Pharmacist's Impact on Medication Adherence and Drug-Related Problems in Patients with Epilepsy.

Objectives: Drug-related problems (DRPs) and non-adherence are important barriers to ensuring optimal antiseizure drug treatment. The aim of this study was to improve medication adherence, detect and manage DRPs, and decrease the number of seizures with pharmacist-led education in patients with epilepsy. Materials and Methods: A prospective and interventional study was conducted in collaboration with the Department of Neurology, the rational drug usage unit of a hospital pharmacy in a university hospital. The impact of pharmacist-led education on medication adherence and interventions in the management of DRPs was assessed in patients with epilepsy who were admitted to the outpatient clinic. A total of 39 patients with epilepsy were evaluated in terms of medication adherence, DRPs, and seizure control over a 2-month follow-up period and patient satisfaction with pharmacy services at the end of the study. Results: A total of 59 DRPs were detected, and 71.2% of them were accepted and implemented both by physicians and/or patients. Pharmacist interventions solved 62.7% of DRPs. The number of patients with high-level medication adherence significantly increased from 17 to 28 after pharmacist-led education (p < 0.001). The number of seizures decreased in 19 patients (48.7%) during the 2-month period. Patient satisfaction was high in all patients. Conclusion: It is shown that the contribution of pharmacists in treating patients with epilepsy is beneficial in improving medication adherence, detection and management of DRPs, and decreasing the number of seizures.

Experiences in the molecular genetic and histopathological evaluation of calpainopathies.

Calpainopathy is mainly characterized by symmetric and progressive weakness of proximal muscles. Several reports showed that the most common LGMD subtype is LGMDR1 or calpainopathy, which had previously been defined as LGMD2A. Until now, more than 500 likely pathogenic/pathogenic variants in the CAPN3 gene have been reported. However, a clear genotype-phenotype association had not yet been established and this causes major difficulties in predicting the prognosis in asymptomatic patients and in providing genetic counseling for prenatal diagnosis. In this report, we aimed to add new data to the literature by evaluating 37 patients with likely pathogenic/pathogenic variants for the detected variants' nature, patients' phenotypes, and histopathological features. As a result, the general clinical presentation of the 23 different variants was presented, the high frequency of NM_000070.3:c.550delA mutation in Exon 4 was discussed, and some novel genotype-phenotype associations were suggested. We have underlined that calpainopathy can be misdiagnosed with inflammatory myopathies histopathologically. We have also emphasized that, in young or adult patients with mild to moderate proximal muscle weakness and elevated CK levels, calpainopathy should be the first suspected diagnosis.

Neuromyelitis optica presenting with horner syndrome: A case report and review of literature.

Neuromyelitis optica (NMO) is a demyelinating disease of the central nervous system that predominantly affects the spinal cord and optic nerves. We describe a 19 years old woman with left Horner syndrome (HS), who was diagnosed as NMO with characteristic longitudinally extensive myelitis and positive serum aquaporin-4 immunoglobulin G antibodies (AQP4-IgG). Our report describes one of the very rare ocular motor symptoms in NMO patients.

Human Leucocyte Antigen B50 Is Associated with Conversion to Generalized Myasthenia Gravis in Patients with Pure Ocular Onset.

OBJECTIVES: The aim of this study was to investigate the associations between major histocompatibility complex (MHC) class I and II alleles and disease characteristics in Turkish patients with myasthenia gravis (MG). SUBJECTS AND METHODS: The MHC class I and II alleles of 108 unrelated MG patients were genotyped. The human leucocyte antigen (HLA) distribution of all MG patients and subgroups of MG patients (grouped according to disease characteristics) was compared to that of 250 healthy controls. RESULTS: Overall distributions of HLA-B*61 and C*05 were more frequent in MG patients (7.4 vs. 2.0% and 14.8 vs. 6.8%, respectively) than in non-MG patients. Subgroup analyses revealed that HLA-DRB1*14 and DQB1*02 alleles were more frequent in early-onset MG [n = 10 (20.8%) vs. n = 25 (10.0%) and n = 21 (43.8%) vs. n = 59 (23.6%)]. In patients seropositive for anti-AchR antibodies, the frequencies of HLA-B*50 and C*05 were higher. HLA-C*05, DRB1*01, and DRB1*11 were higher in patients with ocular MG. In addition, HLA-A*01, A*31, B*08, and DRB1*14 were higher among patients with thymic hyperplasia, whereas DQB1*03 was lower. However, all of these differences lost significance after correction of the p value for multiple comparisons. No allele association was found among patients with thymoma. Strikingly, patients with generalized MG who had pure ocular symptoms at disease onset had significantly increased HLA-B*50 compared to the controls (corrected p < 0.001, OR = 9.92; 95% CI 3.05-32.22). CONCLUSION: The HLA-B*50 allele was associated with conversion to generalized disease in patients with pure ocular symptoms at disease onset. This finding could extend our understanding of the complex interactions between the pathogenesis of MG and genetic heritage.

