Health-related quality of life in adolescents with epilepsy in Montenegro.

OBJECTIVE: The objective of this study was to establish potential risk factors for poor health-related quality of life among adolescents with epilepsy in Montenegro. MATERIAL AND METHODS: A sample of 104 adolescents with epilepsy (age: 11-19years) at a tertiary referral center in Podgorica, Montenegro, completed the validated Serbian version of the QOLIE-AD-48 questionnaire. They were divided into two groups: a group with active epilepsy (60 adolescents) and a group with inactive epilepsy (44 adolescents). Demographic and clinical data were collected. RESULTS: Adolescents with active epilepsy had low quality of life and felt the negative impact of the disease. They also had more cognitive impairments, felt more stigmatized, and had considerably more distorted perception of their health than adolescents with inactive epilepsy (p<0.05). Females reported better social support than males (p<0.05). Older males had lower grades at school (p<0.05) than the younger ones. As expected, adolescents with the highest number of seizures in the past two years had the lowest quality of life (p<0.05). CONCLUSION: In our study, the quality of life in adolescents with epilepsy was determined by severity of the disease, age, and gender.

Case report of Mikulicz's disease: A modern concept of an old entity.

Introduction: Modern knowlegde defines Mikulicz´s disease as a part of immunoglobulin G4-related disease. The main feature is the presence of lymphoplasmacytic infiltrates, immunoglobulin G4 plasma cells positivity, distinctive storiform fibrosis and moderate eosinophilia. Case Report: A 59-years old male presented with a mild keratoconjuctivitis sicca and enlarged lacrimal and salivary glands during the last two years. Althought clinical presentation of the patient was typical, earlier testing did not pinpoint Mikulicz ´s disease. By typical clinical presentation, elevated serum immunoglobulin G4 level and histopathological finding of lacrimal glands tissue we diagnosed Mikulicz´s disease successfully treated with corticosteroid therapy. Conclusion: We reported the first case of IgG4-related Mikulicz´s disease in Serbia. Our report highlights IgG4-related Mikulicz` s disease as an important differential diagnosis with Sjögren`s syndrome and lymphoproliferative disease in rheumatological practice.

Social competence among well-functioning adolescents with epilepsy.

PURPOSE: The aims of the study were to measure the social competence of well-functioning adolescents with epilepsy and compare it with that of their healthy peers as well as to analyze the effects of epilepsy-related variables on the social competence. METHODS: Ninety well-functioning adolescents with epilepsy 12-19years of age were compared with healthy controls using the Achenbach Youth Self-Report Questionnaire measures of social competence. Within the group with epilepsy, the impact of duration of epilepsy, etiology, seizure frequency, seizure type, and antiepileptic drugs (AEDs) (monotherapy or polytherapy) on the above measures was also determined. RESULTS: Twenty-five (27.8%) adolescents with epilepsy obtained Total Competence T scores in the clinical range, as opposed to only two (3.3%) of the healthy adolescents. There were statistically significant differences in the Activity and Social subscales and Total Competence T score between the group with epilepsy and the control group (p<0.05). Comparing T scores for epilepsy-related variables in the group with epilepsy, we found that there were statistically significant differences in all the social competence subscales regarding the seizure control and seizure types. No significant differences were obtained for other epilepsy-related variables: duration of epilepsy, onset of epilepsy, etiology, and AEDs. CONCLUSION: Our results indicate that adolescents with epilepsy are less active in clubs, socialize less with their friends, and have a poorer school performance compared with their healthy peers. This study shows that adolescents with epilepsy are at an increased risk of having difficulties in social competence.

Improvement of post-hypoxic action myoclonus with levetiracetam add-on therapy: A case report.

INTRODUCTION: Chronic post-anoxic myoclonus, also known as Lance-Adams syndrome, may develop following hypoxic brain injury, and is resistant to pharmacological therapy. CASE REPORT: The patient we presented developed post-anoxic action myoclonus with severe, completely incapacitating myoclonic jerks. Myoclonus did not respond to the treatment with commonly used agents, i.e. valproate and clonazepam alone or in combination. Improvement of the action myoclonus was observed only after adding levetiracetam. CONCLUSION: Although Lance-Adams syndrome may not be fully curable at this point, levetiracetam appears to be a promising agent that can significantly improve functional level and overall quality of life of patients with this disorder.

