Responses of people with epilepsy to the COVID-19 pandemic in the time of national lockdown.

The aim of our study was to gather information on how people with epilepsy (PwE) responded to the COVID-19 pandemic during the national lockdown. An online questionnaire was therefore offered to the visitors of the Croatian Association for Epilepsy's website. The 22-items questionnaire was designed to acquire information from adults with epilepsy living in Croatia on demographic data, cognitive, emotional and behavioral responses to the pandemic, and communication problems between patients and their neurologists during the lockdown. Perceived anxiety and fears were expressed with the Likert scale (1-5) and the results of specific fears added to make the Total Fear Score. Results: Out of 186 respondents in total, only 2.8% did not comply with the lockdown measures, and all of those respondents stated that they did not feel any anxiety related to COVID-19. A canceled neurologist examination during the lockdown was significantly associated with pandemic-related anxiety (2.9 ±â€¯1.28 vs. 2.3 ±â€¯1.19, U = 3039, p = 0.001) and fears (Total Fear Score 31.4 ±â€¯9.70 vs. 28.4 ±â€¯9.79, U = 3341, p = 0.036), and 87.4% of respondents expressed the wish to communicate with their neurologist, either by phone/video call (53.0%) or email (34.4%). Conclusion: We think the results of our survey show that the responses from PwE point to a social responsibility appropriate for the existing situation. During future pandemics, telemedicine could have an important role in tackling the fears and anxieties caused by the cancelation of examinations, which corresponds to the wishes expressed by the great majority of our respondents.

Epidemiology of Pharmacological Treatment of Multiple Sclerosis in Croatia.

Treatment of multiple sclerosis has been a dynamic field lately, with many new and emerging treatment options. In this study, we investigate the use of disease modifying therapies (DMTs) for multiple sclerosis in Croatia. The data on DMT use was provided by the Agency for Medicinal Products and Medical Devices of Croatia (HALMED). The data from 2005 to 2016 was available. Consumption of DMTs (in DDD/1000/day) has been increasing by 9% annually on average since 2005. In the same period, the annual cost for those drugs has been increasing by 14.6% annually on average. The consumption of IFN-beta 1-a has been increasing by a much steeper rate than IFN-beta 1-b. Until 2010 the consumption of glatiramer acetate has been negligible, with a steep increase between 2011 and 2014, and a steady rate of consumption since. Recently, several new DMTs became available, namely dimethyl fumarate, teriflunomide and fingolimod. Natalizumab became available after 2010, and its consumption has been growing steadily, but its consumption figures are exceeded by alemtuzumab. New DMTs are not as readily available in Croatia as they are in some countries. However, there is a continuous increase in the number of prescriptions, along with growing costs in pharmacological treatment of multiple sclerosis, and this can be expected to become even more pronounced in the following years, due to the abundance of new therapeutic options that are steadily becoming available.

Antithrombotic therapy in patients with non-traumatic intracerebral haemorrhage and atrial fibrillation: A retrospective study.

INTRODUCTION: The aim of the study was to determine the outcome, prescribed therapy, and localization of non-traumatic intracerebral haemorrhage in patients with atrial fibrillation. PATIENTS AND METHODS: This retrospective study enrolled patients with atrial fibrillation hospitalised for non-traumatic intracerebral haemorrhage from 2004 to 2013. We compared the patients according to previous antithrombotic therapy, demographics, previous CHADS2 score, comorbidities, the international normalised ration, localisation of intracerebral hamorrhage, stroke severity, prescribed antithrombotic therapy and outcome. RESULTS: A total of 85 patients were enrolled and assigned to an AT+ group (n = 49; 14 on aspirin, 35 on warfarin) and an AT- group (n = 36; without antithrombotic therapy prior to hospitalisation). The latter had a lower proportion of known atrial fibrillation (90% vs 47%, P < 0.001). The mean INR was 2.6 ± 1.5. The in-hospital mortality rates in both groups were high: 43% in AT+ group and 47% in AT- group. There were no significant differences in any of the predefined comparisons. CONCLUSION: Treating patients with intracerebral haemorrhage and atrial fibrillation is challenging due to higher mortality rates and issues regarding the use of antithrombotic treatment in stroke prevention. Based on our data, prior antithrombotic therapy was not associated with increased in-hospital mortality rates or poorer functional outcome at hospital discharge in comparison with no prior antithrombotic therapy.

