Maintaining quality of care in a comprehensive dual diagnosis treatment program

This paper describes how a large, multifaceted dual diagnosis treatment program has attempted to preserve its mission through termination of or changes in the nature of resident research projects. Research reports, because of their focus on specific treatment components, often fail to capture the essence of the larger treatment contexts from which they emanate. Although host programs derive benefits from research projects, enhancements are often temporary and difficult to sustain. Programs are thus challenged to respond to resource losses creatively. The author discusses adaptations to losses in the areas of case management, behavioral skills training, an incentive system, money management, and continuity of care.     

Surgical treatment of epilepsy

Approximately 30-40% of patients with focal epilepsy continue to have seizures despite appropriate medical therapy. Surgical treatments should be considered in this important subset of patients. Recent advances in neuroimaging technology have revolutionized the identification and evaluation of surgical candidates. The goal of the presurgical evaluation (video EEG monitoring, neuroimaging, and neuropsychological assessment) is to delineate the epileptogenic zone. Surgery is recommended when this has been adequately identified and the proposed procedure is expected to result in a high likelihood of seizure freedom and a low risk of neurologic and cognitive morbidity.     

Surgical treatment of epilepsy

In this article the possibilities, indications, methods and results of surgery in epilepsy are summarized in general with the Hungarian experience emphasized. Surgery may provide effective treatment in about 5-10% of the epileptic population. Surgical solution nowadays became an essential treatment in medial temporal epilepsy, if hippocampal sclerosis or other lesion is present, in therapy resistant lesional extratemporal epilepsies and in catastrophic childhood epilepsies if the epileptic disorder is restricted to one hemisphere (Rasmussen syndrome, hemimegalencephaly, Sturge-Weber disease and posttraumatic or postencephalitic hemispherial epilepsies). The algorithms of the presurgical evaluation and the current methods for study the pacemaker area, forbidden zones, and hemispherial functions are treated. The currently used type and techniques of surgery, such as lesionectomy, temporal lobe resections, hemispherotomy, callosotomy, multiple subpial transsections and their indications are described. The newest surgical approaches, as deep brain stimulation, vagal nerve stimulation, and irradiation techniques are also briefly touched. Lastly, we deal with prognostical factors of the surgical outcome, reasons of surgical failures and complications. In a brief chapter the importance of postsurgical rehabilitation is emphasized.     

Surgical treatment in startle epilepsy

This report presents a patient with medically intractable startle epilepsy who was treated with surgery. The ictal onset zone was further localized to a part of the premotor cortex on the basis of intracranial electroencephalography recording and surgical resection of the epileptogenic zone was done. The motor area close to the epileptogenic focus was localized using electrical cortical stimulation and thus preserved. Patient has been seizure-free postoperatively (Engel Class I) during the 18-month follow-up. The patient illustrates that surgery can be an option in patients with medically intractable startle epilepsy with well-defined unilateral epileptogenic zone.     

Surgical treatment for epilepsy

Nearly one-third of patients with newly diagnosed epilepsy will develop medically refractory seizure disorders. The initial response to antiepileptic drug therapy is highly predictive of long-term outcome. Patients with intractable epilepsy may have a progressive disorder that is medically, physically, and socially disabling. Surgical resection of the epileptogenic zone or lesional pathology, or both, may significantly reduce seizure tendency in selected patients. The present review supports the position that early and effective epilepsy surgery may not only render the patient with intractable partial epilepsy seizure-free, but also allow the individual to become a participating and productive member of society. Patients with surgically remediable epileptic syndromes should be identified early in the evaluation and treatment of their seizure disorders. Favorable candidates for focal cortical resection include individuals with medial temporal lobe epilepsy and partial seizures related to selected lesional pathology, e.g. primary brain tumor or vascular anomalies. In conclusion, surgical treatment of intractable partial epilepsy has been shown to compare favorably to antiepileptic drug therapy. Individuals rendered seizure-free may experience a significant improvement in quality of life. Patients who fail to respond to initial antiepileptic drug therapy should be “triaged” to a presurgical evaluation. Ictal semiology combined with structural magnetic resonance imaging and the electroclinical correlation may permit identification of candidates for early and effective surgical treatment.     

