Core outcome measurement set for research and clinical practice in post-COVID-19 condition (long COVID) in children and young people: an international Delphi consensus study "PC-COS Children"

The coronavirus disease 2019 (COVID-19) pandemic substantially impacted different age groups, with children and young people not exempted. Many have experienced enduring health consequences. Presently, there is no consensus on the health outcomes to assess in children and young people with post-COVID-19 condition. Furthermore, it is unclear which measurement instruments are appropriate for use in research and clinical management of children and young people with post-COVID-19. To address these unmet needs, we conducted a consensus study, aiming to develop a core outcome set (COS) and an associated core outcome measurement set (COMS) for evaluating post-COVID-19 condition in children and young people. Our methodology comprised of two phases. In phase 1 (to create a COS), we performed an extensive literature review and categorisation of outcomes, and prioritised those outcomes in a two-round online modified Delphi process followed by a consensus meeting. In phase 2 (to create the COMS), we performed another modified Delphi consensus process to evaluate measurement instruments for previously defined core outcomes from phase 1, followed by an online consensus workshop to finalise recommendations regarding the most appropriate instruments for each core outcome. In phase 1, 214 participants from 37 countries participated, with 154 (72%) contributing to both Delphi rounds. The subsequent online consensus meeting resulted in a final COS which encompassed seven critical outcomes: fatigue; post-exertion symptoms; work/occupational and study changes; as well as functional changes, symptoms, and conditions relating to cardiovascular, neuro-cognitive, gastrointestinal and physical outcomes. In phase 2, 11 international experts were involved in a modified Delphi process, selecting measurement instruments for a subsequent online consensus workshop where 30 voting participants discussed and independently scored the selected instruments. As a result of this consensus process, four instruments met a priori consensus criteria for inclusion: PedsQL multidimensional fatigue scale for "fatigue"; PedsQL gastrointestinal symptom scales for "gastrointestinal"; PedsQL cognitive functioning scale for "neurocognitive" and EQ-5D for "physical functioning". Despite proposing outcome measurement instruments for the remaining three core outcomes ("cardiovascular", "post-exertional malaise", "work/occupational and study changes"), a consensus was not achieved. Our international, consensus-based initiative presents a robust framework for evaluating post-COVID-19 condition in children and young people in research and clinical practice via a rigorously defined COS and associated COMS. It will aid in the uniform measurement and reporting of relevant health outcomes worldwide.

Prevalence of ictal injuries in functional (psychogenic nonepileptic) seizures: A systematic review and meta-analysis

OBJECTIVE

Ictal injuries have long been considered typical signs of epileptic seizures. However, studies have shown that patients with functional seizures (FS)-also named psychogenic nonepileptic seizures-can also present these signs, misleading physicians and delaying a correct diagnosis. This systematic review aimed to assess the prevalence of injuries from FS.

METHODS

A literature search was performed in PubMed, Embase, LILACS (Latin American and Caribbean Health Sciences Literature), Scopus, Web of Science, PsycINFO, Google Scholar, OpenGrey, and ProQuest. Observational studies were included. The risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist for studies reporting prevalence data. RStudio was used for meta-analyses. Cumulative evidence was evaluated according to Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria.

RESULTS

From the 2607 identified records, 41 studies were included in the qualitative synthesis, and 28 were included in meta-analyses. A meta-analysis of 13 studies, including 1673 individuals, resulted in an overall lifetime prevalence of injuries due to FS per person of 25% (95% confidence interval [CI] = 19%-32%, I2  = 88%). Considering a limited period (video-electroencephalographic [VEEG] monitoring days), a meta-analysis of 13 studies, including 848 individuals, resulted in an injury prevalence due to FS per person of .7% (95% CI = 0%-3%, I2  = 73%). Also, a meta-analysis of eight studies, including 1000 individuals, resulted in a prevalence of injuries per FS of .1% (95% CI = 0%-.98%, I2  = 49%). The certainty in cumulative evidence assessed by GRADE was rated "very low" for lifetime prevalence of injuries per person, "low" for prevalence per person during VEEG monitoring, and "moderate" for prevalence per number of FS.

SIGNIFICANCE

Overall pooled lifetime prevalence of injuries due to FS per person was 25%. In comparison, the prevalence of injuries per person during VEEG monitoring and per functional seizure was .7% and .1%, respectively. [Correction added on 07 October 2023, after first online publication: In the preceding sentence, 'consecutively' was corrected to 'respectively'.] The evidence of the occurrence of injuries due to FS breaks the paradigm that epileptic seizures can cause injuries but FS cannot.

Association of Human Leukocyte Antigen Alleles with Carbamazepine- or Lamotrigine-Induced Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in an Iranian Population: A Case-control Study

Background

Genetic diversity in human leukocyte antigen (HLA) alleles across populations is a significant risk factor for drug-induced severe cutaneous adverse reactions (SCARs), e.g., carbamazepine (CBZ)- and lamotrigine (LTG)-induced Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). The present study aimed to investigate the frequency of different HLA alleles in Iranian patients with CBZ- and LTG-induced SJS/TEN.

Methods

A case-control study was conducted from 2011 to 2018 at various hospitals affiliated with Shiraz University of Medical Sciences (Shiraz, Iran). A total of 31 patients receiving anticonvulsant drugs (CZB or LTG) were recruited and divided into two groups. The drug-induced group (n=14) included hospitalized patients due to CBZ- or LTG-induced SJS/TEN. The drug-tolerant group (n=17) included individuals receiving CBZ or LTG for at least three months with no adverse effects. In addition, 46 healthy individuals (control group) were recruited. The frequency of HLA-A, -B, and -DRB1 alleles in patients with CZB- or LTG-induced SJS/TEN was investigated. HLA typing was performed using the allele-specific polymerase chain reaction method. The Chi square test and Fisher's exact test were used to determine a potential association between SJS/TEN and HLA alleles. P<0.05 was considered statistically significant.

