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a normal EEG in a patient who is profoundly apathetic is a point in favor of the diagnosis of catatonia, an affective disorder, or schizophrenia (see below) Other Diseases of the Cerebrum Many disorders of the brain cause little or no alteration in the EEG Multiple sclerosis and other demyelinating diseases are examples, though as many as 50 percent of advanced cases will have an abnormal record of nonspeci c type (focal or diffuse slowing) Delirium tremens and Wernicke-Korsakoff disease, despite the dramatic nature of the clinical picture, cause little or no change in the EEG Some degree of slowing usually accompanies confusional states that have been designated by some clinicians as hypokinetic delirium (Chap 20) Interestingly, the neuroses, psychoses (such as manic-depressive disorders or schizophrenia), intoxication with hallucinogenic drugs such as LSD, and the majority of cases of mental retardation are associated either with no modi cation of the normal record or with only minor nonspeci c abnormalities unless seizures are present

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zures Neither is bound to plasma protein, and they have the advantage of few toxic effects and no known adverse drug interactions Topiramate, another new antiepileptic agent, has much the same mode of action and degree of effectiveness as tiagabine It may cause serious dermatologic side effects, especially if used with valproate, and appears to induce renal stones in 15 percent of patients Angle-closure glaucoma has also been reported as a complication A minor problem has been the development of hyperchloremic metabolic acidosis Ethosuximide (Zarontin) and valproate are equally effective for the treatment of absence seizures, the latter one being used mainly in children more than 4 years of age It is good practice, in order to avoid excessive sleepiness, to begin with a single dose of 250 mg of ethosuximide per day and to increase it every week until the optimum therapeutic effect is achieved Methsuximide (Celontin) is useful in individual cases where ethosuximide and valproate have failed In patients with benign absence attacks that are associated with photosensitivity, myoclonus, and clonic-tonic-clonic seizures (including juvenile myoclonic epilepsy), valproate is the drug of choice Valproate is particularly useful in children who have both absence and grand mal attacks, since the use of this drug alone often permits the control of both types of seizure The concurrent use of valproate and clonazepam has been known to produce absence status Teratogenic Effects of Antiepileptic Medications Since it is essential to prevent convulsions in the pregnant epileptic woman, anticonvulsant medication should not be discontinued or arbitrarily reduced, particularly if there have been a number of convulsions in the recent past The conventional drugs (phenytoin, carbamazepine, phenobarbital, valproate) are all appropriately tolerated in pregnancy Plasma levels of most anticonvulsant drugs, both the free and protein-bound fractions, fall slightly in pregnancy and are cleared more rapidly from the blood The main practical issue is the potential teratogenicity of many of the anticonvulsant drugs The most common recorded teratogenic effects has been cleft lip and cleft palate, but infrequently a subtle facial dysmorphism ( fetal anticonvulsant syndrome ), similar to the fetal alcohol syndrome, has also been described In general, the risk of major congenital defects is low; it increases to 4 to 5 percent in women taking anticonvulsant drugs during pregnancy, in comparison to 2 to 3 percent in the overall population of pregnant women These statistics are essentially con rmed in the large study by Holmes and colleagues, conducted among several Boston hospitals When all types of malformations were included, both major and minor, 20 percent of infants born to mothers who took anticonvulsants during pregnancy showed abnormalities compared to 9 percent of mothers who had not taken medications However, similar to other large surveys, major malformations appeared in only 5 percent of infants exposed to anticonvulsants, in contrast to 2 percent in the nonexposed These authors identi ed midface hypoplasia (shortened nose, philtrum, or inner canthal distance) and nger hypoplasia as characteristic of anticonvulsant exposure; these changes were found in 13 and 8 percent of exposed infants, respectively The infants born of a group of women with epilepsy who had not taken anticonvulsants during pregnancy showed an overall rate of dysmorphic features comparable to that in control infants, but there was still a 2 to 3 percent rate of facial and nger hypoplasia This risk is shared more or less equally by all the major anticonvulsants The risk of neural tube defects is also slightly increased by anticonvulsants, and greatest is for the use of valproate; it can be reduced by giving folate before pregnancy has begun, but some.

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As with every trade, the short neutral delta trading strategy has negative aspects The risks of upward changes in implied volatility are signi cant In addition, when placing short straddles or strangles based on trading ranges like those demonstrated in the MCD examples, the trading ranges are meant to be broken, and the short straddle or strangle trader will have to make quick decisions regarding the risk of the trade and the probability of success Some of the important points to consider when trading short straddle and strangle positions include: Short neutral delta positions function most effectively in the accelerated time value of short-term expiration contracts Long-term positions are certainly acceptable as long as the premium captured justi es the risk undertaken for the term of the contract Elevated implied volatility relative to the recent historical volatility is preferred for short option positions, especially neutral delta short option positions Changes in implied