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Geetha Jayaram, M.B.B.S., M.D.

• Co-Director, Short Stay Unit
• Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0004486/geetha-jayaram

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Drug Interactions: Alcohol enhances the impairment of physical abilities produced by carisoprodol, and increased sedation, extreme weakness, dizziness, agitation, euphoria and confusion may be observed. The concurrent administration of other centrally acting drugs such as opiates, benzodiazepines, barbiturates, and other muscle relaxants can contribute to impairment. Performance Effects: Very limited studies are available for carisoprodol, however, single oral doses of 700 mg have not been shown to affect psychomotor and cognitive tests within 3 hours of dosing, to a significant degree. In contrast, single doses of meprobamate are capable of causing significant performance impairment. Performance effects include impaired divided attention, impaired coordination and balance, slowed reflexes and increased reaction time. With chronic dosing of either drug, it is likely that decrements in psychomotor performance would be even more pronounced. Effects on Driving: the drug manufacturer suggests patients should be warned that carisoprodol and meprobamate may impair the mental and/or physical abilities required - 15 - for the performance of potentially hazardous tasks, such as driving a motor vehicle. Reported signs of psychomotor and cognitive impairment in subjects found to be driving under the influence of carisoprodol/meprobamate include poor perception, impaired reaction time, slow driving, confusion, disorientation, inattentiveness, slurred or thick speech, slow responses, somnolence, lack of balance and coordination, unsteadiness, and difficulty standing, walking or exiting vehicles. Signs of impairment were noted at blood concentrations as low as 1 mg/L of meprobamate, however, the most severe driving impairment and the most overt symptoms of intoxication occurred in drivers whose combined carisoprodol and meprobamate blood concentrations were greater than 10 mg/L. Many subjects were involved in accidents, and other observed driving behaviors included extreme lane travel and weaving, striking other vehicles and fixed objects, slow speed, and hit and run accidents where the subject appeared unaware they had hit another vehicle. Other characteristic indicators may include slurred speech, drowsiness, disorientation, drunken behavior without the odor of alcohol, and poor performance on field sobriety tests. However, single therapeutic doses of meprobamate and chronic doses of carisoprodol may produce moderate to severe impairment of psychomotor skills associated with safe driving. Interpretation of blood glutethimide, meprobamate, and methyprylon concentrations in non-fatal and fatal intoxications.

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Relative utility of sphenoidal and temporal surface electrodes for localization of ictal onset in temporal lobe epilepsy. Comparison and correlation of surface and sphenoidal electrodes with simultaneous intracranial recording: an interictal study. Predictors of outcome of anterior temporal lobectomy for intractable epilepsy: a multivariate study. Indices of resective surgery effectiveness for intractable nonlesional focal epilepsy. Electroencephalographic studies of simple partial seizures with subdural electrode recordings. The impact of cerebral source area and synchrony on recording scalp electroencephalography ictal patterns. Intractable seizures of frontal lobe origin: clinical characteristics, localizing signs, and results of surgery. Resection of frontal encephalomalacias for intractable epilepsy: outcome and prognostic factors [see comment]. A potential limitation is that neither ligand has linear uptake at high cerebral blood flow rates, and thus cerebral blood flow is underestimated under certain circumstances (1). A physiologic probe designed to assess a targeted function is labeled with a radioactive tag. The decay of the radioactive tag is associated with the emission of high-energy particles, or gamma rays, that are subsequently detected by the scanner; their origin is then computed. Several studies in patients with partial epilepsy have identified interictal regional decreases in glucose consumption that are invariably ipsilateral to the seizure focus-typically, but not always, most pronounced in the temporal lobe. The area of decreased glucose utilization is often more extensive than the epileptogenic zone, and it may extend into adjacent inferior frontal or parietal lobe neocortex (4,9) and occasionally into ipsilateral thalamus (10) and contralateral cerebellum (4). The regional abnormalities are invariably unilateral to the ictal focus; however, lobar localization is somewhat less reliable, about 80% to 90%.

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Census data are used to determine things such as school district definitions, the allocation of Congressional seats in the House of Representatives, and the distribution of federal funds to tribal, state, and local governments for various programs in criminal justice, health care, education, housing, economic development, and others. Some tribes, for example, have been historically undercounted in the Census, and an inaccurate count of the American Indian/Alaska Native population can have serious implications for critical funding decisions for federal programs that serve Indian Country. Some federal agencies use alternate population estimates to calculate their service population. Census Population with Bridged-Race Categories to calculate mortality and nationality adjusted population rates for its service population. This report explains: the 2000 Census allowed respondents to report more than one race category to describe their race. Vital event totals are used in the numerator and the 2000 Census bridged population is used as the denominator to produce the birth or death rates that occur in the population of interest. The denominator data are based on the 2000 Census bridge file, which recategorizes responses to a single race where more than one race was reported. This corresponds to the single race categories used on birth and death certificates[. This normally results in upward revisions to service population figures projected prior to a census, since each Census tends to do a better job in enumerating American Indian and Alaska Native people. Census Bureau, Native Hawaiian and Other Pacific Islander alone or in combination with one or more other races, 2016 American Community Survey 1-Year Estimates, factfinder. Census Bureau, the Native Hawaiian and Other Pacific Islander Population: 2010 (May 2012), 4. Native Hawaiian and Other Pacific Islander; White; Asian Native Hawaiian and Other Pacific Islander; Some Other Race. Census Bureau, the Native Hawaiian and Other Pacific Islander Population: 2010 (May 2012), 4. As of 2010, the American Indian and Alaska Native alone-or-in-combination population was highly concentrated in certain locations. Census Bureau, the American Indian and Alaska Native Population: 2010 (January 2012), 8.