Results

CBZ- or LTG-induced SJS/TEN was not significantly associated with HLA alleles. However, HLA-DRB1*01 showed a significantly higher frequency in patients with CBZ-induced SJS/TEN than the CBZ-tolerant patients (30% vs. 9%, P=0.07).

Conclusion

Overall, no significant association was found between CBZ- or LTG-induced SJS/TEN and HLA alleles. Further large-scale studies are required to substantiate our findings.

Seizure rescue medications are missing from in-flight medical emergency kits

OBJECTIVE

We aimed to inquire whether any seizure rescue medications are included in the in-flight medical emergency kits of the main airlines in the world. This data could help the airline authorities update their strategies in light of any shortcomings.

METHODS

First, we identified ten major airlines in the world. Then, we searched the Google engine with the following keywords: "name of the airline" and "in-flight medical emergency" or "first aid kit" or "emergency kit". In case there was no information on the web, we emailed the airlines and inquired about the contents of their in-flight medical emergency kits. We also investigated some of the major aviation organizations' websites [i.e., Aerospace Medical Association (AsMA), International Civil Aviation Organization (ICAO), and International Air Transport Association (IATA)].

RESULTS

None of the major airlines were equipped with easily applicable seizure rescue medications (i.e., buccal midazolam, a nasal spray of midazolam, or intranasal diazepam). The AsMA and ICAO recommend including injectable sedative anticonvulsant drugs in the in-flight medical emergency kits without any further specifications. The IATA does not provide specific recommendations for including seizure rescue medications in the in-flight medical emergency kits.

CONCLUSION

A seizure is a significant in-flight medical emergency event. The use of easily applicable seizure rescue medications during prolonged or repeated seizures is significantly associated with fewer sequelae for the affected person. Easily applicable seizure rescue medications should be included in the in-flight medical emergency kits, and the cabin crew should receive training on how and when to use them.

Is Shunt Location a Risk Factor for the Development of De Novo Post-shunt Seizures?

Background

While ventriculo-extracranial shunting procedures have been the standard treatment option for hydrocephalus for a long time, their long-term morbidity, including the development of post-shunt de Novo seizures, should be taken into account. This study aimed to investigate the rate and risk factors of the occurrence of de Novo post-shunt seizures in patients with hydrocephalus.

Methods

In this retrospective longitudinal study, all patients with hydrocephalus who had ventriculo-peritoneal shunt insertion from 2014 to 2017 at Namazi Hospital, (Shiraz, Iran) were studied. Phone calls were made to all patients to obtain their postoperative seizure outcome and other data (e.g., sex, age at surgery, shunt insertion location, history of seizures before surgery, history of seizures after surgery, any other type of brain surgery, and the etiology of their hydrocephalus). The Pearson Chi Square was used for the analysis of binary variable (e.g., sex) differences, and the t test for the analysis of differences in the means of numerical variables (e.g., age). Bonferroni correction tests were also utilized. P values less than 0.05 were considered significant.

Results

A total of 114 patients were included in the study. Overall, 68 (60%) patients had a frontal location of shunt insertion and 46 (40%) had a parietal site. Twenty-four (21%) patients reported experiencing de Novo post-shunt seizures, 15 of which had a frontal location and nine a parietal location for shunt insertion (P=0.824).

Conclusion

De Novo post-shunt seizures are common occurrences. However, shunt location is not a significant risk factor for the development of de Novo post-shunt seizures.

Volumetric Assessment of Extratemporal Structures in Patients With Temporal Lobe Epilepsy

Background: We assessed the presence of brain volume loss in the extratemporal structures in patients with temporal lobe epilepsy (TLE). The associations between brain volume loss in these structures and epilepsy duration, magnetic resonance imaging (MRI) findings, and occurrence of focal to bilateral tonic-clonic seizures (TCS) were assessed. Methods: In this cross-sectional study, all adult patients with drug-resistant TLE, who were admitted to the epilepsy monitoring unit at Loghman-Hakim Hospital, Tehran, Iran, during 2016-2020, were included. For all the participants, brain MRI was performed and patients with TLE were divided into two subgroups of those with hippocampal sclerosis (TLE-HS) and patients with normal-appearing brain MRI findings (TLE-no). Independent sample t test was applied to compare quantitative variables in the study groups. Pearson correlation test examined the correlation between the clinical and volumetric features. Results: 203 participants (81 patients with TLE and 122 healthy controls) were studied. Compared with healthy controls, patients with TLE showed a decrease in their midbrain (P=0.02) and thalamus (P=0.01) volume. The degree of thalamic atrophy was more significant in TLE-HS (P=0.03). Moreover, the degree of midbrain volume loss was more significant (P=0.07) in patients who had TCS in the past two years (N=31) compared with those who did not (N=50). The volume of the thalamus (r: -0.252, P=0.02) and pallidum (r: -0.255, P=0.02) had inverse correlations with the epilepsy duration. Conclusion: Patients with TLE have lower midbrain and thalamus volume compared with the healthy controls, which may be attributed to the seizure-induced injury. Midbrain atrophy may theoretically increase the risk of sudden unexpected death in epilepsy (SUDEP) because of the enhanced autonomic dysfunction.

Risk Factors Associated with Long COVID Syndrome: A Retrospective Study

Background

Recently, people have recognized the post-acute phase symptoms of the COVID-19. We investigated the long-term symptoms associated with COVID-19, (Long COVID Syndrome), and the risk factors associated with it.

