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Herbal medicines are, more than ever, receiving attention, both from the public and healthcare professionals alike, with many countries now undertaking registration schemes for traditional medicines. However, healthcare professionals still freely admit their lack of knowledge in this area, and surveys suggest that patients often rely on friends and family for advice about herbal medicines. Our aim, as ever, has therefore been to critically evaluate the published literature and present it in a familiar, easy-tohandle format, so that the busy healthcare professional can quickly access the information and apply it to their clinical situation. Are the drugs and substances in question known to interact or is the interaction only theoretical and speculative Is it best to avoid these two substances altogether or can the interaction be accommodated in some way In addition, we have included sections on: nomenclature, to help users identify herbal medicines that they or their patients may be familiar with under a different name; uses, so that those less familiar with herbal medicines can put their use into context; and constituents, to allow us to address interactions that occur as a result of a substance common to several plants. A pharmacopoeia section is also included for those herbal medicines, dietary supplements and nutraceuticals that have entries in the latest editions (at time of press) of the British Pharmacopoeia, the European Pharmacopoeia and the United States Pharmacopoeia. An indication of the constituents that the herbal medicine may be standardised for is also provided where necessary, but note that this does not necessarily mean that all marketed products are standardised in this way. Terminology has been carefully considered and international terms have been added where it was thought helpful to do so. This and the inclusion of the synonyms and pharmacopoeia sections will, we hope, cater for the needs of healthcare professionals around the world. As always, the Editorial team have had assistance from many other people in developing this publication, and the Editors gratefully acknowledge the assistance and guidance that they have provided. Of particular note are: the Digital Products Team led by Jane Macintyre; Ithar Malik, Ruchi Birla, Karl Parsons, Tom Whitaker and Darren Searson, who vi Preface have worked tirelessly in transforming our data into a useable output. Particular thanks are also due to the editor of Martindale, Sean Sweetman, who has acted as our mentor on a number of other projects, and continues to provide invaluable support. Thanks are also due to Tamsin Cousins, who has handled the various aspects of producing this publication in print. Ivan Stockley remains an important part of all products bearing his name, and we are most grateful for the feedback that he provided on this new project. Anyone who wishes to contact us can do so at the following address: stockley@rpsgb. Before using this publication it is advisable to read this short explanatory section so that you know how the drug interaction data have been set out here, and why, as well as the basic philosophy that has been followed in presenting it. Clinical evidence, detailing the interaction and citing the clinical evidence currently available. Due to the nature of interactions with herbal medicines much of the data currently available comes from animal and in vitro studies. It has been deliberately kept separate from the clinical data, because this type of data is a better guide to predicting outcomes in practice. As with all Stockley products, providing guidance on how to manage an interaction is our key aim. Some of the monographs have been compressed into fewer subsections instead of the more usual five, simply where information is limited or where there is little need to be more expansive. Reading the Importance and management section will explain which members of the groups are most likely to represent a problem. Action: this describes whether or not any action needs to be taken to accommodate the interaction. Severity: this describes the likely effect of an unmanaged interaction on the patient. These ratings are combined to produce one of five symbols: For interactions that have a life-threatening outcome, or where concurrent use is considered to be best avoided. For interactions where concurrent use may result in a significant hazard to the patient and so dosage adjustment or close monitoring is needed. The monographs this publication includes over 150 herbal medicines, nutraceuticals or dietary supplements. For each of these products there is an introductory section, which includes the following sections where appropriate.

