Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : December | Volume : 3 | Issue : 6 | Page : 1836 - 1840

Preventable Seizures: A Prospective, Cross Sectional Study On The Influence Of Pharmacological Factors

MUSA R KAISER*, SHON G MICHAEL*, KULKARNI CHANDA **

*Completed studies, **Professor and Head, Clinical Pharmacology, St.John’s Medical College & Hospital Bangalore -560 034 (INDIA)

Correspondence Address :
Dr.(Mrs) Chanda Kulkarni. MD; Ph.D; FSASMS; Cert.Clin. Epilepsy Professor
and Head, Clinical Pharmacology,
St.John’s Medical College, Bangalore
60 034, Ph : 080 - 22065045,E-mail :
dr_chanda_k@hathway.com,drchandakulkarni@gmail.com

Abstract

The present study was undertaken with an objective to study the extent and pattern of the Pharmacological factors which are responsible for acute seizures reporting at the emergency medicine department of a tertiary care hospital. This prospective and retrospective observational, cross sectional study involved data collection on a specially designed proforma with respect to - seizure diagnosis, duration, co-existing medical conditions, precipitating factors if any, along with details of drug treatment after admission to the emergency ward. Data analysis of 250 patients with a diagnosis of seizures showed a maximum number of males with the highest number of febrile seizures. The evaluation of aetiological factors revealed a maximum number of patients with non-compliance, followed by CNS infections, metabolic and iatrogenic causes and others of unknown aetiology. Interestingly, majority of the patients were from urban background and were educated. The possible pharmacological factors that were identified to have contributed to acute seizures included – lack of appropriate instructions to patients regarding medication intake, in-appropriate dosage of anti-epileptic medication, anti-epileptic drug-drug interactions, in addition to the use of complementary systems of medications, as well as non-compliance. However, though such multiple factors may be considered to have attributed to acute seizures, it may be concluded that a majority of these could be easily controlled and/or can be prevented with simple precautionary measures that have been highlighted under ‘conclusions’ at the end of this article.

Introduction
India has the highest population of people with epilepsy in the world. It is estimated to be approximately 5.5 million with a prevalence rate of 533 per one lakh population (1). This may be attributed to several causes such as - infectious diseases like tuberculosis of the brain, neurocysticercosis, and malnutrition (2), (3). Iatrogenic causes may also precipitate seizures which include – inadequate physician advice regarding anti-seizure medications (ASMs) use and/or inappropriate choice and dosage of ASMs, drug interactions between ASMs and drugs administered for concomitant illnesses. Other factors include lack of patient compliance of ASMs and the simultaneous use of alternative systems of medicine (4).

Objectives
The primary objective of the present study was to identify the pharmacological factors responsible for precipitating seizures and to evaluate the extent and pattern of acute seizures.

Material and Methods

All patients diagnosed to have seizures and admitted at the Department of Emergency Medicine, St. John’s Medical College Hospital, a tertiary care centre in Bangalore, were included in the study. This was a cross sectional, prospective and retrospective, observational study of one year’s duration. The patient information was collected on a specially designed proforma. The patient data was recorded with respect to - biographical data on - age, sex etc; the disease data - for details with respect to type, frequency, duration of seizure episodes, along with past history and family history of seizures including co-existing illnesses, if any. The details of the medication history for – ASMs used, along with – dose, duration and frequency of their administration, were collected by directly interviewing patients, from their attendants and/or from their medical records. The detailed information on concurrently administered medications with regards to dose, duration of treatment for other illnesses was also recorded.

The information thus collected was entered on MS-excel sheets and was analysed using the Lotus Approach Database Management Software with an inbuilt Sequential Query Language. The results are presented after subjecting the data for descriptive analysis.

Results

Data from a total of 336 patients with the diagnosis of seizures was collected and recorded over a period of one year of the study. Out of 336 cases, 86 cases (25.60%) were not included in the analysis due to erroneous diagnosis, inability to trace patients or refusal of treatment by the patients. Analysis of the data for gender wise distribution showed a distinct predominance of males (62%) over females (38%), with 92 (37%) cases being treated on an outpatient basis.

