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2.
Med Clin North Am ; 104(3): 525-538, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32312413

RESUMEN

Medical emergencies at the end of life require recognition of patients at risk, so that a comprehensive assessment and plan of care can be put in place. Frequently, the interventions depend on the patient's underlying prognosis, location of care, and goals of care. The mere presence of a medical emergency often rapidly changes an estimated prognosis. Education of the patient and family may help empower them to adequately handle many situations when clinicians are not available.


Asunto(s)
Urgencias Médicas/epidemiología , Cuidados Paliativos al Final de la Vida/normas , Planificación de Atención al Paciente/normas , Cuidado Terminal/métodos , Anciano , Anciano de 80 o más Años , Anticonvulsivantes/administración & dosificación , Anticonvulsivantes/uso terapéutico , Diagnóstico Diferencial , Hemorragia/etiología , Hemorragia/terapia , Humanos , Hipercalcemia/etiología , Persona de Mediana Edad , Neoplasias/complicaciones , Cuidados Paliativos/normas , Cuidados Paliativos/estadística & datos numéricos , Planificación de Atención al Paciente/tendencias , Pronóstico , Factores de Riesgo , Compresión de la Médula Espinal/etiología , Compresión de la Médula Espinal/terapia , Estado Epiléptico/tratamiento farmacológico , Estado Epiléptico/etiología , Síndrome de la Vena Cava Superior/etiología , Síndrome de la Vena Cava Superior/terapia
3.
Zhonghua Er Ke Za Zhi ; 58(4): 295-300, 2020 Apr 02.
Artículo en Chino | MEDLINE | ID: mdl-32234136

RESUMEN

Objective: To investigate the effectiveness of ketamine in the treatment of refractory status epilepticus (RSE) and super refractory status epilepticus (SRSE) in children. Methods: A retrospective study was conducted to collect and analyze the medical data of 18 children with RSE or SRSE who received ketamine in intensive care unit of Beijing Children's Hospital from January 2016 to December 2018. According to the different regimen of ketamine, all children were divided into the loading-maintenance group (7 cases) and the maintenance group (11 cases). According to the control of status epilepticus, the patients were divided into controlled group (11 cases) and non-responsive group (7 cases).Wilcoxon's rank sum test or Fisher's exact test were used to compare the effectiveness between groups. Results: There were 9 males and 9 females in the study group, aged 6.7 (4.5, 9.0) years. Seven cases had RSE and the remaining had SRSE. Four cases died during hospitalization. After the initiation of ketamine treatment, RSE and SRSE were controlled in 11 children. The duration of ketamine administration was 4 (2, 11) days. The dose was 2.2 (1.2, 5.3) mg/(kg·h) in all patients, and 2.4 (1.3, 6.0) mg/(kg·h), 2.0 (1.0, 4.0) mg/(kg · h) in the controlled and non-responsive group, respectively (Z=-0.272, P=0.791). The RSE or SRSE were terminated in all the 7 patients who received loading dose of ketamine, with the dose of 1.5 (0.3,1.6) mg/kg. In the 11 patients who only received maintenance treatment, 4 had the RSE and SRSE terminated, which showed a significantly lower effectiveness than in loading-maintenance group (7/7 vs. 4/11, P=0.01). Regarding the adverse reactions, saliva secretion increased in 8 children during the ketamine administration, otherwise unremarkable. Conclusion: Loading dose followed by maintenance of ketamine can control children's RSE and SRSE well, without significant adverse reactions.


Asunto(s)
Epilepsia Refractaria/tratamiento farmacológico , Ketamina/administración & dosificación , Estado Epiléptico/tratamiento farmacológico , Anticonvulsivantes , Niño , Preescolar , Femenino , Hospitalización , Humanos , Unidades de Cuidados Intensivos , Masculino , Estudios Retrospectivos
4.
Lancet ; 395(10225): 735-748, 2020 02 29.
Artículo en Inglés | MEDLINE | ID: mdl-32113502

RESUMEN

Globally, as populations age there will be challenges and opportunities to deliver optimal health care to senior citizens. Epilepsy, a condition characterised by spontaneous recurrent seizures, is common in older adults (aged >65 years) and yet has received comparatively little attention in this age group. In this Review, we evaluate the underlying causes of epilepsy in older people, explore difficulties in establishing a diagnosis of epilepsy in this population, discuss appropriate antiseizure medications, and evaluate potential surgical treatment options. We consider cognitive, psychological, and psychosocial comorbidities and the effect that epilepsy might have on an older person's broader social or care network in high-income versus middle-income and low-income countries. We emphasise the need for clinical trials to be more inclusive of older people with epilepsy to help inform therapeutic decision making and discuss whether measures to improve vascular risk factors might be an important strategy to reduce the probability of developing epilepsy.