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Bilateral rhythmic synchronous delta bursts lasting over 20 seconds were also seen. Ictal events were characterized by staring, bilateral arm jerking, gaze deviation to the right, left facial "pulling," and behavioral arrest that were associated with diffuse polyspike and wave activity followed by attenuation. In brief, she was experiencing multiple daily seizures which were not responsive to several antiepilpetic medications. Her case was discussed in detail at the Multidisciplinary Presurgical Epilepsy Conference. Her data were suggestive of multifocal seizures, which could not be localized to a specific region of the brain. The Chapter 85: Multifocal Resections or Focal Resections in Multifocal Epilepsy 961 goal was to identify one or maybe two seizure foci which could then be approached for resection. The understanding was that bilateral epileptiform activity was likely to be detected and that a complete surgical cure was unlikely. The parents agreed to proceed with this plan, and the patient underwent bilateral subdural strip electrode placement at age 4. Interictally, during the 5 days of intracranial monitoring, very frequent spikes were seen in multiple bilateral strips. Twenty-one typical seizures were recorded: these showed diffuse attenuation with high frequency, low amplitude beta activity seen earliest in the right anterior and posterior frontal strips with fast spread to the right posterior temporal, midtemporal, temporooccipital, right parietal, and right anterior parasagittal strips. After a multidisciplinary discussion and detailed conversations with the family, it was decided to proceed with a surgical resective strategy targeting this right frontal epileptogenic zone. She underwent a staged approach: at the first stage, the right inferior frontal tuber was resected and subdural electrodes were then placed primarily over the remaining frontal lobe, with additional coverage over the parietal and temporal tubers. During the 6 days of monitoring, seizure onsets were detected from the orbitofrontal area, along the margin of the prior frontal resection. Additionally, there was independent seizure activity arising from the right temporal lobe, in the region of a tuber. At the second stage, therefore, these two active areas (frontal and temporal) were resected, and new electrodes were placed to determine if adjacent or distal areas would continue to be active. During the following week, monitoring showed residual seizures originating posterior and superior to the frontal resection cavity, beyond the margins of any apparent tubers. The frontal region was resected further based on the ictal map and the electrodes were removed. Postoperatively, she was seizure-free for 3 months, during which time her parents noted developmental gains. However, her parents then began noting an occasional left-sided "grin" and facial twitching, which were suspicious for recurrent seizures. Her case was discussed in detail with the parents, who were anxious to consider surgery once again because of seizure recurrence and their impression that the initial surgery helped her significantly. Weighing all the possible options, we considered reoperative surgery when her case was presented again at the Conference, because her evaluation suggested that seizures were arising from the same regions that were approached previously. She was monitored for a week, during which time seizure onsets were recorded from the right posterior frontal and anterior parietal lobe regions, beyond the margins of any obvious tubers. At the second stage, these areas were resected, with intraoperative motor mapping, and electrodes were replaced for an additional phase of monitoring. Seizures persisted from the parietal lobe, beyond the margin of the prior resection, necessitating additional resection in this region. The patient was discharged with a mild left hemiparesis, which resolved completely over the next 2 months, and was seizure-free. Invasive recordings are performed uni- or bilaterally according to the presurgical impression, and are used for seizure as well as functional mapping. If, however, a focus is determined, we resect it, possibly leaving grids, strips, and depth electrodes in place after resection to verify the cessation of the electrical network. We acknowledge that, sometimes, persistent electrographic activity will have no clinical significance and may even regress spontaneously over time. As presented in the case above, sometimes reoperation is indicated and can be successful. The down side of this treatment regimen is a long hospitalization (up to 3 to 4 weeks), higher risk of infection, and surgical induced morbidity (including neurological insult). However, over the last few years, we have treated many children this way, and found the complication rate to be low and the epilepsy outcome to be worthwhile. Multifocal epilepsy has traditionally been considered, in most situations, a contraindication for epilepsy surgery.