Methods

This was a retrospective observational study. All the consecutive adult patients referred to the healthcare facilities anywhere in Fars province from 19 February 2020 until 20 November 2020 were included. All the patients had a confirmed COVID-19 diagnosis. In a phone call to the patients, at least three months after their discharge from the hospital, we obtained their current information. The IBM SPSS Statistics (version 25.0) was used. Pearson Chi square, Fisher's exact test, t test, and binary logistic regression analysis model were employed. A P value of less than 0.05 was considered to be significant.

Results

In total, 4,681 patients were studied, 2915 of whom (62.3%) reported symptoms. The most common symptoms of long COVID syndrome were fatigue, exercise intolerance, walking intolerance, muscle pain, and shortness of breath. Women were more likely to experience long-term COVID syndrome than men (Odds Ratio: 1,268; 95% Confidence Interval: 1,122-1,432; P=0.0001), which was significant. Presentation with respiratory problems at the onset of illness was also significantly associated with long COVID syndrome (Odds Ratio: 1.425; 95% Confidence Interval: 1.177-1.724; P=0.0001). A shorter length of hospital stay was inversely associated with long COVID syndrome (Odds Ratio: 0.953; 95% Confidence Interval: 0.941-0.965; P=0.0001).

Conclusion

Long COVID syndrome is a frequent and disabling condition and has significant associations with sex (female), respiratory symptoms at the onset, and the severity of the illness.

Psychological Problems Among Patients With Chronic Medical Disorders During the COVID-19 Pandemic

The aim of the current study was to investigate the rates of stress, anxiety, and depression among people in south Iran (a group from the general population without a history of any chronic medical problems, and cohorts of patients were recruited from epilepsy, diabetes, and cardiac disease clinics). We surveyed a sample of people during September 2020: a group of the general population without a history of any chronic medical problems, people with epilepsy, people with diabetes mellitus (DM), and people with cardiac problems. The survey included four general questions and two COVID-19 specific questions [contracting COVID-19, relatives with COVID-19]. Furthermore, the survey included the DASS (Depression-Anxiety-Stress Scale)-21 questionnaire. 487 people were surveyed (154 people with epilepsy, 127 patients with DM, 98 people with cardiac problems, and 108 healthy individuals). Among people without a history of any chronic medical illnesses, 14% had any psychological problems. The highest rates of depression and anxiety were observed among patients with DM (52% and 57%, respectively), and the highest rate of increased stress was observed among people with cardiac problems (40%). The existence of any underlying medical problem was significantly associated with higher rates of depression, anxiety, and stress among the participants. While many patients with underlying chronic medical conditions suffer from depression, anxiety, and stress during the COVID-19 pandemic, we cannot establish a cause and effect relationship between the COVID-19 pandemic and increased psychological problems among these patients.

The initial impact of the SARS-CoV-2 pandemic on epilepsy research

The COVID-19 pandemic has changed the face of many practices throughout the world. Through necessity to minimize spread and provide clinical care to those with severe disease, focus has been on limiting face-to-face contact. Research in many areas has been put on hold. We sought to determine the impact of the COVID-19 pandemic on epilepsy research from international basic science and clinical researchers. Responses to five questions were solicited through a convenience sample by direct email and through postings on the ILAE social media accounts and an ILAE online platform (utilizing Slack). Information was collected from 15 respondents in 11 countries by email or via Zoom interviews between May 19, 2020, and June 4, 2020. Several themes emerged including a move to virtual working, project delays with laboratory work halted and clinical work reduced, funding concerns, a worry about false data with regard to COVID research and concern about research time lost. However, a number of positive outcomes were highlighted, not least the efficiency of online working and other adaptations that could be sustained in the future.

Burnout among Healthcare Providers of COVID-19; a Systematic Review of Epidemiology and Recommendations

INTRODUCTION

In the current systematic review, we intended to systematically review the epidemiology of burnout and the strategies and recommendations to prevent or reduce it among healthcare providers (HCPs) of COVID-19 wards, so that policymakers can make more appropriate decisions.

METHODS

MEDLINE (accessed from PubMed), Science Direct, and Scopus electronic databases were systematically searched in English from December 01, 2019 to August 15, 2020, using MESH terms and related keywords. After reading the title and the abstract, unrelated studies were excluded. The full texts of the studies were evaluated by authors, independently, and the quality of the studies was determined. Then, the data were extracted and reported.

RESULTS

12 studies were included. Five studies investigated the risks factors associated with burnout; none could establish a causal relationship because of their methodology. No study examined any intervention to prevent or reduce burnout, and the provided recommendations were based on the authors' experiences and opinions. None of the studies followed up the participants, and all assessments were done according to the participants' self-reporting and declaration. Assessing burnout in the HCPs working in the frontline wards was performed in four studies; others evaluated burnout among all HCPs working in the regular and frontline wards.

CONCLUSION

Paying attention to the mental health issues, reducing the workload of HCPs through adjusting their work shifts, reducing job-related stressors, and creating a healthy work environment may prevent or reduce the burnout.

Epilepsy and school in the Middle East and North Africa (MENA) region: The current situation, challenges, and solutions

Education is a human right that plays a key role in social and economic development. Children having active epilepsy may not be properly schooled in ordinary school structures. Students with epilepsy (SWE) are often faced with academic barriers. The lack of information about the current status of special education for SWE obliged the researchers to try to describe the existing reality of the special education practices in the Middle East and North Africa (MENA) region. We disseminated a simple self-administered questionnaire via email to main healthcare professionals involved in epilepsy care in the MENA region, and we also did a literature search on the PubMed, Google Scholar, and Embase engines. We ranked the countries in terms of their educational system. The 1st group contains the most advanced educational system, including specialized schools for SWE. The 2nd group contains an educational system with specialized but less structured schools. The 3rd group includes countries using integrated classes or classes mixing many children with cognitive disabilities. The 4th group includes countries with ordinary classes for SWE, and finally, the 5th group with no schooling for children with epilepsy (CWE). This study indicates that 60% of the countries in the MENA region belong to the 3rd group; there is only one country in each of the first two groups. This work highlights the need to develop structured environments for schooling for SWE in the MENA region.

