Lancet neurology
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More than 150 years after bromide was introduced as the first antiepileptic drug, adverse effects remain a leading cause of treatment failure and a major determinant of impaired health-related quality of life in people with epilepsy. Adverse effects can develop acutely or many years after starting treatment and can affect any organ or structure. In the past two decades, many efforts have been made to reduce the burden of antiepileptic drug toxicity. ⋯ Patient profiles associated with increased risk of specific adverse effects have been uncovered through advances in the areas of epidemiology and pharmacogenomics. Several new-generation antiepileptic drugs with improved tolerability profiles and reduced potential for drug interaction have been added to the therapeutic armamentarium. Overall, these advances have expanded the opportunities to tailor treatment with antiepileptic drugs, to enhance effectiveness and minimise the risk of toxic effects.
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Clinical trials as part of antiepileptic drug development are increasingly expensive and complex, with many pitfalls that can derail even promising drugs and devices. Although a third of patients remain resistant to treatment, the availability of more than 20 approved antiepileptic drugs can reduce the incentive to enrol in trials of unproven agents, for which safety is not assured. ⋯ Furthermore, the availability of so many approved treatments raises questions about the ethics and safety of placebo-controlled trials in patients with epilepsy. Novel trial designs, such as time-to-event adjunctive therapy and historical-control monotherapy, might be more acceptable to patients and their doctors because they restrict exposure to placebo or ineffective treatments.
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Randomized Controlled Trial Multicenter Study Comparative Study
Restenosis after carotid artery stenting and endarterectomy: a secondary analysis of CREST, a randomised controlled trial.
In the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST), the composite primary endpoint of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke thereafter did not differ between carotid artery stenting and carotid endarterectomy for symptomatic or asymptomatic carotid stenosis. A secondary aim of this randomised trial was to compare the composite endpoint of restenosis or occlusion. ⋯ National Institute of Neurological Disorders and Stroke and Abbott Vascular Solutions.
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Consciousness is essential to normal human life. In epileptic seizures consciousness is often transiently lost, which makes it impossible for the individual to experience or respond. These effects have huge consequences for safety, productivity, emotional health, and quality of life. ⋯ Advances in neuroimaging, electrophysiology, and prospective behavioural testing have shed light on how epileptic seizures disrupt the consciousness system. Diverse seizure types, including absence, generalised tonic-clonic, and complex partial seizures, converge on the same set of anatomical structures through different mechanisms to disrupt consciousness. Understanding of these mechanisms could lead to improved treatment strategies to prevent impairment of consciousness and improve the quality of life of people with epilepsy.
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Factors such as inactivity, poor nutrition, smoking, and depression could contribute to an increased risk of dementia in prisoners. But limited prison resources mean that even simple measures to reduce these risks might not be implemented. Mario Christodoulou reports.