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The flexor tendons will also exhibit the property of anisotropy with the tipping of the ultrasound transducer back and forth over the tendons fungus dandruff buy online lotrisone. The flexor carpi ulnaris will be the most ulnar and superficial of the superficial flexor tendons and can be seen to lie just above the dome-shaped pisiform (Fig azamax for fungus gnats lotrisone 10 mg buy on-line. There may be significant effusion surrounding the tendon which will appear on transverse ultrasound imaging as a hypoechoic ring around the tendon antifungal hair cream order 10 mg lotrisone with amex. If there is a question as to whether the tendon is the flexor carpi ulnaris tendon fungi definition and classification generic lotrisone 10 mg fast delivery, the ultrasound transducer can be turned to the longitudinal plane and the tendon can be followed distally to its insertion on the pisiform (Fig fungus gnats terrarium buy lotrisone with a mastercard. Color Doppler may identify hyperemia of the musculotendinous unit and may also be useful in helping identify the ulnar artery if the anatomy is not clear (Fig. After the musculotendinous unit is identified as it passes under the flexor retinaculum, the tendon is evaluated for tendinopathy, tendinitis, tear, extrinsic compression, and rupture (Fig. A: Identification of the flexor carpi ulnaris tendon is facilitated by having the patient forcibly flex his or her wrist. B: Proper ultrasound transducer placement for ultrasound-guided injection for flexor carpi ulnaris tendinitis. Transverse ultrasound view of the flexor carpi ulnaris tendon at the wrist and its relationship to the ulnar nerve and artery. Longitudinal ultrasound view of the flexor carpi ulnaris tendon demontraing its insertion on the trapezium. Color Doppler can be useful in helping identify the ulnar artery which lies just radial to the ulnar nerve and the flexor carpi ulnaris tendon. A: Clinical appearance of severed extensor carpi ulnaris tendon following a cutting injury. An erythematous and tender mass located 2 cm distal to the scar that was left after the repair of a laceration following a cutting injury. Neglected ruptured flexor carpi ulnaris tendon mimics a soft tissue tumor in the wrist. Physical examination combined with judicious use of ultrasound, magnetic resonance imaging, and radiography will help delineate the cause of ulnar-sided wrist pain. The function of the abductor pollicis longus and extensor pollicis brevis muscles is radial abduction of the thumb. The radial artery and the superficial branch of the radial nerve are in proximity to the site for injection to treat de Quervain tenosynovitis and these structures may be traumatized if the needle is placed too medially (Fig. De Quervain tenosynovitis, which is also known as mommy’s thumb or wrist, is caused by inflammation of the tendons and tendon sheaths of the abductor pollicis longus and extensor pollicis brevis muscles. The relationship between the radial styloid, the tendons, and tendon sheaths of the abductor pollicis longus and extensor pollicis brevis muscles, and the radial artery and superficial branch of the radial nerve. This painful condition is named for Swiss surgeon Fritz de Quervain who first described this constellation of symptoms and their cause in 1895. The result of repetitive high-torque twisting motions of the wrist and occasionally as a result of direct trauma to the tendons of the abductor pollicis longus and extensor pollicis brevis at the level of the radial styloid process, de Quervain tenosynovitis can cause significant pain and functional disability if not promptly treated. On rare occasions, de Quervain tenosynovitis can develop without antecedent trauma, especially in the parturient and this setting is often referred to as mommy’s thumb or wrist. The symptoms of de Quervain tenosynovitis are the result of inflammation and edema of the tendons and tendon sheath of the abductor pollicis longus and extensor pollicis brevis muscles at the level of the radial styloid process (Fig. If untreated, a 495 thickening of the tendons and tendon sheath may occur, resulting in a constrictive tenosynovitis. In some patients, a triggering phenomenon of the thumb may occur as a result of the thickened tendon locking or catching in the constricted tendon sheath. Arthritis and gout of the first metacarpal joint also may coexist with and exacerbate the pain and disability of de Quervain tenosynovitis. Transverse ultrasound image of the first dorsal compartment tendons (abductor pollicis longus and extensor pollicis brevis) showing tenosynovitis. Activities associated with the development of de Quervain tenosynovitis include repetitive hand shaking, scooping ice cream, or using a screw driver. The pain of de Quervain tenosynovitis is sharp and constant and is exacerbated by any activities requiring active pinching of the thumb or ulnar deviation of the wrist. The pain is localized to the area over the radial styloid process and is associated with increasing functional disability if the inflammatory process remains untreated. On physical examination, there is tenderness and swelling over the tendons and tendon sheaths along the distal radius, with point tenderness over the radial styloid. A creaking tendon sign may be noted with flexion and extension of the thumb and triggering of the thumb may occur. Patients with de Quervain tenosynovitis demonstrate a positive Finkelstein test (Fig. The Finkelstein test is performed by stabilizing the patient’s forearm, having the patient fully flex his or her thumb into the palm, and then actively forcing the wrist toward the ulna. Patients suffering from de Quervain tenosynovitis will exhibit a positive Finkelstein test. Plain radiographs of the wrist are indicated in all patients suspected of suffering from de Quervain tenosynovitis to rule out occult bony pathology and to identify calcific tendinitis. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the wrist is indicated to assess the status of the abductor pollicis longus and extensor pollicis brevis tendons and tendon sheath as well as to identify other occult pathology including arthritis and gout involving the first metacarpal joint (Fig. Longitudinal ultrasound image of De Quervain tenosynovitis in a volleyball player shows thickening of the extensor carpi radialis. With the patient in the above position, the radial styloid process and the abductor pollicis longus and extensor pollicis brevis tendons at that level are identified by palpation. Identification of the tendons is facilitated by having the patient radially deviate the wrist against the examiner’s resistance (Fig. At the level of the radial styloid a high-frequency linear ultrasound transducer is placed in a transverse position over the abductor pollicis longus and extensor pollicis brevis tendons and an ultrasound survey scan is taken (Figs. Color Doppler may aid in identification of the radial artery and help separate it with the superficial radial nerve which lies just radial to the radial artery (Fig. The tendons will appear as the hyperechoic “hole” in the hypoechoic tendon sheath. However, in a small number of patients, the tendon sheath will appear to travel through separate subcompartments divided by a subcompartmental septum (Fig. An effusion surrounding the affected tendons can often be identified with ultrasound imaging (Fig. When the tendon sheaths are identified, the tendons are evaluated for tendinopathy, tendinitis, effusions, tears, and ruptures (Figs. Color Doppler may aid in identification of neovascularity of inflamed tendons (Fig. Identification of the extensor pollicis brevis and abductor pollicis longus tendons is facilitated by having the patient radially deviate the wrist against the examiner’s resistance. Proper transverse position for the linear high-frequency ultrasound transducer to perform ultrasound evaluation for de Quervain tenosynovitis. Transverse ultrasound image demonstrating the relationship of the extensor pollicis brevis and abductor pollicis longus tendons within their tendon sheath at the level of the radial syloid. Transverse ultrasound image of the first dorsal compartment shows two subcompartments containing the extensor pollicis brevis and abductor pollicis longus tendons within. Longitudinal ultrasound view demonstrating effusion around the extensor pollicis brevis tendon. A: Ultrasound image longitudinal to the extensor pollicis brevis tendon (T) shows thickening of the overlying extensor retinaculum and synovial thickening (arrow). B: Ultrasound image transverse to the first wrist compartment shows retinaculum and synovial thickening (arrow) and abnormal hypoechoic thickening of the abductor pollicis longus tendon (arrowhead). Note the position of the retinaculum, which lies over the radial styloid to retain the abductor pollicis longus and extensor pollicis brevis tendons against it, and the cross- sectional appearance of the radial artery (a) while it crosses the first compartment to reach the dorsal wrist. C: 3D- volume ultrasound image with Z-plane reconstruction demonstrates an hourglass appearance of tendons (T) due to the constricting action of the thickened retinaculum (arrowheads). Note the obstructed gliding of superficial tendon fibers (arrowhead) against the thickened retinaculum. A: Tenosynovitis of the abductor pollicis longus and the extensor pollicis brevis in a patient with de Quervain disease. Note the large, homogeneously anechoic collection of synovial fluid with marked tendon sheath widening. The synovial fluid accumulation dislocates extensor tendons, thus allowing a careful assessment of their shape and profile. Longitudinal ultrasound image of the radial aspect of the left dorsal wrist showing significant thickening of the abductor pollicis longus tendon sheath (asterisk), appearances consistent with De Quervain tenosynovitis. High-resolution ultrasound in the diagnosis of upper limb disorders: a tertiary referral centre experience. However, de Quervain tenosynovitis pain is more common with activity, while the pain and numbness associated with cheiralgia paresthetica is present at rest. Treatment of de Quervain tenosynovitis with ultrasound- guided injections is a safe and effective approach so long as careful attention is paid to the location of the radial artery and superficial branch of the radial nerve (Fig. Careful neurologic examination to identify pre-existing neurologic deficits especially of the radial nerve that may later be attributed to the procedure should be performed on all patients before beginning ultrasound-guided injection for de Quervain tenosynovitis. Complications of surgery to treat de Quervain can often be diagnosed with ultrasonography (Fig. C: Oblique ultrasound image showing the gap (arrow) between the two neuromas (void arrowheads) of the superficial radial nerve. Ultrasound-guided injection of triamcinolone and bupivacaine in the management of De Quervain’s disease. Sonographic identification of the intracompartmental septum in de Quervain’s disease. Ultrasound-guided corticosteroid injection for the treatment of de Quervain’s tenosynovitis. Passing obliquely over the extensor carpi radialis brevis and extensor carpi radialis longus tendons of the second compartment are the abductor pollicis longus and extensor pollicis brevis of the first compartment which all intersect at their musculotendinous junctions (Fig. This intersection is just proximal to the extensor retinaculum which serves to tether down the tendons and may contribute to the