Hormone replacement therapy in a postmenopausal woman with epilepsy.

OBJECTIVE: To prospectively evaluate the effects of hormone replacement therapy (HRT) on seizure activity in a postmenopausal woman with epilepsy. BACKGROUND: Postmenopausal women are at an increased risk for cardiovascular disease and osteoporosis secondary to a lack of estrogen's protective effects. As a result, women without known contraindications often take HRT to counteract this risk. Postmenopausal women with epilepsy are at a greater risk for osteoporosis because of the negative effects that certain antiepileptic drugs have on bone density. Clinical studies and experience have shown that hormonal variances across a woman's lifetime play a significant role in seizure activity, but the effects of HRT in postmenopausal women with epilepsy are unknown. CASE SUMMARY: We report the case of a 51-year-old postmenopausal white woman with epilepsy who presented with frequent vasomotor flushing. To determine individual effects of HRT on seizure activity, therapy was initiated in two three-month phases, with monthly evaluation. A weekly transdermal patch of estradiol 0.1 mg/d was initiated for the first three months. During the second three months, the regimen was expanded to include oral medroxyprogesterone acetate 2.5 mg once daily. Antiepileptic medications and their dosages remained constant. HRT was associated with a decreased incidence of seizures, cessation of vasomotor flushing, improved sleep, and a positive impact on the lipid profile. CONCLUSIONS: This case report describing the prospective addition of HRT in a postmenopausal woman with epilepsy suggests that HRT can be initiated in certain women to achieve therapeutic benefits without adversely affecting seizure activity.

An assessment of epilepsy patients' knowledge of their disorder.

PURPOSE: Patient education is an effective component of comprehensive care. Studies assessing patient's knowledge of their epilepsy are scarce. We report the first objective study evaluating knowledge of epilepsy patients referred to an American tertiary care center. METHODS: Two hundred twenty epilepsy patients referred to an epilepsy center completed a knowledge questionnaire. The questionnaire included topics related to safety, compliance, and legal issues of driving and employment. Questionnaire scores were correlated with demographics, number of years with epilepsy, and educational background. RESULTS: Of 220 patients, 175 were included in study analysis. Thirteen percent (n = 28) were excluded because of the diagnosis of nonepileptic seizures, and 8% (n = 17) were excluded because of having a diagnosis other than epilepsy. The average age and number of years with epilepsy was 34.7 +/- 13 and 14. 4 +/- 13.1, respectively. Neither age (r = 0.20, p

Referral characteristics of primary care physicians for seizure patients.

PURPOSE: To investigate primary care physicians' behavior with respect to referral patterns, antiepileptic drug (AED) initiation, and level of comfort in managing seizure patients. METHODS: A cross-sectional descriptive study design was used for collecting and analyzing data. A 20-item survey was developed and mailed to 8,195 primary care physicians including family practitioners, internal medicine physicians, and obstetrics-gynecologists throughout the state of Ohio; 504 primary care physicians that interact regularly with epilepsy patients responded to the survey. RESULTS: Two patterns of referral emerged. Data showed that the majority (n = 382) of physicians refer >/=50% of their patients, but a minority of physicians (n = 122) refer <50% of their patients. Differences between the two groups existed in three of the four research questions asked: who initiates AED therapy, comfort level, and percentage of patients referred to a neurologist. Influence of managed care on decision making was not different between the two groups. CONCLUSIONS: A minority of primary care physicians rate themselves very comfortable with seizure patients. These same physicians refer a minority of their patients to a neurologist. As a whole, however, primary care physicians refer a majority of their seizure patients to a neurologist. Neurologists evaluate most seizure patients because most primary care physicians claim not to be extremely comfortable with evaluation and treatment of seizures. We conclude that neurologists play an essential role in the treatment of most seizure patients.

Alternative medicine use by patients with epilepsy.

