Neurologic clinics
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The introduction of these new antiepileptic drugs, from felbamate to levetiracetam, raised hope of control of epilepsy with fewer adverse effects and improved quality of life. Unfortunately, many patients continue to experience refractory epilepsy despite the use of these new agents, and dose-related adverse effects and idiosyncratic reactions continue to be problematic. A recent report describes six new compounds in preclinical development, and five in clinical trials [131]. ⋯ These include: choosing the drug appropriate for the epileptic syndrome, assessing accurately the range of a drug's adverse effects in an individual patient, and considering carefully the drug's interactions in combination drug therapy. In considering drug combinations, differing mechanisms of drug action and favorable pharmacodynamic interactions (an area requiring additional studies) are of importance. Clinicians caring for children who have epilepsy anticipate further advances in the pharmacogenetics and molecular pathophysiology of epilepsy, leading to individually tailored, effective, and safe therapy.
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The presurgical evaluation should result in a clear understanding of whether surgery can be undertaken and its associated risks and potential for benefit. The results of surgery are best when there is congruence in the seizure semiology, the irritative zone on interictal EEG, and the ictal onset zone with the epileptogenic lesion as defined on MRI and PET, and when there is a clear understanding of the ictal onset zone's relationship to eloquent cortex as defined by neuropsychologic evaluation, the intracarotid amobarbital test, and cortical functional mapping.
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Amyotrophic lateral sclerosis (ALS) is the most common degenerative motor neuron disease in adults. The clinical picture consists of generalized fasciculations, progressive atrophy and weakness of the skeletal muscles, spasticity and pyramidal tract signs, dysarthria, dysphagia, and dyspnea. Pseudobulbar affect is common. ⋯ Respiratory insufficiency can be effectively treated by non-invasive home mechanical ventilation. The terminal phase of the disease should be discussed at the latest when symptoms of dyspnea appear, in order to prevent unwarranted fears of "choking to death." Psychological and spiritual care of patients and families are important. Collaboration with hospice institutions and completion of advance directives can be of invaluable help in the terminal phase.
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Approximately 30-40% of patients with focal epilepsy continue to have seizures despite appropriate medical therapy. Surgical treatments should be considered in this important subset of patients. ⋯ The goal of the presurgical evaluation (video EEG monitoring, neuroimaging, and neuropsychological assessment) is to delineate the epileptogenic zone. Surgery is recommended when this has been adequately identified and the proposed procedure is expected to result in a high likelihood of seizure freedom and a low risk of neurologic and cognitive morbidity.
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Review
Neurobehavioral and neuropsychiatric symptoms in Alzheimer's disease: characteristics and treatment.
Neuropsychiatric symptoms are common in Alzheimer's disease. Personality changes, mood disturbance, and psychosis are frequently seen and may coexist in the same patient. ⋯ These symptoms are associated with a more rapid cognitive and functional decline that can lead to institutionalization. Cholinergic therapy, disease-modifying therapy, and psychotropic medications can improve these symptoms.