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PubMed2002

Contemporary trends in student selection of medical specialties: the potential impact on general surgery.

HYPOTHESIS: Lifestyle is a priority among senior medical students when selecting a career specialty. The trend toward controllable lifestyle vs noncontrollable lifestyle specialties is affecting the number of students desiring a career in general surgery. DESIGN: The Medical Student Graduation Questionnaire is published and distributed by the Association of American Medical Colleges to all US medical schools for senior medical students to complete before graduation. The results from the survey are published each year in the All Schools Report. We evaluated these reports to track the percentage of students pursuing a career in general surgery during the past decade. The National Resident Matching Program also publishes a report each year outlining the match results. We reviewed these results from 1978 through 2001 and used them to determine the percentage of students choosing to enter general surgery. MAIN OUTCOME MEASURES: First choice of specialty among graduating senior students from US medical schools; positions matched by US and foreign medical students and students from osteopathic medical schools; factors that influenced the decision-making process in choice of specialty; and factors that influenced students to change their mind from one career to another. RESULTS: An established trend of decreasing interest in general surgery exists and has the potential to affect the number of positions that are filled each year in the match. Linear projections confirm that, should the current trend continue (negative slope; P =.01), by 2005 only 4.8% of US graduating senior medical students will be interested in general surgery. This established trend of decreasing interest in general surgery, which began in the early 1980s, did not affect the match until 2001, when the number of positions offered exceeded the number of students interested in general surgery. At present, the specialty of general surgery is at risk for significant numbers of positions remaining unfilled. Our match projections estimate that for 2005, only 76.6% of positions will be filled by US senior students (negative slope; P =.001). CONCLUSIONS: If the trend continues, the students matching in general surgery will not be as competitive as in years past, and there will be a potential shortage of these specialists in the United States.

Career Choice↗
PubMed2005

Characterizing the general surgery workforce in rural America.

BACKGROUND: General surgeons form a crucial component of the medical workforce in rural areas of the United States. Any decline in their numbers could have profound effects on access to adequate health care in such areas. HYPOTHESIS: We hypothesize that the rural areas of the United States are relatively undersupplied with general surgeons. DESIGN AND SETTING: The American Medical Association's Physician Masterfile was used to identify all clinically active general surgeons as well as their locations and characteristics. Their geographic distribution was examined using the ZIP code version of the Rural-Urban Commuting Areas. Surgeons were classified as practicing in urban areas, large rural areas, or small/isolated rural areas. RESULTS: There are currently 17 243 general surgeons practicing in the United States. Nationally, the number of general surgeons per population of 100 000 varies from 6.53 in urban areas to 7.71 in large rural areas and 4.67 in small/isolated rural areas. Only 10.6% of the nation's general surgeons are female. Wide variations in numbers of general surgeons were found between and within individual states. General surgeons in the smallest rural areas are more likely than those in urban areas to be male (92.7% vs 88.3%, P<.001), 50 years of age or older (51.6% vs 42.1%, P<.001), or international medical graduates (25.2% vs 20.1%, P<.001). CONCLUSIONS: The overall size of the rural general surgical workforce has remained static over the last decade, but its demographic characteristics suggest that numbers will decline. Many rural residents have limited access to surgical services. Steps to reverse this trend are needed to preserve the viability of health care in many parts of rural America.

Adult↗
PubMed2006

Local Anesthesia With Monitored Anesthesia Care vs General Anesthesia in Thyroidectomy: A Randomized Study.