Asunto(s)
Anticonvulsivantes/uso terapéutico , Epilepsia/terapia , Procedimientos Neuroquirúrgicos/métodos , Anciano , Enfermedad de Alzheimer/complicaciones , Enfermedades Autoinmunes del Sistema Nervioso/complicaciones , Neoplasias Encefálicas/complicaciones , Trastornos Cerebrovasculares/complicaciones , Toma de Decisiones Clínicas , Ensayos Clínicos como Asunto , Disfunción Cognitiva/epidemiología , Comorbilidad , Países Desarrollados , Países en Desarrollo , Epilepsia/diagnóstico , Epilepsia/epidemiología , Epilepsia/etiología , Humanos , Incidencia , Trastornos Mentales/epidemiología , Prevalencia , Estado Epiléptico/epidemiología , Muerte Súbita e Inesperada en la Epilepsia/epidemiología
5.
Lancet ; 395(10231): 1217-1224, 2020 04 11.
Artículo en Inglés | MEDLINE | ID: mdl-32203691

RESUMEN

BACKGROUND: Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups. METHODS: In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group (<18 years, 18-65 years, and >65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov, NCT01960075. FINDINGS: Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged <18 years), 186 adults (18-65 years), and 51 older adults (>65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41-62) of children, 44% (33-55) of adults, and 37% (19-59) of older adults; with fosphenytoin in 49% (38-61) of children, 46% (34-59) of adults, and 35% (17-59) of older adults; and with valproate in 52% (41-63) of children, 46% (34-58) of adults, and 47% (25-70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group. INTERPRETATION: Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus. FUNDING: National Institute of Neurological Disorders and Stroke, National Institutes of Health.


Asunto(s)
Anticonvulsivantes/administración & dosificación , Levetiracetam/administración & dosificación , Fenitoína/análogos & derivados , Estado Epiléptico/tratamiento farmacológico , Ácido Valproico/administración & dosificación , Adolescente , Adulto , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Anticonvulsivantes/efectos adversos , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Femenino , Humanos , Lactante , Levetiracetam/efectos adversos , Masculino , Persona de Mediana Edad , Fenitoína/administración & dosificación , Fenitoína/efectos adversos , Ácido Valproico/efectos adversos , Adulto Joven
6.
Medicine (Baltimore) ; 99(13): e19601, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32221081

RESUMEN

The aim of this study was to study the predisposing factors and prognosis of status epilepticus (SE) in patients with autoimmune encephalitis (AE).A total of 227 cases of AE were collected from the inpatient department of West China Hospital of Sichuan University from January 2010 to May 2018. All patients met the 2015 criteria for the diagnosis of AE. The binary logistic regression model was used to multivariate and retrospective chart analysis the predisposition factors for SE and its prognostic factors.Of the 227 patients with AE, 50 (22.03%) had SE during hospitalization, and 19 patients with SE had a poor prognosis (modified Rankin score MRS = 3-6), and 7 patients with no SE had a poor prognosis. In the logistic regression model, electroencephalograms (EEGs) abnormalities (P = .000) and head magnetic resonance imaging (MRI) abnormalities (P = .003) were associated with a predisposition to SE, while Glasgow scores <8 (P = .027), abnormal EEG (P = .046), delayed immunotherapy (P = .012), and SE duration at admission lasting >30 minutes (P = .023) were risk factors for a poor prognosis of SE.SE is a common complication in patients with AE. EEG and MRI abnormalities may be predisposing factors for SE. Glasgow scores <8 points, abnormal EEG, delayed immunotherapy, and SE duration lasting >30 minutes at admission are risk factors for a poor prognosis in patients with SE.