Labels and epilepsy - An online survey of patients and those close to them.

Publications on the topic of appropriate labels for someone with diagnosed epilepsy have so far almost exclusively consisted of views of professionals in this field. We conducted an online study of patients treated for epilepsy and persons close to them with the aim of identifying which label they prefer, whether they oppose the term "epileptic", and which characteristics are related with their preferences. In total, 328 responses were analyzed. Subjects mostly favored "person-first" terminology ("person having epilepsy" and "person with epilepsy"), and 53.9% disapproved of the term "epileptic". Parents of patients are more likely than patients themselves to favor the label "person having epilepsy" and to disapprove of the label "epileptic". These results can help with shaping future terminology recommendations.

Women with epilepsy in childbearing age: Pregnancy-related knowledge, information sources, and antiepileptic drugs.

Pregnancy-related issues in epilepsy (PRIE) are essential for management of epilepsy in women. We conducted a study among women with epilepsy (WWE) aged 15-45years about their knowledge, sources, and needs for information regarding PRIE, which included their current antiepileptic drugs (AEDs) usage. Women with epilepsy, visitors of Croatian Association for Epilepsy webpage, were offered an online questionnaire, and 200 responses were analyzed. The mean number of correct answers about PRIE was 3.5 out of 5. Main predictors of knowledge on PRIE were a prior consultation with a neurologist and higher usage of books/brochures. A prior neurologist consultation on PRIE was stated by 45% of subjects. As the preferred future mode of being informed on PRIE, majority of women (61%) chooses their neurologist, 22% written materials distributed by a neurologist, and only 13% Internet. Levetiracetam was the most commonly used AED (34.5%). Valproate was used by 26%, and of those 59% stated no previous consultation on PRIE with their neurologist. In summary, we believe our study shows that knowledge of PRIE among WWE in their childbearing age is unsatisfactory, as are the neurologist consultation rates about PRIE. Our results demonstrate that, despite modern technologies, educational activities should be based on neurologist consultations and providing the patients with appropriate written materials. This is especially true for the relatively large proportion of women still taking valproate.

Impact of troponin I on outcome of ischemic stroke patients.

INTRODUCTION: Stroke is one of the leading causes of morbidity and mortality. Cardiac troponins have been found to be increased in other conditions apart from the cardiac diseases, such as stroke. The aim of the study was to assess the correlation between elevated troponin I levels and stroke outcome. METHODS: This retrospective study included 198 acute ischemic stroke patients in whom troponin I levels have been obtained at admission. Exclusion criteria were concomitant acute coronary syndrome, congestive heart failure, pulmonary embolism, renal failure, rhabdomyolysis and septic conditions. RESULTS: There was a statistically significant difference in the proportion of deaths during hospitalization (p = 0.041) and modified Rankin Scale scores (p = 0.016) between the group of patients with elevated troponin I levels and the control group. Prior ischemic strokes were more common in the group with elevated troponin I levels (p = 0.032). No other differences were observed. CONCLUSIONS: Our study showed that patients with elevated initial troponin I levels are associated with unfavorable outcome or death. Stroke may be associated with mild elevation of troponin levels, contrary to higher levels which are usually related to other conditions.

Online epilepsy counseling in Croatia: What do users want to know?

PURPOSE: The purpose of this study is to better understand which specific epilepsy-related issues are cause for seeking out professional advice online. METHOD: An online epilepsy counseling service introduced by the Croatian Epilepsy Association allows users to anonymously submit questions related to epilepsy via e-mail or online contact form, which are later answered by an epilepsy professional. The questions were classified both by inquirers and by content. Inquirers were classified as patients, patient's parents, family members, partners, and friends of patients with epilepsy. In terms of content, questions were divided into three groups: medical, socially-oriented, and unclassifiable questions. RESULTS: In sum, 355 e-mails, which included 513 questions, were analyzed. The vast majority of inquirers were patients themselves (48%) and parents of patients (28%). While 76% of questions concerned the medical aspects of epilepsy, there was as well significant interest in administrative and practical issues associated with the diagnosis of epilepsy. Among medical questions, the most popular concerned prognosis (15%) and second opinions (14%); among socially-oriented questions, inquirers were primarily interested in matters associated with their profession (28%). As well, the parents of patients were more likely to question an epilepsy diagnosis than the patients themselves (p<0.001). CONCLUSION: According to the results of this study, it is clear that epilepsy professionals should invest more time in discussing with patients the topics which interest them the most, as well as refer them to other professionals that can help them with non-medical epilepsy-related issues, and advise them on reliable Internet sources.