22 Whole-brain functional connectivity based on the graph theory analysiisn Psychogenic Non-Epileptic Seizures (PNES)

Objective

Despite being the subject of many studies over the past two decades, mechanisms underlying psychogenic non-epileptic seizures (PNES) are still poorly understood. We tried to address this issue by utilizing brain functional connectivity analysis to identify brain regions with abnormal activities in patients with PNES. In a case-control study, we performed graph based network analysis, a robust technique that determines the organization of brain connectivity and characterizes topological properties of the brain networks.

Methods

Twelve individuals with PNES and twenty-one healthy control subjects were examined. Resting state functional magnetic resonance imaging (rsfMRI) was acquired. All subjects were asked to keep their eyes open during the scanning process. The rsfMRI analysis consisted of pre-processing, extracting the functional connectivity matrix (FCM) based on the AAL atlas, threshold for binary FCM, constructing a graph network from FCM and extracting graph features, and finally statistical analysis. For all cortical and subcortical regions of the AAL atlas, we calculated measures of ‘degree,’ which is one of the features of the graph theory. Results: Our results revealed that, as compared to the healthy control subjects, patients with PNES had a significantly lower degree in some brain regions including their left and right insula (INS), right Putamen (PUT), left and right Supramarginal gyrus (SMG), right Middle occipital gyrus (MOG), and left and right Rolandic operculum (ROL). In contrast, degree was significantly greater in two regions [i.e., right Caudate (CAU) and left Inferior frontal gyrus orbital part (ORBinf)] in patients with PNES compared to that in controls.

Conclusion

Our findings suggest that functional connectivity of several major brain regions are different in patients with PNES compared with that in healthy individuals. While there is hypoactivity in regions important in perception, motor control, self- awareness, and cognitive functioning (e.g., insula) and also movement regulation (e.g., putamen), there is hyperactivity in areas involved in feedback processing (i.e., using information from past experiences to influence future actions and decisions) (e.g., caudate) in patients with PNES. The observation that individuals with PNES suffer from a wide range of abnormal activities in functional connectivity of their brain networks is consistent with the fact that PNES occur in a heterogeneous patient population; no single mechanism or contributing factor could explain PNES in all patients.

Lateralized hippocampal oscillations underlie distinct aspects of human spatial memory and navigation

The hippocampus plays a vital role in various aspects of cognition including both memory and spatial navigation. To understand electrophysiologically how the hippocampus supports these processes, we recorded intracranial electroencephalographic activity from 46 neurosurgical patients as they performed a spatial memory task. We measure signals from multiple brain regions, including both left and right hippocampi, and we use spectral analysis to identify oscillatory patterns related to memory encoding and navigation. We show that in the left but not right hippocampus, the amplitude of oscillations in the 1–3-Hz “low theta” band increases when viewing subsequently remembered object–location pairs. In contrast, in the right but not left hippocampus, low-theta activity increases during periods of navigation. The frequencies of these hippocampal signals are slower than task-related signals in the neocortex. These results suggest that the human brain includes multiple lateralized oscillatory networks that support different aspects of cognition.

Theta oscillations are implicated in memory formation. Here, the authors show that low-theta oscillations in the hippocampus are differentially modulated between each hemisphere, with oscillations in the left increasing when successfully learning object–location pairs and in the right during spatial navigation.

The epidemiology, risk factors, and impact on hospital mortality of status epilepticus after subdural hematoma in the United States

Introduction

Subdural hematoma (SDH) is a well described risk factor in the development of Status Epilepticus (SE), however the epidemiology of SE after SDH is unknown. In this study, we sought to determine the epidemiology of SE, the prevalence of risk factors, and impact on hospital mortality using a large administrative dataset.

Methods

Data was derived from the Nationwide Inpatient Sample from 1988 through 2011. We queried the NIS database for patients older than 18 years, with a diagnosis of SDH and SE. Diagnoses were defined by ICD 9 CM codes 432.1, 852.2, 852.3 and 345.3 for SE. Adjusted incidence rates of admission and prevalence proportions were calculated. Multivariate logistic models were then fitted to assess for the impact of status epilepticus on hospital mortality.

Results

Over the 23-year period, we identified more than 1,583,255 admissions with a diagnosis of SDH. The prevalence of SE in this cohort was 0.5% (7,421 admissions). The population adjusted incidence rate of admissions of SDH increased from 13/100,000 in 1988 to 38/100,000 in 2011. The prevalence of SE in SDH, increased from 0.5% in 1988 to 0.7% in 2011. In hospital mortality of patients with SDH and without SE decreased from 17.9% to 10.3% while in hospital mortality of patients with SDH and SE did not statistically change. Mortality increased over the same period (2.3/100,000 in 1988 to 3.9/100.000 in 2011) and the diagnosis of SE increased mortality in this cohort (OR 2.17, p < 0.0001). The risk of SE remained stable throughout the study period, but was higher among older patients, blacks, and in those with respiratory, metabolic, hematological, and renal system dysfunction.

Conclusion

Our study demonstrates that the incidence of admissions of SDH is increasing in the United States. Despite a decline in the overall SDH related mortality, SE increased the risk of in-hospital death in patients with a primary diagnosis of SDH.

Management of epilepsy in resource-limited settings: establishing an epileptic surgery program in Southern Iran

Background:

The most common treatment modality for epileptic patients is antiepileptic drug (AED) therapy. However, more than 30% of epileptic patient suffers from drug-resistant epilepsy despite the use of appropriate AEDs. Surgery is a common option for these patients. Epilepsy surgery requires sophisticated medical technologies, many of them not available in Iran. The authors of the present study aim to report the clinical and technical issues of establishing an epilepsy surgery protocol in Iran and the limitations and recommendations for further development.

