Audit of the management of patients with refractory epilepsy.

Achieving rational management for patients with refractory epilepsy can be difficult. We audited our management of 55 patients with refractory epilepsy by comparing two 3-month periods each 9 months apart. Despite attempts to rationalize antiepileptic drug therapy, a smaller proportion of patients were managed with monotherapy by the second analysis (16% vs 22%); however fewer patients were taking three or more AEDs (28% vs 43%). A substantial impact on seizure frequency was made in only six patients whilst 22 patients had a significant deterioration in seizure number (P = 0.005). Monitoring of AED levels was of little value with only six clinical decisions based on 305 AED levels performed at a cost of 2525 pounds. The newer AEDs accounted for a disproportionate expenditure (65% of the total AED cost in the second 3-month period) considering their lack of therapeutic impact. We confirm the need for audit in this patient group to ensure that pre-defined targets are met.

Impact of lamotrigine on patients with refractory epilepsy: the Leicester experience.

We prospectively monitored our experience of lamotrigine as add-on therapy in 45 patients with refractory epilepsy. Nine patients (20%) withdrew from treatment due to adverse drug reactions and five patients (11%) withdrew because of a deterioration in seizure frequency. A further 17 patients (38%) showed little (< 25%) reduction in seizure number, eight patients (18%) showed a 25-50% reduction whilst 15 patients (33%) had a 50% or greater reduction in seizure number (P = 0.002). Lamotrigine was of greater benefit in patients with tonic-clonic seizures (seven of fourteen [50%] showed a > 50% seizure reduction; P = 0.01) than in patients with complex partial seizures (seven of 22 [32%] showed a > 50% seizure reduction; P = 0.02). Despite a high withdrawal rate due to ADRs, lamotrigine proved of significant benefit to one-third of our study group.

Status epilepticus: management and outcome of 107 episodes.

Morbidity and mortality from status epilepticus might be reduced by attention to recommended management protocols. We studied our experience of 107 episodes of status epilepticus in 43 patients over a 5-year period. Overall mortality was 2% and permanent sequelae developed in 11 cases (10%). Although hospital admission was rapid, treatment could be initiated more quickly in the community (P < 0.0001). However treatment given before admission did not significantly reduce the duration of status (median difference 38 minutes, 95% C.I., 24 to 55 minutes). Diazepam was the first line treatment in 98 episodes, chlormethiazole and phenytoin were used in 27 and 18 episodes, respectively. Paraldehyde was used in 12 episodes. Midazolam was used in the intensive care setting in two cases. Clonazepam, lorazepam, lignocaine and phenobarbitone were not used at all. There was a marked failure to adhere to the recommended management protocols.

Pregnancy, epilepsy, management and outcome: a 10-year perspective.

We analysed the management and outcome of 348 pregnancies in 207 women with epilepsy from 1977 to 1981 and 1987 to 1991. Outcome was successful in 88%. There was a marked change in anticonvulsant prescribing away from phenobarbitone and phenytoin towards carbamazepine and sodium valproate but a large number of patients (24%) were treated with two or more anticonvulsants in the second cohort despite a move towards monotherapy. A significant reduction in congenital malformation (4.8%), spontaneous abortion (6.9%) or low birth weight babies (9.4%) was not seen. Until experience is gained with the newer agents, monotherapy remains of major importance in the management of the pregnant woman with epilepsy.

Vigabatrin: a three year clinical analysis.

The effect of introducing vigabatrin into the management of 57 patients with severe epilepsy is reported. Overall it reduced fit frequency by 50% or more in 36% of our patients. We found it to be more effective than previously reported for primary tonic-clonic seizures, but less so for complex partial seizures. Fewer of our patients withdrew from treatment due to adverse drug reactions than in earlier studies.

The apomorphine test in parkinsonian syndromes.

The dopamine receptor agonist apomorphine has been used successfully to treat on-off swings in Parkinson's disease. Its value as a predictor of dopa responsiveness in idiopathic Parkinson's disease (IPD) was assessed and its potential role in differentiating IPD from the Parkinsonian plus syndromes (PPS) of multisystem atrophy, progressive supranuclear palsy and olivopontocerebellar atrophy was investigated. The response to an injection of apomorphine was observed in 20 patients with IPD and eight with PPS after being off levodopa for 12 hours. Patients were reassessed after taking levodopa for one month. Nineteen of the 20 patients (95%) with IPD showed a positive response to apomorphine and 18 (90%) to oral levodopa. In the PPS group, two patients (25%) responded to the apomorphine injection but not to oral levodopa. Apomorphine produced severe drowsiness in the PPS patients. It is suggested that the test can predict dopa responsiveness in IPD and may be of help in confirming a doubtful diagnosis. It has potential value in differentiating IPD from PPS.

Multiple sclerosis associated with trismus.

This report describes the case history of a middle-aged lady who presented with symptoms and signs over one year leading to a diagnosis of multiple sclerosis. During one of her relapses, she developed trismus--an association that has not been described before in multiple sclerosis.

Multiple sclerosis associated with water intoxication.

We present a case of well documented multiple sclerosis which presented with the syndrome of inappropriate antidiuretic hormone secretion, following an exacerbation of the disease. This is a poorly documented association.

Tuberculous meningitis in Asian patients.

17 cases of tuberculous meningitis were seen in Leicester hospitals over a 5 year period; 15 of the patients were Asian. Treatment had often been delayed because presentation of the disease was non-specific and the cereobrospinal fluid findings were atypical. The average interval between the onset of symptoms and admission to hospital was 2 weeks (the shortest period was 5 days). Of the 10 patients admitted with disturbance of consciousness 5 died, whereas all 7 who were alert on admission survived. It is essential to exclude tuberculous meningitis in any Asian patient with a persistent febrile illness even if meningism is not evident, since patients who progress to the later stages of the disease often die or are left disabled.