Clinical characteristics and use of antiepileptic drugs among adolescents with uncomplicated epilepsy at a referral center in Novi Sad, Serbia.

The study aimed to investigate the type and etiology of epileptic seizures and the use of antiepileptic drugs for the treatment of various forms of epileptic seizures among adolescents with active but uncomplicated epilepsy at a tertiary referral center in Novi Sad, Serbia. The study design was cross sectional. Data were obtained from patients and medical records. A total of 103 adolescents (39 males and 64 females) with active but uncomplicated epilepsy were included. Patients with primary generalized seizures had significantly better control of epilepsy than those with partial seizures with or without secondary generalization. A total of 80 (77.7%) adolescents had no known underlying etiology based on initial diagnosis and evaluation. All adolescents were classified into known idiopathic syndromes (54.4%), non-classifiable cryptogenic etiology (23.3%), and secondary epilepsy attributed to MRI-identified lesions (22.3%). Eighty-eight percent of adolescents were taking monotherapy and 64.8% of these were taking valproate. New antiepileptic drugs (AEDs), topiramate and lamotrigine, the only drugs available free of charge at the Serbian market, were used in 19.4% of patients. A total of 57.3% adolescents were seizure-free, 24.2% had occasional seizures, and 18.5% had seizures despite AED treatment.

[Juvenile myoclonic epilepsy: under-diagnosed syndrome].

INTRODUCTION: Juvenile myoclonic epilepsy is an idiopathic, hereditary form of epilepsy. Although juvenile myoclonic epilepsy is a well defined clinical syndrome, attempts at diagnosing it commonly fail. ETIOPATHOGENESIS: The exact cause of juvenile myoclonic epilepsy remains unknown. Clinical, morphological and metabolic data suggest a preferential role for frontal regions in this syndrome. Several major genes for juvenile myoclonic epilepsy have been identified, but these genes account for only a small proportions of juvenile myoclonic epilepsy cases, suggesting multifactorial or complex inheritance in most. CLINICAL MANIFESTATIONS: Juvenile myoclonic epilepsy is characterized by the triad of myoclonic jerks on awakening (all patients), generalized tonic-clonic seizures (> 90% of patients) and typical absences (about one third of patients). Seizures have an age-related onset, circadian distribution and are frequently precipitated by sleep deprivation, fatigue and alcohol intake. Intelligence is normal. DIAGNOSIS: Juvenile myoclonic epilepsy diagnosis is based upon clinical criteria and typical electroencephalographic findings (generalized pattern of spikes and/or polyspikes and waves). All other tests are normal. TREATMENT AND PROGNOSIS: Both medical treatment and counselling are important in the management of juvenile myoclonic epilepsy. Mono-therapy with valproate is the preferred treatment. Some of the newer antiepileptic drugs have been suggested as possible alternatives. Juvenile myoclonic epilepsy has a good prognosis. Lifelong treatment is usually considered necessary in vast majority of patients due to the increased risk of relapse if treatment is discontinued. CONCLUSION: Juvenile myoclonic epilepsy is a common, although under-diagnosed epileptic syndrome. The clinician should study the occurrence of myoclonic jerks and should consider atypical presentations.

[Ischaemic stroke in children: diagnostic and therapeutic specificity].

INTRODUCTION: Although more common in older adults, stroke occurs in neonates, infants and children as well, resulting in significant morbidity and mortality. EPIDEMIOLOGY: The incidence of childhood ischemic stroke exceeds 3.3 in 100,000 children per year. Stroke is one of the top ten causes of death in children. RISK FACTORS: Children's strokes are often caused by birth defects, injections (e.g. meningitis, encephalitis), trauma, and blood disorders. Risk factors for stroke are recognized in more than 75% of children. The most common cause of stroke in children is probably congenital or acquired heart disease. CLINICAL PRESENTATION: Children often experience different symptoms of stroke to adults. These can include seizures, headache and fever. However, many of" the symptoms of stroke in children are similar to those experienced by adults (paralysis, speech and visual impairment). DIAGNOSTIC EVALUATIONS: Urgent neuroimaging is important for confirming the diagnosis of stroke. It is necessary for clinicians to conduct a thorough investigation for possible cardiac, vascular, and hematologic risk factors in all patients. THERAPY: The appropriate choices for in-hospital acute treatment and secondary preventative strategies, including aspirin and anticoagulants, are controversial. The recommendations for children are based mainly upon extrapolation from studies involving adults, and the clinical experience of experts, as reflected in consensus guidelines. CONCLUSION: Advanced forms of thrombolytic and neuroprotective agents may become more readily available to paediatric stroke patients when both the general public and medical staff become more aware of this disorder.