Methods:

Medically-refractory epileptic patients underwent common imaging techniques (mainly brain MRI using a specific temporal lobe protocol) as well as continuous video EEG monitoring. A specialized committee consisting of epileptologists, neurologists, neurosurgeons and radiologists discussed the eligibility of each patient, and defining treatment plans for the surgery.

Results:

A total of 22 committee sessions were hold to discuss 140 cases with medically-refractory seizures during March 2009 to May 2012. Eighty-eight patients (62%) underwent the surgery, 35 patients (25%) were considered not appropriate for surgery, and 17 patients (12%) refused to undergo surgery. The most common cause of intractable seizures was mesial temporal sclerosis (36%), brain tumors (21%), cortical malformations (6%), and encephalomalacia (4%). Among 81 operated patients, 39.5% had anterior temporal lobectomy, 34.5% corpus callosotomy, and 30% underwent lesionectomy.

Conclusions:

The success of epilepsy surgery depends on the accurate identification of good surgical candidates based on available resources and technologies without jeopardizing safety. The key step in establishing a successful plan is having access to trained epileptologist and neurosurgeon.

Keywords:

Epileptology, Epilepsy surgery, Antiepileptic drug, Surgery portocol

The Neurological Manifestations of H1N1 Influenza Infection; Diagnostic Challenges and Recommendations

BACKGROUND

World Health Organization declared pandemic phase of human infection with novel influenza A (H1N1) in April 2009. There are very few reports about the neurological complications of H1N1 virus infection in the literature. Occasionally, these complications are severe and even fatal in some individuals. The aims of this study were to report neurological complaints and/or complications associated with H1N1 virus infection.

METHODS

The medical files of all patients with H1N1 influenza infection admitted to a specified hospital in the city of , from October through November 2009 were reviewed. More information about the patients were obtained by phone calls to the patients or their care givers. All patients had confirmed H1N1 virus infection with real-time PCR assay.

RESULTS

Fifty-five patients with H1N1 infection were studied. Twenty-three patients had neurological signs and/or symptoms. Mild neurological complaints may be reported in up to 42% of patients infected by H1N1 virus. Severe neurological complications occurred in 9% of the patients. The most common neurological manifestations were headache, numbness and paresthesia, drowsiness and coma. One patient had a Guillain-Barre syndrome-like illness, and died in a few days. Another patient had focal status epilepticus and encephalopathy.

CONCLUSIONS

The H1N1 infection seems to have been quite mild with a self-limited course in much of the world, yet there appears to be a subset, which is severely affected. We recommend performing diagnostic tests for H1N1influenza virus in all patients with respiratory illness and neurological signs/symptoms. We also recommend initiating treatment with appropriate antiviral drugs as soon as possible in those with any significant neurological presentation accompanied with respiratory illness and flu-like symptoms.

Vasovagal syncope treated as epilepsy for 16 years

The differentiation of vasovagal syncope and epileptic seizure is sometimes problematic, since vasovagal syncope may mimic epileptic seizures in many ways. The present report describes a patient who had been diagnosed and treated as having epilepsy with medically-refractory seizures for 16 years. Often, unlike epileptic seizures, tonic-clonic convulsions and postictal confusion are uncommon features of vasovagal syncope, but these may occur. Our patient was subjected to subcutaneous injection of one ml normal saline, which caused asystole leading to hypoxia and consequently a typical tonic-clonic convulsion. This patient was proved to have vasovagal syncope. The findings in the present case suggest that the possibility of vasovagal syncope should always be taken into consideration when evaluating patients with medically-refractory or unusual pattern of seizures. In such a circumstance, simultaneous video-electroencephalogram/electocardiogram monitoring may help achieve the correct diagnosis.

Depression and anxiety in patients with epilepsy, with or without other chronic disorders

BACKGROUND

Most people with epilepsy lead a normal emotional and cognitive life, however neurobehavioral problems can be found in a large number of patients. This study evaluates the prevalence of depression and anxiety among patients with epilepsy and determines whether having other chronic somatic illnesses increases the prevalence.

METHODS

Adults with epilepsy were recruited in either the inpatient epilepsy monitoring unit or the Outpatient Epilepsy Clinic at Thomas Jefferson University in 2006. Patients anonymously filled out a questionnaire, included data about age, sex, education, having other chronic illnesses, and degree of seizure control. The Hospital Anxiety and Depression scale was used to define the presence or absence of anxiety and depression. 

RESULTS

Two hundreds patients participated, with a mean age of 40.3±16 years. Nineteen (9.5%) patients had depression and 49 (24.5%) had anxiety. Age, seizure control, and having other chronic illnesses did not have a significant relationship with either depression or anxiety. Gender was significantly related to anxiety, with females displaying greater frequency of anxiety than males. Depression was inversely related to education.

CONCLUSIONS

It is probable that people with higher education use more effective ways to psychologically and physically adapt to their illness.

Effect of treating helicobacter pylori infection on seizure frequency in patients with refractory epilepsy

BACKGROUND

The main purpose of the current study was to determine the effect of treating helicobacter pylori (HP) infection on seizure frequency in patients with refractory epilepsy.

METHODS

A small sample of adult patients above 18 years of age with a diagnosis of refractory epilepsy was studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, from January 2009 through June 2011. If and when urea breath test result was positive, an upper endoscopy with multiple gastric biopsies was requested. Rapid urease test and histopathology examination were performed. For patients with confirmed HP infection, treatment with clarithromycin, amoxicillin and omeprazole was ordered for two weeks. Seizure frequency was recorded before and after HP treatment.

