Multiple Antiepileptic Drugs Research Articles

Cannabinoids for paediatric epilepsy: Weeding out the issues.

Cannabinoids for paediatric epilepsy: Weeding out the issues.

Cross-sensitivity of patient-perceived adverse cognitive effects with antiepileptic drug use

ObjectiveThe extent to which adverse cognitive effects (ACEs) to a specific antiepileptic drug (AED) affect the chance of developing ACEs to other AEDs (i.e., cross-sensitivity) is unknown. We investigated the rates of cross-sensitivity of ACEs among AEDs and examined the association between clinical characteristics and occurrence of having ACEs to multiple AEDs in adults with epilepsy. MethodsThe rates of cross-sensitivity of intolerable ACEs (IACEs; i.e., ACEs leading to dosage reduction or discontinuation) and the non-AED predictors of IACEs were investigated in 2269 patients who had taken at least two AEDs at a single center. We accounted for AED load and looked for specific cross-sensitivities between AEDs as well as cross-sensitivity based on the AED mechanism of action. ResultsAmong the 2269 patients, the highest rates of IACEs were seen with TPM (26.3%), ZNS (9.8%), PHT (8.8%), and VPA (8.5%). Intolerable ACEs to two or more AEDs occurred in 100 patients (4.4%). History of psychiatric condition(s) and absence seizure type were independent predictors of IACEs to two or more AEDs. High rates of cross-sensitivity of IACEs were seen between phenytoin (PHT) and lamotrigine (LTG), valproate (VPA) and phenytoin, and valproate and zonisamide (ZNS). For example, of patients who had IACEs to VPA and were also prescribed ZNS, 46.2% had IACEs to ZNS (abbreviated as VPA→ZNS: 46.2%); of patients who had IACEs to ZNS and were also prescribed VPA, 37.5% had IACEs to VPA (abbreviated as ZNS→VPA: 37.5%). Other results are as follows: LTG→PHT: 28.6%, PHT→LTG: 20.0%, PHT→VPA: 42.9%, and VPA→PHT: 27.3%. No specific cross-sensitivities were found among AEDs sharing a similar mechanism of action. SignificanceThe probability of ACE intolerability to an AED can increase if a patient developed ACE intolerability to another AED. The cross-sensitivity rates for ACE intolerability between LTG and PHT, PHT and VPA, and VPA and ZNS were found to be particularly high. The cross-sensitivity rates provided here may be clinically useful for predicting ACE intolerability in patients taking certain AEDs and for AED selection in individual patients.

Use of Magnesium Sulfate Infusion for the Management of Febrile Illness-Related Epilepsy Syndrome: A Case Series.

Febrile illness-related epilepsy syndrome is a catastrophic epileptic encephalopathy that is highly refractory to most antiepileptic drugs leading to high morbidity and mortality. The authors report the use of a pediatric infusion protocol of continuous intravenous magnesium sulfate for the control of seizures in 2 children with febrile illness-related epilepsy syndrome refractory to multiple antiepileptic drugs in a pediatric intensive care unit of a tertiary care children’s hospital. Both patients, 2 and 16 years of age, respectively, were treated with continuous magnesium sulfate infusion. Serum magnesium concentrations ranging from 2.1 to 5 mmol/L were achieved. Seizure reduction and cessation were noted in 1 patient with magnesium more than 3.0 mmol/L. No significant adverse effects were observed. Magnesium sulfate infusions can be safely used in pediatric refractory status epilepticus. Magnesium sulfate can be considered in the management of children with febrile illness-related epilepsy syndrome.

I cannot stand this anymore!

A 28-year-old right-handed man presented with medically intractable focal reflex epilepsy. He previously underwent resection of a right parietal lobe cortical dysplasia. Postoperatively, he developed focal reflex epilepsy triggered by...

