- OK, WE CAN GET STARTED.
	
	I'D LIKE TO WELCOME YOU ALL TO
	OUR "INTRODUCTION TO EPILEPSY
	
	AND SEIZURES" AUDIO
	CALL SERIES.
	
	MY NAME IS SEAN GAMBLE, AND
	I'M WITH THE EMPLOYEE
	
	EDUCATION SERVICES,
	
	ST. LOUIS, AND I AM THE PROJECT
	MANAGER FOR THE SERIES.
	
	THIS IS A CALL THAT WILL
	CONTINUE TO OCCUR EVERY OTHER
	
	MONTH ON THE FIRST WEDNESDAY
	AT 2:00 P.M. EASTERN.
	
	OUR NEXT CALL WILL BE ON MAY 4
	WITH DR. PAUL RUTECKI.
	
	ALL YOUR LINES ARE MUTED AND
	WILL BE OPENED UP AT THE END
	
	OF THE PRESENTATION WHEN WE
	ARE READY FOR QUESTIONS
	
	AND ANSWERS.
	
	PLEASE BE SURE AT THE END OF
	THIS TO COMPLETE YOUR
	
	EVALUATION TO GET CREDIT
	FOR THIS PROGRAM.
	
	COMPLETE DIRECTIONS FOR YOUR
	EVALUATIONS ARE IN A BROCHURE
	
	OR IN THE CATALOGUE.
	
	YOU WILL HAVE 30 DAYS TO
	SUBMIT YOUR EVALUATION FORMS.
	
	DEADLINE DATE FOR
	THAT IS MAY 1.
	
	NOW I WANT TO WELCOME OUR
	GUEST SPEAKER FOR TODAY.
	
	IT IS DR. KAREN PARKO.
	
	DR. PARKO, YOU CAN GO AHEAD AND
	START YOUR PRESENTATION.
	
	- THANK YOU, SEAN.
	
	HELLO, AND WELCOME TO THE
	FIRST EPILEPSY CENTER SERIES
	
	OF CONTINUING
	EDUCATION LECTURES.
	
	THIS SERIES IS A COMBINED
	PRODUCTION OF THE EMPLOYEE
	
	EDUCATION SYSTEM AND THE
	EDUCATIONAL WORKING GROUP OF
	
	THE EPILEPSY CENTERS
	OF EXCELLENCE.
	
	MY NAME IS KAREN PARKO, AND I
	WORK AT THE SAN FRANCISCO VA.
	
	TODAY I'M GOING TO PROVIDE AN
	INTRODUCTION TO SEIZURES AND
	
	EPILEPSY WITH SPECIFIC
	ATTENTION TO DIAGNOSIS
	
	AND TREATMENT.
	
	PLEASE MOVE TO THE
	FIRST SLIDE.
	
	THESE ARE THE OBJECTIVES OF
	TODAY'S PRESENTATION.
	
	I WILL START WITH SOME
	DEFINITIONS; HOPEFULLY HELP
	
	YOU UNDERSTAND HOW SEIZURES
	AND EPILEPSY ARE CLASSIFIED,
	
	WITH SPECIAL ATTENTION TO THE
	NEW NOMENCLATURE; TALK ABOUT
	
	THE EVALUATION AND DIAGNOSIS
	OF SEIZURES; AND THEN MOVE ON
	
	TO THE TREATMENT OF EPILEPSY
	USING MEDICATION AND SURGICAL
	
	APPROACHES.
	
	I WANT TO GIVE YOU SOME
	GUIDANCE ON SELECTING PATIENTS
	
	TO REFER TO AN EPILEPSY
	CENTER, AND LASTLY, I WANT TO
	
	GO OVER THE ORGANIZATION OF
	THE NEW VA EPILEPSY CENTERS OF
	
	EXCELLENCE, WITH SPECIFIC
	ATTENTION TO HOW TO REACH OR
	
	CONTACT THESE CENTERS IN ORDER
	TO GET HELP CARING FOR YOUR
	
	PATIENTS THAT HAVE EPILEPSY.
	
	NEXT SLIDE.
	
	A SEIZURE IS CAUSED BY AN
	EXCESSIVE ELECTRICAL DISCHARGE
	
	OF NERVE CELLS IN THE BRAIN.
	
	BRAIN CELLS--NEURONS--
	COMMUNICATE WITH EACH OTHER
	
	NORMALLY BY ELECTRICAL AND
	CHEMICAL MEANS.
	
	WHEN THIS COMMUNICATION GOES
	HAYWIRE AND THE NERVE CELLS
	
	ALL DISCHARGE SYNCHRONOUSLY,
	A SEIZURE OCCURS.
	
	THIS CAN OCCUR IN ALMOST ALL
	PARTS OF THE BRAIN,
	
	AND DEPENDING ON WHERE THE
	DISCHARGE IS IN THE BRAIN,
	
	THE PERSON WILL EXPERIENCE
	DIFFERENT SYMPTOMS.
	
	ANY BRAIN UNDER THE RIGHT, OR
	PERHAPS I SHOULD SAY WRONG
	
	CIRCUMSTANCES WILL
	HAVE A SEIZURE.
	
	A SEIZURE WILL OCCUR IN ABOUT
	10% OF ALL PEOPLE.
	
	NEXT SLIDE.
	
	NOW, ALTHOUGH ANYONE'S BRAIN
	CAN HAVE A SEIZURE AND 10% OF
	
	THE POPULATION WILL EXPERIENCE
	A SEIZURE AT SOME TIME IN
	
	THEIR LIFETIME, HAVING
	RECURRENT SEIZURES IS MUCH
	
	LESS COMMON AND WILL OCCUR IN
	ONLY 1% OF THE POPULATION.
	
	WHEN SEIZURES RECUR, THE
	CONDITION IS LABELED EPILEPSY.
	
	OPERATIONALLY DEFINED,
	EPILEPSY IS DIAGNOSED AFTER
	
	A PERSON HAS HAD
	TWOUNPROVOKED UNPROVIKED
	SEIZURES.
	
	IN CLINICAL PRACTICE, THIS IS
	OFTEN REFERRED TO AS A SEIZURE
	
	DISORDER, WHICH I BELIEVE IS
	FELT BY SOME TO CARRY LESS
	
	STIGMA THAN THE WORD
	"EPILEPSY."
	
	HOWEVER, THIS IS REALLY
	CONFUSING TO PATIENTS, AND WE
	
	SHOULD TRY TO USE THE
	CORRECT TERMINOLOGY.
	
	THE PREVALENCE OF EPILEPSY
	INCREASES OVER THE LIFESPAN,
	
	AND BY AGE 75, 3% OF THE
	POPULATION WILL HAVE
	
	DEVELOPED EPILEPSY.
	
	NEXT SLIDE.
	
	EPILEPSY IS THE MOST COMMON
	CHRONIC NEUROLOGICAL CONDITION
	
	THROUGHOUT THE WORLD.
	
	IT IS ALSO ONE OF THE MOST
	TREATABLE NEUROLOGIC CONDITIONS.
	
	NEXT SLIDE.
	
	IF YOU LOOK AT THE INCIDENCE
	OF EPILEPSY, THAT IS, THE NEW
	
	CASES OF EPILEPSY, OVER THE
	AGE OF ONSET, WHICH IS ON
	
	THE BOTTOM LINE HERE, YOU WILL
	NOTICE THAT THE INCIDENCE IS
	
	HIGHEST AT BOTH ENDS OF THE
	SPECTRUM OF LIFE--THAT IS,
	
	IN THE YOUNG AND THE OLD.
	
	THE ONSET OF EPILEPSY IS
	HIGHEST IN PATIENTS OVER 60
	
	YEARS OF AGE.
	
	THE WORK ON THIS SLIDE IS DONE
	BY ALLEN HAUSER, AND IT SHOWS
	
	A TWO-TO-THREEFOLD INCREASE IN
	THE INCIDENCE OF SEIZURES IN
	
	PERSONS 75 AND OLDER COMPARED
	WITH THE YOUNGER GROUP.
	
	HOWEVER, FURTHER ONGOING WORK
	INDICATES THAT IF YOU TAKE
	
	INTO ACCOUNT UNDERDIAGNOSIS,
	SOMETHING THE EPILEPSY
	
	COMMUNITY THINKS OCCURS OFTEN
	IN THE ELDERLY, THE INCIDENCE
	
	MAY ACTUALLY BE SIX-TO-TENFOLD
	HIGHER IN THE ELDERLY
	
	POPULATION.
	
	THIS IS OF PARTICULAR INTEREST
	TO THE VA POPULATION, WHERE
	
	THE MAJORITY OF OUR PATIENTS
	FALL INTO THE OLDER-AGE
	
	CATEGORIES, ALTHOUGH OUR
	PATIENT POPULATION IS CHANGING
	
	WITH THE INFLUX OF MIDDLE
	EAST VETERANS.
	
	NEXT SLIDE.
	
	NOW I WANT TO TALK ABOUT THE
	CLASSIFICATION OF SEIZURES SO
	
	THAT WE ALL UNDERSTAND
	WHERE WE'RE AT.
	
	THIS CURRENTLY CAUSES SOME
	CONFUSION BECAUSE THE NAMES
	
	THAT WE HAVE USED IN HOW WE
	CLASSIFY SEIZURES CHANGED
	
	RECENTLY IN 2010, AND SO I
	WANT TO DIGRESS A LITTLE AND
	
	TALK ABOUT THE CHANGES.
	
	THE INTERNATIONAL LEAGUE
	AGAINST EPILEPSY IS
	
	AN INTERNATIONAL
	PROFESSIONAL GROUP.
	
	ONE OF ITS IMPACTS IT HAS HAD
	IS PROVIDING A STANDARD WAY TO
	
	COMMUNICATE AROUND THE
	WORLD FOR SEIZURES.
	
	THE FIRST INTERNATIONAL
	CLASSIFICATION CAME OUT IN
	
	1981, AND SINCE THAT TIME,
	THERE HAVE BEEN EFFORTS TO
	
	REFINE AND REALLY TRY TO
	PERFECT THE CLASSIFICATIONS.
	
	THE CLASSIFICATIONS ARE DONE
	USING VIDEO RECORDINGS OF
	
	PEOPLE WITH SEIZURES TOGETHER
	WITH THE ELECTRICAL PATTERNS
	
	SEEN ON EEG OR
	ELECTROENCEPHALOGRAPHY FROM
	
	EPILEPSY CENTERS
	AROUND THE WORLD.
	