RESULTS

Nine patients were recruited. Using Wilcoxon signed ranks test, seizure frequency did not differ significantly after HP treatment compared to the period before treatment (P = 0.6).

CONCLUSION

Treating HP infection in patients with refractory epilepsy did not significantly change the seizure frequency.

Celiac disease in children with short stature

OBJECTIVE

The aim of the present study was to determine the prevalence of celiac disease in children with short stature.

METHODS

In all children with short stature (height more than 2 SD below the mean for age and sex) and normal physical examination, attending Motahary pediatric clinic in Shiraz, Iran, from 2003 till 2005, work-ups were made to find a cause for their short stature and of course their serum was assayed for IgG anti-tissue transglutaminase (TTG) antibody by ELISA test, as a marker for CD.

RESULTS

There were 26 girls and 46 boys with mean age of 9.8 years. Routine work-up showed microcytic hypochromic anemia in four children (5.6%) and giardiasis in five (6.9%). GH stimulation test revealed GH deficiency in five children (6.9%). Elevated IgG anti-TTG antibody level was detected in two children (2.8%). Duodenal biopsies of these children were in favor of celiac disease.

CONCLUSION

Although, the prevalence of CD in this study was not significantly different (P value = 0.14) from the prevalence rate in healthy blood donors in Iran, the findings emphasize the fact that CD must be considered in a child with short stature, especially if the height is more than 3 SD below the mean for sex and age, even in the absence of gastrointestinal symptoms. In conclusion, the measurement of anti-TTG antibody should be included in the diagnostic evaluation of children with short stature.

Are laboratory tests necessary in making the diagnosis of limb pains typical for growing pains in children?

BACKGROUND

The present study was conducted to determine if performing laboratory tests are necessary to exclude other possible diagnoses in a child with limb pains typical for growing pains according to history and physical examination.

METHODS

A matched case-control study was carried out on children with limb pains who attended the Motahary clinic, Shiraz, Iran, in a 2 year period. The inclusion criteria were limb pains, which were recurrent and lasted for more than 3 months. The exclusion criteria were any abnormal systemic symptoms and signs, localizing signs, joint involvement; and limp or limitation of activity. The controls were clinically normal children matched for age and sex. Laboratory tests including complete blood count, erythrocyte sedimentation rate, serum calcium, phosphorus, alkaline phosphatase and rheumatoid factor were done for all patients and controls.

RESULTS

In total, 100 patients and 150 controls were included in the study. There were no significant differences between the patients and controls with regard to all of the measured laboratory tests.

CONCLUSION

Growing pain is a clinical diagnosis and if precise inclusion and exclusion criteria in history and physical examination are considered, there will be no need for laboratory tests in order to make a diagnosis.

Potentiation of anti-epileptic drugs effectiveness by pyronaridine in refractory epilepsy

One of the major neurobiological mechanisms proposed in drug resistant epilepsy is removal of anti-epileptic drugs (AEDs) from the epileptogenic tissue through excessive expression of multi-drug efflux transporters such as P-glycoprotein (P-gp). P-gp, the encoded product of the human multi-drug resistance-1 (MDR-1; ABCB1) gene, is of particular clinical relevance in the emergence of multi-drug resistance (MDR), which may play an important role in preventing treatment response of some tumors and infectious diseases to chemotherapeutic agents and antibiotics. It has been shown that MDR-1 is over-expressed in brain tissue (hippocampal neurons) in patients with refractory temporal lobe epilepsy. For direct evidence that drug transporters such as P-gp are responsible for drug resistance, an experiment can be conducted to determine whether seizure control is improved when P-gp inhibitors are administered in addition to existing AEDs in patients with medically refractory epilepsy. In comparison with first and second-generation of P-gp inhibitors, third-generation inhibitors such as pyronaridine (PND) have advantages, such as higher potency and specificity for P-gp, lack of non-specific cytotoxicity, relatively long duration of action with reversibility, and good oral bioavailability. We suggest that a pilot study be conducted to determine whether adding of PND to existing AEDs decreases seizure frequency in patients with drug resistant epilepsy, and should this show promise, that a double-blind randomized controlled trial be designed to test the efficacy of PND.

The experience with 113 patients with Kawasaki disease in Fars Province, Iran

This study was conducted to determine the epidemiology, clinical manifestations, cardiac involvements and laboratory findings of Kawasaki disease (KD) in Fars Province, Iran from January 1991 to December 2002. One hundred and thirteen patients with KD were confirmed. This syndrome occurred mostly in males (ratio=2.1:1). The most commonly affected age group was one to five years old. There was no secondary case in families, none of the patients were related and recurrence of disease was seen in only one patient. Prolonged fever and thrombocytosis were significant risk factors for developing coronary artery disease (p<0.05, respectively). Among the 10 patients with cardiac involvement, seven patients had dilated coronary arteries (>4 mm) and three patients had aneurysm of coronary artery in their first echocardiography. It has been suggested that a high index of clinical suspicion of KD could improve diagnosis and implementation of preventive treatment.

Folic acid supplementation reduces the development of some blood cell abnormalities in children receiving carbamazepine

BACKGROUND

Carbamazepine is a commonly used anticonvulsant agent; however, it has been linked with various blood cell abnormalities. This study evaluated the effect of low-dose folic acid supplementation on the prevention of carbamazepine-induced hematological derangements in children.

METHODS

This randomized clinical trial was conducted in children with epilepsy who received carbamazepine monotherapy. Group 1 received carbamazepine alone, and group 2 received carbamazepine plus folic acid. The two groups were age- and sex-matched. Each group comprised 41 children with epilepsy. Complete blood counts were obtained before starting medication (baseline) and then serially. The patients were followed for at least 1 year.

