The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future
*Diabetes Mellitus, Type 1/complications/drug therapy
Drug Resistant Epilepsy/drug therapy/etiology
Drug resistant epilepsy as the consequence of inadequate control of type 1 diabetes.
Hypoglycemic encephalopathy (HE) is a type of encephalopathy resulting from extremely low blood glucose level. Symptoms are not specific and can be misdiagnosed very often. It can occur during deep and/or prolonged hypoglycemia, which may be a result of inadequately controlled diabetes. Here, we report a case of an 11-year old male patient diagnosed with type 1 diabetes mellitus treated with the use of insulin pump who was admitted to the Pediatric Neurology Department because of multiple incidents of seizures. Boy was found unconscious by his mother. The blood glucose level on the glucometer was 35 mg/dl. It turned out that the reason of hypoglycemia was inadequate insulin dosing. He was given intravenous glucose by the ambulance service without improvement in the state of consciousness. Brain MRI revealed in both cerebral hemispheres, symmetrically, elevated white matter signal, mainly in the subcortex and cortex of the frontal and occipital and parietal lobes with features of diffusion restriction. EEG revealed generalized slow brain activity, without obvious epileptiform. Boy was provided with a variety of antiepileptic drugs. Unfortunately, none of them yielded with satisfactory results so far and the patient is still suffering from drug-resistant epilepsy. In conclusion, glucose is one of the key metabolic agents for the proper brain function and any imbalances in its blood level may impair the neuronal computation. Thus, it is extremely important, especially among diabetic patients, to control glucose blood level and avoid any disturbances, as they may lead to severe consequences, such as HE and drug-resistant epilepsy.
Place: Poland PMID: 39026478 PMCID: PMC11037085
Pediatric endocrinology, diabetes, and metabolism
Seizure occurrences among hypoglycemic patients in the emergency department
Abstract Aim Symptomatic hypoglycemia is a common problem in the emergency department (ED). However, without appropriate recognition and management, hypoglycemia remains a potentially fatal condition. The cause of sudden death associated with hypoglycemia might be attributed to cardiac arrhythmias and hypoxia with seizures. Despite advances in diabetes mellitus management and social background, the frequency and characteristics of patients with hypoglycemia‐related seizures have remained unknown. Hence, our study aimed to investigate the frequency and characteristics of patients with hypoglycemia presenting with seizures in the ED. Methods This retrospective observational study was conducted in a single tertiary care center. Patient information was retrieved from the final diagnostic records in the ED. We reviewed all medical records and included patients with symptomatic hypoglycemia aged 16 years or older. The primary outcome was the frequency of seizures in patients with hypoglycemia. We also compared the initial blood sugar levels of the patients with and without seizures. Results We included a total of 380 patients (median age, 72 years, IQR 64–80 years; median initial blood sugar, 34 mg/dL, IQR 24–46; 62.9% male). Nineteen of 380 patients (5.0%) had seizures. Although 16 of the 19 patients had diabetes mellitus, none of the 19 patients had a history of epilepsy. The initial blood sugar levels of the patients with and without seizures were not significantly different ( p = 0.97). Conclusion Approximately 5% of the patients with hypoglycemia presented with seizures. Blood glucose levels of hypoglycemic patients with and without seizures did not differ.
Traumatic brain injury: molecular biomarkers, genetics, secondary consequences, and medical management
Traumatic brain injury (TBI) has reached epidemic proportions worldwide. The consequences of TBI can be severe even with repetitive mild trauma. If death and coma are avoided, the consequences of TBI in the long term typically involve dizziness, sleep disturbances, headache, seizures, cognitive impairment, focal deficits, depression, and anxiety. The severity of brain injury is a significant predictor of outcome. However, the heterogenous nature of the injury makes prognosis difficult. The present review of the literature focuses on the genetics of TBI including genome wide (GWAS) data and candidate gene associations, among them brain-derived neurotrophic factor (BDNF) with TBI and development of post-traumatic epilepsy (PTE). Molecular biomarkers of TBI are also discussed with a focus on proteins and the inflammatory protein IL1-β. The secondary medical sequela to TBI of cognitive impairment, PTE, headache and risk for neurodegenerative disorders is also discussed. This overview of TBI concludes with a review and discussion of the medical management of TBI and the medicines used for and being developed at the preclinical and clinical stages for the treatment of TBI and its host of life-debilitating symptoms.
Disney to Pixar Transition Causing Epilepsy: A Case Report of Reflex Epilepsy
This case report describes a rare instance of reflex seizures in a 4-year-old boy with a complex medical history, including total anomalous pulmonary venous connection and developmental disabilities. The patient experienced seizures triggered exclusively by a specific visual stimulus: the transition scene from the Disney castle to the Pixar lamp in Disney-Pixar movies. Video electroencephalography (EEG) revealed biparasagittal rhythmic delta waves and diffuse slowing, suggesting parietal involvement and complex cortical processing. The findings highlight the individualized nature of reflex epilepsy and highlight the need for a nuanced understanding of specific seizure triggers. Effective management included avoiding the identified visual stimulus and adjusting medication based on the patient's response. This case emphasizes the intricate relationship between sensory processing and epileptogenic mechanisms, contributing to our knowledge of cortical excitability and guiding targeted treatment strategies for reflex seizures.
