Epilepsy research
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Different approaches to clinical trials are taken by government-sponsored (NIH, VA, MRC) and industry-sponsored clinical trials. Each sector has a different perspective and funding capacity. ⋯ Studies of drug use as monotherapy, direct comparisons among drugs, and comparisons between categories of drugs often are more important to prescribers and payors, thereby requiring government funding. The challenge to clinician-investigators is to now find ways to fund comparison trials to determine evidence-based guidelines so patients receive the best treatment both in the short- and long-term, and the health care system gets the best value.
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Status epilepticus (SE), defined as recurrent epileptic seizures without complete recovery between seizures, is one of the most serious manifestations of epilepsy. Generalized convulsive status epilepticus (GCSE) is the most common and most life-threatening form of SE, and aging increases the mortality risk. In a recent study of treatment of GCSE, 226 of 518 evaluable patients (43.6%) were of age 65 or older. ⋯ The diagnosis can be challenging, particularly in the elderly, as overlapping clinical features and electroencephalogram patterns can be seen in SE and in a variety of encephalopathic conditions. There is a suggestion that aggressive treatment of elderly patients with nonconvulsive SE may worsen prognosis. Clearly, there is a need for more data to better understand management of elderly patients with both convulsive and nonconvulsive SE.
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Treatment of elderly patients with epilepsy may present unique challenges to physicians. Co-morbid conditions and drugs to treat such conditions are common in elderly patients, possibly complicating epilepsy therapies that are dependent on drugs alone. For this reason, surgical intervention may be an attractive option for elderly patients with epilepsy, particularly for medically intractable patients with key disease features, such as lateralization and precisely localized epileptic foci. ⋯ When a curative surgical procedure is not an option, palliative procedures, including vagus nerve stimulation and deep brain stimulation, may be viable options. Vagus nerve stimulation has been reported to reduce seizure rates and improve quality of life in elderly patients with epilepsy. Currently, widespread therapeutic application of deep brain stimulation is limited by risks, costs, and pending studies.