Epileptics should be treated normally

By Nilma DOLE

Epilepsy is a socially normal condition which has now been more understood unlike in the olden days. Earlier, people were ignorant about how to deal with epileptic patients and such people were looked down upon and treated like outcasts.

However, today with better medication and a thorough understanding of the condition, epilepsy is now easily treatable and more tolerable.

Consultant Neurologist, Dr. Githanjan Mendis explained that with proper medication taken timely and better management of the condition, epilepsy is indeed curable.

“In Sri Lanka, there are 400, 000 patients who are suffering from epilepsy out of the total population,” said the doctor. He said that it is a common condition affecting any social class, any family and in any ethnicity. Epilepsy is a common chronic neurological disorder characterised by seizures. “There are three types of epilepsy seen in Sri Lanka.

The first is generalised epilepsy, the second is partial epilepsy and the third is focal epilepsy,” said Dr. Mendis.

Seizures

He explained that generalised epilepsy occurs when the patient has unconsciousness, convulsions, fits, seizures, frothing from the mouth, incontinence of urine and stools, becomes easily injured and has jerks which lasts for about five minutes.

“In epileptic fits, it happens suddenly, without warning and is uncontrollable,” said the doctor.

He said that right after the fit or seizure, the patient has a severe headache, vomits a lot, has drowsiness but they can return to complete normalcy within a day.

The next type of epilepsy is partial epilepsy which causes absence attacks in which the patient is in a stationery position.

“The epilepsy sufferer looks as though they are staring blankly into space without any movement and doesn’t talk but becomes like a statue,” said Dr.Mendis. He said that it also causes micro-chronic jerks which are small jerks and shakes that happen suddenly. “For example, when the patient is drinking water from a cup, they suddenly spill it, or move their body suddenly without any reason,” he said.

The other type of partial epilepsy is salaam attacks which occurs in infancy and early childhood. “It is characterised by seizures involving the muscles of the neck, trunk, and limbs and is manifested by nodding of the head and flexion of the arms.

The seizures are linked with brain abnormalities and regular mental retardation,” said the doctor. According to the doctor, in children, epilepsy causes febrile fits or convulsions.

The third type of epilepsy is focul epilepsy which is brought on by affecting a tiny part of the brain in a particular region.

“This can affect a certain spot of the brain which controls an arm or a leg and when this is affected, the patient can’t move this part of the anatomy,” said Dr. Mendis.

The aetiology pertaining to epilepsy reveals that 75 percent of this is idiopathic, which happens for no reason and has no cause behind it, said the doctor. He said, “In an epileptic shock, an abnormal electric dischange occurs in the brain for absolutely no reason at all.”

The doctor said that the rest of the 25 percent is due to scars in the brain (which can impair circulation), can be brought about by tumours and brain infections.

He said, “In generalised epilepsy, a large abnormal electric discharge occurs, in partial epilepsy a part of it occurs and in focul epilepsy it is only a spot that generates electrical activity.” He mentioned that to a fair degree, epilepsy can be hereditary but it is a common condition that can affect anybody so it is important to control the condition and manage it wisely.

When a seizure occurs in an epileptic patient, the first step is to put them on the ground and roll them over to a side.

“The patient will froth saliva out of their mouth or aspirate by allowing to release it otherwise they might get saliva in their lungs which would affect their breathing,” said the doctor.

Once frothing is done, a proper mechanism should be in place to prevent them from injuring themselves. If it is a horizontal fit and there’s no time to put the patient down, a cork should be fitted in between their mouth to prevent them from biting their lip or mouth.

The way to determine if a person has epilepsy is to do an EEG (electroencephalography), a CT (computed tomography) scan or an MRI (magnetic resonance imaging) scan to check the eletric activity in the brain.

Scans

“These scans are free in government hospitals and all teaching hospitals and provincial hospitals around the country are now fully equipped with these three scanners,” said Dr. Mendis. In private hospitals, they are not very expensive and can be checked quickly and under medical expert supervision.

“After 45 years of age, about 10 percent of people who have fits for the first time, this condition is caused by brain tumours.Even blood tests that show low levels of Calcium and Magnesium along with low hormone counts can also reveal epilepsy in a person,” said the doctor.

“When we first hear about epilepsy in a patient, the first thing we do is educate the family and the patient because it is important that they are treated like normal humans and given the equal opportunities as normal people,” he said.

They should be sent to school, treated normally and be carefully monitored and given medication on time.

However, contact sports, swimming and dangerous sports shouldn’t be encouraged.“We also tell the parents how to manage an epileptic child, to tell their schoolteachers, peers and the principal so that they are not treated any differently,” said the doctor.

He said that in epileptic patients, they need to take their medication on time and have to be careful about what they take.

