RESUMO
OBJECTIVE: To assess whether access to smartphone video capture of infantile spasms at initial presentation is associated with improved time to diagnosis and treatment. METHODS: We conducted a collaborative retrospective cohort study of 80 consecutive infants with confirmed infantile epileptic spasms syndrome initially presenting from 2015 to 2021 at 2 US pediatric centers. Statistical methods used included Mann-Whitney U test to assess the difference in lead times to electroencephalogram (EEG), diagnosis, and treatment between groups with and without video capture. A χ2 analysis was used to assess differences in demographics, clinical characteristics, and treatment outcomes between groups. Multivariate regression analysis was used to account for etiology types and infantile spasms capture on EEG. RESULTS: Patients with smartphone video infantile spasms capture initially presented a median of 9 days earlier (P = .02), had their first EEG 16 days earlier (P = .007), and were diagnosed and started treatment 17 days earlier (P = .006 and P = .008, respectively) compared with the nonvideo group. The video group had a 25% greater response to initial standard treatment (P = .02) and a 21% greater freedom from infantile spasms at long-term follow-up (P = .03), although this long-term outcome lost statistical significance after adjustment for etiology type (P = .07) and EEG capture of infantile spasms (P = .059). CONCLUSION: Our findings suggest a benefit of smartphone video capture of infantile spasms in reduced time to diagnosis and initial standard treatment, which are associated with improved treatment response rates. Substantial differences in lead times and treatment response highlight the clinical importance of pediatricians recommending caregivers to obtain smartphone video of events concerning for infantile spasms.
Assuntos
Espasmos Infantis , Lactente , Criança , Humanos , Espasmos Infantis/diagnóstico , Espasmos Infantis/terapia , Estudos Retrospectivos , Smartphone , Resultado do Tratamento , Eletroencefalografia , Espasmo/complicações , Espasmo/tratamento farmacológico , Anticonvulsivantes/uso terapêuticoRESUMO
OBJECTIVE: Evaluate the seizure-reduction response and safety of mesial temporal lobe (MTL) brain-responsive stimulation in adults with medically intractable partial-onset seizures of mesial temporal lobe origin. METHODS: Subjects with mesial temporal lobe epilepsy (MTLE) were identified from prospective clinical trials of a brain-responsive neurostimulator (RNS System, NeuroPace). The seizure reduction over years 2-6 postimplantation was calculated by assessing the seizure frequency compared to a preimplantation baseline. Safety was assessed based on reported adverse events. RESULTS: There were 111 subjects with MTLE; 72% of subjects had bilateral MTL onsets and 28% had unilateral onsets. Subjects had one to four leads placed; only two leads could be connected to the device. Seventy-six subjects had depth leads only, 29 had both depth and strip leads, and 6 had only strip leads. The mean follow-up was 6.1 ± (standard deviation) 2.2 years. The median percent seizure reduction was 70% (last observation carried forward). Twenty-nine percent of subjects experienced at least one seizure-free period of 6 months or longer, and 15% experienced at least one seizure-free period of 1 year or longer. There was no difference in seizure reduction in subjects with and without mesial temporal sclerosis (MTS), bilateral MTL onsets, prior resection, prior intracranial monitoring, and prior vagus nerve stimulation. In addition, seizure reduction was not dependent on the location of depth leads relative to the hippocampus. The most frequent serious device-related adverse event was soft tissue implant-site infection (overall rate, including events categorized as device-related, uncertain, or not device-related: 0.03 per implant year, which is not greater than with other neurostimulation devices). SIGNIFICANCE: Brain-responsive stimulation represents a safe and effective treatment option for patients with medically intractable epilepsy, including patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior MTL resection.