	NEXT SLIDE.
	
	IN THIS SLIDE, I HAVE PLACED
	THE TERMINOLOGY, THE NAMES FOR
	
	THE SEIZURES, SIDE BY SIDE SO
	THAT YOU CAN COMPARE THE NAMES
	
	YOU OR YOUR PATIENTS MIGHT BE
	FAMILIAR WITH TO THE CURRENT
	
	TERMINOLOGY.
	
	AS SHOWN IN RED--AND I'M GONNA
	DISCUSS THIS FURTHER ON THE
	
	NEXT SLIDE--THE CURRENT TERMS
	FALL INTO ONE OF TWO
	
	CATEGORIES.
	
	SEIZURES ARE EITHER FOCAL
	OR GENERALIZED.
	
	ALTHOUGH IT'S HARD TO
	INCORPORATE NEW NAMES FROM
	
	THOSE WE ALL WORKED SO HARD TO
	PUT INTO MEMORY DURING OUR
	
	CLINICAL TRAINING, I THINK YOU
	WILL FIND THAT THE NEW NAMES
	
	ACTUALLY MAKE SENSE AND HELP
	BOTH OURS AND OUR PATIENTS
	
	UNDERSTAND SEIZURES BETTER.
	
	NEXT SLIDE.
	
	AS NOTED, THERE ARE ONLY TWO
	TYPES OF SEIZURES,
	
	AND THE NAME GIVEN
	TO THE SEIZURE TYPE,
	
	FOCAL OR GENERALIZED,
	
	REFERS TO THE WAY THAT THE
	SEIZURE ORIGINATES IN THE BRAIN.
	
	FOCAL SEIZURES START IN ONE
	SPECIFIC AREA OF THE BRAIN,
	
	WHEREAS GENERALIZED SEIZURES
	START IN THE WHOLE BRAIN AT
	
	THE SAME EXACT TIME.
	
	FOCAL SEIZURES CAN BE DIVIDED
	INTO FOCAL SEIZURES THAT START
	
	IN AN ISOLATED, FOCAL AREA OF
	THE BRAIN AND DO NOT INVOLVE
	
	ANY ALTERATION OF
	CONSCIOUSNESS.
	
	THE OTHER TYPE OF FOCAL
	SEIZURE IS AGAIN A SEIZURE
	
	THAT STARTS IN AN ISOLATED OR
	FOCAL AREA OF THE BRAIN,
	
	BUT IT INVOLVES ALERTNESS OR THE
	PERSON'S ABILITY TO INTERACT
	
	WITH THE WORLD.
	
	THIS IS ONE OF THE MOST COMMON
	SEIZURE TYPES, AND WE USED TO
	
	CALL IT COMPLEX
	PARTIAL SEIZURES.
	
	NOW, A SEIZURE THAT STARTS IN
	A FOCAL AREA OF THE BRAIN CAN
	
	OFTEN SPREAD WITH ELECTRICAL
	EXCITATION AND ACTIVITY ACROSS
	
	THE ENTIRE BRAIN.
	
	WHEN IT DOES THIS, IT IS
	CALLED A FOCAL SEIZURE WITH
	
	EVOLUTION TO A BILATERAL
	CONVULSIVE SEIZURE,
	
	PREVIOUSLY AND STILL CALLED
	SECONDARY GENERALIZATION.
	
	THE SECOND SEIZURE TYPE, SHOWN
	ON THE RIGHT SIDE OF
	
	THE SLIDE, IS GENERALIZED
	SEIZURES.
	
	THESE ARE ALL SEIZURES THAT
	INVOLVE WHOLE-BRAIN
	
	GENERALIZED ELECTRICAL
	INVOLVEMENT FROM THE ONSET OF
	
	THE SEIZURE.
	
	THESE SEIZURES ARE DIVIDED
	BASED ON THE CLINICAL
	
	SEMIOLOGY OF THE PERSON
	DURING THE SEIZURE.
	
	THE MOST FAMILIAR TYPE OF
	GENERALIZED SEIZURE IS THE
	
	TONIC-CLONIC SEIZURE, WHICH
	IS BILATERAL EXTENSION OF THE
	
	EXTREMITIES--THE TONIC PHASE--
	FOLLOWED BY THE CLONIC,
	
	OR JERKING-LIKE PHASE.
	
	NEXT SLIDE.
	
	WHAT WE WERE JUST TALKING
	ABOUT REFERRED TO
	
	THE CLASSIFICATION OF SEIZURES.
	
	NOW I'M GOING TO TALK ABOUT
	CLASSIFYING THE EPILEPSIES.
	
	AGAIN, THIS CLASSIFICATION
	RECENTLY CHANGED.
	
	HOWEVER, I THINK IT'S EASIEST
	TO UNDERSTAND
	
	THE CLASSIFICATION OF THE
	EPILEPSIES BY THINKING ABOUT
	
	THEM IN THE OLDER TERMINOLOGY
	AND THEN APPLYING THIS OLDER
	
	TERMINOLOGY TO THE NEW
	TERMINOLOGY.
	
	SO IN THE GOOD OLD DAYS, THERE
	WERE ONLY TWO TYPES
	
	OF EPILEPSIES, JUST LIKE THERE
	WERE ONLY TWO TYPES OF
	
	SEIZURES, AND THIS WAS SIMPLE
	ENOUGH FOR EVEN ME
	
	TO UNDERSTAND.
	
	EPILEPSIES WERE REFERRED TO AS
	EITHER PRIMARY OR SECONDARY.
	
	PRIMARY EPILEPSIES, ALSO
	CALLED IDIOPATHIC, MEANING WE
	
	HAD NO IDEA WHY THE PATIENT
	HAD EPILEPSY, USUALLY OCCUR IN
	
	CHILDREN AND YOUNG ADULTS WHO
	HAVE NORMAL BRAINS,
	
	AND GENERALLY ARE EASILY TREATED
	WITH ANTICONVULSANTS.
	
	NOW, ON THIS SLIDE, "AED"
	STANDS FOR ANTIEPILEPTIC
	
	DRUGS, AND I USE THAT
	INTERCHANGEABLY WITH THE WORD
	
	"ANTICONVULSANT."
	
	MANY OF THE PRIMARY EPILEPSIES
	ARE TEMPORARY CONDITIONS WITH
	
	ABATEMENT OF THE SEIZURES AND
	THE ABILITY TO STOP MEDICATION.
	
	ALTHOUGH IT WAS ASSUMED THAT
	MANY OF THESE EPILEPSIES WERE
	
	GENETIC DUE TO THEIR
	DISTRIBUTION IN FAMILIES,
	
	MANY OF THE GENES WERE UNKNOWN.
	
	NOW, SECONDARY EPILEPSIES, OR
	SYMPTOMATIC EPILEPSIES,
	
	ARE EPILEPSIES OCCURRING IN
	PEOPLE WHO HAVE A REASON FOR
	
	THEIR BRAIN TO RECURRENTLY HAVE
	ABERRANT ELECTRICAL DISCHARGES.
	
	THESE DISCHARGES OCCUR DUE TO
	SOME PATHOLOGY OR INSULT
	
	OF THE BRAIN.
	
	COMMONLY WE THINK ABOUT
	STROKES, TUMORS, OR TRAUMA.
	
	THESE EPILEPSIES HAVE VARIABLE
	RESPONSE TO ANTICONVULSANTS,
	
	SOME BEING VERY RESISTANT TO
	TREATMENT, AND THE PROGNOSIS
	
	IS ALSO VARIABLE, WITH
	SOMETIMES THE NEED FOR
	
	LIFELONG
	ANTICONVULSANT MEDICATIONS.
	
	NEXT SLIDE.
	
	THIS IS THE NEW TERMINOLOGY
	OF THE EPILEPSIES.
	
	THEY ARE NOW CLASSIFIED BY
	ETIOLOGY, AND ALTHOUGH THE NEW
	
	CLASSIFICATION IS SIMILAR TO
	WHAT I JUST DISCUSSED,
	
	IT REQUIRES MORE ADVANCED
	KNOWLEDGE IN EPILEPSY TO
	
	UNDERSTAND THE NUANCES, AND I
	DON'T THINK IT IS AS HELPFUL
	
	IN GENERAL PRACTICE.
	
	NEXT SLIDE.
	
	ONE CAUSE OF SECONDARY OR
	SYMPTOMATIC EPILEPSY IS
	
	BRAIN TRAUMA.
	
	EPILEPSY IS A WELL-KNOWN
	SEQUELLA OF HEAD TRAUMA,
	
	AND UNLIKE MOST OTHER OF THE
	SEQUELLAE, WHICH ARE APPARENT
	
	IMMEDIATELY, EPILEPSY CAN TAKE
	YEARS TO PRESENT AFTER
	
	THE INJURY.
	
	THERE IS A COHORT OF VETERANS
	FROM THE VIETNAM WAR WHO HAVE
	
	BEEN FOLLOWED AFTER SUFFERING
	COMBAT-RELATED HEAD TRAUMA,
	
	AND OVER 50% HAVE
	DEVELOPED EPILEPSY.
	
	BUT SOME OF THEM DIDN'T
	PRESENT WITH EPILEPSY UNTIL UP
	
	TO 20 YEARS AFTER
	THEIR INJURIES.
	
	FROM THIS COHORT OF VETERANS,
	ALONG WITH STUDIES OF VETERANS
	
	FROM ALL CONFLICTS WORLDWIDE
	IN THE 20th CENTURY, SLIGHTLY
	
	OVER HALF OF ALL VETERANS WHO
	HAVE SUFFERED A SPECIFIC TYPE
	
	OF BRAIN TRAUMA WILL
	EVENTUALLY DEVELOP EPILEPSY.
	
	THIS IS A STAGGERING NUMBER.
	
	NOW, IT'S UNCLEAR IF THE
	CURRENT CONFLICT, WHICH
	
	INVOLVES A DIFFERENT MECHANISM
	OF INJURY, BLASTS,
	
	AND A DIFFERENT SEVERITY,
	MAINLY MILD, WILL HAVE
	
	THE SAME INCIDENCE.
	
	NEXT SLIDE.
	
	A POINT THAT I ALLUDED TO
	EARLIER WHEN I WAS TALKING
	
	ABOUT INCIDENCE AND WANTED TO
	BE SURE TO REINFORCE NOW IS
	
	THAT EPILEPSY IN THE ELDERLY
	IS OFTEN UNDERDIAGNOSED
	
	AND MISDIAGNOSED.
	