BACKGROUND: Early in the 20th century, thyroid surgery was performed using local anesthetic techniques. When general anesthesia became safer, surgeons started performing thyroidectomy exclusively under general anesthesia. However, recent descriptions of thyroidectomy under local anesthesia claim similar results to thyroidectomy under general anesthesia. Surgery conducted under local anesthesia can result in early discharge, ie, a hospital stay of less than 8 hours. HYPOTHESIS: Thyroidectomy can be performed under local anesthesia with monitored anesthesia care (MAC) with results similar to general anesthesia in an outpatient or inpatient surgery setting. DESIGN: A prospective randomized study comparing local anesthesia with MAC vs general anesthesia in adult patients undergoing thyroidectomy in a potential outpatient setting, defined as same-day discharge. Patients were excluded if they were not able to receive local or general anesthesia. In addition, we performed an outcome evaluation of the use of local anesthesia with MAC for thyroidectomy and the use of outpatient surgery for thyroidectomy. We compared 58 consecutive thyroidectomies performed prior to the study with 58 consecutive thyroidectomies performed after the study. SETTING: A 486-bed university-affiliated hospital. RESULTS: Fifty-eight patients undergoing thyroidectomy received random assignment: 29 to local anesthesia with MAC and 29 to general anesthesia under study protocol. Fifty-one surgical procedures (88%) were completed as outpatient surgery. No significant differences were found between the 2 study groups in demographics, postoperative adverse symptoms, complications, hospital admission, or patient satisfaction. Patients in the general anesthesia group spent, on average, more time postoperatively than patients in the group that received local anesthesia with MAC in the outpatient surgery center until same-day discharge (P = .02). When compared before the study, we found a significant increase after the randomized study in the use of local anesthesia with MAC (P<.001) and outpatient thyroidectomies (P<.001). CONCLUSIONS: Thyroidectomy can be performed in the studied patient population under either general anesthesia or local anesthesia with MAC, expecting similar operative results, clinical results, and patient satisfaction. In addition, local anesthesia with MAC can reduce the postoperative time spent in an outpatient surgery setting with potential health care cost savings.

Adult↗
PubMed2003

A UK survey of psychiatric services for older people in general hospitals.

BACKGROUND: Psychiatric illness is common in older people in general hospitals, but little is known of the service models operating in the UK, or of the views of old age psychiatrists regarding service provision in this area. We set out to determine the range of UK old age psychiatry service models for older people in general hospital wards, and the opinions of clinicians on future service priorities and development. METHOD: A postal questionnaire survey of old age psychiatrists providing psychiatric services to older people in general hospital wards. RESULTS: 73% of services were provided through a generic, sector-based, consultation psychiatry model. The remaining 27% employed a range of general hospital-based liaison psychiatry services for older people, involved in proactively seeking referrals and educating general hospital staff. Those providing a generic sector-based model were significantly slower at responding to referrals. 89% of respondents were unhappy with their service to older people in general hospital wards, with only 11% preferring the generic sector-based model. Organisational barriers to change identified included the management of mental health care and physical care by different organisations. Training, both of psychiatric staff in this specialist area, and of general hospital staff in the detection and basic management of common psychiatric conditions in the general hospital setting, was felt to be necessary. CONCLUSIONS: The management of co-morbid psychiatric and physical illness in older people is an important issue for health services. Old age psychiatrists are unhappy with the prevalent, reactive, consultation-based model, preferring a range of liaison psychiatry models based in the general hospital. The most important barriers to service development in this area were the separate managerial arrangements for psychiatric and physical care services, and a lack of evidence for effective old age psychiatry services in this setting.

Aged↗
PubMed2002

Hospital practice more than specialty influences the choice of regional or general anesthesia for Cesarean section.

PURPOSE: Describe the influence of specialty certification and practice style upon the anesthetic technique used for Cesarean deliveries. METHODS: Alberta physician claims and hospital abstracts between April 1, 1998 to March 31, 2000 were used to determine the technique of anesthesia (regional or general). The influence of practice (volume of deliveries, geographic location, presence of regional analgesia providers) and specialty (anesthesiologist or family/general practice) is explored by logistic regression. RESULTS: Hospital abstracts of 13,884 Cesarean sections were analyzed. Anesthesiologists performed 76% of the anesthetics: epidural (33%), spinal (45%), and general anesthesia (22%). Comparing only regional and metropolitan hospitals, the percent of general anesthesia performed by anesthesiologists varied between 5% to 50%. After adjusting for other factors, we found, in order of importance, the following determined the use of general anesthesia for Cesarean sections: 1) hospitals with more epidural procedure providers during labour were 3% less likely to have providers choose general anesthesia; 2) larger, regional and metropolitan hospitals were less likely to have providers choose general anesthesia; 3) hospitals with a high volume epidural procedure provider during labour were 64% less likely to have providers choose general anesthesia; 4) anesthesiologists were 32% less likely to choose general anesthesia. CONCLUSION: The overall use of regional anesthesia for Cesarean sections in Alberta is high. The chance of receiving a general anesthetic for a Cesarean delivery varies across the province and was more related to practice environment than specialty.

