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In the 11 years since the 2006 publication of the International Writing Center Association's (IWCA) Position Statements on Disability and Diversity, writing center scholars have continued to explore how disability issues intersect with writing center work including the development of accessible web content and interfaces (Hawkes, 2010). Recent studies have found that university websites were ineffectively designed, difficult to navigate, and omitting any representation or acknowledgment of students with disabilities (Gabel et al., 2016; Gabel & Miskovic, 2014; Meyer, 2008; Miskovic & Gabel, 2012). In this study, the primary author and four undergraduate student-researchers study where and how disability support is explicitly articulated on writing center websites from regional Institutions of Higher Education (IHEs) and how digital resources have been designed for students with disabilities. Results show that two out of the 35 writing center offices that exist at the 55 universities analyzed have a mission statement that explicitly articulates a support for students with disabilities. Writing center websites also ineffectively incorporate pictures, simple text, simple navigation, and other accessible features (71% of the 35 writing centers analyzed had websites where 21 – 70% of the content is inaccessible). Recommendations to address these problems are provided.

Resumen Introduccion El suicidio es un importante problema de salud publica. Uno de los principales factores de riesgo conocidos para el suicidio es el padecimiento de patologia psiquiatrica que se identifica en un 90-95% de suicidios consumados, incrementandose el riesgo si existe comorbilidad. Los resultados internacionales sobre la patologia psiquiatrica mas frecuente son dicotomicos, divididos entre los trastornos del humor y los trastornos psicoticos, si bien los datos en nuestro entorno sobre casos de suicidio consumado son muy escasos. Metodologia El presente estudio describe las caracteristicas psiquiatricas y forenses de los casos de suicidio consumado (n=79) acontecidos en la region asistencial de un hospital psiquiatrico entre 2007 y 2010. Los datos forenses fueron obtenidos en el Instituto de Medicina Legal de Catalunya y los datos clinicos a partir de la revision de las historias clinicas. Resultados La mayoria de los sujetos fallecidos por suicidio consumado en la muestra de referencia fueron varones (78,5%) (IC 68,4%-87,3%). El 45,5% (IC 33,8%-57,1%) (35 de 77) de los fallecidos disponia de historia en el circuito de salud mental y/o toxicomanias de la zona, desconociendose los antecedentes de dos de los fallecidos por tratarse de menores de edad. De los 35 individuos con historia en el circuito de salud mental, el 54,3% (IC 37,1%-71,4%) presentaba un trastorno afectivo; (37,1%, IC 22,9%-51,4%) trastorno depresivo; 14,3% (IC 2,9%-25,7%) trastorno bipolar y el 17,1% (IC 5,7%-31,4%) un trastorno del espectro psicotico. Ademas, el 48,6% presentaba comorbilidad psiquiatrica no relacionada con toxicos y el 42,9% (IC 25,7%-60,0%) comorbilidad con trastornos relacionados con sustancias. Conclusiones Las caracteristicas psiquiatricas y forenses del fenomeno del suicidio consumado en nuestro entorno confirman los datos internacionales sobre una tasa elevada de patologia psiquiatrica y un patron caracteristico en cuanto a metodologia suicida.

Introduction Suicide is an important Public Health problem. One of the most relevant known risk factors for suicide is suffering from a mental health disorder, identified in up to 90–95% of completed suicides, with this risk being increased if comorbidity is present. Findings from international research on the most common psychiatric disorders are dichotomous, divided into mood disorders and psychotic disorders. In Spain, data of this kind are scarce. Methods This study describes the psychiatric and forensic characteristics of completed suicide cases (n = 79) occurred in a psychiatric hospital healthcare area (in Spain), between 2007 and 2010. The forensic data were obtained from the Institute of Legal Medicine of Catalonia and the clinical data by reviewing the clinical records. Results Most of the subjects in this sample were males (78.5%, 95% CI; 68.4–87.3%). Almost half of the sample (45.4%, 95% CI; 33.8–57.1%, 35/77) had records in the Mental Health Services Network (including substance misuse services). Two of the 79 were under 18, so we were not able to access the records. More than half (54.3%, 95% CI; 37.1–71.4%) of those with psychiatric history suffered from a mood disorder; 37.1% (95% CI; 22.9–51.4% from a depressive disorder; 14.3% (95% CI; 2.9–25.7%) from a bipolar disorder, and 17.1% (95% CI; 5.7–31.4%) suffered from a psychotic disorder. With regard to substance misuse, 42.9% (95% CI; 25.7–60.0%) presented substance misuse, and 48.6% did not. Conclusions Psychiatric and forensic characteristics of completed suicide in this Spanish sample confirm previous findings from international studies: there is a high rate of psychiatric disorders in those who complete suicide, and there is a specific pattern as regards the method used to complete it.