	THIS IS AN EXTREMELY IMPORTANT
	POINT FOR ALL OF US WHOSE
	
	PATIENT PANELS ARE COMPRISED
	ALMOST ENTIRELY OF PERSONS
	
	OVER AGE 60.
	
	THE REASONS FOR UNDERDIAGNOSIS
	ARE MULTIPLE, BUT THE MAIN
	
	REASON IS THAT SEIZURES IN
	THIS AGE GROUP ARE MOST OFTEN
	
	FOCAL IN ONSET AND THE
	SYMPTOMS CAN BE SUBTLE,
	
	WITH LITTLE OR NO MOTOR
	MANIFESTATIONS.
	
	THEY OFTEN INVOLVE ALTERED
	MENTAL STATUS, AND IN THIS AGE
	
	GROUP, THE DIFFERENTIATION
	FOR ALTERED MENTAL
	
	STATUS IS LARGE.
	
	IT IS REALLY IMPORTANT TO
	REMEMBER TO THINK OF SEIZURE
	
	AS AN ETIOLOGY FOR ANY
	PAROXYSMAL COMPLAINT IN
	
	THE ELDERLY AND TO SPECIFICALLY
	THINK ABOUT IT WHEN
	
	FLUCTUATING MENTAL STATUS OR
	CONFUSION IS PRESENT.
	
	NEXT SLIDE.
	
	OK.
	
	WHAT DO YOU DO WHEN YOU THINK
	YOUR PATIENT MAY HAVE HAD
	
	A SEIZURE?
	
	THIS SLIDE OUTLINES THE
	GENERAL EVALUATION.
	
	THE FIRST KEY THING TO DO IS
	TO TRY TO FIGURE OUT FROM
	
	THE HISTORY THE LIKELIHOOD THE
	EVENT IN QUESTION REPRESENTS
	
	A SEIZURE.
	
	I THINK THIS IS A QUESTION
	WHERE NEUROLOGISTS
	
	OR EPILEPTOLOGISTS ARE
	UNDERUTILIZED.
	
	IT CAN BE VERY DIFFICULT AND
	OFTEN IMPOSSIBLE
	
	TO TEASE THIS OUT.
	
	MOST OFTEN, YOU WILL NEED TO
	EMPLOY A WITNESS TO THE EVENT
	
	TO GET AN ACCURATE
	DESCRIPTION.
	
	THIS TOGETHER WITH THE
	PATIENT'S RISK FACTORS
	
	FOR SEIZURES CAN BE HELPFUL IN
	PREDICTING THE LIKELIHOOD THAT
	
	THE EVENT WAS A SEIZURE.
	
	WHEN WORKING UP A SEIZURE OR A
	PRESUMED SEIZURE, YOU NEED TO
	
	OBTAIN A CHEMISTRY PANEL,
	LOOKING FOR ELECTROLYTE
	
	IMBALANCE.
	
	HYPO- OR HYPERGLYCEMIA,
	NATREMIA, OR KALEMIA
	
	CAN CAUSE SEIZURE.
	
	A DRUG SCREEN FOR COCAINE IN
	CERTAIN POPULATIONS CAN
	
	BE HELPFUL.
	
	AND CERTAINLY IF THE PATIENT
	IS ILL, CONSIDER A LUMBAR
	
	PUNCTURE TO EVALUATE
	FOR MENINGITIS.
	
	ELECTROENCEPHALOGRAPHY, OR
	EEG, PROVIDE THE MEANS
	
	TO EVALUATE THE ELECTRO FUNCTION
	OF THE BRAIN, AND IF POSITIVE,
	
	IS EXTREMELY HELPFUL.
	
	REMEMBER, HOWEVER, THAT IF
	NEGATIVE, IT DOES NOT MEAN
	
	THAT YOUR PATIENT DID NOT HAVE
	A SEIZURE OR DOES NOT
	
	HAVE EPILEPSY.
	
	AN EEG CAN ALWAYS BE DONE AS
	AN OUTPATIENT AFTER THEIR
	
	EVALUATION UNLESS THE PERSON
	DOES NOT RETURN TO BASELINE
	
	AFTER THE EVENT.
	
	IF THIS OCCURS, IT MUST BE
	DONE URGENTLY TO ENSURE THAT
	
	THEY ARE NOT HAVING
	ONGOING SEIZURES.
	
	ALL PATIENTS WHO HAVE HAD EVEN
	A SINGLE UNPROVOKED SEIZURE
	
	MUST HAVE BRAIN IMAGING
	WITH AN MRI.
	
	DO NOT WAIT UNTIL THE PATIENT
	HAS EPILEPSY TO OBTAIN AN MRI.
	
	A SINGLE SEIZURE WARRANTS
	BRAIN IMAGING.
	
	REMEMBER THAT SEIZURES IN
	MIDLIFE ARE LIKELY TO BE
	
	SYMPTOMATIC TO SOMETHING IN
	THE BRAIN, AND A COMMON
	
	PRESENTATION OF BRAIN TUMOR
	IS A SEIZURE.
	
	THIS DOESN'T NEED TO BE DONE
	URGENTLY, EITHER.
	
	HOWEVER, DO NOT FOREGO GETTING
	AN MRI BECAUSE THE EMERGENCY
	
	ROOM GOT A CT OF THE HEAD
	WHEN THEY PRESENTED.
	
	IN VETERANS, BRAIN MRI IS
	STANDARD OF CARE AFTER
	
	A SINGLE SEIZURE.
	
	IF YOUR FACILITY DOES NOT HAVE
	MRI, PLEASE REFER YOUR PATIENT
	
	TO A EPILEPSY CENTER OR A
	FACILITY, AND WE WILL PROVIDE
	
	THIS TESTING FOR YOU.
	
	NEXT SLIDE.
	
	I TALKED ABOUT EEG AS A TEST
	TO HELP EVALUATE SEIZURES.
	
	ALTHOUGH THE EEG CAN OFTEN BE
	NORMAL, THERE ARE PATTERNS OF
	
	EEG THAT CAN DIAGNOSE THE
	SEIZURE AND THE EPILEPSY TYPE.
	
	THIS IS AN EEG PATTERN FOR A
	GENERALIZED SEIZURE THAT
	
	REPRESENTS A PRIMARY EPILEPSY.
	
	AND THIS ONE TEST WOULD
	DIAGNOSE THIS PATIENT AND TELL
	
	US WHAT ANTICONVULSANT TO PUT
	THE PATIENT ON.
	
	NEXT SLIDE.
	
	AS I SAID, BRAIN IMAGING
	IS MANDATORY.
	
	IT IS KEY NOT TO MISS
	A BRAIN TUMOR.
	
	HOWEVER, THERE ARE OTHER
	ABNORMALITIES WE LOOK FOR,
	
	AND IN RECENT YEARS, THE
	CORRELATION BETWEEN THIS
	
	IMAGING ABNORMALITY SHOWN IN
	THE TOP RIGHT AND EPILEPSY HAS
	
	BECOME CLEAR.
	
	MESIAL TEMPORAL SCLEROSIS IS
	RELATED TO EPILEPSY,
	
	AND PERHAPS MOST IMPORTANTLY,
	PEOPLE WITH THIS IMAGING
	
	FINDING AND SEIZURES LOCALIZED
	TO THIS AREA HAVE AN EXTREMELY
	
	HIGH--OVER 90%--CHANCE OF
	CURATIVE EPILEPSY SURGERY.
	
	NEXT SLIDE.
	
	THESE ARE THE CURRENT MEANS
	TO TREAT EPILEPSY.
	
	ANTICONVULSANT DRUGS, EPILEPSY
	SURGERY, AND VAGAL NERVE
	
	STIMULATION ARE THE CURRENT
	TREATMENTS WE CAN OFFER
	
	OUR PATIENTS.
	
	THE KETOGENIC DIET IS NOT VERY
	EFFECTIVE IN ADULTS AND CAN BE
	
	VERY DIFFICULT TO ADMINISTER.
	
	THERE ARE SOME NEW THERAPIES
	THAT ARE UNDERGOING FDA
	
	REVIEW, AND I WILL BRIEFLY
	DISCUSS THESE.
	
	THEY ARE NOT CURRENTLY
	AVAILABLE FOR CLINICAL USE.
	
	NEXT SLIDE.
	
	THE GOALS OF THERAPY ARE
	SIMPLE: NO SEIZURES AND NO
	
	SIDE EFFECTS.
	
	GETTING TO THIS POINT,
	HOWEVER, IS NOT SO SIMPLE.
	
	NEXT SLIDE.
	
	IN A NEWLY DIAGNOSED PATIENT,
	ABOUT 70% OF PEOPLE IF PLACED
	
	ON AN APPROPRIATE
	ANTICONVULSANT WILL BE
	
	SUCCESSFULLY TREATED.
	
	THE WAY THAT THIS IS DONE IS
	TO CHOOSE A DRUG THAT CONTROLS
	
	THE SEIZURE TYPE AND USE THAT
	ONE DRUG IN MONOTHERAPY AT
	
	INCREASING DOSAGE UNTIL THE
	SEIZURES ARE COMPLETELY
	
	CONTROLLED.
	
	IF THEY ARE NOT CONTROLLED,
	THEN A SECOND DRUG IS TRIED.
	
	THE MOST COMMON REASON THAT
	THEY ARE NOT CONTROLLED OR ARE
	
	NOT SUCCESSFUL IS THAT THE
	ANTICONVULSANT IS NOT SLOWLY
	
	INCREASED TO THE MAXIMUM DOSE,
	OFTEN BECAUSE SERUM LEVELS ARE
	
	USED, AND WHEN THE DRUG IS
	FOUND TO BE WITHIN THE RANGE
	
	THAT A LAB DETERMINES AS
	THERAPEUTIC, THE TITRATION
	
	IS STOPPED.
	
	THE SERUM LEVEL SHOULD NOT BE
	USED IN THIS WAY.
	
	THE PATIENT THEMSELVES SHOULD
	BE USED, AND IF THEY ARE STILL
	
	HAVING SEIZURES, THE DRUG IS
	NOT THERAPEUTIC, DESPITE WHAT
	
	LEVEL IT IS, AND THAT
	ANTICONVULSANT
	
	SHOULD BE INCREASED.
	
	NOW, THAT'S AS LONG AS THE
	PATIENT IS NOT HAVING
	
	SIDE EFFECTS.
	
