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By: John E. Bennett, MD, MACP

  • Adjunct Professor of Medicine, Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine
  • Director, Infectious Diseases Training Program, NIH Office of Clinical Research Training and Medical Education, Bethesda, Maryland


All disposable instruments that have been in contact with high-infectivity tissues should be clearly identified and disposed of by incineration arthritis upper back order celecoxib master card. Use disposable non-permeable material to arthritis swelling feet treatment purchase celecoxib overnight delivery prevent contamination of the work surface rheumatoid arthritis kill you discount 100 mg celecoxib overnight delivery. This covering and all washings arthritis treatment laser buy discount celecoxib 100mg line, waste material and protective clothing should be destroyed and disposed of by incineration. Fixatives and waste fluids must be decontaminated by a decontamination method described in Section 6. Laboratories handling large numbers of samples are advised to adopt more stringent measures because of the possibility of increased residual contamination. Note: this document contains recommendations designed for health care laboratories and is not intended as a guideline for scientific research laboratories. The tissue categories of high infectivity, low infectivity, and no detectable infectivity are listed and discussed in Section 6. Precautions to be taken when handling different tissue specimens are presented in Figure 6. Where properly packaged according to these guidelines, there is no danger to the carriers. There is no reason for a diagnostic test to be denied if these measures are observed. Guidelines for the safe transport of infectious substances and diagnostic specimens. For phenolics these situations, the methods sodium dodecyl sulfate recommended in Annex 4. The instruments are then treated by one should not be exposed to fixation reagents, and should of the decontamination methods recommended in be kept wet between the time of use and disinfection Annex 4. A minority opinion held that instruments should be decontaminated before mechanical cleaning, and then handled as per 6. In this way, the most stringent (either consecutively or simultaneously) appear to be recommendations are applied to instruments sterilizing under worst-case conditions. Policy-makers are molecules to their constituent subunits, thereby encouraged to adopt the highest decontamination cleaning as well as inactivating. Instead, to the extent possible, safest and most unambiguous method for ensuring such instruments should be protected from surface contamination by wrapping or bagging with disposable materials. All adherent material must be removed and, if at all possible, the exposed surfaces cleaned using a decontamination method recommended in Annex 4. In all instances where unfamiliar decontamination methods are attempted, the manufacturer should be consulted. These cleaning procedures should be applied even if the instrument has been reused before discovery of its potential contamination. Contaminated instruments or other contaminated materials should not be cleaned in automated washers without first having been decontaminated using a method recommended in Annex 4. It is also important to mechanically clean and disinfect equipment and surfaces that are subject to potential contamination, to prevent environmental build-ups. Surfaces that cannot be treated in this manner should be thoroughly cleaned; consider use of a partially effective method as listed in Figure 6. Cleaning tools and methods should be selected to minimize dispersal of the contamination by splashing, splatters and aerosols. Where possible, cleaning tools such as brushes, towelling and scouring pads, as well as tools used for disassembling contaminated apparatus, should either be disposable or selected for their ability to withstand the disinfection procedures listed in Annex 4. Upon completion of the cleaning procedure, all solid wastes including disposable cleaning materials should be collected and decontaminated. The cleaning station should then itself be decontaminated using one of the methods in Annex 4. Automated cleaning equipment must not be used for any instrument or material that has not previously been thoroughly decontaminated following the recommendations in Section 6. All individuals involved with disinfection and decontamination procedures should be familiar with these basic protective measures and precautions. Handling of contaminated instruments during transfers and cleaning should be kept to a minimum. The work area should be selected for easy containment of contamination and for subsequent disinfection of exposed surfaces. Absorbents, such as sawdust, may be used to stabilize liquids that will be transported to an incinerator; 37 the recommended levels of decontamination are shown in Figure 6. The table reflects the consensus of the Consultation, and should be used in conjunction with Section 6. Routine cleaning and disinfection procedures Routine cleaning and disinfection procedures Annex 4. Practitioners should review guidelines prescribed under the laws, procedures, codes of practice or other regulatory provisions in force in the relevant state or territory. All material classified as clinical waste should be placed in secure leak-proof containers and disposed of by incineration at an authorized incineration site. Avoid external