Purpose. The objectives of this study were, first, to determine the prevalence, characteristics, and demographic patterns of alternative medicine (AM) use in patients with epilepsy, and second, to ascertain the extent to which these patients inform the neurologist of AM use. Methods. Surveys were distributed randomly to patients attending a tertiary care epilepsy clinic. The survey assessed use of specific herbal medicine/dietary supplements, along with other forms of AM. Results. Of 150 surveys distributed, 92 were used for analysis. Twenty-two patients with epilepsy (24%) used AM, and only 31% of AM users reported such to their neurologists. Massage and herbs/supplements were used the most, and only two patients used AM specifically for treatment related to epilepsy. Conclusions. A sizable minority of patients with epilepsy who visit our tertiary care clinic use AM. Health professionals should actively monitor therapies to ensure safety and effectiveness with combined traditional medicine and AM use.

Characterization and health risk assessment of postmenopausal women with epilepsy.

Postmenopausal women with epilepsy represent an understudied patient population. The objectives of this cross-sectional study were to characterize the impact of menopause on seizure activity and to conduct a health risk assessment. We conducted telephone interviews of 40 postmenopausal women with epilepsy concerning the effect of menopause on seizure frequency. We surveyed use of hormone replacement therapy, postmenopausal bone fractures, use of vitamins, and frequency of exercise. The average age and mean seizure duration were 55.8 and 27.6 years, respectively. Twenty-six women had onset of seizure activity before menopause. Of these 26, 3 reported fewer seizures after menopause, 7 reported more seizures, 11 reported no change, and 5 were unsure whether menopause affected their seizures. Only 30% of the 40 women were currently taking hormone replacement therapy. The impact of menopause on seizure activity was variable. Osteoporotic and cardiovascular preventive measures are underutilized. Patient education on these protective measures should be part of the comprehensive treatment approach in this "at-risk" patient population.

Endoscopic mucosal resection.

Endoscopic mucosal resection (EMR) is a major advance in endoscopy for treatment of patients with superficial esophageal, gastric, or colonic lesions, providing a nonsurgical treatment option for management of these lesions. With the assistance of endoscopic ultrasonography, it is now possible to obtain an accurate histologic diagnosis, confirm the depth of the lesion, and in many cases resect submucosal tumors. The main goal of EMR using the advances in endosonography is to detect early gastrointestinal cancers and successfully resect them, offering an outpatient, nonsurgical treatment option. Although popular in the Orient, where there is a high incidence of superficial neoplasia, limited data are available on the use of EMR in the United States. Gastrointestinal (GI) endoscopy nurses and assistants play important roles in successful EMR. This article informs GI staff on the indications for EMR, the procedure and accessories needed, the different resection methods, possible complications, and nursing care.

Time-frequency mapping of R-R interval during complex partial seizures of temporal lobe origin.

BACKGROUND: Activation of autonomic nervous system is common with seizures. No reliable biological markers of impending seizures have been found. Evaluation of autonomic changes might help elucidate the transition from interictal to ictal states. METHODS: We studied twelve patients (eight females, four males), from 19 to 62 years old with temporal lobe complex partial seizures (CPS). Dynamics of autonomic functions from oscillations in R-R interval (RRI) using time-frequency mapping based upon a Wigner distribution during pre-ictal, ictal and post-ictal periods. Oscillations in RRI at respiratory frequencies (RF) (> 0.1 Hz) are parasympathetically mediated and at nonrespiratory frequencies (NONRF) (0.01-0.09 Hz) are under combined sympathetic and parasympathetic influence. RESULTS: CPS evoked marked autonomic imbalance and tachycardia. Spectral powers at both RF_RRI and NONRF_RRI increased over the pre-ictal period. RF_RRI power then fell rapidly over the 30 s before seizure onset and remained markedly reduced during seizure (P < 0.004). NONRF_RRI power reached a maximum at seizure onset and declined to a minimum before the seizure cessation (P < 0.05). CONCLUSION: Time-frequency analysis revealed that autonomic activation hallmarks clinical seizure onset for several minutes. After combined parasympathetic and sympathetic activation, rapid parasympathetic withdrawal occurred approximately 30 s before the seizure, and sympathetic activation peaks at seizure onset. Therefore, the transition from interictal to ictal states is relatively long and associated with subclinical autonomic changes.