	THE SAME APPLIES ON THE LOW
	END OF THE THERAPEUTIC RANGE.
	
	IF THE PATIENT STOPS HAVING
	SEIZURES, IT DOESN'T MATTER IF
	
	A SERUM LEVEL IS NOT IN THE
	THERAPEUTIC RANGE.
	
	IT IS ACTUALLY THERAPEUTIC FOR
	THE PATIENT,
	
	AND THE ANTICONVULSANT SHOULD
	NOT BE INCREASED.
	
	NEXT SLIDE.
	
	HERE IS A LIST OF ALL THE
	ANTICONVULSANTS, AND THIS
	
	SLIDE IS REALLY A
	REFERENCE SLIDE.
	
	ON THE LEFT IS THE GENERIC
	NAME, IN THE MIDDLE IS
	
	THE UNIVERSAL STANDARD 3-LETTER
	ABBREVIATION, AND ON THE RIGHT
	
	IS THE BRAND NAME.
	
	NEXT SLIDE.
	
	THIS SLIDE PROVIDES A
	HISTORICAL PERSPECTIVE
	
	AND A OVERVIEW OF THE
	INTRODUCTION OF ANTIEPILEPTIC
	
	DRUG THERAPIES AND THEIR
	AVAILABLE FORMULATION CHOICES.
	
	ON THE RIGHT OF THE SLIDE, YOU
	CAN SEE THAT THE ADDITION OF
	
	EXTENDED RELEASE FORMULATIONS
	OF ESTABLISHED ANTIEPILEPTIC
	
	DRUG THERAPIES BEGAN OCCURRING
	IN THE MID 1990s
	
	AND REPRESENTS A DESIRE TO
	SIMPLIFY REGIMENS WITH
	
	EFFECTIVE THERAPIES WITH
	PREDICTABLE AND MANAGEABLE
	
	SIDE EFFECT PROFILES.
	
	NEXT SLIDE.
	
	THIS SLIDE LOOKS AT BOTH THE
	HISTORICAL INTRODUCTION OF
	
	THE ANTICONVULSANTS AND SHOWS
	HOW FEW CHOICES THERE WERE UNTIL
	
	THE MID 1990s.
	
	IT ALSO CLASSIFIES THE DRUGS
	INTO THE FIRST-GENERATION
	
	DRUGS, ON THE LEFT OF THE
	SLIDE, AND THE SECOND-
	
	GENERATION DRUGS, WHICH ARE
	SHOWN CLUSTERED THERE
	
	ON THE RIGHT OF THE SLIDE.
	
	NEXT SLIDE.
	
	THE FIRST-GENERATION DRUGS
	ARE OUR OLD FRIENDS.
	
	THEY'VE BEEN USED EXTENSIVELY,
	
	AND MOST OF US ARE VERY
	FAMILIAR WITH THEM.
	
	IN GENERAL, THEY CAN BE USED
	IN ALL SEIZURE TYPES,
	
	WITH THE EXCEPTION OF TEGRETOL
	OR CARBAMAZEPINE, WHICH ACTUALLY
	
	CAN MAKE GENERALIZED
	EPILEPSIES WORSE.
	
	I'M SORRY, BUT THIS SLIDE WAS
	TAKEN FROM A SLIDE SET OF MINE,
	
	AND THE ERROR IN
	UTILIZATION OF THE OLD
	
	TERMINOLOGY HERE WAS
	NOT CAUGHT.
	
	"FOCAL" SHOULD BE REPLACED BY
	THE WORD "PARTIAL."
	
	NEXT SLIDE.
	
	ONE OF THE MORE DIFFICULT
	PROBLEMS WITH USING THE FIRST-
	
	GENERATION DRUGS IS THAT THE
	DRUGS HAVE AN EFFECT ON LIVER
	
	ENZYMES AND HEPATIC
	METABOLISM, AND THEY GENERALLY
	
	INDUCE METABOLISM, EXCEPT FOR
	VALPROATE, DEPACON, WHICH
	
	INHIBITS METABOLISM.
	
	THE CLINICAL EFFECT OF THIS IS
	THAT OTHER MEDICATIONS CAN BE
	
	SIGNIFICANTLY ALTERED BY THIS
	PHARMOKINETICS, AND SOMETIMES
	
	THIS RENDERS THE OTHER DRUGS
	LESS OR NON-EFFECTIVE.
	
	THIS IS MOST OFTEN SEEN WITH
	STATENS, BIRTH CONTROL PILLS,
	
	ANTIBIOTICS, AND COUMADIN.
	
	IF YOUR PATIENT IS ON A FIRST-
	GENERATION DRUG, BE SURE TO
	
	LOOK AT THE OTHER MEDICATIONS
	TO ENSURE THAT THEY HAVE BEEN
	
	ADJUSTED ACCORDINGLY.
	
	NEXT SLIDE.
	
	THE SECOND-GENERATION DRUGS
	ARE THE DRUGS THAT ARE DESIGNER.
	
	THE MANUFACTURERS ACTUALLY SET
	OUT TO MAKE THESE DRUGS FOR
	
	EPILEPSY, AND THEY HAVE
	SPECIFIC MECHANISMS OF ACTION.
	
	IN GENERAL, THEY ARE SAFER TO
	USE, HAVE SIMPLE
	
	PHARMOKINETICS, WITH MUCH
	LOWER DRUG INTERACTIONS,
	
	AND ARE BETTER TOLERATED
	BY PATIENTS.
	
	THEY DON'T REQUIRE OR EVEN
	HAVE SERUM LEVELS.
	
	THIS, TOO, IS AN OLD SLIDE,
	AND AT THIS POINT, ALL OF THE
	
	SECOND-GENERATION DRUGS HAVE
	GENERICS AVAILABLE.
	
	AS MANY OF YOU ARE AWARE,
	THERE ARE CONTROVERSIES AROUND
	
	UTILIZING GENERIC
	ANTICONVULSANTS.
	
	BUT IN GENERAL, THIS IS NOT
	SUCH AN ISSUE WITHIN THE VA,
	
	WHERE WE HAVE A STABLE
	SUPPLIER, AND IT IS NOT
	
	AN ISSUE WHEN THE PATIENT IS
	STARTED ON A GENERIC FROM
	
	THE ONSET.
	
	IT IS MORE OF AN ISSUE WHEN
	YOU ARE TRYING TO CHANGE
	
	A PATIENT FROM A BRAND NAME
	TO A GENERIC.
	
	THESE MEDICATIONS CAN BE
	MORE EXPENSIVE.
	
	THAT IS ONE OF THE GREAT
	BENEFITS OF WORKING WITHIN
	
	THE VA, BECAUSE COST IS USUALLY
	NOT AN ISSUE IN OUR PATIENT
	
	POPULATION.
	
	WE HAVE THE PRIVILEGE OF
	CHOOSING THE BEST TREATMENT
	
	FOR OUR PATIENTS.
	
	DESPITE THE SEEMING EXPLOSION
	OF NEW DRUGS IN THE MID 1990s,
	
	NONE OF THESE DRUGS HAVE BEEN
	FOUND TO BE MORE EFFECTIVE
	
	THAN EACH OTHER OR THAN
	PREVIOUS DRUGS.
	
	NEXT SLIDE.
	
	HOW DO YOU CHOOSE A DRUG?
	
	THE BEST WAY IS TO TRY TO
	CHOOSE A DRUG THAT COVERS
	
	THE SEIZURE TYPE OF THE PATIENT,
	AND MY NEXT SLIDE IS GONNA
	
	ADDRESS THIS.
	
	OUTSIDE OF THIS, YOU CHOOSE
	ONE BASED ON THE SIDE EFFECTS
	
	BEST TOLERATED BY YOUR
	PATIENT, DRUG INTERACTIONS,
	
	DOSING REQUIREMENTS, AND OTHER
	COMORBID CONDITIONS.
	
	THIS CAN BE A DIFFICULT
	DECISION, AND OFTEN THESE
	
	DRUGS NEED TO BE
	USED LIFELONG.
	
	IF YOU ARE UNCERTAIN ABOUT
	ANTICONVULSANT CHOICE, PLEASE
	
	UTILIZE THE HELP OF AN
	EPILEPSY CENTER.
	
	NEXT SLIDE.
	
	DIAGNOSIS OF THE EPILEPSY
	SYNDROME, OR AT LEAST
	
	THE SEIZURE TYPE, IS THE FIRST
	STEP IN ANTICONVULSANT
	
	SELECTION.
	
	THIS SLIDE, WHICH DIVIDES
	SEIZURE TOPS--SEIZURE TYPES,
	
	I'M SORRY--AT THE TOP OF THE
	SCREEN, AND THEN IT LISTS
	
	THE ANTICONVULSANTS BY THEIR
	3-LETTER ABBREVIATIONS.
	
	SO YOU MAY NEED TO REFER BACK
	TO THE SLIDE WHERE I FIRST
	
	LIST THESE OUT IF YOU'RE NOT
	FAMILIAR WITH
	
	THE ABBREVIATIONS.
	
	BUT THIS NICELY BREAKS DOWN
	THE ANTICONVULSANTS INTO
	
	NARROW SPECTRUM, THE GROUP
	THAT'S UNDERNEATH FOCAL THERE,
	
	AND BROAD SPECTRUM,
	
	THE GROUP AT THE BOTTOM OF
	THE SLIDE.
	
	BROAD SPECTRUM AGENTS CAN BE
	LOOSELY DEFINED AS AGENTS THAT
	
	ARE EFFECTIVE AGAINST
	BOTH FOCAL
	
	AND GENERALIZED SEIZURES.
	
	WHILE THESE AGENTS MAY NOT BE
	EFFECTIVE AGAINST ALL
	
	GENERALIZED SEIZURES, THEY
	HAVE A LOWER RISK THAN
	
	THE NARROW SPECTRUM AGENTS
	OF AGGRAVATING
	
	GENERALIZED SEIZURES.
	
	ONE EXCEPTION MAY WELL BE
	LAMOTRIGINE SINCE IT APPEARS
	
	TO AGGRAVATE
	MYOCLONIC SEIZURES.
	
	IN CONTRAST, NARROW SPECTRUM
	AGENTS ARE TYPICALLY EFFECTIVE
	
	AGAINST FOCAL SEIZURES
	
	AND SECONDARY
	GENERALIZED SEIZURES.
	