“We give a proper format for them to follow to ensure that they take the proper medication.

In fact, with careful medication taken properly, epilepsy can be cured with minimal side effects,” he said. Dr.Mendis said that local medicines are free in government hospitals and are reasonably-priced at private hospitals and pharmacies.

Medicines

“Sri Lanka even produces high quality epilepsy medicines at Osusala and even gets more medicines from India and the UK,” said the doctor.

For children, there are special medications to bring the fever down so that nothing dangerous happens.

In children, one percent of epilepsy is due to tumours in the brain. In fact, monotherapy where one drug is given to a patient can be prescribed and if that doesn’t work, another drug can also be given to cure epilepsy.

However, various patients respond differently to epileptic drugs, some become completely cured, others have to take medication right throughout their life and others might not respond favourably.

But in 99 percent of all cases, epilepsy can be controlled well and more often than not, be completely cured.

Stressful

As for adults, they should be allowed to lead a normal life, they should not do very stressful jobs. The patient should get at least six hours of sleep, a balanced diet and a normal healthy lifestyle should be maintained without stress and monthly checkups should be done.

Sri Lankan doctors adhere to international standards of epilepsy control and ensure that patients follow the approved medical epileptic format.

“For example, they shouldn’t work with machinery, they should not smoke or drink, they should avoid fire and flammable substances or anything that requires them to do something dangerous,” said the doctor.

Besides that, epileptic patients can get married, and can do normal things, work and lead a stressful life but should only take certain precautions lest something dangerous occur.

“Back in the olden days, epileptic children and adults were stigmatised and were outcast from society but we shouldn’t do that. They should be given equal opportunities and should be encouraged to lead a normal life and epileptic women can even give birth and lead a normal married life.“Just because they have a fit doesn’t mean they are disabled,” said Dr. Mendis.

[ Treatment of epilepsy ]

1. Oral drugs are prescribed depending on the type of seizures
2. Dosage may need to be changed from time to time
3. Regular blood tests need to done to check for side effects
4. Always take medication on time and as directed. Missing a dose can cause a seizure
5. Never not stop taking or change medications without talking to a doctor first
6. Women wishing to become pregnant should tell the doctor in advance in order to adjust medications
7. Surgery to remove the abnormal brain cells causing the seizures may be helpful for some patients
8. Surgery to place a vagus nerve stimulator (VNS) may be recommended.

This device is similiar to a heart pacemaker. It can help reduce the number of seizures
9. Sometimes, children are placed on a special diet to help prevent seizures.

The most popular one is the ketogenic diet. A diet low in carbohydrates, such as the Atkins diet, may also be helpful in some adults

10. Lifestyle or medical changes need to be done
11. New prescribed medications, vitamins, or supplements
12. Emotional stress should be controlled and avoided
12. Illness, especially infection should be carefully monitored
13. Insomnia should be cured
14. Skipping doses of epilepsy medications is dangerous
15. Use of alcohol or other recreational drugs should be stopped
16. Persons with epilepsy should wear medical alert jewellery so that prompt medical treatment can be obtained if a seizure occurs
17. Persons with poorly controlled epilepsy should not drive
18. Also avoid machinery or activities where loss of awareness would cause great danger, such as climbing to high places, biking, and swimming alone - Courtesy: www.ncbi.nlm.nih.gov

Scientists make advances in neuroscience and vision research

Thanks to a new study of the retina, scientists have developed a greater understanding of how the nervous system becomes wired during early development. The findings reflect the expansion of developmental neurobiology and vision research at UCSB.

The work is described in a recent publication of the Journal of Neuroscience.

The research team examined the connectivity of nerve cells, called neurons, in mice.

Neurons communicate with one another via synapses where the dendrites and axon terminals of different cells form contacts.

This is where nerve signals are transmitted from one neuron to another. Scientists have understood for some time how neuronal activation at developing synapses contributes to the patterns of connectivity observed in maturity, explained Ben Reese, senior author and professor in UCSB’s Neuroscience Research Institute and the Department of Psychological & Brain Sciences.

Incoming activity plays a critical role in sculpting neuronal form and the elaboration of synaptic connections.

The new research shows, by contrast, how relationships between neighbouring cells of the same type independently regulate neuronal size and connectivity.

The researchers circumvented the difficulty of visualizing the three-dimensional relationships between neurons within the brain by working within the retina.

The retina is an outgrowth of the brain during embryonic development, and is a precisely layered structure in which the cells, their dendrites and their axons are restricted to discrete strata.

“This makes the visualization and analysis of neuronal morphology and connectivity far simpler,” said Reese.

The scientists used two genetically modified mouse models to modulate the density of one particular type of retinal neuron, a class of cone bipolar cell.

Cone bipolar cells relay information from the population of cone photo receptors to the retinal ganglion cells.