Assuntos
Encéfalo/fisiopatologia , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/terapia , Terapia por Estimulação Elétrica/métodos , Eletroencefalografia , Epilepsias Parciais/fisiopatologia , Epilepsias Parciais/terapia , Epilepsia do Lobo Temporal/fisiopatologia , Epilepsia do Lobo Temporal/terapia , Adolescente , Adulto , Dominância Cerebral/fisiologia , Eletrodos Implantados , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Assistência de Longa Duração , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
OBJECTIVE: Evaluate the seizure-reduction response and safety of brain-responsive stimulation in adults with medically intractable partial-onset seizures of neocortical origin. METHODS: Patients with partial seizures of neocortical origin were identified from prospective clinical trials of a brain-responsive neurostimulator (RNS System, NeuroPace). The seizure reduction over years 2-6 postimplantation was calculated by assessing the seizure frequency compared to a preimplantation baseline. Safety was assessed based on reported adverse events. Additional analyses considered safety and seizure reduction according to lobe and functional area (e.g., eloquent cortex) of seizure onset. RESULTS: There were 126 patients with seizures of neocortical onset. The average follow-up was 6.1 implant years. The median percent seizure reduction was 70% in patients with frontal and parietal seizure onsets, 58% in those with temporal neocortical onsets, and 51% in those with multilobar onsets (last observation carried forward [LOCF] analysis). Twenty-six percent of patients experienced at least one seizure-free period of 6 months or longer and 14% experienced at least one seizure-free period of 1 year or longer. Patients with lesions on magnetic resonance imaging (MRI; 77% reduction, LOCF) and those with normal MRI findings (45% reduction, LOCF) benefitted, although the treatment response was more robust in patients with an MRI lesion (p = 0.02, generalized estimating equation [GEE]). There were no differences in the seizure reduction in patients with and without prior epilepsy surgery or vagus nerve stimulation. Stimulation parameters used for treatment did not cause acute or chronic neurologic deficits, even in eloquent cortical areas. The rates of infection (0.017 per patient implant year) and perioperative hemorrhage (0.8%) were not greater than with other neurostimulation devices. SIGNIFICANCE: Brain-responsive stimulation represents a safe and effective treatment option for patients with medically intractable epilepsy, including adults with seizures of neocortical onset, and those with onsets from eloquent cortex.
Assuntos
Córtex Cerebral/fisiopatologia , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/fisiopatologia , Epilepsia Resistente a Medicamentos/terapia , Terapia por Estimulação Elétrica/métodos , Eletroencefalografia , Neocórtex/fisiopatologia , Adolescente , Adulto , Mapeamento Encefálico , Estimulação Encefálica Profunda/instrumentação , Terapia por Estimulação Elétrica/instrumentação , Eletrodos Implantados , Epilepsias Parciais/fisiopatologia , Epilepsias Parciais/terapia , Epilepsia Parcial Complexa/fisiopatologia , Epilepsia Parcial Complexa/terapia , Epilepsia Motora Parcial/fisiopatologia , Epilepsia Motora Parcial/terapia , Epilepsia Tônico-Clônica/fisiopatologia , Epilepsia Tônico-Clônica/terapia , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
AIM: The aim of this study was to determine the relationship between parent and child Full-scale IQ (FSIQ) in children with epilepsy and in typically developing comparison children and to examine parent-child IQ differences by epilepsy characteristics. METHOD: The study participants were 97 children (50 males, 47 females; age range 8-18y; mean age 12y 3mo, SD 3y1mo) with recent-onset epilepsy including idiopathic generalized (n=43) and idiopathic localization-related epilepsies (n=54); 69 healthy comparison children (38 females, 31 males; age range 8-18y; mean age 12y 8mo, SD 3y 2mo), and one biological parent per child. All participants were administered the Wechsler Abbreviated Scale of Intelligence (WASI). FSIQ was compared in children with epilepsy and typically developing children; FSIQ was compared in the parents of typically developing children and the parents of participants with epilepsy; parent-child FSIQ differences were compared between the groups. RESULTS: FSIQ was lower in children with epilepsy than in comparison children (p<0.001). FSIQ of parents of children with epilepsy did not differ from the FSIQ of the parents of typically developing children. Children with epilepsy had significantly lower FSIQ than their parents (p<0.001), whereas comparison children did not. The parent-child IQ difference was significantly higher in the group with epilepsy than the comparison group (p=0.043). Epilepsy characteristics were not related to parent-child IQ difference. INTERPRETATION: Parent-child IQ difference appears to be a marker of epilepsy impact independent of familial IQ, epilepsy syndrome, and clinical seizure features. This marker is evident early in the course of idiopathic epilepsies and can be tracked over time.