Disney to Pixar Transition Causing Epilepsy
Bhargava and Devries - 2024 - Disney to Pixar Transition Causing Epilepsy A Cas.pdf
Acute Quetiapine Intoxication: Relationship Between Ingested Dose, Serum Concentration and Clinical Presentation—Structured Literature Review and Analysis
Over the past decade, quetiapine has become one of the most commonly used psychotropic drugs in acute intoxication events worldwide. A structured literature review and analysis were conducted to assess the relationship between the kinetic and dynamic profiles in acute quetiapine intoxication. The correlation between dose and peak serum concentration (cmax) was determined using Pearson’s correlation coefficient. Binary logistic regression was used to evaluate dose and cmax as predictors of the most common clinical events, signs and symptoms. One hundred and thirty-four cases of acute quetiapine ingestion were included in the analysis, with a median ingested dose of 10 g and a median cmax of 4 mg/L. The typical half-life was estimated to be 16.5 h, significantly longer than at therapeutic doses. For the immediate-release formulation, a biphasic disposition could not be excluded. Dose and cmax demonstrated a weak but significant correlation (r = 0.256; N = 63; p = 0.043). Central nervous system depression and tachycardia were the most common clinical signs. Higher doses and concentrations increased the risk of severe intoxication and were good predictors of intubation, tachycardia, hypotension, QTc prolongation and seizures, but not QRS prolongation, arrhythmia, heart block, hypokalaemia or acidosis. The thresholds for dose and cmax that increased the risk for individual signs and symptoms varied widely. However, doses > 3 g or cmax > 2 mg/L can be considered as alert levels that represent a high risk for severe clinical course of acute quetiapine intoxication.
Imipenem-Cilastatin-Induced Seizures: A Case Report
Background: Imipenem-cilastatin, a carbapenem antibiotic, is commonly used for severe bacterial infections. While generally well-tolerated, it can rarely cause central nervous system toxicity, including seizures. We have, herein, reported a case of imipenem-cilastatin-induced seizure in a 20-year-old patient. Case Presentation: A 20-year-old male was admitted to the intensive care unit for febrile status epilepticus and acute respiratory distress syndrome. Initial evaluations ruled out underlying causes and anti-epileptic treatment has been initiated. Despite having an effective anti-epileptic treatment for three months of hospitalization, seizure recurrence occurred, leading to antibiotic regimen adjustment as the imputability of imipenem-cilastatin was suspected. After discontinuation of the involved drug, the patient remained neurologically stable. Previous literature has reported cases of imipenem-cilastatin-induced seizures, particularly in elderly patients or at higher dosages. The causality assessment was conducted using the updated French method, which rated the chronological criterion as C2 and the semiological criterion as S2. The intrinsic imputability score was I3, indicating plausible causality, and the extrinsic bibliographic score was B3. Conclusion: Our case has highlighted the importance of promptly recognizing imipenem-cilastatin- induced epileptic seizures in order to treat them more effectively and thus optimize the patient’s care. Therefore, we emphasize that clinicians be vigilant about the side effects of its use, particularly in patients with neurological susceptibilities. We also advocate a personalized choice of antibiotics, taking into account both antimicrobial efficacy and potential adverse effects, for better outcomes with fewer risks.
Aloui et al. - 2024 - Imipenem-Cilastatin-Induced Seizures A Case Repor.pdf
Fluoroquinolones and the risk for incidental seizures: a comparative retrospective study
Abstract Background Over the years, reports have associated fluoroquinolones (FQ) with seizures. The incidence and whether FQ compared to non-epileptogenic antibiotic are associated with increased risk of seizures has yet to be examined. Methods A retrospective observational study of hospitalized patients treated with FQ (ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin) or macrolides (MA: azithromycin or roxithromycin) between January 2009 and January 2021 in a large tertiary academic medical centre. The outcome was the occurrence of a seizure during treatment. The Naranjo scale was used to assess causality between FQ treatment and seizures. Comparative analysis was conducted using propensity score matching to correct for possible bias due to non-random selection, followed by inverse probability weighting (IPW) to estimate the difference in seizure risk between FQ and MA. Results Overall, 52 722 patients were treated with FQ during a total of 178 982 days. Mean age was 65 (±19) years and 47% were females. Thirty-three patients (0.06%) experienced a seizure, yielding an incidence of 1:5422 treatment days. Causality was deemed probable and possible among 9/33 and 24/33, respectively. The MA group composed of 8522 patients treated during 17 954 treatment days. Mean age was 65 (±21) years, 49% were females. Six (0.07%) patients experienced each a single seizure. IPW estimated OR for seizures among the FQ versus MA group was 1.44 (95%CI 0.59–3.5, P = 0.42). Discussion The incidence of FQ associated seizures among hospitalized patients is low and the risk did not significantly exceed that under macrolides. Our results provide evidence for clinicians and decision-makers when balancing fluoroquinolones risks and benefits.
Fluoroquinolones and the risk for incidental seizures
Gueta et al. - 2024 - Fluoroquinolones and the risk for incidental seizu.pdf
Antibiotic-induced neuropsychiatric toxicity: epidemiology, mechanisms and management strategies –a narrative literature review
Antibiotic-induced neuropsychiatric toxicity
Althubyani et al. - 2024 - Antibiotic-induced neuropsychiatric toxicity epid.pdf
Cefepime Neurotoxicity in Patients With Normal Renal Function: An Overlooked Cause of Encephalopathy in the Intensive Care Unit
Cefepime is a fourth-generation cephalosporin with extended antimicrobial coverage. Concerns have been raised about the side effects of cefepime including myoclonus, encephalopathy, and seizures, especially when renal impairment is present. There have been reports of cases of adverse neurological consequences despite appropriate renal adjustment. Here, we present a case of a 69-year-old patient initially diagnosed with pneumonia and treated with cefepime. The patient later developed altered mental status, leading to differential diagnoses including stroke, drug overdose, or non-convulsive seizures. Following a comprehensive workup, it was determined that she had cefepime-induced encephalopathy, despite having normal kidney function, which resolved completely after discontinuing the medication. In addition, we include similar cases retrieved from PubMed up to the present date, to the best of our knowledge.
