Investigation of Correlation between Resistance to Diazepam and Expression of Inflammatory Markers in The Peripheral Blood of Patients with Status Epilepticus

OBJECTIVE

This study investigated several inflammatory markers' gene and protein expression in status epilepticus (SE) and their correlation with diazepam resistance.

MATERIALS AND METHODS

Peripheral blood samples were collected from 18 adult patients with SE in Cipto Mangunkusumo Central Hospital, consisting of 12 diazepam-responsive and six diazepam-resistant samples, within 72 hours of the onset of the seizure. We collected baseline demographic and clinical data from each subject. Peripheral blood mononuclear cells (PBMCs) were isolated, cultured, stimulated with lipopolysaccharide (LPS) 1 mg/ml, and harvested for RNA isolation. The RNA was used to determine the expression of Human Mobility Group Box 1 (HMGB1), Interleukin- 6 (IL-6), IL-10, Toll-like Receptor 4 (TLR4), and Glial fibrillary acidic protein (GFAP). In addition, we performed serum protein assay of HMGB1, IL-6, IL-10, TLR4, and GFAP to compare with gene expression.

RESULTS

We found a significant difference between the responsive and resistant groups for serum HMGB1 and IL-6 concentration. The mRNA expression of HMGB1 and IL-6 was significantly higher in LPS-stimulated samples in the responsive but not in the resistant groups. The ratio of IL-6 to IL-10 showed a significant difference between LPS and control in the responsive group. Diazepam response was significantly correlated with seizure duration and serum protein concentration of HMGB1.

CONCLUSION

HMGB1 was highly expressed in the resistant group and strongly correlated with diazepam response, and there was a significant increase in HMGB1 mRNA expression in response to LPS stimulation. These findings suggest that targeting HMGB1 may be a promising therapeutic strategy and that HMGB1 levels could be a valuable biomarker for predicting diazepam resistance in SE.

Screening of Major Depression Disorder in Patients With Epilepsy in Indonesian National Referral Hospital

Background and Objectives

Major depressive disorder (MDD) is a common psychiatric disorder in patients with epilepsy (PWE). The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is one of the MDD screening tools used in PWE. This study aims to determine the accuracy of the valid and reliable NDDI-E Indonesian version as an MDD screening tool in PWE and investigate the prevalence and risk factors for the development of MDD in PWE.

Methods

A diagnostic cross-sectional study was conducted at Cipto Mangunkusumo National Referral Hospital, Indonesia. Patients were PWE aged 18 years or older who visited the epilepsy outpatient clinic. The valid and reliable NDDI-E Indonesian version and Mini International Neuropsychiatric Interview (MINI) International Classification of Disease, 10th Revision (ICD-10) were used to diagnose MDD. In phase II of the study, diagnostic accuracy was evaluated using the receiver operative characteristic (ROC) curve method to obtain the area under the curve (AUC) and diagnostic 2 x 2 table to determine the cutoff point, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). During phase III of the study, eligible individuals were screened for MDD using the NDDI-E Indonesian version. Demographic and clinical data were collected. Data analysis was performed using the χ2 test, Mann-Whitney test, and multivariate logistic regression analysis.

Results

A total of 105 individuals were involved, and only 23 of them were found to experience MDD based on MINI ICD-10. The best cutoff point for the NDDI-E Indonesian version was ≥11, with a sensitivity of 91.3%, specificity 89%, PPV 70%, and NPV 97.3%. The AUC obtained from ROC analysis was 97.5% (95% CI 95-99%, p < 0.001). Then, the survey was completed by 79 individuals, predominantly male, mostly within the age range of 26-45 years. The prevalence of MDD in PWE was 50.6%, and the significant risk factors were seizure frequency ≥8 times a year and the presence of chronic diseases (p < 0.001).

Discussion

The NDDI-E Indonesian version was a screening tool with a high diagnostic accuracy to detect MDD in PWE at a cutoff point of 11. Poor seizure control and the presence of other chronic diseases were the risk factors correlated with MDD development in PWE.