An 8-year-old girl with Lennox-Gastaut syndrome showed a partial reduction in seizure frequency when lamotrigine (LTG), 15 mg/kg per day, was added to clobazam (CLB) and vigabatrin (VGB). An increase in LTG dosage to 20 mg/kg per day produced no further improvement and was followed by myoclonic status epilepticus. The condition developed insidiously and ultimately became stable. Video-EEG polygraphy and jerk-locked back-averaged EEG demonstrated continuous myoclonus of cortical origin. Discontinuation of LTG resulted in rapid disappearance of clinical and electrophysiological manifestations of myoclonic status epilepticus. No episodes of myoclonus occurred in the subsequent 2 years, during which CLB and VGB were kept unchanged. The striking response to drug discontinuation suggests that LTG may have played a role in the precipitation of status, possibly within the context of paradoxical intoxication.

Summary: Purpose: In severe myoclonic epilepsy of infancy (SME), multiple drug-resistant focal and generalized seizure types occur. Lamotrigine (LTG), found effective in many generalized and partial seizures, has been little used in severe childhood epilepsy syndromes with multiple seizure types. We studied the effects of LTG in SME. Methods: Twenty-one patients with SME, aged 2–18 years, were treated with LTG, 20 in add-on and one in monotherapy. LTG was started at 0.2–2.5 mg/kg/day and increased to 2.5–12.5 mg/kg/day. For each seizure type, excluding atypical absences, >50% variations compared with the 2 months preceding LTG were considered indicators of response, also taking into account the degree of disability each seizure type produced. Results: LTG induced worsening in 17 (80%) patients, no change in three, and improvement in one. There was >50% increase in convulsive seizures in eight (40%) of 20 patients. Myoclonic seizures worsened in six (33%) of 18 patients. Of five patients improving in at least one seizure type, four had concomitant worsening of more invalidating seizures. Clear-cut worsening appeared within 3 months in most patients but was insidious in some. LTG was suspended in 19 patients after 15 days-5 years (mean, 14 months) with consequent improvement in 18. Conclusions: The pronounced seizure deterioration during LTG treatment was not attributable to the natural course of the disease and could be a direct effect of therapeutic LTG doses. LTG treatment seems inappropriate in SME.

Summary: Purpose: We describe 2 girls, aged 19 years, who experienced a rolandic seizure at ages 4 and 5, respectively, together with the interictal EEG features of benign rolandic epilepsy (BRE). In adolescence both patients developed photosensitive occipital seizures accompanied by spontaneous and photic-induced occipital EEG paroxysms. Methods: We have been following 33 patients with a history of BRE, between ages 12 and 28 years (mean 17 years). Twenty-one of these patients had experienced their last rolandic seizure before the age of 10 years and 9 of them had been without treatment since age 11 or earlier. In 2 of these 9 patients, other types of seizures recurred after remission of BRE. Clinical, EEG, and evoked potential findings on these 2 patients are presented. Results: After having experienced BRE, both patients suffered partial seizures from age 12, with elementary visual hallucinations, visual blurring, slow head turning, cephalic pain, epigastric discomfort, unresponsiveness, and vomiting. Seizure onset was related to watching TV or exposure to bright light. EEG showed interictal occipital spikes, and a photoparoxysmal response limited to the occipital lobes. Visual evoked potentials were greatly increased in amplitude. One patient had two visual attacks only and remained seizure free after 4 years of follow-up, while the other had seizures controlled by an association of valproate and carbamazepine. Conclusions: Clinical and neurophysiological characteristics suggest that these two patients may have presented different age-related expressions within the spectrum of a benign seizure susceptibility syndrome rather than sharply distinct epilepsy syndromes.

