Experience of Subcutaneous Levetiracetam in Palliative Care.

BACKGROUND: Seizures are common in palliative care patients and its control is essential in the management of these patients as it helps to reduce suffering at the end of life. Subcutaneous levetiracetam has been used off-license for seizure control in palliative care. OBJECTIVE: The objective of the study was to describe our experience with subcutaneous levetiracetam in two hospitals in Bogota, Colombia. METHODS: We conducted a retrospective review of patients treated with subcutaneous levetiracetam in two hospitals in Colombia during 2019-2021. Data were extracted from medical records, and participants were followed up as outpatients. RESULTS: Twenty-one patients were included into the study. No severe adverse effects or rise in ictal frequency were documented. Twelve patients died during hospitalization and nine continued treatments as outpatients. The principal diagnosis was structural focal epilepsy. The daily dose of levetiracetam ranged from 1,000 mg to 3,000 mg, and the duration of treatment varied among subjects between 1 and 360 days. CONCLUSION: Subcutaneous levetiracetam was well tolerated and effective in controlling seizures in palliative care when oral administration or intravenous access was not an option. Randomized controlled trials are needed to elucidate the efficacy and tolerability of subcutaneous levetiracetam in clinical practice.

Las diferentes facetas de la encefalitis autoinmune / The different facets of autoinmune encephalitis

RESUMEN INTRODUCCIÓN: La encefalitis autoinmune es causada por mecanismos inmunes antineuronales, su presentación clínica es heterogénea, los criterios clínicos y paraclínicos disponibles orientan el abordaje, sin embargo, el reto ocurre cuando no hay autoanticuerpos detectables en suero o líquido cefalorraquídeo (LCR). METODOLOGÍA: Reportamos cuatro casos destacando la variabilidad de las manifestaciones clínicas, que ante la ausencia de anticuerpos (negativos finalmente en tres de los casos) fueron tratados con inmunoterapia con buena respuesta. CONCLUSIÓN: En sitios donde no se dispone de medición de anticuerpos de manera expedita, o a pesar de ser estos negativos, ante la sospecha clínica, apoyado de estudios de LCR, resonancia magnética nuclear y registro electroencefalográfico, se sugiere iniciar inmunoterapia temprana, usualmente dando lugar a reversibilidad del trastorno neurológico.

SUMMARY INTRODUCTION: Autoimmune encephalitis is caused by antineuronal immune mechanisms, its clinical presentation is heterogeneous, clinical and paraclinical criteria guide the approach, however, the challenge occurs when there are no detectable autoantibodies in serum or cerebrospinal fluid. METHODOLOGY: We report four cases that highlight the variability of clinical manifestations, which in the absence of antibodies (finally negative in three of the cases) were treated with immunotherapy with good response. CONCLUSION: In places where antibody measurement is not available expeditiously, or despite it being negative, given clinical suspicion, supported by CSF studies, magnetic resonance imaging and electroencephalographic recording, it is suggested to start early immunotherapy, usually resulting in the reversibility of the neurological disorder.

Barreras de acceso a la cirugía de la epilepsia: revisión de la bibliografía / Barriers impeding access to epilepsy surgery: a review of the literature

La epilepsia farmacorresistente es una condición crónica con consecuencias a largo plazo que puede ser tratada quirúrgicamente. La eficacia y la seguridad de la cirugía de la epilepsia del lóbulo temporal se han establecido a través de un gran número de estudios de cohorte retrospectivos y prospectivos y dos ensayos clínicos controlados aleatorizados. A pesar de los excelentes resultados comunicados con la cirugía, la bibliografía sugiere que este procedimiento es un tratamiento subutilizado. Aunque no existe evidencia de esto, entre algunos de los motivos descritos se apuntan el fallo de los médicos de atención primaria y los neurólogos en proveer información, identificar y remitir a los pacientes a un centro de cirugía; los diferentes niveles de tecnología en los centros, lo que provoca distintas estrategias de selección de los candidatos; la creencia de que la cirugía de la epilepsia es un procedimiento arriesgado que debería contemplarse sólo como última opción; la preferencia del paciente por evitar la cirugía; el deseo de los padres de esperar hasta que sus hijos sean lo suficientemente mayores para participar en el proceso de toma de decisiones; el hecho de que las aseguradoras no cubran los gastos asociados con las evaluaciones prequirúrgicas o la carencia de un seguro médico, y la desigualdad racial y social, entre otros. En este artículo se revisan los datos epidemiológicos disponibles en relación con la falta de acceso a la cirugía de la epilepsia (AU)

Drug-resistant epilepsy, a chronic condition with long-term consequences can be treated with surgery. The efficacy and safety of surgery for temporal lobe epilepsy have been established through a large number of retrospective and prospective cohort studies and two randomized controlled clinical trials. Despite the excellent outcomes reported after surgery, the literature suggests that this procedure is an underutilized treatment. While evidence is lacking as to why epilepsy surgery is underused, cited reasons include: failure of primary care physicians and neurologists to provide information and identify patients who could be referred for surgery; different levels of technology at various centers, resulting in different candidate selection strategies; the belief that epilepsy surgery is a risky procedure and that it should be only viewed as the last option; patient preference to avoid surgery; parents wanting to wait until their child is old enough to participate in the decision-making process regarding surgery; unwillingness of insurers to cover the expenses associated with presurgical evaluations or lack of insurance; racial and social disparities, among others. In this paper we review the available epidemiological data about lack of utilization of epilepsy surgery (AU)

Signo de la "lengua brillante" en esclerosis lateral amiotrófica / "bright tongue" sign in amyotrophic lateral sclerosis / Sinal da "lingua lustrosa" em esclerose lateral amiotrófica

La esclerosis lateral amiotrófica (ELA) es una enfermedad neurodegenerativa. Aunque su diagnóstico sigue siendo clínico, los exámenes adicionales pueden ser utilizados para excluir otras enfermedades, así como para confirmar el diagnóstico. Uno de ellos son las neuroimagenes, donde la más utilizada es la resonancia nuclear magnética (RNM). En la literatura hay pocos signos específicos; el tracto corticoespinal, giro precentral y el cuerpo calloso son los principales sitios de alteración. Un signo patognomónico es el signo de la lengua brillante, debido a la alteración de la lengua en su estructura interna con áreas de aumento y disminución de intensidad de señal, en fases de severo compromiso bulbar con mayor intensidad en T1.

Amyotrophic lateral sclerosis is a progressive neurodegenerative disease, but its diagnosis remains clinical, additional tests may be used to exclude other diseases and to confirm the diagnosis. One of them is the images studies, and the most commonly used is magnetic resonance imaging. In literature there are few signs specific finding as major sites of alteration: the corticospinal tract, precentral gyrus, corpus callosum.. A pathognomonic sign"bright tongue sign'', because alteration in the internal structure with areas of increased and decreased signal intensity in severe bulbar commitment phases with greater intensity in T1.

A esclerose lateral amiotrófica é uma doença neuro-degenerativa. Embora seu diagnóstico ainda seja clínico, os examines podem-se aplicar para excluir outras doenças, assim como para confirmar o diagnóstico. Um de eles são as neuroimagens, onde as mais aplicada é a ressonância nuclear magnética (RNM). Na literatura ha poucas sinales específicas: o trato corticoespinal, giro precentrarl y o corpo caloso são os principais sites de alteração. Una sinal patognómica é a sinal da língua lustrosa, devido a alteração da língua na estrutura interna com áreas de aumento e diminuição de intensidade da sinal, em fases de severo compromisso bulbar com maior intensidades em T1.