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We investigated whether a combination of risk factors affects the free phenytoin (PHT) fraction by multiple regression analyses in 30 patients with severe motor and intellectual disabilities (SMID) with epilepsy. The risk factors analyzed were gender, age, total PHT concentration, albumin concentration, aspartate aminotransferase, alanin aminotransferase, serum creatinine, blood urea nitrogen, and antiepileptic drug concentrations. Serum levels of total and free PHT were measured by fluorescence polarization immunoassay. Free PHT fractions were between 7.2% and 17.3% (average 10.9%). Two factors, hypoalbuminemia and valproate (VPA) coadministratation with PHT, increased free PHT fraction, and a combination of these two markedly increased free PHT fraction. Patients with these double risk factors have a high risk of exceeding the therapeutic range of serum-free PHT concentration even if their total PHT concentration does not. Therefore, we should monitor free PHT concentration, especially in SMID patients with epilepsy, because they may have hypoalbuminemia and are treated with antiepileptic drug polytherapy and, moreover, cannot report adverse effects of the drugs.

The term "children with severe motor and intellectual disabilities (SMID)" is a classification based on the degree of disabilities, but not the name of a disease. Suzuki (1995) indicated the presence of children continuously requiring respiratory care, such as mechanical ventilation, tracheotomy, suction, and oxygen ther

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IntroductionHizen Psychiatric Center has the first ward for Severe Behavior Disorder in Japan which has the highest number of severe cases. We have many specialized ways to intervene over the years, Habilitation, TEACCH Pharmacotherapy and Behavior therapy. On the otherhand, most of patients have traits (such as difficulty in communicating, severe self and other harming, pica) are easy to make their carer feel rewardless, conflict.ObjectivesTo have adequate understanding and give specialized supports for carer, we focus on experiences of care-giving, and analyze the process about formation of care-giving, what kind of rewards they acquire.MethodsHalf-constructed Interview with 10 Nurses at the ward and Qualitative Analysis based on Grounded Theory Approach.Results5 Upper Categories are produced(Shock) (Disgust) (Conflict) (Change) (Acceptance)and those can be the steps. This process is not linear and each nurse has each pattern of achievement and time.ConclusionsWe found the steps of care-giving formation even there are difficulty of interaction. To achieve (Change) (Acceptance)individually, we can suggest the way to make them feel rewarding. Carer (including Staff and Parent) are important environments for patients. It needs to empower them not to be anti-factor of care-giving.