evolution of intersection syndrome. The key landmark when performing ultrasound-guided injection for intersection syndrome is Lister’s tubercle and the intersection of the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus tendons and tendon sheaths. Passing obliquely over the extensor carpi radialis brevis and extensor carpi radialis longus tendons of the second compartment are the abductor pollicis longus and extensor pollicis brevis of the first compartment which all intersect at their musculotendinous junctions. A large number of flexor and extensor tendons pass from the forearm across the wrist to the hand. In order to help delineate the myriad extensor tendons within this anatomic region, anatomists have organized them into six compartments (Table 54. It is at the intersection of the first and second extensor compartments which contain the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus tendons and associated muscles that a painful tenosynovitis known as intersection syndrome can occur (Figs. The inflammation responsible for the pain and functional disability associated with intersection syndrome is due to repetitive flexion and extension of the wrist when performing such activities such as cross-country skiing, sculling, rowing, and weight lifting. Often confused with other radial-sided wrist pain syndromes including de Quervain tenosynovitis, cheiralgia paresthetica (Wartenberg syndrome), and arthritis of the first metacarpal joint, intersection syndrome tends to occur more dorsally and proximally than these other conditions (Table 54. Intersection syndrome is caused by inflammation of the tendons and tendon sheaths of the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus muscles. Contrast-enhanced coronal fat-saturated T1-weighted image (508/14) demonstrates severe peritendinous, muscle, and subcutaneous edema. One of the tendons of the first extensor compartment is seen distally on the radial side. Axial magnetic resonance imaging (T2-weighted fat-suppressed fast spin-echo) demonstrates peritendinous and subcutaneous edema extending proximally and distally from the intersection of the first (abductor pollicis longus and extensor pollicis brevis) and second (extensor carpi radialis longus and extensor carpi radialis brevis) compartment tendons (arrow). Palpation at the site of tendon intersection may reveal tenderness, color, and swelling. A positive creaking tendon sign is often present if there is significant inflammation (Fig. The examiner may appreciate what has been named “wet leather” crepitus with flexion and extension of the wrist. Plain radiographs of the wrist are indicated in all patients suspected of suffering from intersection syndrome to rule out occult bony pathology and to identify calcific tendinitis. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the wrist is indicated to assess the status of the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus tendons and tendon sheaths as well as to identify other occult pathology, including coexistent bursitis, arthritis, and gout involving the first metacarpal joint, cheiralgia paresthetica, and de Quervain tenosynovitis (Fig. T2 axial fat suppressed image demonstrating tendinitis and synovitis at the point of intersection of the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus tendons (arrow). With the patient in the above position, the Lister tubercle of the radius is identified by palpation (Fig. Identification of the affected tendons is facilitated by having the patient extend the wrist against the examiner’s resistance. At the level of Lister tubercle, a high-frequency linear ultrasound transducer is placed in a transverse position over the intersection of the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor pollicis brevis, and the abductor pollicis longus tendons (Figs. The tendons will appear as the hyperechoic “hole” in the hypoechoic tendon sheath. The ultrasound transducer may be turned into the longitudinal axis to further delineate the point of intersection (Fig. When the point of intersection is identified, the tendons are evaluated for tendinopathy, tendinitis, abnormal fluid collections, soft tissue masses, and extrinsic compression (Figs. Proper transverse position of the linear high-frequency ultrasound transducer to perform ultrasound evaluation for intersection syndrome. Transverse ultrasound image demonstrating the relationship of the tendon and tendon sheaths of the first and second extensor compartments and their point of intersection. Edema and fluid at the musculotendinous junction of the extensor compartment 1 as it crosses compartment 2 (arrow). The use of ultrasound imaging and magnetic resonance imaging combined with a careful history and physical examination can distinguish intersection syndrome from de Quervain tenosynovitis and other causes of radial-sided wrist and hand pain.

Tissue sources G-protein-coupled receptor family antifungal wood treatment order lotrisone 10 mg mastercard, the chemokine recep- include the placenta antifungal review discount 10 mg lotrisone, lung fungus gnats nematodes 10 mg lotrisone order otc, and liver fungus dry rot buy lotrisone 10 mg overnight delivery. Tissue sources include Lymphotactin (Ltn) is a member of the γ family (C family) kidney fungus gnats larvae killer lotrisone 10 mg, heart, bone marrow, lung, liver, and pancreas. Ltn G-protein-coupled receptor family, the chemokine recep- employs a unique receptor. It is chemotactic toward mono- of the G-protein-coupled receptor family, the chemokine cytes in vivo and in vitro, and it activates monocytes. Ligands include the human 76-amino acid mature form is derived from a 99-amino acid malarial parasite Plasmodium vivax. It is also can induce not only chemotaxis but also enzyme release and found in adult spleen, kidney, brain, and fetal liver. It has a powerful effect on fbroblast growth, precursors, T lymphocytes, basophils, eosinophils, mast cell, wound repair, infammation, and neoplasia. It is the only β chemokine It is expressed in the late phase of lytic infection of leuko- that fails to form dimers at elevated concentrations. The molecules identifed as part initiation and development of atherosclerotic lesions. Genes found on chromosome 2 encode these two heparin-binding polypeptides with proinflammatory and molecular species. Human chromosome 4 bears the intercrine α genes actions differ according to whether it is produced in lower or and human chromosome 17 bears the intercrine β genes. At low concentrations, the effects Four cysteines are found in the intercrine family. One multiple cells to act as immune or infammatory response amino acid separates cysteines of the intercrines alpha- effector cells. For example, it produces fever and promotes the formation of acute-phase plasma proteins in the liver. It may be either endogenously produced, such as interleukin-1 released from macrophages and monocytes, or it may be an endotoxin asso- ciated with Gram-negative bacteria produced exogenously that induces fever. This interleu- gens such as endotoxin from Gram-negative bacteria that kin-2 complex was generated by homology modeling. This is a elevate body temperature by activating endogenous pyrogen shape-flling diagram. This is based on the demonstration of bands such as a 100-kDa band in addition to that characteristic of the receptor, which is 80 kDa. In the thymus, it is lation are effective when both receptors are present on the also necessary for T cell development for the maturation of cell surface. Powerful antigenic stimulation such as in transplant tion and are termed “regulatory T cells (T-regs). The gene encoding the p55 chain is located on and reacting against self antigens that could lead to autoim- chromosome 10p14 in man. It is expressed only on antigen stim- Differentiation factors are substances that facilitate matu- ulation of T cells, usually within 2 h. Following long-term ration of cells, such as the ability of interleukin-2 to promote T cell activation, the α subunit is shed, making it a potential the growth of T cells. It is a constitutive membrane protein coordinately megakaryocytic, and lymphoid hematopoietic cells. Upon expression of all truncated cytoplasmic domain is associated with the inabil- ity to signal. A cytokine receptor domain 1 1 1 followed by a fbronectin domain is present in each of these :Cysteine : segments. The human alpha chain contains six potential :Motif : N-linked glycosylation sites whereas the β chain has three. Cytokines and Chemokines 357 Interleukin-5 receptor complex is a structure comprised of an α chain and a β chain, both of which resemble members of the hematopoietin receptor superfamily. It has also been cytes, and various neoplasms such as cardiac myxomas, implicated in the pathogenesis of plaques in psoriasis bladder cancer, and cervical cancer. It is known to be requisite for murine resistance against Streptococcus pneumoniae. It is a signifcant mediator of fever and of the acute vous system which are similar to those of leukemia inhibi- phase response. This guishable from interleukin-6, classifed as a monokine, that leads to intracellular signaling that results in infamma- stimulates hepatocytes to produce acute-phase reactants. It also enhances fetal and adult function is to recruit neutrophils to phagocytize antigen, thymocyte proliferation. It prevents adhesion of neutrophils to endothelial cells activated by cytokines, thereby blocking neutrophil- mediated injury. It facilitates neutrophil adher- ence to endothelial cells, accomplishing this through the induction of β2 integrins by neutrophils (Figure 10. It facilitates the growth of some T helper cell clones but not of clones of cytolytic T lymphocytes. It is a hematopoietic growth factor glycoprotein derived from Serine-rich region Figure 10. Selected T lymphocyte lines and peripheral lymphocytes activated by mitogen express it. Genetic inves- tigations on murine models of asthma show that this cytokine is a determining factor in the pathogenesis of bronchial hyperresponsiveness. There are two conserved tryptophans and one pair of is produced by mast cells, counteracting the infammatory conserved cysteines in the frst fbronectin domain and a disulfde loop produced from a second pair of conserved cysteines. It has a key role in differentiation and function of the T regulatory cell which is critical in the control of immune responses and Figure 10. Both β1 and β2 chains are members of the cytokine vates B cells and megakaryocytes. It may be important in the forma- duction induced by lipopolysaccharide in human peripheral tion of platelets. These two cytokines bind common hematopoietin receptor subunits, and may even compete for the same receptor, and thus negatively regulate each other’s activity. It is formed mainly by antigen-presenting cells and is proliferation and mixed lymphocyte reactions. It has been found Th1 immune responses, but it can also stimulate Th2 immune in bronchial airway epithelial cells and fuid of asthmatics. Its overexpression in transgenic mice causes neonatal mosome 1A and human chromosome 2q31. It also induces expan- against intracellular bacteria, including Listeria, Shigella, sion of multi-potential hematopoietic progenitor cells. It acts on nonhematopoietic tissues including skin, lung, and reproductive tissues. Produced by plasmacytoid den- activated monocytes and unstimulated epithelial cells. Il-31 dritic cells, induced by virus infection or double-stranded is believed to have a role in skin infammation. In vivo, it induces the expression tissues, other than brain