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Subsequent medication orders for this drug must also include the signature of a physician. The discussions, decisions, and respective local policy must follow the requirements set forth in the current Joint Commission Medication Management Standard Recommendations and options are also provided for identified medications. This responsibility is deferred to the local level due to the varying missions of our institutions. T" program; however, alternative medications should be sought due to the teratogenicity and long-term effects of acitretin. Failure of non-pharmacologic / Education & Counseling / Psychology Referral to include individual therapy to learn coping, organizational, prioritization, and anger management skills for minimum of 6 months. Patient self-reported trials of medication regimens and doses will not be accepted. Evidence (with specific examples) of inability to function in the correctional environment. Contingent to formulation compatibility, stimulant medications will be crushed prior to administration. Stimulant medications (including atomoxetine) will be our last drug of choice and will only be approved if function is significantly impaired. The use of stimulant in persons with a history of stimulant drug abuse will not be approved. Documentation of significant symptomatic hypotension, orthostatic hypotension, or syncope while receiving terazosin, doxazosin or tamsulosin. Patients previously stabilized on a direct thrombin inhibitor or Factor Xa inhibitor with an appropriate diagnosis. The expectation is that patients will be converted to warfarin within the time frames listed in the non-formulary use criteria. When requesting approval please provide information necessary for evaluation of the request. Previous medications, doses, and documented compliance; blood levels when appropriate. Please be aware that many of the antiepileptic agents have potentially lifethreatening side effects under certain conditions, or in some individuals. Diabetic or circulatory disorders evidenced by absence of pedal pulses and/or extremity hair loss due to poor circulation, or abnormal monofilament exam demonstrating loss of sensation. Patients taking antipsychotic medication with extrapyramidal symptoms not responsive to benztropine and trihexyphenidyl (diphenhydramine and hydroxyzine only) Excessive salivation with clozapine (diphenhydramine and hydroxyzine only) 3. Page 15 of 48 Ascorbic Acid (Vitamin C) Concomitant administration with an imidazole antifungal agent to improve bioavailability by increasing stomach acidity. Patients should have a recent glycosylated hemoglobin (hemoglobin A1c or HbA1c) less than 8. The wound must have an adequate blood supply measured by Oscillometry (at least 2 units), transcutaneous oxygen pressure (TcpO2 >30 mm Hg) or bleeding with debridement. The patient must have failed standard therapy for at least 2 months (careful/frequent debridement, moist dressing changes and non-weight bearing). The provider must see the patient on a weekly to biweekly basis for debridement and assessment of ulcer response. The provider must recalculate a new amount of becaplermin gel to be applied at every visit. Control of severe agitation in psychiatric patients When lack of sleep causes an exacerbation of psychiatric illness Part of a prolonged taper schedule Detoxification for substance abuse Failure of standard modalities for seizure disorders (4th line therapy) Long-term use for terminally ill patients for palliative care. Nausea and Vomiting in Oncology Treatment Patients (Lorazepam only) Brimonidine 0. Patient self-reported trials of medication regimens and doses will not be accepted. Request for its non-formulary use requires completion of the "Donepezil Nonformulary Use Criteria Algorithm" form. For use in opiate detoxification only, non-formulary request may be submitted after opiate detox protocol initiated. Dose taper over 2 to 4 days for arriving inmates taking greater than 1 mg per day. Refer to clonidine withdrawal guidance, particularly for patients on concomitant beta blocker therapy.

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Adverse events reflected the product labeling with no serious or unusual events noted. Summary: Limited evidence which may be confounded by misclassified seizure type, finds no difference in efficacy between phenytoin and carbamazepine for 58 efficacy measures in children and adults with partial onset or generalized seizures. Carbamazepine use resulted in a higher discontinuation rate, suggesting lower tolerability. Phenobarbitone/Phenobarbital vs Phenytoin A Cochrane Review118 compared phenobarbitone vs phenytoin for monotherapy treatment of generalized, tonic-clonic seizures or partial onset seizures in adults of children. Individualized participant data was found in 4 of 8 identified trials for 599 participants reflecting 63% of the data. Care must be taken when interpreting the skewed data with 78% of participants having partial onset seizures and 22% generalized seizures. For every measure of time to treatment withdrawal (pooled participants, pooled by seizure type or stratified by seizure type) phenobarbitone treatment resulted in statistically more withdrawals than phenytoin. The time to 6- and 12-month remission did not differ between the two groups, however, summary statistics with wide confidence intervals do not support equivalence. The time to the first, post-randomization seizure did not differ between treatment groups. Overall, no difference in seizure control was identified between phenobarbitone and phenytoin although phenytoin therapy resulted in significantly fewer treatment withdrawals which may reflect better tolerability. Painter et al119 compared phenobarbital and phenytoin when dosed to predetermined serum concentrations in 59 neonates with seizures. Combination therapy resulted in similar results regardless of whether the patient received phenobarbital or phenytoin initially (57% vs 62%, respectively; p=0. Summary: the evidence suggests that phenobarbitone and phenytoin are not different in efficacy outcomes for neonatal seizures. Although response rates were not statistically different, the evidence is insufficient to prove equivalence in the treatment of generalized, tonic-clonic and partial seizures in adults and children with phenytoin better tolerated. Carbamazepine vs Valproate Marson et al120 performed a meta-analysis comparing valproate and carbamazepine therapy in the treatment of epilepsy in children and adults in which a misdiagnosis of epilepsy could not be ruled out. Assessed outcomes included the retention time, time to first post-randomization seizures and time to 12-month remission. In the setting of generalized-onset seizures no difference was found between treatments. Summary: Evidence, which may be confounded by misclassified seizure type, finds both carbamazepine and valproate were equally efficacious in the treatment of generalized and partial-onset epilepsy in adults and children. Methsuximide 59 Methsuximide was prospectively studied in an open-label protocol of 112 children with epilepsy refractory to first line antiepileptic drugs or combinations or antiepileptic drugs. Methsuximide serum concentrations were positively correlated with reversible ataxia and leukopenia when >45 mg/L. Tennison et al122 found methsuximide efficacious when added to the current regiment of children with intractable epilepsy on maximal, combination therapy. A reduction in seizure frequency was achieved in >50% of children and was maintained for a mean of 19 months although no patient achieved complete seizure remission. Dasheiff et al123 compared clorazepate, methsuximide and valproate treatment in 66 patients with medically refractive, complex partial seizures with secondary generalization or partial seizures with aura who failed phenytoin, carbamazepine or phenobarbital therapy. The elimination of seizures with tolerated side effects occurred in small numbers of patients similarly with each medication. Methsuximide and valproate use resulted in gastrointestinal and mental status changes and valproate therapy resulted in impaired coordination. Summary: In children and adults with refractory epilepsy who failed therapy with multiple medications, limited, low quality evidence suggests methsuximide can reduce the seizure frequency in ~ 1/3 of patients, although the effects do not appear to be long-lived. A small trial suggests methsuximide efficacy may compare favorably with clorazepate and valproate. Methsuximide is associated with gastrointestinal toxicity and mental status changes and at least some of methsuximide adverse effects are dose related (ataxia, leukopenia). Acetazolamide Acetazolamide was assessed for utility as adjunct therapy in 37 Japanese children with refractory epilepsy complicated by mental retardation currently failing therapy to a combination of at least two of the following medications, carbamazepine, clonazepam or sodium valproate124. Acetazolamide therapy was initiated at 10 mg/kg and increased to 20 mg/kg as indicated. No relationship was found between drug dosage or steady state serum concentrations and efficacy. A complete remission persisting > 3 years was observed in 4 patients with localization-related epilepsies.

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Patients and caregivers should be instructed to contact a health care provider if any of these reactions or changes in behavior are observed. Anticonvulsant Medications: Use in Pediatric Patients 9 Valproic Acid and Divalproex Valproic acid and its derivatives, including divalproex, have been associated with hepatotoxicity, teratogenicity, and pancreatitis. Patients requiring valproic acid therapy, and their caregivers, should be made aware of these risks prior to the initiation of therapy. Hepatotoxicity usually occurs in children younger than 2 years old and within the first 6 months of therapy, although it may occur at any time and may occur in patients older than 2 years old. Serum liver tests should be monitored prior to initiation of therapy and periodically throughout the course of treatment. Female patients in their childbearing years, including sexually active teenage girls, should also be provided with the medication guide (included in the prescribing information) that describes the teratogenic potential of valproic acid. Patients should be evaluated for the warning signs of pancreatitis and encouraged to seek treatment if they occur. Serious or fatal hepatotoxicity may be preceded by non-specific symptoms such as malaise, weakness, lethargy, facial edema, anorexia, and vomiting. Serum liver tests should be performed prior to therapy and at frequent intervals thereafter, especially during the first six months [see Warnings and Precautions (5. Children under the age of two years are at a considerably increased risk of developing fatal hepatotoxicity, especially those on multiple anticonvulsants, those with congenital metabolic disorders, those with severe seizure disorders accompanied by mental retardation, and those with organic brain disease. When Depakote is used in this patient group, it should be used with extreme caution and as a sole agent. The incidence of fatal hepatotoxicity decreases considerably in progressively older patient groups. In patients over two years of age who are clinically suspected of having a hereditary mitochondrial disease, Depakote should only be used after other anticonvulsants have failed. This older group of patients should be closely monitored during treatment with Depakote for the development of acute liver injury with regular clinical assessments and serum liver testing. Continued on Page 11 10 Anticonvulsant Medications: Use in Pediatric Patients Continued from Page 10 Fetal Risk Valproate can cause major congenital malformations, particularly neural tube defects. Valproate is therefore contraindicated in pregnant women treated for prophylaxis of migraine [see Contraindications (4)]. Valproate should only be used to