contamination of the container to ensure safe handling of clinical waste. In regions where no incineration facilities are available, it is recommended that these wastes be chemically disinfected and then burnt in pits dedicated to final disposal. Authorities should ensure that waste is adequately managed, as in certain big cities of the developing world it has been estimated that as much as one half of infectious waste is cleaned, repackaged and sold in the marketplace. Low-infectivity tissues and drainage from low-infectivity tissues2 should be handled cautiously. For tissues, secretions, or excretions with no detectable infectivity, no special requirements beyond Standard Precautions are required for the handling of body fluids or body-fluid contaminated linen, equipment or environments. Other infectious wastes from home care require no special precautions beyond those taken for any other disease. The use of enamel, heat-stable plastic or disposable trays when working with infectious specimens will help to confine contamination. Disposable items should be incinerated after use, although methods listed in Annex 4. Use absorbent material to soak up spills, which can then be contained and incinerated or treated by a method described in Annex 4. Drainage from low-infectivity tissue that has not been specifically tested for infectivity, however, may retain infectivity. Disposable gloves and an apron should be worn when removing such spills and should subsequently be disposed of by incineration, together with the recovered waste and cleaning materials, although a method described in Annex 4. It is recommended that the deceased patient be placed in a sealed body bag before moving, in line with normal procedures for bodies where there is a known infection risk. Refer to country-based guidelines and regulations for more information on care and handling of a deceased and infected patient. Electric saws, if used, should be operated inside an aerosol-containing bag unless ventilated helmets with an appropriate filter are worn. Instruments and mortuary working surfaces should be decontaminated following the guidance in Section 6. If examination is limited to the brain, a plastic sheet with absorbent wadding and raised edges is first placed underneath the head to ensure containment of tissue debris and body fluids. After removal of the brain, replacement of the skullcap and suturing of the skin, the plastic sheet containing all tissue debris and drainage is bagged and sealed and sent for incineration. A full postmortem examination is discouraged except in dedicated facilities, unless special circumstances warrant the added difficulty of infectivity containment. Facilities conducting a large number of histological examinations on high-infectivity tissues should dedicate laboratory space, processors, instruments, glassware and reagents for this purpose. Guidelines in some countries and regions require BioSafety Containment Level 3 for handling these tissues. As a result, they should be handled with the same precautions as fresh material and be considered infectious throughout the entire procedure of fixation, embedding, sectioning, staining, and mounting on slides, until or unless treated with formic acid. Although exact procedures may vary, formic acid treatment consists of placing small pieces of fixed tissue, no more than 4 to 5 mm thick, in 50 to 100 ml of 95% formic acid for an hour, and then transferring them to fresh formalin for another two days before further processing. All of the serial steps involved in bringing the blocks from formalin into paraffin and, after sectioning, bringing the mounted paraffin sections back into aqueous staining solutions, can be carried out manually, or in an automatic processor dedicated 39 6. Ideally, three people should be present during the examination: the pathologist assisted by one technician, and one further person to handle and label specimen containers. Except for training purposes, observers should be prohibited or kept to a minimum. All personnel should be made aware of the relevant history of the patient and fully informed of procedures for such post-mortem examinations.


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Each strain could be characterized arthritis pain in hands celecoxib 100mg visa, but it is unknown which strain may be present in a food at a given time; therefore arthritis pain relief drugs discount celecoxib 200 mg line, a single growth rate or D value cannot fully describe what may happen in the future rheumatoid arthritis diagnosis code cheap generic celecoxib uk. Likewise rheumatoid arthritis brain purchase celecoxib 100mg without prescription, when thermal processes reduce the level of a pathogen to a few or less per package, their occurrence in a particular package is typically dependent on binomial and Poisson distributions. Variation can be reduced by redesign of the process or equipment; better control of the oven temperature would reduce the variation in thermal inactivation of microorganisms in the food. Estimates for the length of time an egg is in a retail store or the degree of Sulmonellu inactivation during home cooking of an egg would be examples with high uncertainty. In practice, both variation and uncertainty are present in most parameters in microbial models. Because of variation and uncertainty, each parameter has a distribution of values that it might achieve in any specific instance. This distribution can be described