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Effect of felbamate on valproic acid disposition in healthy volunteers: inhibition of beta-oxidation. The effect of concurrent administration of valproate sodium on phenobarbital plasma concentration/dosage ratio in pediatric patients. Sodium valproate: pharmacokinetics and effectiveness in treating intractable seizures. Sodium valproate and valpromide: differential interactions with carbamazepine in epileptics patients. Lack of an effect of valproate concentration on lamotrigine pharmacokinetics in developmentally disabled patients with epilepsy. Dissociation between free and bound phenytoin levels in presence of valproate sodium. Valproate and lamotrigine level variation with menstrual cycle phase and oral contraceptive use. Treatment of generalized epilepsies of childhood and adolescence with sodium valproate ("Epilim"). Sodium valproate in the treatment of intractable seizure disorders: a clinical and electroencephalographic study. Comparative study of ethosuximide and sodium valproate in the treatment of typical absence seizures (petit mal).

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However, it is not clear if normally ambulatory persons with epilepsy are similarly vulnerable. Bone quality describes structural and material properties of bone as well as biochemical strength. Osteomalacia, which literally means softening of bone, and rickets are pathologic processes of bone quality. Drug-induced osteomalacia and rickets result because of either insufficient availability of calcium, phosphate, and active vitamin D or interference with the deposition of calcium and phosphate in bone. Osteomalacic biopsy specimens exhibit abnormally thick osteoid (unmineralized bone) seams, a prolonged mineralization lag time, and a decrease in the adjusted apposition rate. However, subjects in these studies were primarily institutionalized and treated with Chapter 46: Bone Health and Fractures in Epilepsy 571 phenytoin, primidone, and phenobarbital. Recent biopsy studies of ambulatory persons have found no evidence of osteomalacia. These studies have reported normal osteoid seam width and normal or increased mineralization rates. Other potential influencing factors including effects on bone quality may explain the increased fracture risk. Bone specimens in rats treated with levetiracetam, phenytoin, and valproate had evidence of changes in bone quality (34). Biochemical competence was affected in those rats treated with low-dose levetiracetam. Increased markers of bone turnover have been reported, however, in persons with epilepsy treated with carbamazepine (43,44). Polytherapy may independently result in increased abnormalities of bone metabolism (45,46).

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In addition, most of the studies are retrospective in nature, reporting results in populations that differ in age, severity of seizure, and pathological substrate. There are no studies that directly compare functional versus anatomical hemispherectomy. The group at John Hopkins reviewed their experience with anatomical hemispherectomy in infants and children (17). Of 21 patients with cortical dysplasia, 8 (38%) were seizure-free and an additional six (29%) had mild seizures after surgery. The frequency of complications may also be lower after functional hemispherectomy. In a series of patients with catastrophic epilepsy in young ages, incomplete disconnection was the only variable statiscally associated with persistent seizures after surgery (14). From this group, four patients had incomplete disconnection, always located in the posterior basal frontal areas. All four patients underwent reoperation, converting the procedure to anatomical hemispherectomy. Such anatomical peculiarities, together with irregular and abnormal thickness of the cerebral mantle, deep heterotopic gray matter, distorted trajectory of the anterior cerebral arteries, abnormal large Peri-insular Hemispherotomy Peri-insular hemispherotomy was initially developed by Villemure and colleagues (11). The main features of this approach are: (i) medium-sized craniotomy exposing the frontal, parietal, and temporal operculum in the whole length of the sylvian fissure; (ii) resection of the frontal and parietal operculum and underlying white matter, opening the whole lateral ventricle through the anterior and superior limitans sulcus of the insula and disconnection of the frontobasal area through the intraventricular approach; (iii) resection of the temporal operculum (T1 gyrus and underlying white matter) and exposure of the temporal horn through the inferior limitans sulcus of the insula; (iv) mesial disconnection through the corpus callosum, from the rostrum and knee to the splenium; (v) temporomesial disconnection with only anterior resection of the amygdala, anterior aspect of the hippocampus and uncus. Central Vertical Hemispherotomy this approach was first decribed by Delalande and colleagues in 1992 (10) and, together with Schramm (trans-sylvian approach) and Villemure (peri-insular approach) techniques, consists in another variation of the classical functional hemispherectomy described by Rasmussen. It includes initially a small parasagittal craniotomy, complete callosotomy with opening of the roof of the lateral ventricle.

