THE MEDICAL TREATMENT OF EPILEPSY

The drugs used in the treatment of the various types of epilepsy we have discussed vary according to the seizure type. Some drugs are better for certain seizures than others. It is, however, important to remember that few anticonvulsants are very specific for particular seizures and that there is a choice of drugs for any particular seizure type. The choice may be related to your doctor’s experience, the side effects that he or she might anticipate and the way in which you as an individual tolerate a particular medication. The choice of a single drug is therefore not absolute.

Grand mal seizures: medications used in the treatment of grand mal seizures include carbamazepine, sodium valproate, phenytoin, primidone, phenobarbitone and clonazepam. The order in which the drugs are listed represents some personal bias by the author. Most people would feel that carbamazepine would be effective with the least side effects, but may disagree with the ‘preference’ listing of the rest of the drugs. It is important for patients to realise that the solution to which drug is best for them may not be a black and white issue. Different doctors may have slightly different approaches to a particular problem.

Absences (petit mal): the drug of choice for this condition is ethosuximide. An excellent alternative is sodium valproate, but its possible liver side effects make it a drug of second choice. In children whose absences are particularly resistant to treatment, clonazepam may be helpful.

Temporal lobe epilepsy (complex partial seizures): carba-mazepine is the drug of choice with phenytoin or sodium valproate being acceptable alternatives. Clobazam may be a useful adjunct (additional therapy) in some people with temporal lobe seizures.

Focal seizures: carbamazepine is the drug of choice, followed by phenytoin, sodium valproate or one of the barbiturates.

Reflex epilepsy: drug therapy is not often needed in this condition. Those whose fits are induced by sitting very close to the television should view it from three metres away in a well lit room. In addition, they should not approach the set in order to adjust it or change the channel. If the photosensitivity is induced by sunlight, then polarised sun glasses should be worn. If medication is required, sodium valproate is the drug of choice.

Infantile spasms: the treatment of this condition is difficult and the basis of it little understood. The drugs most commonly used are corticosteroid preparations such as corticotrophin (ACTH) and prednisone. An alternative is a group of drugs, the benzodiazepines, of which the most familiar to the general public would be diazepam (Valium). From this particular group of drugs, nitrazepam and clonazepam may be useful in the management of infantile spasms.

Myoclonic and tonic seizures: these are perhaps the most difficult forms of seizures to treat. The drugs of choice are probably sodium valproate, nitrazepam, clonazepam, and ACTH. If these have failed in children, the use of a ketogenic diet, which will be discussed later, may be considered.
Status epilepticus: as previously mentioned, status epilepticus is a medical emergency. The possibilities for non-professional management of this situation at home are limited. However, in children who recurrently have severe or prolonged seizures, it may be appropriate for a parent to administer rectal diazepam (Valium) to their child. This can be done by drawing up some diazepam into a narrow syringe and inserting it into the child’s rectum (back passage) and injecting the solution. Not all parents wish to do this, but it can be very useful and avoid a lot of trips to hospital.

A further matter worthy of discussion is that of therapeutic drug monitoring (blood level monitoring). Patients with epilepsy will be familiar with the practice of having blood samples taken from time to time to measure the blood levels of their anticonvulsant drugs. When a drug is administered to a person, it accumulates in the body over a few days and eventually reaches a certain level in the blood stream. As far as anticonvulsants are concerned, after taking medication regularly for about a week, the blood concentration will be at what is called ‘steady state’. If the patient continues to take the medication regularly thereafter, while there may be slight ups and downs in the concentration (level) over a 24-hour period, it will eventually remain stable (at a steady state).

Therapeutic drug monitoring determines whether the patient’s blood level is within what is called the ‘therapeutic range’. This is the range of blood concentrations within which the majority of people with epilepsy will have good seizure control with minimal drug side effects. This does not mean that every patient has to be within the therapeutic range. Some patients may be controlled very well with their blood levels below the therapeutic range, while others, if they do not have side effects, may need to be above the therapeutic range. The therapeutic range is just an average level. However, the therapeutic range and blood level monitoring are very useful for the doctor for some anticonvulsants, especially for phenytoin. Blood level measurements may be useful for carbamazepine,

phenobarbitone, primidone and perhaps ethosuximide. They are of little, if any, value for sodium valproate, nitrazepam, clonazepam or clobazam.
When should blood levels be measured? Unfortunately, it has become almost routine to measure the blood levels of anticonvulsants in all epileptic patients, every time they visit their doctor. This is quite unnecessary and has almost replaced the conversation with the doctor which is so essential to those who have epilepsy. Obviously, if a patient has good seizure control and no side effects, there is little need to measure any blood levels. The indications for blood level monitoring include:

Poor seizure control. This may be because the person is not taking his or her medication (non-compliance), is not receiving a sufficient amount of an appropriate medication, or is receiving an inappropriate medication. It may also be because the fits are uncontrollable or that the diagnosis of epilepsy is in fact wrong.