by a variety of functions such as normal, log normal, exponential, beta, or triangle and the appropriate parameter values that describe that distribution, that is, mean and standard deviation. Distributions frequently are skewed, with more of the occurrences toward one end than the other. Distributions also may be described by a frequency graph that simply summarizes experimental data. Each parameter input value in each unit operation, such as temperature, time, pH of food, and microbial growth rate, has a distribution. Monte Carlo simulation is a computational tool to calculate a model with multiple distributions. The simulation will pick a value for each distribution, calculate each model, and proceed stepwise through the entire process operation (Cassin et al. These distributions will tend to cluster about the mean value but will also reflect the range in outcomes likely to occur as a result of the shapes and ranges of the various input distributions. A simulation model can indicate which parameters contribute to the absolute value of the output value and which input distributions contribute to the output distributions. Each critical control point is usually evaluated separately from the other processing steps and critical control points. Establishing an acceptable or tolerable level of risk for a food is a social and value decision, not a scientific decision. The tolerable level of risk is not necessarily constant for different pathogens or foods. The risk managers will then select the specific process to be used, also taking into consideration quality, cost, and feasibility (Morales and McDowell, 1998). The selected process risk assessment specifies what each step will achieve, for example, 7 log, units of inactivation or less than 1 log, unit growth. Similar to the entire process, there may be multiple means to achieve a specific performance criterion. Many time-temperature combinations, for example, can result in the 7 loglo units of inactivation. The selection of the specific combination will again be based on quality, cost, engineering, and other criteria. The specific combination selected is termed the process criteria and becomes the critical control points. Even without designating an acceptable level of risk, the exposure assessment can determine the equivalence of different processes. The risk assessment approach will be used by regulators to change from the classic regulatory approach of specifying specific time-temperature combinations for pasteurization, for example, to performance standards. The specific process steps and critical control points are chosen by each manufacturer. A complete risk-based regulatory approach would specify the food safety objective, and industry would be responsible for demonstrating that the entire processing system meets that objective. Quantitative risk assessment of human listeriosis from consumption of soft cheese made from raw milk. Quantitative microbiological risk assessment: Principles applied to determining the comparative risk of salmonellosis from chicken products. When is simple good enough: A comparison of the Gompertz, Baraiiyi and three-phase linear models for fitting bacterial growth curves. Quantitative risk assessment for Esch~vkhiacoli 0157:H7 i n ground beef hamburgers. Potential application of risk assessment techniques to microbial issues related to international trade in food and food products. Risk assessment and economic analysis for managing risks to human health from pathogenic microorganisms in the food supply. Development of a quantitative risk assessment model for Suln7onellu enteritidis in pasteurized liquid eggs. Special issue from the Proceedings of the Workshop on the Application of Predictive Microbiology and Computer Modeling Techniques to the Food Industry. An excellent introduction to simulation modeling written to be understandable by biologists. The determination of acceptable exposure levels and the estimation of potential exposure to chemicals in food are the primary components of food chemical risk assessment. Regulatory decisions concerning the continued or prospective use of chemicals that may enter the food supply are heavily influenced by the results of risk assessments. Risk assessments also form the basis for discussions among food and agricultural groups and consumer and environmental organizations concerning the adequacy of existing regulations of food chemicals. The contemporary practice of food chemical risk assessment is quite complicated and often controversial. Numerous assumptions are frequently required to be made in both the determination of exposure and the determination of acceptable levels of exposure (Winter and Francis, 1997). These assumptions are frequently derived from legislative mandate and/or regulatory agency policy and often lack a strong scientific basis. The use of differing sets of assumptions on exposure or acceptable levels may lead to widely divergent estimates of risk that frequently are disseminated in the public arena (Winter, 1992). Significant improvements are needed to refine the accuracy of food chemical risk assessments, and many of the present trends to improve the process are discussed in this chapter. The first comprehensive guidelines for performing chemical risk assessments in the U. These guidelines separated the process of risk assessment into four components: 1) hazard identification, 2) dose response evaluation, 3) exposure assessment, and 4) risk characterization. Several