	HOWEVER, THESE AGENTS HAVE A
	HIGHER RISK OF AGGRAVATING
	
	GENERALIZED NON-CONVULSIVE
	SEIZURES SUCH AS ABSENCE
	
	AND/OR MYOCLONIC SEIZURES.
	
	IF YOU ARE UNCLEAR IF THE
	SEIZURE IS FOCAL
	
	OR GENERALIZED, IT IS BEST TO
	USE A BROAD SPECTRUM
	
	ANTICONVULSANT.
	
	AGAIN, THESE ARE THE ONES
	LISTED IN A GROUP
	
	AT THE BOTTOM OF THE SLIDE.
	
	THIS SLIDE IS TAKEN FROM A
	FEDERAL PRACTITIONER
	
	SUPPLEMENT ABOUT EVALUATING
	AND MANAGING PATIENTS IN
	
	EPILEPSY THAT WAS
	PRINTED IN 2004.
	
	IF YOU ARE INTERESTED IN
	RECEIVING THIS SUPPLEMENT
	
	OR THIS SLIDE, IF YOU CONTACT
	ME, I CAN MAIL YOU ONE.
	
	NEXT SLIDE.
	
	ANTICONVULSANTS ALL HAVE TO
	CROSS THE BLOOD-BRAIN BARRIER
	
	IN ORDER TO WORK
	AGAINST SEIZURES.
	
	ALL OF THEM CAN CAUSE SIDE
	EFFECTS REFERABLE TO
	
	THE BRAIN, WITH DROWSINESS,
	COGNITIVE IMPAIRMENT,
	
	AND INCOORDINATION BEING COMMON.
	
	NEXT SLIDE.
	
	SOME OF THE ANTICONVULSANTS
	HAVE SIDE EFFECTS THAT ARE
	
	SPECIFIC TO THEM, AND THIS
	SLIDE CAN BE USED
	
	AS A REFERENCE IN YOUR
	SPECIFIC PATIENTS.
	
	NEXT SLIDE.
	
	I TALKED ABOUT USING MONOTHERAPY
	AND THE PATIENTS' RESPONSE TO
	
	ADJUST THE DOSAGE IN THE
	ANTICONVULSANT.
	
	THIS IS A REMINDER NOT TO USE
	SERUM LEVELS TO GUIDE
	
	YOUR TREATMENT.
	
	OFTEN THE PATIENT'S DOSAGE IS
	ADJUSTED EITHER UP OR DOWN
	
	AFTER THE LAB CALLS A PROVIDER
	TO TELL THEM THAT THE LEVEL IS
	
	NOT IN THERAPEUTIC RANGE.
	
	THESE ADJUSTMENTS HAVE THE
	POTENTIAL TO CAUSE EITHER
	
	SEIZURES OR SIDE EFFECTS, AND
	THE DOSAGE SHOULD NOT BE
	
	ADJUSTED BASED ON THE LAB.
	
	ADJUST THE DOSAGE BASED ONLY
	ON THE PATIENT.
	
	NEXT SLIDE.
	
	DESPITE MORE THAN 20
	ANTICONVULSANTS AND ALL THE
	
	NEW ANTICONVULSANTS, THE
	PROPORTION OF REFRACTORY
	
	PATIENTS HAS REMAINED
	ABOUT THE SAME.
	
	AS I SAID EARLIER, ABOUT 70%
	OF PATIENTS WILL BE ABLE TO BE
	
	TREATED WITH A DRUG.
	
	IT IS CLEAR FROM THE
	LITERATURE THAT IF A PATIENT
	
	DOES NOT RESPOND WELL TO A
	FIRST DRUG, THE CHANCE THAT
	
	THEY WILL BECOME SEIZURE-FREE
	DECREASES WITH EACH ADDITIONAL
	
	DRUG, AND ABOUT 20% OF
	PATIENTS WILL NOT BECOME
	
	SEIZURE-FREE AND WILL BE
	REFRACTORY TO MEDICATION--
	
	A GROUP THAT WE CALL MEDICALLY
	REFRACTORY EPILEPSY.
	
	NEXT SLIDE.
	
	THIS IS THE DEFINITION OF
	MEDICALLY REFRACTORY EPILEPSY.
	
	IF YOU HAVE TRIED TWO
	ANTICONVULSANTS ON YOUR
	
	PATIENTS AND THEY HAVE NOT
	ACHIEVED SEIZURE FREEDOM,
	
	IT IS LIKELY THAT THEY WILL FALL
	INTO THIS CATEGORY.
	
	THESE PATIENTS HAVE INCREASED
	MORBIDITY AND MORTALITY,
	
	AND OFTEN THE BEST OPTION FOR
	THESE PATIENTS IS SURGERY IF
	
	THEY ARE A CANDIDATE.
	
	PATIENTS THAT FALL INTO THIS
	CATEGORY NEED TO SEEK HELP
	
	FROM AN EPILEPSY CENTER.
	
	NEXT SLIDE.
	
	WHEN SEIZURES ARE NOT
	COMPLETELY CONTROLLED
	
	BY MEDICATION, THE PATIENT NEEDS
	TO BE EVALUATED.
	
	THEY NEED VIDEO EEG TO ENSURE
	THAT THE SEIZURES ARE INDEED
	
	ELECTRICAL EVENTS AND TO
	CORRECTLY DIAGNOSE THE TYPE OF
	
	SEIZURE TO ENSURE THE
	TREATMENT IS CORRECT.
	
	THIS EVALUATION CAN ALSO
	IDENTIFY PATIENTS WHO MAY BE
	
	SURGICAL CANDIDATES FOR
	THEIR EPILEPSY.
	
	NEXT SLIDE.
	
	THIS IS A PICTURE OF OUR
	MONITORING UNIT
	
	IN SAN FRANCISCO.
	
	THE PATIENTS ARE ADMITTED TO A
	STANDARD INPATIENT ROOM,
	
	WHERE EEG AND VIDEO IS HARDWIRED
	INTO THE WALL, AND IT CAN BE
	
	RECORDED CONTINUOUSLY.
	
	THEIR ANTICONVULSANT
	MEDICATION IS USUALLY
	
	WITHDRAWN WITH THE INTENT OF
	CAPTURING THEIR EVENTS
	
	AND CHARACTERIZING THESE.
	
	NEXT SLIDE.
	
	DURING THIS ADMISSION, WE CAN
	ALSO PROVIDE OTHER SPECIFIC
	
	TESTING TO HELP IN
	POSSIBLE TREATMENTS.
	
	NEXT SLIDE.
	
	THE SPECIALIZED TESTING ALLOWS
	FOR OPTIONS OF TREATMENTS FOR
	
	PATIENTS AND ALLOWS US TO
	GUIDE SURGICAL TREATMENT.
	
	NEXT SLIDE.
	
	EPILEPSY SURGERY IS THE
	TREATMENT OF CHOICE FOR
	
	CERTAIN PATIENTS, AND IN
	MEDICALLY REFRACTORY PATIENTS
	
	MAY BE THE ONLY
	EFFECTIVE MODALITY.
	
	THIS TREATMENT IS
	SIGNIFICANTLY UNDERUTILIZED
	
	ACROSS THE UNITED STATES AND
	SPECIFICALLY WITHIN THE VA.
	
	NEXT SLIDE.
	
	ANOTHER THERAPY AVAILABLE TO
	CERTAIN PATIENTS IS THE VAGAL
	
	NERVE STIMULATOR.
	
	THIS IS A PACEMAKER-LIKE
	DEVICE IMPLANTED IN THE CHEST.
	
	IT OFTEN REDUCES SEIZURES BUT
	USUALLY DOES NOT COMPLETELY
	
	CONTROL SEIZURES.
	
	IT HAS VERY FEW SIDE EFFECTS
	AND WORKS ABOUT THE SAME
	
	AS AN ANTICONVULSANT DRUG.
	
	NEXT SLIDE.
	
	THERE ARE TWO NEW TREATMENTS
	ON THE HORIZON.
	
	ALTHOUGH THE PRESS TALKED
	ABOUT USING DEEP BRAIN
	
	STIMULATION, DBS, AND THERE
	ARE GOOD STUDIES SHOWING
	
	EFFE3CTIVENESS, THIS THERAPY
	WILL NOT BE AVAILABLE IN THE
	
	U.S. IN THE NEXT FEW
	COMING YEARS.
	
	THE THERAPY THAT YOU WILL BE
	HEARING ABOUT IS LABELED UNDER
	
	THE NAME NEUROPACE, AND IT
	INVOLVES IMPLANTATION OF
	
	ELECTRODES IN AN AREA OF THE
	BRAIN AS WELL AS IMPLANTATION
	
	OF A PACEMAKER-LIKE DEVICE
	INTO THE SKULL.
	
	NEXT SLIDE.
	
	THIS SLIDE DETAILS WHEN TO
	REFER A PATIENT TO AN EPILEPSY
	
	SPECIALIST.
	
	I THINK THAT THIS MOST
	IMPORTANT DETERMINANT IS
	
	WHENEVER YOU HAVE A QUESTION
	OR NEED HELP CARING FOR
	
	A PATIENT WITH EPILEPSY.
	
	THE CENTERS ARE HERE TO HELP
	YOU AS A PROVIDER AND TO
	
	HELP VETERANS.
	
	NEXT SLIDE.
	
	ONE POINT, HOWEVER, NEEDS TO
	BE UNDERSCORED.
	
	IF YOU HAVE A PATIENT THAT
	DOES NOT HAVE COMPLETE SEIZURE
	
	CONTROL, THEY SHOULD BE
	REFERRED FOR FURTHER
	
	EVALUATION.
	
	NEXT SLIDE.
	
	NOW I'M GOING TO SWITCH GEARS
	AND TALK ABOUT THE NEW
	
	EPILEPSY CENTERS OF EXCELLENCE
	AND THEIR ORGANIZATIONS.
	
	NEXT SLIDE.
	
	THE EPILEPSY CENTERS WERE
	ESTABLISHED IN 2008 AS
	
	A CONGRESSIONAL MANDATE UNDER
	PUBLIC LAW 110.
	
	THIS WAS DONE IN CONGRESS IN
	RESPONSE TO THE ANTICIPATED
	
	NEED FOR EPILEPSY CARE,
	KNOWING THAT IN ALL PRIOR
	
	MILITARY CONFLICTS, OVER HALF
	OF VETERANS WITH PENETRATING
	
	HEAD INJURY WILL EVENTUALLY
	DEVELOP EPILEPSY.
	