Polytherapy. This describes patients who are receiving more than one drug, usually because their seizures are difficult to control. There may be interactions between the drugs and in that case measuring the blood levels may be of value.

Side effects. If a patient is on only one drug (monotherapy) and has side effects, there may be no need to measure the blood level as it will be obvious what the cause is. It may be sufficient to stop the drug for a day or two to let the blood level decline. On the other hand if a patient is receiving several drugs (polytherapy), it may not be possible to know which drug is causing the problem without measuring the blood levels.

In the very young, the elderly or the handicapped: These groups may handle anticonvulsants differently in the body and may not be able to describe side effects which they are experiencing.
Phenytoin. Phenytoin is broken down in the body by the liver in a rather complicated way which is different to other anticonvulsants. The difficulty with phenytoin is that, contrary to expectation, as the dosage is increased the concentration in the blood stream does not increase proportionally. This means that as the dosage is increased, the blood concentration may suddenly rise quite precipitously and the patient may become intoxicated. For this reason, patients who are receiving phenytoin should have regular blood tests, at least when they are being started on treatment, until they are stabilised on the medication.

There are a number of other indications for blood level monitoring which are still open to debate, but these are uncommonly needed and will not be discussed in detail. As children grow they will need to have their anticonvulsant dosage increased, so occasional blood level tests may be of value.

HEAVY, PROLONGED MENSTRUAL PERIODS

Women with no previous gynaecological problems, and no reason to think they have fibroids, polyps, a pelvic infection or endometriosis, are in a quandary. Are these bleeding episodes a cause for concern? Or are they a normal response to changing levels of sex hormones, perhaps associated with menopause-related changes, or to something else? Most women experience irregular menstrual periods for between two and seven years prior to menopause, although the range is a few months to eleven years. This can be a stressful time because of concerns about the cause of the bleeding.

Doctors classify excessive heavy bleeding (menorrhagia) as the repeated loss of more than 80 ml of menstrual blood in each menstrual cycle. If this volume is lost consistently during menstruation, women can become anaemic, lethargic and prone to sickness. While this is a concern for health reasons, the social impact is often more worrying still, with the added burden of possibly creating financial difficulties. Some women find they need to plan their activities carefully to minimise the embarrassment of bleeding accidents, or they may take time off work coping with the problem or trying to find out the underlying cause. Kath’s experience of heavy bleeding coincided with a very hot summer. After a couple of bleeding accidents when she ‘flooded’ on her way to, or at, work she took the precaution of wearing dark-coloured clothing that would disguise any such episode, as well as using tampons and sanitary pads of increased absorbency. A number of colleagues unwittingly added to her embarrassment by making disparaging comments about the inappropriateness of her clothing given the sweltering heat. Initially Kath tried to shrug the comments off and joked about getting dressed before the lights came on. But one day she decided enough was enough and, when quizzed about her clothing, she simply said, ‘I’m having a hellish time with my periods at the moment and, believe me, I’ll be celebrating when I can wear white again.’

In normal day to day living, measuring how much blood is lost in a menstrual bleed is virtually impossible. When careful studies are conducted, however, women are found to lose about 35 ml of blood (less than a quarter of a cup) in a cycle on average. Clearly, the 80 ml marker of menorrhagia is set quite high.

The diagnosis of excessive heavy bleeding is usually based on a joint assessment by women and their doctors. Factors taken into account include the number and degree of saturation of pads and/or tampons, the duration of bleeding, and the presence or absence of clots and flooding. This assessment is subjective and various research studies suggest that women may think they are losing more or less blood than is revealed by a careful analysis of sanitary products. In one study, for example, while 59% of women with concerns about menorrhagia were losing more than 60 ml of blood in most cycles, another 20% had average losses of less than 35 ml. Younger women in particular seem to be more likely to regard moderate blood loss as heavy. Reassurance about bleeding patterns, if this is appropriate, or information about how to better organise and cope with tampon and pad use can result in management of the problem without drugs or surgery.