improvements in the risk assessment process have been made since this report was published, but it still forms the basis for contemporary risk assessment approaches for food chemicals such as pesticide residues, food additives, naturally occurring toxins, hormones, antibiotics, environmental contaminants, and even novel products derived from food biotechnology applications. Advances in food chemical safety risk assessment have frequently involved pesticide residues in foods. The report also recommended that risk assessments be made for families of toxicologically related pesticides that cause their effects through a common mechanism of action rather than on a cheniical-by-chemical basis. The basic algorithm for food chemical exposure can be represented as follows: Exposure = Food Consumption x Residue Level In the case of a chemical that may be present on more than one food commodity, the estimated exposure would represent the summation of all the individual commodity exposures. Deterministic Exposure Modeling Historically, exposures have frequently been calculated with a "deterministic" approach that assigns finite values to both the food consumption and residue levels to calculate a "point" estimate of exposure. As an example, a detenninistic exposure estimate for pesticide A on commodity X would require knowledge of the residue level of pesticide A and the food consumption of commodity X. Frequently, with a prudent method unlikely to underestimate exposure, the level of pesticide A might be chosen to represent a maximum legal or maximum detected level rather than a more typical value. Food consumption of commodity X could be chosen to represent the per capita mean consumption or might be chosen to represent a higher level such as the upper 95th percentile of consumption. The choices of residue and food consumption levels are often, although not always, exaggerations of typical values and frequently lead to calculations of worst-case or unrealistic exposures (Archibald and Winter, 1989). Such deterministic approaches are valuable in cases in which the worstcase exposure estimates are still considered to be well within acceptable levels because refinements to improve the accuracy of the exposure assessments would not be necessary. Deterministic approaches also allow for the use of refinements such as substituting "anticipated" residues for maximum legal residues; such an approach may often drive exposure estimates below the levels of concern. Unfortunately, worst-case exposure scenarios are often communicated without reference to the potential degree of exaggeration and as such may lead to an exaggerated perception of the degree of risk (Winter, 1994). In practice, deterministic approaches to predict long-term (chronic) exposure to pesticides in food tend to use more realistic estimates. For the estimation of acute exposures, however, deterministic approaches are frequently being replaced with "probabilistic" approaches that take advantage of improvements in our computational capabilities and are far more data intensive than deterministic methods. Probabilistic Exposure Modeling In the real world, neither residue level nor food consumption data exist as single values but are more appropriately depicted as distributions (Petersen, 2000).

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A review of dietary polyamines: formation arthritis in dogs hip joints discount celecoxib 100 mg amex, implications for growth and health and occurrence in foods arthritis pain top of foot cheap celecoxib 100mg without a prescription. Effect of dynamic high pressure on microbiological arthritis in back mayo clinic celecoxib 200mg overnight delivery, rheological and microstructural quality of Cheddar cheese arthritis young adults symptoms proven 100mg celecoxib. Identification of bacteria crucial to histamine accumulation in pacific mackerel during storage. Identification of the main bacteria contributing to histamine formation in seafood to ensure product safety. Effect of starter culture, spice mix and storage time and temperature on biogenic amine content of dry fermented sausages. Histamine and other biogenic amines and histamineforming bacteria in miso products. Biogenic amines in vacuumpacked and non-vacuum-packed flesh of carp (Cyprinus carpio) stored at different temperatures. Sequencing and transcriptional analysis of the biosynthesis gene cluster of putrescine-producing Lactococcus lactis. Is the production of the biogenic amines tyramine and putrescine a species-level trait in enterococci? Effects of milk high pressure homogenization on biogenic amine accumulation during ripening of ovine and bovine Italian cheeses. Biogenic Amines in Fermented Foods and Health Implications Chapter 27 647 Landete, J. Biogenic amine production by lactic acid bacteria, acetic bacteria and yeast isolated from wine. Molecular methods for the detection of biogenic amine-producing bacteria on foods. Aminogenesis control in fermented sausages manufactured with pressurized meat batter and starter culture. Biogenic amines in traditional fermented sausages produced in selected European countries. Strategies to reduce biogenic amine accumulation in traditional sausage manufacturing. Influence of technological conditions of sausage fermentation on the aminogenic activity of L. Levels of biogenic amines as a measure of the quality of the beer fermentation process: data from Belgian samples. Effect of starter cultures on