Spontaneous Swallowing during All-Night Sleep in Patients with Parkinson Disease in Comparison with Healthy Control Subjects.

STUDY OBJECTIVES: Spontaneous saliva swallows (SS) appear especially during sleep. The rate of SS was rarely investigated in all-night sleep in patients with Parkinson disease (PD). Dysphagia is a frequent symptom in PD, but the rate of SS was never studied with an all-night sleep electroencephalogram (EEG). METHODS: A total of 21 patients with PD and 18 age-matched healthy controls were included in the study. Frequencies of SS and coughing were studied in all-night sleep recordings of patients with PD and controls. During all-night sleep, video-EEG 12-channel recording was used including the electromyography (EMG) of the swallowing muscles, nasal airflow, and recording of vertical laryngeal movement using a pair of EEG electrodes over the thyroid cartilage. RESULTS: The total number of SS was increased while the mean duration of sleep was decreased in PD when compared to controls. Sialorrhea and clinical dysphagia, assessed by proper questionnaires, had no effect in any patient group. The new finding was the so-called salvo type of consecutive SS in one set of swallowing. The amount of coughing was significantly increased just after the salvo SS. CONCLUSIONS: In PD, the rate of SS was not sufficient to demonstrate the swallowing disorder, such as oropharyngeal dysphagia, but the salvo type of SS was quite frequent. This is a novel finding and may contribute to the understanding of swallowing problems in patients with dysphagic or nondysphagic PD.

Is adiponectin a risk factor for transient ischaemic attacks?

Adiponectin is an adipocytokine, and it plays a role in atherosclerosis. The role of adiponectin in the development of ischaemic stroke is controversial. Up to now, adiponectin was not evaluated in transient ischaemic stroke. In this study, we investigated the relationship between adiponectin and transient ischaemic attack. Forty patients with transient ischaemic attack were included into the study. In all patients, traditional risk factors of ischaemic stroke and intima-media thickness of carotid arteries were determined. Also, the relationship between these parameters and adiponectin levels were examined. No difference was found in terms of adiponectin levels between patients and healthy subjects. In addition, there was no association between adiponectin levels and traditional risk factors. Our results suggest that adiponectin may not be a predictive risk factor of transient ischaemic attack.

Electrophysiological association of spontaneous yawning and swallowing.

Yawning and swallowing are fundamental physiological processes that are present from fetal stages throughout life and that involve sequential motor activities in the oropharyngo-larynx making it likely that they may share neuroanatomical pathways. We postulate that yawning and swallowing are controlled by a distributed network of brainstem regions including the central pattern generator of swallowing, and therefore spontaneous swallowing is frequently associated with spontaneous yawning. In this study, we sought to test this hypothesis by evaluating the elementary features of yawning in the facial, masseter and submental muscles, together with laryngeal movement sensor and respiratory recordings for spontaneous swallowing. We investigated 15 healthy, normal control subjects, 10 patients with Parkinson's disease (PD) and 10 patients with brainstem stroke (BSS). Apart from four subjects with PD and two with BSS, who had dysphagia, none of the other study subjects were dysphagic by published criteria. Twenty-five subjects (10 control, 10 BSS, 5 PD) were evaluated by 1-h polygraphic recording, and 10 (5 control, 5 PD) underwent whole-night sleep recordings. One hundred thirty-two yawns were collected, 113 of which were associated with spontaneous swallows, a clear excess of what would be considered as coincidence. The yawns related with swallows could be classified into the following three categories. The characteristics or the duration of swallows and yawns were similar between controls and disease subjects, with the exception of increased duration of yawning in subjects with BSS. Our findings support the presence of common neuroanatomico-physiological pathways for spontaneous swallows and yawning.

IL-1ß, IL-6 and IL1Ra levels in temporal lobe epilepsy.

