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Under such circum- contralateral hemisphere, but this must be confirmed either stances, failure to resect the region of intraictal activation is invasively or noninvasively. Neuroimaging Anatomic imaging localizes the lobes involved, but the epilep- togenic zone often extends beyond the anatomic abnormality. In multilobar cases, the clinical details may be confus- ing or misleading as the seizure semiology may vary or localize Seizure outcome according to the Engel classification system to one affected region despite extensive abnormalities. B: An intraictal secondarily acti- vated focus is evident over the frontal con- vexity grid at electrodes G 5/6 and G13 (arrow). C: Persistent activity at this sec- ondary focus is shown to outlast the tempo- ral seizure activity (arrow). The single show higher rates of seizure control (up to 96%) following most consistent predictor of outcome is completeness of resec- surgical resection (135). In a large Mayo clinic nonlesional epilepsy surgery between 1940 and 1980, the Montreal series, 72% had Engel Class I outcomes at 10-year follow-up Neurological Institute performed 118 nontumoral frontal and (127). Patients remaining seizure-free in the first postoperative temporal lobectomies and 47% had good outcome at mini- year had a high probability of long-term seizure freedom (127). Temporal resections had higher In a smaller series of 24 patients with focal medically rates of favorable outcome but success in frontal lobe cases intractable, only 37% were seizure-free while 75% experi- was influenced by the presence of a discrete, resectable struc- enced at least 90% reduction in seizure frequency (126). In a more recent Canadian pediatric Several studies have analyzed the pathologic substrate for epilepsy surgery study, 75% of frontal resections achieved prognostic value. In a combined adult/pediatric study, 49% nosticator for seizure freedom was completeness. Higher grade terior quadrant resections (117), patients with multilobar abnormalities are often more extensive which may contribute resections generally experience significantly lower rates of to less favorable outcomes, while the presence of balloon cells seizure freedom (4,113,130). Tumors generally given the extensive abnormalities seen electrographically, Chapter 83: Focal and Multilobar Resection 945 structurally, and pathologically in most patients. Posterior temporal epilepsy: most disabling seizure semiology will improve quality of life. Occipital lobe epilepsy: the goal of epilepsy surgery is complete seizure freedom. Seizure symptomatology in infants mental ramifications, but the importance of early seizure con- with localization-related epilepsy. Complex partial seizures in trol and early epilepsy surgery is only now being elucidated. J Clin (124) and overall mortality for epilepsy surgery is less than Neurophysiol. The major- rior temporal lobectomy for intractable epilepsy: a multivariate study.
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For diabetics, the better compliance, the less long-term effects they are going to have. I think the once weekly is beneficial and there is some data with once weekly Bydrueon vs. Carl Jeffery: Fosamax D has been preferred for a long time, even though it hardly has any utilization so theres really no benefit to having the Fosamax D. I think initially had some ideas that would provide some benefit, but we have the alendronate sodium as available and certainly the more widely used. Carl Jeffery: these products are kind of dwindling, Fortical and I think Miacalcin is going away, too, eventually. Right now, the only thing that would be available is the generic calcitonin salmon so Optum recommends the Board consider these clinically and therapeutically equivalent. Carl Jeffery: Alaway is ketotifen which is also Zaditor and the generic so were going to remove that one as a proposal but you see the current utilization. They can easily switch over to the ketotifen which is number two on there but the Pazeo is going to remain as preferred in our proposal, but Optum recommends these be considered clinically and therapeutically equivalent. Carl Jeffery: Optum recommends just removing Alaway brand from the preferred list to make it non- preferred and like I said, the ketotifen and the Zaditor are both available as preferred which is the same ingredient. Carl Jeffery: this is another one where we thought there was going to be some changes in the class and it didnt happen, so I dont think we need the Board to do anything on this one. Carl Jeffery: Restasis has a new multidose bottle and it has all the doses instead of getting them all individually packages single-use vials for the Restasis. Has a one- way valve and an air filter so I think its just smaller packaging but seems to me it still has the potential to get contaminated so I dont know too much about it but you can see the utilization. Its actually pretty high surprisingly for the good amount because right now we dont have a distinction, we just have Restasis listed so its currently hitting as preferred. Artificial Tears is something we wanted to add to make physicians aware that thats another option and probably should be tried first before they try these other agents. Carl Jeffery: Optum recommends the addition of Artificial Tears just to make people aware thats another option and then to make that distinction between the Restasis vials and the Restasis multidose and make the multidose non-preferred. Carl Jeffery: Its over the counter but if they get a prescription from their doctor, Medicaid will pay for it. We didnt have it agendized so Optum doesnt have any recommended changes but its certainly something the Board can review and have the discussion on. For Possible Action: Committee Discussion and Approval of the Drug Classes without Changes Motion to approve remaining drug classes without changes. Report by OptumRx on New Drugs to Market, New Generic Drugs to Market, and New Line Extensions Carl Jeffery: A couple new exciting agents that are coming out. We may see this one in the future and the other ones are not so much that we used. You have Ajovy and Aimovig is the other one so now that weve got a couple of these in the market, well probably bring that one back to the Board.