[The most frequent causes of ischemic stroke in young adults].

INTRODUCTION: Pathogenesis of ischemic stroke in young adults is heterogeneous, thus making differential diagnosis very broad. MATERIAL AND METHODS: The study comprised 60 ischemic stroke patients of both sexes aged 15-45 years who were treated at the Department of Neurology of the Clinical Centre of Vojvodina. Information about sex and age, detailed history, risk factors for ischemic stroke were obtained for all patients who underwent neurological examination as well. Diagnostic procedures applied in all patients included brain computed tomography and/or magnetic resonance imaging, routine laboratory tests, Doppler imaging of extra and endocranial blood vessels and coagulation tests. Contrast and/ or transesophageal echocardiography, immunological blood assays, magnetic resonance angiography and/or computed tomography angiography and/or conventional angiography, immunological tests, assessment of levels of natural coagulation inhibitors, toxicological examination, etc. were performed in selected patients. RESULTS: Causes of ischemic stroke were determined according to the Trial of ORG 10172 in Acute Stroke Treatment criteria. The most frequent were the so called other causes of ischemic stroke, which were found in 26.7% patients. The second most frequent cause was cardiac embolisation, found in 25%. The cause of ischemic stroke remained undetermined in 21.7% of all patients. CONCLUSION: Aetiology of ischemic stroke in young adults is diverse and demands thorough diagnostic evaluation.

Comparison of dissolution profiles and serum concentrations of two lamotrigine tablet formulations.

BACKGROUND: Since 2005, the antiepileptic drug lamotrigine has been present in the market in various generic products, in addition to the original brand of Lamictal®. The linear pharmacokinetics and wide therapeutic window of lamotrigine enable seizure-free patients to easily switch from brand to generic antiepileptic drugs. OBJECTIVE: The aim of this study was to investigate the extent of variations in lamotrigine serum concentrations between two immediate-release tablet formulations. Data were compared with in vitro difference and similarity tests on dissolution profiles of the two formulations. METHODS: Dissolution characteristics of formulations A (reference) and B (test) were evaluated at three points spanning the physiologic pH range (pH 1.2, pH 4.5, pH 6.8). A model-independent approach of difference (f1) and similarity (f2) tests were applied to dissolution data. A clinical study was performed with 16 patients who were divided into two groups - one group received formulation A (n = 9) and the other received formulation B (n = 7). Lamotrigine steady-state concentrations were determined by high-performance liquid chromatography on a reverse-phase column. RESULTS: There were no statistically significant differences in lamotrigine serum concentrations between the two groups, although formulation B had slightly higher mean concentration values (formulation A: 3.97 ± 4.1 µg/mL; formulation B: 5.78 ± 2.7 µg/mL). Dissolution profiles of the two formulations were similar in the pH 1.2 dissolution medium; however, the dissolution profiles of formulation B were outside the dissolution limit (≥85% at 15 minutes) in the pH 4.5 and 6.8 dissolution media. CONCLUSIONS: No significant changes in the serum concentrations of lamotrigine were seen between the two investigated formulations. There is no evidence to suggest that the differences in dissolution profiles at pH 4.5 and pH 6.8 affect the therapeutic efficacy of the formulations. It is evident that the doses of test formulation given to the patients were higher as a consequence of common assumption that generic products have a lower absorption rate, which is proven unnecessary in this study. This investigation was a pilot study and thus further investigations with a larger sample size are necessary to determine if there is a connection between dissolution profiles and the therapeutic effect of investigated formulations.

[Mother's filicide with suicide attempt].