Adult↗
PubMed1997

The general surgery workforce.

BACKGROUND: The workforce in general surgery has been the subject of studies in 1975 and 1994, as has the input of residency program graduates, their subsequent subspecialization, and the retirement pattern of practicing general surgeons. This study analyzes the distribution of general surgeons in the United States. DATA SOURCES: Certified general surgeons were identified from files of the American Board of Medical Specialties (ABMS). Included were general surgeons with no additional certificates except for Surgical Critical Care. Excluded were surgeons certified only by an osteopathic board, noncertified surgeons, retirees, missionaries, federal employees, and military surgeons. The Area Resource File of the Bureau of Health Professions was used to classify metropolitan and rural areas, and primary care health professions shortage areas (PC-HPSA). CONCLUSIONS: General surgeons are well distributed in the various states. More general surgeons are located in metropolitan than in rural areas, and few general surgeons practice in counties in which the whole county is designated as a PC-HPSA. The ratio of general surgeons to the population is similar to that found in 1975.

Adult↗
PubMedDate not supplied

Spectrum of general surgery in rural Iowa.

PURPOSE: One-quarter of the United States of America's population lives in rural areas, but only 12.3% of physicians live and work in rural areas. Nearly one-quarter of the counties in Iowa boast a patient-to-physician ratio of 3000:1. The number of rural surgeons is decreasing, and current residency programs may not optimally train graduates for the spectrum of surgical practice seen in rural areas. The scope of surgical practice differs between rural and non-rural surgeons, and in this study, we identified the types of surgery performed by 6 rural Iowa surgeons and compared the practices of rural and non-rural surgeons in Iowa. METHODS: Data from personal interviews and questionnaires with rural Iowa general surgeons and rural Iowa hospital administrators and results from the Iowa General Surgeon Practice Opportunity Survey were analyzed retrospectively. RESULTS: In 1995, 31 general surgeons were recruiting a general surgeon partner, of which 25 were in rural Iowa communities. Eighteen rural Iowa Hospital administrators were actively recruiting a general surgeon during the same time period. In September 2000, many of these positions remained unfilled. A total of 4963 surgical procedures were performed by 6 rural Iowa general surgeons in Iowa in 1995. Endoscopic, alimentary, and obstetrics and gynecologic procedures were the most frequently performed. Excluding endoscopy, 26% of all procedures performed were procedures not among the Accreditation Council of Graduate Medial Education (ACGME) list of requirements for graduating surgical residents. CONCLUSIONS: Rural Iowa general surgeons perform a large volume of surgery and more subspecialty procedures than do their non-rural counterparts. Surgical residency programs need to more adequately train residents interested in rural general surgery in an effort to increase the pool of graduating surgical residents trained to deal with the scope of procedures a rural practice offers. This will help reduce the shortage of rural general surgeons in the United States of America.

General Surgery↗
PubMed2002

Career pathways of graduates of general surgery residency programs: an analysis of graduates from 1983 to 1990.

