Morning Predominance Research Articles

Epilepsy with generalized tonic-clonic seizures alone: Electroclinical features and prognostic patterns.

Epilepsy with generalized tonic-clonic seizures alone (GTCA) is a common but poorly characterized idiopathic generalized epilepsy (IGE) syndrome. Hence, we investigated electroclinical features, seizure outcome, and antiseizure medication (ASM) withdrawal in a large cohort of GTCA patients. In this multicenter retrospective study, GTCA patients defined according to the diagnostic criteria of the International League Against Epilepsy (2022) were included. We investigated prognostic patterns, drug resistance at the last visit, and ASM withdrawal, along with their prognostic factors. We included 247 patients with a median (interquartile range [IQR]) age at onset of 17 years (13-22) and a median follow-up duration of 10 years (IQR = 5-20). Drug resistance at the last visit was observed in 40 (16.3%) patients, whereas the median latency to achieve 2-year remission was 24 months (IQR = 24-46.5) with a median number of 1 (IQR = 1-2) ASM. During the long-term follow-up (i.e., 202 patients followed ≥5-years after the first ASM trial), 69 (34.3%) patients displayed an early remission pattern and 36 (17.9%) patients displayed a late remission pattern, whereas 16 (8%) and 73 (36.3%) individuals had no-remission and relapsing-remitting patterns, respectively. Catamenial seizures and morning predominance of generalized tonic-clonic seizures (GTCS) independently predicted drug resistance at the last visit according to multivariable logistic regression. Treatment withdrawal was attempted in 63 (25.5%) patients, with 59 (93.7%) of them having at least a 12-month follow-up after ASM discontinuation. At the last visit, 49 (83%) of those patients had experienced GTCS recurrence. A longer duration of seizure freedom was the only factor predicting a higher chance of successful ASM withdrawal according to multivariable Cox regression. GTCA could be considered a relatively easily manageable IGE syndrome, with a low rate of drug resistance and a high prevalence of early response to treatment. Nevertheless, a considerable proportion of patients experience relapsing patterns of seizure control, highlighting the need for appropriate counseling and lifestyle recommendations.

Hyponatremia from oxcarbazepine: A case report

IntroductionOxcarbazepine (OXC) is an antiepileptic drug used as a mood stabilizer in patients diagnosed with bipolar disorder (BD). OXC has been reported as a source of hyponatremia in its use in both epilepsy and BD.ObjectivesWe present the case of a 53 year-old male patient diagnosed with Schizoaffective disorder, bipolar type who developed hyponatremia during his treatment with OXC.MethodsThe patient’s treatment was desvelafaxine 100 mg, Paliperidone depot 150 mg, Oxcarbazepine 600 mg which he had maintained for at least one year. He began to manifest headache, asthenia and mild confusion gradually, with morning predominance, without being clearly suggestive of an acute worsening.ResultsIn control analysis, the existence of sodium leveles of 127 and low osmolarity was observed. Therefore it was decided to suspend furosemide, close monitoring of water intake in order to rule out primary polydipsia and extra salt was introduced into the diet. Given the persistence of the symptoms, laboratory abnormalities and ruled out the existence of primary polydipsia, it was decided to suspend treatment with oxcarbazepine. After the discontinuation of the aforementioned drug the analytical findings went back to normal ranges and the symptoms disappeared.ConclusionsCarrying out control tests in patients with psychiatric pathology and multiple psychiatric treatments is essential to be able to rule out analytical alterations which could be asymptomatic or with nonspecific symptoms that could be attributed to the underlying pathology. The easy reversal of symptoms encourages us to emphasize the study and differential diagnosis of each case.DisclosureNo significant relationships.

Contemporary Impact of circadian symptom-onset patterns of acute ST-Segment elevation myocardial infarction on long-term outcomes after primary percutaneous coronary intervention