INTRODUCTION: Filicide is the killing of a son or daughter by a parent. The paper examines interaction between stress and maternal psychopathology that led to the killing. CASE OUTLINE: After prolonged conflict with her ex-husband and father of her only child, the respondent committed filicide. Two years before committing filicide, after she had divorced the father of the child, the respondent attempted suicide and had to be hospitalized. On that occasion, she was diagnosed with depressive disorder, which was not treated after hospitalization. Having killed her daughter by cutting her throat, she tried to commit suicide in the same manner, by slitting her throat. During further observation, the respondent was found to suffer from acute psychotic disorder, depressive disorder and histrionic personality disorder. These disorders in interaction with stress do not provide us with an explanation for an unusual and psychopathological motivation analysis of killing the child. CONCLUSION: Filicide is a violent act, most frequently multifactorial in its nature. Histrionic personality disorder in mother cannot explain the filicide act. Only interactive and dynamic evaluation of this psychiatric disorder in its longitudinal, development aspects and its potentiality to enable the expression of some other psychiatric disorders, especially dissociative states, as well as the importance of prolonged and acute stress and its subjective importance for the individual can shed some more light on the mental state of the mother at the time of filicide.

[Convulsive status epilepticus in children].

INTRODUCTION: Convulsive status epilepticus is the most urgent neurological medical emergency in children. Generalized convulsive status epilepticus is the most common and life-threatening type of status epilepticus. It is not a syndrome in the same sense as febrile convulsions, benign rolandic epilepsy, and infantile polymorphic epilepsy. These latter disorders have a tight age frame, seizure semiology, and a reasonably predictable outcome. Episodes of convulsive status epilepticus can occur in each: occasionally in symptomatic and febrile convulsions, and Lennox Gastaut syndrome, rarely in benign rolandic epilepsy, and West syndrome. ETIOLOGY OF CONVULSIVE STATUS EPILEPTICUS: Status epilepticus has many causes, which vary depending on the age and patient population. Convulsive status epileptucus continues to be associated with significant neurological morbidity and mortality, with different hazards and outcome. Although the outcome is dependent on etiology, it is known that appropriate early management may reduce mortality and some of the morbidity associated with convulsive status epilepticus. DISCUSSION: Status epilepticus is a disorder in which the mechanisms attempting at terminating the seizure fail. Continued convulsive activity in convulsive status epilepticus results in decompensation of all organs and systems, thus being life threatening. Seizure activity in convulsive status epilepticus is associated with neuronal damage. The aim should be to halt this activity urgently, using, ideally, a 100% effective drug, administered quickly, without compromising the consciousness level or producing other negative effects on cardiovascular, respiratory function or other unexpected effects.

Lamotrigine and valproate pharmacokinetics interactions in epileptic patients.

UNLABELLED: Lamotrigine (LTG, 3,5-diamino-6- (2,3-dichlorphenyl)-,2,4-triazine) is an antiepileptic drug used mainly for partial and generalized seizures. The efficacy of LTG in treating resistant partial seizures was optimized when it was combined with valproate (VPA). The aim of this study was to investigate the influence of VPA on LTG pharmacokinetics in epileptic patients. METHODS: 38 patients were randomly divided into two groups, one given LTG (n = 18) and the other given LTG + VPA(n = 20). The first group consisted of 10 females (32.50 +/- 12.46 years old, 67.80 +/- 15.18 kg) and 8 males (24.88 +/- 8.92 years old, 69.88 +/- 11.41 kg) and the second group consisted of 9 females (28.33 +/- 6.52 years old, 62.89 +/- 13.28 kg) and 11 males (37.64 +/- 10.43 years old, 85.64 +/- 15.4 kg). Patients were either administered an oral dose of LTG (157 +/- 74 mg/day) or LTG + VPA (150 +/- 83.11 mg/day & 774 +/- 330 mg/day respectively). LTG steady state serum concentrations were determined 1.5-8 h post dose. Analyses were performed by a validated HPLC method. RESULTS: LTG serum concentrations were increased significantly from 4.67 +/- 3.66 and 9.56 +/- 5.27 microg/ml by concomitant administration of VPA. DISCUSSION: The inhibition of LTG metabolism by VPA was shown to have a marked effect on LTG kinetics. This inhibitory effect was complicated further by inter-patients variation in body weight and gender. This emphasizes the importance of continuous monitoring of LTG serum concentrations on an individual basis. Accordingly, if the use of potentially interacting drugs cannot be avoided, adverse reactions can be minimized by dose adjustments guided by careful monitoring of clinical response and measurement of LTG serum concentrations.