Assuntos
Epilepsia/fisiopatologia , Inteligência/fisiologia , Adolescente , Adulto , Biomarcadores , Estudos de Casos e Controles , Criança , Epilepsias Parciais/fisiopatologia , Feminino , Humanos , Masculino , Pais/psicologia , Escalas de WechslerRESUMO
BACKGROUND: Epilepsies with encephalopathy are important to promptly and thoroughly evaluate because of their associated refractory nature and potential for neurologic regression. METHODS: The results of epilepsy gene panel testing were obtained for 109 pediatric patients at Nemours Children's Center in Jacksonville, Florida, from 04/2019 to 02/2021. Results were obtained from Invitae TM via the offered epilepsy gene panel test and Behind the Seizure program. The EEGs for each patient were independently analyzed and categorized based on the presence or absence of features consistent with an epileptogenic encephalopathy. RESULTS: EEG characterization and identification of patients with epileptogenic encephalopathy in our study was helpful in identifying patients, with an 80% yield on epilepsy gene panel testing. CONCLUSIONS: EEG characterization can be incorporated into the evaluation of patients with epilepsy in order to optimize the selection of patients who are likely to benefit from an epilepsy gene panel test.
Assuntos
Encefalopatias , Epilepsia , Criança , Humanos , Epilepsia/diagnóstico , Epilepsia/genética , Eletroencefalografia/métodos , ConvulsõesRESUMO
Challenges facing children with epilepsy are understanding the neurobiology of pharmacoresistance of epileptic encephalopathies and the development of effective surgical treatment options for those with "non-lesional" epilepsy. Although, understanding the genetics of childhood epilepsy has advanced, an effective treatment intervention has not occurred. Recently, understanding the neurobiology of hamartin and tuberin in the development of epilepsy and cognitive impairment associated with tuberous sclerosis complex allowed the development of sirolimus and everolimus to be used in human clinical trials. In spite of these breakthroughs a large number of children are likely to be outside the scope of interventional therapies. For such patients the burden of seizures is onerous and psycho-social consequences debilitating. Surgical resective options are often limited by the lack of a well defined epileptic lesion. Co-registered synthesis of advanced functional, structural and electrographic seizure onset allows identification of a focus in patients thought to have "non-lesional" epilepsy. Developments of a Pipeline for prospective data sharing are likely to increase understanding and validation of the epileptogenic zone and offer the hope of seizure freedom. Two outstanding young investigators provide a review of their exciting research and its implications in pediatric epilepsy.
Assuntos
Transtornos Cognitivos/complicações , Biologia Computacional , Epilepsia/patologia , Esclerose Tuberosa/complicações , Criança , Transtornos Cognitivos/patologia , Transtornos Cognitivos/fisiopatologia , Epilepsia/tratamento farmacológico , Epilepsia/metabolismo , Humanos , Esclerose Tuberosa/patologia , Esclerose Tuberosa/fisiopatologia , Proteína 1 do Complexo Esclerose Tuberosa , Proteína 2 do Complexo Esclerose Tuberosa , Proteínas Supressoras de Tumor/metabolismoRESUMO
BACKGROUND: A large number of patients have epilepsy that is intractable and adversely affects a child's lifelong experience with addition societal burden that is disabling and expensive. The last two decades have seen a major explosion of new antiseizure medication options. Despite these advances, children with epilepsy continue to have intractable seizures. An option that has been long available but little used is epilepsy surgery to control intractable epilepsy. METHODS: This article is a review of the literature as well as published opinions. RESULTS: Epilepsy surgery in pediatrics is an underused modality to effectively treat children with epilepsy. Adverse effects of medication should be weighed against risks of surgery as well as risks of nonefficacy. CONCLUSIONS: We discuss an approach to selecting the appropriate pediatric patient for consideration, a detailed evaluation including necessary evaluation, and the creation of an algorithm to approach patients with both generalized and focal epilepsy. We then discuss surgical options available including outcome data. New modalities are also addressed including high-frequency ultrasound and co-registration techniques including magnetic resonance imaging-guided laser therapy.