FOODS THAT PREVENT AND CONTROL CANCER: OLIVE OIL

Eating too much fat has been linked with breast cancer. This has been adequately proved by a research study of 750 Italian women.

 It was found in this study that the women who eat the most saturated fats have triple the risk of breast cancer as compared to those eating the least. Eating too much fat can influence the spread and virulence of an existing breast cancer, its recurrence and survival chances. Some researches show that the more saturated animal fat in your diet, the greater the odds of auxiliary lymph node involvement or spread of the cancer, and the more total fat in a diet, the greater the chances of dying from breast cancer. Monounsaturated fat, the type predominant in olive oil, is however, not cancer a culprit. In fact, new evidence suggests that olive-oil-type fat can help counteract cancer. Mediterranean women who eat lots of olive oil have low rates of breast cancer, as do Japanese women who eat lots of fish oils but little animal fat.

COMBATTING ASTHMA IN CHILDREN: ANTI-INFLAMMATORY DRUGS

These drugs are offsprings of adrenelin, the major hormone produced by the adrenal gland, and act directly on particular sites called receptors or nerve cells of sympathetic nervous system. There are three main types of receptor sites called alpha, beta-1 and beta-2. These receptor sites are located in the airways, but they are also found in other parts of the body such as the inside of heart muscles, and muscles in the arms and legs. Some of these drugs act on all three types of receptor sites, but others are more selective.

The most effective adrenergic bronchodilator drugs are called beta-2 agonists, or simply beta agonists. They primarily influence the beta-2 receptors which are present only in the bronchial airways. These drugs are preferred because of their property to selectively relax bronchial muscles only, without stimulating muscles in the heart or other body areas.

 They cause fewer side effects. Examples of these drugs are salbutamol and terbutaline. They are available in tablet form as well as in aerosols in metered-dose inhalers and nebulizers. However care should be taken not to overuse these drugs during an attack. If their use does not provide adequate relief, it is an indication that some other group of drugs should also be added.


Beta-2 agonists also provide more rapid action with inhalers rather than with oral intake. While salbutamol or terbutaline may provide more or less immediate relief through inhalation, it may take upto three hours to obtain similar relief through the oral route.

HETEROSEXUAL AGGRESSORS VS. ADULTS: EXTRAMARITAL COITUS

Seventy-seven per cent of the ever-married individuals, while married, had coitus with females other than their wives. This is the third largest percentage and not far below the record of the aggressors vs. minors. All the heterosexual aggressors fall within the first five ranks in this respect. The age-specific incidence of extramarital coitus with companions is greater for these aggressors than for any other group. In the four age-periods available for comparison (spanning ages sixteen to thirty-five) they rank first in three periods and second in one, with proportions varying from 50 to 63 per cent. In brief, within any five-year age-period for which we have data, half or more of the aggressors vs. adults had extramarital coitus with companions. Not counting the peak years from sixteen to twenty, only a moderate proportion had extramarital coitus with prostitutes.

Although the frequency of extramarital coitus was moderate to low, a comparatively large amount of it was with prostitutes. While in most groups the frequency with companions far exceeds that with prostitutes, for the aggressors vs. adults the two figures are often closer. For example, the average individual with extramarital coitus in age-period 21-25 had coitus 0.14 times per week with companions as against 0.10 with prostitutes.

The average individual had coitus with a total of about five females, whether companions or prostitutes—a relatively low number.

The proportion of total outlet from extramarital coitus with companions was relatively large in youthful marriages. These aggressors are in first place in age-period 16-20 with 11 per cent and maintain third or fourth position in rank-order until after the age of thirty, when the proportions become small. The notable high frequency of extramarital coitus with prostitutes is not evident in the proportion of total outlet; it is submerged by the other activities.

BACH FLOWER REMEDIES: CHICORY TYPE

Love of self; selfish, mania of possessing things, self-pity, greedy, always wants to get something, never wants to part with any of his possessions, wants company. In the positive CHICORY state, the person is full of that divine quality which is called LOVE – selfless love, universal love which shows by self-less service to fellow beings, assists them to become self-reliant, strong and independent individuals, always willing to give without expecting anything in return – a very loveable person.
However, in the negative chicory state the love turns in- wards – love of self- then the person becomes selfish, and does everything to serve his self-interest. He becomes greedy and wants to add to his possessions.