microbial ecosystem and biogenic amines in fermented sausage. Histamineproducing pathway encoded on an unstable plasmid in Lactobacillus hilgardii 0006. Agmatine deiminase pathway genes in Lactobacillus brevis are linked to the tyrosine decarboxylation operon in a putative acid resistance locus. Inhibition of biogenic amine formation in a salted and fermented anchovy by Staphylococcus xylosus as a protective culture. Effect of the use of autochthonous Lactobacillus curvatus, Lactobacillus plantarum and Staphylococcus xylosus strains on microbiological and biochemical properties of the Sardinian fermented sausage. Sequencing, characterization and transcriptional analysis of the histidine decarboxylase operon of Lactobacillus buchneri. A new ultra-pressure liquid chromatography method for the determination of biogenic amines in cheese. Tyramine in foods and monoamine oxidase inhibitor drugs: a crossroad where medicine, nutrition, pharmacy, and food industry converge. Biogenic amines and polyamines: similar biochemistry for different physiological missions and biomedical applications. Isolation and characterization of biogenic amine-producing bacteria in fermented soybean pastes. Screening of biogenic amine production by lactic acid bacteria isolated from grape must and wine. Effect of processing conditions on the formation of biogenic amines and ethyl carbamate in soybean tempe. Biogenic Amines in Fermented Foods and Health Implications Chapter 27 649 Paulsen, P. Formation of cadaverine, histamine, putrescine and tyramine by bacteria isolated from meat, fermented sausages and cheeses. Assessment of alimentary histamine exposure of consumers in Austria and development of tolerable levels in typical foods. Evidence of two functionally distinct ornithine decarboxylation systems in lactic acid bacteria. Putrescine production via the ornithine decarboxylation pathway improves the acid stress survival of Lactobacillus brevis and is part of a horizontally transferred acid resistance locus. The influence of the brewing process on the formation of biogenic amines in beers. Effect of an argon-containing packaging atmosphere on the quality of fresh pork sausages during refrigerated storage. Biogenic amine production in Spanish dry-cured "chorizo" sausage treated with high-pressure and kept in chilled storage. Biogenic amines in lowand reduced-fat dry fermented sausages formulated with konjac gel. Determination of biogenic amines in Korean traditional fermented soybean paste (Doenjang). Effect of high hydrostatic pressure processing on biogenic amine content of sausage during storage. Application of lactic acid bacteria starter cultures for decreasing the biogenic amine levels in sauerkraut. Cloning and sequencing of the histidine decarboxylase genes of gram-negative, histamine-producing bacteria and their application in detection and identification of these organisms in fish. In vitro tests of suitability of bacteriocin-producing lactic acid bacteria, as potential biopreservation cultures in vacuumpackaged cold-smoked salmon. Biologically active amines in fermented and non-fermented commercial soybean products from the Spanish market. Histamine contents of fermented fish products in Taiwan and isolation of histamine-forming bacteria. Histamine formation by histamineforming bacteria in douchi, a Chinese traditional fermented soybean product. Reduced nitrite and biogenic amine concentrations and improved flavor components of Chinese sauerkraut via co-culture of Lactobacillus plantarum and Zygosaccharomyces rouxii. Bacterial inactivation by high-pressure homogenisation and high hydrostatic pressure. Reduction of biogenic amine concentration in fermented sausage by selected starter cultures. A review: microbiological, physicochemical and health impact of high level of biogenic amines in fish sauce. Biogenic Amines in Fermented Foods and Health Implications Chapter 27 651 Zaman, M. Novel starter cultures to inhibit biogenic amines accumulation during fish sauce fermentation. Effect of fermentation with mixed starter cultures on biogenic amines in bighead carp surimi. This page intentionally left blank Chapter 28 Occurrence of Aflatoxins in Fermented Food Products S. Kim1 1Yeungnam University, Gyeongsan, Republic of Korea; 2National Agricultural Products Quality Management Service, Gimcheon, Republic of Korea; 3Korea University, Seoul, Republic of Korea 28. Aspergillus flavus produces only aflatoxin B, while the two other species (Aspergillus parasiticus and Aspergillus nomius) produce both aflatoxins B and G, which are considered to be significant threats to both humans and animals due to potent carcinogenic and mutagenic activities (Pitt et al. These aflatoxins are consumed by humans through intake of plants and animal-derived foods, such as dairy products contaminated either directly or indirectly with these aflatoxigenic fungi (Smith, 2001). Mycotoxins are produced directly by molds present in foods, whereas they indirectly enter via cross-contamination in food chain (Arab et al. Aflatoxin contamination has caused huge economic losses to food commodities in the last few decades (Benblesa et al. Major economic losses caused by aflatoxin contamination can either be direct in the form of losses to crop, livestock, and dairy productivity or indirect with adverse effects on quality control programs, research, education, foreign exchange earnings, as well as storage and packaging costs of vulnerable commodities (Benblesa et al.

