Richa Agarwal, MD
https://medicine.duke.edu/faculty/richa-agarwal-md
Lyrica dosages: 150 mg, 75 mg
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Compared with the psychosis of schizophrenia, patients with interictal psychosis typically have an absence of negative symptoms or formal thought disorder, better premorbid states, and less deterioration of personality (65). Patients with psychosis related to epilepsy also have an older age of onset compared to those with schizophrenia, with symptoms beginning in the late 20s to mid 30s (65,66). Those with epilepsyrelated psychosis are more likely to be male, as opposed to patients with schizophrenia (65). Patients with interictal psychosis may also have a better prognosis, with a tendency for remissions and positive responses to treatment (65). In some patients, a positive correlation exists between overall seizure frequency and psychotic symptoms. A notable exception to this pattern, however, is the concept of "forced normalization" or "alternative psychosis" introduced by Landolt in 1953 (63). Although evident with other psychiatric disorders as noted above, forced normalization is classically associated with psychotic behavior. De novo psychosis after epilepsy surgery has also been reported, with rates varying from 1% to 28. Symptoms most often occur transiently after surgery, and the diagnosis may be easily missed. Risk factors include a family history of psychosis, surgery after 30 years of age, and preoperative psychosis. Some authors suggest an increased incidence in those undergoing nondominant temporal resections, although this is not a consistent finding. It typically presents after a cluster of seizures or status epilepticus, oftentimes in someone whose seizures were otherwise well controlled. Symptoms often begin after 24 to 48 hours of normal baseline behavior, a period termed the "lucid interval. A history of interictal psychosis, a family history of psychosis, and low intellectual functioning predict a longer duration of symptoms (68). Symptoms may include visual or auditory hallucinations, paranoia, delusions, confusion, affective changes, violence. It is important to distinguish between postictal psychosis and postictal mania, as treatment options differ (Table 93. The two entities may be easily confused, as both may involve manic features and exhibit a similar lucid period.
The use of corticotropin and a corticosteroid in patients with minor motor seizures. Treatment and long-term prognosis of myoclonic-astatic epilepsy of early childhood. Effects of high-dose intravenous corticosteroid therapy in Landau-Kleffner syndrome. Pneumocystis carinii pneumonia in infants given adrenocorticotropic hormone for infantile spasms. Pneumocystis carinii pneumonia associated with adrenocorticotropic hormone treatment for infantile spasms. Randomised, placebocontrolled study of vigabatrin as first-line treatment of infantile spasms. Vigabatrin as first-line drug in West syndrome: clinical and electroencephalographic outcome. Randomized trial comparing vigabatrin and hydrocortisone in infantile spasms due to tuberous sclerosis. Visual field loss associated with vigabatrin: quantification and relation to dosage. Vigabatrin in the treatment of childhood epilepsy: a retrospective chart review of efficacy and safety profile. Ganaxolone for treating intractable infantile spasms: a multicentre, open-label, add-on trial. Among those with epilepsy, 30% to 40% continue to have seizures or experience unacceptable side effects that affect their quality of life (5,6). Moreover, the available anticonvulsant drugs neither influence the process of epileptogenesis in humans nor alter the underlying brain dysfunction that expresses itself as epilepsy. Rather, they merely suppress the symptoms of epilepsy, and therefore are not actually antiepileptic or antiepileptogenic. An agent considered to be truly antiepileptogenic or antiepileptic in nature would prevent epilepsy. National Institutes of Health (9), which has screened more than 24,000 compounds (provided by industry and academia) for potential anticonvulsant efficacy in traditional animal models (9,10).
Oral glucosamine sulphate in the management of arthrosis: report on a multi-centre open investigation in Portugal. G Glucosamine + Antineoplastics the interaction between glucosamine and antineoplastics is based on experimental evidence only. Clinical evidence No interactions found Experimental evidence An in vitro study found that colon and ovary cancer cell lines showed resistance to doxorubicin and etoposide after exposure to glucosamine at a concentration of 10 mmol. Only a weak effect of glucosamine was found in the responsiveness of breast cancer cell lines to etoposide. Importance and management this possible interaction appears not to have been studied in vivo and, until more data are available, the clinical significance of the Glucosamine + Food No interactions found. Glucosamine + Paracetamol (Acetaminophen) Limited evidence suggests that glucosamine may reduce the efficacy of paracetamol (acetaminophen). Note that this would only occur with glucosamine sulfate salts and would not occur with glucosamine hydrochloride. The combined use of glucosamine and paracetamol to alleviate the symptoms of osteoarthritis is common, and the limited evidence here does not provide any reason to suggest any changes to this practice. Adverse interactions between herbal and dietary substances and prescription medications: a clinical survey. Importance and management Glucosamine is a widely used supplement, particularly in the middle-aged and elderly, who are also the group most likely to be using warfarin or similar anticoagulants. Even taking into account the possible cases reported to regulatory authorities, the interaction would seem to be quite rare. Clinical evidence A single-dose study in healthy subjects given tetracycline 250 mg alone or with glucosamine 250 mg found that the serum tetracycline levels were 105%, 50% and 25% higher at 2, 3 and 6 hours after administration, respectively, in those patients who had received the combined treatment. Similar results were found when oxytetracycline was given with glucosamine, with the corresponding increases being 36%, 44% and 30% at 2, 3 and 6 hours after administration, respectively. In contrast, in another single-dose study in 12 healthy subjects given tetracycline 250 mg alone, and then with glucosamine 125 mg and 250 mg at 1-week intervals, the addition of glucosamine slightly increased serum tetracycline levels at 2, 3, 6 and 8 hours, but this was not statistically significant. In the dogs, the increase in radioactivity was over twofold at 30 minutes, 1 hour and 24 hours after drug administration, whereas in the mice the increase was only greater than twofold at 15 minutes after drug administration.