Factors Associated with Quality of Life in Adult Epilepsy Patients: a Hospital Based Study from South India

Background: Epilepsy is a chronic condition which affects quality of life (QOL). QOL is considered as an important outcome measure and component of management in studies of adult epilepsy. Objective: To evaluate factors associated with quality of life in adult epilepsy patients. Materials and Methods: A cross-sectional study was performed to examine the quality of life in 560 adult patients with epilepsy. The data collected included detailed clinical and socio-demographic data, epilepsy details, psychiatric diagnosis (ICD-10 for Mental and behavioral disorders), Liverpool seizure severity scale (LSSS) and Quality of life in epilepsy (QOLIE-31) are assessed. Descriptive statistics-Percentages, ANOVA, Univariate odds and Multiple Logistic Regression analysis with step-down procedure were done. Results: Study population comprised 337 males and 223 females with mean age of 29.26 + 10.83 (range 18-50) years. On Univariate Odds ratio (OR) (95% CI) for single anti-epileptic drug (AED) 2.75(1.85 to 4.09) and absence of psychiatric diagnosis 1.60(1.02 to 2.53) are predictors for good QOL. On one-way ANOVA with QOLIE subscales, seizure frequency and psychiatric diagnosis were found to be statistically significant (p<0.01) but no significant interaction between them. On Logistic Regression step down procedure, psychiatric diagnosis (OR 95% C.I) 7.29(1.65 to 32.10) and multiple AED 1.86(1.24 to 3.51) was found to be predicting factors for poor QOLIE. Conclusion: The presence of psychiatric diagnosis (Depression and Anxiety) was the strongest predictor of poor QOLIE patients. Early psychiatric evaluation and intervention would improve quality of life in epilepsy patients.

Antiepileptic drugs--a review.

Epilepsy is a common neurological condition that affects approximately 1% of the general population. In addition, about 10% of the population experiences a seizure sometime during life. The treatment options for epilepsy have come a long way from the bromides to the current era in which we now have multiple treatment modalities, including medications, implantable devices, and surgery. Antiepileptic drugs (AEDs) are the mainstay for treatment of epilepsy with about 70% of children achieving good control with medications alone. The past decade has witnessed the emergence of multiple AEDs-with more than 24 AEDs to choose from presently. The newer drugs provide us with novel mechanisms of action and improved safety profile. This expanded choice of AEDs has made it possible to offer tailored-treatment plans based on unique patient profiles. However, such an ever-increasing choice of medications also poses a challenge for the treating physician as far as choosing the initial drug is concerned-especially because there is limited data comparing the efficacy of one drug to the other. An additional humbling fact remains that, despite an increase in the choice of medications, we are still only able to treat the symptoms of seizures without making any significant progress in reversing or stopping the underlying mechanism of epileptogenesis or in offering neuroprotection from epileptogenesis. Therefore, it is not surprising that, despite the wide array of AED choices, the prevalence of drug-resistant epilepsy has not improved. This article aims at giving a short overview of currently available AEDs.

Recurrent status epilepticus as the primary neurological manifestation of CADASIL: A case report.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) often presents with a history of migraine with aura and eventual manifestations of dementia with unrelenting, repeated cerebral vascular insults. Only 6–10% of patients with CADASIL have been reported to develop seizures, and status epilepticus (SE) is exceedingly rare. Here, we describe a patient who presented with recurrent SE, with eventual biopsy diagnosis of CADASIL.An 80-year-old woman presented to our hospital three times in two years with decreased level of consciousness and subtle intermittent right-sided upper extremity and facial twitching. There was no known significant family history and no past medical history for seizures, stroke, migraine headache, or overt dementia. Electroencephalography revealed recurrent focal seizures with left hemispheric onset and evolution, fulfilling the criteria for focal SE each time. All three admissions required sedation with midazolam to control seizure activity, in addition to high doses of multiple antiepileptic drugs. Brain MRI repeatedly showed extensive abnormalities in the periventricular and deep white matter, subcortical white matter, and bilateral basal ganglia. Skin biopsy was obtained on the third admission, and electron microscopy showed numerous deposits of granular osmiophilic material, which are pathognomonic for CADASIL. Detailed investigations failed to reveal any other etiology for the patient's condition.This case illustrates the potential for nonconvulsive SE to be the sole manifestation of CADASIL. With the appropriate brain MRI findings, CADASIL should be added to the list of rare causes of SE.