Cefepime Neurotoxicity in Patients With Normal Renal Function
Journal of Investigative Medicine High Impact Case Reports
Clinical characteristics of seizure recurrence and epilepsy development in patients with alcohol‐related seizures
Abstract Background Alcohol withdrawal is widely recognized as a trigger for acute symptomatic seizures among individuals with chronic alcohol consumption. While most alcohol withdrawal seizures occur shortly after cessation, chronic alcohol consumption can be associated with the development of epilepsy, necessitating anti‐epileptic drug (AED) therapy. This study aimed to investigate the clinical characteristics, seizure recurrence, and epilepsy development in patients with alcohol‐related seizures and to identify prognostic factors for epilepsy. Methods In a retrospective analysis at Ewha Womans University Mokdong Hospital, 206 patients with alcohol‐related seizures were examined and 15 were excluded due to preexisting epilepsy. Demographic and clinical data, including alcohol withdrawal duration, seizure recurrence, types, and comorbidities, were investigated. Logistic regression models were used to analyze the risk factors for seizure recurrence and epilepsy development. The performance of the final models was evaluated based on the area under the receiver operating characteristic curve (AUC) and validated using calibration plots and leave‐one‐out cross‐validation. Results Of the 191 patients (146 males; mean age 48.3 ± 12.1 years) with alcohol‐related seizures, 99 patients (51.8%) experienced seizure recurrence and 79 patients (41.4%) developed epilepsy. Factors associated with seizure recurrence included alcohol consumption levels, occurrence of focal impaired awareness seizure, anxiety, and headache. The number of recurrent seizures, semiology, status epilepticus, electroencephalogram findings, and brain imaging findings was associated with epilepsy development. The predictive models showed strong diagnostic performance, with AUCs of 0.833 for seizure recurrence and 0.939 for epilepsy development. Conclusion High alcohol consumption and specific clinical and diagnostic features are significant predictors of seizure recurrence and the development of epilepsy among patients with alcohol‐related seizures. These findings underscore the importance of early identification and intervention to prevent seizure recurrence and the onset of epilepsy, emphasizing the importance of AED treatment in managing these conditions.
Alcohol, Clinical and Experimental Research
Subacute encephalopathy with seizures in alcoholics (SESA) syndrome: Relevant questions
Subacute encephalopathy with seizures in alcoholics (SESA) syndrome
Fernández-Torre et al. - 2024 - Subacute encephalopathy with seizures in alcoholic.pdf
Caffeine and Its Interactions with Antiseizure Medications—Is There a Correlation between Preclinical and Clinical Data?
Experimental studies reveal that caffeine (trimethylxanthine) at subconvulsive doses, distinctly reduced the anticonvulsant activity of numerous antiseizure medications (ASMs) in rodents, oxcarbazepine, tiagabine and lamotrigine being the exceptions. Clinical data based on low numbers of patients support the experimental results by showing that caffeine (ingested in high quantities) may sharply increase seizure frequency, considerably reducing the quality of patients’ lives. In contrast, this obviously negative activity of caffeine was not found in clinical studies involving much higher numbers of patients. ASMs vulnerable to caffeine in experimental models of seizures encompass carbamazepine, phenobarbital, phenytoin, valproate, gabapentin, levetiracetam, pregabalin and topiramate. An inhibition of R-calcium channels by lamotrigine and oxcarbazepine may account for their resistance to the trimethylxanthine. This assumption, however, is complicated by the fact that topiramate also seems to be a blocker of R-calcium channels. A question arises why large clinical studies failed to confirm the results of experimental and case-report studies. A possibility exists that the proportion of patients taking ASMs resistant to caffeine may be significant and such patients may be sufficiently protected against the negative activity of caffeine.
International Journal of Molecular Sciences
Seizures provoked by over-the-counter cough and cold medications in an elderly patient: a case report
Abstract Background Seizures are common neurological emergencies in the elderly that are frequently provoked. Geriatrics have higher rates of neurological disorders and other comorbidities that could affect seizure threshold. Case presentation An 83-year-old male Arabic patient presented to the emergency department with an acute confusional state and urinary incontinence followed by a witnessed tonic–clonic seizure in the hospital. Thorough investigations and imaging were positive only for nonspecific magnetic resonant imaging findings with a negative electroencephalogram. The patient was diagnosed with provoked seizure due to over-the-counter cold medications that included pseudoephedrine and caffeine. He was not prescribed antiepileptic medications at discharge and did not develop subsequent seizures up to this date. Conclusion Over-the-counter cough and cold medications with sympathomimetic ingredients can be associated with provoked seizures in the elderly. Physicians should be aware of the potentially serious adverse events associated with commonly used nonprescription sympathomimetics such as pseudoephedrine and caffeine in elderly patients.
Seizures provoked by over-the-counter cough and cold medications in an elderly patient
caffice eldery
Caffeine exacerbates seizure-induced death via postictal hypoxia
Abstract Sudden unexpected death in epilepsy (SUDEP) is the leading epilepsy-related cause of premature mortality in people with intractable epilepsy, who are 27 times more likely to die than the general population. Impairment of the central control of breathing following a seizure has been identified as a putative cause of death, but the mechanisms underlying this seizure-induced breathing failure are largely unknown. Our laboratory has advanced a vascular theory of postictal behavioural dysfunction, including SUDEP. We have recently reported that seizure-induced death occurs after seizures invade brainstem breathing centres which then leads to local hypoxia causing breathing failure and death. Here we investigated the effects of caffeine and two adenosine receptors in two models of seizure-induced death. We recorded local oxygen levels in brainstem breathing centres as well as time to cessation of breathing and cardiac activity relative to seizure activity. The administration of the non-selective A 1 /A 2A antagonist caffeine or the selective A 1 agonist N6-cyclopentyladenosine reveals a detrimental effect on postictal hypoxia, providing support for caffeine modulating cerebral vasculature leading to brainstem hypoxia and cessation of breathing. Conversely, A 2A activation with CGS-21680 was found to increase the lifespan of mice in both our models of seizure-induced death.
