This document discusses the classification, management, and treatment of intractable epilepsy. It begins with summaries of the 2017 ILAE classification of seizure types and reminiscences of past classifications from 1981 and 2010. It then discusses definitions of intractable epilepsy, risk factors, current treatment approaches including antiepileptic drugs, surgery, diet, and ideal drug characteristics. Newer adjunctive drugs and their effectiveness are reviewed based on clinical studies and guidelines. The impact of uncontrolled seizures on quality of life and risks are highlighted. Controlled trials showing significantly better outcomes of surgery compared to continued medical therapy are also summarized.
Treatment Options for Drug-Resistant Epilepsy
In some people with drug resistant epilepsy, there are effective treatment options, with a high chance of seizure freedom. These include:
Resective Epilepsy Surgery
Resective epilepsy surgery consists of removing the area of the brain that is causing the seizures. However, for a patient to be a good candidate for surgery, the following conditions have to be met:
The area of the brain where seizures originate is clearly identified.
That area of the brain can be safely removed with surgery. In other words if the risk is greater than “minimal risk,” the patient is not a candidate.
The probability to achieve seizure freedom with epilepsy surgery varies depending on the structures of the brain involved. For example, patients whose seizures originate in the temporal lobe have a 50% to 70% chance of achieving seizure-freedom.
Today, newer, less-invasive techniques are being used in the place of resective surgery in appropriate cases. These include the use of laser, in which a laser probe burns the area of the brain causing the seizures. However, these new techniques may not work for all candidates for resective surgery.
Specific Metabolic Treatment
While metabolic causes of epilepsy are uncommon, identifying some of these conditions can lead to specific treatments to allow the body to compensate for the metabolic change.
Examples are treatment with a ketogenic diet for GLUT1 deficiency, treatment with pyridoxine or pyridoxal-5-phosphate for vitamin dependent epilepsies, and creatine supplementation for creatine deficiency syndromes.
Specific Genetic Causes
Identifying a specific genetic cause can help your doctor choose the best treatment for seizures.
For example, with SCN1A pathogenic variants, medications such as Oxcarbazepine (Trileptal), Carbamazepine (Tegretol) or Phenytoin (Dilantin) should be avoided. Whereas with other types of pathogenic variants, such as SCN2A and SCN8A variants, these medications can be very helpful.
Some specific treatments which target the underlying problem caused by the genetic variant are in clinical trials, and may improve learning and development as well as help with seizures.
Immunotherapy
In the last decade, the role of inflammatory processes in certain types of epilepsy has been recognized. In these cases, medications that counteract these processes have been used with success. However, they have to be used with caution as they are associated with a variety of adverse events.
Treatment Options for Drug-Resistant Epilepsy
In some people with drug resistant epilepsy, there are effective treatment options, with a high chance of seizure freedom. These include:
Resective Epilepsy Surgery
Resective epilepsy surgery consists of removing the area of the brain that is causing the seizures. However, for a patient to be a good candidate for surgery, the following conditions have to be met:
The area of the brain where seizures originate is clearly identified.
That area of the brain can be safely removed with surgery. In other words if the risk is greater than “minimal risk,” the patient is not a candidate.
The probability to achieve seizure freedom with epilepsy surgery varies depending on the structures of the brain involved. For example, patients whose seizures originate in the temporal lobe have a 50% to 70% chance of achieving seizure-freedom.
Today, newer, less-invasive techniques are being used in the place of resective surgery in appropriate cases. These include the use of laser, in which a laser probe burns the area of the brain causing the seizures. However, these new techniques may not work for all candidates for resective surgery.
Specific Metabolic Treatment
While metabolic causes of epilepsy are uncommon, identifying some of these conditions can lead to specific treatments to allow the body to compensate for the metabolic change.
Examples are treatment with a ketogenic diet for GLUT1 deficiency, treatment with pyridoxine or pyridoxal-5-phosphate for vitamin dependent epilepsies, and creatine supplementation for creatine deficiency syndromes.
Specific Genetic Causes
Identifying a specific genetic cause can help your doctor choose the best treatment for seizures.
For example, with SCN1A pathogenic variants, medications such as Oxcarbazepine (Trileptal), Carbamazepine (Tegretol) or Phenytoin (Dilantin) should be avoided. Whereas with other types of pathogenic variants, such as SCN2A and SCN8A variants, these medications can be very helpful.
