A multicenter retrospective study of patients treated in the thalamus with responsive neurostimulation.

Introduction: For drug resistant epilepsy patients who are either not candidates for resective surgery or have already failed resective surgery, neuromodulation is a promising option. Neuromodulatory approaches include responsive neurostimulation (RNS), deep brain stimulation (DBS), and vagal nerve stimulation (VNS). Thalamocortical circuits are involved in both generalized and focal onset seizures. This paper explores the use of RNS in the centromedian nucleus of the thalamus (CMN) and in the anterior thalamic nucleus (ANT) of patients with drug resistant epilepsy. Methods: This is a retrospective multicenter study from seven different epilepsy centers in the United States. Patients that had unilateral or bilateral thalamic RNS leads implanted in the CMN or ANT for at least 6 months were included. Primary objectives were to describe the implant location and determine changes in the frequency of disabling seizures at 6 months, 1 year, 2 years, and > 2 years. Secondary objectives included documenting seizure free periods, anti-seizure medication regimen changes, stimulation side effects, and serious adverse events. In addition, the global clinical impression scale was completed. Results: Twelve patients had at least one lead placed in the CMN, and 13 had at least one lead placed in the ANT. The median baseline seizure frequency was 15 per month. Overall, the median seizure reduction was 33% at 6 months, 55% at 1 year, 65% at 2 years, and 74% at >2 years. Seizure free intervals of at least 3 months occurred in nine patients. Most patients (60%, 15/25) did not have a change in anti-seizure medications post RNS placement. Two serious adverse events were recorded, one related to RNS implantation. Lastly, overall functioning seemed to improve with 88% showing improvement on the global clinical impression scale. Discussion: Meaningful seizure reduction was observed in patients who suffer from drug resistant epilepsy with unilateral or bilateral RNS in either the ANT or CMN of the thalamus. Most patients remained on their pre-operative anti-seizure medication regimen. The device was well tolerated with few side effects. There were rare serious adverse events. Most patients showed an improvement in global clinical impression scores.

Hospital readmissions in older adults with epilepsy in the US - A population-based study.

OBJECTIVE: Our objective was to determine proportions, causes, and predictors of 30-day readmissions among older adults with epilepsy. Understanding predictors of readmissions may inform future interventions aimed at reducing avoidable hospitalizations in this vulnerable population. METHODS: Individuals 65 years or older with epilepsy were identified using previously validated ICD-9-CM codes in any diagnostic position in the 2014 Nationwide Readmissions Database. Proportions of 30-day readmissions and causes of readmissions in older adults with epilepsy were compared to both older adults without and younger adults (18-64 years old) with epilepsy. We identified predictors of readmission in older adults with epilepsy using logistic regression. RESULTS: There were 92,030 older adults with, 3,166,852 older adults without, and 168,622 younger adults with epilepsy. Proportions of readmissions were higher in older adults with (16.2%) than older adults without (12.5%) and younger adults with epilepsy (15.1%). The main cause of readmission for older adults with and without epilepsy was septicemia, and epilepsy/seizure in younger adults with epilepsy. Predictors of 30-day readmissions in older adults with epilepsy were: non-elective admissions (OR 1.37, 95%CI 1.27-1.48), public insurance (Medicaid vs. private insurance OR 1.19, 95%CI 1.02-1.39; Medicare vs. private insurance OR 1.11, 95%CI 1.00-1.22), lower median household income for patient's zip code ($1-$39,999 vs. $66,000 + OR 1.15, 95% CI 1.08-1.22), hospital location in large metropolitan areas (OR 1.22, 95%CI 1.05-1.42), higher Charlson-Deyo comorbidity index (OR 1.11, 95%CI 1.10-1.02), and male sex (OR 1.04, 95%CI 1.00-1.09). SIGNIFICANCE: Our findings suggest that targeted interventions to reduce the risk of infection may potentially reduce readmission in older people with epilepsy, similarly to those without. Provision of coordinated care and appropriate discharge planning may reduce readmissions particularly in those who are males, are of lower socioeconomic status and with more comorbidities.

Angiectasias yeyunales como causa de sangrado intestinal oculto: identificación con cápsula endoscópica / Jejunal angiectasis as a cause of hidden intestinal bleeding: identification with endoscopic capsule

Una paciente de 83 años, con antecedentes de hipertensión arterial y diabetes mellitus bajo tratamiento, fue ingresó al hospital por un cuadro de sangrado digestivo, caracterizado por melenas y rectorragia, con compromiso hemodinámico. La endoscopia alta y colonoscopia no encontraron el origen del sangrado, por lo cual se empleó una cápsula endoscó- pica. El examen reveló a nivel de yeyuno medio y distal la presencia de sangrado activo proveniente de varios vasos pequeños y tortuosos, ligeramente elevados de diferentes tamaños, lesiones compatibles con múltiples angiodisplasias (foto 1 y 2). Además, a las dos horas del estudio, se visualizó imagen de una lesión ulcerada comprometiendo la luz yeyunal y cubierta con fbrina, sin sangrado activo, que como consecuencia generaba una estenosis luminal, por lo que la cápsula permaneció a este nivel por el lapso de 5 horas (foto 3). La paciente evolucionó con deterioro de su condición médica, fue ingresada a la Unidad de Terapia Intensiva y posteriormente falleció por una falla multiorgánica.

An 83-year-old patient with a history of hypertension arterial and diabetes mellitus under treatment, was admitted to hospital for a picture of digestive bleeding, characterized by mane and rectorragia, with hemodynamic commitment. The high endoscopy and colonoscopy did not find the origin of bleeding, whereby an endoscopic capsule was used pica. The examination revealed at the level of middle and distal jejunum the presence of active bleeding from several vessels small and tortuous, slightly elevated from different sizes, lesions compatible with multiple angiodysplasias (photo 1 and 2). In addition, two hours after the study, it was visualized image of an ulcerated lesion compromising jejunal light and covered with fbrine, without active bleeding, which as consequence generated a luminal stenosis, so the capsule remained at this level for 5 hours (photo 3). The patient evolved with deterioration of her medical condition, she was admitted to the Intensive Care Unit and He subsequently died of a multi-organ failure.