Neurologist
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Gabapentin has been used effectively for neuropathic pain with mild side effects. Two cases of gabapentin-induced sexual dysfunction are reported and discussed.
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Evidence-based medicine establishes guidelines for clinical decision-making in which priority is given to processes that have the highest level of evidence. Although these guidelines provide valuable general guidance, the information is partial, because oftentimes obtaining evidence on antiepileptic drugs is promoted by commercial expectations and not by clinical priorities. Furthermore, the guidelines tend to classify different types of epilepsy into large groups, often without contemplating the different syndromes. Expert opinions are subject to criticism on the basis of methodology and their authoritarian aspect, although they can supplement medical literature and advice on specific clinical situations quickly and efficiently. ⋯ We have found that in all types of epilepsy [except in focal epilepsy in children where a new drug (oxcarbamazepine) is considered to be the first choice for initial treatment], classic drugs (valproic acid in idiopathic generalized epilepsy and carbamazepine in focal epilepsy) are recommended as long as there are no contraindications due to adverse effects or concomitant use of other drugs that interact with the antiepileptics. However, despite the general recommendations, it can be deduced from the studies and reflections on the subject that the decision as to whether to start treatment or not, as well as the drug of choice, must be made on a case-by-case basis, taking into account the patient's personal and social circumstances.
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Despite the correct use of antiepileptic drugs, control of seizures is not possible in 20% to 30% of people with epilepsy. This group of patients is considered to suffer from drug-resistant epilepsy, a clinical situation that can be caused by certain syndromes in which surgery can be used to bring the seizures under control. ⋯ The aim of this review is to update knowledge on the indications for surgery and electrical stimulation in the management of epilepsy.
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Therapeutic hypothermia (TH) has been employed as a neuroprotective strategy for a wide array of clinical problems since the late 1940s. Animal studies have determined that the neuroprotective effect of hypothermia is pleiotropic, impacting many steps in both the ischemic cascade and reperfusion injury. Interest in the neuroprotective effects of TH for ischemic brain injury has been resurgent, fueled by both recent positive and negative clinical trials. A review of preclinical and clinical reports on TH in adult patients is provided in this article. ⋯ TH is a safe, effective neuroprotective strategy for global cerebral ischemia. Because of the neuroprotective efficacy of TH in adult comatose survivors of cardiac arrest, neurologists should advocate the implementation of this strategy. TH for focal ischemia is a promising therapeutic option, but requires more basic and clinical investigation.
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Animal and human studies support mild therapeutic hypothermia as an effective means of preventing brain injury in comatose patients resuscitated from cardiac arrest. However, there is little clinical experience with predicting neurologic outcome in this patient population. We present 4 comatose patients resuscitated from cardiac arrest treated with mild hypothermia whose in-hospital neurologic prognosis was determined by board-certified neurologists to be grave, yet were ultimately discharged from the hospital with no or minimal neurologic sequelae. ⋯ This case series suggests that neurologic assessment-based prognosis of patients after cardiac arrest undergoing therapeutic mild hypothermia should be considered unreliable for at least the first 72 hours. Use of additional assessments such as brain injury markers or evoked potentials, in addition to clinical examination, should be strongly considered to help determine an estimated prognosis. Functional reversibility after a global insult could be an intrinsic potential of the brain, similar to myocardial stunning, and deserves investigation.