Lamotrigine-Related Severe Cutaneous Adverse Reaction in Patient with Epilepsy

Background: Epilepsy is a common neurological disorder for which lamotrigine is an effective antiepileptic medication as monotherapy or as an add-on therapy with good tolerability and safety profile. Side effects, including serious skin reactions, can develop during treatment with lamotrigine and can be life threatening. The aim of this research is to study the local experience of adult Saudi patients with epilepsy who developed lamotrigine-related skin reactions. Methods: This observational retrospective study included all epilepsy patients who received lamotrigine and were followed up in the adult epilepsy clinic at King Fahad Hospital, Madinah, Saudi Arabia, between July 2011 and June 2014. Results: A total of 147 epilepsy patients received lamotrigine. Eleven patients (7.48%), aged 24 to 62 years old (mean 39.73 SD 11), of which 6 were male (54.5%) and 5 female (45.5%), developed cutaneous adverse drug reactions. Lamotrigine was used as monotherapy in one patient and as add-on therapy for 10 patients. Eight patients (72.73%) had high liver enzymes. Seven patients (63.6%) had systemic symptoms. Cutaneous adverse drug reactions were noted 1 to 4 weeks after lamotrigine initiation (mean=2.36, mode=3); 7 patients (63.63%) had maculopapular rashes, and 4 patients (36.37%) had urticaria. Six patients (54.5%) had good recovery; 1 patient developed sepsis; 2 patients developed hyperpigmentations; and 2 patients developed drug reactions with eosinophilia and systemic symptoms. Conclusion: Lamotrigine is an effective medication for management of epilepsy and other nervous system disorders, with a good tolerability and safety profile. However, lamotrigine-related cutaneous adverse drug reactions can be serious and healthcare providers’ thorough clinical knowledge of the potential side effects of lamotrigine is crucial in clinical practice particularly when patients receive multiple antiepileptic drugs.

Carnitine deficiency: Risk factors and incidence in children with epilepsy.

Carnitine deficiency is relatively common in epilepsy; risk factors reportedly include combination antiepileptic drug (AED) therapy with valproic acid (VPA), young age, intellectual disability, diet and enteral or parenteral feeding. Few studies have examined the correlation between each risk factor and carnitine deficiency in children with epilepsy. We examined the influence of these risk factors on carnitine deficiency, and identified a formula to estimate plasma free carnitine concentration in children with epilepsy. Sixty-five children with epilepsy and 26 age-matched controls were enrolled. Plasma carnitine concentrations were measured using an enzyme cycling assay, and correlations were sought with patients' other clinical characteristics. Carnitine deficiency was found in approximately 17% of patients with epilepsy and was significantly associated with carnitine-free enteral formula only by tube feeding, number of AEDs taken (independent of VPA use), body weight (BW), body height and Gross Motor Function Classification System (GMFCS) score. Stepwise multiple linear regression analysis indicated that carnitine concentration (in μmol/L) could be accurately estimated from a formula that does not require blood testing: 42.44+0.14×(BW in kg)-18.16×(feeding)-3.19×(number of AEDs), where feeding was allocated a score of 1 for carnitine-free enteral formula only by tube feeding and 0 for taking food orally (R(2)=0.504, P<0.001). Carnitine-free enteral formula only by tube feeding, multiple AED treatment and low BW are risk factors for carnitine deficiency in children with epilepsy. l-carnitine should be administered to children at risk of deficiency to avoid complications. Treatment decisions can be informed using an estimation formula that does not require blood tests.

Depression and anxiety in women with epilepsy during pregnancy and after delivery: A prospective population‐based cohort study on frequency, risk factors, medication, and prognosis