Hypocalcemia‐induced seizures in a peritoneal dialysis ( PD ) patient: A case report
Key Clinical Message A thorough evaluation is necessary for seizures caused by hypocalcemia, both during the patient's presentation and following their recovery from the postictal seizure episode. This is because the underlying cause of hypocalcemia must be ruled out in order to ensure the best possible clinical outcome from calcium and vitamin D therapy. Abstract Patients with multiple systemic issues, including neurological involvement and seizure development, are not uncommon among nephrologists. Both the central and peripheral neural systems can be impacted by kidney disease. The main symptoms are myopathy, cranial or peripheral neuropathy, cognitive impairment, and seizures. A 22‐year‐old female with an unusual medical history who had been known to have end‐stage kidney disease (ESKD) for a year and regularly had CAPD (continuous ambulatory peritoneal dialysis) suffered from two episodes of tonic‐colonic seizures 2 weeks apart. On physical examination, symptoms of tongue biting, decreased vision in the left eye, and mild bilateral pulmonary air entry were notable. Upon examination, there was evidence of severe hypocalcemia, hyponatremia, a high renal profile (urea and creatinine), anemia, and a severe vitamin D deficiency. Her peritoneal dialysis (PD) prescription was reviewed, her seizures ceased, and she was released from the hospital after the hypocalcemia was treated with intravenous calcium and high doses of vitamin D. The issue of hypocalcemic seizures should be carefully evaluated both at the presentation and after the patient recovers from the postictal stage. By following this, seizure episodes can be prevented with good success if patients strictly adhere to the medication for which they are responsible.
Hypocalcemia‐induced seizures in a peritoneal dialysis ( <span style="font-variant
Taha et al. - 2024 - Hypocalcemia‐induced seizures in a peritoneal dial.pdf
Association of dietary fiber intake with epileptic seizures in U.S. adults: A Population-base study of 13,277 participants
Association of dietary fiber intake with epileptic seizures in U.S. adults
Zhang et al. - 2024 - Association of dietary fiber intake with epileptic.pdf
Clinical characteristics and serum 25-hydroxyvitamin D levels in children with febrile seizures in China
Febrile Seizures, Ongoing Epileptiform Activity, and the Resulting Long-Term Consequences: Lessons From Animal Models
Febrile Seizures, Ongoing Epileptiform Activity, and the Resulting Long-Term Consequences
Harris et al. - 2024 - Febrile Seizures, Ongoing Epileptiform Activity, a.pdf
A Very Rare Side Effect of a Very Commonly Used Drug: Pantoprazole-induced Seizure
Pantoprazole is an extensively used proton pump inhibitor (PPI) for acid peptic disease. PPI rarely cause hypomagnesemia. Hypomagnesemia is commonly associated with hypokalemia and hypocalcemia. Severe hypomagnesemia and hypocalcemia can cause seizures. Here, we report a patient on long-term pantoprazole who presented with generalized tonic-clonic seizures and had severe hypomagnesemia, hypocalcemia, hypokalemia, and secondary hyperparathyroidism. When patients on long-term PPI present with seizures, hypomagnesemia/hypocalcemia has to be excluded.
A Very Rare Side Effect of a Very Commonly Used Drug
The Journal of the Association of Physicians of India
hypi cacalcemia and hypomagnesia
Vitamin B12 Deficiency Newborn Screening
BACKGROUND: Vitamin B12 deficiency (VitB12D) might cause neuro-developmental impairment in the first year of life. Newborn screening (NBS) for VitB12D was shown to be technically feasible and early treated infants developed favorably. This study aims to evaluate the impact of NBS in prevention of symptomatic infantile VitB12D. METHODS: In a nationwide surveillance study in cooperation with the German Pediatric Surveillance Unit, incident cases with VitB12D (<12 months of age) were prospectively collected from 2021 to 2022. RESULTS: In total, 61 cases of VitB12D reported to German Pediatric Surveillance Unit were analyzed, either identified by NBS (N = 31) or diagnosed after the onset of suggestive symptoms (non-NBS; N = 30). Ninety percent of the infants identified by NBS were still asymptomatic, whereas the non-NBS cohort presented at median 4 month of age with muscular hypotonia (68%), anemia (58%), developmental delay (44%), microcephalia (30%), and seizures (12%). Noteworthy, symptomatically diagnosed VitB12D in the first year of life was reported 4 times more frequently in infants who did not receive NBS for neonatal VitB12D (14 in 584 800) compared with those screened for VitB12D as newborns (4 in 688 200; Fisher's Exact Test, odds ratio 4.12 [95% confidence interval: 1.29-17.18], P = .008). The estimated overall cumulative incidence was 1:9600 newborns per year for neonatal VitB12D and 1:17 500 for symptomatic infantile VitB12D. CONCLUSIONS: NBS for neonatal VitB12D may lead to a fourfold risk reduction of developing symptomatic VitB12D in the first year of life compared with infants without NBS.
Seizure and Takotsubo Cardiomyopathy Due to Proton Pump Inhibitor
Proton Pump Inhibitor (PPI)-induced hypomagnesemia, first described in 2006, has gained increasing recognition in recent years as a potentially life-threatening adverse event. In comparison to histamine-2 receptor antagonists (H2RA), PPIs exhibit a higher frequency of electrolyte abnormalities, including hypomagnesemia, hypocalcemia, hypokalemia, and hyponatremia; hypomagnesemia is the most common. We report a case of an 80-year-old woman who presented with generalized weakness and diarrhea. She was found to have multiple electrolyte abnormalities that failed to resolve even after the resolution of diarrhea and resumption of feeding. However, her condition improved within one week of discontinuing PPI medication. Her hospital course was complicated by a seizure, attributed to alterations in ionic gradients across cellular membranes affecting neuronal discharge and facilitating epileptiform activities. Additionally, she experienced Takotsubo cardiomyopathy due to decreased myocardial contractility, both in the context of electrolyte imbalance induced by prolonged PPI use.