Suppressive efficacies by adaptive temporal filtering system on photoparoxysmal response elicited by flickering pattern stimulation. Understanding dissociations in dyscalculia: a brain imaging study of the impact of number size on the cerebral networks for exact and approximate calculation. Reflex seizures in patients with malformations of cortical development and refractory epilepsy. Role of television, video games and computers in epileptic photosensitive patients: preliminary results. Flicker illness: An underrecognized but preventable complication of helicopter transport. Wind turbines, flicker, and photosensitive epilepsy: Characterizing the flashing that may precipitate seizures and optimizing guidelines to prevent them. A controlled study of the effect of sodium valproate on photosensitive epilepsy and its prognosis. Reflex partial seizures of sensorimotor cortex (including cortical reflex myoclonus and startle epilepsy). From molecules to networks: cortical/subcortical interactions in the pathophysiology of idiopathic generalized epilepsy. Magnetic resonance spectroscopy reveals an epileptic network in juvenile myoclonic epilepsy. Seizures induced by singing and recitation: a unique form of reflex epilepsy in childhood. Language-induced epilepsy, acquired stuttering, and idiopathic generalized epilepsy: phenotypic study of one family. Musical consonances and dissonances: are they distinguished independently by the right and left hippocampi Discrimination and recognition of tonal melodies after unilateral cerebral excisions. Functional imaging of the auditory system: the use of positron emission tomography.
Diseases
Normal magnetic resonance imaging and medial temporal lobe epilepsy: the clinical syndrome of paradoxical temporal lobe epilepsy. Clinical and electrographic manifestations of lesional neocortical temporal lobe epilepsy. Surgical treatment of limbic epilepsy associated with extrahippocampal lesions: the problem of dual pathology. Frequency and characteristics of dual pathology in patients with lesional epilepsy. Selective amygdalohippocampectomy as a surgical treatment of mesiobasal limbic epilepsy. Magnetic resonance imagingbased volume studies in temporal lobe epilepsy: pathological correlations. Long-term seizures and quality of life after epilepsy surgery compared with matched controls. Long-term seizure outcomes following epilepsy surgery: a systematic review and meta-analysis. Long-term outcome of epilepsy surgery among 399 patients with nonlesional seizure foci including mesial temporal lobe sclerosis. Temporal lobectomy: long-term seizure outcome, late recurrence and risks for seizure recurrence. The spectrum of long-term epilepsy-associated tumors: long-term seizure and tumor outcome and neurosurgical aspects. Long-term outcome after temporal lobe surgery-prediction of late worsening of seizure control. Long term follow-up of the first 70 operated adults in the Goteborg Epilepsy Surgery Series with respect to 94.
At least one technologist should have experience with the technical and safety issues encountered during electrocorticographic recordings in the operating room. Additionally, several technologists should have experience with long term monitoring with intracranial electrodes and the safety and recording issues occurring during cortical stimulation. At least one technician should have experience with electrocorticographic recordings in the operating room. Allow nursing or monitoring staff easy access to patients to facilitate examination and first aid b. Number or duration of seizures over given period requiring physician notification c. Transportation and designated provider of emergency services in the event of emergencies. Medication reduction to increase seizure yield is not recommended in the outpatient setting. It should not be done without close supervision by a physician or extensively trained nurse clinician on premises. Measures taken should be more thorough than in the outpatient setting because likelihood of seizures occurring is greater with medication reduction. Reliable and appropriately trained family members or nursing assistants may assist in some situations. Mandatory Protocols (modified as necessary to account for individual situations) a. Examination of speech, memory, level of consciousness and motor function during and following a seizure. Number or duration of seizures over given period requiring physician notification. Measures to be taken if number, duration, or severity of seizures observed is excessive.