BACKGROUND: Approximately 1,000 individuals complete graduate surgical education in general surgery each year. Their subsequent career pathways have not been described but may have relevance to the supply of general surgeons available to provide a broad range of surgical care to the population of the USA. STUDY DESIGN: Data for this study were obtained from the American College of Surgeons's Surgery Resident Masterfile, developed for the annual Longitudinal Study of Surgery Residents, and the American Board of Medical Specialties's Official Directory of Board Certified Medical Specialists. For verification purposes, the American Medical Association's Physician Masterfile and the American Board of Surgery's certified database were searched. Yearly analyses of certified general surgery graduates from 1983 to 1990 were conducted, and rates of certification between US or Canadian medical school graduates and international medical school graduates (IMG) were compared. RESULTS: Ten to 18 years after completion of a residency program in general surgery, 93.6% of graduates had been certified in general surgery or by another American Board of Medical Specialties board. A total of 43.7% of the 8,068 graduates were certified, in addition, in a general surgery-based specialty. Overall, evidence of certification was not available for 6.4% of graduates. The certification rate for US or Canadian graduates was 95.8% of general surgeons and increased for IMG surgeons from 69.4% for 1983 graduates to 94.7% for 1990 graduates. The number of IMGs in general surgery residency programs declined from 19.7% of 1983 graduates to 7.8% of 1990 graduates. The rates of American Board of Surgery certification are 96.1% for male and 93.6% for female US or Canadian graduates; 79.2% of male IMG graduates and 83.7% of female IMG graduates became certified. CONCLUSIONS: Most surgeons who completed a general surgery residency program from 1983 to 1990 are certified and presumably have met high standards for knowledge and experience. More than half of the graduates specialize further.

Canada↗
PubMed2003

Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) is a common complication after cardiac and major non-cardiac surgery with general anaesthesia in the elderly. We hypothesized that the incidence of POCD would be less with regional anaesthesia rather than general. METHODS: We included patients aged over 60 years undergoing major non-cardiac surgery. After giving written informed consent, patients were randomly allocated to general or regional anaesthesia. Cognitive function was assessed using four neuropsychological tests undertaken preoperatively and at 7 days and 3 months postoperatively. POCD was defined as a combined Z score >1.96 or a Z score >1.96 in two or more test parameters. RESULTS: At 7 days, POCD was found in 37/188 patients (19.7%, [14.3-26.1%]) after general anaesthesia and in 22/176 (12.5%, [8.0-18.3%]) after regional anaesthesia, P = 0.06. After 3 months, POCD was present in 25/175 patients (14.3%, [9.5-20.4%]) after general anaesthesia vs. 23/165 (13.9%, [9.0-20.2%]) after regional anaesthesia, P = 0.93. The incidence of POCD after 1 week was significantly greater after general anaesthesia when we excluded patients who did not receive the allocated anaesthetic: 33/156 (21.2%[15.0-28.4%]) vs. 20/158 (12.7%[7.9-18.9%]) (P = 0.04). Mortality was significantly greater after general anaesthesia (4/217 vs. 0/211 (P < 0.05)). CONCLUSION: No significant difference was found in the incidence of cognitive dysfunction 3 months after either general or regional anaesthesia in elderly patients. Thus, there seems to be no causative relationship between general anaesthesia and long-term POCD. Regional anaesthesia may decrease mortality and the incidence of POCD early after surgery.

Activities of Daily Living↗
PubMed1996

The use of general anaesthesia for tooth extraction in young handicapped adults in France.

The anaesthetic management of handicapped young adults is often difficult. However, few examples were found in the literature that attempted to specifically measure the frequency of general anaesthesia in the dental treatment of this group of patients. This paper focuses on the management of mentally or physically handicapped young patients undergoing extractions at a specialist dental service in Southern France. A survey of 184 young patients treated during a 39-month period, either under general (34 cases) or local (150 cases) anaesthesia was carried out. A minimum one-year follow-up period was used for each patient. The main characteristics of the patients who received general or local anaesthesia were compared and the factors which indicated the choice of general rather than local anaesthesia were assessed. This study attempts to define precise selection criteria, including dental and non-dental factors. Limited past treatment history was found to be a strong indicator of the need for general anaesthesia. The results of this study suggest that non-dental background factors were also important. The need for general anaesthesia was markedly increased in the groups with severe behavioural disturbances or low levels of contact with the general dental practitioner. If provision of regular dental services for disabled young patients can significantly reduce the need for general anaesthesia, care will have to be taken in developing the relationships between the hospital and general dental practitioner.