and spinal cord, serve as targets. All and other types of cells following stimulation with viruses, of the type I interferons manifest potent antiviral activity. They Mononuclear phagocytes represent the principal source of facilitate a cell’s resistance to viral infection. Type I interferons block viral replication, potentiate have immunomodulatory functions. Whereas the ability of interferon to cells that resemble lymphocytes and synthesize 100-fold prevent infection of noninfected cells is species specifc, it more type I interferon than do other types of cells. In addition to gamma interferon formation by T cells of transcription factors that have a novel helix-turn-helix activated with mitogen, natural killer cells also secrete it. They have a func- molecules, with molecular weights ranging from 15,000 to tional role in the regulation of host defense, such as innate 21,000 daltons, synthesized and secreted by cells following a and adaptive immune responses in oncogenesis. Type I interferons include 25α interferon, expression in cells subjected to interferons. Whereas all α interferons have similar biological effects, not all activities are shared by each Adrenergic receptor agonists: the β2-adrenergic receptor α interferon. The potential, which is opposite to the angiogenic effect of other gene encoding it is located on chromosome 9 in man. Interferon 13 immunomodulatory 189-amino acid residue glycopro- beta-1b is a purifed protein that has 165 amino acids but does teins synthesized by macrophages and B cells that are able not include the carbohydrate side chains present in the natu- to prevent the replication of viruses, are antiproliferative, ral material. Interferon beta is synthesized by fbroblasts and and are pyrogenic, inducing fever. It also has an immunoregulatory effect through altera- Binding to its receptor activates a sequence of intracellular tion of antibody responsiveness. Patients may experience It is a powerful activator of mononuclear phagocytes, increas- severe fu-like symptoms as long as the drug is administered. Bone marrow suppression has been reported in facilitates differentiation of both B and T lymphocytes. It has been found effective in decreasing syn- thesis of collagen by fbroblasts and might have potential in the treatment of connective tissue diseases. This complex requires a dif- Among these substances are interleukins and interferons. Cachectin is an earlier name for tumor necrosis factor α found in the blood serum and associated with wasting in these indi- viduals. Two of the three receptors and graft rejection and was previously termed lymphotoxin. Cytokines and Chemokines 373 carcinogen-, or ultraviolet light-induced transformation of cells. Lymphotoxin has cytolytic or cytostatic properties for tumor cells that are sensitive to it. Approximately three quarters of the amino acid sequence is identical between human and mouse lymphotoxin. Human lymphotoxin has 205 amino acid residues, whereas the mouse variety has 202 amino residues. Lymphotoxin does not produce membrane pores in its target cells, such as those produced by perforin or complement, but it is taken into cells after it is bound to their surface and it subsequently interferes with metabolism. It activates the formation of granulocytes tors have essentially no homology in their intracellular domains. It glycoprotein comprised of a 5- and a 15-kDa protein frag- is synergistic with other factors in activating hematopoietic ment. Renal interstitial cells synthesize erythropoi- either in vitro or in vivo, and it also blocks chemical-, etin that activates erythroid colony formation. They are critical for erythocyte, granulo- cyte, monocyte, and lymphocyte maturation. There are two An inducer is a substance that promotes cellular differentia- forms of the human receptor, i. This cytokine alone apparently does not induce col- contains 9 potential N-linked glycosylation sites. Low doses can elevate of polymorphonuclear neutrophils to replace those spent by neutrophil counts. It has also been used to mobilize periph- tivate granulocyte production in the marrow of irradiated eral blood progenitor cells for collection by apheresis and or chemotherapy-treated patients. It promotes almost exclusively multiple cell lines which include erythroid cells, granulo- the development of neutrophils from normal hepatopoietic cytes, megakaryocytes, and macrophages. It has been facilitates the differentiation of Langerhans cells into mature prepared in recombinant form to stimulate production of dendritic cells. It is a cytokine that and survival and serves as an activating mechanism for induces the proliferation, differentiation, and functional macrophages and their precursors. It has an established role ous sources such as lymphocytes, monocytes, endothelial in clinical medicine. The mature protein is preceded but there is only 47% homology in the remainder of the by a 17-amino acid leader sequence. In 100-kDa glycoprotein, or a 130- to 160-kDa chondroitin sul- the mouse, it has been mapped to chromosome 11 and in the fate proteoglycan, or is expressed as a biologically active cell human to the long arm of chromosome 5. Both forms eration and differentiation for granulocyte, monocyte, and are present in the blood circulation. The cell surface form eosinophil progenitors and as an enhancer of the function participates in local regulation, whereas the proteoglycan of mature effector cells. This receptor is expressed biological effects are mediated through binding to specifc on osteoclasts and tissue macrophages and their precursors, cell surface receptors which may be either of low or high as well as on embryonic cells, decidual cells, and tropho- affnity on hematopoietic cells. Three- dimensional structure of dimeric human recombinant macrophage colony-stimulating factor. It is synthesized by T lymphocytes, mac- rophages, endothelial cells, and stromal fbroblasts. Following demonstration of its role in humans, transfer factor was later shown to transfer delayed- type hypersensitivity in laboratory animals. It was shown to be capable of also transferring cell-mediated immunity as well as delayed-type hypersensitivity between members of numerous animal species. It also became possible to transfer delayed-type hypersensitivity across species barriers using transfer factor. However, it has now been shown that transfer factor combines with specifc antigen. It also interacts with antibody plasma but are associated with binding proteins that may specifc for V-region antigenic determinants. It may be a have the function of limiting the bioavailability of circulat- fragment of the T-cell receptor for antigen.

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The results of three of these studies [54 antifungal drying powder lotrisone 10 mg without a prescription,142 fungus gnats freezing generic 10 mg lotrisone visa,143] were evaluated in four meta-analyses [144 antifungal liquid equate cheap lotrisone 10 mg mastercard,145 fungus gnats driving me crazy order 10 mg lotrisone amex,146 kingdom fungi definition and examples 10 mg lotrisone sale,147]. A study Clorazepate in a prehospital setting used lower than usual initial dosages (5 mg Tere are no reports on the use of clorazepate as emergency treat- diazepam or 2 mg lorazepam) [54]. Another study included only ment of seizures, and the use of this drug in the treatment of epilep- children [143]. Most studies have been conducted analysed together, there was no diference in mortality between in patients with refractory epilepsy. Tere [30,53,139,164,165,166,167,172,173,174,175,176,177,178,179,180, were 273 children aged 3 months to younger than 18 years rand- 181,182,183]. The rates for cessation of status epilepticus within Only a small proportion of patients had generalized convulsive sta- 10 min and without recurrence over 30 min were 72. Tere were also no diferences in Seven randomized studies have compared intravenous loraze- all secondary outcomes (e. Four of these studies were double-blind Non-randomized trials using rectal diazepam for the treatment [32,54,142,184], one is only published in abstract form [171] and of seizure clusters, prolonged seizures and early status epilepticus four included children [143,171,184,185]. Tree meta-analyses in- have reported termination of seizures in approximately 80% with- cluding most of these trials are available [144,145,146,147]. Two randomized placebo-con- ysis of the data led to the conclusion that, compared with diaze- trolled trials using rectal diazepam in acute repetitive seizures were pam, patients treated with lorazepam in the early phase of status performed in adults and children [153,154,155]. Rectal phenytoin alone (51%), although there was no statistical signifcant diazepam was used as active comparator in six randomized tri- diference with respect to diazepam plus phenytoin (59. Lorazepam has no place in the chronic long-term treatment of ep- The results of this trial, which provide evidence for the superiori- ilepsy because of its sedating efects. However, it is a very valuable ty of intramuscular midazolam over intravenous lorazepam in the agent for the treatment of status epilepticus. Its binding discussed in more detail in the section dedicated to intramuscu- characteristics to the benzodiazepine receptor are quite similar lar midazolam. Finally, a small randomized open-label study that to clonazepam [162], but the longer duration (up to 72 h) of the compared intravenous lorazepam with intravenous levetiracetam clinical efect of lorazepam suggest that other mechanisms may be in 79 patients with early (stage 1) status epilepticus [185] reported involved in its action. The longer duration of action of lorazepam is that both drugs were equally efective in reaching clinical seizure a very important advantage over diazepam because, when used in- cessation within 10 min of administration (75. The favourable pharmacokinetics of intranasal loraze- efect of lorazepam might be slow, because of lower lipid solubility of pam in relation to standard (intravenous) administration has been the drug compared with diazepam [31,163]. However, this concern confrmed in a randomized open-label non-inferiority trial con- is not supported by results of clinical studies, which showed a rapid ducted in 141 children, showing that intranasal lorazepam was not onset of action within 3 min (range 1–15 min) in neonates [164], inferior to intravenous lorazepam in terms of clinical seizure remis- children [165,166,167] and adults [30,142]. Sublingual refractory status epilepticus treated with intravenous midazolam, lorazepam therefore is not recommended for emergency treatment propofol or pentobarbital and found an overall initial response rate of seizures. Soon afer, given intravenous midazolam experienced signifcantly fewer epi- midazolam was ofen used in early status epilepticus despite its short sodes of hypotension requiring pressor agents (30%, 42% and 77%, duration of action and high risk of recurrence of seizure activity. The authors concluded that none of these drugs is refractory status epilepticus, midazolam is used as a high-dose con- superior to the others, and that the lower response rate with mi- tinuous infusion, to overcome its short-lasting efects. Ferlisi and Shorvon of intravenous midazolam in acute seizure emergencies has been [231] reviewed all available studies that reported the outcomes of demonstrated in 22 non-randomized [140,191,192,193,194,195,196, patients treated with intravenous midazolam (n = 585), propofol 197,198,199,200,201,202,203,204,205,206,207,208,209,210,211] and (n = 143) and barbiturates (n = 192) for refractory and super-re- two randomized trials [212,213], including more than 900 patients. Tey found control of status epilepticus Because of the water solubility of midazolam, which is unique in 78% (458 out of 585) for midazolam, 68% (97 out of 143) for among the clinically used benzodiazepines, alternative routes of propofol and 64% (123 out of192) for barbiturates, while death rates administration (intramuscular, intranasal, buccal or sublingual) are during therapy were 2% (12 out of 585), 8% (12 out of 143) and 19% feasible and ofer an advantage over other benzodiazepines. The authors concluded that midazolam of 12 non-randomized [214,215,216,217,218,219,220,221,222,223, given by continuous infusion is the preferred choice for most cases, 224] and 11 randomized trials using intranasal [156,157,225,226,227], while barbiturates and propofol should be restricted to the most buccal [158,160,161] and intramuscular [184,228] midazolam have severe or super-refractory cases. Most studies included children, and some includ- Naritoku and Sinha [211] found an unexpectedly slow clear- ed neonates [184,208,210]. This could contribute to a more delayed awakening afer a continuous infusion included patients with refractory and su- long-term treatment of refractory status epilepticus. Overall, more than 2000 patients In an open-label trial conducted in 40 children aged 2–12 years treated with midazolam in various forms for acute seizures or status with refractory status epilepticus (motor seizures uncontrolled af- epilepticus have been reported. Small case series using intravenous midazolam in the treatment of Status was controlled in 86% of children with midazolam and 89% early status epilepticus found excellent response rates of up to 100% with diazepam, but relapse rates were signifcantly higher in the [207] but, as expected, the short duration of action led to a disap- midazolam group (57% versus 16%). About half of the patients pointingly high number of relapses (75%) within a short time. A sub- study from a large centre in Serbia, fve of seven patients with early sequent randomized trial has been conducted in 120 children aged status epilepticus experienced severe respiratory depression and hy- 6 months to 14 years with persisting seizures at arrival to the emer- poventilation afer 15 mg midazolam given intravenously at a rate gency department. Numbers of patients with seizure cessation were signifcantly continuous infusion most ofen started at 0. No signifcant diferences in mean duration to clinical sei- activity [191,194,196,197,200,202,213] with overall response rates zure cessation or in side-efects were found except excessive somno- of 64. In one study, exceptionally high continuous infusion lence, which was signifcantly higher in the diazepam group. In children, there have been virtually no reports of local reactions or systemic adverse Intramuscular use events in these case series, except for one study which found a 3% Early reports using intramuscular midazolam for acute seizures or rate of respiratory depression requiring ventilator support [197]. Benzodiazepines Used in the Treatment of Epilepsy 409 In two studies [219,228], one of which was randomized [228], in- 93. Although response rates did zolam is now a widely accepted and efective treatment for acute not difer signifcantly, patients in the midazolam group received seizures in childhood. Nitrazepam used as chronic treatment has been reported to be ef- A subsequent large, double-blind, randomized, non-inferiority fective against myoclonic, atonic and atypical absence seizures in trial compared intramuscular midazolam with intravenous loraze- West syndrome [238,239] and Lennox–Gastaut syndrome [36,37]. At the time of drome, a malformation syndrome ofen with refractory seizures arrival in the emergency department, seizures were absent without and status epilepticus [240]. The two treatment groups were compared with baseline (75% of children had >50% reduction) similar with regards to need for endotracheal intubation (14. The efcacy of nitrazepam in Lennox–Gastaut syndrome, subjects with midazolam and 14. A previous open-label midazolam group because an intramuscular injection is faster to study conducted in 20 children with medically refractory infantile accomplish, although the onset of action (i. Intranasal use Adverse effects Intranasal application is easy to use and has the advantage of rapid Because all benzodiazepines share a common mode of action, it access in the early phase of status or in the treatment of prolonged is not surprising that these compounds show a similar adverse ef- or acute repetitive seizures in childhood. The adverse efects of benzo- [156,157,233,233] and prolonged febrile convulsions (>10 min) diazepines also vary in relation to dosage, duration of treatment, [224,225]. The initial response rate was uniformly excellent, 67– presence of absence of concomitant medications, route of admin- 100%, and midazolam was at least as efective as the comparator. In istration and specifc clinical context in which these drugs are one study, intranasal midazolam was even superior to rectal diaze- used (e. Adverse efects of particular rele- studies [157,225], whereas in others seizures were controlled more vance during chronic treatment include sedation, drowsiness, quickly with intravenous diazepam than with intranasal midazolam incoordination, cognitive impairment, fatigue, muscle weakness, [226,227]. Some of these efects, Four randomized controlled trials, including 564 patients, com- particularly sedation and drowsiness, tend to be more marked at pared the efcacy of buccal midazolam with rectal diazepam in early initiation of treatment and to decrease gradually during prolonged childhood status epilepticus [158,159,160,161]. Tree studies found administration because of development of pharmacodynamic tol- no diference in efcacy (buccal midazolam versus rectal diazepam: erance. In 75% versus 59% [158], 57% versus 67% [160] and 78% versus 85% particular, behavioural disturbances, including hyperactivity, rest- [161], respectively). However, all authors concluded that the buccal lessness, irritability and aggression, occur much more frequently route was easier to use and socially more acceptable for initial treat- in children than in adults. Hypersecretion in the tracheobronchial ment of early status epilepticus in childhood. In addition, one study tree and drooling are also well-recognized side-efects of benzo- found buccal midazolam even more efective than rectal diazepam diazepines in children, but they are virtually absent or negligible (56% versus 27%) [159]. A randomized study compared buccal midazolam with intrave- To minimize the occurrence of dose-related toxicity, benzodiaz- nous diazepam in 120 children with seizures persisting at arrival at epines should be initiated at a low dosage in elderly people, and emergency department. On the other hand, the In a comparative study, clorazepate was better tolerated than phe- risk of withdrawal symptoms, including rebound aggravation of nobarbital [255] based on a non-standardized score that included seizures, which occur when benzodiazepines are discontinued too diferent symptoms ranging from ‘sleepiness’ to ‘grossly impaired rapidly, does complicate clinical management in some cases [63]. In a study comparing add-on clobazam (55 patients) When benzodiazepines are used as emergency treatment, most with add-on clorazepate (n = 170), fewer adverse efects were ob- of the adverse efects listed are of lesser importance, and the major served in those treated with clorazepate (31% versus 47%) [247]. Tese Idiosyncratic reactions, including skin rashes and blood dyscra- efects were related to high initial doses and rapid titration. Use of benzodiazepines during pregnancy is not con- sidered to be associated with a high risk of teratogenicity, although Diazepam a possible association with oral clefs has been reported in some Respiratory depression, hypotension and sedation are the main studies [63]. Afer intravenous administration of diazepam for status epilep- Clobazam ticus and other indications, mild to severe hypotension or respirato- The most common side-efect reported with the use of clobazam ry depression occurred in 5. Browne and Penry [116] re- 1,5-benzodiazepine, is usually less severe than that occurring with viewed the reports on 439 patients in 35 articles and found 16 cases 1,4-benzodiazepines such as nitrazepam and clonazepam [243,244]. In three reports, previous treatment clobazam was 38%, with drug discontinuation because of side-ef- with barbiturates was regarded as a predisposing factor for diaze- fects being reported in 4% of patients [245]. In the randomized clobazam with carbamazepine and phenytoin [66], no signifcant trials using intravenous diazepam, 7 out of 100 (7%) of the patients had diference was observed in occurrence of side-efects such as som- hypotension [54,143] and 15 out of 153 (10%) patients had respiratory nolence or ataxia [246]. The incidences of intravenous phenytoin, 22 out of 113 (20%) of patients had respiratory adverse efects may to a large extend depend upon dosage and on depression/failure and 33 out of 113 (29%) had hypotension [32,259]. A meta-analysis of three randomized controlled studies compar- A summary of adverse events reported in the pivotal randomized ing intravenous diazepam with intravenous lorazepam in the treat- double-blind trial of clobazam in patients with Lennox–Gastaut ment of status epilepticus [54,142,143] found no signifcant difer- syndrome [76] is illustrated in Table 30. Discon- study not included in this meta-analysis, and comparing intrave- tinuation rates for adverse events were 3. A prospective study analysed 122 Clonazepam episodes treated with either intravenous or rectal diazepam in 97 Behavioural changes (hyperactivity, irritability, aggressive behav- children, and found an overall incidence of respiratory depression iour) have been reported in children treated with this drug with of 9%. Of the patients with respiratory depression, 72% needed ven- a frequency ranging 2–50% [248]. In some cases, these adverse ef- tilator support afer diazepam administration [260]. Treatment have been described in open studies or case reports, including with clonazepam has also been suggested as a risk factor for devel- previous use of barbiturates, chlordiazepoxide, methaqualone, gal- opment of depression in patients with epilepsy [249]. Tese symptoms, which are most prominent lar disease are also likely to be at greater risk, at least for respiratory in the frst few days or weeks of treatment, may improve with dos- depression. Although not formally assessed, the rate at which the age reduction and over time. Overall, about 20% of patients have bolus is injected seems to be particularly crucial for the develop- intolerable adverse efects which can lead to dose reduction or even ment of respiratory depression and hypotension [267,268]. Although probably rare, respiratory failure may occur afer Paradoxical efects with diazepam appear to be rare. This adverse efect is tonic status epilepticus in patients with Lennox–Gastaut syndrome probably related to the dosage and rate of infusion. Adverse events are listed in descending order of frequency in the all-clobazam group. In contrast to the diazepam fat emulsion (Diazemuls®), the con- With respect to reactions at the site of administration, local pain, ventional formulation of diazepam (Valium®) contains propylene phlebitis and venous thrombosis may occur afer