Search

Objectives: The use of off‐label pharmacotherapies for neuropathic pain (NP) is growing relating to the many unmet needs of patients. However, clinical guidelines fail to address it, and the available evidence is sparse and fragmented. We arranged a formal expert consensus to address this controversial issue and provide some guidance on judicious use. Methods: A two‐round standard Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 40‐item questionnaire prepared by the authors. Consensus on each statement was defined as at least either 80% endorsement or rejection after the second round. Results: Forty‐three and thirty‐seven panelists participated in the first and second round, respectively. Consensus was reached in 34 out of 40 statements. Endorsed alternatives for unresponsive patients include non‐gabapentinoid antiepileptics (oxcarbazepine and eslicarbazepine), venlafaxine, intravenous lidocaine (when doses can be optimized), and some vaporized cannabinoids (under appropriate surveillance). In addition, lacosamide, low‐dose naltrexone, propofol, or ketamine could prove beneficial if subjected to more research. Other options were rejected, and there was controversy about the usefulness of topical preparations. Discussion: For patients who do not respond to standard NP treatments, some other viable pharmacological options can be attempted before advancing to other therapeutic stages. This may help patients who are reluctant to or have some contraindication for interventional therapies. [ABSTRACT FROM AUTHOR]

Summary: Objective: The purpose of this study is to investigate the outcomes of epilepsy surgery targeting the subcentimeter‐sized resting state functional magnetic resonance imaging (rs‐fMRI) epileptogenic onset zone (EZ) in hypothalamic hamartoma (HH). Methods: Fifty‐one children with HH‐related intractable epilepsy received anatomical MRI‐guided stereotactic laser ablation (SLA) procedures. Fifteen of these children were control subjects (CS) not guided by rs‐fMRI. Thirty‐six had been preoperatively guided by rs‐fMRI (RS) to determine EZs, which were subsequently targeted by SLA. The primary outcome measure for the study was a predetermined goal of 30% reduction in seizure frequency and improvement in class I Engel outcomes 1 year postoperatively. Quantitative and qualitative volumetric analyses of total HH and ablated tissue were also assessed. Results: In the RS group, the EZ target within the HH was ablated with high accuracy (>87.5% of target ablated in 83% of subjects). There was no difference between the groups in percentage of ablated hamartoma volume (P = 0.137). Overall seizure reduction was higher in the rs‐fMRI group: 85% RS versus 49% CS (P = 0.0006, adjusted). The Engel Epilepsy Surgery Outcome Scale demonstrated significant differences in those with freedom from disabling seizures (class I), 92% RS versus 47% CS, a 45% improvement (P = 0.001). Compared to prior studies, there was improvement in class I outcomes (92% vs 76%‐81%). No postoperative morbidity or mortality occurred. Significance: For the first time, surgical SLA targeting of subcentimeter‐sized EZs, located by rs‐fMRI, guided surgery for intractable epilepsy. Our outcomes demonstrated the highest seizure freedom rate without surgical complications and are a significant improvement over prior reports. The approach improved freedom from seizures by 45% compared to conventional ablation, regardless of hamartoma size or anatomical classification. This technique showed the same or reduced morbidity (0%) compared to recent non–rs‐fMRI‐guided SLA studies with as high as 20% permanent significant morbidity. [ABSTRACT FROM AUTHOR]

Background Colonic dilation is common in children with intractable functional constipation ( FC). Our aim was to describe the association between segmental colonic dilation and colonic dysmotility in children with FC. Methods We performed a retrospective study on 30 children with intractable FC (according to the Rome III criteria) who had undergone colonic manometry and contrast enema within a 12-month time period. Colonic diameter was measured at 5 cm intervals from the anal verge up to the splenic flexure. Moreover, the distance between the lateral margins of the pedicles of vertebra L2 was measured to provide a ratio (colonic diameter or length/distance between the lateral margins; 'standardized colon size' [ SCS]). All manometry recordings were visually inspected for the presence of high-amplitude propagating contractions ( HAPCs); a parameter for colonic motility integrity. The intracolonic location of the manometry catheter sensors was assessed using an abdominal X-ray. Key Results Colonic segments with HAPCs had a significantly smaller median diameter than colonic segments without HAPCs (4.08 cm vs 5.48 cm, P<.001; SCS 1.14 vs 1.66, P=.001). Children with prematurely terminating HAPCs had significantly larger SCS ratios for colonic diameter than children with fully propagating HAPCs ( P=.008). SCS ratios for the length of the rectosigmoid and the descending colon and the SCS ratio for sigmoid colon diameter were significantly larger in children with FC compared to a previously described normative population ( P<.0001, P<.0001 and P=.0007 respectively). Conclusions & Inferences Segmental colonic dilation was associated with prematurely terminating HAPCs and may be a useful indicator of colonic dysmotility. [ABSTRACT FROM AUTHOR]