Background Daytime variation with regard to onset time of ST-elevation myocardial infarction (STEMI) symptoms has been observed. Nevertheless, with the advanced medical therapy, it is not uncertainty if a similar circadian pattern of STEMI symptom onset occurs, as well as its possible impact on clinical outcomes. Few long-term data are available. We assess the impact of circadian symptom-onset patterns of STEMI on major adverse cardiovascular events (MACE) in more contemporary patients treated with primary percutaneous coronary intervention (PPCI). Methods and results A total of 1099 consecutive STEMI patients undergoing PPCI ≤12h from symptom onset during 2013 to 2019 were classified into 4 groups by 6-h intervals according to time-of-day at symptom onset: night (0:00–5:59), morning (6:00–11:59), afternoon (12:00–17:59), and evening (18:00–23:59). Incidence of MACE including cardiovascular death and nonfatal MI during a median follow-up of 48 months was compared among the 4 groups. A morning peak of symptom onset of STEMI was detected during the period 06:00–11:59 (p < .001). Compared with other three 6-h intervals, the incidence of long-term MACE during night onset-time (18.8%, 10.1%, 10.7% and 12.4%, p = .020) was significant higher that was driven by more mortality (13.1%, 6.5%, 7.1%and 7.7%, p = .044). Night symptom-onset STEMI was independently associated with subsequent MACE (hazard ratio = 1.57, 95%CI: 1.09–2.27, p = .017) even after multivariable adjustment. Conclusions Circadian variation of STEMI symptom-onset with morning predominance still exists in contemporary practice. Night symptom-onset STEMI was independently associated with increased risk of MACE in Chinese patients treated with PPCI.

Trait impulsivity in Juvenile Myoclonic Epilepsy.

ObjectiveImpulsivity is a multidimensional construct that can predispose to psychopathology. Meta‐analysis demonstrates an association between response impulsivity and Juvenile Myoclonic Epilepsy (JME), a common genetic generalized epilepsy. Here, we test the hypotheses that trait impulsivity is (i) elevated in JME compared to controls; (ii) moderated by specific seizure characteristics; and (iii) associated with psychiatric adverse effects of antiepileptic drugs (AEDs).Methods322 participants with JME and 126 age and gender‐matched controls completed the Barratt’s Impulsiveness Scale (BIS‐brief) alongside information on seizure history and AED use. We compared group BIS‐brief scores and assessed associations of JME BIS‐brief scores with seizure characteristics and AED adverse effects.ResultsThe mean BIS‐brief score in JME was 18.1 ± 4.4 compared with 16.2 ± 4.1 in controls (P = 0.0007). Elevated impulsivity was associated with male gender (P = 0.027), frequent absence seizures (P = 0.0004) and lack of morning predominance of myoclonus (P = 0.008). High impulsivity significantly increased the odds of a psychiatric adverse event on levetiracetam (P = 0.036), but not any other psychiatric or somatic adverse effects.InterpretationTrait impulsivity is elevated in JME and comparable to scores in personality and neurotic disorders. Increased seizure frequency and absence of circadian seizure pattern moderate BIS score, suggesting disruption of both cortico‐striatal and thalamocortical networks as a shared mechanism between seizures and impulsivity in JME. These findings warrant consideration of impulsivity as a distinct target of intervention, and as a stratifying factor for AED treatment in JME, and perhaps other types of epilepsy. The role of impulsivity in treatment adherence and psychosocial outcome requires further investigation.

Presentation Times of Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance.

Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning. We hypothesized that there no longer is a morning predominance of MI, and that the timing of ST-elevation myocardial infarction (STEMI) vs. non-ST-elevation myocardial infarction (NSTEMI) presentation differs. We reviewed MI, STEMI, and NSTEMI patients (2013-2017) from a multiple-hospital system, identified by diagnostic codes. Daily emergency department arrival times were categorized into variable time intervals for count and proportional analysis, then examined for differences. There were 18,663 MI patients from 12 hospitals included in the analysis. Most MIs occurred between 12:00 pm and 5:59 pm (35.7%), and least between 12:00 am-5:59 am (16.3%). After subdividing all MIs into STEMIs and NSTEMIs, both groups continued to have the greatest presentation between 12:00 pm and 5:59 pm (33.1% and 36.0%, respectively). STEMIs (17.2%) and NSTEMIs (16.2%) were least frequent between 12:00 am and 5:59 am. We found the second most common presentation time for MIs was in the 6 pm-11:59 pm time period, whichheld true for both subtypes (MI 26.7%, STEMI 26.4%, NSTEMI 26.7%). These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.