Assuntos
Epilepsia Resistente a Medicamentos/cirurgia , Epilepsias Parciais/cirurgia , Epilepsia Generalizada/cirurgia , Procedimentos Neurocirúrgicos , Criança , Congressos como Assunto , Epilepsia Resistente a Medicamentos/diagnóstico , Epilepsias Parciais/diagnóstico , Epilepsia Generalizada/diagnóstico , Humanos , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas , Procedimentos Neurocirúrgicos/tendênciasRESUMO
PURPOSE: Thalamofrontal abnormalities have been identified in chronic primary generalized epilepsy, specifically in juvenile myoclonic epilepsy (JME). These regions also underlie executive functioning, although their relationship has yet to be examined in JME. This study examined the relationship between thalamic and frontal volumes and executive function in recent-onset JME compared to healthy control subjects and recent-onset benign childhood epilepsy with centrotemporal spikes (BCECTS), a syndrome not typically associated with thalamocortical or executive dysfunction. METHODS: Twenty children with recent-onset JME were compared to 51 healthy controls and 12 children with BCECTS using quantitative magnetic resonance imaging (MRI) and measures of executive abilities. Quantitative thalamic and frontal volumes were obtained through semi-automated software. Subtests from the Delis-Kaplan Executive Function System (D-KEFS) and the Behavior Rating Inventory of Executive Function (BRIEF) were used to measure executive function. RESULTS: Executive functions were impaired in JME subjects compared to control and BCECTS subjects. Subjects with JME had significantly smaller thalamic volumes and more frontal cerebrospinal fluid (CSF) than control and BCECTS subjects. Thalamic and frontal volumes were significantly related to executive functioning in the JME group, but not in the other two groups. DISCUSSION: Children with JME have significant executive dysfunction associated with significantly smaller thalami and more frontal CSF. Children with recent-onset BCECTS do not display the same pattern. Frontal and thalamic volumes appear to mediate the relationship between executive functioning and brain structure in JME.
Assuntos
Transtornos Cognitivos/etiologia , Lobo Frontal/patologia , Epilepsia Mioclônica Juvenil/complicações , Epilepsia Mioclônica Juvenil/patologia , Resolução de Problemas/fisiologia , Tálamo/patologia , Adolescente , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Análise Multivariada , Vias Neurais/patologia , Testes Neuropsicológicos , Análise de RegressãoRESUMO
Misinterpretations of the EEG can result in erroneous diagnosis of epilepsy, causing considerable family anxiety, over protectiveness of children, and delays in normal development and developmental exploration. The burden of a chronic disease can result in expensive and unnecessary medical treatment. The misdiagnosis of epilepsy has been well documented in adults, but misdiagnosis in normal children can have a long-lasting impact on their health. Furthermore, the EEG has a wider range of morphology and hence a greater opportunity for the missed diagnosis of epilepsy. Lack of familiarity of normal sleep patterns and age-related changes from the premature neonate to the young child make children particularly susceptible to misdiagnosis of epilepsy.
