阿司匹林与颅内动脉瘤破裂的相关研究

目的 探讨既往服用阿司匹林与颅内动脉瘤破裂的关系。方法 纳入2019年1月至2023年4月于南京市江宁医院神经内科住院的颅内动脉瘤患者177例。根据颅内动脉瘤是否破裂分为破裂组（59例）和非破裂组（118例）;根据患者诊断为颅内动脉瘤时既往是否规律服用阿司匹林分为既往服药组（82例）和既往未服药组（95例）。收集患者一般临床资料和颅内动脉瘤资料。通过单变量分析及多因素Logistic回归分析探讨既往服用阿司匹林对颅内动脉瘤破裂的影响。结果 破裂组患者高脂血症、既往服用他汀类药物和既往服用阿司匹林的比例与未破裂组比较差异有统计学意义（P<0.05）。采用多因素Logistic回归校正年龄、性别、高血压、吸烟、高脂血症、既往服用他汀类药物等因素后发现,既往服用阿司匹林是颅内动脉瘤破裂的保护因素（OR=0.235,95%CI：0.102～0.541,P=0.001）。既往服药组患者炎症因子（C反应蛋白、中性粒细胞与淋巴细胞比值）的水平、动脉瘤破裂比例均明显低于既往未服药组,差异有统计学意义（P<0.05）。既往服用阿司匹林>1年的患者发生颅内动脉瘤破裂的比例明显低于服用阿司匹林≤1年的患者（P<0.05）。结论 既往服用阿司匹林与颅内动脉瘤破裂密切相关,是颅内动脉瘤破裂的保护因素,考虑与阿司匹林的抗炎作用有关,且这种保护因素在既往服用阿司匹林>1年的患者中更为显著。国际神经病学神经外科学杂志, 2023, 50(6): 24-28]     

激光雕刻/编织支架辅助弹簧圈栓塞绝对宽颈破裂动脉瘤的疗效对比

目的 比较研究编织支架和激光雕刻支架辅助栓塞颅内破裂动脉瘤的疗效及优缺点。方法 回顾性分析60例颅内破裂宽颈动脉瘤的临床资料，根据支架的制造工艺分为编织支架组（n=30）与激光雕刻支架组（n=30）。统计分析两组患者术前一般资料、围术期并发症、术后即刻Raymond分级、术后随访Raymond分级及预后情况。结果 编织支架组的预后良好率90.0%高于激光雕刻支架组的73.3%，差异有统计学意义（P＜0.05），编织支架组和激光雕刻支架组远期闭塞率I级分别为90%、63.3%,II级分别为6.7%、10.0%，和Ⅲ级分别为3.3%、26.7%，两组间差异有统计学意义（P＜0.05）。两组患者年龄，性别比，术前Hunt-Hess改良分级，动脉瘤位置（编织支架组大脑前动脉4例、大脑中动脉10例、颈内动脉11例、椎基底动脉5例；激光雕刻支架组大脑前动脉5例、大脑中动脉8例、颈内动脉13例、椎基底动脉4例），术后即刻Raymond分级及术中血栓形成，术后脑梗死，术中动脉瘤再破裂比较，差异无统计学意义（P＞0.05）。结论 编织支架和激光雕刻支架辅助栓塞颅内破裂宽颈动脉瘤均是安全有效的，编织支架远期的栓塞程度更好及预后更佳，且围术期并发症无明显差异。     

老年颅内前循环动脉瘤显微外科手术治疗的效果

目的 分析和比较不同年龄段老年患者颅内前循环动脉瘤的显微外科手术治疗效果和安全性。方法 回顾性分析2018年3月—2020年12月在武汉大学中南医院神经外科接受显微外科手术治疗的95例老年颅内前循环动脉瘤患者，根据年龄大小将患者分为2组：低龄老人组（60~70岁）和中龄老人组（≥70岁）。收集这些患者的基本信息、病史和临床数据，包括格拉斯哥昏迷量表（GCS）评分、改良Fisher分级（mFisher）、格拉斯哥结局量表（GOS）评分和改良Rankin量表（mRS）评分。结果 共纳入95例老年患者，所有患者平均年龄为（67.9±4.3）岁。两组患者在性别、合并症、GCS评分、Fisher评分、动脉瘤部位、动脉瘤有无破裂、动脉瘤形态和患者的动脉瘤数目、动脉瘤大小等方面比较，差异无统计学意义（P>0.05）。两组均接受显微外科夹闭术。术后低龄老人组和中龄老人组手术相关并发症的发生率分别为12%和35%(P=0.015)，所有动脉瘤手术均达到影像学方面的完全闭塞。两组患者具有相似的GOS评分（P>0.999）和住院期间死亡率（P=0.512），且在随访期间的mRS评分也无统计学差异（P=0.677）。与中龄老人组相比，低龄老人组的住院费用更低（P=0.003）。两组患者随访期间影像学检查均未见动脉瘤复发。结论 对老年前循环动脉瘤患者，显微外科夹闭手术风险随着年龄的增长而增加；该术式对低龄老年患者是一种相对可行且相对安全的手术方式。     