Febrile illness (18.80%) was found to be the most common aetiology for seizures, followed by non-compliance (18.40%), Central Nervous System (CNS) infections (11.20%), iatrogenic (8%) and metabolic causes (8%) (Table/Fig 1), while 35.50% cases were of unknown aetiology. 31.90% of cases of febrile seizures were also identified to be cases of non-compliance with ASMs, whereas the remaining patients reported to have seizures for the first time. There were no other factors that could be identified in any of the patients in this latter category which contributed to the incidence of seizures. Non compliance with ASMs was identified in 46 patients (18.40%) and a majority of these were males (73.90%). Surprisingly, most of such patients were from the urban areas and were educated (32, 69.50%). The main reasons for non-compliance ranged from being ‘fed up with the illness’ (34.40%), to ‘a desire to experiment’ (9.40%) (Table/Fig 2). The use of alternative systems of medicine was acknowledged by 10 patients and these were also found to be irregular with their ASM intake. These were hence regarded as being non-compliant to the ASMs prescribed by the allopathic physician. CNS infections included neurocysticercosis (12), meningitis/encephalitis (13) and rickettsial fever (3), which formed 11.20% of the total cases studied. Patients diagnosed to have iatrogenic seizures (20, 18.40%) included - 9 cases with a concomitant treatment for tuberculosis and 1 case on aminophylline for asthma, 4 with insufficient ASM dose, 4 on excessive ASM dose, 1 case of seizure due to withdrawal of ASM on doctor’s orders and 1 with seizure following vaccination.

Metabolic causes for seizures accounted for 20 (8%) cases and included diabetes, vomiting, acidosis, alkalosis, hypertension, hypocalcaemia and hyponatraemia. Miscellaneous cases including those with secondary causes such as - head injuries, space occupying lesions (diagnosed by CT scan) and migraine made up 17 (6.80%) of the total cases. Alcohol induced seizures (3.60%), brain infarcts (2.40%), behavioural disturbances (2.40%), pregnancy related seizures (2%), drug resistance (0.80%) and accidental drug ingestion (0.80%) were other causes of seizures.

Discussion

A number of causes have been reported to precipitate acute seizures, such as – febrile seizures in children (5), CNS infections and metabolic causes (2), (3). While some seizures are of unknown aetiology, the present study showed ASM non-compliance as well as iatrogenic causes as the second most common cause for seizure precipitation. ASM non-compliance or iatrogenic i.e. seizures caused unintentionally due to - a medical intervention and/or administration of the inappropriate dose of ASM and/or due to co-administration of other drugs leading to seizure precipitation as a result of drug-drug interactions were also reported (6),(7),(8).

Lack of appropriate advice/instructions to patients regarding the consumption of ASMs, coupled with inadequate understanding of pharmacological issues among physicians, have been shown to result in either non-compliance or ASM toxicity (9).

It is well known that compliance plays an important role in controlling seizures as well as in the prevention of their recurrence. Non-compliance was the second most common cause of seizures in our study. The large majority (34.40%) of patients said that they were fed up of using the ASMs and also with the duration of the disease. Other reasons were forgetfulness (25%), a feeling that the drugs were unimportant (18.80%), financial difficulties (12.50%) and a desire to experiment without the drugs (9.40%).

Among those who were non-compliant, some acknowledged the use of alternative systems of medicine, i.e. Ayurveda and Homeopathy. Only limited studies have been carried out on the concomitant use of the Alternative Systems of Medicine with allopathic medication and there is only one study which has examined the interaction between the herbal drug, Shankhapushpi and phenytoin – a commonly used ASM. The results revealed that the levels of phenytoin were reduced by 50% following co-administration of the plant product4. It has therefore been recommended to study such interactions systematically and to avoid the use of alternative systems of medicine together with allopathic medication until further research is conducted to evaluate the outcome of their interaction and their concurrent use in therapeutic practice.

It would be expected that with higher education levels, the compliance on the part of the patients would be better. However, in the present study, it was found that 32 patients who were non-compliant were educated and also had an urban background, as against 14 patients whose educational status was not above high school and hailed from a rural background. While 6 patients who were interviewed thought that it was alright to stop taking their drugs, interestingly, 5 of these were males above 30 years of age and had completed their graduation. Such high proportion of non-compliance, even among the educated, suggests that patients are not getting adequate inputs regarding their disease from the medical professionals/community. Since patient compliance leading to better seizure control is well documented (10), (11), it is interesting to note that non-compliance is not necessarily reported from underdeveloped countries, but is also common in the developed world. The importance of patient education programs, therefore, needs to be highlighted. Furthermore, only few studies have shown that such educational programs help to reduce the risk and occurrence of unnecessary seizures12.

A Nigerian study showed that there was only 25.50% compliance with ASMs after two years of starting treatment (10), while an audit of admissions of patients with seizures to a district general hospital in the UK demonstrated that poor compliance was a major factor for most admissions among patients with seizure disorders (13). These studies conclude and suggest that consistent support to these patients would have prevented many of the seizure episodes. Remedying this situation requires the educational intervention with regards to consumption of medications and some knowledge about the disorder, both on the part of doctors as well as the patients.