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If you have suicidal thoughts or actions, your healthcare provider may check for other causes. Call your healthcare provider between visits as needed, especially if you are worried about symptoms. You may have problems walking normally if you are unsteady because you feel dizzy. Your risk of feeling dizzy and having problems walking normally may be higher if you are elderly. Call your healthcare provider right away if you have: o a skin rash, hives o f ever or swollen glands that do not go away o swelling of your face o shortness of breath, swelling of the legs, yellowing of the skin or whites of the eyes, or dark urine. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Active ingredient: perampanel Inactive ingredients (tablets): lactose monohydrate, low substituted hydroxypropyl cellulose, povidone, microcrystalline cellulose, magnesium stearate, hypromellose, polyethylene glycol, talc, and titanium dioxide. Inactive ingredients (oral suspension): sorbitol, microcrystalline cellulose, carboxymethylcellulose sodium, poloxamer, simethicone, citric acid, sodium benzoate, and purified water. This leaflet does not take the place of talking to your healthcare provider about your medical condition or treatment. Uncap the bottle and insert the bottle adapter into the bottle by pressing downward. Push the plunger of the syringe all the way down then insert the syringe into the upright bottle through the opening in the bottle adapter. Pull the plunger to withdraw the dose prescribed by your healthcare provider (the amount of liquid medicine in Step 4). If you see air bubbles in the oral syringe, fully push in the plunger so that the oral solution flows back into the bottle. If the dose is more than 20 mL, repeat Steps 4 through 6 when drawing up the remaining dose of medicine. If you need 2 syringes for the dose, slowly squirt the medicine from the first syringe into the mouth, then slowly squirt the medicine from the second syringe into the mouth.

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Occasionally, extensive dysplasia can sustain activation for motor, sensory, and language tasks (41). Processes that affect the left hemisphere before the age of 7 years-such as meningitis, encephalitis, traumatic brain injury, stroke, developmental tumors, malformations of cortical development, and seizures- are more strongly associated with atypical language. Atypical language activation patterns may represent persistence of immature networks rather than reorganization as a shift from left to right homologs (36). When atypical language occurs, be it compensation or reorganization, activation occurs in righthemisphere homologs or in regions immediately adjacent to areas that typically sustain language. Other imaging methods that investigate the strength of functional connections between regions in epilepsy patients are in their infancy (52). Memory is difficult to study, however, because almost everything humans do requires memory, and presumably the hippocampus, in some capacity. Designing paradigms to achieve signal differences between task and control conditions is therefore difficult. Paradigms using encoding and retrieval of complex images demonstrate activation of posterior and bilateral hippocampus and parahippocampal gyrus, whereas retrieval using verbal identifiers of encoded memory for pictures appears to involve anterior subiculum bilaterally. Encoding of novel stimuli followed by recall is associated with activation of posterior parahippocampal. Preferential activation of right and/or left mesial temporal structures reflects material specificity. Verbal encoding appears to preferentially activate left mesial temporal structures, whereas nonverbal stimuli such as patterns preferentially activate right mesial temporal. Unlike language studies, where a number of paradigms have been successfully studied in normal and patient populations, an insufficient, but growing, number of normal volunteers have been studied to establish normative data for memory tasks. These techniques have not been extensively used for evaluating patients, and predictive paradigms have not yet been replicated and validated. However, the analysis is reported as a group study, and individual variation may have been lost in the left temporal lobe epilepsy group.

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Ballock, 27 years: At 2 years, the pooled estimate of recurrence risk was 32% for patients with idiopathic first seizures and 57% for patients with remote symptomatic first seizures (6). Significance of interictal bilateral temporal hypometabolism in temporal lobe epilepsy. The muscle is mobilized off the underlying bone with a "T" incision, reflecting each muscle cuff inferiorly.

Bandaro, 51 years: Treatment of refractory status epilepticus with inhalational anesthetic agents isoflurane and desflurane. Additional classification details may also be used (Fisher et al 2017A, Fisher et al 2017B). The court found (i) that the plaintiff had failed to establish a connection between malformations and phenytoin and (ii) that informed consent did exist.

Nefarius, 44 years: Multicentre, double-blind, randomised comparison between lamotrigine and carbamazepine in elderly patients with newly diagnosed epilepsy. Please refer to our Evidence of Coverage for more information about this coverage. Usually, male patients are reluctant to discuss their sex lives, and physicians tend to ascribe the problem to psychosocial conflict.

Barrack, 63 years: Nonresponders and those with adverse effects were crossed over to the alternative treatment and followed up for another 6 weeks. Technology insight: neuroengineering and epilepsydesigning devices for seizure control. Absorption occurs primarily in the duodenum, where the higher pH increases the solubility of phenytoin.

Seruk, 32 years: Structural and functional lesions may lead to plasticity of eloquent cortex, making it impossible to predict location of function based on anatomy alone. Rapid, forced eye blinking when the seizure begins is thought to indicate occipital lobe onset (54). Some federal agencies use alternate population estimates to calculate their service population.

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