Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): vitamin K, folic acid, blood levels, and breastfeeding: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society.

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including preconceptional folic acid use, prenatal vitamin K use, risk of hemorrhagic disease of the newborn, clinical implications of placental and breast milk transfer of antiepileptic drugs (AEDs), risks of breastfeeding, and change in AED levels during pregnancy. METHODS: A 20-member committee evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and October 2007. RESULTS: Preconceptional folic acid supplementation is possibly effective in preventing major congenital malformations in the newborns of WWE taking AEDs. There is inadequate evidence to determine if the newborns of WWE taking AEDs have a substantially increased risk of hemorrhagic complications. Primidone and levetiracetam probably transfer into breast milk in amounts that may be clinically important. Valproate, phenobarbital, phenytoin, and carbamazepine probably are not transferred into breast milk in clinically important amounts. Pregnancy probably causes an increase in the clearance and a decrease in the concentration of lamotrigine, phenytoin, and to a lesser extent carbamazepine, and possibly decreases the level of levetiracetam and the active oxcarbazepine metabolite, the monohydroxy derivative. RECOMMENDATIONS: Supplementing women with epilepsy with at least 0.4 mg of folic acid before they become pregnant may be considered (Level C). Monitoring of lamotrigine, carbamazepine, and phenytoin levels during pregnancy should be considered (Level B) and monitoring of levetiracetam and oxcarbazepine (as monohydroxy derivative) levels may be considered (Level C). A paucity of evidence limited the strength of many recommendations.

Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): obstetrical complications and change in seizure frequency: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society.

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy, including the risk of pregnancy complications or other medical problems during pregnancy in WWE compared to other women, change in seizure frequency, the risk of status epilepticus, and the rate of remaining seizure-free during pregnancy. METHODS: A 20-member committee including general neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review and classification of relevant articles published between 1985 and February 2008. RESULTS: For WWE taking antiepileptic drugs, there is probably no substantially increased risk (greater than two times expected) of cesarean delivery or late pregnancy bleeding, and probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery. There is possibly a substantially increased risk of premature contractions and premature labor and delivery during pregnancy for WWE who smoke. Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%-92%) of remaining seizure-free during pregnancy. RECOMMENDATIONS: Women with epilepsy (WWE) should be counseled that seizure freedom for at least 9 months prior to pregnancy is probably associated with a high rate (84%-92%) of remaining seizure-free during pregnancy (Level B). However, WWE who smoke should be counseled that they possibly have a substantially increased risk of premature contractions and premature labor and delivery during pregnancy (Level C).

Practice parameter update: management issues for women with epilepsy--focus on pregnancy (an evidence-based review): teratogenesis and perinatal outcomes: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society.

OBJECTIVE: To reassess the evidence for management issues related to the care of women with epilepsy (WWE) during pregnancy. METHODS: Systematic review of relevant articles published between January 1985 and June 2007. RESULTS: It is highly probable that intrauterine first-trimester valproate (VPA) exposure has higher risk of major congenital malformations (MCMs) compared to carbamazepine and possible compared to phenytoin or lamotrigine. Compared to untreated WWE, it is probable that VPA as part of polytherapy and possible that VPA as monotherapy contribute to the development of MCMs. It is probable that antiepileptic drug (AED) polytherapy as compared to monotherapy regimens contributes to the development of MCMs and to reduced cognitive outcomes. For monotherapy, intrauterine exposure to VPA probably reduces cognitive outcomes. Further, monotherapy exposure to phenytoin or phenobarbital possibly reduces cognitive outcomes. Neonates of WWE taking AEDs probably have an increased risk of being small for gestational age and possibly have an increased risk of a 1-minute Apgar score of <7. RECOMMENDATIONS: If possible, avoidance of valproate (VPA) and antiepileptic drug (AED) polytherapy during the first trimester of pregnancy should be considered to decrease the risk of major congenital malformations (Level B). If possible, avoidance of VPA and AED polytherapy throughout pregnancy should be considered to prevent reduced cognitive outcomes (Level B). If possible, avoidance of phenytoin and phenobarbital during pregnancy may be considered to prevent reduced cognitive outcomes (Level C). Pregnancy risk stratification should reflect that the offspring of women with epilepsy taking AEDs are probably at increased risk for being small for gestational age (Level B) and possibly at increased risk of 1-minute Apgar scores of <7 (Level C).

Ross syndrome plus: beyond horner, Holmes-Adie, and harlequin.

BACKGROUND: Ross syndrome is an uncommon disorder characterized by the triad of segmental anhidrosis, hyporeflexia, and tonic pupils. METHODS: The authors describe the clinical findings of five patients with Ross syndrome and detail the results of their pharmacologic and autonomic testing. RESULTS: In four patients, the classic findings of Ross syndrome were accompanied by Horner's syndrome. Other symptoms of dysautonomia were also common. CONCLUSIONS: These findings suggest that Ross syndrome is a dysautonomic condition of varying expression resulting from a generalized injury to ganglion cells or their projections.

Spontaneous thrombosis of a basilar artery traumatic aneurysm in a child.

Traumatic aneurysms are rare and occur most commonly in young adults; however, the relative frequency in the pediatric population is high, owing to the low prevalence of congenital saccular aneurysms in children. Traumatic aneurysms typically involve the anterior circulation, and spontaneous thrombosis is uncommon; hence, surgery is usually necessary. We present a case of a posttraumatic aneurysm in a child that occurred after a fall from a large height and that spontaneously thrombosed.

Uncertain value of electronic fetal monitoring in predicting cerebral palsy.