Journal of Community Hospital Internal Medicine Perspectives
electrolyte info
Proton Pump Inhibitor Induced Hypomagnesemia Causing Seizures: A Rare Adverse Effect of a Commonly Used Medication
Hypomagnesemia is defined as serum magnesium levels less than 0.7mmol/L and can result in a plethora of symptoms ranging from mild gastrointestinal symptoms to serious conditions such as cardiac arrhythmias and neurological complications. When considering the etiological factors, drug-induced hypomagnesemia is highlighted because commonly used medications such as proton pump inhibitors (PPIs), aminoglycoside antibiotics, and loop and thiazide diuretics can cause low magnesium levels. A 49-year-old male presented to the emergency department with severe vomiting worsening over three days complicated with generalized tonic-clonic seizures. He was an averagely built male, a non-smoker, and a non-alcoholic with no significant co-morbidities. He had a history of chronic over-the-counter pantoprazole intake over the last one year, and apart from that, his medication history was unremarkable. Initial investigations revealed severe hypomagnesemia (with serum magnesium level of 0.1mmol/L), with marginal hypokalemia, hypophosphatemia, and hypocalcemia. Following the initial resuscitation and magnesium supplementation, the patient's clinical condition significantly improved. Due to the lack of proper knowledge, the patient continued to take omeprazole 20mg tablets after discharge, and up until proper education and total cessation of PPIs, marginal hypomagnesemia, with serum magnesium level of 0.5mmol/L, persisted without any significant overt clinical manifestations. In this case report, we intend to highlight the importance of assessing for all possible electrolyte abnormalities in a patient presenting with neurological symptoms, relevance of taking a thorough drug history including all undocumented over-the-counter medications, and importance of patient education in the prevention of further episodes.
Proton Pump Inhibitor Induced Hypomagnesemia Causing Seizures
hypomagnesemia
Gastrointestinal surgery, malabsorptive conditions, and postoperative hypocalcemia after neck surgery
BACKGROUND: Postoperative hypocalcemia is a common complication of thyroid and parathyroid surgery. Patients with prior gastric bypass face increased risk of postoperative hypocalcemia, but the impact of other malabsorptive conditions is not well understood. In this study, we evaluated the relationship between multiple medical and surgical malabsorptive states and hypocalcemia after thyroid and parathyroid surgery. METHODS: We performed a retrospective cohort study of patients who underwent total thyroidectomy and/or parathyroidectomy in Optum's deidentified Clinformatics Data Mart Database (2004-2022). Patients were categorized as having surgical (foregut/midgut: gastrectomy, intestinal bypass, enterectomy, enterostomy, pancreatectomy, or hindgut: colectomy/colostomy) or medical (Crohn or Celiac disease) malabsorptive conditions. The primary outcomes were early (<7 days) and late (7-365 days) postoperative hypocalcemia. Logistic regression was performed to determine the associations between malabsorptive conditions and outcomes. RESULTS: Of 25,400 patients (56.9% total thyroidectomy, 40.8% parathyroidectomy, and 2.4% both procedures), 4.0% had a pre-existing malabsorptive condition. Early postoperative hypocalcemia occurred in 8.8% of patients, and late hypocalcemia in 18.3%. Thyroidectomy was associated with a greater likelihood of hypocalcemia than parathyroidectomy (odds ratio: 1.22; P < .001). Pancreatectomy was associated with twice the adjusted odds of postoperative hypocalcemia (odds ratio: 2.27; P = .031) across both procedures. Patients with prior foregut/midgut surgery were at higher risk after total thyroidectomy (odds ratio: 1.65, P = .002). This association was significant in late (odds ratio: 1.82, P < .001) rather than early hypocalcemia (odds ratio: 1.33, P = .175). Hindgut surgery and medical malabsorption did not demonstrate such associations. CONCLUSION: Prior foregut and midgut resections may predispose patients to postoperative hypocalcemia, particularly in patients undergoing total thyroidectomy.
Passman et al. - 2024 - Gastrointestinal surgery, malabsorptive conditions.pdf
Education Research: Educating Child Neurology Residents About Psychogenic Nonepileptic Seizures: A Needs Assessment
BACKGROUND AND OBJECTIVES: Psychogenic nonepileptic seizures (PNES) are difficult to differentiate from epileptic seizures (ES) even for neurologists who see these conditions frequently. This difficulty is due to overlapping semiologic findings between the 2 diagnoses. Previous studies have shown that trainees, including neurology trainees, are not accurate in differentiating PNES from ES. Neurologists often find the communication of PNES difficult. Despite these challenges, most programs do not have formal curricula for teaching PNES, and there are no standards for residency curricula in this topic. The aim of this study was to understand the gaps in resident education on PNES. METHODS: This study was accomplished through a needs assessment of current pediatric neurology residents and residency program directors (PDs). Two unique surveys were distributed, 1 for child neurology trainees and 1 for PDs. Questions were designed to understand trainees' self-reported knowledge, confidence, current education received, and desired teaching. Similarly for PDs, questions were designed to assess the state of education on PNES at their programs, sufficiency of education, and their desire for standardized curriculum. RESULTS: Sixty-eight trainees and 21 PDs responded to the survey. Approximately one-quarter of trainees reported neutral to low levels of confidence and 38% reported neutral to low levels of knowledge in caring for patients with PNES. Trainees reported that directing patients with PNES to appropriate management was the most challenging aspect of care, followed by communicating the diagnosis, with 60% and 46% reporting difficulty, respectively. Only 21% of residents felt their current PNES education needs no improvement. One-fifth of PDs felt their current PNES education is not sufficient, and all reported they would incorporate a standardized curriculum. Trainees reported preferring to learn about this topic through lectures and simulation, while PDs preferred online modules and simulation. DISCUSSION: While residents and PDs report high confidence and knowledge in treating pediatric patients with PNES, respondents felt improvement is needed to their curricula regarding this topic. Multiple learning methods are preferred, with emphasis on communicating the diagnosis and management of patients once the diagnosis has been made. PDs desire a standardized curriculum and would incorporate one into their programs. Findings of this study could be used to create a national curriculum.