intravenous di- glycol as a solvent, which may also lead to systemic efects. A retrospective study found thrombophlebi- drome of propylene toxicity with otherwise unexplained anion gap, this in only 3. A retrospective survey on and clinical deterioration has been described [272,273]. Local reactions are associated with polypropylene glycol-based 412 Chapter 30 preparations and are not reported with diazepam fat emulsions with 1 of 60 patients given intravenous midazolam [293]. The best prevention measures against local vein reactions comparing intramuscular midazolam with intravenous lorazepam, include administration in an antecubital vein [281], fushing with injection-site complications were observed in 4 out of 448 patients saline [282] and injection rates below 5 mg/min. The rectal solution receiving midazolam and 2 out of 445 patients treated with loraze- or gel is generally well tolerated. Nitrazepam Nitrazepam can cause drooling, coughing, gagging and eating dif- Lorazepam fculty, and aspiration pneumonia. Drowsiness is common and should discoordination has been suggested as the most likely underlying be expected in all patients afer intravenous injection, but severe mechanism [294]. A dosage not exceeding 1 mg/kg/day has been stupor or coma are rare, even afer extremely high doses with serum recommended, because at higher doses there have been several drug levels of 300–600 ng/mL [284,285]. Interestingly, respiratory depression, if at all, seems to occur afer the frst injection, but not afer repeated use [5,167]. It has been Place of benzodiazepines in current claimed that co-medication is not a major risk factor for respiratory therapy depression or failure [286], based on studies analysing the infuence of morphine and meperidine as co-medication [287,288]. How- Chronic epilepsy treatment ever, this view was not supported by the results of a prospective Clobazam has an established place in the adjunctive treatment of randomized double-blind study in patients scheduled for coronary focal and generalized childhood epilepsies, especially in Lennox– artery bypass graf [289]. Other co-medications were not studied, Gastaut syndrome, where it has shown to be particularly efcacious and pharmacodynamic interactions may have to be anticipated in against drop attacks, and in benign myoclonic epilepsy of infancy. Patients It can also be considered as initial monotherapy in focal epilepsies with respiratory disorders and muscular disease are also likely to be with or without secondarily generalized tonic–clonic seizures in at greater risk of respiratory depression. Europe, to use clobazam to provide transient therapeutic cover, for As is the case with diazepam, there are few reported cases of tonic example when switching a patient to another therapy, or for rapid status epilepticus in patients with Lennox–Gastaut syndrome afer oral loading in seizure clusters and in epilepsy monitoring units. No other paradoxical has to be emphasized, however, that there is no evidence for this efects of lorazepam have been reported. Local pain and irritation at the injection site may occur, but they Clonazepam is ofen used as adjunctive treatment in syndromes are less frequently reported than with diazepam [290]. Its sedative and behavioural ad- lorazepam in 20 mL 5% dextrose or Ringer’s lactate diminishes the verse efects limit the broader use of the drug. Teir Midazolam use cannot be supported by high-quality randomized controlled Like other benzodiazepines, midazolam has prominent sedative ef- studies. Respiratory depression and hypoventilation are dose-related phenomena and were reported more frequently in early case series Emergency treatment [140] and in anaesthetic studies [292], which use higher doses. Pa- Because of its high efcacy and long-lasting efect, lorazepam is tients with respiratory disorders and muscular disease are likely to usually the preferred choice for the frst-line intravenous manage- be at greater risk of respiratory depression. In childhood refractory ment of premonitory and early status epilepticus, acute repetitive status epilepticus treated with a continuous midazolam infusion, seizures and acute symptomatic seizures. Its efcacy in generalized hypotension may occur in up to 40% and respiratory depression convulsive status epilepticus has been demonstrated in randomized requiring mechanical ventilation in up to 50% [212]. However, the frst-choice agent for emergency management of acute seizure dis- tolerability of the drug is generally good, particularly when the in- orders by non-medical personnel, prior to admission to hospital. Seizure aggravation or in- to be at least as efective as intravenous lorazepam in convulsive duction of tonic seizures has not been observed with midazolam.

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Improved surgical procedures fungus gnats report discount lotrisone 10 mg visa, advanc- es in techniques for preoperative localization of the seizure focus antifungal treatment for scalp 10 mg lotrisone for sale, New therapies and future directions as well as better understanding of the pathophysiology of distinct Patients with temporal and extratemporal lobe epilepsy may not be surgically remediable syndromes of epilepsy antifungal supplements safe 10 mg lotrisone, are responsible for the candidates for resection of the epileptic focus or may not choose to increasing success of epilepsy surgery over the years antifungal weight loss generic 10 mg lotrisone visa. New stimulation technologies are to the patient and class I evidence of high efcacy in eliminating now available or being investigated for the treatment of medically seizures fungus in mulch 10 mg lotrisone order amex, with seizure-free rates ranging from 58% to 77%, tempo- refractory epilepsy. J Clin Neurophysiol ilepsy or epilepsy involving the lateral structures in the temporal 2012; 29: 366–370. Surgically remediable lobe may harbour a favourable surgical prognosis if an apparent le- extratemporal syndromes. J Clin Neurophysiol 2012; in some patients, although less efective than temporal lobectomy 29: 379–384. Postoperative defcits and lack of class I evidence make these surgeries a clinical option for functional recovery following removal of tumors involving the dominant hemi- medically refractory epilepsy that should be carefully considered on sphere supplementary motor area. Parietal lobe ep- loop neuroprosthetic devices may in the future be of use in selected ilepsy: clinical manifestations and outcome in 82 patients treated surgically be- epilepsy cases, thus complementing the spectrum of available sur- tween 1929 and 1988. Resection of parietal lobe gliomas: incidence and evolution of neurological defcits in 28 consecutive pa- tients correlated to the location and morphological characteristics of the tumor. Clinical manifestations of insular We wish to thank Irene Wainwright for editorial assistance. Cortical dysplastic lesions in children with intractable epilepsy: role of complete resection. J Neurosurg 2011; posterior medial temporal lobe structures in the surgical treatment of temporal 114: 1176–1186. Lesionectomy: management of sub- of selective amygdala-hippocampectomy in one hundred patients with nonlesion- strate-directed epilepsies. New outcome afer mesial temporal lobe epilepsy surgery: corticalamygdalohip- York: Raven Press, 1998: 1841–1850. Cortical excitability as a functional neuroimaging in pre-surgical epilepsy evaluation. Front Neurol 2014;5: potential clinical marker of epilepsy: a review of the clinical application of tran- 1–16. Early surgical therapy for drug-resistant difusion-tensor imaging distinguish epileptogenic tubers and cortex in patients with temporal lobe epilepsy; a randomized trial. In vivo normative atlas of the hippocampal tion length and memory outcome in selective epilepsy surgery. Ictal magnetic source imaging ilepsy surgery: a systematic review and meta-analysis. Initial outcomes in the multicenter study large series of medically refractory partial epilepsy patients that are candidates for of epilepsy surgery. Long-term outcome of extratemporal alographic localization in pediatric epilepsy surgery: comparison with invasive epilepsy surgery among 154 adult patients. Clinical application of spatiotemporal distributed comes in epilepsy surgery: antiepileptic drugs, mortality, cognitive and psycho- source analysis in presurgical evaluation of epilepsy. Surgical versus medical treatment for refractory epilep- A meta-analysis and systematic review. Surgical and neurological complica- of gamma knife radiosurgery for mesial temporal lobe epilepsy: Seizure response, tions in a series of 708 epilepsy surgery procedures. Better object recognition and naming lepsy surgery complication rates: a 32-year systematic review and meta-analysis. Potential intracranial applications of vagus nerve stimulation for treatment of medically intractable seizures. The occurrence of seizures and epilepsy free and improve their quality of life [11,12,13,14]. Seizures are the most common pre- neurological examination, electrophysiological studies, seizure senting symptom in patients with slow-growing or well-diferenti- types and response to antiepileptic medications may not be useful ated low-grade tumours and seizures have been reported to occur in predicting the nature of the underlying pathology. The ing focal epilepsy may be related to an indolent low-grade glioma typical range for the prevalence of tumours in epilepsy is from ap- with a clinical course indistinguishable from that of a non-neoplas- proximately 6% of newly diagnosed epilepsy in community popu- tic process. Lesional epilepsy can be associated with simple partial lations to 17% who undergo epilepsy surgery where seizure control seizures, complex partial seizures or secondary generalized ton- is the primary goal [7,8]. It is the purpose of this chapter to elaborate on chronicity of the growth of the neoplasm and the incidence of sei- the current concepts concerning the diagnosis and surgical man- zures. In the Montreal series of 230 patients with tumours of the agement of patients with epilepsy associated with neoplastic mass central nervous system, the majority were gliomas [4,5]. The lesion associated with epilepsy may warrant neurosur- occurred in 70% of patients with astrocytomas, in 92% of patients gical intervention because of mass efect, growth or haemorrhage. The a clear distinction between focal seizures due to a demonstrable results of surgical resection of the lesion with respect to seizure fre- pathological lesion and generalized seizures, constituting idio- quency, surgical morbidity and psychosocial outcome will be dis- pathic epilepsies, was emphasized. Seizures specifcally associated with cortical dysplasias and [6] was the frst to provide a comprehensive understanding of the vascular and infective lesions are discussed elsewhere in this book. He emphasized that epilepsy could be the initial and Focal or localization-related epilepsy only clinical manifestation of a brain tumour [6]. Victor Horsley Focal or localization-related epilepsy is the most common seizure [9] reported his three landmark cases in which he surgically cured disorder in the adult patient and the most frequently occurring the patients of their focal epilepsy. More recently, various seizure seizure type is a complex partial seizure [17,18,19]. Approximately patterns in patients with structural lesions and their surgical man- 45% of patients with focal epilepsy will experience medically refrac- agement were described by Penfeld and Jasper [10], Spencer et al. Epilepsy