Lamotrigine therapy of epilepsy in tuberous sclerosis

PURPOSE

Lamotrigine (LTG), a newer antiepileptic drug (AED), has activity against both partial-onset and generalized seizures. Its reported benefits for behavior, and its effectiveness in Lennox-Gastaut syndrome and other forms of refractory epilepsy, make it a logical choice for treatment of epilepsy in tuberous sclerosis complex (TSC). We present our experience with LTG therapy of epilepsy in 57 patients with TSC.

METHODS

Patients fulfilled the diagnostic criteria for clinically definite TSC. LTG was initiated and increased until improvement in seizure frequency was noted, intolerable side effects occurred, or maximal doses were reached. Seizure frequency and behavioral changes were recorded during LTG therapy and compared with those prior to the introduction of LTG.

RESULTS

Twenty-four (42%) were seizure free, and 21 (37%) had a >50% reduction in seizure frequency. Eighteen (32%) had subjectively improved behavior and/or alertness with daily activities. Thirty-eight (67%) had no change in this regard, whereas one (2%) became worse. Responders were more likely to not have a history of infantile spasms, and to have experienced only partial seizures (p < 0.05). Otherwise no phenotypic correlations with response were apparent.

CONCLUSIONS

Among patients with TSC and epilepsy, LTG was effective and well tolerated, including as initial monotherapy. Improved alertness and behavior were apparent in many patients. The incidence of side effects is similar to that reported for other pediatric populations with symptomatic partial epilepsy. The usefulness of LTG in TSC may relate to an underlying defect of glutamatergic neurotransmission in partial epilepsy.

Topiramate therapy of epilepsy associated with Angelman's syndrome

Angelman's syndrome, a genetic disorder involving a defect in the DNA coding for subunits of the gamma-aminobutyric acid (GABA) type A receptor, often is associated with intractable epilepsy. Topiramate is a novel anticonvulsant that enhances GABAergic neurotransmission. Five children with Angelman's syndrome and epilepsy were treated with topiramate for clinical indications. The drug was effective and well tolerated, possibly because of its GABAergic properties. Further studies are necessary to confirm and elucidate this observation.

Medicare, managed care, and cancer

The Medicare program has undergone phenomenal changes during the last decade. Many of the changes relate to the growth of Medicare managed care. Changes in Medicare will continue as the Health Care Financing Administration implements the provisions of the Balanced Budget Act of 1997. As a result, Medicare should be open to more types of delivery systems that are organized in different ways than traditional health maintenance organizations. Payments should be improved so that these organizations can enroll sicker people and can be paid for accepting and treating those people. Beneficiaries should be provided with enough information that they have the necessary data to select plans based on quality, not just cost.

[Quantitative trabeculectomy]

The outcomes of the trabeculectomy which finally establish one normal ocular pressure are presented. The surgery method is adjustment of the thickness of the sclera, fragment depending on the initial ocular pressure. The evacuation of the aqueous humor after trabeculectomy is indirect proportionally with the thickness of the scleral fragment. The method was used in 36 eyes with different patterns of glaucoma. At this patients the initial ocular pressure was until 50 mm Hg. In 72.2% from cases was necessary only one surgery intervention for maintain the ocular pressure, without auxiliary drugs; two eyes underwent still one surgical intervention and in seven eyes was necessary auxiliary hypotensor drugs. The outcomes were good in 97.2% from cases. One failure was obtained in one eye with closed angle glaucoma where the trabeculectomy was complicated with malignant glaucoma. Complications were hypema, atalamy with or without choroidal detachment and high ocular pressure. All complications were improved after conservative treatment excepting the case with malignant glaucoma.

Health status of Medicare enrollees in HMOs and fee-for-service in 1994

We compared the health status of 863 health maintenance organization (HMO) enrollees with that of 4,576 non-enrollees, controlling for demographics and area of residence, using 1994 data from the Medicare Current Beneficiary Survey (MCBS). HMO respondents were less likely to report fair or poor health, functional impairment, or heart disease. Average predicted costs based on various health-status measures were substantially lower for HMO respondents than for respondents in fee-for-service (FFS) arrangements. The Medicare payment formula for HMOs does not adequately adjust for the better health and consequent lower expected costs of HMO enrollees. The addition of health-status measures would improvement payment accuracy and reduce average HMO payments significantly below current levels.