Adult↗
PubMed1998

Trends in exodontia under general anaesthesia at a dental teaching hospital.

AIMS: To survey the use of simple exodontia for children under general anaesthesia on an out-patient basis at a Northern Dental Hospital. To monitor any effects resulting from the introduction of the Poswillo guidelines on the referral for and treatment of patients under general anaesthesia. DESIGN: A retrospective longitudinal analysis. SETTING: A Northern Dental Hospital in England. MATERIALS: Information was recorded from original case records of children undergoing exodontia under general anaesthesia on an out-patient basis during October between 1989 and 1997. RESULTS: The mean and modal age of the children decreased from 7.7 years to 6.0 years respectively in 1989 to 5.7 years and 4.0 years in 1997. The proportion receiving a general anaesthetic for orthodontic extractions substantially decreased from 18.0% in 1989 to 0.7% in 1997 and the need for repeat dental general anaesthetics within 18 months was eliminated with the introduction of a pre-general anaesthetic screening service. CONCLUSION: Dental treatment under general anaesthesia should continue to be available where it is justified. A separate assessment appointment reduces the prescription of general anaesthesia and minimises its usage for orthodontic extractions and the necessity for repeat general anaesthesia.

Age Factors↗
PubMed1996

Generalization to novel images in upright and inverted faces.

An image of a face depends not only on its shape, but also on the viewpoint, illumination conditions, and facial expression. A face recognition system must overcome the changes in face appearance induced by these factors. Two related questions were investigated: the capacity of the human visual system to generalize the recognition of faces to novel images, and the level at which this generalization occurs. This problem was approached by comparing the identification and generalization capacity for upright and inverted faces. For upright faces, remarkably good generalization to novel conditions was found. For inverted faces, the generalization to novel views was significantly worse for both new illumination and viewpoint, although the performance on the training images was similar to that on the upright condition. The results indicate that at least some of the processes that support generalization across viewpoint and illumination are neither universal (because subjects did not generalize as easily for inverted faces as for upright ones) nor strictly object specific (because in upright faces nearly perfect generalization was possible from a single view, by itself insufficient for building a complete object-specific model). It is proposed that generalization in face recognition occurs at an intermediate level that is applicable to a class of objects, and that at this level upright and inverted faces initially constitute distinct object classes.

Adolescent↗
PubMed2004

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma.

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.

Adult↗
PubMed1987

Modulation of oxygen-free radicals from human leukocytes during halothane- and enflurane- induced general anesthesia.

Oxidative metabolism correlates with the release of microbiocidal oxygen-free radicals, measured as luminol-dependent chemiluminescence. The effect of general anesthesia on the oxidative metabolism of human leukocytes was investigated. Sixteen patients undergoing a halothane-induced general anesthesia and 14 patients receiving an enflurane-induced general anesthesia participated in the study. Halothane-induced anesthesia was accompanied both by a suppression of basic chemiluminescence and by a decrease in chemiluminescence during the phagocytosis of zymosan A. This was monitored 15 min, 30 min and 60 min after starting general anesthesia and compared to the level of chemiluminescence before starting general anesthesia. Ninety minutes after finishing general anesthesia, a significant recovery of chemiluminescence was seen to exceed the level before general anesthesia. Comparable findings were observed with enflurane-induced general anesthesia, suggesting a decreased release of oxygen-free radicals during general anesthesia, and afterwards an increase exceeding the initial level.

Adolescent↗
PubMed2004

Prism adaptation during walking generalizes to reaching and requires the cerebellum.