PURPOSE: There is now extensive evidence to support the involvement of inflammation in the course of epileptic seizures. Seizure-induced changes in serum IL-1ß, IL-6 and IL-1Ra levels are reported in several studies. Serum cytokine levels may also be disturbed in inter-ictal period due to seizure activity. METHODS: Twenty-one patients (12 women; mean age 35±12.3) with temporal lobe epilepsy (TLE), 17 patients (8 women; mean age 31.8±10.4) with extra-temporal lobe epilepsy (XLE) and 20 normal controls (10 women; mean age 35.6±8.8) were included in the study. Serum levels of IL-1ß, IL-6 and IL-1Ra of the TLE, XLE groups in inter-ictal period and of the normal control group were compared. RESULTS: All three cytokine levels are found to be significantly elevated in epilepsy patients when compared to controls (p<0.05). In TLE group, IL-1ß serum levels were significantly higher than in the XLE group (p<0001). CONCLUSION: The major findings in our study were increased levels of IL-1ß, IL-6 and IL-1Ra in epileptic patients and high levels of IL-1ß in TLE group. Our results support the existence of a chronic inflammatory state in epileptic patients.

Risk Factors for Hemorrhagic Transformation in Patients with Acute Middle Cerebral Artery Infarction.

INTRODUCTION: Hemorrhagic transformation (HT) after acute ischemic stroke (AIS) can be seen at any time following ischemic stroke. Although HT usually occurs as a complication of antithrombotic, anticoagulant, or thrombolytic treatments, it can also occur spontaneously. We aimed to investigate the occurrence of early HT and its relevant risk factors in patients diagnosed with acute middle cerebral artery (MCA) infarction who were not treated with thrombolytic agents. METHODS: We recruited 171 patients with acute MCA infarction between January 2011 and July 2012 who were not treated with thrombolytic agents and were suitable to our inclusion criteria. Controlled neuroimaging was performed immediately in patients with deterioration, otherwise on day 7 following stroke. All patients were investigated for AIS risk factors and biochemical analyses were performed. Patients with HT in controlled neuroimaging were grouped both clinically (i.e., symptomatic or asymptomatic) and radiologically, according to "European Cooperative Acute Stroke Radiological Study" (ECASS), and risk factors were examined. RESULTS: We enrolled 171 patients [94 men (55%) and 77 women (45%)] in the study. HT developed in 37 patients (21.63%). In terms of risk factor analysis, the most frequent etiological factor was atherosclerosis in AIS patients (50.3%). National Institutes of Health Stroke Scale scores were significantly higher both in sHT patients according to asHT patients and in HT patients on day 7 compared with their initial scores. Serum low-density lipoprotein (LDL-C), triglycerides (TG), and total cholesterol (TC) levels were significantly lower in patients with HT (p<.001). CONCLUSION: HT is a major complication in AIS that considerably increases the morbidity and mortality. To reduce the occurrence of HT, risk factors for each patient population should be determined. Acute thrombolytic therapy should be used cautiously in high-risk patients, and appropriate alternative therapies should be revised in them.

Dural puncture: an overlooked cause of cerebral venous thrombosis.

Cerebral venous thrombosis (CVT) accounts for 0.5-1 % of all strokes. Although dural puncture is proposed as one of the rare risk factors, this association has only been mentioned in anecdotal reports. Headache, i.e., usually the first and the most frequent clinical symptom on admission, is often attributed to the dural puncture itself. We investigated the frequency of CVT following a recent dural puncture in our stroke database, together with the other risk factors. The computerized medical records of patients (n = 10,740) registered in our tertiary-care neurology clinic stroke database were reviewed retrospectively. Patients diagnosed with CVT were reanalyzed. Patients who had a dural puncture in the preceding 7 days were included in the study. A total of 46 patients were diagnosed with CVT. Nine patients (19.6 %) had a recent dural puncture before the onset of the symptoms. Patients were younger than 45 years and had at least one more predisposing condition for thromboembolism other than the dural puncture. All patients have received either spinal anesthesia or intrathecal chemotherapy. Dural puncture seems to trigger CVT particularly in patients with predisposing disorders. Although reported as an extremely rare complication, our data indicate a much higher association. This case series emphasize the importance of reevaluation of patients with persistent/progressive headache following dural puncture. The effect of change in the biochemical composition of CSF due to intrathecal drug administration in pathogenesis is not known. Larger controlled trials are warranted to clarify the causal relationship between lumbar puncture and/or intrathecal drug administration and CVT.

Eagle syndrome: case report.