	THIS WAS DONE PROSPECTIVELY,
	AND I AM DELIGHTED TO BE PART
	
	OF A SYSTEM THAT HAS BEEN
	ALLOWED TO BE BUILT BEFORE
	
	THERE WAS A PROBLEM THAT
	NEEDED TO BE FIXED.
	
	THIS IS DEFINITELY A SHIFT IN
	PARADIGM FOR HEALTH CARE.
	
	NEXT SLIDE.
	
	THE REQUIREMENTS OF THE PUBLIC
	LAW ARE AS FOLLOWS: VETERANS
	
	AFFAIRS WAS TO ESTABLISH 4 TO 6
	EPILEPSY CENTERS AND APPOINT
	
	AN OVERALL DIRECTOR.
	
	EACH OF THE CENTERS MUST BE
	LINKED TO AN EXISTING
	
	POLYTRAUMA CENTER AND MUST BE
	LINKED TO AN ACADEMIC CENTER
	
	AND CONDUCT RESEARCH.
	
	THEY MUST BE ESTABLISHED BY A
	PEER REVIEW PANEL,
	
	BE GEOGRAPHICALLY DISPERSED, AND
	BE INVOLVED WITH EDUCATION
	
	AND FELLOWSHIP TRAINING.
	
	THE FUNDING LEVEL WAS SET AT
	$6 MILLION PER YEAR FOR
	
	THE OVERALL SYSTEM.
	
	NEXT SLIDE.
	
	BASED ON THESE REQUIREMENTS,
	AN ORGANIZATION WAS CREATED
	
	THAT DIVIDED THE UNITED STATES
	INTO 4 REGIONS, EACH LINKED TO
	
	ONE OF THE 4 POLYTRAUMA
	CENTERS, AND EACH HAD
	
	ESTABLISHED VA CENTERS WHO ARE
	ALREADY INVOLVED IN EPILEPSY
	
	CARE WITHIN THE VA.
	
	AS YOU CAN SEE FROM THIS
	WRITTEN SLIDE--AND I'LL SHOW
	
	THIS ON A PICTURE IN A MINUTE--
	
	EACH OF THE STATES ARE
	DIVIDED INTO REGIONS.
	
	SO IF YOU LOCATE THE STATE
	THAT YOU'RE IN ON THE RIGHT
	
	SIDE OF THE SLIDE, YOU CAN
	LOOK AT THE REGION THAT YOUR
	
	STATE IS AFFILIATED WITH.
	
	NEXT SLIDE.
	
	PICTORIALLY, THE REGIONS
	LOOK LIKE THIS.
	
	NOW, THIS IS NOT AN EVEN
	DIVISION ACROSS THE UNITED
	
	STATES, BUT REMEMBER THAT OUR
	POPULATION DOES NOT LIVE IN
	
	AN EVEN DIVISION AND THAT THERE
	IS AN ABUNDANCE OF VETERANS IN
	
	CERTAIN STATES, LIKE FLORIDA.
	
	IF YOU LOOK ON THIS MAP AND
	IDENTIFY YOUR STATE AND YOUR
	
	REGION, REMEMBER ITS COLOR
	BECAUSE I'M GONNA TALK ON
	
	THE NEXT SLIDES ABOUT THE COLOR.
	
	THIS'LL GUIDE YOU ON
	DETERMINING WHERE YOU SHOULD
	
	SEEK REFERRAL HELP.
	
	SO, LOOKING AT THIS MAP, IF
	YOU ARE IN A YELLOW STATE,
	
	THAT IS THE NORTHEAST REGION.
	
	NEXT SLIDE.
	
	AND THESE ARE THE CENTERS IN
	THE NORTHEAST REGION WHO ARE
	
	READY TO HELP YOU AND
	YOUR PATIENTS.
	
	I HAVE A SPECIFIC SLIDE AT THE
	END WITH ACTUAL PHONE NUMBERS,
	
	AND ALL OF THE PHYSICIANS CAN
	BE FOUND ON THE GLOBAL
	
	VA OUTLOOK.
	
	NEXT SLIDE.
	
	THESE ARE THE
	NORTHWEST SLIDES.
	
	IF YOU ARE IN A GREEN STATE,
	THIS IS YOUR REGION.
	
	NEXT SLIDE.
	
	THE SOUTHEAST SITES, THE RED
	STATES ON THE MAP, ARE IN
	
	THIS REGION.
	
	NEXT SLIDE.
	
	AND THE BLUE STATES, THE
	SOUTHWEST SITES, ARE ON
	
	THIS SLIDE.
	
	NOTE THAT THERE IS GOING TO BE
	A SITE IN SAN ANTONIO WHICH IS
	
	ALSO A PLANNED SITE FOR A
	FIFTH VA POLYTRAUMA CENTER.
	
	THAT'S ALREADY BEING BUILT AND
	WILL BE FINISHED SHORTLY.
	
	NEXT SLIDE.
	
	HERE ARE THE NAMES, STATION
	NUMBERS, AND CONTACT
	
	INFORMATION FOR EACH SITE.
	
	PLEASE FEEL FREE TO CONTACT
	ANY OF US IN ANY REGION, EVEN
	
	OUTSIDE YOUR REGION, FOR HELP
	AND INFORMATION.
	
	ALSO, YOU CAN UTILIZE OUR
	WEBSITE FOR THE SAME.
	
	I HAVE THE ADDRESS FOR THE
	WEBSITE AT THE END OF THIS
	
	PRESENTATION.
	
	IN THE FUTURE, WE HOPE TO BE
	ABLE TO HAVE A REFERRAL SYSTEM
	
	BUILT INTO THE WEBSITE FOR
	BOTH PROVIDERS AND VETERANS.
	
	NEXT SLIDE.
	
	THE GOALS OF THE EPILEPSY
	CENTERS ARE TO DELIVER THE
	
	HIGHEST-QUALITY CARE TO
	VETERANS WITH EPILEPSY,
	
	TO ESTABLISH A NETWORK FOR
	REGIONAL EPILEPSY CARE THAT
	
	COVERS THE ENTIRE UNITED
	STATES SO THAT VETERANS LIVING
	
	IN ANY AREA HAVE ACCESS TO
	TERTIARY-LEVEL CARE,
	
	TO PROMOTE OUTREACH AND
	EDUCATIONAL EFFORTS IN
	
	THE COMMUNITY, AND TO PROVIDE AN
	EFFICIENT AND COST-EFFECTIVE
	
	MECHANISM OF CARE
	DELIVERY THAT REDUCES
	
	FEE-BASED SPENDING.
	
	NEXT SLIDE.
	
	HERE ARE SOME WEB RESOURCES
	THAT HAVE ADDITIONAL
	
	INFORMATION AVAILABLE AND CAN
	BE USED BY BOTH YOU
	
	AND YOUR PATIENTS.
	
	HERE'S OUR WEBSITE ADDRESS.
	
	THANK YOU FOR YOUR ATTENTION,
	AND I WANT TO THANK
	
	SEAN GAMBLE AND THE EMPLOYEE
	EDUCATION SYSTEM FOR THEIR
	
	PARTNERSHIP AND EXCELLENT
	SUPPORT WITH THIS PROGRAM.
	
	PLEASE PLAN ON TUNING IN TO
	OUR NEXT AUDIO CONFERENCE ON
	
	MAY 4, WHEN DR. PAUL RUTECKI
	FROM THE NORTHWEST REGION WILL
	
	TALK ABOUT EPILEPSY AND
	TRAUMATIC BRAIN INJURY.
	
	IF YOU WANT CONTINUING
	EDUCATION CREDITS, REMEMBER TO
	
	FILL OUT THE REQUIRED
	EVALUATION.
	
	THE EPILEPSY CENTERS ARE
	ESPECIALLY INTERESTED IN YOUR
	
	FEEDBACK REGARDING
	FUTURE PROGRAMMING.
	
	WE WANT TO MEET YOUR NEEDS.
	
	SO LET US KNOW WHAT YOU'D
	LIKE TO HEAR ABOUT.
	
	THANK YOU, AND I'M OPEN
	FOR QUESTIONS.
	
	- THANK YOU, DR. PARKO, FOR
	THAT REALLY GOOD POWERPOINT
	
	PRESENTATION.
	
	IF ANYBODY HAS ANY QUESTIONS,
	DR. PARKO IS ON THE LINE.
	
	IS THERE ANY QUESTIONS?
	
	- YES.
	
	I'M SPEAKING FROM [INDISTINCT].
	
	- ALL RIGHT. GO AHEAD.
	
	- AND I WANT TO KNOW WHAT IS
	THE BREAKTHROUGH SEIZURE?
	
	- THE PHONE IS BREAKING UP A
	LITTLE, BUT I THINK THE
	
	QUESTION IS, WHAT IS A
	BREAKTHROUGH SEIZURE?
	
	- RIGHT, RIGHT.
	
	- OK.
	
	THANK YOU FOR ASKING
	THAT QUESTION.
	
	A BREAKTHROUGH SEIZURE IS A
	SEIZURE THAT OCCURS WHEN
	
	A PATIENT IS ON A KNOWN REGIMEN
	OF DRUGS AND IS USUALLY
	
	CONTROLLED BUT THEN THEY
	HAVE A SEIZURE.
	
	- OH, GREAT. THANK YOU.
	
	- A SEIZURE THAT BREAKS
	THROUGH MEDICATION.
	
	DOES THAT ANSWER
	YOUR QUESTION?
	
	- RIGHT. THANK YOU.
	
	- THANK YOU.
	
	- [INDISTINCT].
	
	DR. PARKO, THANK YOU FOR THE
	EXCELLENT REVIEW.
	
	I HAVE TWO QUESTIONS.
	
	ONE IS, WHAT'S THE MAXIMUM
	DOSE FOR LEVETIRACETAM?
	
	AND THE SECOND ONE IS, IS THAT
	BASICALLY, A PATIENT OF MINE
	
	WHO WAS SEEN AT MADISON VA
	3 YEARS AGO
	
	AND I WOULD LIKE TO REFER
	HIM BACK TO AN EPILEPSY CENTER.
	
	AND SINCE WE ARE IN THE
	SOUTHWEST, DO I NEED TO SEND
	
	HIM TO HOUSTON VA?
	
	AND I'M NOT AWARE OF HOUSTON
	VA DOING EPILEPSY [INDISTINCT].
	
	- EXCELLENT.
	
	THANK YOU FOR THOSE QUESTIONS.
	
	LET ME TAKE THEM
	ONE AT A TIME.
	
