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• Assistant Professor and Associate Residency
• Program Director
• Department of Emergency Medicine
• Temple University School of Medicine
• Philadelphia, Pennsylvania

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Medicare patient experience with vagus nerve stimulation for treatment-resistant depression. A one-year comparison of vagus nerve stimulation with treatment as usual for treatment-resistant depression. Observations on the use of vagus nerve stimulation earlier in the course of pharmacoresistant epilepsy: patients with seizures for 56. Comprehensive long-term outcome of best drug treatment with or without add-on vagus nerve stimulation for epilepsy: a retrospective matched pairs case-control study. Practice trends and the outcome of neuromodulation therapies in epilepsy: A single-center study. Outcome of vagus nerve stimulation for drug-resistant epilepsy: the first three years of a prospective Japanese registry. Comparing the effects of cortical resection and vagus nerve stimulation in patients with nonlesional extratemporal epilepsy. Durability of symptomatic responses obtained with adjunctive vagus nerve stimulation in treatment-resistant depression. Quality of life and memory after vagus nerve stimulator implantation for epilepsy. Children with autism spectrum disorders and drugresistant epilepsy can benefit from epilepsy surgery. Refractory generalized seizures: response to corpus callosotomy and vagal nerve stimulation. Effects of 12 months of vagus nerve stimulation in treatment-resistant depression: a naturalistic study. Quality of life and seizure outcome after vagus nerve stimulation in children with intractable epilepsy. Vagus nerve stimulation therapy randomized to different amounts of electrical charge for treatment-resistant depression: acute and chronic effects.

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Analysis of the inhibitory potential of Ginkgo biloba, Echinacea purpurea, and Serenoa repens on the metabolic activity of cytochrome P450 3A4, 2D6, and 2C9. In vivo assessment of botanical supplementation on human cytochrome P450 phenotypes: Citrus aurantium, Echinacea purpurea, milk thistle, and saw palmetto. Use and indications the main contemporary use of saw palmetto fruit is to treat the urological symptoms of benign prostatic hyperplasia. It has also been used as a diuretic, a sedative, an endocrine agent, an antiseptic and for treating disorders involving the sex hormones. Excessive bleeding during surgery has been reported in another patient who had been taking saw palmetto. Curbicin is a herbal remedy used for micturition problems, and contains extracts from the fruit of saw palmetto and the seed of Cucurbita pepo. An estimated 2 litres of blood were lost during surgery and bleeding time did not return to normal for 5 days. Importance and management Evidence appears to be limited to case reports and an experimental study of unknown clinical relevance. It may be better to advise patients to discuss the use of any herbal products that they wish to try, and to increase monitoring if this is thought advisable. Cases of uneventful use should be reported, as they are as useful as possible cases of adverse effects. Herbal drug Curbicin and anticoagulant effect with and without warfarin: possibly related to the vitamin E component. Intraoperative haemorrhage associated with the use of extract of Saw Palmetto herb: a case report and review of literature. In vitro study suggested that saw palmetto inhibited this route or metabolism, but this does not appear to be clinically relevant. Importance and management the findings of these studies suggest that saw palmetto does not alter the metabolism of alprazolam or midazolam, and therefore no dosage adjustments of these benzodiazepines would be expected to be needed on concurrent use. Multiple doses of saw palmetto (Serenoa repens) did not alter cytochrome P450 2D6 and 3A4 activity in normal volunteers. In vivo assessment of botanical supplementation on human cytochrome P450 phenotypes: Citrus aurantium, Echinacea purpurea, milk thistle, and saw palmetto. Saw palmetto + Caffeine Saw palmetto does not appear to affect the pharmacokinetics of caffeine.

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The goal of epilepsy surgery is to remove the epileptogenic zone, while at the same time preserving eloquent areas. The Functional Deficit Zone the functional deficit zone is the region that functions abnormally during the interictal period. The functional deficit may be related to interictal epileptiform discharges or to an underlying structural lesion. The functional deficit zone may also be related to functional abnormalities, without structural abnormalities. These authors concluded that interictal epileptiform discharges and seizure spread may influence speech reorganization (46). Binnie showed that frequent interictal spike discharges can lead to impairment during neu- ropsychological testing (44). A "secondary" ictal-onset zone is a different cortical region that is dependent on the primary ictal-onset zone. It is associated with a network of seizure propagation and has potential epileptogenic properties. However, this secondary epileptic focus may disappear after removal of the primary focus. At times, it may also be "independent," and present as a new epileptic focus (47,48). Patients with a prolonged history of seizures before epilepsy surgery have a poorer seizure outcome after resection of the primary focus when compared to individuals with a shorter history of seizures (49). This suggests that secondary epileptogenesis at sites located elsewhere in the brain may develop with persistence of uncontrolled seizures (49). Therefore, it is important to identify the ictalonset zone as well as the associated "epileptic network.