Identificação da hora de início da sintomatologia de enfarte agudo do miocárdio

Background: Acute myocardial infarction is one of the leading causes of death in Portugal and worldwide. Several studies have shown a morning predominance of the onset of symptoms in this pathology. Objective: Describe the variation in onset of the infarction symptomatology and to analyze the average delay of admission in the emergency service of patients between 2015 and 2016 to a unit in northern Portugal. Methodology: Retrospective cross-sectional study. Fifty patients were studied, admitted to an emergency department diagnosed with acute myocardial infarction between 2015 and 2016 using clinical records. Results: The majority of participants were male (52%), with an average age of 79.6 years, presenting with hypertension (72%), dyslipidemia (54%), diabetes (46%), and obesity (20%). Onset time of acute myocardial infarction symptoms was generally between 6 a.m. and 12 p.m. (34%) and on average at 10 a.m. Conclusion: There was a predominance of symptom onset in the morning period

68 Presentation Times of STEMIs and Acute Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance

A number of previous studies have demonstrated a peak incidence of STEMI or acute myocardial infarction occurring in the morning between 6AM - 12PM. We hypothesized that there is no longer a morning predominance of STEMIs and acute myocardial infarctions based on the time of presentation to the emergency department. A retrospective review of patients with acute myocardial infarctions presenting to a multiple-hospital system were retrieved from electronic medical records for the years 2013-2017. We identified cases of STEMI and acute myocardial infarction by diagnostic codes and also collected their times of arrival to the emergency department. They were categorized into 4 time periods (12AM - 5:59AM, 6AM - 11:59AM, 12PM - 5:59PM, 6PM - 11:59PM). Chi-Square test for goodness of fit was used to compare presentation times of patients with STEMIs, and separately for all acute myocardial infarctions. We identified 18,663 myocardial infarctions which included 2,395 STEMIs from 11 hospitals. We found that 33.1% of STEMIs presented between 12PM - 5:59PM (χ2 = 124.6, p < 0.001), and 35.7% of myocardial infarctions during the same time period (χ2 = 1,534.8, p < 0.001). The second most prevalent time of presentation (6PM - 11:59PM) had 26.4% of the STEMIs and 26.7% of the myocardial infarctions. In the past 4 decades there have been significant changes in medical therapy and lifestyles that may have contributed to a shift in the circadian pattern of STEMIs and acute myocardial infarctions. This cohort demonstrates there may be a shift in this circadian pattern to later in the day, with the highest prevalence occurring between 12PM - 5:59PM, followed by 6PM - 11:59PM. This is significantly different from what was previously reported.

P16.21 Medulloblastoma in adult: a case report and literature review

Introduction: Medulloblastoma is an embryonic tumor mainly located at the level of structures derived from the myelencephalon. It is the most common malignant tumor in children with a prevalence of 15-20% of intracranial tumors. In adult constitutes less than 1% of encephalic tumors. Method: The authors report a case of a 34 years old woman, who started complaining of occipital headache with morning predominance that prompted several visits to general emergency, with no other focal neurological signs. The clinical and imagiological investigation revealed a left cerebellar hemisphere lesion with about 40 mm larger diameter, heterogeneous signal capture T2, with apparent implantation base on the tentorium and edema that determinated partial collapse of the IV ventricle. Meningioma, pilocytic astrocytoma, glioma, cerebellar abscess, hemangioblastoma and metastasis were considered in the diferential diagnosis. The patient underwent total excision of well-defined contours lesion with lower tentorial insertion. Results: Pathological examination was consistent with medulloblastoma with neuronal and glial differentiation, IV grade (WHO classification). Postoperatively she presented loca haematoma with associated edema, conditioning acute hydrocephalus. The patient was reoperated with hematoma drainage and placement of external ventricular drainage. She has a follow-up of 2 years, with no evidence of recurrence or tumor dissemination. Karnofski performance score of 100% Conclusions: Although Medulloblastoma is a relatively rare brain lesion it should be considered in the differential diagnosis of posterior fossa tumors. The diagnosis is histological only and in cases of a high grade lesions maximum excision is indicated, once complete recession is the strongest good prognostic factor in this pathology.

Time‐of‐Day Predominance of Allergic Rhinitis Symptoms during Treatment with Intranasal Ciclesonide 200 mcg qd

Objectives: (1) Effectiveness of intranasal ciclesonide 200 mcg qd (CIC). (2) Time-of-day predominance (TDP) of nasal and nonnasal AR symptoms. TDP is the main focus of this report. Methods: Phase IV, open-label, noninterventional study. Patients aged 12 years with at least a 2-year history of AR were eligible; 1526 patients with active AR were enrolled and received CIC during 4 weeks. TDP was recorded by patients and classified as: Morning, noon, afternoon, night or none. TDP was evaluated at T0 (basal), once daily during the first treatment-week, and once a week during the rest of the study (weeks 2 to 4). Relative frequencies of AR symptoms were calculated with corresponding 95% confidence intervals. Differences between basal TDP-relative frequency and at treatment-days 7 and 28, were calculated using z test. Results: All symptoms were of morning predominance at baseline, for example, runny nose 51%, nasal congestion 51%, sneezing 49%. Morning predominance remained the highest for all evaluated symptoms during CIC-treatment period, but its frequency decreased after 7 and 28 treatment-days; as a result, the no-predominance category increased in frequency during the follow-up. Symptoms showed relative lower probability density after treatment as compared with basal evaluation: Between 0.53 and 0.57 at treatment day 7, and between 0.34 and 0.38 at day 28. All P values (z test) were &lt;.001. Conclusions: In this study, TDPs for individual AR symptoms are described in a Mexican population. Treatment with CIC helps to reduce morning predominance of AR symptoms, and increases the asymptomatic state after 4 weeks of treatment.