Assuntos
Eletroencefalografia/métodos , Epilepsia/diagnóstico , Pediatria , Adolescente , Adulto , Criança , Pré-Escolar , Erros de Diagnóstico , Feminino , Humanos , Recém-Nascido , MasculinoRESUMO
OBJECTIVE: Bone mineral density (BMD) is reduced in epilepsy and may underlie the observed increased fracture rate. Non-ambulatory patients have reduced BMD, although, it is not clear if normally weight bearing ambulatory patients are similarly vulnerable. DESIGN: Cross-sectional study examining age- and gender-specific z-score total bone mineral density (z-BMD) in 116 normally ambulatory children with epilepsy between ages 6 and 18 years (79 idiopathic epilepsy and 37 symptomatic epilepsy) were compared to 36 healthy controls. RESULTS: Both idiopathic and symptomatic epilepsies were associated with lower z-BMD (0.38+/-1 and 0.17+/-1, respectively) compared to controls (0.52+/-0.76). For both groups patients with generalized seizures had lower z-BMD than those with partial seizures. Symptomatic generalized epilepsy was associated with the lowest z-BMD (-0.15+/-1.1) compared to controls (p < 0.05). Increasing duration of symptomatic epilepsy, but not idiopathic epilepsy, was associated with lower z-BMD (correlation coefficient = 0.1; p < 0.01). CONCLUSIONS: Both idiopathic and symptomatic epilepsy are associated with reduced BMD. Those with symptomatic epilepsy, particularly symptomatic generalized epilepsy, had the greatest reduction in BMD despite normal weight bearing and ambulation. These data suggests that BMD is reduced in epilepsy beyond what can be explained by lack of ambulation and may underlie the vulnerability to fractures.
Assuntos
Osso e Ossos/patologia , Epilepsia/patologia , Adolescente , Densidade Óssea , Criança , Desenvolvimento Infantil , Estudos Transversais , Epilepsia/classificação , Feminino , Humanos , Masculino , Estatísticas não ParamétricasRESUMO
Non-adherence to epilepsy medications can interfere with treatment and may adversely affect clinical outcomes, although few studies have examined this relationship. This study assessed barriers and drivers to adherence, its impact on quality of life, and the importance of the patient-physician relationship to adherence. Two cross-sectional online surveys were conducted among 408 adult patients with epilepsy and 175 neurologists who treat epilepsy patients. Twenty-nine percent of patients self-reported being non-adherent to antiepileptic medications in the prior month. Non-adherence was found to be associated with reduced seizure control, lowered quality of life, decreased productivity, seizure-related job loss, and seizure-related motor vehicle accidents. Patient-oriented epilepsy treatment programs and clear communication strategies to promote self-management and patients' understanding of epilepsy are essential to maximizing treatment and quality of life outcomes while also minimizing economic costs.
Assuntos
Anticonvulsivantes/administração & dosagem , Epilepsia/tratamento farmacológico , Relações Médico-Paciente , Recusa do Paciente ao Tratamento , Acidentes de Trânsito/psicologia , Acidentes de Trânsito/tendências , Atividades Cotidianas/psicologia , Adolescente , Adulto , Anticonvulsivantes/efeitos adversos , Estudos Transversais , Epilepsia/epidemiologia , Epilepsia/psicologia , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Análise Multivariada , Educação de Pacientes como Assunto/estatística & dados numéricos , Qualidade de Vida/psicologia , Autocuidado/psicologia , Autocuidado/estatística & dados numéricos , Fatores Socioeconômicos , Recusa do Paciente ao Tratamento/psicologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Desemprego/psicologia , Desemprego/estatística & dados numéricos , Estados UnidosRESUMO
Guidance for seizure emergency plans exists, although their impact and extent of use in patients with epilepsy are undetermined. This study's primary purpose was to measure the estimated use and content of seizure emergency plans. Secondary objectives included measuring: disease severity, quality of life, productivity, and adherence among patients with and without a plan. An online survey was conducted among 408 patients with epilepsy (ages 18-64) who took one or more antiepileptic drugs. Only 30% of patients reported having a plan, which included avoiding injury, notifying a physician, resting/relaxing, and seeking emergency assistance. Those with a plan were more likely to have experienced more seizures in the past year, to have missed school/work, to have incurred injury, to have visited the ER, to have been hospitalized, to fear additional seizures, and to have lost a job. Seizure emergency plans appear to be reserved for adults with more severe disease, but there may be clinical benefits to developing a plan for all adult patients with epilepsy.