treat pregnant women with epilepsy or bipolar disorder if other medications have failed to control their symptoms or are otherwise unacceptable. Valproate should not be administered to a woman of childbearing potential unless the drug is essential to the management of her medical condition. This is especially important when valproate use is considered for a condition not usually associated with permanent injury or death. Pancreatitis Cases of life-threatening pancreatitis have been reported in both children and adults receiving valproate. Some of the cases have been described as hemorrhagic with a rapid progression from initial symptoms to death. Cases have been reported shortly after initial use as well as after several years of use. Patients and guardians should be warned that abdominal pain, nausea, vomiting, and/or anorexia can be symptoms of pancreatitis that require prompt medical evaluation. Alternative treatment for the underlying medical condition should be initiated as clinically indicated. Patients should have their vision tested within 4 weeks of starting vigabatrin and every 3 months during the course of therapy. It should only be considered after several alternative therapies have not worked and should only be prescribed for patients for whom the benefits outweigh the risk of vision loss. Because assessing vision may be difficult in infants and children, the frequency and extent of vision loss is poorly characterized in these patients. For this reason, the risk described below is primarily based on the adult experience. Vision loss of milder severity, while often unrecognized by the patient or caregiver, can still adversely affect function. It is expected that, even with frequent monitoring, some patients will develop severe vision loss.

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Three of the 13 evaluable patients had complete abolition of photosensitivity, and an additional 7 had clinically significant reduction. At carisbamate doses of 300, 800, and 1600 mg/day, patients experienced a reduced seizure frequency of 24% (P 0. The efficacy of ganaxolone in the treatment of women with catamenial epilepsy is also being investigated. Huperzine A Huperzine A, an N-methyl-D-aspartate receptor and acetylcholinesterase inhibitor, is a sesquiterpene lycopodium alkaloid isolated from the Chinese club moss Huperzia serrata, traditionally used in China for swelling, fever and inflammation, blood disorders, and schizophrenia (16,59,60). A maximum protection was observed at three doses of 1, 2, and 4 mg/kg in mice; however, rotarod test impairment was observed in a majority of mice at doses of 2 and 4 mg/kg (61). Currently, a pilot doseranging study is planned to evaluate the tolerability and efficacy of adjunctive huperzine A in human patients with medically refractory epilepsy. Ganaxolone Ganaxolone (3 -hydroxy-3 -methyl-5 -pregnan-20-one) is the 3- -methyl analog of the neurosteroid allopregnanolone (16). Findings from animal models also suggest that certain neurosteroids may possess antiepileptogenic properties, slowing the development of spontaneous recurrent seizures (57). It has a 10-hour effective half-life and a terminal elimination half-life of 35 to 40 hours (16). One issue is its variable absorption pattern in the presence or absence of food; plasma exposure values are 5 to 15 times higher when ganaxolone is taken with food, compared to values when ingested during fasting. To combat this problem, several unique formulations have been created including two solid capsule forms, one immediate-release and the other pH-sensitive delayed-release. The largest of the three enrolled a total of 45 patients with partial or generalized refractory seizures, ages 2 to 15 years. A maximum dose of ganaxolone of 12 mg/kg three times daily was administered for an 8-week maintenance period. Of the original 45 patients, 27 (60%) completed the entire study and 12 patients (27%) experienced a 50% reduction in seizure frequency (58). Therapy has been continued in patients on a compassionate use basis, citing improvement in behavior and seizure frequency as beneficial effects (58). The Kv7 site of action of retigabine might ultimately expand the application of the drug. Its use in the treatment of neuropathic pain, as well as neuroprotection in the setting of acute stroke, has been investigated and early findings have been promising (71,75,76). Retigabine has a half-life of 8 to 10 hours, and displays linear pharmacokinetics (in doses up to 1200 mg/day) (16,80). It is metabolized primarily by glucuronidation and acetylation producing two inactive N-glucuronide metabolites and one N-acetylated metabolite which has minimal pharmacologic activity (16). Clearance is reduced by 30% in the elderly, indicating lower doses will be needed (16). Clearance is also reduced by moderate and severe hepatic impairment, by 30% and 50%, respectively, and by mild and severe renal impairment by 25% and 50%, respectively (16). No clinically significant changes have been seen in either electrocardiograms or laboratory parameters (15,16). Retigabine doses of 600, 900, and 1200 mg/day produced a median percent reduction of 23%, 29%, and 35%, respectively, in monthly total seizures compared to 13% with placebo. In addition, 50% seizure reduction was seen in 23%, 32%, and 33% in patients receiving 600, 900, and 1200 mg retigabine, respectively, compared to 16% for those receiving placebo (80,81). In both studies, side effects leading to discontinuation included dizziness, somnolence, headache and fatigue, as well as confusion and dysarthria at the 1200-mg dose (82,83). Two pharmaceutical companies are currently collaborating on the drug and are planning to file a New Drug Application with the U. Stiripentol Stiripentol [4,4 dimethyl-1-(3,4-methylenedioxyphenyl)-1penten-3-ol] is a structurally novel molecule belonging to the aromatic allylic alcohol family. It has been used in France and Canada for over 10 years, but only recently began development for use in the United States.