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Given the totality of nonclinical and clinical data, the submitted information provides reasonable assurance that the device performs its intended function correctly and safely and does not alter the safety and effectiveness profiles of the approved catheters for the treatment of arrhythmias in the right atrium. No part of this publication may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review. Furthermore, the publisher ensures that the text paper and cover board used have met acceptable environmental accreditation standards. Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check that any product mentioned in this publication is used in accordance with the prescribing information prepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this book. During the past several decades, however, pioneering work has revealed many of the complexities of cardiac arrhythmias and of the drugs used to treat them. To the dismay of most reasonable people, the old, convenient viewpoint nally proved utterly false. Indeed, in the decade since the rst edition of this book appeared, the widespread notion that antiarrhythmic drugs are a salve for the irritated heart has been, appropriately, completely reversed. Every clinician worth his or her salt now realizes that antiarrhythmic drugs are among the most toxic substances used in medicine, they are as likely as not to provoke even more dangerous arrhythmias, and, indeed, the use of most of these drugs in most clinical situations has been associated with an increase (and not a decrease) in mortality. This newfound respect for (if not fear of) antiarrhythmic drugs has been accompanied by the comforting murmurs of an elite army of electrophysiologists, assuring less adept clinicians that, really, there is no reason to worry about these nasty substances anymore. After all (they say), what with implantable debrillators, radiofrequency ablation, and other emerging technologies (that, by the way, only we are qualied to administer), the antiarrhythmic drug as a serious clinical tool has become nearly obsolete. It is certainly true that the use of antiarrhythmic drugs has been considerably curtailed over the past decade or so and that other emerging treatments have led to signicantly improved outcomes for many patients with cardiac arrhythmias. But neither the widely acknowledged shortcomings of these drugs nor the dissemination of new technologies has eliminated the usefulness of antiarrhythmic drugs or obviated the need to apply them, when appropriate, in the treatment of patients with cardiac arrhythmias. Consider that implantable debrillators, while in clinical use for over 25 years, are still indicated for only a tiny proportion of pa- tients who are at increased risk of arrhythmic death and are actually v vi Preface implanted in only a small proportion of these. It remains important, therefore, for any health-care professional caring for patients who are at risk of developing cardiac arrhyth- mias (and not just the electrophysiologists) to understand some- thing about antiarrhythmic drugs.
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We are so focused on reading food labels, agents, and under what circumstances would you we often do not think about reading the labels on recommend one used over another Individualize choices for different It is best to avoid products patient populations Dr. There is a lot of controversy particularly sensitive or has over whether there is a diference between lubri- a history of a hormone- cants and what is going to help or interfere with couples conceiving. Krychman: Infertile couples or those trying to conceive are often under pressure to perform and Dr. Dweck: The amount of choices can be over- the time scheduling may impact natural lubrica- whelming for women. I typically make very spe- tions, so we often recommend they use adjunc- cifc recommendations, usually beginning with tive products. It is an over-the-counter water-based lubricant, such marketed specifcally for the couple trying to con- as K-Y Jelly or Astroglide. They are so slick, in fact, that just Fertility-friendly lubricants are designed to mini- a little bit needs to be used with each sexual act. We do not have cone lubricants during water play, such as in the clear evidence about which lubricants are better shower or bath, because they are so slick that they than others, but couples often have so much anxiety can cause slipping. Kingsberg: We always think about lubricants so-called fertility-friendly products to them, I think and moisturizers with regard to vaginal penetra- it will reduce some anxiety. Dweck: The 2 ingredients that are talked about There are gels specifcally designed to be used as most in my patient population are glycerin and anal lubrication that are thicker and last longer, al- parabens. Parabens are used lubricant or moisturizer should have an osmolal- as preservatives to increase shelf-life and are often ity of not greater than 1,200 mOsm/kg, and this is ingredients in various lubricants; they also have an important feature to consider when choosing a been considered possible hormone disruptors, product to recommend. Dweck: Hyaluronic acid is naturally found in still out on them, I think it is best to avoid products the body and is all the rage right now as an anti- with parabens if a patient is particularly sensitive aging and smoothing ingredient. As a vaginal gel, hy- and other organizations have stated that, in such aluronic acid has been shown to improve vaginal low quantities, these chemicals are not causative itching, painful intercourse, and vaginal burning agents of cancer. In addition, many An ideal water-based lubricant of the compounding pharmacies are making com- pounded moisturizers for vaginal use that contain or moisturizer should have an hyaluronic acid with good result. Krychman: I recommend Lubrigyn Cream, when choosing a product to with hyaluronic acid (a little goes a long way). Cost is always an issue; it is not necessarily the There are emerging data indicating that some more you pay, the better the product.