Talai et al. - 2024 - Education Research Educating Child Neurology Resi.pdf
Results of a National Delphi consensus on the outpatient management of pediatric psychogenic nonepileptic seizures in the United States
BACKGROUND AND OBJECTIVES: The purpose of this study was to develop national consensus based on expert opinion on the optimal outpatient care model of pediatric psychogenic nonepileptic seizures (PNES). METHODS: A core working group (CWG) within the PNES special interest group of the Pediatric Epilepsy Research Consortium was established. The CWG developed a rigorous scoring rubric to select experts in pediatric PNES within the United States of America and a three-round Delphi study was conducted to assess consensus on key components of the management of pediatric PNES in the outpatient setting. RESULTS: Eighteen experts representing neurology, psychology, psychiatry, social work and nursing participated in the study. Strong consensus was reached that the multidisciplinary clinic (MDC) model is the gold standard for the outpatient management of pediatric PNES. Consensus was obtained that a neurologist, psychologist and social worker are essential members of the MDC and in the setting of unlimited resources, psychiatry and nursing are also recommended. Further consensus was established on the roles of specific personnel, structure of the clinic, billing practices, trainee inclusion, patient inclusion and exclusion, and end of visit management. While consensus was reached that a new term should be developed for this diagnosis, consensus was not reached on the ideal term. DISCUSSION: Expert consensus was established for the multidisciplinary management of pediatric PNES in the outpatient setting. Specific recommendations were provided that can facilitate the development and implementation of MDCs in other institutions. Further prospective studies are warranted to validate this practice model.
Talai et al. - 2024 - Results of a National Delphi consensus on the outp.pdf
Exacerbation of Psychogenic Non-epileptic Seizures Related to the Diagnosis and Disease Burden of Epilepsy: A Case Report
Psychogenic non-epileptic seizures (PNES), which closely resemble epileptic seizures (ES), are typically triggered by psychological distress and represent the most prevalent form of conversion disorder encountered in clinical practice. Multiple physical conditions can both precipitate and sustain PNES episodes. Epilepsy, a common neurological disorder, imposes significant emotional and physical burdens, frequently resulting in elevated levels of anxiety and depression. This case report details the clinical course of a 19-year-old female whose PNES was exacerbated by the diagnosis and disease burden of epilepsy. The patient's background of childhood trauma, bullying, and sexual abuse likely predisposed her to the development of PNES. Upon receiving a diagnosis of epilepsy, characterized by focal seizures originating from the left parietal region, the patient experienced increased anxiety and required frequent hospitalizations. Despite adjustments to her treatment regimen, including the administration of levetiracetam (LEV) and lacosamide (LCM), her seizures persisted. Comprehensive evaluations, comprising electroencephalography (EEG) and single-photon emission computed tomography (SPECT), indicated the coexistence of epilepsy and PNES. Although surgical intervention was initially considered, it was ultimately deemed unnecessary, which subsequently alleviated the patient's anxiety. Psychoeducation highlighting the manageability of her epilepsy with ongoing pharmacotherapy significantly reduced her PNES episodes. This case emphasizes the critical role of addressing the psychosocial burden associated with an epilepsy diagnosis, as these factors may exacerbate PNES. It also underscores the importance of a holistic treatment approach that integrates psychological support with medical management.
Exacerbation of Psychogenic Non-epileptic Seizures Related to the Diagnosis and Disease Burden of Epilepsy
Reversible dementia and seizures due to metformin-induced vitamin B12 deficiency
Laroussi et al. - 2024 - Reversible dementia and seizures due to metformin-.pdf
Diabetes mellitus: a risk factor for seizures in the elderly-a population-based study
AIMS: To evaluate the association between diabetes mellitus (DM) and risk of seizures in a well-defined elderly population. METHODS: The administrative databases of the Lombardy region (a 10 million population area in Northern Italy) were used to identify persons aged 65 years or older with DM (defined by prescription of antidiabetic drugs and/or through ICD-9 CM code and/or exemption code for diabetes) during the year 2002. Seizure-free DM subjects were followed until 2012 in search of individuals with incident seizures (identified through ICD-9 CM codes for epilepsy/seizures or ATC codes for antiepileptic drugs associated with the prescription of an electroencephalogram). To adjust for confounding, comorbidities having epileptogenic potential were also identified through the ICD-9 CM codes. RESULTS: The population at risk included 1,494,071 persons. Of these, 136,941 seizure-free patients had DM. At the end of follow-up, the cumulative time-dependent incidence of seizures was 3.0% in DM patients and 1.9% in No-diabetic individuals (hazard ratio, HR 1.47; 95% confidence interval, 1.41-1.53, adjusted for age classes, sex, comorbidities and number of hospital admission). The HR was unchanged in patients with no history of stroke. The cumulative incidence of seizures after DM increased with the number of hospital admissions. CONCLUSIONS: DM is an independent risk factor for seizures in elderly individuals. In diabetic patients, the risk of seizures increases with the number of comorbidities, supporting the role of vascular disease as a cause of seizures.
Baviera et al. - 2017 - Diabetes mellitus a risk factor for seizures in t.pdf
Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia
Hyponatremia and hypernatremia are electrolyte disorders that can be associated with poor outcomes. Hyponatremia is considered mild when the sodium concentration is 130 to 134 mEq per L, moderate when 125 to 129 mEq per L, and severe when less than 125 mEq per L. Mild symptoms include nausea, vomiting, weakness, headache, and mild neurocognitive deficits. Severe symptoms of hyponatremia include delirium, confusion, impaired consciousness, ataxia, seizures, and, rarely, brain herniation and death. Patients with a sodium concentration of less than 125 mEq per L and severe symptoms require emergency infusions with 3% hypertonic saline. Using calculators to guide fluid replacement helps avoid overly rapid correction of sodium concentration, which can cause osmotic demyelination syndrome. Physicians should identify the cause of a patient's hyponatremia, if possible; however, treatment should not be delayed while a diagnosis is pursued. Common causes include certain medications, excessive alcohol consumption, very low-salt diets, and excessive free water intake during exercise. Management to correct sodium concentration is based on whether the patient is hypovolemic, euvolemic, or hypervolemic. Hypovolemic hyponatremia is treated with normal saline infusions. Treating euvolemic hyponatremia includes restricting free water consumption or using salt tablets or intravenous vaptans. Hypervolemic hyponatremia is treated primarily by managing the underlying cause (e.g., heart failure, cirrhosis) and free water restriction. Hypernatremia is less common than hyponatremia. Mild hypernatremia is often caused by dehydration resulting from an impaired thirst mechanism or lack of access to water; however, other causes, such as diabetes insipidus, are possible. Treatment starts with addressing the underlying etiology and correcting the fluid deficit. When sodium is severely elevated, patients are symptomatic, or intravenous fluids are required, hypotonic fluid replacement is necessary.