Childhood epilepsy with occipital paroxysms is an age-related idiopathic focal epilepsy. Occipital EEG paroxysms are considered necessary for diagnosis. We carried out a close clinical and EEG follow-up (range, 2-12 years; mean, 6 years 7 months; median, 7 years) in 24 patients (age range, 4-19 years; mean, 11 years 8 months; median, 11 years). In five children with early seizure onset and particularly benign prognosis without any treatment, EEG abnormalities appeared 3-10 months after the first seizure. Four of them exhibited the ictal pattern of versive seizures with vomiting. Our findings confirm that in the early idiopathic focal seizure disorders, interictal EEG abnormalities may be lacking at the beginning of the disorder.

Suicide is an important Public Health problem. One of the most relevant known risk factors for suicide is suffering from a mental health disorder, identified in up to 90-95% of completed suicides, with this risk being increased if comorbidity is present. Findings from international research on the most common psychiatric disorders are dichotomous, divided into mood disorders and psychotic disorders. In Spain, data of this kind are scarce.This study describes the psychiatric and forensic characteristics of completed suicide cases (n=79) ocurred in a psychiatric hospital healthcare area (in Spain), between 2007 and 2010. The forensic data were obtained from the Institute of Legal Medicine of Catalonia and the clinical data by reviewing the clinical records.Most of the subjects in this sample were males (78.5%, 95% CI; 68.4%-87.3%). Almost half of the sample (45.4%, 95% CI; 33.8%-57.1%, 35/77) had records in the Mental Health Services Network (including substance misuse services). Two of the 79 were under 18, so we were not able to access the records. More than half (54.3%, 95% CI; 37.1%-71.4%) of those with psychiatric history suffered from a mood disorder; 37.1% (95% CI; 22.9%-51.4% from a depressive disorder; 14.3% (95% CI; 2.9%-25.7%) from a bipolar disorder, and 17.1% (95% CI; 5.7%-31.4%) suffered from a psychotic disorder. With regard to substance misuse, 42.9% (95% CI; 25.7%-60.0%) presented substance misuse, and 48.6% did not.Psychiatric and forensic characteristics of completed suicide in this Spanish sample confirm previous findings from international studies: there is a high rate of psychiatric disorders in those who complete suicide, and there is a specific pattern as regards the method used to complete it.

Patients with depressive disorders present abnormalities in the hypothalamic pituitary adrenal (HPA) axis. The effects of a partial relapse with regard to HPA axis has not been studied so far.To assess whether patients with partial relapse have a different neuroendocrine profile compared with those with complete relapse and with those without relapse over a 2-year follow-up.The adrenocorticotropin hormone (ACTH) and cortisol responses to corticotrophin releasing factor (CRF) stimulation was assessed in 62 outpatients diagnosed with unipolar depressive disorder with melancholic features according to DSM-IV. Twenty-three healthy controls were included in the study for comparison. Monthly follow-up visits were performed over a 2-year period after remission; partial and complete relapses were established using the Hamilton Depression Rating Scale (HDRS) and according to Frank's criteria. Fifty-four patients completed the study. A comparative statistical analysis was performed.Stratifying the net area under cortisol curve (NAUCC) (µg/ml/min) at three levels-150, 150-350 and ≤ 350-significant differences appear between the three depressive groups of patients (non-relapsers, partial relapsers and complete relapsers). Particularly, there are more patients with a NAUCC ≤ 350 who show partial or complete relapses than patients with a NAUCC ≤ 350 who do not relapse (P ≤ 0.05).Our results show an increasingly altered HPA axis in those depressive patients with complete or partial relapses compared with those who did not relapse or with healthy controls, but there are not differences in HPA axis between partial and complete relapsers.

