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Although small decreases may completely alle- trial compared the efficacy, tolerability, and impact on quality viate complaints, significant dose alterations may dramatically of life and cognitive functioning of anticonvulsant prophylaxis decrease serum concentrations, leading to a recurrence of with phenytoin versus valproate in 100 patients following seizures. Fourteen patients (seven in each group) improved by dividing the dose or taking it with meals (or experienced postoperative seizures. A double- than 30 g/mL include dysarthria, far-lateral nystagmus, move- blind comparison of phenytoin or carbamazepine with no ment disorders (usually choreoathetosis and orofacial dyskine- treatment after supratentorial craniotomy noted no significant sia), exacerbation of seizures, external ophthalmoplegia, or differences but a higher incidence of side effects in the treated encephalopathy (including lethargy, delirium, psychosis, group (141). In general, however, effects appear modest when phenytoin-loading dose within 24 hours of injury; free pheny- serum concentrations are kept within standard thera- toin serum levels were maintained in a range from 0. From the time of drug loading to day 7, significantly Unfortunately, patients taking phenytoin may suffer from cog- fewer seizures occurred in the phenytoin group than in the nitive side effects even when these guidelines are followed placebo group (3. In one study, phenytoin appeared the incidence of seizures only during the first week after injury. In a random- When used as prophylaxis against seizures following head ized, double-blind, placebo-controlled trial in children with trauma, phenytoin demonstrated negative cognitive effects moderate to severe blunt head injury, phenytoin did not prevent compared with placebo (169). No clinically significant differ- posttraumatic seizures within 48 hours of the trauma (144). Phenytoin has been shown to be useful in neuropathic pain In one study of elderly patients, phenytoin and valproic (145), motion sickness (146,147), cardiac arrhythmias, con- acid had similar effects (171), whereas a second study tinuous muscle fiber activity syndrome, myotonic muscular reported no cognitive impairment resulting from modest dystrophy, and myotonia congenita (148). It may also have a increases in serum phenytoin concentrations (between role in the treatment of recessive dystrophic epidermolysis bul- 11 g/mL and 16 g/mL) (172). Motor disturbances are losa, intermittent explosive disorder, and anxiety disorder common in children taking phenytoin (173). Fluctuations in phenytoin serum concentrations by as much as 50% had no or an immeasurably small effect in children Fosphenytoin with well-controlled seizures receiving monotherapy with low therapeutic dosages (175). Removal of chronic phenytoin in Fosphenytoin itself has no known anticonvulsant activity; it patients receiving polypharmacy resulted in significant derives its utility from its rapid and total conversion to pheny- improvement in one test of concentration and two tests of toin (15,16). Chapter 52: Phenytoin and Fosphenytoin 641 Idiosyncratic Reactions Cerebellar atrophy has been reported after long-term Phenytoins idiosyncratic reactions are proposed to result (191,192) and acute use (193) of high doses, although from the formation of a reactive metabolite (an arene oxide) whether the true etiologic agent was phenytoin or the seizures that either directly (owing to deficiencies in detoxification is unclear (194,195); single-photon-emission computed resulting from inadequate epoxide hydrolase activity) or indi- tomography scans may be a means for early detection (194). The in vivo and in vitro cross-reactivity prolactin (199) and apolipoprotein A and A1 (198) increase, between phenytoin, phenobarbital, and carbamazepine is as as does high-density lipoprotein cholesterol, although at doses high as 70% to 80% (180). A recent study on cross-sensitivity of 100 mg/day this lipid fraction was unchanged (200). Phenytoin therapy may suppress immuno- ine, oxcarbazepine, and zonisamide) was not as high as with globulin (Ig) production, leading to decreases in IgG (206,207) carbamazepine (181). Panhypoglobulinemia was reported in one cratic reaction is the hypersensitivity syndrome (180).