To assess incidence, prevalence, risk factors, and prognosis of peripartum depression and anxiety in a prospective study of women with epilepsy. Pregnancies in women with epilepsy (n=706) were compared to pregnancies in all women without epilepsy (n=106,511) including women with specified nonepileptic chronic diseases (n=8,372) in the Norwegian Mother and Child Cohort Study. The database was linked to the Medical Birth Registry of Norway. Depression and anxiety were assessed with validated questionnaires five times from the second trimester to 36 months after delivery. Blood was drawn for analysis of antiepileptic drug (AED) concentrations. Women with epilepsy more often had peripartum depression (26.7%) or anxiety (22.4%) than women without epilepsy (18.9% and 14.8%, respectively, p<0.001 for both comparisons) and women with other chronic diseases (23.1% and 18.4%, respectively, p=0.03 and 0.01). Women using AEDs during pregnancy were especially at risk regardless of AED type. The risk further increased with the use of multiple AEDs and with high doses and/or plasma levels. Risk factors associated with peripartum depression and/or anxiety in the epilepsy cohort were high seizure frequency, a history of physical and/or sexual abuse, adverse socioeconomic factors, previous loss of a child, AED use, unplanned pregnancy, and prepregnancy depression and/or anxiety. The recovery rate 3 years after delivery was lower for women with epilepsy with a history of depression/anxiety or physical/sexual abuse than for women without epilepsy. Depressed women with epilepsy were less frequently treated with antidepressive drugs during pregnancy than women without epilepsy. Women with epilepsy frequently have depression and anxiety during and after pregnancy. Patients at risk should be identified before delivery as depressive symptoms could be undertreated in this group.

Psychosocial factors and antiepileptic drug use related to delayed diagnosis of refractory psychogenic nonepileptic seizures.

We analyzed clinical and psychosocial factors in patients with refractory psychogenic nonepileptic seizures, seeking characteristics that could hasten diagnosis. Psychogenic nonepileptic seizures remain a diagnostic challenge. Prognosis is best if patients are treated within 2 years of symptom onset. Psychosocial factors have been shown to provide important information for differential diagnosis. Over a year and 1132 consecutive patients, our hospital's Epilepsy Unit suspected 93 patients of having psychogenic nonepileptic seizures and confirmed refractory psychogenic nonepileptic seizures in 67. We referred these patients to our psychiatric consultation unit for detailed diagnostic interviews, and 53 of the patients followed through. Two months after the psychiatric evaluation we gave them a psychiatric intervention, explaining the diagnosis and treating their comorbidities. We also tracked the patients' use of antiepileptic drugs for 3 months, from just before the psychiatric evaluation until a month after they started the intervention. Women, patients with an inadequate primary support group, and patients who had tried many antiepileptic drugs were most likely to have their diagnosis of psychogenic nonepileptic seizures delayed by >2 years after onset. A stepwise logistic regression showed that the 2 best predictors of late diagnosis were lack of availability of a primary support group and patients trying many antiepileptic drugs. Clinicians evaluating patients with questionable seizures should raise their suspicion of psychogenic nonepileptic seizures especially in female patients with an insufficient primary support group and a history of taking multiple antiepileptic drugs.

Post-Traumatic Epilepsy in Children—Experience From a Tertiary Referral Center

BackgroundPost-traumatic epilepsy after a traumatic brain injury occurs in 10%-20% of children. Unfortunately, a biomarker that could provide prognostic information about both post-traumatic epilepsy and cognitive development is lacking. In this first of a series of studies, we have reviewed and analyzed clinical variables in children following traumatic brain injury to understand the epidemiologic and clinical characteristics of post-traumatic epilepsy in our urban population. MethodsWe performed a retrospective electronic chart review of patients who had suffered traumatic brain injury and subsequently evaluated at Children's Hospital of Michigan from 2002 to 2012. Various epidemiologic and clinical variables were analyzed. ResultsPatients who had severe traumatic brain injury and post-traumatic epilepsy had an abnormal acute head computed tomography. These patients had increased number of different seizure types, increased risk of intractability of epilepsy, and were on multiple antiepileptic drugs. Hypomotor seizure was the most common seizure type in these patients. There was a high prevalence of patients who suffered nonaccidental trauma, all of whom had severe traumatic brain injury. ConclusionsThis study demonstrates a need for biomarkers in children following traumatic brain injury to reliably evaluate the risk of post-traumatic epilepsy.

Reversible homonymous hemianopia secondary to occipital lobe seizures

Occipital lobe infarcts, hemorrhages, or metastatic tumors can present with complex visual hallucinations, sensory or proprioceptive abnormalities, speech dysfunction, visual loss, and homonymous hemianopia (HH). Treatment of occipital lobe seizures is by single or multiple antiepileptic drugs. We present a case of idiopathic occipital lobe epilepsy where the seizures were controlled by antiepileptic drugs, but the HH did not subside until treated with high dose intravenous (IV) steroids.