[The importance of the early diagnosis of primary persistent hyperplastic vitreous]

The early diagnosis of PHPV is often difficult to be established, because of the frequent opacification of the ocular transparent media. So the echography and the computerized tomography, the early surgical intervention using up-to-date techniques in vitreous surgery is imposed, in order to maintain functionally or anatomically the affected globe.

Cervical root compression by a loop of the vertebral artery: case report

A case of an abnormal loop of the extracranial vertebral artery enlarging the intervertebral foramen at C5-C6 and the transverse foramen at C5 is reported. This occurrence is rare and was associated with cervicobrachial neuralgia caused by neurovascular compression of the C6 root. The patient was cured by microvascular decompression.

[The criteria for echographic diagnosis in retinoblastoma]

The paper present an echographic survey on 27 pathological eyes suspected to present retinoblastoma, investigated with the same devices and by the same investigator. The diagnosis of retinoblastoma has been echographically put on 13 eyes. We haven't noticed any error on the investigated set since the diagnosis was histopathologically confirmed on 11 eyes. 2 eyes were not enucleated because they had before the enucleation of the contralateral ocular globe. It is discussed the utility of the echographic investigation for the positive and differential diagnosis of the retinoblastoma.

Subacute subdural hematoma

The subacute subdural hematoma (SASDH) is an entity which is still to be analyzed because the attention of the clinicians was directed towards the acute subdural hematoma (ASDH) and to the chronic subdural hematoma (CSDH). A series of 69 patients with SASDH was studied outlining the particularities of the affection. A trauma caused the hematoma but it was a milder one. The associated cerebral lesions were generally produced by concussion (34%) and cerebral dilacerations represented only 8.4%. Clinical symptoms were obvious between the third and the fourteenth day after trauma due to the cerebral compression. The consciousness was moderately impaired. The patients with GCS < 8 represented 18.9%. The neurological picture stated with time allowed a programmed paraclinical investigation: a. radiography of the skull revealed cranial fractures in 10.1%; b. carotid arteriography showed a lentiform aspect of the avascular space; c. CT presented variable densities (isodensity--3%, hypodensity--14.5%, and hyperdensity--27.5%) depending on the length of the interval between trauma and admission. The operation evacuated the liquid blood collection through a widened burr hole. Death during operation was 17.4% and 79.8% survived.

Traumatic intracerebral hematoma. A report of 50 cases

The study presents an analysis of demographic, clinical and paraclinical characteristics of 50 cases as well as the surgical treatment results of 50 cases with traumatic intracerebral hematoma (TIH) out of 70 admitted. The men showed the greatest incidence, the male/female ratio was 5:1. Age mean was 55.3 yrs. Hematomas were caused in one third of the cases by traffic collisions, followed by severe cranial traumata associated or not with other traumatic lesions and/or preceding diseases. The most frequent location was anterior in the frontal (30%) and temporal lobes (26%). Diagnosis was confirmed by arteriography and tomography. Specific paraclinical aspects of TIH were discussed together with those of the primary intracerebral hematoma (PIH). All patients were operated on under general anesthesia. A minimum craniectomy was carried out aimed at the lesion. Surgery was planned after a full neurological examination. Postoperative mortality was increased (42%) due to the severity of trauma (88%) in patients with a Glasgow coma scale assessment under 8, to age (50% of the patients were over 50 yrs), to hematoma size (84-100% in patients with a diameter of the hematoma between 50 and 100 cu cm, and over 100 cu cm, respectively) and to the location (66% in the frontal hematomas compared to 33% in temporal ones).

Contribution to the early diagnosis of diabetes mellitus

The authors present the results of an investigation for diabetes mellitus (DM), in a selected group of 9,901 persons at high risk for the disease, using oral glucose tolerance test (OGTT). In the group investigated they included 4,753 diabetic blood relatives, 4,123 obese patients and 935 women who delivered big babies. The percentage of diagnosed DM was 30.58 for the entire group, with variations between: 39.47 in the obese, 27.27 in women with macrosomia, and 23.35% in the diabetic blood relatives. The results showed the value of OGTT as a diagnostic tool, the importance of early diagnosis and the necessity of careful long time follow-up of the newly diagnosed diabetics.