Assessing the needs of pharmacists and physicians in caring for patients with epilepsy.

OBJECTIVE: To obtain primary care physicians' and community pharmacists' opinions of the Pharmacist Note, a model epilepsy patient profile maintained by the pharmacist and transmitted to the physician as needed, and the information it contains. DESIGN: A cross-sectional descriptive study design was used for collecting and analyzing data. Separate surveys were developed and mailed to physicians and pharmacists. PARTICIPANTS: 554 primary care physicians and 114 community pharmacists in Ohio who interact regularly with epilepsy patients. MAIN OUTCOME MEASURES: Pharmacist and physician opinions on the Pharmacist Note program. RESULTS: Physicians ranked seizure frequency as their most useful piece of information, followed by medication compliance and drug interaction screening. For medication profile and drug interaction screening, most physicians currently use themselves as their primary source of information, although a significant number would prefer to use pharmacists as information sources in these areas (p < .05). A majority (62%) would like to have pharmacists more involved in the care of their patients. Pharmacists identified lack of time and lack of appointments with patients, inadequate pharmacy staff, and insufficient reimbursement as barriers to implementing the Pharmacist Note program. CONCLUSION: Physicians desire pharmacist involvement in specific areas of care for patients with epilepsy, and the feasibility of implementing the Pharmacist Note and similar programs appears promising. However, pharmacists identified barriers to implementation, and these barriers need to be addressed if this type of program is to be successful.

A pilot study of electroencephalographic changes associated with ki.

OBJECTIVE: To measure changes in the electroencephalogram (EEG) of a ki master and ki recipients during ki emission. DESIGN: A 54-year-old, male ki master and three recipients were recorded with 21-channel digital EEG technique using the 10-20 electrode placement system. Ki recipients were three Caucasian females with no prior experience with ki practice. The ki master has practiced ki healing for more than 20 years. EEG recordings were obtained from the ki master and each recipient during baseline, direct healing ki emission, transtelephonic healing ki emission, and emission of fighting ki through the study subject to a third individual. EEG recordings were reviewed in a blinded fashion by a neurologist with no ki experience. RESULTS: No detectable EEG changes occurred during ki emission, either in the ki master or in the subjects. CONCLUSIONS: EEG may not be an appropriate objective instrument to measure ki activity, at least for moving-type ki.

Frequency asymmetry of sleep spindles associated with focal pathology.

Focal cerebral lesions are often associated with voltage asymmetry of sleep spindles, usually with depressed voltage on the side of the lesion. In this report, we document a case in which a brain tumor was associated with a frequency asymmetry in addition to a voltage asymmetry of sleep spindles. The slower frequency spindles occurred on the side of the lesion.

The practical aspects of epilepsy: critical components of comprehensive patient care.

Patients with epilepsy are often exposed to difficult social dilemmas, some of which may be more challenging than the actual seizure. Although all patients with chronic conditions experience social hardships, the epileptic patient may be at greater risk for social difficulties. Due to unjust restrictions and an overall lack of emphasis on psychosocial matters, patients with epilepsy may be wrongfully denied participation in routine activities. These patients may also lack an understanding of appropriate prevention measures related to self injury. Appropriate restrictions for patients with epilepsy include driving and selected extra-curricular activities. The home environment is particularly dangerous for epilepsy patients. Other social issues for epilepsy patients include suicide attempts, employment and alcohol consumption.

Factors associated with work outcome after anterior temporal lobectomy for intractable epilepsy.