It is a given understanding in Medicine that both – the medications used and their doses are equally important for the proper control of all medical conditions. Eight patients in our study had seizures due to inappropriate ASM dosage, of which few had received an insufficient ASM dose and hence, had lack of seizure control, while a few were found to have received larger than required doses of ASMs when compared to standard recommended doses. In both groups, there was one case each where a serum drug level was done. The results showed that serum unbound phenytoin levels were lower and above the therapeutic levels, respectively [normal range being – 4-8 µg/L]. The remaining six patients were found to have received a lower or higher dose with reference to their body weight. Manon-Espaillat R, et al. reported an increase in seizure frequency following higher than required doses of ASMs, but the underlying mechanisms are not clearly understood.

Drug-drug interaction is yet another cause for precipitating seizures. Such negative interactions are reported to be either of the dynamic or the kinetic type. There have been several reports including our own on pharmacodynamic antagonistic interactions between xanthines and some of the ASMs in animal seizure models, which showed a decrease in seizure protection by ASMs (15). Similar Pharmacokinetic interaction studies in humans have shown a decrease in the levels of carbamazepine following the co-administration of caffeine and theophylline (16), (17). Sporadic reports of seizure precipitation after the consumption of xanthines as beverages or as therapeutic agents have also been reported (18),(19). The seizurogenic potential of xanthines seen in these studies is attributed primarily to their non-selective adenosine antagonistic activity at the adenosine receptor sites in the CNS, as well as due to their inhibitory effects on the phosphodiesterases, leading to accumulation of CYP-AMP. Pre-clinical studies indicated the possible role of free radicals as the cause for theophylline-induced seizures (20). In the present study, there were two patients who had received xanthines with ASMs. Although, antagonistic interactions have been reported (18), (19), studies involving a larger number of patients with simultaneous pharmacokinetic and pharmacodynamic [PK-PD] evaluation may help in identifying such antagonistic interactions among patients receiving xanthines with ASMs. Further, careful evaluation of patients with epilepsy receiving xanthine containing bronchodilators for co-existing asthma will be necessary to confirm these results.

In the present study, nine patients were on anti-tuberculosis treatment (ATT). All of them were on isoniazid, which is known to precipitate seizures by decreasing the serum concentration of phenytoin and carbamazepine (8). However, there is no reported evidence for other anti-tubercular drugs as potential seizurogenic agents.

There is a need to educate and counsel patients by increasing awareness regarding importance of compliance, adverse effects and about drug-drug interactions with ASMs, along with an emphasis on guided ASM monitoring among prescribers.

Conclusion
There is a need to implement measures to improve drug compliance with ASMs, among patients with epilepsy and to encourage doctors/medical professionals to educate and counsel their patients regarding this. Further, educational and counselling programs may be considered as one of the simple tools relevant to the Indian setting that may be anticipated to help in reducing the incidence of seizures. Additionally, there is a need to study drug-drug interactions between various allopathic drug combinations and between allopathic and alternative systems of medicine. Also, increasing awareness among physicians on beneficial and harmful drug interactions; and the need for appropriate drug dosage will be essential.

The present study supports the view that educational interventions at the ‘grass root’ level among the various levels of health care professionals, as well as among the public and patients may serve as one of the cost effective measures in preventing preventable seizures.

Acknowledgement

The authors wish to gratefully acknowledge the co-operation rendered by Dr. Mabel Vasnaik, Professor and Head, Department of Emergency Medicine, SJMCH, for extending her valuable support and co-operation in collecting the data.

References

1.
Sridharan R, Murthy BN. Prevalence and pattern of epilepsy in India. Epilepsia 1999; 40: 631-6.
2.
Bittencourt PM. Ed., Edinburgh. Epilepsy in Latin America. In A Textbook of Epilepsy, 3rd edn. Churchill Livingstone. 1988. 123-160.
3.
Singh LM, Mehta S. Monitoring of phenobarbitone in epileptic children. Indian Journal of Pharmacology, Therapeutics and Toxicology. 1987; 25:15-22.
4.
Dandekar UP, Chandra RS, Dalvi SS, Joshi MV, Gokhale PC, Sharma AV, Shah PU, Kshirsagar NA. Analysis of clinically important interaction between phenytoin and Shankhapushpi, an Ayurvedic preparation. J Ethnopharmacol. 1992; Jan; 35(3):285-8.
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Hoption Cann SA. Febrile seizures in young children: role of fluid intake and convservation. Med Sci Monit. 2007; Sep;13 (9):RA159-67.
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Manon-Espaillat R, Burnstine TH, et al. Antiepileptic drug intoxication: Factors and their significance. Epilepsia. 1991; 32: 96.
7.
Mitchell J, Dower JC, Green RJ. Interaction between carbamazepine and theophylline. New Zealand Medical Journal 1986; 99:69-70.
8.
Ogunniyi A, Oluwole OS, Osuntokun BO. Two year remission in Nigerian epileptics. East African Medical Journal. 1998; 75(7):392-5.
9.
Irving P, Al Dahma A, et al. An audit of admissions of patients with epilepsy to a district general hospital. Seizure 1999; 8(3): 166-9.
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