Epilepsy in Clinical Practice: A Case Study Approach
 
By Andrew N. Wilner, MD, FACP, 270 pp, $34.95, ISBN 1-888799-34-X, New York, NY, Demos Medical Publishing, 2000.
Reviewed by: Aatif M. Husain, MD
 

 

This is a well-written concise book that addresses common issues in managing patients with epilepsy. It is written by a single author in a unique format, with typical cases from the author's practice presented to highlight a particular issue. Following the case presentations, questions relevant to the issue being discussed are posed and answered. The author intends the book to be used by general neurologists, primary care physicians, residents, medical students, physician assistants, pharmacists, nurses, social workers, and others.

The book is divided into 2 main sections: "Case Studies" and "Resources." There are 12 chapters in the "Case Studies" section, each highlighting a particular issue in the management of epilepsy. The "Resources" section contains 31 chapters (some of which are only tables) that serve as references for the reader. Following these 2 sections are a glossary of acronyms, a glossary of terms, and an index.

The case studies presented by the author highlight many of the typical problems seen by any practitioner who sees patients with epilepsy. The cases presented are not "textbook"; rather they represent what one encounters most commonly in practice. The questions that follow the case presentations are very logical, often reminiscent of questions usually asked by neurology residents on rounds with epileptologists. The questions inspire the author to discuss each topic in an interesting and interactive rather than a didactic manner. For example, questions in the chapter, "The First Seizure," discuss the definition and epidemiology of epilepsy, risk factors, types of seizures, the diagnostic workup of new-onset seizures, and treatment. The author gives appropriate attention to the very important and often overlooked topic of psychological/psychiatric comorbidity in epilepsy. Many of the scenarios presented can have more than 1 appropriate approach; the author's approach and his reasons for using it are described. While this approach may not be appropriate in reference textbooks, this book aims to provide suggestions on management by one author and as such, this format is used well.

The "Case Studies" section contains some inaccuracies, however, and they bear mentioning. The author notes that magnetic resonance imaging is contraindicated after vagus nerve stimulating electrodes have been implanted. In fact, patients with vagus nerve stimulators can have magnetic resonance imaging done with a head coil after their stimulators have been temporarily turned off. The chapter on generalized convulsive status epilepticus notes that, "Status epilepticus commonly produces hyperpyrexia." Hyperpyrexia is an extreme elevation in body temperature, often beyond 107F. Patients in status epilepticus are often febrile; however, hyperpyrexia is very uncommon.

The author is also inconsistent with terminology at times. In the preface he notes that the " . . . international classification of seizures and epilepsy syndromes has become a fundamental requirement for successful patient management," yet in the text often refers to juvenile myoclonic epilepsy as myoclonic epilepsy of Janz and generalized tonic-clonic seizures as convulsions. To the inexperienced, these terms may produce confusion.

More significant than the occasional inaccuracies was the breach of patient anonymity on at least 2 occasions. Throughout the book, the author presents cases from his practice to illustrate clinical points. When cases are presented, care must be taken to exclude any remarks that may jeopardize patient anonymity. In chapter 3, "Stopping Antiepileptic Medications," the case of "Jack" is presented with details of his past illicit drug use. A few paragraphs later the author mentions, "Yesterday Jack was promoted to corporate vice president of my (the author's) hospital network." In a later chapter, the author presents another case: "My partner's father came to me with . . . " Both of these examples include details about the patients that can potentially identify them and do not add to the topic under discussion. Yet a third example, less egregious than the first 2, is in chapter 6, "Rash!" Here the author presents the case of "Tony." "He (Tony) had just come from his job as floor manager at the BMW dealership . . . "

A topic of great interest to the practitioner taking care of patients with epilepsy (the target audience for this book) is how to use the newer antiepileptic drugs and how to choose between them. Unfortunately neither of these topics was discussed in detail. Brief remarks about some of the newer agents were made; however, a detailed description was not presented for any of them. Chapter 4, "Seizures and Medications," focused predominantly on the use of phenytoin in a 23-year-old woman. Most epileptologists now seldom use phenytoin in young women. A discussion on the characteristics of the newer antiepileptic drugs that would make them better choices for this patient would have been appropriate. Similarly, "Rash!" only made a passing reference to lamotrigine. The omission of the newer drugs from this book is particularly unfortunate, especially since the author notes in the preface that improved medications have elevated the state of the art.

On rare occasions, the brevity of the book compromised its clarity. In chapter 2, "Intractable Epilepsy," the discussion on epilepsy surgery was very rudimentary. Further discussion of invasive monitoring with illustrations would have aided understanding. A description of the Wada test, how it is performed and interpreted, and more information about the vagus nerve stimulator and the ketogenic diet would have been useful.

The "Resources" section provides the practitioner with resources that are likely to aid in various aspects of patient management. Particularly useful resources for the target audience include a seizure history checklist, drugs affecting phenytoin and carbamazepine levels, a checklist for women and pregnancy, driving regulations in various states, first aid for seizures, and several others. Other interesting resources include Web sites for physicians and patients, literature for the waiting room, and summer camps for children with epilepsy. Some resources, however, are of no clear benefit for the target audience, ie, "Antiepileptic Drugs in Development" and the "Heidelberg Declaration on Epilepsy." Useful resources that could have been included but were not are a listing of scholarships available to students with epilepsy and the Americans with Disability Act as it relates to patients with epilepsy.

The author has hoped to target " . . . general neurologists, primary care physicians, residents, medical students, physician assistants, pharmacists, nurses, social workers, and others . . . ." General neurologists are likely to find this book useful since many cases presented likely mirror the kind of cases they see. The information is presented in an easy-to-follow, concise format. Primary care physicians may not find this book useful since they are unlikely to have time to read a book on epilepsy cover-to-cover. It can also be argued that many of the issues discussed in this book, ie, epilepsy and pregnancy, are best left to the neurologists. Residents and medical students need a more in-depth and thorough education about this important pillar of neurology, especially the new advances in the field. Pharmacists, nurses, social workers, and others will find selected chapters useful. I must agree with the author, however, when he says about the book, "When used as directed, it should provide a mix of useful information and modest entertainment for those who strive to help patients with epilepsy."

 
Aatif M. Husain, MD
Durham, NC