外伤后癫痫的外科治疗

目的评价并总结外伤后癫痫（PTE）手术治疗的方法及治疗情况,为PTE的手术治疗提供经验。方法回顾性分析2008年1月至2010年1月在我院行开颅手术治疗的PTE病例42例,总结这些病例的术前定位技术、手术治疗方法以及0.5～2年期的随访情况。结果手术结果EngelⅠ级17例,Ⅱ级22例,Ⅲ级3例,IV级0例,术后出现暂时性轻度偏瘫28例,一过性动眼神经麻痹2例,暂时性运动性失语3例,无死亡病例。结论 PTE发作形式多为部分性发作,一般影像学检查可发现明确病理改变,致痫灶多位于其附近,药物难以控制病例行手术治疗效果较好。     

Surgical treatment for musicogenic epilepsy

We report a patient with medically intractable musicogenic epilepsy (ME) who was treated with surgery. Using the non-invasive methods of ictal and interictal electroencephalography (EEG), MRI, interictal single photon emission computed tomography and clinical manifestations, we first localized the musicogenic seizures (MS). The ictal onset zone was then further localized using intracranial EEG to the middle part of the left superior temporal gyrus. Surgical resection of the epileptogenic zone was then performed. The patient had two seizures within 2 weeks post-operatively, but has then had no seizures during the following year (Engel class II). The results suggest that patients who have medically intractable ME combined with unilateral ictal onset zones should be considered for the surgical treatment of epilepsy.     

儿童难治性癫痫的手术治疗

癫痫是儿童神经系统常见疾病之一,其发病原因、临床表现及治疗原则较成人癫痫具有明显差异.随着抗癫痫药物的不断创新、扩展及人们对癫痫的深入研究,大多数癫痫患儿可以得到理想的控制,但仍有部分患者经药物治疗无效而成为难治性癫痫,是外科干预治疗的潜在目标.近年来手术治疗难治性癫痫的技术得到迅速发展,特别是针对儿童难治性癫痫的手术治疗取得重大突破.目前用于儿童癫痫的外科治疗方法主要有切除性手术、毁损性手术、阻断通路手术和神经调控手术等.     

继发性癫痫的手术治疗

继发性癫痫病因复杂．治疗方法和手段也不尽相同。自2000年7月至2006年5月我们对37例继发性癫痫患者根据病因不同进行不同手术治疗．取得了较好的疗效，现报告如下。     

Surgical treatment of epilepsy in pediatric patients

Surgery has become an accepted treatment modality for carefully selected adults with intractable focal epilepsy. More recently, increasing numbers of pediatric patients with intractable epilepsy are also being referred for surgical consideration. Key elements of surgical candidacy include medically intractable focal epilepsy, a localized epileptogenic zone, and a low risk for new postoperative neurologic deficits. The most common etiologies of the epilepsies in pediatric surgical candidates are malformation of cortical development and low grade tumor but some patients with childhood onset temporal lobe epilepsy due to hippocampal sclerosis also present for early surgery. Based on results from several recent pediatric surgical series, the chance for favorable seizure outcome after surgery is not adversely affected by young age, with seizure-free postoperative outcome reported for 60% to 65% of infants, 59% to 67% of children, and 69% of adolescents, compared to 64% reported in a large, predominantly adult series. Some subgroups of patients have higher percentages of seizure-free outcome, including those with hippocampal sclerosis or low grade tumor. In addition to seizures, developmental issues are also a major concern in children with intractable epilepsy. Few quantitative data are available, but some anecdotal experience suggests that surgical relief of catastrophic epilepsy may result in resumption of developmental progression after surgery, although the rate of development often remains abnormal. In one series, best developmental outcomes were seen in patients with earliest surgery and highest level of preoperative development. For each patient, the timing of surgery must be carefully considered, based on a full assessment of the relative risks and benefits, derived from a detailed presurgical evaluation.     

An integrated program for comprehensive HIV care

HIV-AIDS medical care systems that do not have full integration of mental health, alcohol, and substance use services--including the key components of prophylaxis, medication adherence, and outpatient symptom management--risk less-than-optimal outcomes. This chapter provides a model for integrated treatment.     

A collaborative effort to establish a comprehensive epilepsy program in Peru

We report the achievements obtained, over a period of 4 years, by the collaborative partnering effort of the Epilepsy Program at Western University in Canada and the Instituto of Ciencias Neurologicas in Lima, Peru, building an epilepsy program in Peru.