RESULTS

In group 1, 31.4% of the patients developed leukopenia and 17.1% neutropenia, but in group 2, these figures were 14.6 and 9.8% (P = 0.067 and P = 0.331, respectively). At the end of the first year of follow up, white blood cell and polymorphonuclear cell counts were significantly higher in group 2 (P = 0.007 and P = 0.001, respectively). Hemoglobin concentration dropped in group 1, but rose slightly in group 2; these changes were significant. Platelet, lymphocyte, and monocyte counts and changes in serial blood tests did not differ significantly between the two groups.

CONCLUSIONS

Folic acid is a safe drug that can reduce the development of some blood cell abnormalities linked to carbamazepine. It has a favorable effect on preventing the leukopenia and drop in hemoglobin observed in patients receiving carbamazepine, but its exact effect and the optimal dose required to enhance its benefits require further investigation.

Etiologies and outcomes of status epilepticus in children

PURPOSE

Status epilepticus (SE) is a medical emergency with significant associated mortality and morbidity. This study was conducted to determine the etiology and outcome of SE in children.

METHODS

All patients from 1 month to 15 years old with SE admitted to Nemazee Hospital, Shiraz, Iran, the main pediatric hospital in the area, between 1999 and 2004, were studied in a retrospective cross-sectional study. Outcomes were rated according to the Glasgow Outcome Score (GOS).

RESULTS

In all, 135 patients (76 boys, 59 girls) were studied. The most common cause of SE was fever. Etiology of SE did not differ significantly between various age groups and also between boys and girls (P=0.736 and P=0.156, respectively). Fourteen patients died in hospital and 81 were discharged in good health. Outcome did not differ significantly between the age groups (P=0.695) or between boys and girls (P=0.386). When classified as good (GOS=5) and bad (GOS=1-4), outcome was significantly correlated with etiology of SE (P=0.017). Prolonged febrile seizures had the best, and symptomatic SE the worst, outcome.

DISCUSSION

In this study, even in children above 3 years of age, fever was the most common cause of SE. This is noteworthy and heralds the need to pay more attention to febrile seizures, especially in children at risk for their occurrence. Outcome was not related to age and sex, but etiology of SE significantly influenced outcome.

Drug compliance of children and adolescents with epilepsy

BACKGROUND

Compliance behavior depends on the specific clinical situation, the nature of the illness, and the treatment program. The aim of this study was to determine the rate of drug compliance in families caring for a child or adolescent with epilepsy and to describe some associated factors.

METHODS

All the patients with epilepsy under 18 years of age who were attending the Motahary Clinic of Shiraz for a six-month period and their families were interviewed.

RESULTS

The total number of participants was 181 patients. Drug compliance was satisfactory in 72.4% of the patients. Etiology of epilepsy, mono-therapy versus poly-therapy, duration of the disease, age of the patient, accompanying disease, parental smoking, parental education and living in urban versus rural areas did not significantly influence the drug compliance but maternal age was significantly higher in patients with poor compliance. Also, patients with positive family history of epilepsy had more noncompliance. Moreover, family size had a significant effect on drug compliance. Finally, patients using phenobarbital were more complaint than other patients.

CONCLUSIONS

In this study, drug compliance was satisfactory in almost three-fourths of the patients with epilepsy. There was no significant association between noncompliance and the cause of epilepsy, duration of the disease, socio-economic status (parental smoking, living place, education) and number of drugs used to treat the illness. But paying attention to medication education for patients and parents, decreasing the complexity of the treatment regimen and younger possibly more motivated mothers in a small family, increased the drug compliance.

What do nurses and physicians think about the need for specific dietary restrictions in patients with epilepsy?

PURPOSE

It is the responsibility of physicians and nurses to provide patients and their families with appropriate information. In the study described here, we attempted to identify nurses' and physicians' beliefs about and experience with the need for specific dietary restrictions in patients with epilepsy.

METHODS

A cross-sectional study was carried out using a questionnaire in Shiraz, Iran, in 2004. All nurses from the pediatric and internal medicine wards of Nemazee and Dastghaib hospitals and also a random sample of general practitioners, pediatricians, and internists from around the city were included in the study.

RESULTS

The total number of participants was 250. Among the participants, 58.4% believed there existed a relationship between consumption of specific foods and occurrence of seizures. Personal experience with the occurrence of a seizure in a patient who consumed a specific food was reported by 28% of the participants. Dairy products, sour foods, food additives, meats and fish, and fruits and vegetables were the most common foods reported.

CONCLUSIONS

It is clear that health care professionals want to know if their epileptic patients require dietary restrictions and, hence, collect information from different and sometimes unreliable sources. It will be invaluable, in future studies, to take into consideration the experience of health care workers caring for epileptic patients in the evaluation of the relationship between consumption of specific foods and seizures.

Risk factors for childhood epilepsy: a case-control study

BACKGROUND

Risk factors for epilepsy are conditions associated with an increased frequency of epilepsy, and those for childhood epilepsy are different from those for epilepsy occurring later in life. In the present matched case-control study, we attempted to identify some possible risk factors for childhood epilepsy.

METHODS

All children with epilepsy who attended the clinic of Motahary in Shiraz, Iran during a 6-month period were included in the study. Neurologically normal children, matched for age and sex, visiting the same clinic were considered as controls. The data on patients and controls were obtained from answers to a questionnaire obtained through personal interviews. Details on the patient, family history, parental smoking, breast versus formula feeding, and parental age at the time of childbirth were included. Medical records were then reviewed.

RESULTS

In total, 142 patients and 138 controls participated. Positive family history of epilepsy increased the risk of developing epilepsy by 3.34-fold. A higher risk of epilepsy was observed in patients living in rural areas (OR = 2.44).

CONCLUSIONS

Positive family history of epilepsy and residence in rural areas were the two major risk factors associated with epilepsy in this study; neonatal jaundice, parental age, and passive smoke exposure added no risk. Breast-feeding was not shown to have a protective effect against development of epilepsy.