Diagnosis and Management of Sodium Disorders
Dementia in Diabetes: The Role of Hypoglycemia
Hypoglycemia, a common consequence of diabetes treatment, is associated with severe morbidity and mortality and has become a major barrier to intensifying antidiabetic therapy. Severe hypoglycemia, defined as abnormally low blood glucose requiring the assistance of another person, is associated with seizures and comas, but even mild hypoglycemia can cause troubling symptoms such as anxiety, palpitations, and confusion. Dementia generally refers to the loss of memory, language, problem-solving, and other cognitive functions, which can interfere with daily life, and there is growing evidence that diabetes is associated with an increased risk of both vascular and non-vascular dementia. Neuroglycopenia resulting from a hypoglycemic episode in diabetic patients can lead to the degeneration of brain cells, with a resultant cognitive decline, leading to dementia. In light of new evidence, a deeper understating of the relationship between hypoglycemia and dementia can help to inform and guide preventative strategies. In this review, we discuss the epidemiology of dementia among patients with diabetes, and the emerging mechanisms thought to underlie the association between hypoglycemia and dementia. Furthermore, we discuss the risks of various pharmacological therapies, emerging therapies to combat hypoglycemia-induced dementia, as well as risk minimization strategies.
Seizures as a clinical manifestation in somatic autoimmune disorders
The risk of epileptic seizures seems increased in several systemic autoimmune disorders including systemic lupus erythematosus, type 1 diabetes mellitus, myasthenia gravis, celiac disease, rheumatoid arthritis, Hashimoto's encephalopathy, psoriasis, multiple sclerosis, neuromyelitis optica, and bullous pemphigoid. Immune dysfunction may be partly responsible for this association. Elevated levels of pro-inflammatory cytokines, autoantibodies seen in these autoimmune disorders and antibodies against neuronal antigens may contribute to the etiopathogenesis of seizures and epilepsy associated to immune conditions. Other unknown factors, the effect of different co-morbid conditions of epilepsy as well as shared risk factors such as common etiological factors, environmental triggers, or a common genetic predisposition may also explain the association. We review different autoimmune disorders which may present with co-morbid seizures and discuss possible underlying mechanisms of this co-occurrence focusing on a potential role of immune system dysfunction.
Relation of Serum Magnesium Level in Adult Patients with Idiopathic Generalized Epilepsy in a Tertiary Care Hospital
Magnesium plays a vast role in the nervous system. In particular, high magnesium in cerebrospinal fluid appears to enhance the neural functions, while low magnesium induces neuronal diseases. The aim of the study was to find out the relation of serum magnesium with idiopathic generalized epilepsy attending in a tertiary care hospital. This cross-sectional comparative study was conducted in the department of Neurology at Mymensingh Medical College and Hospital, Bangladesh from January 2019 to June 2020 following ethical approval. Total 110 purposively selected participants (55 with idiopathic generalized epilepsy and 55 non epileptic apparently healthy individuals) were enrolled in this study. Serum total Mg was measured by EMP-168 Biochemical Analyzer. Average age of epileptic individuals was 33.13±9.5 years and majority was female (60.0%). Mean serum magnesium level was lower in epileptic patients than controls (1.80±0.041 vs. 2.02±0.19 mg/dl; p<0.001). Patients with higher seizure attack (>3 per month) had significantly lower mean serum magnesium level than the patients with seizure attack three or less per month. Serum magnesium levels are reduced in epileptic patients compared to healthy age and gender matched controls. Studies involving larger numbers of patients are needed to confirm these results.
Abstract Magnesium plays a vast role in the nervous system. In particular, high magnesium in cerebrospinal fluid appears to enhance the neural functions, while low magnesium induces neuronal diseases. The aim of the study was to find out the relation of serum magnesium with idiopathic generalized epilepsy attending in a tertiary care hospital. This cross-sectional comparative study was conducted in the department of Neurology at Mymensingh Medical College and Hospital, Bangladesh from January 2019 to June 2020 following ethical approval. Total 110 purposively selected participants (55 with idiopathic generalized epilepsy and 55 non epileptic apparently healthy individuals) were enrolled in this study. Serum total Mg was measured by EMP-168 Biochemical Analyzer. Average age of epileptic individuals was 33.13±9.5 years and majority was female (60.0%). Mean serum magnesium level was lower in epileptic patients than controls (1.80±0.041 vs. 2.02±0.19 mg/dl; p<0.001). Patients with higher seizure attack (>3 per month) had significantly lower mean serum magnesium level than the patients with seizure attack three or less per month. Serum magnesium levels are reduced in epileptic patients compared to healthy age and gender matched controls. Studies involving larger numbers of patients are needed to confirm these results.
Role of Magnesium in Skeletal Muscle Health and Neuromuscular Diseases: A Scoping Review
Magnesium (Mg) is a vital element for various metabolic and physiological functions in the human body, including its crucial role in skeletal muscle health. Hypomagnesaemia is frequently reported in many muscle diseases, and it also seems to contribute to the pathogenesis of skeletal muscle impairment in patients with neuromuscular diseases. The aim of this scoping review is to analyze the role of Mg in skeletal muscle, particularly its biological effects on muscle tissue in neuromuscular diseases (NMDs) in terms of biological effects and clinical implications. This scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. From the 305 studies identified, 20 studies were included: 4 preclinical and 16 clinical studies. Preclinical research has demonstrated that Mg plays a critical role in modulating pathways affecting skeletal muscle homeostasis and oxidative stress in muscles. Clinical studies have shown that Mg supplementation can improve muscle mass, respiratory muscle strength, and exercise recovery and reduce muscle soreness and inflammation in athletes and patients with various conditions. Despite the significant role of Mg in muscle health, there is a lack of research on Mg supplementation in NMDs. Given the potential similarities in pathogenic mechanisms between NMDs and Mg deficiency, further studies on the effects of Mg supplementation in NMDs are warranted. Overall, maintaining optimal Mg levels through dietary intake or supplementation may have important implications for improving muscle health and function, particularly in conditions associated with muscle weakness and atrophy.