PURPOSE: Whereas the effect of anterior temporal lobectomy on seizure frequency is well recognized, less is known about its impact on work status. METHODS: One hundred thirty-four of 190 consecutive patients with temporal lobectomy participated in this study. Eligibility criteria were developed to ensure that only patients with the potential of achieving specific outcomes were included in the corresponding analyses. RESULTS: After surgery, significantly more patients were independent in activities of daily living (p < 0.001) or able to drive (p < 0.001). Income from work also increased (p < 0.01). Nearly one fifth of the patients who were eligible for analysis had either a gain (8%) or a loss (11%) of full- or of part-time work. Univariate analyses revealed the following factors to be associated with full-time work after surgery: student or full-time work within a year before surgery, full-time work experience before surgery, full- or part-time employment experience before surgery, no disability benefits before surgery, low postsurgical seizure frequency, improved postsurgical seizure control, excellent postsurgical seizure control, driving after surgery, and further education after surgery (p < 0.05). Significant factors on multivariate analysis were being a student or having full-time work within a year before surgery [odds ratio, 16.2 (95% CI, 4.3-60.5)], driving after surgery [15.2 (3.2-72.0)], and obtaining further education after surgery [9.2 (2.2-53.0)]. CONCLUSIONS: Anterior temporal lobectomy for intractable epilepsy improves activities of daily living and the ability to drive. Work outcome of this surgery is influenced by presurgical work experience, successful postsurgical seizure control especially to allow driving, and obtaining further education after surgery.

Clinical accompaniments of the burst-suppression EEG pattern.

A burst-suppression pattern on the EEG following anoxic insult is usually associated with a poor prognosis. Myoclonic jerks may accompany the electrographic burst. On rare occasions oral, ocular, or appendicular movements can be associated with bursts of EEG activity recorded following cerebral anoxic insult. At times these movements may cause confusion about the patient's state of consciousness or the purposefulness of the movements; they may mimic volitional movements in response to external stimuli. To better describe the variety of movements that may accompany bursts of EEG activity in comatose patients, we review 12 cases where movements occurred in association with the electrographic bursts.

Movement disorders associated with the use of gabapentin.

PURPOSE: We report two cases of unusual movement disorders associated with the use of gabapentin (GBP) in patients being treated for epilepsy who were otherwise neurologically intact. METHODS: We describe two cases of unusual movement disorders associated with the use of GBP. RESULTS: There were significant differences in the clinical findings between the two cases. In the first case, movements were very pronounced and the patient was in oculogyric crisis. Movements in the second case were quite subtle but nonetheless problematic for the patient. In each case, discontinuation of GBP led to rapid resolution of the movements, although a single dose of lorazepam was used in the first case. CONCLUSIONS: Although formal electrophysiologic studies have not been performed, the movements associated with GBP use appear to be dystonic or myoclonic. Discontinuation of GBP led to rapid resolution of the movements. In severe cases, as in patients with oculogyric crisis, small doses of a benzodiazepine (BZD) appear to be efficacious and safe.

The ictal bradycardia syndrome.

PURPOSE: Episodic loss of consciousness presents a diagnostic challenge to the neurologist. A perhaps underrecognized cause of episodic loss of consciousness, which we call the ictal bradycardia syndrome, occurs when epileptic discharges profoundly disrupt normal cardiac rhythm, resulting in cardiogenic syncope during the ictal event. We attempt to determine whether the presence of the ictal bradycardia syndrome provides localizing information regarding the site of seizure onset and to describe the demographics of patients with this syndrome. We also discuss difficulties in diagnosis and treatment. METHODS: We review 23 cases of the ictal bradycardia syndrome from the literature and present four additional cases. Brief histories are provided for the four previously unreported cases. Where data are available, cases are analyzed with respect to age, sex, and site of seizure onset. RESULTS: Patients with the ictal bradycardia syndrome ranged from 4 months to 72 years (mean 39 years). There was an approximately 5:1 ratio of males to females. Twenty of the 23 patients (87%) whose site of ictal onset could be localized had temporal lobe epilepsy, although no clear lateralizing predominance was apparent. CONCLUSIONS: The ictal bradycardia syndrome should be considered in patients with unusual or refractory episodes of syncope, or in patients with a history suggestive of both epilepsy and syncope. It suggests seizure onset in temporal lobe, and is more commonly diagnosed in males. Diagnosis may be aided by ambulatory EEG/ECG monitoring. Cardiac pacemaker implantation along with antiepileptic drug therapy may be necessary to minimize the possibility of death.