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Narcolepsy and Cataplexy Narcolepsy is a state of excessive daytime drowsiness causing rapid brief sleep, sometimes during conversation or play; the patient usually awakens refreshed. Narcolepsy also includes sleep paralysis (transient episodes of inability to move on awakening) and brief hallucinations on arousal along with cataplexy, although not all patients demonstrate the complete syndrome. Cataplexy produces a sudden loss of tone with a drop to the ground in response to an unexpected touch or emotional stimulus such as laughter. Basilar Migraine Most common in adolescent girls, basilar migraine begins with a sudden loss of consciousness followed by severe occipital or vertex headache. Dizziness, vertigo, bilateral visual loss, and, less often, diplopia, dysarthria, and bilateral paresthesias, may occur. A history of headache or a family history of migraine is helpful in making the diagnosis. Children may respond to classic migraine therapy or antiepileptic drugs (105,106). Tremor An involuntary movement characterized by rhythmic oscillations of a particular part of the body, tremor may appear at rest or with only certain movements. Consequently, it is occasionally mistaken for seizure activity, particularly when the movement is severe and proximal such as in the "wing-beating tremor" of Wilson disease or related basal ganglia disorders. Examination at rest and during activities, possibly by manipulating the affected body part while observing the tremor, usually can define the movement by varying or obliterating the tremor. The electroencephalogram is unchanged as the tremor escalates and diminishes (107). Panic Disorders Panic attacks may occur as acute events associated with a chronic anxiety disorder or in patients suffering from depression or schizophrenia. These attacks last for minutes to hours and are accompanied by palpitations, sweating, dizziness or vertigo, and feelings of unreality. The following symptoms also have been noted: dyspnea or smothering sensations, unsteadiness or faintness, palpitations or tachycardia, trembling or shaking, choking, nausea or abdominal distress, depersonalization or derealization, numbness or tingling, flushes or chills, chest pain or discomfort, and fears of dying, aura, going crazy, or losing control. An electroencephalogram recorded at the time of the attacks differentiates ictal fear and nonepileptic panic attacks (108). Panic disorders involve spontaneous panic attacks and may be associated with agoraphobia. Although they may begin in adolescence, the average age at onset is in the late 1920s. Episodes of cyanosis, dyspnea, and unconsciousness followed by a convulsion may occur in as many as 10% to 20% of children with congenital heart disease, particularly those with significant hypoxemia. In "tet" spells, young children with tetralogy of Fallot squat nearly motionless during exercise as their cardiac reserve recovers (110). Children and adults with shunted hydrocephalus may have seizures, although these are not usual (111). Obstruction associated with the third ventricle or aqueduct may cause the bobble-head doll syndrome (two to four head oscillations per second) in mentally retarded children (112). In hydrocephalic patients treated by ventricular shunting, acute decompensation may increase seizure frequency or give rise to symptoms misdiagnosed as seizures. So-called hydrocephalic attacks, characterized by tonic, opisthotonic postures frequently associated with a generalized tremor, are caused by increased intracranial pressure and herniation. Head tilt or dystonia also may indicate increased intracranial pressure, a posterior fossa mass, or a Chiari malformation. Urgent evaluation for malfunctioning shunt or increased intracranial pressure is warranted with any of these symptoms. The episodic nature of periodic paralysis may lead to misidentification of the symptoms as epilepsy. Familial and sporadic cases typically are associated with disorders of sodium and potassium metabolism. Cerebrovascular disorders of various types and etiologies may have transient recurrent symptoms and thus are confused with epilepsy. The exact clinical presentation of cerebrovascular disorders in both children and adults depends primarily on the size and location of the brain lesion and on the etiology of the vascular compromise (114,115). Transient ischemic attacks, episodes of ischemic neurologic deficits lasting less than 24 hours, are typically caused by small emboli or local hemodynamic factors that temporarily prevent adequate brain perfusion. Symptoms begin suddenly following an embolus, with the deficit reaching maximum severity almost immediately. Symptomatology is characteristically separated into carotid artery syndromes with symptoms of middle cerebral artery, anterior cerebral, and lacunar deficits.