Sleep disturbance in post COVID-19 conditions: Prevalence and quality of life

Post COVID-19 conditions are complaints and symptoms in patients with a history of probable or confirmed COVID-19 after 3 months of the onset of COVID-19 and last at least 2 months. About 10-20% of people may experience post COVID-19 conditions, one of which is sleep disturbance. There is a wide range of prevalence of sleep disturbances from 6% to more than 70%. An online survey of the post COVID-19 conditions in various countries showed that 78.58% of subjects had sleep disturbances, including insomnia, sleep-disordered breathing, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, parasomnias, and sleep-related movement disorders. Sleep disturbance can be found starting from 2 weeks until 48 weeks or more after discharge or after having a negative COVID-19 test results. Women aged < 50 years old with severe COVID-19 infection reported a worse outcome. Several mechanisms may cause sleep disturbance in post COVID-19 condition, namely persistent viral infection and inflammation, immunity dysregulation, and mitochondrial dysfunction. Several studies discovered sleep disturbance was a major problem that affected different domains of QoL in post COVID-19 conditions. Significant correlation was found between several dimensions of SF-36 with moderate-to-severe insomnia in post COVID-19 conditions. Therefore, sleep disturbance is a major problem in post COVID-19 conditions and may affect patients' QoL, and the existence of sleep disturbance should be a concern in post COVID-19 conditions period. Further research is required to determine the prevalence based on agreed definition as well as methods to assess this condition and its impact on QoL.

Multidrug Resistance-1 C3435T Polymorphism and Carbamazepine Plasma Level in Indonesian Temporal Lobe Epilepsy Patients

BACKGROUND

Temporal lobe epilepsy (TLE) has the highest probability of becoming resistant. One of the causes was Polymorphism in multidrug resistant-1 (MDR1) C3435T. In Dr. Cipto Mangunkusumo Hospital, potential drug-resistant epilepsy prevalence was 84.51%; 66.6% of them used carbamazepine (CBZ) as antiseizure medication. This comparative cross-sectional study aimed to investigate MDR1 C3435T polymorphism and CBZ plasma level (plCBZ) in Indonesian TLE patients.

METHODS

TLE patient was selected consecutively; divided into drug-responsive (DRV) and drugresistant (DRE) groups. Healthy subjects were included as a control for the gene polymorphism comparison. MDR1 was identified using the restriction fragment length polymorphism PCR technique; C allele at 159 and 57bp while T allele at 216bp. High-performance liquid chromatography was used to determine plCBZ.

RESULTS

There were 86 subjects; 61 in the study group and 25 controls. The genotype distribution between them was 0.58 vs 0.42, x²=0.54, p=0.000. In the study group, CBZ within therapeutic doses (dCBZ) had outreached the therapeutic plCBZ and found similar in all genotypes. DRE criteria were found in 37 subjects. Distribution of C and T in DRV was 0.63 vs 0.37, x²=10.4; and DRE 0.55 vs 0.45 x²=6.17 (p=0.019). In Tukey's multiple comparison post hoc test, CT in DRV had significantly lower dCBZ (330,36 ± 174,91 mg) and plCBZ (7.15 ± 2.64 mcg/mL) compared to all genotypes in DRE. Whereas mean dCBZ was around 800mg and plCBZ outreached the toxic level; TT was the highest.

CONCLUSION

The genotype MDR1 distribution was similar in the normal population and DRE. Therapeutic plCBZ was achieved using the low dose. CT genotype responds to lower dCBZ, while TT genotype outreached the highest toxic plCBZ.

Characteristics of menstrual disorders and reproductive hormones in women with epilepsy at an Indonesian national referral hospital

Objective

Menstrual disorders are more common in women with epilepsy than in those without epilepsy. This study aimed to examine the characteristics of reproductive function in women with epilepsy at an Indonesian national referral hospital.

Methods

A case-control study was conducted from March 2020 to March 2021. Women with and without epilepsy aged ≥18 years were enrolled. All women were premenopausal before epilepsy diagnosis. Data on demographic characteristics, menstrual profiles, epileptic syndrome, seizure type, seizure frequency, etiology, localization, and anticonvulsant medication were collected. Hormone levels (follicle stimulating hormone, luteinizing hormone, prolactin, and estradiol) were measured.