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The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always seek the advice of a physician or other qualified health provider with any questions regarding a medical condition. Clinicians should refer to the full prescribing information and published resources when making medical decisions. Food and Drug Administration Approved Indications for Buprenorphine and Buprenorphine/Naloxone Products Single Entity Agent Combination Products Indication Sublocade (buprenorphine) subcutaneous injection Subutex (buprenorphine) sublingual tablets Bunavail (buprenorphine/ naloxone) film Suboxone (buprenorphine /naloxone) sublingual tablets Suboxone (buprenorphine/ naloxone) film Zubsolv (buprenorphine /naloxone) sublingual tablets Treatment of opioid dependence Treatment of opioid dependence and is preferred for induction Maintenance treatment of opioid dependence Treatment of moderate to severe opioid use disorder For use in patients who initiated treatment with transmucosal buprenorphine-containing product, followed by dose adjustment for at least 7 days. It is intended for internal use only and should be disseminated only to authorized recipients. The contents of the therapeutic class overviews on this website ("Content") are for informational purposes only. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Patients should always seek the advice of a physician or other qualified health provider with any questions regarding a medical condition. Clinicians should refer to the full prescribing information and published resources when making medical decisions. Information on indications, mechanism of action, pharmacokinetics, dosing, and safety has been obtained from the prescribing information for the individual products, except where noted otherwise. Studies have shown that in adult patients with opioid dependence, the percentage of opioid negative urine tests was significantly higher for both buprenorphine and buprenorphine/naloxone compared to placebo, while no significant difference was seen between the 2 active treatment groups (Daulouede et al 2010, Fudala et al 2003). In addition, a small randomized controlled trial (N=32) also showed no significant difference in withdrawal symptoms between buprenorphine and buprenorphine/naloxone (Strain et al 2011). Several studies have compared the effectiveness of short-term detoxification to medium- or long-term maintenance treatment with buprenorphine monotherapy or buprenorphine/naloxone.

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Use and indications Lycium (dried berries or root bark) has been used to treat diabetes, ophthalmic disorders, hypertension and erectile dysfunction, and is thought to possess anti-inflammatory, antioxidant and anticancer properties. L 277 278 Lycium Lycium + Antidiabetics the interaction between lycium and antidiabetics is based on experimental evidence only. Experimental evidence In an experimental study in rats with streptozotocin-induced type 2 diabetes,1 Lycium barbarum polysaccharide (extracted from the fruit of lycium) decreased insulin resistance, and reduced fasting insulin and postprandial glucose levels. In another study, a fruit extract of Lycium barbarum 10 mg/kg twice daily for 10 days significantly reduced blood-glucose levels in diabetic rabbits but did not reduce blood-glucose levels in healthy mice. Importance and management the evidence is limited and purely experimental but what there is suggests that lycium may have antidiabetic properties. Therefore, there is a theoretical possibility that lycium may enhance the bloodglucose-lowering effects of conventional antidiabetics. However, until more is known, it would be unwise to advise anything other than general caution. Hypoglycemic and hypolipidemic effects and antioxidant activity of fruit extracts from Lycium barbarum. Lycium + Warfarin A case report suggests that lycium may enhance the effects of warfarin. It was found that 4 days before visiting the clinic she had started to take one glass (about 170 mL) 3 or 4 times daily of a Chinese herbal tea made from the fruits of lycium to treat blurred vision caused by a sore eye. Inhibition of this isoenzyme may therefore lead to increased warfarin levels and effects. It may be better to advise patients to discuss the use of any herbal products that they wish to try, and to increase monitoring if this is thought advisable. Cases of uneventful use should be reported, as they are as useful as possible cases of adverse effects. It should be noted that lycium berries are also used as an ingredient in Chinese foods. Interactions overview There is very little information on the interactions of lycopene supplements, but there is some information on dietary lycopene. Combined use with sucrose polyesters, colestyramine, probucol or betacarotene modestly reduces dietary lycopene absorption. A low-fat diet does not alter dietary lycopene absorption when dietary intake is high.

