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The pharmacotherapy of epilepsy is a complex process guided by evidence-based research and clinical experience. Some patients achieve seizure freedom upon treatment with the first anti-seizure medication (ASM) prescribed, whereas others may be treated with two or three medications before one (or a combination) is found that reduces seizure frequency and/or severity with minimal side effects. Many patients demonstrate a partial response to treatment, leading to reduced seizure frequency and/or severity, but do not become completely seizure free. It is often stated that ~30% of epilepsy patients have seizures that cannot be controlled pharmacologically, and these patients are defined as having medication-resistant epilepsy (MRE). The International League Against Epilepsy (ILAE) published the following definition of MRE: ‘drug resistant epilepsy may be defined as failure of adequate trials of two tolerated and appropriately chosen and used ASM schedules (whether as monotherapies or in combination) to achieve sustained seizure freedom’. Treatment success or sustained seizure freedom is defined as one year without seizures or three times the inter-seizure interval (whichever is longer). The ILAE definition provides a useful standard from which to work, and MRE can be clinically identified in patients that fail to achieve seizure freedom after multiple ASM trials. However, the ILAE definition of successful treatment does not account for partial response to pharmacotherapy. Indeed, many partial responders have improved quality of life, even if they are not seizure-free for one year or more.
One of the first and most sustained teases in White Noise, Don DeLillo's stinging appreciation of the contemporary American family, concerns the genealogies of the children who reside with narrator Jack Gladney and his current wife, called simply Babette. “Babette and I and our children by previous marriages live at the end of a quiet street in what was once a wooded area with deep ravines,” announces Jack on the second page. Which children by what previous marriages? A not unreasonable question, the reader assumes, especially given that the novel revolves around the daily life of the household, and that each of these children (even the still mostly silent toddler) is an important character in the book. For the reader whose curiosity has been provoked (and by DeLillo's design it has), it will take a novel-long information hunt to sort out the relations persisting among the Gladneys. In Chapter 2, a family lunch introduces the names of four children but not their descent lines. By Chapter 11, a careful reader has determined that there are indeed only four children – two boys, two girls – and that one of the boys and one of the girls are offspring of Jack, the other boy and girl are offspring of Babette. It takes considerably longer to determine who the other parent of each child in the house is, where these other parents live and what they do, and what offspring of Jack and Babette not in residence exist; and, by my tracking, we do not receive the last set of details (a scheme of Jack's marital history) until Chapter 28, a full two-thirds through the novel.
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