Eagle syndrome is an aggregate of symptoms caused by an elongated styloid process, most frequently resulting in headache, facial pain, dysphagia and sensation of foreign body in throat. The proper diagnosis is not difficult with clinical history, physical examination and radiographic assessment if there is a sufficient degree of suspicion. The treatment is very effective. We report here a typical case of Eagle syndrome which was misdiagnosed as trigeminal neuralgia for many years and was treated with carbamazepine. We aim to point the place of Eagle syndrome in the differential diagnosis of facial pain. We also re-emphasize the usefulness of the three-dimensional computed tomography in the diagnosis of Eagle syndrome. Even though Eagle syndrome is a rare condition, in cases of facial pain refractory to treatment or unexplained complaints of the head and neck region, it should be considered in the differential diagnosis as it has therapeutic consequences.

Interleukin-6, interleukin-1 beta and interleukin-1 receptor antagonist levels in epileptic seizures.

PURPOSE: Data are accumulating to support the involvement of inflammatory mechanisms in the pathogenesis and course of epilepsy. METHODS: The aim of this study was to examine seizure-induced changes in plasma concentrations of interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1Ra), and interleukin-1 beta (IL-1ß) in 23 patients with epilepsy undergoing a video-electroencephalography (EEG) study. Patients were divided into groups based on epilepsy type as follows: temporal lobe epilepsy (TLE) (n=6), extra-temporal lobe epilepsy (XLE) (n=8) and idiopathic generalised epilepsy (IGE) (n=9). Serum levels of IL-1ß, IL-1Ra and IL-6 were measured at baseline, immediately after the epileptic seizure, and at 3h, 6h, 12h and 24h after the seizure. RESULTS: We demonstrated a significant increase in plasma levels of IL-6 and IL-1Ra that peaked at 12h into the post-ictal period (p<0.05). IL-1ß levels did not differ from the baseline levels. We did not observe any differences in post-ictal cytokine release patterns between the TLE, XLE and IGE groups. CONCLUSION: The present study confirms the findings that epileptic seizures induce the production of IL-6 and IL-1Ra.

Myasthenia gravis as a cause of head drop in Parkinson disease.

Head drop is characterized by marked anterior flexion of the cervical spine. As a result, the affected patient presents with the head tilted forward and the chin resting on the chest. We report a 75-year-old male patient with parkinsonism and head drop caused by isolated myasthenic weakness of the neck extensor muscles. Our case is the second report of isolated head drop as a presenting symptom of myasthenia gravis in a patient with parkinsonism.

Sensory nerve conduction in branches of common interdigital nerves: a new technique for normal controls and patients with morton's neuroma.

In this article, a new electrodiagnostic approach is described for patients with Morton's neuroma. The new method is based on the anatomic fact that the two branches of the common plantar interdigital nerves innervate the lateral side of one toe and the medial side the next one. This study included 20 normal subjects (aged 28-58 years, 10 men and 10 women) and 4 patients with Morton's neuroma (aged 44-52 years, 4 women). The branches of adjacent common plantar interdigital nerves that innerve one toe were stimulated superficially and separately with half of one toe covered with a piece of medical tape. The recordings were obtained on the posterior tibial nerve at the medial malleolus with needle electrodes. Thus, the difference in latencies of obtained sensory nerve action potentials on the posterior tibial nerve with needle electrode was measured. From normal subjects' data, it was determined that a latency difference value of above 0.17 milliseconds (mean +/- 2.5 SD) in one toe was abnormal. All of the patients with Morton's neuroma showed abnormal interlatency difference values. This new method, which we have developed, is more sensitive, simple to use, does not require extra equipment, and does not cause excessive pain. We suggest that interlatency difference between branches of the common plantar interdigital nerves is a useful and sensitive method for the diagnosis of Morton's neuroma.

The effect of carbamazepine treatment on serum leptin levels.

Patients with epilepsy may manifest metabolic adverse effects throughout the course of their management with antiepileptic drugs. Leptin is a hormone that plays a major role in the regulation of feeding and energy expenditure. Leptin has been expected to form a link to weight gain in epilepsy with the use of some antiepileptic drugs. The aim of this study is to evaluate the effect of carbamazepine on body weight and serum leptin levels. This study was conducted in Izmir Tepecik Training and Research Hospital, Neurology Department. 56 epileptic patients who were on continuous carbamazepine monotherapy for at least 6 months before the study and 42 control subjects were included. Serum leptin and insulin levels were measured. Body mass index, leptin and insulin were not significantly elevated in carbamazepine group compared to control subjects (p>0.05). Our study demonstrated that carbamazepine therapy does not affect significantly body mass index, leptin and insulin. Data regarding the effect of carbamazepine on serum leptin level is limited but the results of these recent studies are correlated with ours. It can be concluded that carbamazepine is a relatively low risky antiepileptic drug in terms of obesity and metabolic syndrome but further studies are needed.