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There were no clinically or community because of inappropriate fear of statistically significant differences between the two adverse effects. Harms Bioresonance No adverse effects were described in the study, though the therapy can attract a considerable Bioresonance therapy, also called biophysical financial cost outside of health services. Bioenergy is defined this study was very carefully reported and authors as the bioelectric magnetic field which is unique to were meticulous in giving the bioresonance a fair materials, and that bioelectric waves produced by test by following the intervention as meticulously people can have diagnostic and therapeutic as possibly. The results do not show any evidence to magnetic waves of the patients body, as well as support benefit of bioresonance therapy. Although their disturbances and presence of allergens, are the study was relatively small, the study was purported to be transmitted for diagnostic and powered to exclude a 35% benefit of relevant therapy using brass wire electrodes analysed by treatment benefit of bioresonance therapy in the a bioresonance apparatus. Therefore, instrument allegedly distinguishes between although small benefits cannot be excluded by pathological and normal healthy waves from a the study, the study failed to show evidence of patient. Pathological waves can be reversed any moderate or large treatment effects of this electronically (corrected to healthy ones) by mode of treatment. It may be argued that the the separator, and transmitted back to the patient treatment was tried in a situation where marked for a therapeutic effect. Results are reported more and that such habit is detrimental, as scratching fully in the section on topical corticosteroids (see damages the skin and leads to further eczema chapter 4 and appendix 3). Scratching was reduced by 65% in identify situations that provoke the habit, and the hydrocortisone only group, 74% in the then to progressively train them to develop a betnovate followed by hydrocortisone group, 88% competing response practice such as simply in the hydrocortisone plus habit-reversal group, touching, squeezing or tapping the itching area, and 90% in the betnovate and hydrocortisone and or to develop other ways of moving their hands habit-reversal groups (statistics not presented). One group was treated with mean skin severity lesion score dropped from hydrocortisone cream alone and the other group 29. Harms Mean percentage reduction of scratching episodes In the Ehlers study, the behavioural approaches per day was 79% in the habit-reversal and hydro- required 12 weekly group sessions of 1. No adverse events were reported in any conducted by the same team,106 45 patients (mean of the trials, though some of the drop-outs could age 24. The the mechanisms by which ultraviolet light affects authors also performed statistical tests in comparison atopic eczema are not completely understood. Nevertheless, the magnitude of improve- blocks the function of antigen-presenting Langer- ment for those receiving behavioural techniques in hans cells and alters the production of cytokines by addition to their standard dermatological care (which keratinocytes. The measures was not possible due to the differences in magnitude of the benefits in these unblinded the type of ultraviolet light in each study and the studies were considerable, particularly when these lack of common outcomes at the same endpoints. Blinding was likely to have become Ultraviolet light unmasked in placebo-controlled trials due to the obvious tanning on one half of the body, along A proportion of atopic eczema sufferers have fewer with mild burning and marked treatment effects. Although the right/left body comparison design this observation, along with the benefit of ultra- had its limitations in terms of blinding, the lack violet light in psoriasis led to the introduction of of effect on placebo-treated body halves argues different forms of ultraviolet light for the treat- against a systemic effect of ultraviolet light treat- ment of atopic eczema.

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As discussed earlier, talking with friends was an important source of emotional support not least because friends could provide reassurance that what was being experienced was not uncommon or unusual. Maintaining a positive outlook was considered to be important as was trying to think about the experience differently. This could take different forms such as reminding oneself that hot flushes were not harmful, that most women go through it, that there was no need to panic and identifying mechanisms to relax and reduce stress. It helps me block out thoughts you have in the middle of the night Low treatment utiliser (28) Going with the flow was more likely to be mentioned by low treatment utilisers, who felt they were able to adapt and adjust, but the concept of just dealing with it was mentioned by most participants. This meant being stoical(8), learning to live with it(14), not labelling menopause as an illness(9), and not making a big song and dance out of it(10). However, denial and distraction, which might be considered negative, could be just as effective and 12 out of the 30 participants mentioned this form of coping. Twenty-two women out of 30 complained that each doctor they had seen, or heard about from friends, responded differently and had provided different information. There seems to be a lot of conflicting information and experience out there Low treatment utiliser (3) this tendency was not considered to be gender specific; female doctors seemed no more likely to be understanding than male doctors. The conclusion reached was that menopause was not a priority for most clinicians, because they showed limited interest. For example saying its what you get isnt it, go away and see what happens(30) rather than listening to concerns or explaining what is occurring and what type of relief may be available. Women were dismayed that doctors seemed unable to give a precise diagnosis and blood tests were not definitive. I think it is a sort of condition that has to be treated with 2 or 3 approaches for each person. It isnt solely a medical thing and it isnt purely erm something you have to deal with by yourself. High treatment utiliser (25) Clinicians were expected, perhaps unfairly, to be knowledgeable about all common conditions and so women were surprised that the advice they received was unclear or confusing. Even if a clinician took a womans concerns seriously and was sympathetic the only treatment on offer was hormone therapy, and it is to this we turn next. One woman described it as a treatment that was so ubiquitous it was like being offered antibiotics to cure an infection (15). As a result of talking with friends, reading magazines and discussing the situation with their doctor they had received mixed reports.

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