Temporal lobe resection is the most prevalent epilepsy surgery procedure. However, there is no consensus on the best surgical approach to treat temporal lobe epilepsy. Complication rates are low and efficacy is very high regarding seizures after such procedures. However, there is still ample controversy regarding the best surgical approach to warrant maximum seizure control with minimal functional deficits. We describe the most frequently used microsurgical techniques for removal of both the lateral and mesial temporal lobe structures in the treatment of medically intractable temporal lobe epilepsy (TLE) due to mesial temporal sclerosis (corticoamygdalohippocampectomy and selective amygdalohippocampectomy). The choice of surgical technique appears to remain a surgeon's preference for the near future. Meticulous surgical technique and thorough three-dimensional microsurgical knowledge are essentials for obtaining the best results. [ABSTRACT FROM AUTHOR]

This case series describes 3 horses rescued from flooded areas, hospitalised and treated at the Louisiana State University Veterinary Teaching Hospital in the wake of Hurricane Isaac. The purpose of the paper is to familiarise practitioners with the injuries that may be found in flood-afflicted horses and livestock. Case 1 presented with a degloving injury of the right hindlimb. The gelding developed neurological signs and was subjected to euthanasia; necropsy was consistent with Salmonella sepsis and disseminated mycosis due to Candida krusei, the first case reported in a horse. Case 2 presented with dermatitis attributable to chemical exposure and pneumonia and was subjected to euthanasia due to severe bilateral laminitis. Case 3 sustained a degloving injury of the left hindlimb and was subjected to euthanasia due to intractable pain. This case series illustrates the need for preparation and evacuation to avoid life-threatening injuries in equids and livestock caused by hurricanes and their aftermath. [ABSTRACT FROM AUTHOR]

When pain is refractory to systemic opioid and non-opioid analgesic therapy and palliative chemoradiation or ablative or stimulant neurosurgical procedures are not possible, palliative treatment becomes limited, particularly if the patient wishes to be at home at the end of life. Intracerebroventricular (ICV) infusion of morphine in the home setting might be presented as an option. The present article reviews the basic and clinical evidence of the efficacy and safety of ICV administration of opioids. Information was gathered from various bibliographic sources, including PubMed and others, and summarized and evaluated to assess the efficacy and safety of ICV opioids for pain relief. Results from ICV infusion of morphine into terminally ill patients refractory to other pain treatments have been reported since the early 1980s. Good efficacy has been achieved for the vast majority of patients, without serious development of analgesic tolerance. There have also been a low incidence of adverse effects, such as constipation and respiratory depression, and a significant retention of alertness associated with this route of administration. Intracerebroventricular infusion of opioid analgesics thus appears to be a safe and effective therapy for the palliative treatment of refractory pain. [ABSTRACT FROM AUTHOR]

Summary Purpose: Intractability in epilepsy is difficult to define, and little is known about its onset, course, and duration. We investigated these aspects (as well as the occurrence of intractability) during long-term follow-up in patients with epilepsy, focusing on possible explanations for the variation in time of onset and duration of intractability. Methods: After diagnosis, 453 patients with childhood-onset epilepsy had a 5-year follow-up with regular visits and data collection. Ten years later they received a questionnaire with items concerning epilepsy, which was completed by 413 patients resulting in a mean follow-up of 15 years. Intractability during the first 5 years was compared with that in the last year of follow-up. Intractability was defined as having no 3-month remission during a 1-year period despite adequate medical treatment. Key Findings: At least 12.1% of the cohort had a period of intractability during the 15-year follow-up, and 8.5% were intractable in the final year. Of the patients with idiopathic etiology 4.3% had a period of intractability versus 17.0% for those with cryptogenic, and 22.6% for those with remote symptomatic etiology (p < 0.001). Other risk factors at baseline were younger age at first seizure, generalized cryptogenic/symptomatic or localization-related symptomatic epilepsy, mental retardation, and febrile convulsions before enrollment. The cumulative risk of a period of intractability was 6.1% (95% confidence interval [CI] 3.7-8.5) at 2 years follow-up and 8.2% (95% CI 5.4-11.0) at 5 years. The mean time to onset of intractability during the first 5 years of follow-up was 1.6 (95% CI 1.3-2.0; median 1.0) years and the mean duration of intractability during these 5 years was 3.3 (95% CI 2.8-3.8; median 3.6) years. Fifteen patients were intractable only during the first 5 years of follow-up (group A), and 19 subjects were intractable both during the first 5 years and the last year of follow-up (group B). Compared with group A, group B had shorter remission and a longer time to intractability during the first 5 years and more were intractable in the fifth year of follow-up. Sixteen other patients had a late onset of intractability after 5 years of follow-up, sometimes after long periods of remission (group C). No significant differences in baseline characteristics were found among groups A, B, and C, but slightly more children in groups B and C became mentally retarded during the follow-up. In all groups, antiepileptic drugs were of little use in preventing and ending intractability. Significance: There is a large unpredictable variation in time of onset, course, and duration of intractability, with a higher chance of final intractability after a poor course during the first 5 years of follow-up. The natural course of epilepsy probably best explains the variable course of intractability. The effect of medication seems to be minor. [ABSTRACT FROM AUTHOR]