脑动脉粥样硬化性狭窄患者合并颅内动脉瘤的血流动力学特征及其危险因素研究

目的 探讨脑动脉粥样硬化性狭窄患者合并颅内动脉瘤（IA）的血流动力学特征及其危险因素。方法 收集2019年9月至2023年1月在安徽医科大学附属宿州医院接受治疗的160例脑动脉粥样硬化性狭窄患者的临床资料。所有患者均进行了CT血管成像（CTA）以及数字减影血管造影（DSA）检查,依据影像学检查结果分为合并IA组（25例）和单纯狭窄组（135例）。比较2组基线资料信息、血流动力学指标。采用多因素Logistic回归分析探讨脑动脉粥样硬化性狭窄患者合并IA的危险因素。通过受试者操作特征（ROC）曲线分析壁面切应力（WSS）及振荡切应指数（OSI）预测脑动脉粥样硬化性狭窄患者合并IA的价值。结果 合并IA组WSS、OSI均明显高于单纯狭窄组（P<0.05）。合并IA组中有吸烟史、糖尿病、高血压的百分比均高于单纯狭窄组（P<0.05）。多因素Logistic回归分析显示,吸烟史、糖尿病、高血压、WSS>0.450 Pa、OSI>0.057是脑动脉粥样硬化性狭窄患者合并IA的危险因素（P<0.05）。ROC曲线分析显示,WSS、OSI可用于预测脑动脉粥样硬化性狭窄患者合并IA,曲线下面积分别为0.857、0.784,敏感度分别为0.681、0.859,特异度分别为0.751、0.771（P<0.05）。结论 脑动脉粥样硬化性狭窄患者合并IA的危险因素包括吸烟史、糖尿病、高血压、WSS>0.450 Pa、OSI>0.057。WSS、OSI可用于预测脑动脉粥样硬化性狭窄患者合并IA。     

血清可溶性CD40配体与急性脑梗死患者颈动脉斑块的关系

目的 探讨血清可溶性CD40配体（sCD40L）水平与急性脑梗死患者颈动脉粥样硬化斑块的关系。方法 选取2018年5月至2019年5月在中国医科大学附属盛京医院神经内科住院的急性脑梗死患者108例。根据颈部动脉超声结果分为无斑块组和斑块组,斑块组根据斑块性质进一步分为稳定斑块组和不稳定斑块组。应用酶联免疫吸附法（ELISA）测定血清sCD40L水平;分析血清sCD40L水平与颈动脉粥样硬化斑块的关系。结果 颈动脉斑块组患者高血压（P=0.026）、空腹血糖（P=0.045）、三酰甘油（P=0.027）、低密度脂蛋白胆固醇（LDL-c）（P=0.005）和sCD40L水平（P<0.001）均高于无斑块组。高血压（OR=2.598,P=0.028）、LDL-C（OR=4.247,P=0.006）和sCD40L水平（OR=1.079,P=0.009）是急性脑梗死患者存在颈动脉粥样硬化斑块的危险因素。颈动脉不稳定斑块组患者高血压（P=0.031）、白细胞计数（P=0.002）、低密度脂蛋白胆固醇（P=0.003）和sCD40L水平（P<0.001）均高于稳定斑块组。不稳定颈动脉斑块组患者,高血压（OR=2.918,P=0.033）和sCD40L水平（OR=2.712,P<0.001）是急性脑梗死患者颈动脉斑块不稳定性的危险因素。结论 急性脑梗死患者血清sCD40L水平的升高与颈动脉粥样硬化斑块的发生和发展相关,亦与颈动脉斑块的不稳定性相关。     