   In   his mania to accumulate things, he does not bother about the worth, or utility or even the means of securing those possessions. Think of an office superintendent stealing office stationary, or a well-to-do gentleman pocketing a silver spoon after dining at a five-star hotel. Years ago there was this news item in an Indian paper ‘The son of a Union Cabinet Minister caught stealing in an American Store and jailed” He feels no compunctions in sacrificing the vital interests of his nearest and dearest relatives to serve his petty self-interest.
Take the case of a parent who would not let his brilliant son or daughter to go away for higher studies to improve his career prospects for narrow selfish ends.
A widowed mother put all types of obstacles in the marriage of her son lest his present love and care for the mother may be shared between the mother & the wife. An old mother feighned to be ill and remained bed-ridden for several years just to prevent her daughter from marrying and leaving her alone.

BERRIES – HEALTH BENEFITS (SYRUP AND TREATMENT)

Formerly, a specially prepared syrup made from cherries together with the stones, which contain hydrocyanic acid, served as a diuretic for dropsy and as a refreshing drink. The fruits and their stones were crushed together, the pulp was squeezed out, and sixty-five parts of sugar were added to thirty-five parts of juice. Cherry stones were also once used for people who suffered from kidney stones, six to be taken daily. Even cherry stalks, especially those of red and sour cherries, were used for medicinal purposes; a tea was made from them to treat infections of the respiratory tract and to increase the flow of urine.

In former times, dried cherries were a remedy for chlorosis and anaemia. And even today, prunes, soaked and eaten before going to bed and before breakfast, are still used for sluggish bowels.

Continuing this simple treatment over a period of time will help even in stubborn cases of constipation.

Fully ripe and uncontaminated apricots and peaches are a wholesome addition to our food. They are relatively rich in vitamin C, contain some vitamins B3 and B2, a substantial amount of carotene and also pantothenic acid, which helps to prevent the hair turning

TREATING MIGRAINE WITHOUT DRUGS: MEDITATION AND YOGA

MeditationThe many different forms of meditation can be grouped into two general categories: those concerned with ‘emptying the mind’ and those in which internal thoughts are built up and maintained by an effort of concentration.Transcendental meditation became very fashionable in the West during the 1960s and much is claimed for it by headache sufferers. It is not surprising that an act of relaxation or withdrawal from everyday activities is associated with relief of tension which produces a reduction in headache frequency. It is less likely to be effective once a headache has started, presumably because the metabolic changes which occur during the headache make it difficult to maintain the appropriate state of mind.

YogaYoga is an ancient Indian technique of achieving total bodily and mental control in an attempt to reach new heights of awareness and in promoting relaxation. There have been several trials of yoga methods of meditation in the prevention of migraine and the results, although preliminary, are encouraging.’Yoga of the body’ is concerned with making the body a fit vehicle for the mind as it meditates. The first precepts of control are based on the type of foods ingested, and are similar to much of the dietary advice often given for migraine: no citrus fruits, little cheese, no alcohol or wine, no garlic or onions and, in addition, no smoking.

 Garlic and onions are excluded because they may cause gastric upset. Meals are taken three times a day, the stomach being ‘half filled with food, a quarter filled with water and one quarter left empty’, to avoid any feeling of fullness. Food has to be chewed thoroughly and eaten slowly (in contrast to the gulping of quick snack lunches seen in British pubs). Constipation is avoided by adding bran to the diet. Much of this advice is commonsense and it is understandable that, with this regime, the body will function in a better way.The exercises of yoga are divided into those in which breathing is the main concern, and those which exercise the rest of the body.

 The breathing exercises are designed to establish conscious control over respiration as well as using the stomach muscles to ensure that the lungs are fully inflated.The bodily exercises are performed very slowly and involve either stretching movements or the maintenance of particular positions for periods of time. Physiologically, the maintenance of posture utilizes the stretch reflex of muscles. The whole system can be likened to a cat stretching and rolling, with movements being slow and graceful. It is essential that these exercises become comfortable and patience is needed for this but, after three months’ practice, many patients find they feel much better, fitter, and much less likely to develop headaches.There are many techniques of teaching yoga.

 The meditation aspect of yoga is the most important so that those techniques controlling thought, or holding thoughts in the mind and so building on them, are likely to be of benefit in developing control.Current approaches involve combining certain yoga techniques with biofeedback and it will be interesting to see how much this will achieve; it is conceivable that migraine patients who practice these techniques will not be so much at the mercy of stress and therefore will suffer fewer headaches.