Asunto(s)
Encefalitis/epidemiología , Enfermedad de Hashimoto/epidemiología , Estado Epiléptico/epidemiología , Adolescente , Adulto , Anciano , China/epidemiología , Electroencefalografía , Encefalitis/mortalidad , Femenino , Enfermedad de Hashimoto/mortalidad , Humanos , Modelos Logísticos , Angiografía por Resonancia Magnética , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Estado Epiléptico/mortalidad , Adulto Joven
8.
AJR Am J Roentgenol ; 214(4): 907, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32045303

RESUMEN

OBJECTIVE. Myelography is a commonly used procedure to evaluate the spinal canal. However, the procedure is not without risk, chiefly risk of seizure after intrathecal administration of iodinated contrast material. CONCLUSION. The risk of seizure remains an important concern for radiologists, who should strongly consider practice parameter guidelines that address this risk.


Asunto(s)
Medios de Contraste/efectos adversos , Mielografía/efectos adversos , Estado Epiléptico/etiología , Estado Epiléptico/mortalidad , Humanos , Factores de Riesgo
13.
Fortschr Neurol Psychiatr ; 88(1): 52-63, 2020 Jan.
Artículo en Alemán | MEDLINE | ID: mdl-31986552

RESUMEN

Neuromonitoring by means of continuous EEG (cEEG) has been increasingly used in intensive care patients. Standardized EEG criteria can be used to reliably detect and distinguish nonconvulsive seizures or status epileptici as well as rhythmic and periodic ictal-interictal continuum EEG patterns. Likewise, cerebral ischemia can be detected early by means of cEEG, and sedation and therapy management can be monitored and controlled.


Asunto(s)
Cuidados Críticos/métodos , Electroencefalografía , Monitoreo Fisiológico/métodos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Diagnóstico Precoz , Humanos , Convulsiones/diagnóstico , Estado Epiléptico/diagnóstico , Estado Epiléptico/terapia
15.
Life Sci ; 240: 117072, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-31751584

RESUMEN

Deficits in cognitive functions are often observed in epileptic patients, particularly in temporal lobe epilepsy (TLE). Evidence suggests that this cognitive decline can be associated with the occurrence of focal brain lesions, especially on hippocampus and cortex regions. We previously demonstrated that the erythrinian alkaloids, (+)-erythravine and (+)-11α-hydroxy-erythravine, inhibit seizures evoked in rats by different chemoconvulsants. AIMS: The current study evaluated if these alkaloids would be acting in a neuroprotective way, reducing hippocampal sclerosis, and consequently, improving learning/memory performance. MAIN METHODS: Here we confirmed the anticonvulsant effect of both alkaloids by means of the pilocarpine seizure-induced model and also showed that they enhanced spatial learning of rats submitted to the Morris Water Maze test reverting the cognition deficit. Additionally, immunohistochemistry assays showed that neuronal death and glial activation were prevented by the alkaloids in the hippocampus CA1, CA3 and dentate gyrus regions at both hemispheres indistinctly 15 days after status epilepticus induction. KEY FINDINGS: Our results show, for the first-time, the improvement on memory/learning elicited by these erythrinian alkaloids. Furthermore, data presented herein explain, at least partially, the cellular mechanism of action of these alkaloids. Together, (+)-erythravine and (+)-11α-hydroxy-erythravine seem to be a promising protective strategy against TLE, comprising three main aspects: neuroprotection, control of epileptic seizures and cognitive improvement. SIGNIFICANCE: Moreover, our findings on neuroprotection corroborate the view that seizure frequency and severity, hippocampal lesions and memory deficits are interconnected events.


Asunto(s)
Alcaloides/uso terapéutico , Epilepsia/tratamiento farmacológico , Epilepsia/psicología , Compuestos Heterocíclicos de 4 o más Anillos/uso terapéutico , Trastornos de la Memoria/tratamiento farmacológico , Trastornos de la Memoria/psicología , Fármacos Neuroprotectores/uso terapéutico , Trastorno Específico de Aprendizaje/tratamiento farmacológico , Trastorno Específico de Aprendizaje/psicología , Animales , Convulsivantes , Epilepsia/inducido químicamente , Hipocampo/patología , Inmunohistoquímica , Masculino , Aprendizaje por Laberinto/efectos de los fármacos , Pilocarpina , Ratas , Ratas Wistar , Esclerosis/prevención & control , Estado Epiléptico/inducido químicamente , Estado Epiléptico/psicología
16.
Ann Neurol ; 87(1): 84-96, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31675128

