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This chapter provides an overview of a conceptual approach to providing care for the patient with medication-resistant epilepsy (MRE), with consideration of the care sequence and components. This discussion of the gestalt is not intended to provide one established algorithm, as one treatment pathway cannot serve the needs of the diverse MRE patient population. Nevertheless, the considerations described below comprise a generally accepted care process aimed to improve the MRE clinical outcome. Detailed discussions of the care elements are provided in other chapters.
The vagus nerve performs many different functions in the human body. Understanding these functions helps inform the potential side effects of vagus nerve stimulation (VNS). The nerve consists of 80% afferent fibres [1,2]. These include visceral sensory and taste fibres which travel primarily to the nucleus of the tractus solitarius, as well as cutaneous sensation fibres from the external auditory meatus which project to the spinal nucleus of the trigeminal nerve. The efferent component includes branchial motor fibres from the nucleus ambiguus, parasympathetic fibres primarily from the dorsal nucleus of the vagus and parasympathetic fibres from the nucleus ambiguus to the heart. The motor fibres innervate skeletal muscles in the head and neck involved in speech production and swallowing, while the parasympathetic fibres innervate most of the viscera serving to control heart rate, respiration, gastrointestinal motility and many other autonomic functions. The majority of fibres in the vagus nerve consist of unmyelinated C fibres, but commensurate with its wide variety of functions, it also contains larger and faster-conducting A- and B-type fibres. The brainstem nuclei that receive vagal inputs integrate homeostatic information, provide commensurate adjustments to autonomic functions and also send this information to other brainstem nuclei projecting widely throughout the brain.
Fifty million people worldwide have epilepsy and yet up to 35% of patients experience seizures that are resistant to anti-epileptic drugs. Patients with medication-resistant epilepsy have increased risks of premature death, psychosocial dysfunction and a reduced quality of life. This key resource delivers guidance for all clinicians involved in caring for patients with medication-resistant epilepsy in order to reduce these risks. Covering the epidemiology, biology, causes and potential treatments for medication-resistant epilepsy, this definitive and focused text reviews the clinical care needs of patients. Guidance is practical and includes treatment for specialized groups including pediatric patients and those with psychiatric comorbidities. Several promising non-pharmacologic interventions available for patients, such as surgery, neuromodulation diet therapy and botanical treatment are explored in detail. Leading international figures from a range of disciplines bring their expertise together holistically in this essential manual.
More than 3 million individuals in the United States have epilepsy, and over 50 million worldwide. One million in the United States continue to suffer from seizures, despite medication. Their mortality is twice that of the general population, i.e., about 2% mortality per year.1,2 Surgery for epilepsy has a favorable outcome. Among well-selected patients, 70% are seizure-free after surgery. Many of the remaining patients have seizure frequency greatly reduced, e.g., from twice weekly to twice yearly. Surgical outcome avoids mortality risk, morbidity, and costs of medically refractory seizures, and greatly enhances the patient’s quality of life. Yet only 2000 patients per year undergo resective surgery. Surgery for epilepsy is very underutilized.3
To evaluate the association between hospital room square footage and acquisition of nosocomial Clostridium difficile infection (CDI).
A case-control study was conducted at a university hospital during the calendar year of 2011. Case patients were adult inpatients with nosocomial CDI. Control patients were hospitalized patients without CDI and were randomly selected and matched to cases in a 2:1 ratio on the basis of hospital length of stay in 3-day strata. A multivariate model was developed using conditional logistic regression to evaluate risk factors for nosocomial CDI.
A total of 75 case patients and 150 control patients were included. On multivariate analyses, greater square footage of the hospital room was associated with a significantly increased risk of acquiring CDI (odds ratio for every 50 ft2 increase, 3.00; 95% CI, 1.75–5.16; P<.001). Other factors associated with an increased risk of CDI were location in a single room (odds ratio, 3.43; 95% CI, 1.31–9.05; P=.01), malignant tumor (4.56; 1.82–11.4; P=.001), and receipt of cefepime (2.48; 1.06–5.82; P=.04) or immunosuppressants (6.90; 2.07–23.0; P=.002) within the previous 30 days.
Greater room square footage increased the risk of acquisition of CDI in the hospital setting, likely owing to increased environmental contamination and/or difficulty in effective disinfection. Future studies are needed to determine feasible and effective cleaning protocols based on patient and room characteristics.
We agree that promoting intergroup harmony “carries insidious, often unacknowledged, ‘system-justifying’ consequences” (sect. 4.1.3, para. 2) and identify several ways in which “benevolent” and “complementary” stereotypes, superordinate identification, intergroup contact, and prejudice reduction techniques can undermine social change motivation by reinforcing system-justifying beliefs. This may “keep the peace,” but it also prevents individuals and groups from tackling serious social problems, including inequality and oppression.