Adaptation of arm movements to laterally displacing prism glasses is usually highly specific to body part and movement type and is known to require the cerebellum. Here, we show that prism adaptation of walking trajectory generalizes to reaching (a different behavior involving a different body part) and that this adaptation requires the cerebellum. In experiment 1, healthy control subjects adapted to prisms during either reaching or walking and were tested for generalization to the other movement type. We recorded lateral deviations in finger endpoint position and walking direction to measure negative aftereffects and generalization. Results showed that generalization of prism adaptation is asymmetric: walking generalizes extensively to reaching, but reaching does not generalize to walking. In experiment 2, we compared the performance of cerebellar subjects versus healthy controls during the prism walking adaptation. We measured rates of adaptation, aftereffects, and generalization. Cerebellar subjects had reduced adaptation magnitudes, slowed adaptation rates, decreased negative aftereffects, and poor generalization. Based on these experiments, we propose that prism adaptation during whole body movements through space invokes a more general system for visuomotor remapping, involving recalibration of higher-order, effector-independent brain regions. In contrast, prism adaptation during isolated movements of the limbs is probably recalibrated by effector-specific mechanisms. The cerebellum is an essential component in the network for both types of prism adaptation.

Adaptation, Physiological↗
PubMed2000

Treatment of acute schizophrenia in open general medical wards in Jamaica.

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.

Acute Disease↗
PubMed2004

Unique clinical phenomenology can help distinguish primary from secondary generalized seizures in children.

The physical manifestations a seizure produces provide critical information. It is assumed that all generalized convulsions are ostensibly the same, regardless of whether they are primary or secondary generalized seizures. We undertook a pilot study to determine if the clinical phenomenology of secondary generalized seizures in children with epilepsy is different from classic descriptions of generalized tonic-clonic convulsions. A data capture sheet was created and applied to the video-electroencephalographic (EEG) records of 64 secondary generalized seizures from 13 children with intractable and/or refractory epilepsy. Many features of secondary generalized seizures were different from traditional descriptions of generalized convulsions. In 100% of cases, the mouth either remained open or repeatedly opened and closed rather than slamming shut. In 77% of cases, a variety of late motor activities were seen to occur after the seizure activity had ceased and the EEG record was quiet. The clinical features of a generalized convulsion in a child, especially mouth opening and late motor events, can be useful in establishing the origin as either focal or primary generalized.

Adolescent↗
PubMed1997

Lamotrigine in absence and primary generalized epilepsies.

Although lamotrigine has been approved in the United States as adjunctive therapy for partial seizures in patients older than 12 years, there is increasing evidence that it is just as effective, if not more effective, in the treatment of generalized seizures. A large number of open-label studies and some single-blind data, all using lamotrigine as add-on therapy in patients with previously refractory generalized seizures, are available. Controlled studies, some on newly diagnosed, previously untreated patients with generalized seizures are ongoing. Investigations have demonstrated that patients with the following generalized seizure types improve with lamotrigine add-on therapy: Typical and atypical absence, atonic, generalized tonic-clonic, myoclonic, and clonic seizures. Response rates, defined as the percentage of patients with better than 50% reduction in seizure frequency, have been, depending on seizure type, in the range of 30% to 56%, with 0 to 33% of the patients becoming seizure free. The best responses have been noted in typical and atypical absences, and atonic seizures. Children and adults appear to have comparable responses. In addition, add-on studies in patients with specific, previously refractory, epilepsy syndromes have demonstrated that the best improvement in seizure control occurs in patients with petit mal epilepsy, "other symptomatic" generalized epilepsies, and in Lennox-Gastaut syndrome, followed by patients with other myoclonic epilepsies, myoclonic absence and West syndrome. Many previously refractory patients are able to achieve lamotrigine monotherapy. However, patients with nonprogressive myoclonic epilepsy have little, if any, response. Early data from ambulatory encephalographic (EEG) recordings in patients with previously refractory absence seizures, and from controlled studies on patients with newly diagnosed typical absence seizures, appear to confirm the efficacy of lamotrigine in those patients. Controlled studies are ongoing in patients with absence seizures, in patients with generalized tonic-clonic seizures, and in patients with Lennox-Gastaut syndrome. Dosing in generalized seizures is similar to that for partial seizures. Because of the shorter half-life of lamotrigine in children, as compared to adults, higher (mg/kg) doses are often needed in young patients. We conclude that lamotrigine is a promising drug for absence and primary generalized seizures in both children and adults.

Adolescent↗