surgery has been shown repeatedly to be medically intractable epilepsy [11,12,13,14]. Primary brain tu- an efective therapy for selected patients with intractable focal epi- mours, hamartomas and vascular malformations are the underly- lepsy [20 21,22,23,24,25]. Patients with lesional epilepsy may have ing pathology in approximately 20–30% of patients with intractable a primary brain tumour, vascular anomaly or a malformation of epilepsy. The common primary brain to distinguish a mass lesion from other pathological entities in pa- tumours encountered in patients with focal epilepsy include a low- tients with epilepsy [14,15,16]. Patients with primary intra- have focused on how tumours located in the brain disrupt signal parenchymal neoplasms almost invariably have an abnormal struc- processing. The rationale for the presurgical evaluation In defning the area of resective surgery, Rasmussen [20] iden- is to identify the site of ictal onset and initial seizure propagation, tifed a primary localization, which is the site of seizure initiation, that is the epileptogenic zone, and determine the likely pathological and a secondary localization, which indicates the volume of tissue fndings underlying the epileptic brain tissue [35]. The amygdala and hippocampus appear to be crit- clinical correlation is essentially to confrm the epileptogenicity ical sites of secondary localization by providing synchronized out- of the structural abnormality [13,14]. Seizures originating as pathological substrate and the ictal onset zone indicates a highly far posteriorly as the occipital lobe may preferentially spread for- favourable operative outcome in selected individuals. Anterior temporal lobectomy can result in seizure relief despite the presence of a posteriorly lo- cated temporal lobe tumour [51,52,53]. This suggests that the efect Mechanism of epileptogenesis associated of surgery need not depend on the excision of the primary epilep- with structural mass lesions togenic focus, but on the elimination of the recruitment of other The mechanism(s) of epileptogenesis associated with brain tumours cells for full seizure development and interruption of the neuronal is unknown. Hughlings Jackson observed that the pathogenesis of pathways required for seizure propagation. Penfeld suggested that impaired vascularization of the sur- sions in more posterior parts of the temporal lobe [54,55,56,57,58]. In the mon’s horn sclerosis was signifcantly more common in patients symptomatic focal epilepsies, a focal structural abnormality is in- without focal mass lesions as compared to those with focal lesions timately associated with the epileptogenic area, the site of seizure [45]. Early proposed mechanisms included impaired vascularization of the surrounding cerebral cortex and direct irritation of the brain and denervation Pathology: neoplastic lesions hypersensitivity due to partial isolation and transection of a region Seizures occur in approximately 50% of patients with intracerebral of the cerebral cortex [35,39]. The incidence of seizures among patients with ing the contribution of hereditary predisposition in the develop- primary brain tumour is related to the tumour pathology and corti- ment of epilepsy in patients with intracranial structural lesions [12]. Slow-growing, low-grade and well-dif- lesions must vary because some are extracerebral while others ferentiated gliomas are the most epileptogenic lesions [36,60]. In are intracerebral, some tumours are infltrative into the brain and the Montreal series of 230 patients with gliomas, seizures occurred others distort it by mass efect. This suggests that the aetiology of in 70% of those with astrocytomas, in 92% of those with oligo- seizures in various lesional pathologies is multifactorial, involving dendrogliomas and in 37% of those with glioblastomas [36]. The factors intrinsic to the lesion itself, the location of the tumour and incidence of epilepsy is lower in patients with glioblastoma, perhaps factors unique to the host harbouring the pathology. Tese more aggres- Factors unique to a pathological lesion, particularly tumours, sive lesions, including cerebral metastasis, are associated with a risk may be associated with the expression of various ion channels and of seizures in the range of 20–30% [36]. In addition to properties of the Low-grade fbrillary astrocytoma tumours themselves, numerous studies have investigated the role Pilocytic astrocytoma of various properties of peritumoral tissue [40]. Rare, but common in the epilepsy population Uncommon, comprising 5–10% of gliomas Seen in the frst three decades of life Generally occur in the ffth and sixth decades of life Two-thirds occur in patients under the age of 18 years Male predominance 2 : 1 Most patients have a long history of seizures Ten-year survival rate is 46% with mean survival 9. Contain both neuronal and glial elements Occur less frequently compared to high-grade lesions Rare, accounting for 0. In Can be associated with focal cortical dysplasia a series from the Cleveland Clinic consisting of 133 patients who underwent operations for extratemporal epilepsy, tumours were Calcifcations occur in 30% of cases identifed in 27. Surrounding oedema is minimal Brain tumour as a cause of chronic epilepsy When peripheral, often associated with bony remodelling of the During presurgical evaluation of 190 patients with intractable focal skull epilepsy, Spencer et al. Because Often present in the second and third decades of life of diferences in the selection and histopathological criteria used, Usually cause seizures that can be refractory the distributions of the neoplasms according to type have varied Over 50% are accompanied by focal cortical dysplasia widely between series. Nevertheless, indolent or slow-growing gli- al or neuronal tumours constitute the majority. Although tumours Slow-growing neoplasm occur more frequently in patients with an onset of epilepsy during Most commonly found in the temporal lobes adulthood, brain tumours also remain an important cause of in- May remodel overlying bone tractable epilepsy in children and adolescents [27,33]. In a series of Usually no surrounding oedema 33 children who underwent temporal lobectomy at an average age of 8 years, 48% were diagnosed as having tumours [71]. Often wedge-shaped, cortical mass with multiple cysts May extend towards the ventricle Gangliogliomas Calcifcation in 20–36% Gangliogliomas are mixed tumours that are composed of neoplas- tic glial and dysplastic neuronal cell types (Table 66. Tey comprise 10–50% of the neoplasms associated with medically in- Tumours located in close proximity to the centrotemporopari- tractable focal epilepsy [30,31,32,34,72]. Seizures are the primary etal region are more frequently associated with epilepsy [20,36,60]. Among 11 patients with gangliogliomas, the age at diagno- involve the temporal lobe [11,12]. Seizures ofen occur years least as frequent as lesions in the temporal lobe in patients with ne- before the tumour is detected [32]. This discrepancy is possibly Tese tumours are located within the temporal and frontal related to the lower seizure threshold of the temporal lobe, and also lobes in most cases [30,31,32,34,72]. Mesial temporal sclerosis was Resective surgery of neoplasms 845 (a) (b) (c) (d) (e) (f) (g) Figure 66. Gadolinium-enhanced T1 axial image demonstrates a partially non- contrast-enhancing cystic mass within the lef posterior inferior temporal lobe (a). Difusion tractography demonstrates optic radiation deep and arcuate fascuculus anterior to the cystic mass (d). The patient underwent lef posterior temporal craniotomy for stereotactic resection of the tumour. When tures into seizure generation requires careful preoperative evalua- associated with glial nodules and focal cortical dysplasia, this cor- tion to delineate the extent of the epileptogenic zone (Figure 66. The non-specifc form is identifed on the basis of the same glial and dysplastic components in complex Dysembryoplastic neuroepithelial tumours forms but without the specifc glioneuronal element [78,79]. Nodular or heterogeneous signal and the frontal lobe in one-third of patients; parietal and occipi- (usually neocortical) or dysplastic appearing, poor delineation and tal lobe involvement was infrequent [29]. Tese tumours typically grey–white matter blurring (mesial temporal) corresponds to the present in childhood or adolescence and one-third may show focal non-specifc histological form [78]. Axial T2 images demonstrate foamy cystic mass within the lef temporal lobe with no apparent involvement of mesial temporal lobe structures. Patient underwent gross total removal of lesion and has been seizure free for 3 years. Duration of epilepsy In the past, the majority of patients with lesional epilepsy previous- ly considered for surgery have had seizures for more than 10 years Presurgical evaluation [11,12,13]. The main purpose of the presurgical Clinical seizure characteristics evaluation in patients with intracranial lesions and intractable Lesional epilepsy may be associated with simple partial, complex seizures is to confrm the relationship between the lesion and the partial or secondary generalized tonic–clonic seizures [11,12,13,14]. In some patients, the epileptogenic focus is contigu- The most frequent seizure type associated with lesional epilepsy is ous with but extends beyond the structural lesion [11,12,13,14]. Tirty-four of the 50 patients The lesion may occasionally be incidental and bear no causal re- with intractable seizures associated with space-occupying lesions lationship to the epileptogenic focus. With the exception of visual auras in patients with oc- of the brain and intractable epilepsy is essential in planning ther- cipital lesions, the characteristics of the aura did not help in the lo- apeutic strategies. Resective surgery of neoplasms 847 The most frequent seizure type associated with lesional epilepsy presented with intractable epileptic seizures as the main feature of is the complex partial seizure. However, when present, a unilateral focal interictal temporal lobe lesions had typical temporal lobe seizures [12]. A simple partial seizure as a manifestation tant from the site of a structural lesion is not uncommon. Patients with temporal lobe lesions were not found to be a reliable indicator of a cerebral neoplasm. However, signifcantly more likely than extratemporal patients to have an afer successful treatment, return of seizures has been an indicator ipsilateral temporal spike or sharp wave focus. Poor interictal scalp localization has been attributed to the fact that the recorded focal History and examination abnormality may only be a part of a deeply localized, more extend- A careful history should be taken in all patients with seizures, with ed focus that propagates to the surface. A mality, and bilateral independent temporal paroxysmal activity has thorough neurological examination can detect abnormalities such been observed in patients with extratemporal lesions as well [14]. Among a group of 27 patients with intracranial mass lesions and medically refractory focal epilepsy, age at onset of seizures was the Neuroimaging same for neoplastic and non-neoplastic lesions [11]. In a selected Advanced neuroimaging is arguably the most important aspect of series of operated cases, Boon et al. The diagnostic yield of the Routine electroencephalogram recording neuroimaging studies depends on the underlying pathology and the Structural lesions are now most ofen recognized on neuroimaging anatomical localization of the epileptogenic area.