Wake-up stroke and stroke of unknown onset: a critical review.

Patients, who wake up with an ischemic stroke, account for a large number of the total stroke population, due to circadian morning predominance of stroke. Currently, this subset of patients is excluded from revascularization-therapy since no exact time of onset is known. A large group of these patients might be eligible for therapy. In this review, we assessed the current literature about the hypothesis that wake-up-strokes occur just prior on awakening and if this subgroup differs in characteristics compared to the overall stroke population. We looked at the safety and efficacy of thrombolysis and interventional techniques in the group of patients with unknown stroke-onset. We performed a meta-analysis of the diagnostic accuracy of the diffusion-FLAIR mismatch in identifying stroke within 3 and 4.5 h. The different imaging-selection criteria that can be used to treat these patients are discussed. Additional research on imaging findings associated with recent stroke and penumbral imaging will eventually lead to a shift from a rigid time-frame based therapy to a tissue-based individualized treatment approach.

PII: S1525-5050(12)00697-X

Most murine and rodent epilepsy syndromes provide models for absence epilepsies. The baboon, on the other hand, not only provides a model of photosensitive generalized epilepsy but closely resembles a common form of idiopathic generalized epilepsy, namely juvenile myoclonic epilepsy (JME). Baboons, regardless of subspecies, exhibit rare spontaneous generalized seizures: myoclonic and generalized tonic-clonic seizures; the seizures present in adolescence occurring with morning predominance. In addition to intermittent light stimulation (ILS), seizures can be triggered by stress and handling as well as by proconvulsant medications. Absence seizures also occur, but they are less prevalent in baboons than in people with JME. On scalp EEG, interictal epileptic discharges are commonly generalized spike-and-wave discharges of 4- to 6-Hz frequency, rarely 2- to 3-Hz frequency. These can be activated by sleep and medications, including low-dose ketamine. The prevalence of photosensitivity in baboons is 38%, which is similar to its prevalence in human JME. Antiepileptic medications have mainly been tested with respect to reduction of ictal or interictal discharges provoked by ILS, with similar AED profiles proved to be efficacious in suppressing photoparoxysmal and convulsive responses as generalized seizures in JME. As a potential model for JME, the baboon provides the opportunity to correlate functional and structural neuroimaging findings with invasive electrophysiology and histopathology. This presentation reviews preliminary imaging, intracranial EEG and histopathological data recently acquired in this animal model by our laboratory, and discusses the potential relevance to mechanisms underlying JME.

Síndrome confusional agudo en pacientes ancianos ingresados por patología médica

Delirium or acute confusional syndrome (ACS) is a frequent problem during hospitalization of elderly patients. We study the appearance of delirium and its characteristics in patients admitted to an internal medicine service.Prospective study of 148 patients over 64 years admitted due to medical condition (non-surgical) in the internal medicine service of the University Hospital of Bellvitge. Functionality was quantified with the Barthel index (BI) and comorbidity with the Charlson index (CI). The Confusional Assessment Method was used for the diagnosis of the ACS.Seventy-seven (77) (52%) of the 148 patients were women, with a mean age of 78.5 years. The CI was 2.2. Mean of previous BI was 81.7. Mortality during admission was 8% (12 patients). A total of 42.5% of the patients (63) had ACS (30% prevalent). It was hyperactive in 68%, hypoactive in 16% and mixed in 16%. In 38% of the patients, the ACS had morning predominance and 62% it appeared after the evening. Advanced age was the only significant differences between patients with or without ACS (p < 0.001). There were no significant differences in the ACS percentage between patients who survived or who died (p = 0.36).Frequency of appearance of the confusional picture is high in patients admitted to acute hospitals, it being more frequent in the elderly. Measures to prevent the confusional picture in elderly patients who are hospitalized should be increased.