Some specific treatments which target the underlying problem caused by the genetic variant are in clinical trials, and may improve learning and development as well as help with seizures.
Immunotherapy
In the last decade, the role of inflammatory processes in certain types of epilepsy has been recognized. In these cases, medications that counteract these processes have been used with success. However, they have to be used with caution as they are associated with a variety of adverse events.
Author: Danielle Cassidy, Pharm.D., BCPS
Audience: Third year pharmacy students at University of Colorado School of Pharmacy
Background: describes common causes of seizures, differentiates dosing of antiepileptic drugs in pediatrics vs. adults, common risk factors associated with febrile seizures, treatment of febrile seizures, treatment of status epilepticus (inpatient & outpatient), & how to dispense/counsel parents on the administration of Diastat.
Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th
Epilepsy is a common condition, encountered by neurologists, pediatricians, physicians and other doctors. It can be easily treated with anti-epileptic drugs. The current presentation discusses the approach to management of epilepsy, focussing on diagnosis and treatment.
Author: Danielle Cassidy, Pharm.D., BCPS
Audience: Third year pharmacy students at University of Colorado School of Pharmacy
Background: describes common causes of seizures, differentiates dosing of antiepileptic drugs in pediatrics vs. adults, common risk factors associated with febrile seizures, treatment of febrile seizures, treatment of status epilepticus (inpatient & outpatient), & how to dispense/counsel parents on the administration of Diastat.
Presentation given by Dr Catherine Poots from Craigavon Area Hospital at the 2014 Northern Ireland Intensive Care Society annual Coppel Prize on Wednesday November 26th
Epilepsy is a common condition, encountered by neurologists, pediatricians, physicians and other doctors. It can be easily treated with anti-epileptic drugs. The current presentation discusses the approach to management of epilepsy, focussing on diagnosis and treatment.
New Treatment Devices and Clinical Trials jgreenberger
Dr. Kathryn Davis from Penn Epilepsy Center present on new treatment devices and clinical trials for epilepsy. From the 2014 Epilepsy Education Exchange.
Epilepsy is a common neurological illness. Systematic evaluation and management leads to successful outcomes in most patients with epilepsy. Clinical description along with brain imaging and EEG would lead to accurate diagnosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
1. Avinash ChandraAvinash Chandra
Annapurna Neurological Institute and AlliedAnnapurna Neurological Institute and Allied
Management of IntractableManagement of Intractable
2. Motor
tonic-clonic
clonic
tonic
myoclonic
myoclonic-tonic-clonic
myoclonic-atonic
atonic
epileptic spasms1
Non-Motor (absence)
typical
atypical
myoclonic
eyelid myoclonia
Unknown Onset
Motor Onset
automatisms
atonic1
clonic
epileptic spasms1
hyperkinetic
myoclonic
tonic
Non-Motor Onset
autonomic
behavior arrest
cognitive
emotional
sensory
focal to bilateral tonic-clonic
Generalized OnsetFocal Onset
Aware
Impaired
Awareness
Motor
tonic-clonic
epileptic spasms
Non-Motor
behavior arrest
ILAE 2017 Classification of Seizure TypesILAE 2017 Classification of Seizure Types
Unclassified2
1
These could be focal or generalized, with or without alteration of awareness
2 Due to inadequate information or inability to place in other categories
From Fisher et al. Instruction manual for the ILAE operational classification of seizure types. 2017 ,Epilepsia
6. IncidenceIncidence
4% of the population
1% of the population
0.4% of the population
80% has epileptogenic focus
WHO, 2017 Feb update
Shorvon et al., 1996 Epilepsia
Epilepsy
First seizure ever
Epilepsy
(intractable)
7. Intractable SeizureIntractable Seizure
No generally accepted definition of intractability.
No single step in the treatment defines medical intractability.
The definition of medical intractability has to be based on the type and
number of the drugs that have failed, despite the adequate trials.
In our setting:
- the number of AED failures to be 2 to 3,
- seizure frequency to be near to none*
- time factor to be 2 years.
8. Intractable SeizureIntractable Seizure
• The ILAE proposed a definition of drug-resistant epilepsy as a failure of
adequate trials of 2 tolerated and appropriately chosen and used AED
schedules.
• This for now, could provide an operational definition for clinical and
research settings. However, with emergence of new data and novel
treatments the criteria for intractability may change.
• Ideally, it is lack of acceptable seizure control despite the adequate
trials of appropriate drugs at adequate level with minimal side effects.