	THE FIRST ONE WAS THE MAXIMUM
	DOSE OF LEVETIRACETAM
	
	OR KEPPRA.
	
	- YES.
	
	- AND WITH ALL THE
	ANTICONVULSANTS, THERE'S NOT
	
	REALLY A MAXIMUM DOSE.
	
	MOST EPILEPTOLOGISTS CONTINUE
	TO INCREASE A DOSAGE AS LONG
	
	AS THE PATIENT HAS A RESPONSE.
	
	AND SO WITHIN THE PDR, A DOSE
	THAT'S LISTED AS A MAXIMUM
	
	DOSE IS USUALLY NOT A MAXIMUM
	DOSE THAT WE WILL USE.
	
	A COMMON DOSE FOR KEPPRA IS 3
	GRAMS A DAY, BUT AGAIN, I HAVE
	
	PATIENTS ON MUCH LOWER DOSE
	THAN THAT, AND I HAVE PATIENTS
	
	ON MUCH HIGHER DOSE.
	
	DOES THAT ANSWER
	THAT QUESTION?
	
	- YES. I MEAN, I TRY IT UP TO
	3,000, AND THEN NO RESPONSE.
	
	SO I BACK IT
	OFF FROM THAT. SO...
	
	- AND AGAIN, THE MAXIMUM
	DOSE--IF YOU HAVE NO RESPONSE,
	
	THEN WE TEND NOT TO GO
	UP REALLY HIGH.
	
	BUT IF YOU'RE GETTING A GOOD
	RESPONSE IN A PATIENT, YOU CAN
	
	PUSH A DRUG VERY, VERY HIGH AS
	LONG AS THE PATIENT IS
	
	TOLERATING IT AND DOESN'T
	HAVE SIDE EFFECTS.
	
	- OK. THANK YOU.
	
	- BUT IF THEY'D HAD NO
	RESPONSE, I WOULDN'T
	
	CONTINUE PUSHING.
	
	- OK.
	
	- NOW, THE SECOND QUESTION IS
	ACTUALLY A GREAT QUESTION,
	
	AND THANK YOU
	FOR BRINGING IT UP.
	
	YOU HAVE A PATIENT THAT WENT
	TO MADISON, BUT YOU'RE
	
	CURRENTLY WITHIN THE
	SOUTHWEST REGION.
	
	THESE REGIONS AND THIS
	DIVISION ARE NOT HARD AND FAST.
	
	THEY ARE PUT THERE
	SPECIFICALLY TO TRY TO HELP
	
	DIRECT CARE AND NOT TO
	IMPEDE CARE.
	
	SO IF YOU HAVE A PATIENT OR A
	RELATIONSHIP WITH MADISON,
	
	YOU CAN CONTINUE TO UTILIZE THAT
	RELATIONSHIP, AND CERTAINLY IF
	
	THEY KNOW YOUR PATIENT, IT'S
	PROBABLY THE BEST THING
	
	FOR THAT PATIENT.
	
	HOWEVER, IF THE PATIENT WANTS
	A CENTER CLOSER BY YOU,
	
	THEN YOU CAN USE ONE OF THE
	CLOSER ONES.
	
	HOUSTON AND SAN ANTONIO BOTH
	DO FULL--THEY'RE COMPREHENSIVE
	
	CENTERS, SO THEY DO BOTH
	EPILEPSY AND MONITORING.
	
	BUT ANYPLACE--I MEAN, THIS IS
	REALLY VETERAN-DEPENDENT.
	
	SOMETIMES THERE'S A VETERAN
	THAT LIVES IN A CERTAIN AREA
	
	BUT THEY HAPPEN TO HAVE CLOSE
	FAMILY CLOSE TO A VA CENTER,
	
	AND THAT'S AN OK REASON, ALSO,
	TO REFER TO A SPECIFIC CENTER.
	
	DON'T FEEL BOUND BY
	THE BOUNDARIES.
	
	THEY'RE SUPPOSED TO
	HELP, NOT INHIBIT.
	
	DOES THAT HELP?
	
	- YES, DEFINITELY. THANK YOU.
	
	- DR. PARKO?
	
	- YES.
	
	- MY NAME IS KIRSTEN.
	
	I'M AT THE LITTLE ROCK VA AT
	McCLELLAN, AND I WAS JUST
	
	CURIOUS--I'M AN EEG TECH--JUST
	FROM A TECH STANDPOINT,
	
	HOW MANY BEDS DO YOU GUYS
	TYPICALLY HAVE IN AN EPILEPSY
	
	CENTER OF EXCELLENCE?
	
	- HI, KIRSTEN.
	
	IT DEPENDS ON THE
	CENTER ITSELF.
	
	HERE IN SAN FRANCISCO, WE HAVE
	4 MONITORING UNIT BEDS.
	
	- OK. THANK YOU.
	
	- NOW, EVERYBODY DOES IT
	A LITTLE DIFFERENT.
	
	WE HAVE 4 FIXED BEDS, AND WE
	HAVE A PORTABLE ONE THAT WE
	
	USE FOR OUR ICU BECAUSE WE
	DON'T HAVE A FIXED BED
	
	IN OUR ICU.
	
	BUT USUALLY
	CENTERS ARE DIFFERENT.
	
	- OK.
	
	- DR. PARKO?
	
	- YES.
	
	- YEAH.
	
	I'M CALLING FROM THE MIDWEST
	STATES, AND WE SEEM TO HAVE
	
	A PROBLEM HERE AS FAR AS WITH
	THE USE OF THE VAGAL NERVE
	
	STIMULATOR.
	
	AND SOME OF THE EPILEPSY
	CENTERS THAT WE REFER TO FOR
	
	OUR MONITORING THAT OUR
	PATIENTS GO TO BE EVALUATED
	
	ARE VERY MUCH AGAINST EVEN
	RECOMMENDING ANYBODY FOR
	
	THE VAGAL NURSE STIMULATOR.
	
	WOULD YOU TELL ME WHAT YOUR
	PARAMETERS ARE AS FAR AS FOR
	
	USE OF THE VAGAL NERVE
	STIMULATOR WHEN THE PATIENT IS
	
	APPROPRIATE FOR IT AND WHY
	SOME OF THESE VAs HAVE SUCH
	
	A STANCE AGAINST THE
	USE OF THIS?
	
	- SURE.
	
	CAN YOU TELL ME WHAT YOU MEAN
	WHEN YOU SAY YOU HAVE
	
	VNS PROBLEMS?
	
	DO YOU MEAN PATIENTS
	ARE HAVING--
	
	- WE HAVE PATIENTS THAT--YOU
	KNOW, WE HAVE SOME PEOPLE THAT
	
	HAVE THE LEFT TEMPORAL LOBES
	AND THEY HAVE, YOU KNOW,
	
	LANGUAGE AND THINGS COMING
	FROM WITHIN THE REGION.
	
	THEY CAN'T BE CONTROLLED, OR
	THEY DO NOT WANT A MORE
	
	INVASIVE EPILEPSY SURGERY.
	
	AND WE CAN'T CONTROL THEM ON
	ANY ANTICONVULSANTS.
	
	WE REFER UP TO THE CENTER AS
	FAR AS FOR MONITORING,
	
	AND THEY TALK VERY MUCH AGAINST
	THE VAGAL NERVE STIMULATOR,
	
	SEND THEM BACK HOME ON
	MEDICATIONS THAT WE TRIED
	
	OR THAT HAVEN'T WORKED, AND THE
	PATIENT THEN HAS A VERY
	
	BITTER TASTE IN THEIR MOUTH
	AND THEY DON'T EVEN WANT TO
	
	HEAR ABOUT VAGAL NERVE
	STIMULATORS.
	
	SO CAN YOU KIND OF GIVE
	YOUR OPINION?
	
	- SURE.
	
	I CAN TELL YOU WHAT MY OPINION
	IS, AND IT'S HARD WITHOUT
	
	TALKING ABOUT A SPECIFIC
	PATIENT TO KNOW THE DETAILS,
	
	BUT VAGAL NERVE STIMULATION IS
	A THERAPY THAT WORKS ABOUT
	
	AS WELL AS AN ANTICONVULSANT.
	
	IT RARELY CAUSES COMPLETE
	SEIZURE FREEDOM.
	
	THE NICE PART OF VAGAL NERVE
	STIMULATION IS THAT IT TENDS
	
	TO HAVE LESS CENTRAL NERVOUS
	SYSTEM SIDE EFFECTS--SO LESS
	
	SEDATION AND
	COGNITIVE IMPAIRMENT.
	
	IT DOES REQUIRE THAT IT'S PUT
	IN IN A PLACE WHERE
	
	THE SURGEONS, EITHER ENT OR
	NEUROSURGEONS, KNOW HOW TO DO
	
	IT, AND IT HAS TO BE MONITORED
	OVER THE COURSE OF TIME WITH
	
	SOMEONE WHO KNOWS HOW
	TO PROGRAM IT.
	
	THE EFFECTS OF THE
	PROGRAMMING, UNLIKE
	
	A MEDICATION, CAN TAKE A LONG
	TIME TO TAKE EFFECT.
	
	SO IF YOU CHANGE PARAMETERS,
	
	THE CHANGE DOESN'T HELP
	RIGHT AWAY.
	
	IT CAN TAKE MONTHS TO
	TAKE EFFECT.
	
	WE UTILIZE VAGAL NERVE
	STIMULATION IN PATIENTS THAT
	
	HAVE NOT RESPONDED TO
	MEDICATION AND ARE NOT
	
	SURGICAL CANDIDATES, AND THE
	REASON THAT I PUT THAT CAVEAT
	
	IN THERE IS THAT FOR MOST
	PATIENTS THAT ARE SURGICAL
	
	CANDIDATES, THEIR CHANCES OF
	HAVING SEIZURE FREEDOM ARE
	
	MUCH HIGHER IF THEY UNDERGO AN
	EPILEPSY SURGERY, A RECEPTIVE
	
	SURGERY, THEN IF
	THEY HAVE VNS.
	
	SO MY FIRST LINE OF TREATMENT
	FOR THOSE PATIENTS IS REALLY
	
	TO RECOMMEND AN
	EPILEPSY SURGERY.
	
	NOW, NOT EVERYBODY WANTS AN
	EPILEPSY SURGERY, AND NOT
	
	EVERYBODY IS ACTUALLY A
	CANDIDATE FOR EPILEPSY SURGERY.
	