RESUMEN

OBJECTIVE: Generalized convulsive status epilepticus is associated with high mortality. We tested whether α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor plasticity plays a role in sustaining seizures, seizure generalization, and mortality observed during focal onset status epilepticus. We also determined whether modified AMPA receptors generated during status epilepticus could be targeted with a drug. METHODS: Electrically induced status epilepticus was characterized by electroencephalogram and behavior in GluA1 knockout mice and in transgenic mice with selective knockdown of the GluA1 subunit in hippocampal principal neurons. Excitatory and inhibitory synaptic transmission in CA1 neurons was studied using patch clamp electrophysiology. The dose response of N,N,H,-trimethyl-5-([tricyclo(3.3.1.13,7)dec-1-ylmethyl]amino)-1-pentanaminiumbromide hydrobromide (IEM-1460), a calcium-permeable AMPA receptor antagonist, was determined. RESULTS: Global removal of the GluA1 subunit did not affect seizure susceptibility; however, it reduced susceptibility to status epilepticus. GluA1 subunit knockout also reduced mortality, severity, and duration of status epilepticus. Absence of the GluA1 subunit prevented enhancement of glutamatergic synaptic transmission associated with status epilepticus; however, γ-aminobutyric acidergic synaptic inhibition was compromised. Selective removal of the GluA1 subunit from hippocampal principal neurons also reduced mortality, severity, and duration of status epilepticus. IEM-1460 rapidly terminated status epilepticus in a dose-dependent manner. INTERPRETATION: AMPA receptor plasticity mediated by the GluA1 subunit plays a critical role in sustaining and amplifying seizure activity and contributes to mortality. Calcium-permeable AMPA receptors modified during status epilepticus can be inhibited to terminate status epilepticus. ANN NEUROL 2020;87:84-96.


Asunto(s)
Plasticidad Neuronal/fisiología , Receptores AMPA/fisiología , Estado Epiléptico/fisiopatología , Adamantano/análogos & derivados , Adamantano/farmacología , Amantadina/farmacología , Animales , Atropina/farmacología , Región CA1 Hipocampal/fisiología , Relación Dosis-Respuesta a Droga , Estimulación Eléctrica , Femenino , Técnicas de Silenciamiento del Gen , Hipocampo/fisiología , Masculino , Ratones , Ratones Noqueados , Receptores AMPA/antagonistas & inhibidores , Receptores AMPA/genética , Estado Epiléptico/mortalidad , Transmisión Sináptica/fisiología
17.
Zh Nevrol Psikhiatr Im S S Korsakova ; 119(10): 121-126, 2019.
Artículo en Ruso | MEDLINE | ID: mdl-31793553

RESUMEN

Continuous spike and waves during sleep (CSWS) may lead to different cognitive, motor and behavioral symptoms. CSWS is characterized by an electroencephalography (EEG) pattern of electrical status epilepticus during sleep (ESES). The article reviews the main criteria of ESES, localization of EEG-changes and main EEG-patterns. An analysis of abnormal neuroimaging findings in patients with ESES was performed. The main pathophysiologic theories of ESES pattern formation are reviewed. ESES diagnosis is usually based on rough visual assessment of the number of spikes and waves, but other methods of assessment are also utilized, including spike-wave index (SWI), which is widely used in clinical practice. SWI reflects the percentage of sleep covered with spikes and waves. Two different strategies of SWI calculation are used, but none of them is officially validated. Moreover, there is no consensus on the period of sleep to be used for the calculation of SWI. The article presents a detailed review of calculation and utilization of SWI. It is concluded that further research is needed to develop an optimal algorithm of SWI calculation.