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Consequently, we do not recommend that fourth-level centers must be able to perform corpus callosum section or hemispherectomy. However, physicians making health care decisions at these centers should be aware of the indications for these procedures. They should establish referral arrangements with other fourth-level centers that perform these procedures and refer patients requiring these procedures when necessary. Emergency or elective neurosurgery, including biopsy and removal of incidental lesions and treatment of cerebral complications of epileptic seizures. Surgical resection of epileptogenic structural lesions with the goal of treating seizures (``straightforward lesionectomy'). Standard anterior temporal lobectomy in the presence of mesial temporal sclerosis. Implantation and management of vagus nerve stimulators or other neuromodulatory devices. If the third level center does not actually perform surgery, it must have established referral procedures with one or more level 4 surgical centers. Levels of newer anticonvulsant drugs and free drug levels should be readily available. An established referral arrangement for comprehensive management of psychogenic nonepileptic events. Clinical psychological services for assessment and basic treatment of emotional disorders associated with chronic epilepsy. Physical, occupational, and speech therapy for basic evaluation and treatment of multiply handicapped individuals. Sufficient physical, occupational, and speech therapy for managing complications of surgeries performed at the center.

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Removal of a radiation-induced frontal lobe cavernous malformation resulted in amelioration of his disabling seizure type, illustrating how focal resection of the more deleterious focus may dramatically improve quality of life, despite the multifocal background (53). The hypothesis we began with was that, despite the multifocal findings on imaging and electrophysiology, an ictal focus could be identified and resected in these patients. The multidisciplinary epilepsy team felt that the alternative path, a continued course of severe epilepsy despite multiple medications, entailed significant risk as well. The real challenge facing the treating team lies in not only identifying a potentially discrete resectable focus in patients with multifocal epilepsy, but in distinguishing whether this focus is primary, necessitating removal, or secondary. Ultimately, this is determined by whether the removal of a presumed primary ictal focus results in cessation of seizures. Therefore, the goal in multifocal epilepsy should be to identify a primary epileptogenic zone for strategic resection. However, in reality, this is often not possible, raising the need to consider multifocal resection, in which the aim is to remove all individual sites of presumed ictal onset. However, this too, is often not feasible in many cases, due to several factors, which include the presence of too many disparate epileptogenic zones to be handled surgically, bilaterally homologous foci, or their overlap with eloquent cortex (32). Indeed, it is often difficult to define the epileptogenic zone with precision when only a single seizure focus exists (14). Their surgical approach for addressing this multifocal situation was to utilize extensive surgery, with resection of not only the polymicrgyria lesion, but also distal brain areas that were determined to be part of this large network (55). Their excellent outcomes allowed them to argue that this strategy was optimal, although they did not definitively prove that removing the extralesional sites was required for seizure freedom. We have proposed multistage epilepsy surgery as one possible approach for rationally trying to distinguish which foci need to be resected in the patient with presumed multifocal epilepsy (14,33,56). Theoretically, this strategy should define those multifocal epilepsy settings in which one needs to carry out actual multifocal resections.

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Girls are more likely to be depressed than boys, and teenagers are more likely to be depressed than younger children. Depression is common in patients with epilepsy; up to half of children with epilepsy develop depression at some point in their lives. Some studies have reported a definite relationship between depression and epilepsy. It is important to recognize the symptoms and degree of severity early on, since children and youth with epilepsy are at risk for attempted suicide. Depression in children and adolescents can look very different from how it looks in adults with mood disorders. Sometimes parents will notice 12 Mental Health Tool Kit a decrease in school grades or important changes in behavior such as refusing to do regular chores or routines. Patients with epilepsy and depression usually have a poor quality of life, even when seizures are under control. Sometimes parents decide to wait to get treatment for depression until the seizures are under control, but the longer the depression lasts, the tougher it is to treat. In addition, the issue of how children who have epilepsy feel about themselves, and how they get along with others, is still not completely understood. Some studies suggest that children with epilepsy might have lower self-esteem because of their disorder. Other studies show that children with epilepsy have poorer self-concepts than children with other chronic medical conditions and frequently struggle in school and other social settings. Studies have consistently shown that patients with epilepsy are at higher risk for committing suicide. Patients with epilepsy have two to four times greater mortality (death) rates compared to the general population. In patients with epilepsy, thoughts of suicide occur more often in patients who are depressed. Among patients who have epilepsy, those with temporal lobe epilepsy are at higher risk for suicide compared with other types of epilepsy.

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Jaffar, 22 years: Suppression of synchronized epileptic activity is routinely and repeatedly seen in acute models of generalized seizures. Positron emission tomography demonstrated a bilateral increase of glucose metabolism in the opercular regions in one patient with this type of nonconvulsive status (55).

Frillock, 29 years: The agreement should be viewed as an opportunity for ongoing dialogue about the risks of opioids and what the patient and clinician can expect from each other. The risk of development of digitalis toxicity, including cardiac arrhythmias, is increased by hypokalaemia, which can be induced by the excessive use of anthraquinone laxatives.

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