Epilepsy and consanguinity in Shiraz, Iran

BACKGROUND

The importance of consanguinity and its association with epilepsy has been suggested in some studies, but in one study the risk contributed to consanguinity for childhood epilepsy was not significanta. In the present study, there was an attempt to determine if consanguinity has any important association with epilepsy.

METHODS

All the epileptic children and adolescents up to the age of 18 years, who had been referred to Motahary Clinic in Shiraz, Iran, during a six-month period, were included in this cross-sectional study. The percentage of consanguinity in parents of the epileptic patients was compared to a sample of the general population in the same geographical area.

RESULTS

In total, 181 unrelated epileptic children were included in this study. The mean age of these children was 7+/-4.6 years. The male/female ratio in these patients was 1.29. Overall, 61(33.7%) of the parents were first cousins (OR=2.264, 95%-CI: 1.618-3.169 in comparison to the general population), 37 (20.4%) were second cousins (OR=3.557, 95%-CI: 2.389-5.296), and 83 (45.9%) were not related.

CONCLUSIONS

The percentage of consanguinity in parents of the epileptic patients was significantly higher in comparison to a sample of the general population (OR=2.612, 95%-CI: 1.929-3.536, P<0.0001) which signifies the importance of consanguinity as a potential risk factor for epilepsy. In this regard, more education and awareness of young individuals about the increased risk of epilepsy after familial marriages (at least by 2.2 folds), as well as pre-marriage counseling for couples who have a family history of epilepsy are necessary as an effective preventive program.

Body mass index in children with beta-thalassemia major

Underweight or low body mass index (BMI) is associated with developing many health problems. Despite the presence of many growth abnormalities in patients with beta thalassemia major, BMI has not been adequately studied. All of the thalassemic patients under 18 years of age, registered in thalassemia center of Shiraz, were studied. Medical history was taken and complete physical examination was done. BMI (weight/height2) at different ages was calculated and compared with standardized percentile curves of BMI for children and adolescents. BMI less than 10th percentile for sex and age was observed in 12.4% of thalassemic patients under 10 years of age and in 46.5% of patients above 10 years of age (p< 0.000001). Also the observed difference between girls and boys, specially when they are more than 10 years of age is significant (p< 0.000001). Underweight is a common finding in patients with beta-thalassemia major specially when they are older than 10 years of age. This is possibly because of the occurrence of multiple endocrinopathies and also the presence of under-nutrition in these patients. So growth should be monitored routinely at regular intervals in order to detect any decline in growth velocity and also any derangement in BMI to establish an appropriate protocol for investigation and treatment.

Do patients with epilepsy believe they need specific dietary restrictions?

PURPOSE

Almost 1000 years ago, Avicenna, the great Iranian scientist, recommended that patients with epilepsy should avoid some foods. In the present study we attempted to identify beliefs and experiences of families with epileptic children with respect to the need for specific dietary restrictions in these patients.

METHODS

A cross-sectional study was carried out using a questionnaire at the outpatient clinic of Motahary in Shiraz, Iran, in 2004. Patients with unprovoked seizures and abnormal electroencephalograms who were under follow-up for at least 2 months were included in the study.

RESULTS

In total 125 families participated. Of these, 55.2% believed there was a relationship between specific foods and the occurrence of seizures. Personal experience with seizures after consumption of specific foods was reported by 31.2% of the families. Dairy products, sour foods, fruits, and vegetables were the most common foods reported to be responsible.

CONCLUSION

It was clearly observed that parents desire to know if their children with epilepsy require dietary restrictions and, hence, try to collect information from different and sometimes unreliable sources. It would be invaluable to consider the experience of families caring for epileptic children when evaluating the relationship between consumption of specific foods and seizures in future studies. This relationship may be due to a food-disease or food-drug interaction.

Thalassemia major and consanguinity in Shiraz city, Iran

Beta-thalassemia is among the most common genetic disorders in the world and in Iran, with widespread occurrence. A cross-sectional study on 648 beta-thalassemia patients in Shiraz, Iran was carried out to determine the demography of beta-thalassemia major in Shiraz city, Fars province, Iran and also the rate of consanguinity and the significance of pre-marriage counseling in decreasing familial marriages and consequently preventing this autosomal recessive genetic disease. All interviewed patients had thalassemia major and their age, sex, and the consanguinity between parents were recorded. 40.6% of beta-thalassemia patients were outcomes of first-cousin marriages. Comparison of the percentages of familial marriages (consanguinity) between parents of beta-thalassemia patients and a sample of normal population, revealed a statistically significant difference (p< 0.00001). A nonstatistically significant difference was observed between male (53.5%) and female (46.5%) thalassemia patients. Comparison of data with the situation in 22 years ago revealed a 16.4% decrease in familial marriages among thalassemic families, however, more education and awareness of young women and men about the increased risk of beta-thalassemia after familial marriage through pre-marriage counseling is still necessary.

The antimycobacterial effect of honey: an in vitro study

Avicenna recommended honey in the treatment of tuberculosis. Honey has potent bactericidal activity against many pathogenic organisms, but its antimycobacterial effect has never been studied. In this study the antimycobacterial effect of honey was evaluated in vitro. Standard Lowenstein-Jenson media and L-J media containing various concentrations of honey were prepared. Two bacilli from positive cultures and two from positive smears of the affected patients were inoculated on each of the prepared plates. It was demonstrated that the growth of mycobacteria was inhibited by adding 10% honey to the media. Mycobacteria did not grow in culture media containing 10% and 20% honey while it grew in culture media containing 5%, 2.5% and 1% honey. The good antimycobacterial effect, sterility, low cost, and easy availability of honey makes it an ideal antimycobacterial agent.