Disseminated varicella zoster virus encephalitis

A 33-year-old homeless woman presented to the emergency room in September, 2012, with 2 days of dry cough, dyspnoea, and fever, and 1 week of pruritic rash. On examination she had a temperature of 41·0°C, blood pressure of 98/65 mm Hg, heart rate of 85 bpm, respiratory rate of 16 bpm, and O2 saturation of 47% on room air. She had a diff use papular rash with vesicles of diff erent ages with haemorrhagic crust aff ecting the trunk, extremities, face, and scalp, but sparing the palms and soles (fi gure). She had normal mental status, cranial nerves, motor, and sensory examination. Chest radiograph showed diff use bilateral airspace opacities. Within a few hours of presentation she suddenly became confused, with fl accid paralysis necessitating intubation and admission to the medical intensive care unit. Electroencephalogram showed non-convulsive status epilepticus. MRI brain showed multiple foci of punctate microhaemorrhages throughout the corpus callosum, both temporal lobes, and left posterior cingulate gyrus, consistent with infectious haemorrhagic encephalitis (fi gure). HIV testing was positive, with CD4 count 4 cells/μL (normal 348–1456 cells/μL), and viral load was 66 000 copies/mL (normal < 50 copies/mL). A skin biopsy sample stained positive for varicella zoster virus (VZV), but negative for herpes simplex virus (HSV). Zoster-associated encephalitis from disseminated VZV can develop within days of the disseminated rash, and should be strongly suspected in immunosuppressed patients. Characteristic signs of zoster-associated encephalitis include acute delirium, typical signs of stroke such as headache with acute hemiplegia, aphasia, ataxia, hemisensory loss, or visual changes, dependent on the predominant location of the VZV vasculitis. Intravenous aciclovir 10 mg/kg every 8 h for 7–10 days should be started early if there is clinical suspicion of encephalitis. Our patient was given intravenous aciclovir and multiple antiepileptic drugs to control her seizures. We treated her for VZV pneumonia, aspergillus pneumonia, propofolinduced pancreatitis, Escherichia coli urinary tract infection, and critical illness myopathy. After stabilisation in hospital she was started on antiretrovirals and pneumocystis pneumonia prophylaxis. After 2 months of rehabilitation she could walk independently and communicate without diffi culty. At last follow-up in March, 2014, she had made a near full recovery in terms of her cognitive and motor function. Lancet 2014; 384: 1698

Treatment strategy for the patient with hippocampal sclerosis who failed to the first antiepileptic drug.

Despite many epilepsy patients respond to antiepileptic drugs (AED) successfully, more than 30% of patients continue to have seizures on multiple AEDs. The refractory epilepsy increases the risk of cognitive deterioration, psychosocial dysfunction, and sudden unexpected death of epilepsy patients (SUDEP). It is important to identify refractory epilepsy early and make the goal of epilepsy treatment as the prevention of decline in social, vocational, and cognitive performances and minimizing the risk of accident or SUDEP. The syndrome of medial temporal lobe epilepsy with hippocampal sclerosis (MTLE with HS) is often resistant to AEDs, and surgically remediable. Initially well-controlled seizures often become intractable to AEDs. There are progressive behavioral changes including increasing memory deficit. Surgical outcome is also worse with longer duration of epilepsy or increasing age at surgery, which suggests that MTLE is a progressive disorder. Some emphasized the ultimate intractability of MTLE in which intractability of MTLE could be evident only after some years following initial diagnosis. However, when patients considered to have intractable epilepsy were followed up for a long period of time, many of them experienced seizure-free state. Some studies clearly demonstrated the wax and wane courses of treatment response in epilepsy. Late remission could be achieved up to in a half of patients. Thus intractable state is not a static condition but a fluctuating one and initial refractoriness does not necessarily mean the final intractability. Even though the chance of seizure remission with AEDs is not high for MTLE, some of them do well respond to drugs. It is even possible to withdraw AEDs for a few patients. Though epilepsy surgery is very effective method to treat MTLE, considering the fluctuation courses of intractability and the possibility of delayed remission, at least two adequate AEDs could be applied to the patients before surgery. However, medical intractability becomes evident by definition, it is not reasonable to delay epilepsy surgery.