	SO IN THAT SELECT GROUP OF
	PATIENTS, WE DO USE VNS.
	
	I LIKE TO USE VNS, AND OUR
	CENTER OFFERS IT AND IS VERY
	
	COMFORTABLE GIVING IT.
	
	IT'S A LITTLE DIFFICULT WHEN
	PATIENTS ARE REFERRED FROM
	
	DISTANCE BECAUSE AGAIN IT
	TAKES ONGOING MANIPULATION
	
	OR PROGRAMMING OF THE VNS THAT
	HAS TO BE DONE BY SOMEONE THAT
	
	KNOWS HOW TO DO THAT.
	
	I HAVE AN EXPEDIATED METHOD
	THAT WE USE FOR OUR PATIENTS
	
	THAT ARE FAR AWAY, AND IT'S
	PRETTY WELL TOLERATED.
	
	BUT DIFFERENT CENTERS WILL
	HAVE DIFFERENT EXPERIENCE AND
	
	DIFFERENT SURGEONS WHO WILL OR
	WILL NOT BE COMFORTABLE
	
	PLACING IT.
	
	CERTAINLY IF IT'S SOMETHING
	THAT YOUR PATIENT WANTS,
	
	I WOULD ENCOURAGE YOU TO FIND A
	CENTER THAT WILL PROVIDE IT
	
	FOR THAT PATIENT, AND MOST ALL
	US WILL,
	
	BUT I'LL OFFER BECAUSE
	I'M ON THE LINE.
	
	THE SAN FRANCISCO CENTER
	CERTAINLY WILL, AND IF YOU
	
	HAVE A PATIENT WHO IS A
	CANDIDATE, WE'D BE HAPPY TO
	
	HELP YOU WITH THAT.
	
	YOU CAN CONTACT ME, AND WE
	CAN SET THAT UP.
	
	- THANK YOU.
	
	- DID THAT ANSWER
	THE QUESTION?
	
	- DR. PARKO?
	
	- YES.
	
	- HI. THIS IS DR.[INDISTINCT]
	
	FROM CLEVELAND AT THE
	LOUIS STOKES VA.
	
	TWO QUESTIONS: ONE OF THEM,
	AMBULATORY VIDEO EEG,
	
	AND THE OTHER ONE, ICU BEDSIDE
	CONTINUOUS EEG MONITORING.
	
	THE FIRST QUESTION--IT'S PAST
	THE [INDISTINCT]
	
	COMPUTER TECHNOLOGY, CURRENT
	EEGs, AMBULATORY--A FEW OF
	
	THEM NOW WITH VIDEO...
	
	[CLICKING AND STATIC]
	
	THEY HAVE PRETTY GOOD QUALITY.
	
	SO DO WE HAVE--I MEAN, IS
	THERE ANY USE OF AMBULATORY
	
	VIDEO EEG IN CARING FOR
	PEOPLE WITH EPILEPSY?
	
	AND THERE ARE SOME ADVANTAGES
	AND CERTAINLY SOME
	
	DISADVANTAGES, SEVERAL
	DISADVANTAGES.
	
	[INDISTINCT].
	
	THE SECOND ONE IS, THE BEDSIDE
	MONITORING, IT'S REALLY TOUGH
	
	TO TRANSPORT THIS ICU
	PATIENT [INDISTINCT].
	
	AND SO BEFORE SENDING A PATIENT
	TO ANOTHER UNIVERSITY,
	
	A LOCAL UNIVERSITY, WE WILL
	
	TRY TO DO THE BEST WE CAN HERE
	AT CLEVELAND'S VA,
	
	DOING VIDEO EEGs
	ON THE BEDSIDE.
	
	IS THERE ANY GUIDELINES ABOUT
	WHAT POINT WE HAVE TO TRANSFER
	
	THE PATIENT TO ANOTHER
	[INDISTINCT] UNIT?
	
	LIKE A SAFETY OR ANY OTHER
	GUIDELINE THAT IS CLARIFIED
	
	OR [INDISTINCT].
	
	THANK YOU.
	
	- WELL, LET ME START WITH THE
	AMBULATORY VIDEO EEG.
	
	THIS IS SOMETHING THAT IS
	OFFERED AT SOME OF THE CENTERS.
	
	IT'S NOT SOMETHING THAT I
	UTILIZE AT THE SAN FRANCISCO VA.
	
	I HAVE NOT FOUND--TECHNOLOGY
	IS IMPROVING, BUT I HAVE NOT
	
	FOUND IN THE PAST THE
	AMBULATORY EEG IS ALL THAT
	
	MUCH BETTER OVER OUTPATIENT
	EEG, AND FOR MOST OF THE
	
	PATIENTS THAT YOU'RE LOOKING
	TO CHARACTERIZE CELLS AND TO
	
	TRY TO FIGURE OUT WHAT IS
	GOING ON BECAUSE THEY'RE
	
	MEDICALLY REFRACTORY, I THINK
	THE OPTION FOR COMING INTO
	
	IN ACTUAL FIXED UNIT IS A MUCH
	BETTER OPTION BECAUSE OFTEN
	
	THAT CAN BE DONE IN THE SAME
	AMOUNT OF TIME
	
	AS THE AMBULATORY EEG, AND IT
	JUST SHOWS HIGHER-QUALITY DATA.
	
	USUALLY IF AN AMBULATORY EEG
	IS POSITIVE, THE NEXT STEP IS
	
	TO GET VIDEO EEG, ANYWAY, AND
	SO I THINK IT'S BEST TO DO
	
	THAT FROM THE PATIENT'S
	STANDPOINT ALL AT ONCE UP FRONT.
	
	AGAIN, THAT'S AN OPINION.
	
	DIFFERENT PEOPLE HANDLE
	THIS DIFFERENTLY.
	
	NOW, AS FAR AS THE ICU
	RECORDINGS, THERE AREN'T
	
	GUIDELINES FOR TRANSFER.
	
	THE GUIDELINES WOULD BE, YOU
	KNOW, TO TRANSFER CERTAINLY IF
	
	YOU'RE UNCOMFORTABLE WITH IT OR
	IF IT'S SOMETHING THAT YOU DON'T
	
	FEEL CAN BE HANDLED AT THE
	CLEVELAND VA FOR WHATEVER
	
	REASON--AND EACH VA HAS
	DIFFERENT REASONS.
	
	SOMETIMES THERE'S NOT
	TECHNOLOGICAL SUPPORT.
	
	SOMETIMES THERE'S
	NOT EQUIPMENT.
	
	YOU KNOW, SOMETIMES NURSING
	CARE BECOMES AN ISSUE.
	
	SO THERE AREN'T STRICT
	GUIDELINES FOR THAT, AND IF
	
	YOU ARE IN A SITUATION WHERE
	YOU'RE DEALING WITH A PATIENT
	
	AND YOU'RE MONITORING IN THE
	ICU, I THINK CALLING
	
	A EPILEPTOLOGIST AT ANY OF THE
	CENTERS AND SAYING,
	
	"I WANT TO RUN THIS BY YOU.
	
	WHAT WOULD YOU DO?
	WHAT DO YOU THINK IS BEST?"
	
	IS COMPLETELY APPROPRIATE,
	AND THAT'S WHAT WE'RE HERE FOR,
	
	TO TRY TO HELP YOU DECIDE WHAT
	IS EASIEST AND BEST FOR YOU.
	
	- THANK YOU VERY MUCH.
	
	CAN I ASK ONE QUICK QUESTION?
	
	- SURE.
	
	- I WAS TRAINED [INDISTINCT]
	ANN ARBOR.
	
	THIS IS NOT A COMPREHENSIVE
	
	CENTER OF EXCELLENCE, BUT WE
	ARE TRYING TO DO OUR BEST.
	
	SO WE TEND TO [INDISTINCT].
	
	WE ARE TRYING TO DO LIMITED
	DIAGNOSTIC MONITORING.
	
	IT'S GONNA BE VERY
	SELECTIVE PATIENTS.
	
	WE DON'T HAVE ENOUGH SAFETY
	PRECAUTIONS IN PLACE, SO WE
	
	CANNOT CHANGE TO MAKE
	PATIENTS [INDISTINCT].
	
	IF THEY ARE ON MEDICATION OR
	THEY ARE NOT MEDICATION AND DO
	
	NOT CHANGE MEDICATION.
	
	ANY GUIDELINES FOR DIAGNOSIS?
	
	I UNDERSTAND [INDISTINCT]
	
	REVIEWING THE AFTER
	MORTALITY [INDISTINCT]
	
	...IMPROVE THE SAFETY DURING
	VIDEO MONITORING.
	
	IS THERE ANY GUIDELINE FOR
	DIAGNOSTIC VIDEO EEG MONITORING?
	
	- THERE ARE GUIDELINES FOR
	SAFETY IN HOW TO SET UP
	
	VIDEO EEG.
	
	BUT THOSE ARE--YOU CAN FIND
	THOSE ON THE NATIONAL EPILEPSY
	
	MONITORING CENTER'S...E-MAIL
	ME, AND, I'M SORRY, I'LL SEND
	
	YOU THE WEBSITE.
	
	IT'S ESCAPING ME.
	
	THE NATIONAL ORGANIZATION THAT
	HANDLES MONITORING GROUP IS
	
	ESCAPING ME, BUT IF YOU E-MAIL
	ME, I WILL SEND YOU THOSE
	
	GUIDELINES.
	
	I THINK IT'S FABULOUS THAT
	YOU'RE OFFERING THAT SERVICE
	
	THERE TO YOUR PATIENTS.
	
	YOU DON'T NEED TO BE AN
	EPILEPSY CENTER OF EXCELLENCE
	
	TO TAKE GREAT CARE OF
	PATIENTS WITH EPILEPSY.
	
	AND CERTAINLY, WE WOULD WANT
	TO SUPPORT THAT ENDEAVOR.
	
	AND E-MAIL ME, AND I WILL SEND
	YOU THOSE GUIDELINES.
	
	- THANK YOU.
	
	- OK. THANK YOU SO MUCH FOR
	JOINING THIS AUDIO CONFERENCE,
	
	AND HOPE TO HEAR FROM YOU AND BE
	ON THE CALL WHEN DR. RUTECKI
	
	GIVES THE NEXT EVENT.
	
	- THANK YOU, DR. PARKO,
	FOR TAKING THE TIME
	
	TO DO THE PRESENTATION.
	
	- THANK YOU, DR. PARKO.
	- YOU'RE WELCOME.
	
	- THANK YOU.