颅内动脉瘤介入患者术中及苏醒期血流动力学变化趋势及临床药物干预效果

目的 探讨颅内动脉瘤介入患者术中及苏醒期血流动力学变化趋势及临床药物干预效果。方法 选取该院颅内动脉瘤介入手术患者86例（2017年11月—2019年6月）,随机数字表法分为研究组（n=43）与对照组（n=43）。对照组采取瑞芬太尼+七氟醚,研究组在对照组基础上加用右美托咪定。统计两组围术期[麻醉诱导前（T0）、气管插管后（T1）、麻醉后15 min （T2）、术毕（T3）]血流动力学指水平、脑氧代谢情况、拔管、睁眼及恢复自主呼吸用时、不良反应。结果 （1）血流动力学：①不同时间点的HR、MAP、SBP、SPO₂有差别（P<0.05）,②组间HR、MAP、SBP、SPO₂有差别（P<0.05）,③研究组与对照组的HR、MAP、SBP、SPO₂变化趋势有差别（P<0.05）;（2）脑氧代谢：①不同时间点的CERO₂、Da-jvO₂有差别（P<0.05）,②组间CERO₂、Da-jvO₂有差别（P<0.05）,③研究组与对照组的CERO₂、Da-jvO₂变化趋势有差别（P<0.05）;（3）拔管、睁眼及恢复自主呼吸用时：研究组拔管时间短于对照组（P<0.05）,睁眼时间、恢复自主呼吸时间与对照组比较,差异无统计学意义（P>0.05）;（4）不良反应：研究组不良反应发生率（13.95%）低于对照组（32.56%）（P<0.05）。结论 颅内动脉瘤介入手术患者术中及苏醒期血流动力学异常波动,通过右美托咪定复合七氟醚可抑制其波动程度,并能改善脑氧代谢状态,缩短术后拔管时间,且不良反应发生率较低,此方法安全可靠。     

脑血流动力学与缺血性脑卒中患者脑白质病变严重程度的相关性研究

目的 研究缺血性脑卒中患者脑血流动力学与脑白质病变严重程度之间相关性。方法 分析2015年7月至2019年8月收治的108例缺血性脑卒中患者资料，采用Fazekas量表对患者脑白质病变严重程度进行分级。比较不同脑白质病变严重程度、患者颅内大动脉硬化程度和脑血流动力学指标，进行患者脑血流动力学与脑白质病变严重程度之间相关性分析，并分析脑白质中重度病变的危险因素。结果 Fazekas量表<3分者61例纳入轻度病变组，≥ 3分者47例纳入中重度病变组。中重度病变患者颅内大动脉硬化严重程度高于轻度病变组（P<0.05）。中重度病变组脑部动脉搏动指数（PI）显著高于轻度病变组；收缩期峰值血流（Vs）、平均血流（Vm）以及舒张末期血流（Vd）等脑血流动力学指数显著低于轻度病变组（P<0.05）。颅内大动脉硬化程度、PI与脑白质病变严重程度正相关（r=0.416，0.527；P<0.05），Vs、Vm以及Vd等脑血流参数与脑白质病变严重程度负相关（r=-0.316，-0.524，-0.668；P<0.05）。颅内大动脉硬化程度与PI为脑白质中重度病变的危险因素（P<0.05）。结论 缺血性脑卒中患者脑白质病变严重程度与患者脑血流动力学指标异常有关，而颅内动脉硬化会加重患者脑白质病变严重程度。     

急性脑梗死患者颅内侧支循环形成影响因素的模型构建及分析

目的 分析急性脑梗死(ACI)患者颅内侧支循环形成的影响因素并构建风险因素模型。方法 纳入2020年7月至2021年12月该院收治的ACI患者100例进行研究,根据患者颅内侧支循环形成情况将患者分为无侧支循环组（34例）、侧支循环组（66例）。回顾性收集所有患者临床资料。通过单因素分析及多因素Logistic回归分析法分析ACI患者无侧支循环的影响因素,建立风险因素模型,并绘制受试者工作特征(ROC)曲线分析风险因素模型对ACI患者无颅内侧支循环的预测价值。结果 多因素Logistic分析结果显示,合并高血压、有吸烟史、血清同型半胱氨酸(Hcy)、全血中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比率(PLR),血清神经元特异性烯醇化酶(NSE)水平升高为ACI患者无颅内侧支循环的危险因素（OR=1.929、2.361、2.382、2.375、2.275、2.022,均P<0.05）;血清高密度脂蛋白胆固醇(HDL-C)、碱性成纤维细胞生长因子(bFGF)水平升高为ACI患者无颅内侧支循环的保护因素(OR=0.446、0.517,均P<0.05)。将上述因素纳入风险因素模型：logit(P)=-15.173+高血压×0.657+吸烟史×0.859-HDL-C×0.807+Hcy×0.868+NLR×0.865+PLR×0.822-bFGF×0.659+NSE×0.704,绘制ROC曲线。结果显示,当logit(P)>15.46时,曲线下面积(AUC)为0.883,诊断灵敏度88.0%、特异度为80.0%。结论 ACI患者颅内侧支循环无法建立与高血压、有吸烟史、血清Hcy、NSE水平升高,全血NLR、PLR水平升高,血清HDL-C、bFGF水平降低密切相关,据此建立风险因素模型预测ACI患者无颅内侧支循环价值较高,临床可对高危患者采取相应干预策略,以改善其预后。 [国际神经病学神经外科学杂志, 2022, 49(6): 13-17]     