Epidemiological Characteristics of Dementia Treatment in Croatia.

BACKGROUND: In spite of the increase in the number of patients with dementia in countries with older population, basic epidemiologic data are still scarce. The objective of this paper is to investigate pharmacoepidemiological characteristics of treatment of dementia in Croatia, and to present them in the context of certain epidemiological characteristics that illustrate the growing pressure this disease exerts on the healthcare system. SUBJECTS AND METHODS: Data on medication utilization were taken from Croatian Health Insurance Fund (HZZO) and Agency for Medicinal Products and Medical Devices of Croatia (HALMED). Data on the number of hospital stays were supplied by Croatian Institute of Public Health (HZJZ). Internal data on the number of outpatient examinations from the Clinical hospital "Sveti Duh" were used as well. RESULTS: In the observed period (2012-2014), 4568 patients were treated with anti-dementia medications, of which 1275 (32%) with donepezil, and 2753 (68%) with memantine. According to HALMED, the utilization of those medications is constantly increasing, and has increased manifold from 2005 to 2014. The estimate of the proportion of treated patients with dementia aged 60 years and over is around 9.2%. The number of dementia-related hospital stays is also increasing, and has increased by 9.6% in the last 5-year period, compared to the preceding 5-year period. The number of outpatient examinations in Clinical Hospital "Sveti Duh" grew from 351 in 2007 to 1151 in 2015 (January 1(st) - October 26(th)). CONCLUSION: The strain this condition exerts on the healthcare system is increasing yearly. In spite of the large increase in the medication utilization over the previous years, the proportion of treated patients is still small, and further increase in their use is to be expected. It is necessary to monitor this in the years ahead.

Carotid Body Tumor as a Cause of Stroke.

We herein report a case of a 78-year-old woman who was admitted to our hospital due to a stroke with left-sided hemiparesis. Ultrasound of the carotid arteries showed a carotid body tumor on the bifurcation of the right common carotid artery, which was subsequently confirmed by a further neuroradiological investigation. Magnetic resonance imaging of the head confirmed an acute ischemic lesion located in the right periventricular region. The carotid body tumor (CBT) was surgically removed and confirmed on histopathology. Our case reveals the role of carotid ultrasound in the diagnosis of a CBT, which may be a potential cause of stroke.

Transient Obstructive Hydrocephalus in Patients with Intracerebral Hemorrhage: Report of Two Cases

Obstructive hydrocephalus is a relatively common complication of intraventricular hemorrhage resulting in high morbidity and mortality. We report two cases of transient obstructive hydrocephalus caused by obstruction of mesencephalic duct in patients that presented with altered consciousness which resolved spontaneously in a few hours. In very rare cases, obstructive hydrocephalus due to intraventricular hemorrhage may be transient and does not need neurosurgical or invasive procedures for lowering raised intracranial pressure, which otherwise are currently preferred treatment options.

How does the label "epileptic" influence attitudes toward epilepsy?

PURPOSE: The purpose of our research was to study the possible differences in attitudes toward epilepsy based on the label used: "person"/"child with epilepsy" vs. "epileptic"/"epileptic child". METHODS: Two randomly assigned groups of college-preparatory high school students were questioned using anonymous questionnaires about their demographics, knowledge on epilepsy and attitudes toward epilepsy. Attitudes were measured using three general attitude questions and a six item modified version of the Bogardus social distance scale. Two versions of the questionnaire were identical except for the term "person"/"child with epilepsy" in first group (group A) being replaced with the term "epileptic"/"epileptic child" in the second one (group B). Mann-Whitney test was used to compare attitude scores between groups. RESULTS: There were 425 subjects in total, 208 in group A and 217 in group B. The results on the Social distance scale indicated significantly more negative attitudes in group B (p=0.008). Subjects in group B also expressed more negative attitudes than those in group A when asked about sharing a room with a person with epilepsy (p=0.005) and marrying a person with epilepsy, either themselves (p=0.033) or when the person getting married is someone close to them (p=0.024). CONCLUSION: In conclusion, using term "epileptic" can evoke more negative attitudes toward a person with epilepsy and this seems to be especially true for more intimate life domains (cohabitation or marriage), while in more impersonal domains (such as communicating and working with a person with epilepsy), no significant influence of the label on attitudes was proven.