Self-reported narcissism and perceived parental permissiveness and authoritarianism.

The hypothesis that inadequate parenting promotes the development of pathological narcissism was tested in a sample of 370 undergraduate students. They responded to the O'Brien (1987) Multiphasic Narcissism Inventory (OMNI) and to measures of parental permissiveness, authoritarianism, and authoritativeness. Perceived parental permissiveness and authoritarianism served as independent predictors of greater narcissistic tendencies. The students who scored high on the OMNI were also less likely to evaluate both of their parents as having been especially strong in their use of the adjustment-promoting authoritative style. Theoretical efforts to link narcissism with inadequate parenting therefore may have merit and may deserve additional research attention.

Beryllium carcinogenesis.

Beryllium is a proven bone carcinogen in rabbits, and proven pulmonary carcinogen in rats. Median effective doses or concentrations can be computed only with considerable uncertainty; they appear to be in the 10 mg area (as total dose, in divided intravenous injections, expressed as Be for zinc beryllium silicate) for rabbits, and in the 20 alpha/m3 area (as atmospheric concentration for inhalation exposures lasting for at least three months, expressed as Be for beryllium sulfate) for rats. It is also proven that, at least from inhalation, guinea pigs do not develop beryllium cancers. Epidemiologic studies in humans are thus far unconfirmed but do not show increased cancer morbidity among beryllium workers. Current research is aimed at explaining the mechanism of carcinogenic action in the susceptible species, which seems to involve nucleic acid transcriptional interference, or the species specificity, which seems to involve immune mechanisms. No experiments were reported thus far besides the carcinogenesis studies to show that beryllium is a chemical mutagen. In the species thus far tested, there appeared to be mutual exclusion of development of a delayed (cell-mediated) hypersensitivity to beryllium and development of neoplasia from beryllium. Further research on this subject might lead to new possibilities in the understanding of cancer susceptibility.

The carcinogenic effect of inhaled asbestos fibers.

Inhalation of asbestos fibers is associated with high incidence of lung cancers and pleural or peritoneal mesotheliomas in humans. All of these lesions were successfully reproduced in animal experiment, and it was shown that asbestos neoplasm may occur with or without accompanying asbestosis. Incidence of tumors from crocidolite was nearly three times as high as from chrysotile or amosite. It is possible that different carcinogenic entities are responsible for the causation of lung tumors and mesothelial tumors. Lung tumors seem to depend on the adsorptive capacity of asbestos fibers, allowing other carcinogens (heavy metals, polycyclic hydrocarbons, cigarette smoke) to attain a critical focal concentration. Mesothelial tumors, on the other hand, might arise in response to mechanical irritation by fibers which may become lodged during lymphatic spread. Tissues subject to constant respiratory movement (e.g., pleura or peritoneum) are specifically vulnerable to the latter action.

Berylliosis as an auto-immune disorder.

Exposure to compounds of beryllium can cause dermatitis, acute pneumonitis and chronic pulmonary granulomatosis ("berylliosis") in humans. These syndromes seem to have an allergic-immunologic component in common. Hypersensitivity to beryllium is of the delayed (cell-mediated) type and can be measured as skin reactivity to patch test; lymphocyte blast transformation; and macrophage migration inhibition. There is good correlation between the results of these tests in exposed populations, but the degree of hypersensitivity is not necessarily a measure of either extent of exposure or severity of berylliosis. In animal experiment, inhalation exposure has suppressed a previously established cutaneous hypersensitivity, and degree of hypersensitivity and degree of berylliosis were in significant inverse correlation.