Results

A total of 72 women with and 50 without epilepsy (controls) were included. Dysmenorrhea was more common in women with epilepsy than in those without (59.7 vs. 20%, p &lt; 0.001; odds ratio: 5.931 [95% confidence interval: 2.566–13.709]). Marriage rates were higher in women without epilepsy (82 vs. 45.8%, p &lt; 0.001). No difference was found in hormone levels between the groups. The frequency of seizures was associated with prolactin and estradiol levels (p &lt; 0.001). Polytherapy with clobazam was associated with menstrual cycle regularity. In women with epilepsy with menstrual disorders, valproic acid was associated with higher estradiol levels (p = 0.001) and lamotrigine with lower follicle stimulating hormone levels (p = 0.008).

Significance

Women with epilepsy experienced more dysmenorrhea. A higher frequency of seizures associated with lower prolactin and estradiol levels. Polytherapy with clobazam was associated with irregular menstrual cycles, while valproic acid and lamotrigine was associated with estradiol and follicle stimulating hormone levels.

Altered mental status in moderate-severe traumatic brain injury in Indonesia: the clinical manifestation and EEG features of non-convulsive status epilepticus

Introduction

Moderate-to-severe traumatic brain injury (msTBI) can cause non-convulsive status epilepticus (NCSE). Electroencephalography (EEG) is employed as a diagnostic tool due to the non-specificity of clinical symptoms. This study aimed to identify clinical and EEG features related to NCSE in patients with msTBI.

Methods

This was a cross-sectional study. Suspected NCSE in msTBI was examined using EEG data collected in consecutive patients from January 2017 to December 2019 at Dr. Cipto Mangunkusumo Hospital, Jakarta. Diagnoses of NCSE were made based on clinical manifestations and EEG features using the modified Salzburg Consensus Criteria for NCSE (mSCNC).

Results

Of the 39 msTBI patients, 19 were diagnosed with NCSE; only two fulfilled the definitive criteria, and the remaining were possible NCSE. Delirium and perceptual impairment were only found in NCSE, while psychomotor agitation was higher (12.8% vs. 5.1% in NCSE vs. non-NCSE). The most common EEG feature was rhythmic activity (>0.5 Hz) without fluctuation, which improved with anti-epileptic drug administration. The Glasgow Coma Scale (GCS) score at onset and at hospitalisation discharge was significantly lower in patients with NCSE. The lesions in NCSE mostly originated from the temporal lobe. Injury to the temporal lobe had a significant relationship with NCSE occurrence (p = 0.036, odds ratio 11.45 [95% confidence interval 1.17–111.6]).

Discussion

Post-traumatic NCSE can manifest as an alteration in mental status that could lead to missed diagnosis. In this study, delirium, perceptual impairment, and psychomotor agitation were confirmed as NCSE using EEG. The most common discharge originated from the injured temporal lobe, and this site was a significant factor associated with NCSE in patients with msTBI.

Conclusion

NCSE can be found in msTBI cases with clinical manifestations of altered mental status, psychomotor agitation, and hallucination. An injured temporal lobe was a susceptible site for the development of NCSE.

Nonconvulsive Status Epilepticus in Metabolic Encephalopathy in Indonesia Referral Hospital

Background

Nonconvulsive status epilepticus (NCSE) is often underdiagnosed in patients with metabolic encephalopathy (ME). The diagnosis of ME should be made specifically to recognize the underlying etiology. Delay in seizure identification and making a diagnosis of NCSE contributed to the poor outcome.

Objective

This study aimed to find the incidence and outcome of NCSE in patients with ME.

Methods and Material

This was an observational prospective cross-sectional study in patients with ME in emergency and critical care units in Cipto Mangunkusumo General Hospital. The diagnosis of NCSE was based on EEG using Salzburg Criteria for Nonconvulsive Status Epilepticus (SCNC). The outcome was assessed within 30 days after the NCSE diagnosis has been made.

Results

A total of 50 patients with ME were involved in this study. NCSE was confirmed in 32 subjects (64%). The most common etiology of ME was sepsis (58%). The mortality rate in the NCSE and non-NCSE group was 40.6% vs 44.4%. Multiple aetiologies were risk factors to poor outcome in the NCSE group.

Conclusions

The incidence of NCSE among patients with ME at our hospital was high. Despite the anti-epileptic treatment of the NCSE group, the underlying cause of ME is still the main factor that affected the outcome. Therefore, aggressive treatment of anti-epileptic drug (AED) should be very carefully considered knowing the possible side-effect that might worsen the outcome of patients with ME.