The latter are neurons that in turn project information to locations within the brain where further visual processing of the retinal image takes place.

The lead author on the study, Sammy Lee, was a post doctoral researcher working in Reese’s lab and supported by a C.J. Martin National Health & Medical Research Council fellowship from Australia during the course of the study. Lee labelled individual cone bipolar cells with a fluorescent dye through a new micro injection procedure developed by Patrick Keeley, a graduate student in the Reese lab.

“What Dr. Lee has shown is that cone bipolar cells modulate the size of their dendritic fields (branched extensions of the neuron) in association with the local density of like-type neurons,” said Reese.

“One line of mice has conspicuously fewer cone bipolar cells, each now with a larger dendritic territory, while the other line shows heightened densities and correspondingly smaller dendritic fields.”

Other studies have suggested such homotypic (like-type) modulation of dendritic field size, but the current study directly shows this modulation following genetic manipulation of neuronal density, according to Reese.

Additionally, the researchers found that connectivity with the afferent population of cone photoreceptors is impacted directly, with the larger dendritic fields being innervated by more cones, and the smaller dendritic fields connecting with fewer cones.

At any individual cone, the number of dendritic endings associating with that cone was not observed to change, so that the total number of connections made by a cone bipolar cell was remarkably plastic, defined solely by the number of cone contacts formed.

“This developmental plasticity in dendritic growth and synapse number may be well-suited to ensure uniform coverage and connectivity between two populations of neurons - afferents and their targets - when the number of cells in each population is specified independently,” said Reese.

Studies like these may prove relevant for re-establishing connectivity following nerve cell re-specification or replacement in degenerative diseases, particularly as advances in stem cell biology make this an increasing possibility, said Reese.

Salt intake and cardiovascular events

by Dr. Saman Gunaherath

A new study suggests that both high and low levels of salt intake may put people with heart disease or diabetes at increased risk of cardiovascular complications. The study, published in the Journal of the American Medical Association (JAMA) on November 23rd 2011, that moderate salt intake was associated with the lowest risk of cardiovascular events, while a higher intake of sodium was associated with an increased risk of stroke, heart attack and other cardiovascular events and low intake was associated with an increased risk of cardiovascular death and hospitalization for congestive heart failure.

The research, conducted by investigators in the Michal G. De Groote School of Medicine at Mc Master University and the Population Health Research Institute (PHRI) at Mc Master and Hamilton Health Sciences, was co-led by Dr. Martin O’ Donnell, an associate clinical professor of medicine, and Dr. Salim yusuf, a professor of medicine and executive director of the PHRI.

Actually this research addresses an important population health issue - the association between salt intake and cardiovascular disease, In general, previous observational studies have either reported a positive association, no association or an inverse association between sodium intake and heart disease and stroke. This has resulted in a lot of controversy. For the Mc Master observational study, the researchers examined 28,880 people at increases risk of heart disease from clinical trials conducted form 2001 to 2008.

The researchers estimated 24-hour urinary sodium and potassium excretion from a morning fasting urine sample. Follow up found more than 4,500 cardiovascular events occurred, making this one of the largest studies examining the relationship between sodium excretion as, well as potassium excretion and cardiovascular events. Extensive and careful statistical analytic methods were used to determine the association of urinary sodium and potassium with cardiovascular events, in particular heart attack, stroke, hospitalization for congestive heart failure and death. Compared with moderate sodium excretion (between 4 to 5.99 grams per day), the researchers found that sodium excretion of greater than seven grams per day was associated with an increased risk of all cardiovascular events, and sodium excretion of less than three grams per day was associated with an increased risk of cardiovascular death and hospitalization for congestive heart failure.

The findings call into question current guidelines for salt intake, which recommend less than 2.3 grams (or 2,300 mg) per day.

The guidelines are based on previous clinical trials that found blood pressure is lowered modestly when sodium intake is reduced to this level. However, there are no large studies looking at whether such low levels of sodium intake reduce the incidence of heart attacks and stroke.

Clarifying the optimal daily intake of sodium is particularly important in patients with established heart disease, as they may be especially vulnerable to the cardiovascular effects of very high- and low-salt intake and are most likely to receive recommendations on restricting sodium in their diets, the authors concluded.

“Our study confirms the association between high- sodium intake and cardiovascular disease.

Our findings highlight the importance of reducing salt intake in those consuming high-salt diets and the need for reducing sodium content in manufactured foods that are high in salt,” said Yusuf, who is also vice-president of research, Hamilton Health Sciences.

“However, for those with moderate (average) intake, whether further reduction of salt in the diet will be beneficial is an open question.

We believe that large clinical trials are the most reliable way to determine if reducing sodium intake to lower is of benefit.”