Aims: Patients with intractable disease require long-term treatment and experience repeated bouts of progressive symptoms and resolutions, which cause them severe suffering. The aim of this study was to elucidate the concepts of self-transcendence and subjective well-being in patients with intractable disease. Methods: Forty-four patients with intractable disease (men/women: 22/22) participated. The diseases of the participants were classified into five systems: (i) neural/muscle system; (ii) digestive system; (iii) immunity/blood system; (iv) visual system; and (v) bone/joint system. The controls were 1854 healthy individuals (men/women: 935/869). Participants completed the Self-Transcendence Scale (STS) and the Japanese version of the World Health Organization-Subjective Inventory. The Japanese version of the Mini-International Neuropsychiatric Interview was also used for the intractable disease group. Results: Analysis of covariance found a significant increase in STS score among the intractable disease group ( P < 0.001). Multiple regression analysis showed that the positive affect measured by the World Health Organization-Subjective Inventory showed the greatest effect on the STS score for the intractable disease group (β = 0.539, P < 0.001). Conclusion: As a life-changing experience, an intractable disease may influence an increase in self-transcendence. The results also showed that there was a strong correlation between self-transcendence and respondents' subjective well-being. Our results suggest that patients with life-changing intractable disease can have a high level of self-transcendence, which may lead them to regain mental well-being, and increase their psychological health even in situations that cause physical and mental suffering. [ABSTRACT FROM AUTHOR]

OBJECTIVE: • To evaluate the long-term success and tolerability of sacral neuromodulation (SNM) in the control of the symptoms of bladder pain syndrome (BPS). METHODS: • This was a retrospective study of all patients with BPS who underwent peripheral nerve evaluation and then SNM in our department of urology by a single surgeon from 1994 till 2008. The global response assessment scale was used to evaluate the outcome of the SNM. RESULTS: • A total of 78 patients fulfilled the International Consultation on Incontinence clinical criteria for BPS and showed cystoscopic evidence of glomerulation or ulcer as recommended by the European Society for the Study of Interstitial Cystitis/ Painful Bladder Syndrome. All patients failed conservative management before considering SNM. • Permanent SNM implant was performed in patients who showed at least 50% improvement in their symptoms with a temporary peripheral nerve evaluation test. Median follow up was 61.5 months ( SD ± 27.7). Good long-term success of the SNM was seen in 72% of the patients. • Presence of urgency was a positive predictor of the long-term success of the implant. The explantation rate was 28%. The commonest reason for explantation was poor outcome (54% of the failed patients). The revision rate was 50%. • The most common indication for revision was lack of stimulation sensation and worsening of symptoms. The average durability of the pulse generator battery was 93 months. CONCLUSION: • SNM is an effective treatment to control the symptoms of BPS. It should be considered before any major invasive surgical intervention if conservative measures have failed. It is a minimally invasive, safe procedure with good longterm outcome. However, the revision rate is high and patients require lifelong follow-up. [ABSTRACT FROM AUTHOR]