Assuntos
Epilepsia/epidemiologia , Epilepsia/terapia , Pesquisas sobre Atenção à Saúde/métodos , Pesquisas sobre Atenção à Saúde/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Emergências , Epilepsia/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas On-Line , Médicos/psicologia , Médicos/estatística & dados numéricos , Qualidade de Vida , Estudos Retrospectivos , Índice de Gravidade de Doença , Cônjuges/psicologia , Carga de Trabalho/estatística & dados numéricos , Adulto JovemRESUMO
PURPOSE: Conversion to lamotrigine (LTG) monotherapy from sodium valproate (VPA) is complicated by the robust pharmacokinetic interaction between the two AEDs. This study examined changes in LTG serum concentrations immediately following VPA discontinuation. METHODS: Ten healthy female and male adult subjects were initiated on LTG (Lamictal) 10â¯mg orally every morning for 30â¯days and VPA (Depakote ER) 500â¯mg orally every morning for 14â¯days. Morning trough (pre-dose) venous blood samples were obtained for determination of LTG and VPA concentrations on study days 14, 15, 16, 18, 20, 22, 24, 26, 28, and 30. Following the collection of the blood sample on day 15, VPA was discontinued. RESULTS: Despite stable LTG dosage serum concentrations on study day 20, 22, 24, 26, and 28, all were significantly lower compared to baseline (pâ¯<â¯0.05). CONCLUSIONS: These observations demonstrate that the pharmacokinetic interaction between LTG and VPA is reversible, and that de-inhibition appears to follow a predictable time course. Complete offset, or reversal of this interaction takes place 10-14â¯days after VPA discontinuation. Our data also confirms the observation that LTG oral clearance may be inhibited by very low concentrations of VPA. These data support the conversion algorithm suggested by the manufacturer, and provide guidance to the clinician. These data provide clinically useful information in developing a dosing algorithm for converting patients to LTG monotherapy.
Assuntos
Anticonvulsivantes/sangue , Anticonvulsivantes/farmacologia , Triazinas/sangue , Triazinas/farmacologia , Ácido Valproico/sangue , Ácido Valproico/farmacologia , Administração Oral , Adulto , Anticonvulsivantes/farmacocinética , Interações Medicamentosas , Substituição de Medicamentos , Feminino , Humanos , Lamotrigina , Masculino , Fatores de Tempo , Triazinas/farmacocinética , Ácido Valproico/farmacocinéticaRESUMO
Childhood and adolescence are critical periods of skeletal mineralization. Peak bone mineral density achieved by the end of adolescence determines the risk for later pathological fractures and osteoporosis. Chronic disease and medication often adversely affect bone health. Epilepsy is one of the most common neurological conditions occurring in persons under the age of 21. Epilepsy may affect bone in a number of ways. Restrictions of physical activity imposed by seizures, cerebral palsy or other coexisting comorbidities adversely affect bone health. It has been observed that treatment with phenytoin and phenobarbital can be associated with rickets. More recently, established agents such as carbamazepine and valproate have been shown to be associated with decreased bone mineral density. The literature related to bone health in pediatric epilepsy is reviewed.
