoniae Lactiflorae, White Peony Root, Peony) - 9g.  -nourish yin and fluids, soothe liver, relax sinews
*Sheng Di Huang (Radix Rehmanniae Glutinosae, Chinese Foxglove Root, Rehmannia) - 15g.  -nourish yin and fluids, soothe liver, relax sinews
*Chuan Bei Mu (Bulbus Fritillariae Cirrhosae, Tendrilled Fritillaria Bulb, Fritillaria) - 12g.  -clear heat, transform phlegm
* Zhu Ru (Caulis Bambusae in Taeniis, Bamboo Shavings) - 15g.  -clear heat, transform phlegm
*Fu Shen (Sclerotium Poriae Cocos Pararadicis, Poria Spirit) - 9g.  -clears heat, relieves irritability, calms restlessness
*Gan Cao (Radix Glycyrrhizae Uralensis, Licorice Root) - 2.4g.  -harmonize other herbs within formula, nourish yin, relax sinews, relieve spasms

2. Heat entering the terminal Yin channel. Vigorous Heat generates Wind, which leads to internal movement of Liver Wind
a. Symptoms
a.1. Migraine
a.2. Muscle spasms in the extremities
a.3. Opisthotonos
a.4. Tetanus
a.6. Scarlet red,
a.7. Stiff tongue
a.8. Rapid-Wiry pulse
a.9. Etc.

b. Formula Zhi Jing San
*Quan Xie (Buthus Martensi, Scorpion, Buthus)  -extinguish wind, relieve spasms, stop pain, relieve toxicity
*Wu Gong (Scolopendra Subspinipes, Centipede, Scolopendra)  -extinguish wind, relieve spasms, stop pain, relieve toxicity

3. Heat excess which leads to internal movement of Liver Wind (in children). Phlegm-Heat in the Lungs
a. Symptoms
a.1. High fever
a.2. Pneumonia
a.3. Tetanus
a.4. Body rigidity
a.5. Opisthotonos
a.6. Restlessness
a.7. Spasms
a.8. Stiff jaw
a.9. Etc.

b. Hu Po Bao Long Wan(74)
*Niu Huang (calculus bovis) 7.8%
*Tian Zhu Huang (Concretio Siliceae Bamusae) 7.8%
*Dan Nan Xing (Pulvus Ariseamatis Cum Felle Bolvis) 3.1%
*She Xiang (Secretio Moschus)0.6%
*Quan Xie  (Buthus Martensi) 4.7%
*Jiang Can (Bombyx Batryticatus) 15.3%
*Zhu Sha (Cinnabaris) 4.7%
*Hu Po (Succinun) 3.8%
*Xiong Huang (Realgar)1.6%
*Chi Fu Ling (Sclerotium Poriea Cocus) 15.5%

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