Arteriovenous malformations are rare clinicopathological entities with varied distribution and a constellation of symptoms. In the extremities they are usually associated with dermatological manifestations, such as angiodermatitis with a potential risk of torrential haemorrhage. Surgical resection is a morbid procedure. Transcatheter embolization and sclerotherapy is an attractive alternative to surgical resection. However, proper case selection is a prerequisite and may not be possible in all the cases. The case reported here is a paradigm of a complex and extensive vascular malformation with torrential haemorrhage where a unique therapeutic approach of radiation therapy was used as an alternative to morbid surgery after embolization and sclerotherapy failure. [ABSTRACT FROM AUTHOR]

A retrospective study of lamotrigine (LTG)–valproic acid (VPA) combination therapy in medically refractory epilepsy. Patients were identified with an adult epilepsy clinic database and were included if they had been on LTG–VPA combination therapy for at least 6 months. Patient demographics and information about epilepsy type, severity, and degree of medical intractability were obtained by retrospective chart review. The primary outcome measure was change in baseline seizure frequency, and patients were stratified into three groups: (i) seizure-free, (ii) improved (at least 50% reduction in baseline seizure frequency), and (iii) not improved. Thirty-five patients met all inclusion–exclusion criteria. Epilepsy type was generalized in 25 patients (71%) and partial in 10 patients (29%). Before LTG–VPA treatment, 27 of 35 (77%) experienced disabling seizures on a monthly basis, and 17 of 35 (49%) of patients had at least one disabling seizure per week. Patients had previously failed treatment with a median of five antiepileptic drugs (AEDs), alone or in combination. With LTG–VPA therapy, 18 (51.4%) remained completely seizure-free, four (11.4%) were improved, and 13 (37.1%) were unimproved. Median follow-up was 42 months. Of the 22 patients who improved, 11 had previously failed LTG and VPA monotherapy. There was no significant difference between improved and unimproved patients with respect to demographics, epilepsy type or severity, or number of previously failed AEDs. The combination of LTG and VPA should be considered in patients with medically refractory epilepsy. The effectiveness of this combination appears to be independent of epilepsy type or patient demographics. [ABSTRACT FROM AUTHOR]

The study of migraine has yielded many benefits for headache patients. Little research, however, has been performed on refractory migraine (RM) headache, a term often used interchangeably with intractable migraine. This may be a consequence of a lack of a well-accepted definition. In a survey performed by the Refractory Headache Special Interest Section (RHSIS) on the American Headache Society (AHS) in 2006, 58% of the members agreed that a definition for refractory headache should be added to the International Classification of Headache Disorders-2. A PubMed search identified 21 articles that defined refractory or intractable headache/migraine. Sixteen (76%) defined the term “refractory” and 5 (24%) defined the term “intractable.” Many of these definitions did not address the need for an adequate trial of a preventive medicine, disability, and medication overuse. An operational definition will allow us to better characterize the disorder, address unmet medical needs, and identify the most effective treatments. RHSIS of the AHS has proposed a definition of RM. It is our hope that this definition will spur interest in this entity and will lead to further research in the area. [ABSTRACT FROM AUTHOR]

Certain migraines are labeled as refractory, but the entity lacks a well-accepted operational definition. This article summarizes the results of a survey sent to American Headache Society members to evaluate interest in a definition for RM and what were considered necessary criteria. Review of the literature, collaborative discussions and results of the survey contributed to the proposed definition for RM. We also comment on our considerations in formulating the criteria and any issues in making the criteria operational. For the proposed definition for RM and refractory chronic migraine, patients must meet the International Classification of Headache Disorders, Second Edition criteria for migraine or chronic migraine, respectively. Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. The definition requires that patients fail adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta-blockers, anticonvulsants, tricyclics, and calcium channel blockers. Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulation and either nonsteroidal anti-inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated. An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least 2 months at optimal or maximum-tolerated dose, unless terminated early due to adverse effects. The definition also employs modifiers for the presence or absence of medication overuse, and with or without significant disability. [ABSTRACT FROM AUTHOR]

The proposed definitions for refractory migraine (RM) and refractory chronic migraine (R-CM) comprise 5 key components that must be operationalized for epidemiologic research. Persons with RM or R-CM must meet the second edition of the International Classification of Headache Disorders criteria for migraine or chronic migraine. They must experience significant interference with function or quality of life due to headaches. This interference must be present despite adequate treatment in 3 domains: modification of triggers and lifestyle factors, acute medication, and preventive medicines. The epidemiologic data which address these 5 components will be reviewed herein though specifically designed studies will be required to fully explore RM and R-CM. In addition, 2 “modifiers” of RM and R-CM have been proposed; one addresses medication overuse and the other considers disability based on a Migraine Disability Assessment score of 11 or greater. The epidemiology of these modifiers is discussed. [ABSTRACT FROM AUTHOR]