Anterior corpus callosotomy in school-aged children with Lennox–Gastaut syndrome: A prospective study

AimsTo compare outcomes of anterior corpus callosotomy (CCT) with anti-epileptic drugs (AEDs) treatment in school-aged children with Lennox–Gastaut syndrome (LGS). MethodsSixty school-aged children with LGS were prospectively enrolled and divided into either the medicine or surgery group according the choice of the patients' caregivers. Cases in the medicine group were treated with multiple rational AEDs and patients in the surgery group underwent anterior CCT. Seizure control at 1–5 years after enrollment and changes of intelligence quotient (IQ) and quality of life (QOL) from pre-treatment to the 2-year follow-up were compared between the two groups. ResultsThe percentages of patients who were totally seizure-free in the surgery group were 17.4% at the 1-year follow-up, 13.0% at the 2-year follow-up and 8.7% at the 5-year follow up, and the data for patients in the medicine group were 2.9%, 5.9% and 2.9%, respectively. Significant differences were found in total seizure control between the two groups at 1, 2, and 5-year follow-up (personal χ2 test). Significant differences were found in mean changes of IQ and overall QOL between the medicine and surgery groups at the 2-year follow-up, showing positive results for the surgery group, but these changes were not related to postoperative outcomes of seizure control (t-test). ConclusionAnterior CCT is a promising treatment for school-aged children with LGS, and can present marked seizure control and improvement in QOL and IQ, all of which were significantly better than the effects of treatment with multiple AEDs.

Efficacy and safety of felbamate in children with refractory epilepsy

BackgroundDespite the introduction of multiple new antiepileptic drugs in the past two decades, many patients with epilepsy continue to experience uncontrolled seizures or significant side effects. AimTo present our experience with felbamate therapy in children with drug-resistant epilepsy. MethodsWe retrospectively reviewed the medical charts and video-EEG recordings of all patients receiving felbamate until May 2012. Efficacy was determined according to seizure frequency during the week prior to treatment initiation and the week after the maximal dosage of felbamate was reached. ResultsFifty patients (34 boys) aged 4 months to 17 years (mean – 5.5 years) were identified. Nearly third of the patients had Lennox–Gastaut syndrome. Mean epilepsy duration was 3.4 years (range – 1 month to 13 years). The mean number of previous antiepileptic drugs was 7.5. The mean duration of follow-up was 1.1 years. Seizure frequency decreased by at least 50% in 29 (58%) patients. Side effects were reported in 22 (44%) patients, none of them included aplastic anemia or liver failure. In the responder group, the maximal dose of felbamate was lower and the patients were older compared to non-responders. ConclusionsDespite current recommendations, felbamate is initiated following multiple AEDs. Based on its efficacy and safety data, earlier initiation of felbamate is recommended in children with refractory epilepsy.

Panayiotopoulos syndrome: A case series from Turkey

The aim of the study was to evaluate the demographic, clinical, and EEG characteristics of patients with Panayiotopoulos syndrome (PS) and the course of their illness.Thirty-eight patients followed up with a diagnosis of PS between January 2011 and December 2013 were evaluated.We found high rates of personal history of febrile convulsions, breath-holding spells, and family history of febrile convulsions, afebrile convulsion/epilepsy, migraine, and breath-holding spells. Seizures started before the age of eight in 87% of the patients, and the mean age at seizure onset was 4.6years. Seizures were sleep-related in 81.5%, and autonomic status was seen in a third of the patients. The number of seizures was between 2 and 10 in 66% of the patients. The most common symptoms were ictus emeticus, eye/head deviation, and altered consciousness. Rolandic features were seen in 26% of the patients, and visual symptoms in 5%. Multifocal epileptiform discharges on EEG were identified in 84% of the patients. Two or more antiepileptic drugs were required in only 13% of the patients. Evolution to electrical status epilepticus in sleep and Gastaut-type epilepsy were seen in patients with more than ten seizures.The high rates of febrile convulsions, afebrile convulsions/epilepsy, migraine, and breath-holding spells in the patients and families suggest the importance of genetic factors and, perhaps, a common pathogenesis. However, the high rates of febrile convulsions and breath-holding spells in patients can be related to a misdiagnosis because of the similar symptoms. Despite its disturbing symptoms, PS is a benign epileptic syndrome requiring multiple antiepileptic drug use only in a small proportion of patients.