Assuntos
Anticonvulsivantes/efeitos adversos , Desenvolvimento Ósseo/efeitos dos fármacos , Desenvolvimento Ósseo/fisiologia , Epilepsia/patologia , Absorciometria de Fóton , Anticonvulsivantes/uso terapêutico , Densidade Óssea/efeitos dos fármacos , Densidade Óssea/fisiologia , Conservadores da Densidade Óssea/uso terapêutico , Criança , Epilepsia/tratamento farmacológico , Humanos , Vitamina D/uso terapêuticoRESUMO
Bone mass, largely accumulated during childhood and adolescence, may be reduced in patients with epilepsy as a result of epilepsy or of antiepileptic medications. Enzyme-inducing medications increase bone-turnover markers, although the effects of newer medications on bone accrual are not well-defined. Total z-score bone mineral density was measured in 13 children, treated with lamotrigine monotherapy, who had never been exposed to other medications, and compared with 36 control subjects and 40 patients exposed to polytherapy. All patients were normally ambulatory and had similar physical activity and calcium intake. The z-scores of bone mineral density for lamotrigine and control subjects were similar (0.52 +/- 0.76 versus 0.49 +/- 0.7) and higher than those receiving polytherapy for 1-5 years (0.14 +/- 0.8, P = 0.12) and >or=6 years (-0.27 +/- 01.15, P < 0.003). Increasing duration of epilepsy was associated with lower bone density for 1-5 years of polytherapy (Spearman's correlation coefficient r = +0.006, P = 0.74) and >or=6 years of polytherapy (Spearman's correlation coefficient r = +0.12, P = 0.13), but not for lamotrigine. These data suggest that lamotrigine may not interfere with bone accrual.
Assuntos
Anticonvulsivantes/efeitos adversos , Densidade Óssea/efeitos dos fármacos , Epilepsia/tratamento farmacológico , Epilepsia/metabolismo , Triazinas/efeitos adversos , Adolescente , Anticonvulsivantes/administração & dosagem , Anticonvulsivantes/uso terapêutico , Cálcio/administração & dosagem , Criança , Estudos Transversais , Dieta , Esquema de Medicação , Quimioterapia Combinada , Epilepsia/fisiopatologia , Feminino , Crescimento , Humanos , Lamotrigina , Masculino , Atividade Motora , Triazinas/administração & dosagem , Triazinas/uso terapêuticoRESUMO
Lennox-Gastaut syndrome (LGS) is a severe form of childhood-onset epilepsy associated with high morbidity and mortality. The peak period for manifestations of Lennox-Gastaut syndrome is between ages 3 and 5 years, a time of critical brain development and corresponding vulnerability to the electroclinical dysfunction arising from Lennox-Gastaut syndrome. Diagnosis is based on a triad of symptoms: multiple seizure types, cognitive impairment, and slow spike-and-wave pattern on electroencephalography. In practice, Lennox-Gastaut syndrome presentation is diverse, and there may be a delay between initial symptoms and emergence of the full triad of clinical features. Additionally, differential diagnosis is complicated by the resemblance of Lennox-Gastaut syndrome to other forms of epilepsy and by the need for varied diagnostic techniques requiring specific clinical skills. Because diagnosis is complex and early intervention may lead to improved outcomes, clinicians should consider treatment when Lennox-Gastaut syndrome symptoms are present, even in the absence of a formal diagnosis.
Assuntos
Síndrome de Lennox-Gastaut/diagnóstico , Síndrome de Lennox-Gastaut/terapia , Diagnóstico Precoce , HumanosRESUMO
BACKGROUND: Ictal confusion, particularly if protracted, often presents a diagnostic challenge. OBJECTIVES: To define protracted ictal confusion in elderly patients and to characterize its features and outcome. DESIGN: Case series. SETTING: Neurology outpatient and emergency departments at 2 tertiary care centers. PATIENTS: Consecutive series of 22 ambulatory patients with acute ictal confusion. MAIN OUTCOME MEASURES: Duration of ictal confusion was correlated with age and lesions noted on cerebral images and videoelectroencephalographic studies. RESULTS: The ictal basis underlying confusion was not recognized for up to 5 days in 22 patients (mean +/- SD age, 70 +/- 8.5 years). Twenty patients had partial complex status epilepticus, and 2 patients had newly diagnosed primary generalized status epilepticus. Motor movements were not present in either group, although reduced mood states and ictal neglect were noted in some patients. Fifteen patients had previous episodes (2-10) of protracted ictal confusion. Once identified, treatment reversed confusion, and eventually patients were discharged to home, although a few patients sustained persistent reduction in baseline cognition. CONCLUSIONS: Protracted ictal confusion is often not considered in the ambulatory elderly patient, with resulting delay in diagnosis. Electroencephalographic and videoelectroencephalographic studies performed while the patient is experiencing symptoms are crucial to early diagnosis and timely management.