Intrathecal injection of phenol (ITP) has been used to control intractable pain and spasticity. Direct caustic nerve damage has been postulated as the mechanism of analgesia. Sensation is commonly recovered, suggesting that a spontaneous regeneration process takes place. There is, however, a lack of mechanistic information on ITP therapy. To define morphologically the neurolysis and regeneration phenomena produced by ITP, anesthetized rats were subjected to laminectomy at L5; 5 μl of 22% phenol in saline solution or vehicle (control) was injected. Light and electron microscopy studies of nerve roots were performed at 2, 14, and 60 days after injection. Rats given ITP showed at the early stage a variable amount of roots with signs of infarction characterized by loss of axon-myelin units and thrombosis of intra-root vessels. At 14 days, abundance of macrophages removing debris, open vessels, and nerve sprouts was identified in damaged roots. At this time, non-myelinating glial fibrillary acidic protein-positive Schwann cells were observed in both damaged and apparently undamaged roots. At 60 days, abundance of 2′,3′-cyclic nucleotide 3′-phosphodiesterase-positive Schwann cells myelinating newly formed axons was observed in damaged roots. Control rats did not show signs of neural or vascular pathology. Attempting to prevent thrombosis, another group of rats received heparin before ITP; these anti-coagulated rats developed radicular thrombosis, neurolysis, and hemorrhage. In conclusion, neurolysis produced by ITP is associated with acute ischemia (not prevented by heparin) and is followed by vascular, nerve, and myelin regeneration. Our results help understand the lack of efficacy of and some complications by ITP clinical therapy. [ABSTRACT FROM AUTHOR]

One of the most significant concerns about the legalization of physician-assisted death in the United States relates to the possibility that a chronically or terminally ill person would choose to end her or his life for financial reasons. Because we believe that the life insurance industry is uniquely poised to help minimize any such incentive, we submit that it has a moral obligation to do so. In particular, we propose that the industry encourage greater flexibility in the payout of policy benefits in the event an insured should be diagnosed with a terminal illness or suffer from intractable pain. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The Multidimensional Pain Inventory (MPI) and the MMPI have been used widely to assess chronic pain patients. This study examined the relationship between patient profile classifications generated by the MPI and psychopathology as measured by the MMPI. MPI Dysfunctional and Interpersonally Distressed means were significantly different than the MPI Adaptive Coper means on scales 4, 6,7, and 8 of the MMPI. The Dysfunctional and Adaptive Coper means were also significantly different on MMPI scale 2. MMPI profiles for 79% classified as Dysfunctional and 62% classified as Interpersonally Distressed displayed psychopathology as defined by significant two-point scale elevations. Only 23% of those classified as Adaptive Copers had significant two-point MMPI scale elevations. [ABSTRACT FROM AUTHOR]

This study investigated the relationship of age and gender to the MMPI scores of patients with chronic pain; 1,766 patients with musculoskeletal lumbar and/or cervical pain were evaluated, using the MMPI. Multivariate analysis of variance (p < .001) revealed main effects for gender and age group variables; no interaction effects were found. For the age group variable, significant differences were found on two validity and seven clinical scales. Subjects in the 70- to 90-year age group produced the lowest scores on all scales except L, F, and Mr. Linear declines across age groups, and quadratic effects were found on some scales. The authors hypothesize that developmental transitions may account in part for these findings. [ABSTRACT FROM AUTHOR]

Cervical spinal cord stimulation (cSCS) has been employed as a treatment for intractable pain for the past 20 years. Recently, we reported that cSCS increased regional cerebral blood flow (rCBF) in cats and humans. The present study was designed to examine the effects of cSCS on experimental cerebral strokes, using a cat middle cerebral artery occlusion model (MCAO). A total of 31 cats were randomly assigned to three groups; Group 1: control, Group 2: sham operation, Group 3: cSCS. Mortality of the control group was 92% as long as 4 days after MCAO. Groups 2 and 3 showed a prolongation of survival rate (44% and 56%, respectively). CSCS reduced the rate of death within 24 hours after MCAO. There was no alteration of infarct size, which was estimated by the TTC method and measured by computer technique (PDP-11/23), was found in dead cats of all groups. In cats that survived in Group 3, however, drastic prevention of an infarct progression was found, compared to Group 2. The results provide a clinical application of cSCS for stroke patients, although no evident mechanism was obtained. [ABSTRACT FROM AUTHOR]