Rohracher et al, 2015 Journal of Epileptology
Kwan et al., 2009 Epilepsia
ILAE task force, 2017
9. Risk of intractibility against the time
Berg et al., 2001 Neurology
Time in months
Riskin%
10. Intractable SeizureIntractable Seizure
Underlying Pathology is a major prognostic factor for recurrence
Etiology % Controlled (>1 year)
Cryptogenic Generalized 82%
Partial 45%
Head injury 30%
Dysgenesis 40%
TLE 20%
HS 11%
Dual Pathology 3%
Sonah et al., 1998 Neurology
11.
12. What Are Today’s Clinical Needs?What Are Today’s Clinical Needs?
Current status of epilepsy treatment
When to consider intractable
How many of them intractable
Impact of newer drugs/ newer trials on intractable
13. Quantifying IntractableQuantifying Intractable
Sufficient Number of Drug Trials: 2 to 4 major drugs at maximal
tolerated drugs and 6 combinations. (Spectrum of opinions!)
If one AED doesn’t work at maximal tolerated dosage, take that out!!
Frequency change in epileptic attacks.%controlled
No. of drugs
14. What if Left Uncontrolled…?What if Left Uncontrolled…?
Quality of life (psychological, social, occupational..)
Interictal dysfunction (learning, memory..)
Increasing risk of SUDEP
Progressive neurological dysfunction(Epileptic
encephalopathy)
Kindling Effect
Neuropsychiatric comorbities
Placing substantial burden on the individuals, carers
17. An Ideal Antiepileptic DrugAn Ideal Antiepileptic Drug
Prevent or inhibit excessive pathological neuronal discharge
Does not interfere with normal physiological neuronal activity
Free of adverse effect
Does not exist!!!!
18. AEDs
Blockade of voltage-gated Na+
Phenytoin, CBZ, Valp. Lamotrigine
Inhibition of glutamatergic
neurotransmission
Phenobarb., Topiramate
Enhancement of GABAergic
neurotransmission
Barbiturates, BDZ, Valp. Vigabatrin, Gabap.
Ca+ gated
channels
Ethosux
Other Targets
NMDA/AMPA/
K+..
23. Impact of AEDs on IntractabilityImpact of AEDs on Intractability
AED Seizure Syndrome Observation
period
Seizure Free Our Experience
Levetiracetam Focal onset 16 weeks 5.7%
14 weeks 8.2% 4 out of 6
12 weeks 8.2%
Generalized onset 16 weeks 15.6%
12 weeks 3 out of 3
Vigabatrin Focal onset 12 weeks 6%
Not categorized N/A 50%
Clobazam Not categorized 48 weeks 8%
Focal/impaired awareness 12 weeks 74% 3 out of 3
Generalized onset 48 weeks 15%
12 weeks 3 out of 8
Acetazolamide Focal onset 12 weeks 44%
CBZ+Valproat
e
Focal to Genaralized tonic
clonic
48 months 38%
12 weeks 6 out of 7
24. Controlled Randomized Clinical Trial of EpilepsyControlled Randomized Clinical Trial of Epilepsy
SurgerySurgery
Surgical treatment for epilepsy has offered the chance of cure or greater
cure for this disorder.
• Single center trial, 116 children refractory (medical therapy group 59,
surgery group 57). Outcome, seizure free 12 months- 7 % vs 77%
• Single center trial, for TLE, 80 Adults (medical 40, TLE surgery 40).
Outcome, seizure free 12 months 58% vs 8%
Dwivedi et al., 2017 NEJM
Weibe et al., 2001 NEJM
One could define intractability as the probability of seizure control by further steps of 5% or less, like the p-value.
The certainty that a patient will remain refractory to medications can only be approached in an asymptotic manner and
Multiple factors including number of antiepileptic drug (AED) failures, seizure frequency and duration of unresponsiveness, etiology, and epilepsy syndromes are considered in formulating the definition of pharmaco-resistant epilepsy.
A patient who has one seizure every 2 months or a patient who has one seizure every day will not require the same amount of time for you to decide that the drug has failed.
Studies suggest that each year there are about 1.16 cases of SUDEP for every 1,000 people with epilepsy, although estimates vary.
Even ingle seizure can be treated !!! Since anoxic damage created by seizure
does not necessarily control the epilepsy. It simply provides the rough guide of response