Decreased expression of the righting reflex and locomotor movements in breech-presenting newborns in the first days of life.

AIM: To investigate differences between the infants born in occipital and breech presentation relative to the passive and active motility. METHOD: A prospective study was conducted in the period from 2006 to 2007 at the Department of Obstetrics and Gynecology in Novi Sad. Subjects were 50 breech-presenting and 87 occipital-presenting term newborns delivered by elective cesarean section following a regular course of pregnancy, without fetal, newborn, and the pregnant female disease. Outcome measures were popliteal angle; extension of the hip-joint; ventral flexion and dorsal extension in the axis; spontaneous displacement; crawling reflex; righting reaction in vertical and sitting positions; righting reaction in horizontal suspension, the automatic walking investigated on the second and fourth day of life. RESULTS: Except for righting reaction in horizontal suspension, the newborns from breech presentation had a significantly lower score for all investigated parameters of active movements at the first and second examination. There was no difference between occipital and breech-group relative to the ventral flexion and dorsal extension in the axis. The popliteal angle was significantly increased, whereas the extension in the hip joint was significantly decreased in the breech group. CONCLUSIONS: Investigations showed a significantly decreased expression of active movements in the breech group, which cannot be explained only by postural deformities.

[Prophylactic use of antiepileptic drugs for posttraumatic epilepsy].

The link between severe brain trauma and epilepsy in humans is well recognized Posttraumatic epilepsy is reported after 2-5% of closed head injuries but up to 50% or more following penetrating head injury. The control of "early seizures", i.e., those occurring hours or weeks after injury, is mandatory because those acute attacks may add secondary damage to the injured brain. Seizures occuring months or years after injury are called "late seizures". Recurring "late seizures" make up the clinical syndrome of "post-traumatic epilepsy". Prophylaris is the process of guarding against the development of a specific disease by action or treatment that affects pathogenesis. In animal "prophylaxis" by antiepileptic drugs seems efficacious in many experimental models including iron induced epilepsy which is considered a model of post-traumatic epilepsy. In the hunman being "prophylaxis" has been attempted by phenytoin, phenobarbital, carbamazepine and valproate but without any success. During the treatment period the occurrence of scizures is prevented but, after discontinuation of the drug, seizures occur just as in non treated patients. Although prevention of acute seizures that occur following head injury is a practical goal, such treatment is not likely to have a prophylactic effect against late development of epilepsy.

[Surgical treatment of temporal lobe epilepsy].

INTRODUCTION: The surgical treatment of epilepsy is a therapeutic procedure aimed at removal of the brain tissue responsible for seizures. Neurological examinations are performed to delineate the epileptic zone, which is then removed, without causing a functional deficit. In order to fulfill these goals, it is essential to localize accurately and lateralize the epileptogenic zone and the surrounding eloquent cortex. MATERIAL AND METHODS: Ninety-four adult patients were included in the study of the Epilepsy Center, National Institute of Psychiatry and Neurology, Budapest. All patients underwent a standard anterior temporal lobectomy between 1989 and 2001, whereas their preoperative evaluation consisted of detailed history of epilepsy, interictal EEG (awake and asleep), video EEG monitoring of seizures, magnetic resonance imaging, all according to the epilepsy protocol and neuropsychological investigations. The mean follow up was 6.1 years (range: 2-17 years). Seizure outcome was assessed annually, using Engel's classification. Seventy-two percents of patients were seizure-free 1 year after surgery. RESULTS: The percentage of seizure-free patients two, five and ten years after the surgery was 67%, 59%, and 61%, respectively. DISCUSSION AND CONCLUSION: According to cost analysis, epilepsy surgery is considered to be cost effective. However, in the long run, indirect cost benefits (employment, independent living) add even more to the cost effectiveness of this method. Although the economic aspect is of great importance, especially in countries with limited financial resources, it is often neglected both by neurologists and health authorities.