Seven patients suffering intractable pain from head and neck cancer (age 48-73, mean 57.5 years) underwent acute stimulation of dorsal periaqueductal gray matter (PAG) with immediate cessation of pain. Two patients received chronic PAG stimulation with relief of pain during stimulation. The effect was not reversed by naloxone and there were no changes in CSF peptides. [ABSTRACT FROM AUTHOR]

The Intractable Liver Diseases Study Group of Japan, supported by the Ministry of Health, Labor and Welfare, established novel diagnostic criteria for 'acute liver failure' in 2011. In these criteria, patients without histological findings of hepatitis are included in the disease entity of 'acute liver failure', as in Europe and the USA. In this report, classification criteria for the etiologies of 'acute liver failure' in Japan are proposed. [ABSTRACT FROM AUTHOR]

We describe a patient with intractable chronic cluster headache that responded well to supraorbital nerve electric stimulation. [ABSTRACT FROM AUTHOR]

Editorial. Examines the risks and benefits of long-term intrathecal analgesia. Safety and effectiveness of long-term administration for control of intractable pain; Improvements in the risk-benefit ratio; Effect of long-term administration on pituitary hormone release.

Background.—Intractable migraine presents a significant treatment challenge to both patient and physician. Most attacks are treatable or self-limiting, but occasionally they may continue for extended periods regardless of treatment. Objective.—To determine the efficacy of naratriptan 2.5 mg twice daily for the treatment of intractable migraine. Methods.—We reviewed 24 patients treated with naratriptan twice daily for an intractable migraine attack. Patients were permitted to take prophylactic medication if such treatment had been effective in the past. Results.—Nineteen patients (79%) improved. Twelve patients showed excellent response with cessation of pain and associated symptoms, 7 patients partially responded with lessening of pain and cessation of associated symptoms, and 5 patients were nonresponsive. Conclusion.—Short-term daily administration of naratriptan may be effective in terminating status migrainosus. [ABSTRACT FROM AUTHOR]

Some migraineurs have the additional misfortune of suffering from cluster headaches; this situation can be challenging. [ABSTRACT FROM AUTHOR]

The clinical picture of a fixed flexed hip associated with pain in a person with haemophilia is suggestive of a haemorrhage in that area. Sonography facilitates differentiation between a haemarthrosis, intraperitoneal haemorrhage, subperiosteal bleed, a bleed into the soft tissue around the hip joint or a psoas haematoma. All these aforementioned causes may result in the same clinical presentation. Two cases are described in which coxhaemarthrosis resulted in a flexion contracture of the joint associated with severe intractable pain. Narcotic drugs failed to alleviate the severe pain. Joint aspiration produced dramatic pain relief and early joint rehabilitation. [ABSTRACT FROM AUTHOR]

The article describes a clinical test for detecting defects of cingulate lesions in man. Bilateral anterior cingulotomies that use stereotaxic techniques have been performed on man for relief of psychic stress and intractable pain. Until recently, there was no indication of any cognitive impairments in man consequent to this operation. The animal 1iterature, however, indicated that for rats cingulate lesions severely disrupted time-dependent sequential behavior. It was possible to develop a clinical test based upon the animal findings and use this test to evaluate the cognitive effects of cingulotomies on a small group of patients at Baltimore City Hospitals.

The article focuses on the connection between epilepsy and mental retardation. Epilepsy occurs in patients with mental retardation much more frequently than expected. This is mainly because the two neurodevelopmental disorders often have a common aetiology. It may be very difficult to distinguish epileptic seizures from nonepileptic attacks in people with mental retardation. In mentally retarded people, epilepsy also tends to be difficult to treat or intractable in many cases. Consequently, polypharmacy is often needed. This, in turn, increases the risk of side effects. It is often difficult to distinguish chronic mental side effects from symptoms associated with epilepsy per se.

As many as 25-30 per cent of people with epilepsy do not respond to adequate antiepileptic treatment and are said to suffer from refractory epilepsy. Although most people with refractory epilepsy have partial seizures, there is no definitive or all-inclusive definition of refractory epilepsy. Epilepsy can be considered medically intractable when satisfactory seizure control cannot be achieved with any of the potentially available effective antiepileptic drugs at doses or levels not associated with unacceptable side effects. There is, however, no single step in the medical management of an adult or child with epilepsy after which he or she can be declared medically intractable.