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Neve- The metabolic pathways of carbamazepine and oxcarbazepine theless, the major efect appears to be on voltage-gated sodium difer significantly (Figure 40. Oxcarbazepine is rapidly and 536 Chapter 40 extensively reduced by cytosolic aldoketoreductase enzymes in pharmacokinetics of oxcarbazepine has not been evaluated in se- the liver to the active metabolite monohydroxycarbazepine (96%). Monohydroxycarbazepine exists in two isomeric tion, but patients with creatinine clearances of <30 mL/min/1. At steady-state about 81% of the monohydroxycarbazepine exhibited significant increases in elimination half-life and plasma concentration is in the form of the L-enantiomer (eslicarbazepine) concentrations of monohydroxycarbazepine [16]. Before steady state is reached, the proportions of the two enantiomers are more similar, suggesting that the R-enantiomer is Drug interactions cleared more rapidly [9]. The addition of oxcarbazepine can produce a small in- unchanged monohydroxycarbazepine (28%). A tive accounts for 3% of the dose excreted in the urine, with <13% of variable increase in phenytoin concentration can occur, mainly at the drug excreted as minor conjugates of oxcarbazepine and mono- higher phenytoin serum levels because at high serum levels pheny- hydroxycarbazepine [18]. Serum monohydrox- An open-label study of oxcarbazepine as monotherapy or adjunc- ycarbazepine concentrations can decrease by 29–40% (Table 40. In 109 children, aged 3–17 years, oxcar- when oxcarbazepine is added to a stable regimen of oral contra- bazepine was found to have a low propensity to inhibit or induce ceptives, as a result of induction of the metabolism of both ethi- oxidative enzymes. Young chil- epine, oxcarbazepine does not interact significantly with warfarin, dren can be given higher milligram per kilogram doses than older cimetidine, propoxyphene or erythromycin [30]. This may be explained by age-related decreases in creatinine minophen (paracetamol) and amiodarone [22]. Because of their difering efects on the drug metabolizing en- Mild to moderate hepatic dysfunction did not alter the pharma- zyme systems, substituting carbamazepine with oxcarbazepine cokinetics of oxcarbazepine or monohydroxycarbazepine, but the may result in de-induction and a consequent increase in the serum Table 40. Oxcarbazepine is not indicated for absence, myo- clonic and other types of generalized seizures other than tonic– clonic seizures, and indeed may exacerbate them [49]. Serum level monitoring Measurement of monohydroxycarbazepine, not oxcarbazepine it- Double-blind trials in comparison with carbamazepine self, may be useful. The usual method is high-performance liquid Tree randomized double-blind controlled trials compared ox- chromatography. If a carbamazepine level is ordered in error, it will carbazepine with carbamazepine (Table 40. In a group of 214 patients treated with a clinically opti- enrolled 40 patients whose phenytoin therapy had been unsatis- mized dose, the mean serum level of monohydroxycarbazepine was factory, and randomized them to either carbamazepine or oxcar- 15. A reference (optimal) range of monohydroxycarbazepine con- with either focal or primary generalized seizures, but equivalent ef- centrations of 3–35 mg/L has been suggested, although this is not fcacy for the two drugs was noted. Routine monitoring of levels is not pine for 12 weeks each in random order, in addition to the titra- recommended, although it may be helpful to assess compliance or tion period. Oxcarbazepine significantly reduced tonic–clonic and to gauge dosage in the presence of enzyme-inducing concomitant tonic seizures in comparison with carbamazepine, but there was no drugs. As monohydroxycarbazepine levels have been reported to diferential efect on complex partial seizures. Tese trials conception, during pregnancy and in the immediate post partum were far too small to prove non-inferiority of either drug, but the period. In a larger double-blind controlled monotherapy trial enroll- ing 235 patients with newly diagnosed epilepsy [35], patients with Effcacy previously untreated primary generalized tonic–clonic seizures The efficacy of oxcarbazepine has been established in many rand- or focal seizures with or without secondary generalization were omized controlled clinical trials. Oxcar- mazepine with fexible dosage adjustments allowed during a 4- to bazepine was compared with carbamazepine [36,37,38], phenytoin 8-week titration period [38]. At the end of the 48-week mainte- [39,40], valproate [41] and levetiracetam [42] in controlled trials, nance phase, carbamazepine patients were taking a mean dose of mostly as monotherapy. Other randomized trials utilized oxcar- 685 mg/day, while oxcarbazepine patients were taking 1040 mg/ bazepine monotherapy in comparison with either placebo [43] or day. Fify-two per cent of oxcarbazepine patients and 60% of car- lower dose oxcarbazepine [44,45]. Randomized controlled trials of bamazepine patients were seizure-free during this year-long study, adjunctive therapy for refractory patients have enrolled adults aged not a significant diference. Oxcarbazepine therefore was sim- 15–65 [46], children aged 3–17 years [47] and infants from 1 month ilar in efficacy to carbamazepine in this series of double-blind, to 4 years of age [48]. Percentage of Number and type drop-outs for Study of patients Trial design Mean dose/day Effcacy results adverse events Houtkooper 48 adult inpatients Crossover Oxcarbazepine: 9% seizure None on either et al. In a Cochrane review, this trial was the only one deemed to ondary generalized seizures, or generalized tonic–clonic seizures meet the reviewers’ criteria for a direct comparison of monotherapy without focal onset, were seizure-free while taking oxcarbazepine efcacy between carbamazepine and oxcarbazepine for non-refrac- during a 48-month maintenance treatment period, compared with tory focal seizures [51]. The mean daily dose at the start oxcarbazepine and carbamazepine were similarly efective, using of the maintenance period was 1028 mg for oxcarbazepine and these criteria. A similar result emerged from a study of 193 Oxcarbazepine was reported to be slightly less efective (72% children aged 5–18 years, who were randomized to oxcarbazepine seizure-free) than levetiracetam (90% seizure-free) in a rand- or phenytoin afer a new diagnosis of epilepsy with focal or gener- omized, open-label trial of 39 children with benign epilepsy with alized tonic–clonic seizures [40]. Sixty per cent in each group was centrotemporal spikes, although the study was too small to state seizure-free during the maintenance period. However, in both these either statistical superiority or non-inferiority of either drug [42]. A study of similar Short-term double-blind monotherapy trials in design compared oxcarbazepine with valproate among 249 patients comparison with placebo or low-dose active control with focal or generalized tonic–clonic seizures aged 15–65 years A small double-blind, placebo-controlled study enrolled patients [41]. Seizure-free rates were 57% for oxcarbazepine and 54% for with recent-onset untreated focal seizures, who received a placebo valproate, not significantly diferent. The median daily maintenance or 1200 mg/day oxcarbazepine for a period of up to 90 days or until dose was 900 mg for each drug. Tese very short end-points raise a question as epine, lamotrigine, gabapentin and topiramate for treatment of to whether this cohort was truly representative of a population of patients with newly diagnosed and mostly focal epilepsy [50]. Patients exited the ences in efficacy between oxcarbazepine and the other drugs were trial afer completing 10 days of treatment, or afer meeting exit cri- found, although fewer patients took oxcarbazepine than the other teria indicating drug failure, such as four focal seizures within this drugs because it was added as a treatment arm later. Forty-seven per cent in the oxcarbazepine arm and 84% in 210 patients randomized to receive oxcarbazepine remained on the placebo arm met one of the exit criteria, a statistically signifcant Table 40. Percentage of drop- Number and type of Effcacy results (% outs for adverse Study patients Mean dose/day seizure-free) events Bill et al. This study also demonstrated 50% for placebo and 600, 1200 and 2400 mg/day oxcarbazepine, the feasibility of quick initiation of oxcarbazepine when necessary respectively. However, discontinuation rates for adverse events also for inpatients: 1500 mg on the first day, then 2400 mg on subse- increased with increasing dosage, with 66. Among the 75% of Two outpatient studies employed a more gradual conversion to patients who were taking carbamazepine as one of their baseline oxcarbazepine monotherapy for patients with refractory focal sei- drugs, the improvement in seizure frequency afer adding oxcar- zures [44,45]. As there are no controlled studies designed, it was believed that the minimum efective dose of drug of the efect of adding carbamazepine to oxcarbazepine, the con- might be 300 mg/day, as in the absence of enzyme-inducing drugs verse of this efect may or may not occur. In any case, the results this dose was felt to have comparable efcacy to 600 mg/day given of this study do not fully answer the question of whether the ad- to patients taking enzyme-inducers [44]. In retrospect, it is clear dition of oxcarbazepine to carbamazepine produces a qualitatively that 300 mg/day is not an efective dose, but positive results from diferent efect on seizure frequency or merely an additive one (i. The primary end-point, 41% of patients in the high-dose group met one of the exit criteria