Prevalence estimates of psychiatric disturbance in epilepsy tend to rheumatoid arthritis wiki order celecoxib on line range from 20% to rheumatoid arthritis exhaustion buy cheap celecoxib 200 mg 50% epidural for arthritis in back discount celecoxib 100 mg line, with higher estimates arising in specialty clinics and lower estimates coming from community-based samples arthritis in the knee bone on bone generic 100mg celecoxib with visa. Similar prevalence rates have been observed in children and adults (Davies and Goodman 2003; Rutter et al. Studies examining prevalence rates of psychiatric comorbidity in epilepsy have been limited by a lack of large community-based surveys (Manchanda 2002), and a frequent failure to employ reliable standardized measures of psychopathology (Swinkels et al. However, study methodology and measures have improved over the past decade, particularly for symptoms of depression. Depression in Epilepsy the association between epilepsy and depression has been recognized for recorded medical history. Hippocrates noted in about 400 bc that: "Melancholics ordinarily become epileptics, and epileptics melancholics: What determines the preference is 16 Epilepsy and Seizures 483 the direction the malady takes; if it bears upon the body, epilepsy, if upon the intelligence, melancholy (Lewis 1934). Variability across studies has been attributed to genuine differences across samples. Increased risk of depression among patients with epilepsy is associated with female gender, minority status, older age, being unmarried, unemployment, lower levels of education, and lower socioeconomic status (Ettinger et al. For example, Fuller-Thomson and Brennenstuhl (2009) found epilepsy resulted increased odds of depression by 43% after adjusting for demographic factors. Patients with epilepsy also experience higher rates of suicidal ideation and suicidal behavior than the general population. The lifetime prevalence rate of suicide and suicide attempts is between 5% and 14. Despite the increased risk for depression and suicide in epilepsy, mood disorders in this population often go unrecognized and/or untreated by practitioners. For example, Fuller-Thomson and Brennenstuhl (2009) found nearly 40% of patients with depression had not received mental health treatment, suggesting that better screening for psychiatric conditions is needed in this population. The reasons for not recognizing depression in this population appear to be multi-factorial and include: (1) patients may minimize their psychiatric symptoms for fear of being further stigmatized, (2) clinical manifestations of certain types of depressive disorders in epilepsy differ from depressive disorders in patients without epilepsy, and (3) clinicians frequently fail to inquire about psychiatric symptoms (Gilliam and Kanner 2002; Hermann et al. Both patients and clinicians can minimize symptoms of depression because they consider depression to be a "normal adaptation process" to having epilepsy (Kanner and Palac 2000). The concern that antidepressant drugs may lower the seizure threshold has also resulted in reluctance among some clinicians to use psychotropic drugs to treat patients with epilepsy (Gilliam and Kanner 2002). Although there is general agreement that prevalence rates of psychiatric comorbidity is higher among patients with epilepsy than the general population, the relationship between seizure type, seizure focus, and psychiatric status remains uncertain. Patients with multiple seizure types also appear to experience greater emotional maladjustment than those without (Dodrill 1984; Hermann et al. Intriguing findings involve evidence that depression often antedates seizure onset, and that epilepsy and depression may be bidirectional in terms of causality. For example, behavioral abnormalities have been observed more than 6 months prior to seizure onset in children with new onset seizures as compared to sibling controls (Austin et al. Academic problems were thought to precede initial seizure onset in children (Berg et al. There are limited data regarding the efficacy of standard treatment interventions (pharmacological or psychotherapeutic) for depression in patients with epilepsy (Kanner and Schacter 2008). However, patients with epilepsy respond favorably to pharmacological treatment, and some data suggest antidepressant medication may have some anticonvulsant properties at therapeutic doses. The effectiveness of psychological treatment at reducing depressive symptoms has also been demonstrated for patients with epilepsy. Gilliam (1990) reported that patients involved in psychotherapy not only showed significant improvement in rating scales of depression and anxiety, but also showed a decline in seizure frequency. Emerging research suggest the presence of a psychiatric disorder increases the risk for seizures (lowers the seizure threshold), while antidepressant medications may reduce the risk for seizures among patients with epilepsy (Alper 2008). Rule of thumb: Depression in epilepsy ­ 10­60% of patients with active epilepsy meet criteria for depressive disorder ­ 3­9% of patients with controlled epilepsy meet criteria for depressive disorder ­ Risk of suicide 6­25 times the general population ­ Treatment of depressive symptoms undertreated/under-recognized ­ Treatment for depressive symptoms is efficacious ­ Depressive symptoms can antedate seizure onset Anxiety in Epilepsy Anxiety disorders are the second most common psychiatric disorder among patients with epilepsy, with prevalence