This was a prospective open comparative pilot study to assess the efficacy and tolerability of first-line vigabatrin monotherapy in childhood partial epilepsies. Two groups of patients were recruited over the same period. The vigabatrin monotherapy group comprised 40 patients (18 male, 22 female; mean age at last visit 7.5 years); the comparative carbamazepine monotherapy group comprised 40 consecutive clinic patients (22 male, 18 female; mean age at last visit 7.8 years). Seizures disappeared in 82% of vigabatrin patients and in all carbamazepine patients with idiopathic partial epilepsy, and in 50% of vigabatrin patients and 55% of carbamazepine patients with symptomatic partial epilepsy. Interictal EEG abnormalities decreased in vigabatrin patients more than in carbamazepine patients (P < 0.05). Tolerability was good in vigabatrin patients, but four out of 37 showed mild irritability by the end of the trial. Persistent sedation was observed in eight of the 40 patients receiving carbamazepine. No patient had drug therapy discontinued because of side-effects. During vigabatrin long-term monotherapy, efficacy and good clinical tolerability were maintained. These results suggest that vigabatrin may be an alternative first-line treatment for childhood partial epilepsies. Further blinded comparative randomized trials are needed.

Summary: Purpose: To describe an 11-year-old girl with symptomatic localization-related epilepsy and normal intelligence who developed reversible mental deterioration and pseudoatrophic brain changes while receiving valproate (VPA). Methods: Assessment of mental function using Wechsler Intelligence Scale for Children-III (WISC) and Raven's Progressive Matrices (PM), EEG recordings while awake and asleep, and brain magnetic resonance imaging (MRI), were performed at the beginning of VPA therapy, after 2 years and 8 months of treatment and following VPA discontinuation. Results: After 2 years and 6 months on VPA (≤26 mg/kg/day) the girl insidiously developed mental deterioration (loss of 18 IQ points and drop in age-adjusted PM score from the 95th to the 50th percentile) associated with MRI-documented pseudoatrophy of the brain. Onset of severe cognitive impairment coincided with serum VPA concentrations near 100 μg/ml. There were no other manifestations of drug toxicity or hyperammonemia. Background EEG activity was normal. Reduction of VPA dosage and subsequent discontinuation 4 months later resulted in disappearance of clinical symptoms with a 20-point improvement at IQ testing and recovery of previous PM score. Repeat MRI showed disappearance of pseudoatrophic changes. Conclusions: The striking cognitive improvement and reversal of pseudoatrophic brain changes following VPA discontinuation strongly suggest a drug-induced condition. Based on this and previous reports, the syndrome of VPA-associated mental deterioration and pseudoatrophy of the brain appears to encompass different but possibly related clinical entities, which include parkinsonism with cognitive deterioration, mental deterioration with signs of VPA-toxicity, and isolated mental deterioration, as seen in our patient. A drug-induced effect should be considered whenever cognitive deterioration and imaging findings of brain atrophy occur in VPA-treated patients.

Paroxysmal tonic upgaze of childhood with ataxia is a rare form of age related dystonia. Out of 12 previously reported cases, three had a clinical history of similar symptoms occurring in at least one first degree relative belonging to the same or two consecutive generations. Autosomal dominant inheritance was therefore hypothesized. We report on a family in which the disorder appeared in three consecutive generations between ages 6 and 11 months, disappearing gradually and spontaneously between ages 18 to 24 months. All affected individuals had normal neurologic development. The pedigree analysis of previously reported cases and of the family reported herein provides strong evidence that the disorder may be inherited as an autosomal dominant trait and represents a form of transient paroxysmal dystonia with benign long-term prognosis.