percentage change in seizure frequency from baseline, was 35% for compared with 93% of patients in the low-dose group. Forty-one per cent of patients kg/day oxcarbazepine added to one or two baseline drugs [48]. This was a multicentre, multination- (or a low-dose active control) were added to existing therapy for al, adjunctive-therapy trial in which 366 patients aged 18–65 with patients with inadequately controlled focal seizures are listed in refractory focal seizures were allocated to either placebo, 1200 or Table 40. Only the diference between A dose-ranging trial enrolled 694 patients aged 15–65 years in the placebo group and the 2400 mg/day group was statistically sig- a parallel comparison of placebo and three doses of oxcarbazepine nifcant (P = 0. A linear dose–response association was found, with median efcacy in this trial was ascribed by the authors to the very high percentage reductions in seizure frequency of 8%, 26%, 40% and placebo response rate, and a subanalysis of patients enrolled only at Table 40. Number and type of Mean percentage reduction in seizure frequency Percentage of drop-outs Study patients (versus baseline) for adverse events Barcs et al. Oxcarbazepine has been used as an adjunct in Uncontrolled studies acute bipolar depression and bipolar depression prophylaxis. A ran- Uncontrolled studies have very limited value in assessing efcacy, domized, prospective, double-blind trial of carbamazepine and ox- but may provide some insight into the performance of a drug in carbazepine as add-on therapy to lithium for residual (non-acute) clinical practice. Tese results refected median daily doses of for bipolar afective disorders in children and adolescents [66]. Pilot randomized, controlled, double-blind trials for with a 4-week taper of concomitant drugs, 52% were found to have treatment of migraine ([68] and alcohol withdrawal [69] demon- their seizures reduced by half or more and 18% were seizure-free strated no beneft compared with placebo. Among 147 newly diagnosed patients treated at single centre in Turkey and followed prospectively, 63% achieved at least a 12-month remission but 37% Adverse effects continued to have seizures despite maximum tolerated doses of oxcarbazepine [55]. Still better results were reported from a similar study in It- exacerbate myoclonic and absence seizures in patients with genetic aly, with a 72% 1-year seizure-free rate for a series of 202 new-onset (idiopathic) generalized epilepsy [70,71]. In a retrospective study of 290 children with epilepsy treated with A prospective, multicentre, open label trial of oxcarbazepine oral oxcarbazepine, 12 children with new-onset seizures developed ei- suspension monotherapy was carried out in children with newly ther worsening of pre-existing seizures, new seizure types and/or diagnosed focal seizures [57]. The Tree children with electroclinical patterns consistent with be- mean maintenance dose was 25 mg/kg/day. In another study, ox- nign epilepsy with centrotemporal spikes were reported to have carbazepine was reported to be efective in the treatment of eight seizure exacerbations during oxcarbazepine therapy [42]. The third pa- sults from several open-label patient series suggest that retention tient developed more frequent partial motor seizures, which were on oxcarbazepine therapy is relatively high. Ataxia, fatigue and diplopia or visual blurring The authors of a Cochrane review of oxcarbazepine for neuropathic were uncommon during monotherapy, although present much pain concluded that there was ‘moderate’ evidence for efectiveness more ofen than with placebo in adjunctive-therapy trials. This was based on verse efect profile is qualitatively similar to that of carbamazepine. Long-term use in diabetic neuropathy is reported to be accept- serum levels of monohydroxycarbazepine, with levels over 30 mg/L ably safe and tolerable [62]. Initial monotherapy trials Initial monotherapy trials Adjunctive trials Adjunctive trials Adverse effect Oxcarbazepine (n = 440) Placebo (n = 66) Oxcarbazepine (n = 705) Placebo (n = 302) Headache 37 12 26 21 Somnolence 22 6 26 12 Dizziness 20 4 30 11 Ataxia 2 0 17 5 Diplopia 0. In these direct comparative trials, discontinuation bazepine (20 of 210) or carbamazepine (38 of 378) developed an rates were significantly lower for oxcarbazepine in comparison with allergic rash [50]. Cross-reactivity with carbamazepine is also fre- carbamazepine (14% versus 26%) [38] and phenytoin [39,40], but quent, with 25. Discontinuation rates are, carbamazepine also developing a rash when they were converted to as expected, higher in adjunctive-therapy trials, mostly because of oxcarbazepine [75]. In an adjunctive The risk of serious dermatological reactions exceeds the back- study in children [47], there was a 10% drop-out rate in the ox- ground population risk by 3- to 10-fold [4]. Because persons car- carbazepine treatment group, versus 3% in the placebo group [47]. Drop-out for serious skin reactions with carbamazepine (see Chapter 32), the rates due to adverse efects may be lower with more gradual intro- same may be true for oxcarbazepine. If it is essential to use one of these cognitive efects appear to be relatively benign. Small studies have drugs in a person of at-risk ancestry, genotyping can be carried out. In an open-label 6-month trial enroll- haematologic reactions are less common than with carbamazepine, ing 112 children randomized to oxcarbazepine, carbamazepine or but dose-related mild leucopenia is less common. Hyponatraemia The only side-efect that is clearly more problematic with oxcarba- Gastrointestinal effects zepine than with carbamazepine is hyponatraemia. In a series of 73 adults, every 1 mg/day increase in dose increased ing adjunctive oxcarbazepine therapy: 22. The incidence of hyponatraemia to <4 years, gastrointestinal efects and somnolence were the two varies directly with age, with sodium levels <135 mEq/L occurring most common adverse efects of adjunctive oxcarbazepine, and at least once in 0. Patients prone to hyponatraemia for other reasons, such as those taking natriuretic diuretics, may be at Rash and serious idiosyncratic reactions higher risk. The fall in serum sodium usually occurs within the first In most studies, oxcarbazepine was found less likely to cause 3 months of therapy, but may happen later if the dosage is increased. In a single study, from all clinical trials suggest that there is a 3% incidence of rash both carbamazepine and oxcarbazepine reduced serum vitamin with oxcarbazepine compared with 7% with carbamazepine [4]. The authors suggest that these drugs may produce 542 Chapter 40 a secondary hypoparathyroidism and that patients may need sur- because of the open-label uncontrolled design, and possible bias veillance of bone density or need for replacement therapy. Oxcar- due to the fact that the study population was preselected because bazepine was reported to stimulate linear growth in children with of inadequate efcacy or poor tolerability on the medications taken ‘idiopathic’ epilepsy afer 6 and 18 months of therapy through before conversion to oxcarbazepine. Oxcarbaze- pine monotherapy caused alterations in lipid and thyroid profles Mode of use in children with epilepsy [83]. Clinical experience suggests, however, that for many out- Types and rates of adverse efects among children [40,47], and patients a slower titration schedule is better tolerated. Although hyponatraemia initiation at 300 mg/day, beginning with 150 mg at bedtime on the is more common in the elderly [79], discontinuation rates due to first day and then 150 mg twice daily thereafer [92]. Other author- adverse efects among elderly adults were similar to those among ities also suggest beginning with lower doses, such as 300 mg/day younger adults [86]. The most common adverse efects among 52 in two divided doses, or even 150 mg/day with increases of 150 mg/ patients aged 65 or older were vomiting (19%), dizziness (17%), day every 2 days [93]. The extended release When given to pregnant rats at intermediate to high doses, oxcar- preparation can be started as one 600-mg tablet at bedtime [5], al- bazepine was associated with an increased incidence of craniofacial, though some patients tolerate 300 mg better at frst. Outpatients needing rapid attainment well-controlled studies of oxcarbazepine in pregnant women, and of an efective dose can be started at 600 mg/day, and inpatients the drug should be used only if the benefits outweigh the risk to the can be started at 900–1200 mg/day. In a retrospective database review, six ponatraemia another drug may be preferable [94], congenital malformations occurred among 248 infants born to For children aged 4–16 years, the recommended starting dose women who had received oxcarbazepine monotherapy during is 8–10 mg/kg/day [4]. Weekly increases of about mark identifed 1532 infants who had received one of fve newer 5 mg/kg/day are appropriate. Among 393 in- fants exposed to oxcarbazepine, there were 11 major birth defects, Conversion from carbamazepine for a rate of 2. This number tial percentage of patients enrolled in controlled clinical trials either had risen to 211 according to the Fall 2014 newsletter of the North were converted from carbamazepine or had oxcarbazepine added American Registry. Making this change because of carbamazepine Quality of life for persons with epilepsy depends upon the occur- side-efects is less appealing as evidence has accumulated that the rence of side-efects as well as the degree of seizure control. A conversion otherapies: carbamazepine (n = 121), phenytoin (n = 65) or val- ratio of carbamazepine to oxcarbazepine of 1.

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