Assuntos
Encéfalo/fisiopatologia , Confusão/diagnóstico , Confusão/fisiopatologia , Estado Epiléptico/diagnóstico , Estado Epiléptico/fisiopatologia , Fatores Etários , Idoso , Anticonvulsivantes/uso terapêutico , Atrofia/complicações , Atrofia/diagnóstico , Encéfalo/diagnóstico por imagem , Encéfalo/patologia , Transtornos Cerebrovasculares/complicações , Transtornos Cerebrovasculares/diagnóstico , Doença Crônica/tratamento farmacológico , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/tratamento farmacológico , Transtornos Cognitivos/fisiopatologia , Confusão/tratamento farmacológico , Diagnóstico Precoce , Eletroencefalografia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estado Epiléptico/tratamento farmacológico , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Optimal epilepsy management in teenage patients represents a particular challenge. These patients are often likely to respond more positively to a regimen that least disrupts their activities. In addition, as a patient group, they are more sensitive to peer perception. Current perceptions of older antiepilepsy drugs do not take into account frequent undesirable side effects or potential adverse interactions with other drugs. Furthermore, they often do not completely control seizures. Recent data suggest that not only do the newer antiepileptic drugs appear to be as efficacious as the older drugs, they also often have more favorable cognitive, cosmetic, and teratogenic side-effect profiles. In addition, newer antiepileptic drugs are being used more often in monotherapy. Successful management of epilepsy in teenagers requires that physicians not only understand the advantages that the newer antiepileptic drugs appear to provide but also consider the social impact of treatment on their patients.
Assuntos
Anticonvulsivantes/uso terapêutico , Epilepsia/tratamento farmacológico , Adolescente , Comportamento do Adolescente/psicologia , Anticonvulsivantes/efeitos adversos , Quimioterapia Combinada , Feminino , Humanos , Cooperação do Paciente/psicologia , Medição de RiscoRESUMO
INTRODUCTION: Hospitals have begun to shift toward patient-centered care because of the pay-for-performance system that was established by the Patient Protection and Affordable Care Act. In pediatrics, the needs of both the caregiver and the pediatric patient have to be taken into account. Pediatric practices have been shifting toward a family-centered approach, although the primary drivers have not been well defined. Identifying the key patient experiences that lead to higher patient satisfaction would enable a more meaningful clinical encounter. To better understand patient experience, we examined waiting time and the elements of the physician-patient interaction in pediatric neurology. We predict that the determining factor in patient satisfaction is the physician-patient interaction. METHODS AND MATERIAL: Patient satisfaction surveys were sent to families via mail or e-mail after their ambulatory pediatric neurology visit. The visits took place between January 1, 2012, and December 31, 2014, at one of multiple locations in a children's health system spanning four states. A Likert scale was used for these surveys, and a top-box method (measuring percent of survey questions were rated 5 out of 5) was used to filter data from this database. Statistical analysis using a Pearson correlation was used for data analysis, with likelihood to recommend practice as the dependent variable. RESULTS: The five survey questions that correlated most with overall likelihood to recommend the practice were cheerfulness of practice (r = 0.79); staff working together (r = 0.76); cleanliness of practice (r = 0.70); wait time at clinic, from entering to leaving (r = 0.66); and likelihood of recommending care provider (r = 0.65). CONCLUSION: Pediatric neurologists striving to enhance overall patient satisfaction in their practices should work toward providing an atmosphere that supports office staff cheerfulness, teamwork, and visit efficiency provided in a clean and friendly environment.