伴中重度阻塞性睡眠呼吸暂停低通气综合征的抑郁症患者多导睡眠监测特点

目的 探讨伴中重度阻塞性睡眠呼吸暂停低通气综合征（OSAHS）的抑郁症患者多导睡眠监测（PSG）特点。方法 回顾性分析2017年12月-2019年10月在苏州市广济医院睡眠医学中心完成整夜多导睡眠监测（PSG）的门诊和住院患者以及健康体检人群,从中筛选出四组被试,分别为伴中重度OSAHS的抑郁症患者（n=31）、不伴OSAHS的抑郁症患者（n=79）、中重度OSAHS患者（n=96）和正常对照组（n=32）。比较四组被试睡眠进程相关指标（总睡眠时间、睡眠潜伏期、觉醒次数）和睡眠结构相关指标（N1、N2、N3期及REM期占总睡眠时间的比例,REM潜伏期、REM期持续时间）以及睡眠呼吸相关指标（氧减指数）等参数。结果 睡眠进程方面,四组被试总睡眠时间、睡眠潜伏期和觉醒次数差异均有统计学意义（F=2.874、3.959、12.291,P<0.05或0.01）。睡眠结构方面,四组被试N2期、N3期占总睡眠时间比例差异均有统计学意义（F=13.885、48.013,P均<0.01）;四组被试REM潜伏期、REM期持续时间、REM期占总睡眠时间比例差异均有统计学意义（F=41.492、11.827、10.552,P均<0.01）。睡眠呼吸相关指标方面,四组被试氧减指数差异有统计学意义（F=170.585,P<0.05）。结论 伴中重度OSAHS的抑郁症患者存在严重的睡眠进程和结构紊乱,同时伴有更频繁和更严重的呼吸相关事件。     

老年白内障患者合并抑郁状况及其自我感受负担的影响

背景 伴抑郁症状的老年白内障患者自我感受负担较重,术后视觉相关生活质量较无抑郁症状的患者更差,家庭负担更重。既往研究多认为家庭关系、视力等是导致老年白内障患者出现抑郁症状的主要因素,自我感受、合并疾病等对老年白内障患者心理状态的影响研究有限。目的 探讨老年白内障患者抑郁症状与自我感受负担和术后视觉相关生活质量的关系,分析患者抑郁症状的危险因素,对其进行针对性的心理干预提供参考。方法 连续纳入2020年7月1日—2022年12月31日在江苏省人民医院（南京医科大学第一附属医院）住院治疗的老年白内障患者104例,采用自编调查问卷收集患者基本资料,采用患者健康问卷抑郁量表（PHQ-9）、自我感受负担量表（SPBS）、25项美国国家眼科研究所视功能问卷（NEI-VFQ-25）评定患者抑郁症状、自我感受负担以及术后视觉相关生活质量水平。采用Pearson相关分析考查伴抑郁症状的老年白内障患者PHQ-9、SPBS、NEI-VFQ-25评分的相关性,采用Logistic回归分析老年白内障患者抑郁症状的影响因素。结果 共100例老年白内障患者完成有效问卷调查,检出31例（31.00%）患者存在抑郁症状。抑郁组SPBS评分高于无抑郁组（t=11.062,P<0.01）,NEI-VFQ-25评分低于无抑郁组（t=-5.235,P<0.01）。Pearson相关分析结果显示,伴抑郁症状的老年白内障患者PHQ-9评分与SPBS评分呈正相关（r=0.485,P<0.01）,与NEI-VFQ-25评分呈负相关（r=-0.440,P<0.01）。合并糖尿病（OR=1.441,P<0.01）、合并骨关节炎（OR=1.324,P<0.05）和高SPBS评分（OR=1.340,P<0.05）是老年白内障患者出现抑郁症状的危险因素。结论 老年白内障患者抑郁症状检出率较高;伴抑郁症状的老年白内障患者术后视觉相关生活质量更低;合并糖尿病、骨关节炎以及自我感受负担较重是老年白内障患者出现抑郁症状的危险因素。     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.