If a first antiepileptic drug fails to control a child's epilepsy, what are the chances of success with the next drug?

OBJECTIVE: This study was carried out to determine how often a child's epilepsy is controlled and remits if a first antiepileptic drug (AED) fails to control seizures. STUDY DESIGN: We used the Nova Scotia population-based epilepsy study, which identified children between 1977 and 1985 who had two or more unprovoked seizures without progressive cause and followed them up for at least 4 years. Seizure types were partial, primary, and secondarily generalized (excluding absence seizures). The study documented success or failure of the initial AED in the first year of treatment, as well as long-term seizure control and remission. RESULTS: The number of eligible children was 417, with an average follow-up period of 8 years. The initial prescribed AEDs were phenobarbital (48%), carbamazepine (38%), and phenytoin (11%). Overall, 345 (83%) children received only one AED in the first year of treatment; 61% became free of seizures and no longer required AED treatment at the end of follow-up (remission). Only 4% of those treated with a single AED during the first year later experienced intractable epilepsy. In contrast, 72 of 417 (17%) had inadequate seizure control with their first AED and received a second AED, with only 42% having complete remission of their epilepsy. The 72 children in whom seizures were not controlled with the first AED were more likely to have neurologic deficits (p = 0.01) and complex partial seizures (p = 0.01), and 29% had intractable epilepsy (p < 0.0001). CONCLUSIONS: If the first AED is not efficacious, the outcome is less favorable, although many children will have remission of their epilepsy. Invasive or complex treatments for epilepsy with partial and generalized tonic-clonic seizures should not be used until at least two AEDs have failed to control seizures.

Failure of pulse intravenous methylprednisolone treatment in juvenile dermatomyositis.

OBJECTIVE: To review the experience with high-dose intravenous pulse methylprednisolone (IVMP) therapy in patients with juvenile dermatomyositis (JDM) in our institution. STUDY DESIGN: We reviewed the charts of seven consecutive patients (four female subjects; three male subjects; age 3 to 18 years (mean age 8 years) treated for JDM between 1989 and 1992. RESULTS: All patients met the criteria of Bohan and Peter for JDM and were treated within 3 months of onset of weakness. All received initial treatment with IVMP, 30 mg/kg per day for 3 days, administered weekly for between 1 and 4 weeks. Treatment with orally administered prednisone was required because of deteriorating muscle strength and persistent elevation of creatine kinase activity despite IVMP in five patients, increased skin vasculitis in one patient, and elevated creatine kinase activity with no improvement in strength in one patient. CONCLUSION: We conclude that muscle strength in patients with JDM may deteriorate during pulse IVMP therapy when this is used alone as initial treatment, even early in the course of the illness. We recommend either conventional high doses of orally administered corticosteroids or IVMP with oral corticosteroid therapy as initial treatment of JDM.

Biologic factors as predictors of social outcome of epilepsy in intellectually normal children: a population-based study.

We studied social outcome for all the normally intelligent children in our province with onset of epilepsy between 1977 and 1985 (excluding absence and "minor motor" seizures). After follow-up averaging 7 1/2 years, the 337 patients were 7 to 28 years of age. Outcome measures were age dependent. Of those old enough to be at risk, the percentage with each unfavorable outcome was as follows: school failure 34%, use of special educational resources 34%, mental health consultation 22%, psychotropic medication 5%, unemployment 20%, social isolation 27%, inadvertent pregnancy 12%, and criminal conviction 2%. In social isolation 27%, inadvertent pregnancy 12%, and criminal conviction 2%. In a multivariate model correcting for number of potential unfavorable outcomes (based on age at end of follow-up), many variables related to epilepsy, seizure control, and electroencephalographic findings were not associated with social outcome. Only two variables were associated with at least one unfavorable outcome--learning disorder (p < 0.001) and more than 21 seizures before treatment was begun (p < 0.03). The only variable with no unfavorable outcome was simple partial seizures (p < 0.003). Sensitivity and specificity of this model were 54% and 68%, respectively, indicating that social outcome for these children was often not related to biologic factors reflected by the medical details and clinical course of their disorder.

Outcome of childhood epilepsy: a population-based study with a simple predictive scoring system for those treated with medication.

A population-based study was conducted in an attempt to predict which child's epilepsy will remit. Use of data from a regional electroencephalography laboratory allowed identification of all children in Nova Scotia with epilepsy onset from 1977 through 1985 (excluding those with absence and "minor motor" seizures). Children were followed for an average of 7 years. On the basis of clinical characteristics, a multivariate analysis was used to develop a scoring scheme to predict remission (defined as off medication at the end of the follow-up period). Survival curve methods were used to estimate the duration of medication treatment for those with remission. Of the 504 eligible patients, approximately 70% became seizure free long enough to discontinue medication. Approximately 70% of those stopping medication a first time remained seizure free. At the end of follow-up, 55% of the total cohort were in remission. At diagnosis, the best predictors of remission were age < 12 years at onset, normal intelligence, no prior neonatal seizures, and fewer than 21 seizures before treatment. If predicted to have a remission, then, on the basis of survival curve analysis, 80% were without medication 100 months after diagnosis. After 12 months of treatment, prediction was enhanced by including a score for the number of seizures between 6 and 12 months on treatment. We conclude that approximately 55% of childhood epilepsy will remit. Our scoring system predicts reasonably accurately who will have a remission and when medication is likely to be discontinued.