rates reported to vary from 10% to 50% (see Mensah et al. Rates of anxiety in community based samples are generally lower, 16 Epilepsy and Seizures 485 ranging from 14% to 25%. Anxiety symptoms were not strongly associated with epilepsy variables, including side of seizures or if seizures were focal or generalized. Like the treatment of depression, psychopharmacological and psychological treatment have demonstrated some success, although both are less well researched than treatment for depression in epilepsy. Rule of thumb: Anxiety in epilepsy ­ 10 to 50% of patients with active epilepsy meet criteria for anxiety disorder ­ Anxiety symptoms/disorders often comorbid with depressive symptoms/ disorders ­ Treatment of depressive symptoms undertreated/under-recognized ­ Anxiety symptoms not associated with side of seizure ­ Treatment for anxiety symptoms is efficacious Broader Psychopathology in Epilepsy We have chosen to focus on depression in epilepsy, as it appears to be the most commonly occurring psychiatric comorbidity. Nevertheless, anxiety disorders, substance abuse, personality disorders, and psychosis also occur with significant frequency in this population. Clinical neuropsychologists represent a core group of clinicians that can obtain objective data on the presence of psychiatric disorders in patients, which is necessary to track disease prevalence and to recognize the need for intervention. Neuropsychological evaluations frequently include a psychometric based instrument of mood/psychiatric functioning, and many epilepsy centers also include a measure of quality-of-life. Measure of mood are useful for monitoring levels of distress, tracking change over time, and picking up on critical issues in need of intervention. Personality profiles can also provide greater insight into the presence of disease, and the underlying personality traits that may contribute to their development and recalcitrance. Measures of mood do not typically allow for making psychiatric diagnoses, and do not provide any information with regard to lifetime prevalence rates. Quality of Life and Psychosocial Consequences Patients with epilepsy experience higher rates of unemployment, lower income, lower education, and remain unmarried at rates that exceed the general population (Kobau et al. The worst functioning tends to be observed in patients with active epilepsy, and those with comorbid psychiatric conditions. Nonepilepsy variables (psychosocial) appear to have less impact, but several variables, including family/ parent variables can significantly impact children with epilepsy. For those individuals with active epilepsy, treatment variables have a large impact. Rule of thumb: Quality of life in epilepsy ­ Epilepsy associated with lower quality of life ­ Patients less likely to be employed, have less education, have less income, and more likely to be single. Psychomotor speed/reaction time Language Memory/learning Visuoperceptual/visuoconstructional Emotion/mood/quality of life Task engagement Sensory-perceptual Wechsler intelligence scales Wechsler intelligence scales attention subtests. The presence of mesial temporal sclerosis greatly aides in predicting neuropsychological outcome. Knowledge of age of seizure onset and duration of epilepsy can 16 Epilepsy and Seizures 489 be helpful. Also, carefully watch for abnormal eye movements or episodes in which the patient appears to briefly pause while talking or "space off. Ask the patient if (s)he has experienced a loss of time or if they recall what they were thinking about. Sensory-perceptual examination: the clinical neuropsychologist can evaluate for gross visual field cuts, tactile sensory function (extinction task), simple audition functions, and apraxias. We recommend evaluating for hemi-inattention to visual, auditory, and tactile sensation. Inattention can be rapidly assessed by using a brief bedside bilateral simultaneous stimulation test. One may also assess for finger agnosia, astereognosis, Right/Left orientation, and apraxia. Cranial nerve exam and evaluation of deep tendon reflexes may also assist the neuropsychologist complete the evaluation. Motor examination: Evaluation of grip strength and manual dexterity of both upper extremities is recommended. Neuropsychological psychometric instruments: the selection of instruments should (1) have demonstrated validity (evidence-based) and (2) assist the neuropsychologist to make some statement about the relative risk for neuropsychological impairment following surgery. Ideally, this will include a statement about the type and extent of neuropsychological and psychological impairments that may occur from the proposed surgical procedure. Secondarily, the neuropsychologist may assist with confirming the lateralization or localization of the seizure focus, keeping in mind that this information will be misleading in some patients and assumes normal functional neuroanatomic organization. The neuropsychological measures specified below are guides, and as new tests are developed, neuropsychologists should evaluate the evidence-based research of older and newer instruments, and how new tests may better serve the needs of the patient (Loring and Bauer 2010). Borderline to impaired general cognitive functioning prior to elective surgery could raise concerns about 490 M. The processing speed and working memory indices can be useful for examining the effects of medications, acute seizures, and other transient, acute factors.

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