RESUMEN
Ictal bradycardia (IB) and ictal asystole (IA) are uncommonly recognized phenomena that increase morbidity in patients with epilepsy by causing syncope and seizure-related falls. These arrhythmias are also suspected to be involved in the pathophysiology of sudden unexpected death in epilepsy (SUDEP). We report a case of a 57-year-old male with left temporal lobe epilepsy who experienced both IB and IA. This patient was initially managed with pacemaker implantation, prior to undergoing left temporal lobectomy. Following surgery, the patient had no ongoing IB or IA on his pacemaker recordings, and his seizure control was greatly improved. His pacemaker was removed approximately one year post-operatively and he continued treatment with anti-seizure drugs (ASDs). A literature review of cases of IB and IA that were managed with pacemakers was performed. Pacemaker implantation appears to be quite effective for reducing seizure-related syncope and falls in the setting of IB/IA. Epilepsy surgery also seems to be an effective treatment option for IB/IA, as many patients are able to have their pacemakers removed post-operatively. Further investigations into the pathophysiology of IB and IA and long-term outcomes using different treatment modalities are clearly needed to help formulate treatment guidelines and, potentially, to reduce the occurrence of SUDEP in these patients.
RESUMEN
OBJECTIVE: To quantify the degree of non-attendance of medical appointments, as well as to identify the social reasons behind the missed appointments, at an inner-city primary care clinic. DESIGN: Retrospective chart review and survey. SETTING: Inner-city clinic in Saskatoon, Sask, serving a primarily low-income and First Nations population. PARTICIPANTS: Patients with appointments in the clinic between January 2016 and June 2016. MAIN OUTCOME MEASURES: Number of non-attended clinic appointments and the reasons for missed appointments. RESULTS: Of the 1976 booked appointments during the study period, 487 (24.6%) appointments were not attended. Among the patients with walk-in appointments, 123 (15.5%) of them left the clinic before seeing a physician. New patients had a high rate of non-attendance (44.4% did not show up to appointments). Among those who did not attend an appointment, 19.9% of them missed more than 1 appointment; 77.8% of missed appointments were made more than a week in advance of the appointment, and 51.7% of those who missed an appointment saw a physician at the clinic at a later date (18.5 days later on average). The most common reasons for non-attendance were forgetting the appointment or feeling too sick to attend. Social determinants such as transportation were also found to play a role in non-attendance. Most survey participants stated that a telephone call reminder would aid them in keeping their appointments. CONCLUSION: Non-attendance is a multifactorial issue that causes a considerable waste of resources, limits the provision of preventive care, and negatively affects patient health. As forgetting was found to be a frequent cause of missed appointments, introducing a telephone reminder system might be an affordable and effective first measure to address non-attendance. Factors associated with poverty and other social determinants of health also affect attendance and are more challenging to address.