BACKGROUND: Electronic monitoring of the fetal heart rate is commonly performed, in part to detect hypoxia during delivery that may result in brain injury. It is not know whether specific abnormalities on electronic fetal monitoring are related to the risk of cerebral palsy. METHODS: Among 155,636 children born from 1983 through 1985 in four California counties, we identified singleton infants with birth weights of at least 2500 g who survived to three years of age and had moderate or severe cerebral palsy. The children with cerebral palsy were compared with randomly selected control children with respect to characteristics noted in the birth records. RESULTS: Seventy-eight of 95 children with cerebral palsy and 300 of 378 controls underwent intrapartum fetal monitoring. Characteristics found to be associated with an increased risk of cerebral palsy were multiple late decelerations in the heart rate, commonly defined as slowing of the heart rate well after the onset of uterine contractions (odds ratio, 3.9; 95 percent confidence interval, 1.7 to 9.3), and decreased beat-to-beat variability of the heart rate (odds ratio, 2.7; 95 percent confidence interval, 1.1 to 5.8); there was no association between the highest or lowest fetal heart rate recorded for each child and the risk of cerebral palsy. Even after adjustment for other risk factors, the association of abnormalities on fetal monitoring with an increased risk of cerebral palsy persisted (adjusted odds ratio, 2.7; 95 percent confidence interval, 1.4 to 5.4). The 21 children with cerebral palsy who had multiple late decelerations or decreased variability in heart rate on fetal monitoring represented only 0.19 percent of singleton infants with birth weights of 2500 g or more who had these fetal-monitoring findings, for a false positive rate of 99.8 percent. CONCLUSIONS: Specific abnormal findings on electronic monitoring of the fetal heart rate were associated with an increased risk of cerebral palsy. However, the false positive rate was extremely high. Since cesarean section is often performed when such abnormalities are noted and is associated with risk to the mother, our findings arouse concern that, if these indications were widely used, many cesarean sections would be performed without benefit and with the potential for harm.

Microparticles of polyvinyl alcohol for nasal delivery. I. Generation by spray-drying and spray-desolvation.

Spray-drying and spray-desolvation are described for the generation of polyvinyl alcohol microparticles intended for nasal administration. The spray-dried microparticles of polyvinyl alcohol were of an appropriate size distribution but consisted of hollow spheres, which made them unsuitable for nasal delivery, as rapid clearance and a varied deposition pattern would be expected. Microparticles were also produced by spraying polyvinyl alcohol (average molecular weight of 14,000) solution (12.5%, w/v) at 0.332 ml/min onto the surface of acetone (spray-desolvation). These microparticles were solid collapsed spheres with the desired size for nasal deposition (10-200 microns). This method can be applied to encapsulation of drugs that are heat labile such as peptides and proteins.

Innovation-diffusion or adjustment: the case of Taiwanese fertility transition.

PIP: This study uses KAP data sets to analyze the determinants of Taiwan's fertility decline between 1964 and 1980 and to evaluate whether innovation-diffusion or adjustment or both can be applied to explain the transition. Furthermore, this study examines the roles of innovation-diffusion and adjustment in the stages of the transition of Taiwan's fertility from high to low levels. The 5 cross-sectional KAP surveys, collected by the Taiwan Provincial Institute of Family Planning and used in this study, focus on the fertility behavior of married women living in Taiwan in 1965, 1969, 1970, 1973, and 1980. Analyses of both cross-sectional and pooled-time series data sets provide evidence to support the theory that demand-side diffusion of birth control behavior from urban centers to more rural areas plays an important role in Taiwan's fertility transition. Contradictory findings on the supply-side of diffusion suggest that family planning programs have no consistently direct effects on fertility behavior. The adjustment variables of wife's education, husband's occupation, and the index of consumer goods generally have important influences on changes in family size, suggesting that the adjustment model has significant impact on fertility transition in Taiwan. Duration of marriage, not surprisingly, is the most powerful explanatory variable. Overall, the innovation-diffusion model is more useful in explaining Taiwanese fertility transition in the 1960s, and the adjustment model plays a more important role throughout the late years.^ieng

Innovation-diffusion: a geographical study of the transition of family limitation practice in Taiwan.

PIP: This paper uses map analysis to study the transition of family limitation practice in Taiwan between 1961-80. The innovation-diffusion perspective emphasizes that birth control, particularly contraception, is a recent innovation and is essentially new in human culture. The innovation-diffusion theory assumes that the decline of fertility began in a setting where there was no, or at most very limited, previous practice of birth control. The theory emphasizes the importance of the spread of information. It also assumes that innovation starts in metropolitan centers, diffuses to other urban places with some delay, and penetrates to rural areas still later. Innovation behavior also diffuses from 1 area to another which is culturally and linguistically similar. Although there was some urban to rural diffusion from the Taiwan family planning program, the government supported program provided services more evenly between urban and rural areas, thus somewhat limiting the diffusion effect from the program. For the diffusion of family practice in Taiwan, it is expected that the availability of of information about and means of family limitation practice may effect the rate of the increase of small m values -- an index of family limitation -- in an area. The case study of Pingtung county shows that the demand-side diffusion from urban to rural areas was important in the earlier decade of the transition of family plimitation practice, but distance from urban center was less important as practice became more uniform through diffusion. Ethnicity, whether or not the township was dominated by Hakka or Fukienese, also seems to have played an important role in determining the pace at which the local residents adopted family practice limitation. Hakka townships seem to have adopted family limitation practice more slowly than Fukienese townships about the same distance from the urban center. The map analysis of Pingtung county provides descriptive evidence to support the diffusion of family limitation from urban centers to distant areas, while ethnic variables like Hakka population tend to delay the adoption of family limitation practice. In general, the urban center had higher m values than the surrounding rural areas in Pingtung county and for areas other than the urban center the the level of m values is a negative function of the distance to the urban center.^ieng