Prevalencia de caídas, consumo de fármacos, presencia de enfermedades y calidad de vida de las personas mayores que viven en la comunidad

ObjectivesThis study has aimed to describe the prevalence of falls, presence of illnesses, drugs consumption, and quality of life and their association with falls among community-dwelling elderly people (ages 65 to 75). Material and methodsA cross-sectional, observational study was performed. We randomly selected 198 of 1214 community-dwelling people aged 65 to 75. Sociological data, illnesses, falls and health-related quality of life (HRQL) data were recorded with the EuroQol-5D (EQ-5D) protocol, use of multiple medication (medications>4), psychoactive medication and anticonvulsants. A bivariate analysis was made to assess the effect of the independent variables over tendency to fall. ResultsPrevalence of falls was 16.67%. Serious illnesses of the nervous system (OR=63.10), acute infections or inflammation (OR=3.72), severe limitation of mobility (OR=2.91) and having EQ-5D limitations were related to falls. Percentage of subjects with EQ-5D limitations was: mobility 34.1% (women: 42.4%, men 25.8%), self-care 14.4% (women: 19.8%; men 8.9%), usual activities 29.65% (women: 44.7%, men 14.1%), pain/discomfort 69.1% (women: 81.7%, men 56.9%) and anxiety/depression 35.1% (women: 50.0%, men 19.8%). EQ-5D's Visual Analogue Scale average score was 68.5±20.8 (women: 61.8±23.0, men 75.0±16.1.). ConclusionsThe prevalence of falls was 16.67%. We found a high percentage of polymedication, mobility problems, pain/discomfort, anxiety/depression and poor self-perceived HRQL among elderly people. Women declared more problems than men on all of the EQ-5D dimensions. We therefore recommend including programs aimed at improving mobility, and HRQL and that prevent risk of falls, with special attention on women.

Efficacy and safety of intravenous valproate for status epilepticus: a systematic review.

IntroductionThe effectiveness of valproate (VPA) in the treatment of focal and generalized epilepsies is well established. The drug has a wide spectrum of action, good tolerability, and has been available as an injectable formulation since 1993. Despite the lack of class A evidence, it has been used extensively in various forms of status epilepticus (SE).AimOur aim was to present a systematic review of data from randomized and non-randomized controlled trials to evaluate the efficacy and safety of intravenous VPA for the treatment of SE.MethodsData sources included MEDLINE, back tracing of references in pertinent studies, and contact with the manufacturer of VPA (Sanofi-Aventis).ResultsOverall, the search strategy yielded 433 results (425 MEDLINE, seven congress abstracts, one unpublished study); after excluding duplicate publications and case reports, 30 studies were identified (the earliest was published in 1993, the most recent in 2012); ten were controlled (six randomized controlled trials, four non-randomized controlled studies), and 20 uncontrolled trials (eight prospective observational studies, 12 retrospective case series). The cumulative literature describes the experiences of 860 patients with various forms of SE treated with intravenous VPA. The overall response rate to abrogate SE was 70.9 % (601/848; 95 % confidence interval [CI] 67.8–73.9). Response rates to intravenous VPA were better in children than in adults and did not differ between the SE types. The most commonly reported effective doses were between 15 and 45 mg/kg in bolus (6 mg/kg/min) followed by 1–3 mg/kg/h infusion. Safety studies of intravenous VPA administration in patients with SE showed a low incidence of adverse events overall (<10 %), mainly dizziness, thrombocytopenia, and mild hypotension, which was independent of infusion rates. Of note, good cardiovascular and respiratory tolerability was observed in these studies, even at high doses and fast infusion rates (up to 30 mg/kg at 10 mg/kg/min), despite multiple morbidities or other antiepileptic drugs. The most serious concern relates to the possibility of acute encephalopathy, sometimes related to hepatic abnormalities or hyperammonemia.ConclusionsThe published experience is consistent with VPA being a safe and effective therapeutic option for patients with established SE who have previously failed conventional first-line treatment with benzodiazepines, but high-quality randomized controlled trials are needed to inform clinicians on its comparative effectiveness in SE.