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This section provides resources, strategies and measurement for use in closing the gap between current clinical practice and the recommendations set forth in the guideline. Increase the accurate diagnosis of primary headaches in patients age 12 years and older. Percentage of patients diagnosed with primary headache using the appropriate diagnostic criteria. Increase the percentage of patients with primary headache diagnosis who receive educational materials about headache. Percentage of patients with primary headache who received educational materials on headache. Increase the percentage of patients with primary headache syndrome who receive prophylactic treatment when appropriate. Percentage of patients with primary headache syndrome who are prescribed prophylactic treatment when appropriate. Increase the percentage of patients with migraine headache who have improvement in their functional status. Percentage of patients with migraine headache who are showing improvement in functional status shown by using one of the following disease-specific tools or questionnaires. Percentage of patients with migraine headache seen for migraine in the emergency department/ urgent care. Increase the percentage of patients with migraine headache who have a treatment plan or report adherence to a treatment plan for mild, moderate and severe migraine headaches. Percentage of patients with migraine headache with treatment plan who report adherence to their treatment plan. Decrease the percentage of patients with migraine headache who are prescribed opiates and barbiturates for the treatment of migraines to less than 5%. Percentage of patients with migraine headache with a prescription for opiates or barbiturates for the treatment of migraine. Increase the percentage of patients with migraine headache who have appropriate acute treatment. Percentage of patients with migraine headache prescribed appropriate acute treatment. Population Definition Data of Interest Patients age 12 years and older diagnosed with a primary headache. Method/Source of Data Collection Review electronic medical records for patients age 12 years and older with one of headache diagnoses: migraine, tension-type, cluster, sinus or chronic daily headache. Determine whether appropriate diagnostic criteria were used to determine diagnosis. Notes this is a process measure, and improvement is noted as an increase in the rate. Population Definition Data of Interest Patients age 12 years and older with a primary headache. Method/Source of Data Collection Review electronic medical records for patients age 12 years and older with a primary headache. Review records to determine whether patients received written educational materials on headache. Notes Providing education is of paramount importance in managing any chronic illness; it is especially important in the ongoing management of migraine. Patients may have to make lifestyle changes and are often required to make self-management choices in the treatment of individual headaches and to maintain a diary to clarify the frequency, severity, triggers and treatment responses to their headaches. Population Definition Data of Interest Patients age 12 years and older with primary headache syndrome. Number of patients age 12 years and older with primary headache diagnosis syndrome. Method/Source of Data Collection Review electronic medical records for patients age 12 years and older with primary headache syndrome. Review records to determine whether patients were prescribed prophylactic treatment when appropriate.

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Samuel, 43 years: Brain-derived neurotrophic factor and autoantibodies to neural antigens in sera of children with autistic spectrum disorders, Landau-Kleffner syndrome, and epilepsy. The risk did not vary substantially by age (5-100 years) in the clinical trials analyzed. The Kingdom of Hawaii was an extremely impressive, cosmopolitan multi-racial, multi-ethnic society.

Hanson, 48 years: In vitro correlates of benzodiazepine cerebrospinal fluid uptake, pharmacodynamic action and peripheral distribution. The initial treatment for patients who experience rapid cycling should include lithium or valproate; an alternative is lamotrigine. Caregivers of school children with epilepsy: Findings of a phenomenological study.

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