Role of Magnesium in Skeletal Muscle Health and Neuromuscular Diseases
Liguori et al. - 2024 - Role of Magnesium in Skeletal Muscle Health and Ne.pdf
Syndrome of inappropriate antidiuretic hormone
Hyponatremia-Induced Epileptic Seizure Provoked by Levetiracetam and Pain Medication Intake in a Patient with Central Diabetes Insipidus
INTRODUCTION: Causes of epileptic seizures are often multifactorial but for an effective therapy, they should be uncovered in detail. CASE PRESENTATION: We present a 67-year-old male patient with a central diabetes insipidus, who experienced a generalized tonic-clonic seizure. The patient was treated with levetiracetam for prevention of further seizures, opioids and non-steroidal anti-inflammatory drugs, i.e., ibuprofen because of severe back pain due to vertebral compression fractures. In this setting, he developed significant hyponatremia and experienced another epileptic seizure. After stopping analgesics and switching from levetiracetam to lacosamide, sodium levels returned to normal and the patient remained free of seizures since then. CONCLUSION: The interrelationships of medical therapy, sodium levels and epileptic seizures in the context of central diabetes insipidus are discussed.
Short-Term Outcomes of Patients With Hyponatremia Presenting to the Emergency Department: An Observational Study
BACKGROUND: Hyponatremia is the predominant electrolyte imbalance disorder in the emergency department. It can manifest with a diverse array of symptoms, ranging from non-specific and moderate to severe and even life-threatening. There is a scarcity of literature addressing the clinical characteristics and prognosis of patients with hyponatremia presenting to the emergency department in the western part of Rajasthan. The objective of this study was to investigate the impact of hyponatremia on the outcomes of patients presenting to the emergency department. METHODS: In this prospective, cross-sectional, observational study, 200 patients aged more than 18 years who presented to the emergency department with serum sodium < 135 mEq/l were included. The triage of patients was determined by their primary complaints. The primary outcome was to study the clinical profile of patients with hyponatremia presenting to the emergency department. The secondary outcomes were to examine the etiology, i.e., hypovolemic, euvolemic, or hypervolemic, and the outcome of patients on the 7th day (patient admitted to the ward or intensive care unit) and the 28th day (discharged or death) with hyponatremia presenting to the emergency department. The clinical status of the patients was noted by telephonic follow-up in case they were not admitted for this period. RESULTS: Out of 200 patients, 66 (33%) had hypovolemic, 96 (48%) had euvolemic, and 38 (19%) had hypervolemic hyponatremia. We observed that seizures (84.2%), confusion (56%), and coma (77.7%) were the most common clinical features of patients with severe hyponatremia in the emergency, which was statistically significant than mild and moderate hyponatremia (p = 0.03, 0.023, and 0.029, respectively). On the 7th day of hospitalization, out of 181 (90.5%) admissions in the ward, 116 (64.08%) had severe hyponatremia, and out of 19 (9.5%) ICU admissions, 13 (68.4%) had severe hyponatremia. Death was seen in five (2.5%) patients, one (20%) in moderate and four (80%) in severe hyponatremia cases. CONCLUSION: Most cases of hyponatremia in this study were euvolemic. Most patients experienced severe hyponatremia, and seizures, confusion, and coma were the most prevalent symptoms. These disorders must be recognized early to properly diagnose and treat hyponatremia and prevent its morbidity and death.
Short-Term Outcomes of Patients With Hyponatremia Presenting to the Emergency Department
Shekar et al. - 2024 - Short-Term Outcomes of Patients With Hyponatremia .pdf
Prevalence of hyponatremia among medically hospitalized patients and associated outcomes: a retrospective cohort study
BACKGROUND: Hyponatremia is a common electrolyte disturbance among hospitalized patients and is linked to increased mortality as well as poor outcomes. OBJECTIVES: Study the prevalence of hyponatremia among medically admitted patients and the outcomes associated with hyponatremia. DESIGN: Retrospective cohort. SETTING: Medical ward at tertiary hospital setting. PATIENTS AND METHODS: The study included adult (≥18 years) hospitalized patients in general medical wards. Three readings of serum sodium level were taken (initial sodium level, nadir during admission, and before discharge). SAMPLE SIZE AND BASIS: The sample size of 350 was determined based on a presumed 35% incidence of hyponatremia among hospitalized patients, with a 5% error margin. MAIN OUTCOME MEASURES: The prevalence of hyponatremia among medically hospitalized patients and association with health outcomes including length of hospital stay, inpatient mortality, 90-days readmission and 1-year mortality. RESULTS: In this study, 736 patients met the inclusion criteria. Of these, 377 (51.2%) had hyponatremia on admission, increasing to 562 (76.35%) during hospitalization. Mild hyponatremia was observed in 49.6% (n=365), moderate in 13.6% (n=100), and severe in 13.2% (n=97). Severe hyponatremia patients were significantly older (P<.01), predominantly female (P=.014), and had lower serum magnesium and albumin levels (P<.01). Hypertension, ischemic heart disease, heart failure, and diabetes were more prevalent in severe hyponatremia cases (P<.01, P<.01, P=.045, P<.01, respectively). Hospital stays were significantly shorter for patients with normal sodium levels (P<.01). Patients with severe hyponatremia had a shorter time for first hospital readmission (HR=0.80, P<.01 [95% CI; 0.69-0.94]). CONCLUSION: Hyponatremia was prevalent among medically hospitalized patients and more common among old patients, women, and patients with comorbidities. Hyponatremia was associated with increased length of stay in hospital and increased risk of 90-day re-admission. LIMITATIONS: Single-centre design and retrospective nature.
Prevalence of hyponatremia among medically hospitalized patients and associated outcomes