Epilepsy & behavior : E&B
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Status epilepticus (SE) is a major neurological emergency with an incidence of about 20/100,000 and a mortality between 3 and 40% depending on etiology, age, status type, and status duration. Generalized tonic-clonic SE, in particular, requires immediate, aggressive, and effective treatment to stop seizure activity, and to prevent neuronal damage and systemic complications and death. Benzodiazepines and phenytoin/fosphenytoin are traditionally used as first-line drugs and are effective in about 60% of all episodes. ⋯ Therefore, there is a need for more effective first-line treatment options. Recently, valproic acid was approved for the treatment of status epilepticus in some European countries, and two of the newer antiepileptic drugs have become available for intravenous use: Levetiracetam (LEV) and lacosamide (LCM) should be evaluated in prospective controlled trials as possible treatment options. Standardized protocols for the management of SE are useful to improve immediate care.
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Epilepsy & behavior : E&B · Apr 2009
Clinical TrialIntravenous midazolam in convulsive status epilepticus in children with pharmacoresistant epilepsy.
Although the efficacy of midazolam in refractory status epilepticus and as a first-line agent in children with established status epilepticus has been reported, differences in starting doses, continuation method, timing of efficacy assessment, and discontinuation pose limitations in deriving a specific protocol for midazolam use. An audit of clinical experience with a protocol of midazolam as first-line agent for impending status epilepticus (defined as a continuous, generalized, convulsive seizure lasting >5 minutes) in 76 episodes of unprovoked convulsive status epilepticus in children 1-15 years old with treatment-refractory epilepsy demonstrated that: (1) repeated bolus midazolam 0.1mg/kg (every 5 minutes, maximum 5) controlled 91% of events; (2) three bolus doses controlled 89% of the episodes, with minimal chance of response beyond that; (3) treating impending status resulted in lower doses (mean 0.17 mg/kg) than reported and infrequent utilization of additional anticonvulsants (9%); and (4) adverse events were infrequent (respiratory depression 13%, assisted ventilation 3%).
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During the past decade, substantial progress has been made in delineating clinical features of the epilepsies and the basic mechanisms responsible for these disorders. Eleven human epilepsy genes have been identified and many more are now known from animal models. Candidate targets for cures are now based upon newly identified cellular and molecular mechanisms that underlie epileptogenesis. ⋯ Cognitive, emotional and behavioral co-morbidities are common and offer fruitful areas for study. These advances in understanding mechanisms are being matched by the rapid development of new diagnostic methods and therapeutic approaches. This article reviews these areas of progress and suggests specific goals that once accomplished promise to lead to cures for epilepsy.
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Epilepsy & behavior : E&B · Mar 2009
Do psychiatric comorbidities predict postoperative seizure outcome in temporal lobe epilepsy surgery?
Clinical and demographic presurgical variables may be associated with unfavorable postsurgical neurological outcome in patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS). However, few reports include preoperative psychiatric disorders as a factor predictive of long-term postsurgical MTLE-HS neurological outcome. We used Engel's criteria to follow 186 postsurgical patients with MTLE-HS for an average of 6 years. ⋯ Twenty-three (12.4%) patients had Axis II personality disorders. Regarding seizure outcome, preoperative anxiety disorders (P=0.009) and personality disorders (P=0.003) were positively correlated with Engel class 1B (remaining auras) or higher. These findings emphasize the importance of presurgical psychiatric evaluation, counseling, and postsurgical follow-up of patients with epilepsy and psychiatric disorders.
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Epilepsy & behavior : E&B · Feb 2009
Prevalence and cost of nonadherence to antiepileptic drugs in elderly patients with epilepsy.
Retrospective insurance claims from the United States were analyzed to assess nonadherence to antiepileptic drugs (AEDs) and the association between AED nonadherence, seizures, and health care costs in elderly persons with epilepsy. Inclusion criteria were: age 65, epilepsy diagnosis between 1 January 2000 and 31 June 2006, 2 AED prescriptions, and insurance enrollment for 6 months pre- and 12 months post-AED initiation. Adherence was evaluated using the medication possession ratio (MPR), with MPR<0.8 defining nonadherence. ⋯ Seizure, defined by epilepsy-related inpatient or emergency department admission, occurred in 12.1% of nonadherers versus 8.2% of adherers (P=0.0212). Nonadherers had higher inpatient (+$872, P=0.001), emergency department (+$143, P=0.0008), other outpatient ancillary (+$1741, P=0.0081), and total health care (+$2674, P=0.0059) costs. AED adherence among elderly patients with epilepsy is suboptimal and associated with increased seizures and health care costs.