Asunto(s)
Trastornos del Sueño-Vigilia , Estado Epiléptico , Electroencefalografía , Humanos , Sueño , Estado Epiléptico/terapia , Resultado del Tratamiento
18.
BMC Neurol ; 19(1): 307, 2019 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-31787084

RESUMEN

BACKGROUND: Status epilepticus (SE) is an emergency neurological disorder that affects quality of life and is associated with high mortality risk. Three scores have been developed to predict the risk of in-hospital death, but these scores are poor discrimination of mortality after discharge. This study aimed to develop and validate a simple risk score for long-term mortality in SE patients. METHODS: This retrospective cohort study was conducted using SE patient data collected from Thailand's Universal Coverage Scheme database between the fiscal years of 2005 and 2015 and followed-up to 2016. Patients who died in hospital or within 30 days after discharge were excluded. Data were divided at random into either a derivation or validation set. A proportional hazards model for the sub-distribution of competing risks was fitted with backward stepwise method. The coefficients from the model were used to develop a point-based scoring system. The discrimination ability of the model was evaluated using a time-dependent receiver operating characteristic (ROC) curve. RESULTS: A total of 20,792 SE patients (with ages ranging from the first day of life to 99 years at first admission) were randomly separated into two groups: 13,910 in the development group and 6882 in the validation group. A sub-distribution hazard model was used to determine nine predictors to be included in the final model, which was, in turn, used to develop the scoring system: age (0-19 points), male (two points), brain tumor (12 points), stroke (three points), cancer (11 points), diabetes (three points), chronic kidney disease (five points), pneumonia (five points), and urinary tract infection (four points). The possible total score ranged from zero to 64 and the cumulative incidence function was used to determine the probability of mortality associated with each total score within the first 10 years after the first admission. The area under the ROC curve (AUC) of the first to last time point ranged from 0.760 to 0.738. CONCLUSION: A nine-factor risk score for predicting 10-year mortality in SE patients was developed. Further studies should focus on external validity and including a range seizure types and duration of seizure as the predictors.


Asunto(s)
Hospitalización/estadística & datos numéricos , Alta del Paciente , Estado Epiléptico/mortalidad , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Calidad de Vida , Curva ROC , Estudios Retrospectivos , Factores de Riesgo , Tailandia , Adulto Joven
20.
BMC Neurol ; 19(1): 345, 2019 Dec 29.
Artículo en Inglés | MEDLINE | ID: mdl-31884946

RESUMEN

BACKGROUND: Hyperprolinemia type 2 (HPII) is a rare autosomal recessive disorder of the proline metabolism, that affects the ALDH4A1 gene. So far only four different pathogenic mutations are known. The manifestation is mostly in neonatal age, in early infancy or early childhood. CASE PRESENTATION: The 64-years female patient had a long history of abdominal pain, and episode of an acute neuritis. Ten years later she was admitted into the neurological intensive-care-unit with acute abdominal pain, multiple generalized epileptic seizures, a vertical gaze palsy accompanied by extensive lactic acidosis in serum 26.0 mmol/l (reference: 0.55-2.2 mmol/l) and CSF 12.01 mmol/l (reference: 1.12-2.47 mmol/l). Due to repeated epileptic seizures and secondary complications a long-term sedation with a ventilation therapy over 20 days was administered. A diagnostic work-up revealed up to 400-times increased prolin-level in urine CSF and blood. Furthermore, a low vitamin-B6 serum value was found, consistent with a HPII causing secondary pyridoxine deficiency and seizures. The ALDH4A1 gene sequencing confirmed two previously unknown compound heterozygous variants (ALDH4A1 gene (NM_003748.3) Intron 1: c.62 + 1G > A - heterozygous and ALDH4A1 gene (NM_003748.3) Exon 5 c.349G > C, p.(Asp117His) - heterozygous). Under high-dose vitamin-B6 therapy no further seizures occurred. CONCLUSION: We describe two novel ALDH4A1-variants in an adult patient with hyperprolinemia type II causing secondary pyridoxine deficiency and seizures. Severe and potentially life-threatening course of this treatable disease emphasizes the importance of diagnostic vigilance and thorough laboratory work-up including gene analysis even in cases with atypical late manifestation.


Asunto(s)
1-Pirrolina-5-Carboxilato Deshidrogenasa/deficiencia , Errores Innatos del Metabolismo de los Aminoácidos/genética , 1-Pirrolina-5-Carboxilato Deshidrogenasa/genética , Acidosis Láctica/etiología , Adulto , Errores Innatos del Metabolismo de los Aminoácidos/complicaciones , Femenino , Humanos , Mutación , Estado Epiléptico/etiología
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