Subtle hippocampal asymmetries only detected using volumetric analyses were less predictive of outcome (36). With extratemporal hypopmetabolism, chances of seizure freedom are even worse: complete seizure freedom at last follow-up (mean 6. These patterns often have a multilobulated "hourglass" appearance with the largest and most intense hyperperfusion cluster often representing ictal propagation and not necessarily requiring resection to render a patient seizure free (48). In general, interictal evidence of a diffuse irritative zone predicts a worse outcome: postoperative seizure freedom is worse when interictal spiking was posterior temporal, extratemporal, or bitemporal (36). One study found that if 90% of surface interictal bitemporal spikes arise from one temporal lobe, excellent outcome is possible (92% seizure free in the second postoperative year vs. Those modalities are therefore reserved for patients with a poorly defined epileptogenic zone, which may explain poorer outcomes seen in cases that required invasive recordings preoperatively compared to those that did not (4,26,31). Yet, specific findings obtained with such invasive evaluations may provide useful prognostic information. During depth recordings, more favorable outcomes are seen with exclusively unilateral seizure onset and ictal spiking as opposed to low-voltage fast activity, electrodecrement, or any other rhythmic sustained activity at seizure onset, whereas evolution into distinct contralateral electrographic seizures lowered seizure freedom from 84% to 47% at 1 postoperative year (36). The amount of amygdala that must be resected to achieve seizure freedom is unclear, although one study found no correlation between residual amygdalar tissue and surgical outcome (52). The ideal extent of lateral temporal resection also remains to be defined with conflicting data currently available (36). In the presence of a well-circumscribed lesion, such as a tumor or a vascular malformation, a lesionectomy might suffice unless there is associated hippocampal atrophy. In such cases of dual pathology, complete seizure freedom after a mean follow-up of 37 months was lowered from 73% with lesionectomy plus mesial temporal resection to 20% with mesial temporal resection alone and 12. Etiology, Pathology, and Seizure Outcome When pathologic findings in the resected temporal lobe were restricted to nonspecific gliosis, worse short- and long-term outcomes have consistently been observed (36).
In general, rates of absorption, protein binding, metabolism and renal elimination are lower in neonates than adults, while the free/unbound drug fraction and volume of distribution are increased. Infants demonstrate increased absorption and metabolism with lower protein binding resulting in higher free fraction of anticonvulsants. Children have increased metabolic enzyme capacity resulting in lower plasma concentrations, necessitating higher doses of phenytoin. Phenobarbital bioavailability is reduced in infants and children due to lower gastric acid secretion and slower absorption than adults. Neonates exhibit lower protein binding with higher active, unbound concentrations. Metabolism is reduced in neonates, exceeds the rate of metabolism in adults at a few months of age (resulting in a shorter half-life and lower plasma concentrationdose ratio) and slows to adult rates by 10-14 years of age. Primidone disposition is not well studied in newborns or infants, however, the pharmacokinetic parameters in children are similar to adults. Carbamazepine metabolism is reduced in the newborn, increased in the infant and matches adults by childhood. Children have higher ratios of carbamazepine-epoxide-metabolite to carbamazepine concentrations which may play a more significant role as anticonvulsant in children than in adults. Valproic acid is metabolized more quickly in children resulting in a shorter half-life. Children less than 2 years of age have reduced hepatic elimination which may increase the concentration of toxic metabolites associated with hepatotoxicity. Protein binding changes associated with age or concomitant declines in renal function result in a higher free fraction of drug. Adverse events associated with the use of antiepileptic drugs are common in the elderly due to these age-associated changes in drug biotransformation. Even though carbamazepine is the gold standard for treatment of partial seizures; valproate is the gold standard 51 for treatment of generalized seizures; phenobarbital and phenytoin are broad spectrum, inexpensive anticonvulsants, the use of these medications may be problematic in the elderly.
Osmund, 34 years: Navigational Note: Precocious puberty Physical signs of puberty with Physical signs and biochemical no biochemical markers for markers of puberty for females <8 years and males <9 females <8 years and males <9 years years Definition: A disorder characterized by unusually early development of secondary sexual features; the onset of sexual maturation begins usually before age 8 for girls and before age 9 for boys. Data from a population-based case control study demonstrate that the risk of developing these reactions is 5 to 8 times greater than in the general population. Extent of Resection and Seizure Outcome Complete resection of the epileptogenic lesion has consistently been found to predict seizure freedom.
Ortega, 49 years: Conversely, patients may undergo an exacerbation of an underlying psychopathology or develop de-novo psychopathology after surgery. Seizure-free periods increased every year; one patient continued to be seizure free after 36. The fetal inflammatory response syndrome and cerebral palsy: yet another challenge and dilemma for the obstetrician.
References
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