Asymptomatic dissecting intimal lesions of common carotid arteries after carotid endarterectomy.

PURPOSE: Carotid endarterectomy is a standard treatment for symptomatic high-degree internal carotid artery stenosis. The aim of this article is to present possible intimal lesions after carotid endarterectomy. These lesions could be manifested as intimal flaps, intimal steps or dissections with or without occlusion or stenosis of the artery. METHODS: The evaluation of the frequency and characteristics of the asymptomatic dissecting intimal lesions of the common carotid arteries was performed in a sample of 100 patients who underwent endarterectomy for symptomatic high-grade stenosis of the internal carotid artery. RESULTS: We found five patients with asymptomatic dissecting intimal lesions of the common carotid arteries. CONCLUSION: The most common causes of these intimal lesions were shunting and prolongation of the clamping time. Routine carotid ultrasound follow-up exams are necessary because of the potential need for a change in the antithrombotic therapy or due to a need to perform an endovascular treatment.

Gorlin-Goltz syndrome and stroke: a case report.

We report on the case of a 32-years old male patient who was previously diagnosed with Gorlin-Goltz syndrome. The patient presented with sudden-onset right-sided hemiparesis, supranuclear facioparesis, and motor aphasia. He was treated with thrombolytic therapy, which successfully alleviated the symptoms. Subsequent radiologic work-up revealed anomalies in the vertebral arteries, a bifid rib, an ischemic lesion in the supply area of the left middle cerebral artery, and falx calcifications. Laboratory tests showed a 4G/4G polymorphism of the plasminogen activator inhibitor 1 (PAI-1) gene whose correlation with stroke is discussed in the article.

Bilateral subclavian steal syndrome in an intensive care unit. A case report.

We report the case of a 56-year-old man who presented with arterial hypotension, lightheadedness, vomiting, a sense of tingling in his right arm, and a right-beating horizontal nystagmus. He was initially admitted to the Intensive care unit and treated with standard vasopressor agents. A neurosonological examination showed the steal phenomenon on both vertebral arteries; the neuroradiological examination revealed occlusion of the left subclavian artery and subtotal stenosis of the innominate artery. Percutaneous transluminal angioplasty was performed. Our case demonstrates how bilateral subclavian steal syndrome should be taken into account in the case of a seemingly hypotensive patient unresponsive to standard therapy.

An aberrant subclavian artery exhibiting the partial steal phenomenon in a patient with VACTERL association.

We herein report the case of a 22-year-old Caucasian man with known vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, cardiac defects, renal and limb anomalies (VACTERL) association who presented with a headache and vertigo following the sudden and temporary loss of consciousness while attending a concert four days before admission to the hospital. On a physical examination, the following findings were found: a low body height, low-set ears, thoracic scoliosis and a mild holosystolic heart murmur. A neurosonological examination revealed a partial subclavian steal phenomenon. CT angiography of the neck vessels and aortic arch confirmed an anomalous right subclavian artery -known as the lusorian artery. Further studies are warranted in patients with VACTERL in order to identify possible links between the prevalence of an aberrant right subclavian artery (lusorian artery) and possible congenital subclavian steal syndrome or dysphagia lusoria. In addition, duplex ultrasound of the carotid and vertebral arteries may be performed as part of screening examinations in patients with congenital syndromes.

General recommendations for the management of aneurysmal subarachnoid hemorrhage.

Subarachnoid hemorrhage is a neurologic emergency and a detrimental cerebrovascular event with a high rate of death and complications. Recommendations have been developed and based on literature search, evaluation of the results of large international clinical trials, collective experience of the authors, and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. The aim of these guidelines is to provide current and comprehensive recommendations and to assist physicians in making appropriate decisions in the management of subarachnoid hemorrhage. Evidence based information on the epidemiology, risk factors and prognosis, as well as recommendations on diagnostic work up, monitoring and management are provided, with regard to treatment possibilities in Croatia.

Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage.

These are evidence based guidelines for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage, developed and endorsed by the Croatian Society of Neurovascular Disorders, Croatian Society of Neurology including Section for Neurocritical Care, Croatian Neurosurgical Society, Croatian Society for Difficult Airway Management and Croatian Medical Association. They consist of recommendations for best monitoring, medical treatment and interventions based on the literature, evaluation of the results of large international clinical trials, and collective experience of the authors.

Factors associated with perceived stigma of epilepsy in Croatia: a study using the revised Epilepsy Stigma Scale.

PURPOSE: It is believed that a large number of factors influence feelings of stigma, but their relative contribution is not yet entirely clear. Most studies to date were conducted using the Epilepsy Stigma Scale (ESS); only one used a revised version of the ESS (rESS). The following study aims to determine factors contributing to epilepsy stigma in outpatients with chronic epilepsy in Croatia, and to analyze some psychometric properties of the Croatian translation of the rESS. METHODS: Alongside standard testing for validity of the scale, a simulation model of the original ESS (smESS) was created. This model, which does not include a grading Likert 0-3 scale, was compared with the rESS. RESULTS: In total, 159 out of 298 subjects (53%) reported feeling stigmatised, with 136 (45%) mild to moderately and 23 (8%) highly. Internal consistency of the Croatian translation of the rESS was 0.887. Feelings of stigma were significantly associated with age ≤ 50 years, younger age of epilepsy onset, more than 50 seizures to date, generalized tonic-clonic seizures, and a shorter seizure-free period. Multiple stepwise regression showed number of seizures to date as a significant variable (Beta=0.246). By adapting data into the smESS significant associations with younger age and age of epilepsy onset were lost. Internal consistency of the smESS was 0.849. CONCLUSIONS: The Croatian translation of the rESS has been proved to be a suitable instrument for diagnosing epilepsy stigma. The results of our model point to the possibility that the rESS might be more sensitive than the original ESS.

[Guidelines for diagnosis, therapy and follow up of Anderson-Fabry disease]. / Smjernice za dijagnostiku, lijecenje i pracenje Anderson-Fabryjeve bolesti.

Fabry disease (Anderson-Fabry disease) is one of the most common lysosomal storage diseases (after Gaucher disease) caused by deficient activity of the α-galactosidase A (α-Gal A) enzyme, which leads to progressive accumulation of globotriaosylceramide in various cells, predominantly in endothelium and vascular smooth muscles, with multisystem clinical manifestations. Estimates of the incidence range from one per 40,000 to 60,000 in males, and 1:117,000 in the general population. Pain is usually the first symptom and is present in 60%-80% of affected children, as well as gastrointestinal disturbances, ophthalmologic abnormalities and hearing loss. Renal failure, hypertrophic cardiomyopathy, or stroke as the presenting symptom may also be found even as isolated symptoms of the disease. Life expectancy is reduced by approximately 20 years in males and 10-15 years in females, therefore enzyme replacement therapy should be introduced in patients of any age and either sex, who meet treatment criteria for Anderson-Fabry disease.

Acute oxcarbazepine-induced hepatotoxicity in a patient susceptible to developing drug-induced liver injury.

Oxcarbazepine (OXC) is generally accepted as a drug without risk of severe drug-induced hepatotoxicity, but according to recently reported pharmacovigilance data this statement has been challenged. However, in the literature there have been no reports of acute OXC-induced hepatotoxicity without systemic manifestations of Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome. We present a female with seizures one month after delivery who had borderline elevated liver enzymes prior to the initiation of OXC treatment. Two weeks after introducing OXC, highly elevated liver enzymes were found. After discontinuation of OXC the enzymes continued to rise for another week, and afterward gradually decreased. The causal relationship with OXC intake was determined to be highly probable. Two years later, the transitory elevation of liver enzymes was observed during the treatment of acute tonsilopharingitis with amoxicillin + clavulanic acid. The repeated elevation of liver enzymes related to use of different drugs might indicate patients susceptibility for drug induced liver injuries. We suggest that monitoring of liver function tests would be clinically rational for early detection of acute OXC-induced liver hepatotoxicity in the patients with clinical and/or laboratory features which might be interpreted as possible risk factors of the increased susceptibility to drug induced liver injuries.