The effects of age, dosage, and type of comedication on plasma lamotrigine (LTG) concentrations and the relationship between plasma drug levels and clinical response were evaluated in a prospective study of 45 patients, aged 3 to 38 years, with epilepsy uncontrolled by conventional anticonvulsant therapy. Six of the 45 patients were on single-drug therapy, and 39 were on two to five concurrently administered antiepileptic drugs when LTG was added. Thirteen patients were assessed at three or more LTG dosage levels. Within individuals, steady state plasma LTG concentrations increased linearly with increasing daily dosage over the examined dose range (25 to 575 mg/day or 0.75 to 21 mg/kg.day). Among patients also receiving enzyme-inducing agents, such as carbamazepine, barbiturates, or phenytoin, plasma LTG concentrations normalized to a 1 mg/kg daily dose were lower in children aged 3 to 6 years (0.30 +/- 0.17 microgram/ml; n = 6) than in the older children (0.43 +/-0.18 microgram/ml; n = 12) and adolescents/adults (0.68 +/- 0.26 microgram/ml; n = 10). In patients treated with valproate, the age dependency of plasma LTG was less evident, possibly because of a smaller sample size and the confounding effect of comedication. Within any given age group, dose-normalized LTG concentrations were about five-fold higher in patients comedicated with valproic acid than in those comedicated with enzyme inducers. Twenty patients showed a favorable response (with a > or = 40% reduction in seizure frequency compared with the pre-LTG period) and continued on long-term treatment. Plasma drug concentrations in these apparent responders were highly variable and did not differ significantly from those observed in nonresponders (6.6 +/- 5.2 versus 4.8 +/- 3.3 microgram/ml). These findings show that plasma LTG concentrations exhibit a wide interindividual variability under the influence of age and type of comedication, but they are predictably related to dosage within individual patients. Although there was no apparent relationship between drug levels and clinical response in this difficult-to-treat population, further studies on the potential value of monitoring plasma LTG concentrations are indicated.

Antiepileptic drugs (AEDs) may aggravate pre-existing seizures and trigger new seizure types. However, the extent and mechanisms of this problem are unclear, for several reasons. AED trials are not designed to detect worsening of seizures, severe childhood epilepsies may fluctuate in severity, and worsening of seizures may be over-hastily ascribed to the introduction of a new AED. Moreover, the seizure and the epilepsy type may have been incorrectly diagnosed. The problem is identification of true aggravation of epilepsy in the absence of overdosage or toxicity. This is a common and clinically important problem that concerns both established and newer AEDs, but the biologic mechanisms involved are unknown. An increase in seizure frequency due to overdosage has been reported with phenytoin but is rare with other AEDs. Paradoxical reaction has been reported with carbamazepine (CBZ), benzodiazepines, and vigabatrin (VGB). Exacerbation of seizures may also occur during AED-induced encephalopathy or hepatopathy. An inappropriate choice of the AED (i.e., a purely pharmacodynamic mechanism) can induce worsening when CBZ or VGB is used in absence and myoclonic seizures. Further research should determine whether seizure exacerbation is associated with the type of epilepsy or with the type of EEG abnormality. Recent evidence indicates that lamotrigine is inappropriate in severe myoclonic epilepsy. Some childhood epileptic encephalopathies have been affected by certain seizure-worsening mechanisms. Whether this is due to a predisposition in specific syndromes or to an increased risk for adverse effects in patients undergoing multiple AED manipulations is unclear. Furthermore, some syndromes are not the sum of accompanying seizure types but have unique neurobiology.

We evaluated the efficacy and safety of lamotrigine in 41 children and young adults (age range, 3-25 years; mean, 12 years) with drug-resistant, partial epilepsies, based on a prospective, add-on study Patients had severe symptomatic/cryptogenic partial epilepsies (mean seizure frequency = 3.6/day), resistant to one to four major antiepileptic drugs. Mean seizure frequency significantly decreased (P < .001) throughout the period of treatment. A good response (>50% seizure reduction) was observed in 15 patients of whom 6 were seizure-free (follow-up: 12-48 months). Higher responder rate was found among cryptogenic epilepsies and epilepsies symptomatic of cerebral malformation, whereas patients with posthypoxicischemic perinatal damage were poor responders. Lamotrigine discontinuation was mainly due to lack of efficacy (46% of patients), whereas only 2 patients developed a transient skin rash and did not drop out. Lamotrigine represents a valuable treatment for severe partial epilepsies of childhood that have proved resistant to previous antiepileptic drugs. (J Child Neurol 2000;15:671-674).